Analysing contractual environments: lessons from Indigenous health in Canada, Australia and New Zealand

Mitigating the impact of the COVID-19 pandemic on Inuit living in Manitoba: community responses

We document community responses to the COVID-19 pandemic among Inuit living in the province of Manitoba, Canada. This study was conducted by the Manitoba Inuit Association and a Council of Inuit Elders, in partnership with researchers from the University of Manitoba. We present findings from 12 health services providers and decision-makers, collected in 2021.Although Public Health orders led to the closure of the Manitoba Inuit Association's doors to community events and drop-in activities, it also created opportunities for the creation of programming and events delivered virtually and through outreach. The pandemic exacerbated pre-existing health and social system's shortcomings (limited access to safe housing, food insecurity) and trauma-related tensions within the community. The Manitoba Inuit Association achieved unprecedented visibility with the provincial government, receiving bi-weekly reports of COVID-19 testing, results and vaccination rates for Inuit. We conclude that after over a decade of advocacy received with at best tepid enthusiasm by federal and provincial governments, the Manitoba Inuit Association was able effectively advocate for Inuit-centric programming, and respond to Inuit community's needs, bringing visibility to a community that had until then been largely invisible. Still, many programs have been fueled with COVID-19 funding, raising the issue of sustainability.

Disruption as opportunity: Impacts of an organizational health equity intervention in primary care clinics

BACKGROUND

The health care sector has a significant role to play in fostering equity in the context of widening global social and health inequities. The purpose of this paper is to illustrate the process and impacts of implementing an organizational-level health equity intervention aimed at enhancing capacity to provide equity-oriented health care.

METHODS

The theoretically-informed and evidence-based intervention known as 'EQUIP' included educational components for staff, and the integration of three key dimensions of equity-oriented care: cultural safety, trauma- and violence-informed care, and tailoring to context. The intervention was implemented at four Canadian primary health care clinics committed to serving marginalized populations including people living in poverty, those facing homelessness, and people living with high levels of trauma, including Indigenous peoples, recent immigrants and refugees. A mixed methods design was used to examine the impacts of the intervention on the clinics' organizational processes and priorities, and on staff.

RESULTS

Engagement with the EQUIP intervention prompted increased awareness and confidence related to equity-oriented health care among staff. Importantly, the EQUIP intervention surfaced tensions that mirrored those in the wider community, including those related to racism, the impacts of violence and trauma, and substance use issues. Surfacing these tensions was disruptive but led to focused organizational strategies, for example: working to address structural and interpersonal racism; improving waiting room environments; and changing organizational policies and practices to support harm reduction. The impact of the intervention was enhanced by involving staff from all job categories, developing narratives about the socio-historical context of the communities and populations served, and feeding data back to the clinics about key health issues in the patient population (e.g., levels of depression, trauma symptoms, and chronic pain). However, in line with critiques of complex interventions, EQUIP may not have been maximally disruptive. Organizational characteristics (e.g., funding and leadership) and characteristics of intervention delivery (e.g., timeframe and who delivered the intervention components) shaped the process and impact.

CONCLUSIONS

This analysis suggests that organizations should anticipate and plan for various types of disruptions, while maximizing opportunities for ownership of the intervention by those within the organization. Our findings further suggest that equity-oriented interventions be paced for intense delivery over a relatively short time frame, be evaluated, particularly with data that can be made available on an ongoing basis, and explicitly include a harm reduction lens.

Adverse birth outcomes and infant mortality according to registered First Nations status and First Nations community residence across Canada

OBJECTIVE

Studies of perinatal health outcomes in Canadian First Nations populations have largely focused on limited geographical areas and have been unable to examine outcomes by registered status and community residence. In this study, we compare rates of adverse birth outcomes among First Nations individuals living within vs. outside of First Nations communities and those with vs. without registered status.

METHODS

Data included 13,506 singleton pregnancies from the 2006 Canadian Birth-Census Cohort. Outcomes examined included preterm birth (PTB), small- and large-for-gestational-age birth (SGA, LGA), stillbirth, overall infant mortality, and neonatal and postneonatal mortality. Risk ratios (RRs) were estimated with adjustment for maternal age, education, parity, and paternal education.

RESULTS

Mothers living in First Nations communities and those with status had elevated adjusted risks of LGA (RR for First Nations community residence = 1.22, 95% CI = 1.09-1.35; RR for status = 1.50, 95% CI = 1.16-1.93). Rates of SGA were significantly lower among mothers with status (adjusted RR = 0.62, 95% CI = 0.44-0.86). Rates of PTB did not vary substantially by residence or by status. Adjusted differences in fatal outcomes could not be estimated, owing to small cell sizes. However, mothers living in First Nations communities had higher crude rates of infant mortality (10.9 vs. 7.7 per 1000), particularly for neonatal mortality (6.1 vs. 2.9).

