Background
Methods
Event: | Stakeholder dialogue 1 | Stakeholder dialogue 2 | Stakeholder dialogue 3 | iHEA symposium |
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Topic | Pharmaceutical pricing and health technology assessment | Hospital funding and physician remuneration | Healthcare financing and social insurance | Policy options to improve healthcare sustainability |
Participants: | ||||
Policy-maker—federal | 3 | 2 | 1 | 2 |
Policy-maker —provinciala
| 1 | 6 | 4 | 6 |
Other stakeholders—nationalb
| 15 | 8 | 13 | 24 |
Other stakeholders—provincial | 0 | 7 | 2 | 8 |
Researchers | 3 | 2 | 4 | 21 |
International | 0 | 0 | 0 | 31 |
Total | 22 | 25 | 24 | 92 |
Results
Environment |
“What I liked particularly about today is that it wasn’t merely the transfer uh or the communication of a set of conclusions it was actually much more generative then that. [PPM1] |
“I think that these open forums that focus on specific policy issues and go through challenges, solutions, and opportunities. I think that sort of thing should happen more often --” [PPM2] |
“Well what I think was really unique about today’s symposium was the opportunity to consider several options at the same time with the same group of people”. [R6] |
“I think the single most thing- most surprising thing I found about today was just how long and how engaged people stayed throughout the entire day. These sorts of symposiums can very quickly become exercises in attrition but we started with pretty much the same group of people we finished with.” [PPM1] |
Participants |
“I think it’s valuable to have those different players in the room like the medical association, presidents, or CEO’s along with the policy [advisors] because a lot of us are academics and focus more on solutions on how to do this stuff rather than this whole thing be a show and tell for a particular government on their new policy.” [PPM2] |
“Having senior leaders from different organizations, whether it was a regional health authority or a deputy minister within government, you have individuals who truly can make big thing decisions about-- or influence the future organization management delivering financing of the respective health system. From that standpoint of that I found it very strong.” [NSO2] |
“… you had some very different players that probably normally wouldn’t get together, who would be on opposite sides of negotiating tables, for example -- the membership, the event was great. But the participants, I think it was set up well to bring up all those different perspectives and [promote] natural discussion.” [PPM2] |
Evidence use |
“Yes and I think um that really is why today’s symposium was such a unique opportunity for to do that, to reach out around the world and hear about practice in other countries. Certainly all of [the] knowledge synthesis that [were] commissioned … look to the international evidence that is published in the literature, but by having people from other countries in the room … that can talk from their own experience within a country … goes beyond what you can capture in a published journal article to have that kind of experiential knowledge in the room as well.” [R6] |
“And what I think I took away from today was both the value of the evidence but the value of having discussion around the evidence so that people start to come up with recommendations, findings, conclusions that go far behind what was included in any of the reports on their own.” [PPM1] |
individual capacities | |
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Mutual understanding | “I hope that we did bring enough of the policy wonk types, and the academics, and the health people together to walk away … and then after some connections with someone else, they get to a place they weren’t before. So that’s my opinion about any kind of policy workshop. It just gets people in a room and builds trust and cohesion, and it gets people focused on common issues.” [R7] |
New ways of thinking | “The exchange allows here just an exchange of ideas. So hopefully put other than your own thoughts and our own views, based on where we worked or how we see things functioning. I would hope that it’s kind of broadened everyone’s mind about different ways to do things.” [NSO2] |
Relationships | “I suspect that the communities have been strengthened, just by opening more effective lines of communication” [NSO2] |
Empowerment | “We get the confidence about maybe the path we’re taking, or we change the path we’re taking based on what we learned. So in that sense, they’re useful.” [PPM3] |
Organizational capacities | |
Agenda setting | “… I probably would have mentioned something at some point where again, all of [province] is kind of implementing this stuff too right now … It might have been this sort of thing that these things rub off on other people there, help them advance their own agendas.” [PPM2] |
Policy formulation | “But I think forums like this help us learn from each other find out what’s worked what isn’t working and not necessarily take something holis bolis from [one jurisdiction to the next] because they are different in structure and… or they might have some successes in [jurisdiction] to learn from and I think that is probably the best way to go forward.” [PPM3] |
Preparation for policy windows | “As long as those windows are open, policy dialogues like this do play a role, because we get ideas from each other.” [PPM3] |
ideas | |
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Viewing the landscape (A) | “From my perspective in my role here, it’s really important for me to understand what kind of a landscape is out there of different views around issues. So that’s a key part of our policy assessment, of what ideas might fly and what ideas are likely not going to be supported.” [PSO2] |
