Grant: Travel Awards - Institute Community Support

Vertical integration of health care facilities is one of various solutions to reorient health systems, but such experiments remain limited. In 2003-2004, a major reform launched in the province of Quebec (Canada) completely revised the health system governance scheme. A new organizational model was introduced integrating acute, long term, community and primary care services through health facilities mergers defined on a geographical basis. The objective of this study was to look into how and under what conditions this policy implementation was made possible in local territories. Rooted in a political economy theoretical framework, six case studies were conducted in territories within two regions (Bas-Saint-Laurent and Chaudière-Appalaches). Data was collected using documentary analysis of governmental, organizational and media publications (n=1048) and 32 semi-structured interviews with key decision-makers. Results show implementation dynamic and strategies being highly influenced by local context. Our key findings first point to the high significance of territorial boundaries for local actors, who opposed mergers when they implied the given institutionalised geographical boundaries be redefined. Second, past mergers experiences also weighted in. Previous conflicting mergers experiments impeded the implementation of the new organizational model, whereas past experiences with more consensual, non-merger forms of organizational integration facilitated the transition. In the end, even after the mergers took place, health care institutions' missions showed resilience and therefore integrated at different paces in each territory. The practices described in our research shed light on a resistance logic which generates conflicts mediated through negotiation and compromise. Despite a strong legislative policy instrument and commitment by the central government, this study points to the importance of considering local politics national health systems reform implementation.