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ORIGINAL ARTICLE

arly studies suggested regionalization is inimical to public health ingeneral and to a population health perspective in particular.1

Researchers argued that regionalization entrenched the conven-tional public health focus on communicable disease control.Further, according to critics such as Michael Rachlis, provinciallymandated integration under hospital auspices would inevitablyimpose costs to public health’s identity and its claims on resources.

In other words, integrated health regions would be hospital dominated and,consequently, would operate to make public health the handmaiden of thehealthcare delivery system.1 Regionalization was also thought to jeopardizethe development and enforcement of province-wide public health programsand standards. At the micro-level of resource allocation within a healthregion, the tyranny of the urgent, such as an emergency room crisis, wouldalways threaten to trump funding lengthy community interventions withuncertain results.

Yet provincial governments argued that regionalization was pursued as avehicle to drive the population health agenda. The provinces undergoingmajor structural reforms in the 1990s, that is, all Canadian provinces exceptOntario, claimed a major goal was the re-orientation of the health systemaway from health services for individuals and toward determinants of healthfor populations. But was this merely rhetoric as many critics claimed?

This paper argues that the relationship between population health andregionalization is not as straightforward as assumed, nor are the relation-ships between service integration and public health one-way. The story ismore complicated and nuanced, and the prognosis for public health in gen-eral and population health in particular is better than the literature sug-gests. The counter story will be told in several parts. First, the paper looksat some of the conceptual issues regarding regionalization and populationhealth. Second, it investigates the development of public health initiativesin the B.C. Interior Health Authority (IH) and their relationship to a popula-tion health perspective. Third, it teases out some of the bases for practicalsuccess and failure in advancing population health in a regionalized healthsystem.

Advancing the Population Health Agendaby Alan Davidson

Alan Davidson is an AssociateProfessor of Health Studies at UBC-Okanagan. He previously served asDean of Health and SocialDevelopment, Okanagan UniversityCollege, Director, Health Services,Government of Yukon, and RegionalAdministrator, Yukon Region, HealthCanada. Davidson holds a PhD inHealth Care and Epidemiology fromthe University of British Columbia.

AbstractUsing the case of the B.C. Interior Health Authority, the paper teases out some of the bases for practical success and failure in advancing population health in aregionalized health system.

RésuméÀ partir du cas de la B.C. Interior Health Authority, l’article fait ressortir certainesbases de succès et d’échecs pratiques dans le contexte d’un effort pour faire progresser le programme de santé de la population dans un système de santérégionalisé.

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18 Healthcare Management FORUM Gestion des soins de santé – Winter/Hiver 2005

What is a Population Health Perspective?The hallmark of “population health” is its attention to col-

lective variables such as societal level determinants ofhealth, including cultural, social, economic, and spatial vari-ables of neighbourhood, housing, physical environment, andcommunity resources. Also central is the claim that health-care services operate at the individual level as only onedeterminant of human health. From this perspective, healthpolicy is multi-sectoral and collaborative and finds applica-tion at the neighbourhood, community or regional level. Theview contrasts sharply with the established healthcare serv-ice orientation. It also contrasts with the classic health pro-motion framework with its emphasis on personal lifestyleand behavioural issues. Both the established healthcareservice and the classic health promotion perspectives areindividualistic, whereas the population health perspective iscollectivist, that is, it operates at the conceptual level ofgroups of varying size.2 This of course aligns well with pub-lic health thinking.

Within population health there are camps, indeedschisms.3 The main divide is between quantitativeresearchers from an epidemiological background whoemphasize the effects of structural variables on populations.They are squared off against public health advocates whocombine the theory of population health with the values-base of the community health framework – equity, solidarity,participation, and accountability. This latter group has abroader view of health, measuring health as a resource forliving rather than as a function of disease incidence orlongevity. Stated most simply, from the advocacy perspec-tive, the proper object of health policy is citizen enablementto lead healthy lives within healthy communities. The fate ofthis broader, action-oriented conception of policy (oftencalled “the new public health”) is the subject of interest forthis paper.