Seeding new ideas (A, F) | “The exchange allows here just an exchange of ideas. So hopefully put other than your own thoughts and our own views, based on where we worked or how we see things functioning. I would hope that it’s kind of broadened everyone’s mind about different ways to do things.” [NSO2] |
Socializing ideas (A, F) | “I think policy dialogues like that, like these big large events are important because of how they socialize information, not because of how they influence decisions. When I was a policy-maker, the really important discussions for me often were very small groups, or Chatham House Rule type thing. Because then I could test out ideas, and I could see directly where stakeholders I had to get outside were going with this.” [PPM1] |
Prioritizing options (A, F) | “As I listen to this, I understand the sophistication of the ideas, the relative sophistication of the ideas, I guess, that’s-- people are positioning around, and so on. It helps me kind of make my mind up about what I’m going to advocate about.” [PPM1] |
Forming a tighter consensus (A, F) | “But what you see through a conference like that, is you see the broad socialization of idea and a chance to critique it. You see broad support for it, and perhaps as importantly, no one’s saying ‘No, don’t do that.’ Which makes it a lot safer for folks.” [PPM1] |
Shaping options for discussion (F) | “I think by having a more detailed discussion like this you get down to some of the mechanics and then you realize these are some very different policies that [province] is doing… and I think you really need to get down to that more detailed level of the policy mechanics” [PB03SI] |
Interests | |
Creating a more cohesive policy community (A, F) | “I think events like that confirm that you weren’t alone in this, you weren’t crazy, certainly when you were-- you go and speak with people in the minister’s office and justify why you’re doing this or that. You could say, ‘Hey, the rest of Canada is thinking the same thing too.’ Since I was the only one from the … Ministry there, and I recall it was useful for me to be able to sort of reference that conversation to folks afterward, certainly” [PPM2] “It really, I think, led to just a more cohesive community, less confrontational, because more leaders from different sides of the equation knew each other. And it allowed for free-forum, free-flow discussion on a whole range of policy issues that, when you put people in rooms where they’re wearing their hats and their titles you don’t always have that kind of possibility.” [NSO2] |
Face-to-face connection (A, F) | “So, it was more what I gained from those dialogues was more like a connection. I knew that there was an incentive somewhere and I could contact someone that would [?] me to the appropriate person.” [PPM4] “Honestly I think that the only role they bring is connecting people in a room.” [R7] |
Will for change (A, F) | “Well for me as an observer and a participant there, the remarkable thing to me was that everybody knows what the problems are and it’s a lack of political will on the part of governments, on the part of physician representation organizations. Just everybody shares the blaming as far as the current system is concerned, and the notion of moving away from it.” [PSO2] |
Institutions | |
Centralized evidence-gathering (A, F) | “Perhaps something that actually transcends the political process as well, and not just collaboration among the provinces and territories, but really collaboration that sets a Canadian tone, a Canadian perspective - particularly on the evidence side. We kept on hearing the notion of the evidence perhaps collected at the national level, or pan-Canadian level, but perhaps interpreted at a provincial and territorial level” [PPM1]. |
Centralized benchmarks (A, F) | “…the policy makers said, ‘Well, why are you presenting option one, option two, option three? We need all these options together. We just need to see how we can put in place all the conditions and make sure that we can anticipate the different consequences of doing that and that and that, not taking them separately and analyzing the evidence on each aspect.’”[R16] |
Common performance measures (F, E) | “There’s a few clinical indicators that we probably can say - it should be eight - but there’s relatively few. Good performance is what’s better than just about everyone else and what’s getting better over time. And so building on that, I take [event participant name]’s point. I’d say agree entirely now, and one of the most important things we could do is actually have comparable measures of performance, not just within a jurisdiction but across the jurisdictions in this country.” [PPM1] |
Intervention characteristics | |
Evidence strength and quality | “So in my example, I think that’s certainly true where there has been no visible or no - at least what I’m aware of - significant discussion about the policy option. It may … be that the evidence … is so mixed that there isn’t a very strong case for taking it forward in a more practical or thinking about feasibility and implementation … it doesn’t mean there’s no impact [of the dialogue], it could mean that there was some impact.” [R1] |
Relative advantage | “There’d be a couple things that’d be helpful at the discussion. One is, it did help me, as a whole, to understand the relative importance of different mechanisms, or the relative likelihood of payoff of the different mechanisms.” [PPM1] |
Adaptability | “I don’t think we succeeded very well to try to imagine what would a social insurance model applied to healthcare look like in the Canadian context. We kind of keep defaulting back to countries where we observe that approach to financing healthcare and can’t seem to get to the point where we say, “Well, this is how you could construct something like that in the Canadian context whether you apply it to drugs, or mental health, or to the system as a whole.” So that one I think is really interesting. I don’t think the paper itself and by the dialogue … got us to where we could have gone.” [FPM1] |