CONCLUSION

Future investigations should explore risk factors, including food security and access to health care services, that may explain disparities in SGA and LGA by status and residence within First Nations populations.

Sentinels of inequity: examining policy requirements for equity-oriented primary healthcare

BACKGROUND

Non-government, not-for-profit community health centres (CHCs) play a crucial role within healthcare systems in fostering equity, acting both as direct providers of services and as sentinels of health and social inequity. In a study of an intervention to promote equity-oriented health care, we enlisted four diverse primary healthcare clinics with mandates to serve highly marginalized populations. All of these CHCs operate as not-for-profit, non-government organizations (NGOs), and have a marginal relationship financially and socially to other parts of the system. The purpose of this paper is to provide an analysis of the factors that shape how CHCs are able to carry out an equity mandate and, from this, to identify what is required at the level of policy to enhance capacity to provide equity-oriented health care.

METHODS

We systematically examined the clinics' policy and funding contexts, and identified influences on the clinics' capacities to promote equity-oriented health care.

RESULTS

We identified three key mechanisms of influence, each playing out against the backdrop of a contested and marginal position of CHCs within the health care system: a) accountability and performance frameworks; b) patterns of funding and allocation of resources, and c) pathways for emergent priorities. We examine these mechanisms, considering how each influenced the pursuit of equity, and propose policy directions to optimize the primary health care sectors' capacity to support equity-oriented health care.

CONCLUSIONS

Although this analysis is based on a study within a high-income country, we argue that because the dynamics between community health centres and broader healthcare systems are similar across national boundaries, the implications have applicability to low and middle-income countries.

Expanding the breadth of Medicare: learning from Australia

The design of Australia’s Medicare programme was based on the Canadian scheme, adapted somewhat to take account of differences in the constitutional division of powers in the two countries and differences in history. The key elements are very similar: access to hospital services without charge being the core similarity, universal coverage for necessary medical services, albeit with a variable co-payment in Australia, the other. But there are significant differences between the two countries in health programmes – whether or not they are labelled as ‘Medicare’. This paper discusses four areas where Canada could potentially learn from Australia in a positive way. First, Australia has had a national Pharmaceutical Benefits Scheme for almost 70 years. Second, there have been hesitant extensions to Australia’s Medicare to address the increasing prevalence of people with chronic conditions – extensions which include some payments for allied health professionals, ‘care coordination’ payments, and exploration of ‘health care homes’. Third, Australia has a much more extensive system of support for older people to live in their homes or to move into supported residential care. Fourth, Australia has gone further in driving efficiency in the hospital sector than has Canada. Finally, the paper examines aspects of the Australian health care system that Canada should avoid, including the very high level of out-of-pocket costs, and the role of private acute inpatient provision.

Implementing Indigenous community control in health care: lessons from Canada

Objective Over past decades, Australian and Canadian Indigenous primary healthcare policies have focused on supporting community controlled Indigenous health organisations. After more than 20 years of sustained effort, over 89% of eligible communities in Canada are currently engaged in the planning, management and provision of community controlled health services. In Australia, policy commitment to community control has also been in place for more than 25 years, but implementation has been complicated by unrealistic timelines, underdeveloped change management processes, inflexible funding agreements and distrust. This paper discusses the lessons from the Canadian experience to inform the continuing efforts to achieve the implementation of community control in Australia. Methods We reviewed Canadian policy and evaluation grey literature documents, and assessed lessons and recommendations for relevance to the Australian context. Results Our analysis yielded three broad lessons. First, implementing community control takes time. It took Canada 20 years to achieve 89% implementation. To succeed, Australia will need to make a firm long term commitment to this objective. Second, implementing community control is complex. Communities require adequate resources to support change management. And third, accountability frameworks must be tailored to the Indigenous primary health care context to be meaningful. Conclusions We conclude that although the Canadian experience is based on a different context, the processes and tools created to implement community control in Canada can help inform the Australian context. What is known about the topic? Although Australia has promoted Indigenous control over primary healthcare (PHC) services, implementation remains incomplete. Enduring barriers to the transfer of PHC services to community control have not been addressed in the largely sporadic attention to this challenge to date, despite significant recent efforts in some jurisdictions. What does this paper add? The Canadian experience indicates that transferring PHC from government to community ownership requires sustained commitment, adequate resourcing of the change process and the development of a meaningful accountability framework tailored to the sector. What are the implications for practitioners? Policy makers in Australia will need to attend to reform in contractual arrangements (towards pooled or bundled funding), adopt a long-term vision for transfer and find ways to harmonise the roles of federal and state governments. The arrangements achieved in some communities in the Australian Coordinated Care Trials (and still in place) provide a model.