Regionalization, Integration, and Population HealthThe historic fragmentation of responsibility for the health

of residents of a given locale made it virtually impossible forany one health-related service to take into account commu-nity-wide risk factors. In the view of provincial policy-makers,fragmentation not only blocked consideration of the broaderdeterminants of health, but also contributed toBalkanisation, which in turn inhibited multi-sectoral collab-oration. By 1990, interest in determinants of health was dis-placing policy interest in healthcare services as the latter,medical and hospital services, were becoming less relevantto a rapidly ageing population for whom chronic disease andmultiple health challenges were the major issues.Fragmentation and the associated stove piping became bug-bears for ministries of health because they were seen as amajor source of system inefficiency. Service fragmentationwas addressed by mandated integration. The epidemiologi-cal transition was addressed by government advocacy of apopulation health approach. Politically, both reducing frag-mentation and advancing population health found policyexpression in regionalization.

Service integration per se does not require regionalizationand may occur without it, as it has in Ontario. There is, how-ever, a relationship. Integration and the population healthperspective bear contingent relationships with one anotherand with regionalization. Integration is consistent with thepopulation health tenet that healthcare services are only onedeterminant of a population’s health. Construing hospitaland medical services as determinants on par and in interac-tion with other important population health determinantsleads naturally to the strategic decision to put as manydeterminants of human health as possible under commonmanagement, informed by common goals. Regionalizationis, among other things, an approach to service integration. Itis the integration of a specified range of services over abounded, geographically defined area. In other words, whileregionalization is not a necessary condition for populationhealth, the co-ordinated approach it drives is. Likewise, con-ceptually, regionalization does not imply population health.However, the dynamics of geographically defined serviceunits focus attention on communities and the health ofgroups within the region’s boundaries, thereby contributingto a shift in thinking from individual attributes to more col-lective ones of populations and places.

Public health has been regionalized for decades. But itwas not integrated with other health-related activities. Thehistoric regionalization of public health sat well with the factthat many public health goals, in contrast to the goals ofhealthcare service, are collective, public goods, such as asafe water supply. Even services provided to individuals thatlook like analogues of healthcare services, the paradigm onebeing immunizations, are very different in their logic fromhealthcare. The objective of immunization is to create a largeenough pool within a population to achieve herd immunity.The point is not to intervene at the individual level to attainan individual result but rather to influence population-levelhealth outcomes.

This observation highlights an interesting feature of thepopulation health perspective. Population health in effectfuses public health with healthcare services by construingthe latter, healthcare services, as one of the determinants ofthe former – the overall health of the population. The posi-tion is controversial as it suggests that individual healthcareinterventions are valued only when they lead to positive dif-ferences in the health of a population. Here we see the crit-ical link between population health and evidence-basedhealth services. Among the implications are comparing thecost-effectiveness of individual-level interventions not onlyagainst one another, but also against community-level ones.Those potentially include interventions in housing, or recre-ation or education or incomes policy – any one of whichmight have a greater impact on population health thanhealthcare services. On the one hand, there is a threat to thestatus and legitimacy of claims on resources made by healthprofessionals and healthcare unions. On the other, legitima-cy is conferred on public health and with it the potential forlarger shares of health-related spending.

DAVIDSON

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Expressing matters this way brings out the ideologicalnature of the policy dispute. The ideas supporting access tohealthcare services and those comprising a populationhealth perspective link to the material interests of differentparties within society and within the health system itself.That linkage makes policy change very difficult because theinterests of powerful groups are affected by policy change.Hence reforms involving competing policy perspectives areresisted and frequently fail.4

While new public health and the conventional health serv-ices policy perspectives are genuinely different and may fuelideological conflict, there are in fact points of overlap. One isthe case where a population-level intervention has knock-oneffects for healthcare services. An example is an influenzaimmunization blitz. The strategy is legitimately populationhealth but an outcome is reduced pressure on emergencydepartments and medical wards. A public health strategydesigned to reduce hospital costs as well as improve popu-lation health is more obvious to decision-makers (and morelikely to be implemented effectively) where acute care, long-term care, and public health services are integrated. It istherefore no surprise that studies in Alberta andSaskatchewan show regionalization has facilitated influenzaimmunization of older adults.5

While exploiting overlaps might be construed as hospitaland medical services channelling public health into servingtheir interests, there is an alternative, strategic way of view-ing interventions that demonstrably reduce institutionalcare burden. Advocates of the new public health can seize onsuch overlaps to demonstrate the practical value of popula-tion health initiatives to regional managers and boards ofgovernors. This is a point to which the paper will return witha discussion of IH’s “wedge model.”

The Case of the B.C. Interior Health AuthorityThe B.C. Interior Health Authority serves a client popula-

tion of over 700,000 people residing in south central andsoutheastern B.C. IH is responsible for acute care, mentalhealth, public health, home support and community care, aswell as residential and supportive living facilities. Its2004/05 budget exceeds $1.1 billion.

