Population-based approach and integration of services: their relationship to the territory in the context of Québec's integrative reforms

Context : Two major reforms 2004 and 2015 have transformed Quebec's health and social care system over the last twenty years. In 2004, the reform was based on a coordination model of integration in order to promote the implementation of the principle of population-based responsibility. The population-based approach emphasises planning and delivery of services aimed at improving the health and well-being of a geographically defined population. Concretely, this principle was manifested in 2004 by the implementation of Local Health Networks LHNs, which promote inter-organisational consultations between public, community and private health services of a given territory. On the other hand, the 2015 reform instead pushed in a fully integrated model that breaks down organizational and geographical boundaries over vast territories; effectively abandoning consultations. Aims : To analyze how Quebec’s health and social services system has succeeded in embodying and combining the principles that underlie the integration of services and the population-based approach. Methods : This research is part of an international research program "implementing community based integrated care for older adults with complex health needs" ICOACH. This presentation is based on data collected in Quebec from 44 semi-structured interviews with policy makers n = 11 and managers n = 33. The thematic analysis of interviews was based on the principles of the population-based approach Couturier, Bonin and Belzile, 2016, Roy, Litvak and Paccaud, 2010. Results : The population-based approach remained a core principle in the design and structuring of both reforms, but its operationalization weakened over time. For instance, an important operational indicator such as the presence of intersectoral consultation mechanisms, were undermined during the transition from the first to the second reform, thus favoring a managerial rather than participatory conception of governance. The LHNs which were the consultation sites, were intended, in principle, to enable integrated organizations to respond to the needs of the population under their responsibility, and to produce health upstream of traditional curative strategies alone. These LHNs were abandoned by the second reform, in favor of the creation of large centralized organizations, implanted over large geographical areas. Their essentially top-down governance is centralized, making consultation venues irrelevant, characterised by a curtailment of organizations towards their own internal priorities rather than the needs of the population. However, the population-based approach has recently re-emerged as a potential solution to the excesses of the second reform. The populational-based approach makes it possible to revisit the concerns about the relationship between the health system and the dynamics of local populations in their territories, which are small by nature. Conclusion : The population-based approach seems useful to positively conceive integrative reforms at the systemic level of healthcare systems. But its capacity to be durably translated into practices is limited by the implementation of such reforms. They primarily respond to political and managerial imperatives, hence, producing a more service-driven managerial logic rather than a population needs driven logic.