People-centred integration in a refugee primary care service

Purpose

Services for refugees and asylum seekers frequently experience gaps in delivery and access, poor coordination, and service stress. The purpose of this paper is to examine the approach to integrated care within Companion House (CH), a refugee primary care service, whose service mix includes counselling, medical care, community development, and advocacy. Like all Australian refugee and asylum seeker support services, CH operates within an uncertain policy environment, constantly adapting to funding challenges, and changing needs of patient populations.

Design/methodology/approach

Interviews with staff, social network analysis, group patient interviews, and service mapping.

Findings

CH has created fluid links between teams, and encouraged open dialogue with client populations. There is a high level of networking between staff, much of it informal. This is underpinned by horizontal management and staff commitment to a shared mission and an ethos of mutual respect. The clinical teams are collectively oriented towards patients but not necessarily towards each other.

Research limitations/implications

Part of the service’s resilience and ongoing service orientation is due to the fostering of an emergent self-organising form of integration through a complex adaptive systems approach. The outcome of this integration is characterised through the metaphors of “home” for patients, and “family” for staff. CH’s model of integration has relevance for other services for marginalised populations with complex service needs.

Originality/value

This study provides new evidence on the importance of both formal and informal communication, and that limited formal integration between clinical teams is no bar to integration as an outcome for patients.

Enhancing health care equity with Indigenous populations: evidence-based strategies from an ethnographic study

BACKGROUND

Structural violence shapes the health of Indigenous peoples globally, and is deeply embedded in history, individual and institutional racism, and inequitable social policies and practices. Many Indigenous communities have flourished, however, the impact of colonialism continues to have profound health effects for Indigenous peoples in Canada and internationally. Despite increasing evidence of health status inequities affecting Indigenous populations, health services often fail to address health and social inequities as routine aspects of health care delivery. In this paper, we discuss an evidence-based framework and specific strategies for promoting health care equity for Indigenous populations.

METHODS

Using an ethnographic design and mixed methods, this study was conducted at two Urban Aboriginal Health Centres located in two inner cities in Canada, which serve a combined patient population of 5,500. Data collection included in-depth interviews with a total of 114 patients and staff (n = 73 patients; n = 41 staff), and over 900 h of participant observation focused on staff members' interactions and patterns of relating with patients.

RESULTS

Four key dimensions of equity-oriented health services are foundational to supporting the health and well-being of Indigenous peoples: inequity-responsive care, culturally safe care, trauma- and violence-informed care, and contextually tailored care. Partnerships with Indigenous leaders, agencies, and communities are required to operationalize and tailor these key dimensions to local contexts. We discuss 10 strategies that intersect to optimize effectiveness of health care services for Indigenous peoples, and provide examples of how they can be implemented in a variety of health care settings.

CONCLUSIONS

While the key dimensions of equity-oriented care and 10 strategies may be most optimally operationalized in the context of interdisciplinary teamwork, they also serve as health equity guidelines for organizations and providers working in various settings, including individual primary care practices. These strategies provide a basis for organizational-level interventions to promote the provision of more equitable, responsive, and respectful PHC services for Indigenous populations. Given the similarities in colonizing processes and Indigenous peoples' experiences of such processes in many countries, these strategies have international applicability.

Responding to health inequities: Indigenous health system innovations

Over the past decades, Indigenous communities around the world have become more vocal and mobilized to address the health inequities they experience. Many Indigenous communities we work with in Canada, Australia, Latin America, the USA, New Zealand and to a lesser extent Scandinavia have developed their own culturally-informed services, focusing on the needs of their own community members. This paper discusses Indigenous healthcare innovations from an international perspective, and showcases Indigenous health system innovations that emerged in Canada (the First Nation Health Authority) and Colombia (Anas Wayúu). These case studies serve as examples of Indigenous-led innovations that might serve as models to other communities. The analysis we present suggests that when opportunities arise, Indigenous communities can and will mobilize to develop Indigenous-led primary healthcare services that are well managed and effective at addressing health inequities. Sustainable funding and supportive policy frameworks that are harmonized across international, national and local levels are required for these organizations to achieve their full potential. In conclusion, this paper demonstrates the value of supporting Indigenous health system innovations.