Turning to the place of population health within IH, doc-umentary evidence of the commitment of the senior man-agement of the B.C. Interior Health Authority to populationhealth is available from the statements of the board chair-man and chief executive officer. For example, Alan Dolman,the board chair, is quoted as saying: “It’s too easy to havepopulation health overshadowed by pressing health serviceissues. A focus on population health is really what mattersbecause this is what will keep people from having to use thehealth system in the future.”6 Senior management gave con-crete support in the form of approximately $750,000 in start-up money in fiscal year 2002/03.

Management commitment has been made manifest in aconcerted effort to build IH capacity to employ more effec-tive population health approaches. Capacity building initial-ly focused on internal organizational capacity building. This

took the form of ramping up research and analysis capabili-ty, constructing and analyzing relevant databases, providingknowledge and transferring skills to middle-level managersand field personnel, and forging sustainable partnershipswith relevant organizations and units within the IH organiza-tion. Much of this activity is centred in the Population HealthPlanning and Support Unit, founded in 2002, and whichreceived its formal launch in the November 2002 PopulationHealth Conference held in Kelowna. That conferencebrought the key stakeholders from across a wide variety ofsectors together with IH managers and front-line communi-ty health personnel from all corners of the region.

By the end of 2002, IH adopted a model for improvement,the Population Health Planning and Implementation Cycle,and agreed on three priority areas upon which to focus itsefforts from 2003 to 2006: (1) early childhood development,(2) injury prevention, and (3) chronic disease prevention.Chronic disease management subsequently moved fromPopulation Health to the Primary Care Directorate and build-ing capacity for population health was added by thePopulation Health Unit. Crucially, for each priority, measura-ble targets were set, responsible agents identified, andbudgets allocated. An evaluation plan was also mapped outfor all population health-related activity.

Of particular interest is “Building Capacity for PopulationHealth.” The goal of the focus area is “to improve the healthof the entire population and to reduce inequities in healthwhere they are found” through an objective of building IH’scapacity to employ evidence-based population healthapproaches. The objective required the creation and dissem-ination of reliable, comprehensive, and relevant health infor-mation, theory, and skill transfer to managers and front-lineemployees, as well as building coalition support within IHand between IH and community partners.

An example is the ongoing collaboration between IH andthe North Okanagan Social Planning Council to reduce acci-dental injury among seniors. Initially, the North OkanaganFalls Prevention Program was piloted using funds fromVeteran’s Affairs and Health Canada. The project was refinedand extended under a contract between IH and PlanningCouncil in October 2004. The focus shifted to an integratedapproach to identifying factors contributing to falls by sen-iors at home, in the community, and in care settings, identi-fying evidence regarding prevention, reviewing existing con-ditions, policies, and practices in light of the evidence, build-ing contacts and networks, developing surveillance tools andsystems, launching properly evaluated pilot projects, anddisseminating the results. A manager was appointed tosponsor better practices throughout the entire region basedon the work of the North Okanagan partnership incubator.

What Has Happened to the Expression of a Population Health Perspective in IH Compared With What Has Been Anticipated inthe Literature?

The first issue raised in the Introduction was whetherregionalization would harm the new public health by makingthe prime directive the short-term reduction of the health

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DAVIDSON

system’s care burden. The answer is that regionalization perse does not seem to make much difference one way or theother. While it is true that the magnitude of change associat-ed with healthcare reform in B.C. disrupted public health,that disruption was no more intense or extensive for publichealth than for other healthcare services caught up inregionalization. There is no budgetary or programmatic evi-dence within IH that public health services were wound up orredirected in favour of medical and hospital ones, althoughpublic health was certainly consolidated.

The second issue is the predicted negative impact region-alization would have on provincial public health programsand public health standards. Here the evidence runs in theopposite direction to the prediction. First, the B.C. provincialgovernment did a reasonable job of anticipating the need forguidelines and standards. Second, the increased autonomyof regions actually brought focus to areas where more, notfewer, common strategies were necessary to meet emerginghealth goals. Third, innovations that were now possible with-in regions could be brought more readily to bear on thewhole province through the co-ordinating mechanismsdeveloped among the regions. For example, IH is a leader inB.C. in the field of population health and has managed topush the provincial agenda on this front. It appears thatregionalization may have an effect akin to the way federalismin Canada created a context for Saskatchewan to push thefederal government on Medicare. Fourth, and perhaps mostimportantly, regionalization reduced the number of B.C.authorities operating in the public health field – the newregions were few (only six), and of sufficient geographic size,with large enough populations to mobilize coherent, consis-tent programming. In consequence, public health in B.C. isactually better organized, more consistent, and yet alsopotentially more innovative, than it was prior to regionaliza-tion. None of this means success is somehow assured, but itdoes mean that regionalization is not the cause for failure.