NHS commissioning practice and health system governance: a mixed-methods realistic evaluation

Background

By 2010 English health policy-makers had concluded that the main NHS commissioners [primary care trusts (PCTs)] did not sufficiently control provider costs and performance. After the 2010 general election, they decided to replace PCTs with general practitioner (GP)-controlled Clinical Commissioning Groups (CCGs). Health-care commissioners have six main media of power for exercising control over providers, which can be used in different combinations (‘modes of commissioning’).

Objectives

To: elicit the programme theory of NHS commissioning policy and empirically test its assumptions; explain what shaped NHS commissioning structures; examine how far current commissioning practice allowed commissioners to exercise governance over providers; examine how commissioning practices differ in different types of commissioning organisation and for specific care groups; and explain what factors influenced commissioning practice and the relationships between commissioners and providers.

Design

Mixed-methods realistic evaluation, comprising: Leximancer and cognitive frame analyses of policy statements to elicit the programme theory of NHS commissioning policy; exploratory cross-sectional analysis of publicly available managerial data about PCTs; systematic comparison of case studies of commissioning in four English sites – including commissioning for older people at risk of unplanned hospital admission; mental health; public health; and planned orthopaedic surgery – and of English NHS commissioning practice with that of a German sick-fund and an Italian region (Lombardy); action learning sets, to validate the findings and draw out practical implications; and two framework analyses synthesising the findings and testing the programme theory empirically.

Results

In the four English case study sites, CCGs were formed by recycling former commissioning structures, relying on and maintaining the existing GP commissioning leaderships. The stability of distributed commissioning depended on the convergence of commissioners’ interests. Joint NHS and local government commissioning was more co-ordinated at strategic than operational level. NHS providers’ responsiveness to commissioners reflected how far their interests converged, but also providers’ own internal ability to implement agreements. Commissioning for mental health services and to prevent recurrent unplanned hospital readmissions relied more on local ‘micro-commissioning’ (collaborative care pathway design) than on competition. Service commissioning was irrelevant to intersectoral health promotion, but not clinical prevention work. On balance, the possibility of competition did not affect service outcomes in the ways that English NHS commissioning policies assumed. ‘Commodified’ planned orthopaedic surgery most lent itself to provider competition. In all three countries, tariff payments increased provider activity and commissioners’ costs. To contain costs, commissioners bundled tariff payments into blocks, agreed prospective case loads with providers and paid below-tariff rates for additional cases. Managerial performance, negotiated order and discursive control were the predominant media of power used by English, German and Italian commissioners.

Conclusions

Commissioning practice worked in certain respects differently from what NHS commissioning policy assumed. It was often laborious and uncertain. In the four English case study sites financial and ‘real-side’ contract negotiations were partly decoupled, clinician involvement being least on the financial side. Tariff systems weakened commissioners’ capacity to choose providers and control costs. Commissioners adapted the systems to solve this problem. Our findings suggest a need for further research into whether or not differently owned providers (corporate, third sector, public, professional partnership, etc.) respond differently to health-care commissioners and, if so, what specific implications for commissioning practice follow. They also suggest that further work is needed to assess how commissioning practices impact on health system integration when care pathways have to be constructed across multiple providers that must tender competitively for work, perhaps against each other.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The use of standard contracts in the English National Health Service: a case study analysis

The use of contracts is vital to market transactions. The introduction of market reforms in health care in the U.K. and other developed countries twenty years ago meant greater use of contracts. In the U.K., health care contracting was widely researched in the 1990s. Yet, despite the changing policy context, the subject has attracted less interest in recent years. This paper seeks to fill a gap by reporting findings from a study of contracting in the English National Health Service (NHS) after the introduction of the national standard contract in 2007. By using economic and socio-legal theories and two case studies we examine the way in which the new contract was implemented in practice and the extent to which implementation conformed to policy intentions and to our theoretical predictions. Data were collected using non-participant observation of 36 contracting meetings, 24 semi-structured interviews, and analysis of documents. We found that despite efforts to introduce a more detailed ('complete') contract, in practice, purchasers and providers often reverted to a more relational style of contracting. Frequently reliance on the NHS hierarchy proved to be indispensable; in particular, formal dispute resolution was avoided and financial risk was re-allocated in compromises that sometimes ignored contractual provisions. Serious data deficiencies and shortages of skilled personnel still caused major difficulties. We conclude that contracting for health care continues to raise serious problems, which may be exacerbated by the impending transfer of responsibility to groups of general practitioners (GPs) who generally lack experience and expertise in large-scale, secondary care contracting.