The third issue is the obstinacy of the old policy regime.In the case of Interior Health, population health proponentssimply sidestepped the problem of changing the policy par-adigm by focusing on internal capacity building. Rather thanbroad-based external collaboration and partnership build-ing, the architects of the population health initiative focusedon infrastructure, training, and select high-profile, highvalue-added activities. This helped cement relationshipswith champions within the organization, which in turn allowsfor growing the health authority’s population health-relatedactivities and increasing the reach outside of the organiza-tion. Now, three years into the initiative, the populationhealth advocates have resources, skills, and knowledge toshare with potential partners, shifting power and influence intheir favour. This may never lead to a total transformation ofthe health policy perspective, but that scarcely matters if theinitiatives succeed and the mindsets of many involved inhealth-related activities are broadened and refined.

The fourth issue is the tyranny of the urgent. Contrary toexpectations, in IH, population health has stable, indeedgrowing, funding and executive support, in spite of the usual

stresses and strains of health authority budgets and acutecare deficits. The reason is that people make the difference.There are capable senior managers in IH who champion pop-ulation health and those directly managing the initiative areenergetic and credible. Importantly, the population healthinitiative managers ensure that there are at least some con-crete outcomes everyone agrees to be valuable. That doesnot mean all initiatives are crafted to serve the machine.What it does mean is that there must be an intelligent bal-ance of short- and longer-term initiatives, and that at leastsome of the short- and medium-term initiatives must yieldwidely valued deliverables. This is the only approach thatcan sustain longer-term organizational support.

Practical Bases for SuccessIn a paper entitled “Success or Sell Out,”7 the Population

Health Planning and Support Unit describe their wedgemodel. In their words, “guided by the determinants of health,we moved forward with a targeted intervention for each keyarea.” In their example of child health and development, thefat end of the wedge incorporates a range of determinantsfrom income, to education and social supports, physicalenvironment, early childhood experiences, health services,and so on. The thin end of the wedge is a specific target out-come, in this example, 30 fewer low birth weight babies bornthis calendar year. A clear, achievable target, with a plan andresources attached, builds success and credibility with deci-sion-makers. A well-chosen target that also can be shown tohave important knock-on effects for the healthcare systemmakes the initiative and its proponents valuable to theorganization. Doing this, however, does not preclude, indeedit facilitates, working up the wedge by concurrently commis-sioning research on determinants of child health, dissemi-nating the findings from such research, establishing moni-toring and health surveillance, and identifying services andsupports that are relevant, and determining how those mightbe improved in light of the emerging evidence. This is exact-ly what the population health initiative has done in IH overthe past two years, placing the advocates where they cancommence work with external collaborators and move frominternal capacity building to community capacity building,knowing they have the resources and institutional support tosucceed.

The Population Health Planning and Support Unit has acheeky motto to describe their wedge model approach: “Givethem what they want but do what we want.” Fortunately, thetwo go together rather well. Important, focused, short-terminitiatives meet critical goals of the organization and buildsupport for the medium- and longer-term goals of the newpublic health. Donald Light once remarked that advocates ofthe new public health are a bit like Fins during the Cold War.However, instead of huddling on the frontiers, populationhealth in IH is mainstream yet subversive, conventional yetradical, but above all successful.8

In conclusion, regionalization is neither a driver nor aninhibitor of population health. The relationship between pop-ulation health and service integration in general, and region-

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ADVANCING THE POPU;ATION HEALTH AGENDA

alization in particular, is contingent and the actual outcomesdepend on a number of other variables. Chief amongst thosevariables in the case of IH’s success to date are:- champions in senior management- stability in regional management - bright, energetic, and credible advocates in population

health working under dynamic leadership- early focus on internal capacity building.9

AcknowledgmentsThe author would like to acknowledge the contributions of Dr.

Nelson Ames and his associates in the IH population health initia-

tive to this paper.

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