Design quality and packaging | “… any given dialogue helps contribute to developing a compelling package of evidence that might incrementally, over time, contribute to the policy-making process and in turn, the opening of a policy window for potential reform.” [PPM1]. |
Cost | “What is the opportunity cost? Which patient groups will lose out because the money for funding that has been taken from their account?” [R11] |
Characteristics of individuals | |
Knowledge and beliefs about the intervention | “It [the dialogue] probably just helped to nudge it along. I don’t think it’s hurt at all, the information was very useful - whether it was around strategy, tactics or system design - for certain individuals around the table. So I would say, if anything, it was again incremental, but generally that’s the way we make gains in our system. It is really incremental.” [NSO2] |
Self-efficacy | “Well, you have to remember at the time, it was 2011, and at the time all of these things, what happens is people start feeling, at the end of these things, they all feel good. You know what I mean? Most of these meetings, they’re designed to make you feel good about yourself. And within the context of what’s going on at the time, that’s important because people can tell they get a little bit more confident.” [PPM3] |
Outer setting | |
Patient needs and resources | “The difficulty to get traction on change around, and excitement about, a national pharma-care plan. If you talk to Canadians about what their big problem is in terms of healthcare coverage, pharmaceuticals isn’t the issue that comes up. It has to do with other issues about access to a doctor, access to an emergency room” [R12] |
Cosmopolitanism | “The dialogue creates such a face-to-face connection. I would say that I reached people in the various sectors when I needed to and it was easy to connect with them and ask them like, “Alberta, I remember you had this policy on long-term care. Can you refer me to someone that will be able to give me extra information on this and that? So it was more what I gained from those dialogues was more like a connection. I knew that … I could contact someone that would direct me to the appropriate person” [PPM4] |
Peer pressure | “I think it was a topic area [hospital funding] that was right for action because Canada is sort of behind in most of the other countries in the developed world in changing how hospitals are funded. Pretty much every other country in the world has moved away from the block funding system that predominates in Canada, and so this is the topic area that’s right for change since we’re sort of, we haven’t evolved the way the rest of the world has.” [FPM2] |
External policy and incentives | “The Federal Government has been less active, that’s a result of not engaging in the Accord. So that changing policy environment sort of had an effect of limiting the uptake of some of the-- but not eliminating, but it reduced the uptake of what was in the policy dialogues.” [FPM2] |
Inner setting | |
Structural characteristics | “…one of the things that I learned was the turnover in government, especially future government, is the half-life of those people is at least half of what it takes to make real change happen. So the turnover problem was huge. It was always huge, because new people have come who are in senior positions who I had to bring outside and educate, and just as soon as I’d finished doing that and they were outside, they were gone and somebody else came in and that was a constant problem.” [PPM3] |
Culture | “… but the thing that’s preventing change, frankly it’s fear. It’s fear of doing anything different. Because all those things contain a risk. Every time you do something different, there’s a risk involved. And we have a very risk-averse structure here. Both inside health care, and at the political level - highly risk-averse. And the risk involves two different risks. One is the risk of adverse publicity. … And even good news in health care can turn to bad news overnight depending on how it’s played in the media. And I think governments have figured that out, and that’s why they’re backing off with health care. At every level, governments they’re trying to just distance themselves from anything having to do with health care as much as they can, so to stay away from hot arguments” [PPM3]. |
Implementation climate | |
Tension for change | “So it’s not a shortage of knowledge. We don’t need to study what the problems are in health care, we actually have a really good idea of what the problems are, we know what most of the solutions would be, at least in a broad sense … [however] we won’t change health care dramatically until there’s a crisis because there’s no incentive to do so, and so health care at some point in time will fail catastrophically and what will come out of the other side will be worse for everybody, and I don’t think that’s going to be a surprise to anybody.” [PSO2] |
Relative priority | “You could see when it was a policy option that was … embraced, that there was incentives to put them in place as opposed to other options where…they could see there were more limitations.” [PPM4]. |
Readiness for change | |
Leadership engagement | “[the dialogue] … created this big buzz, and [province] got really attracted. The Minister … got really attracted. … It provides them also a momentum, which was really important for the Minister… they’ve been able to use this information … to move and to bring this to life.” [PPM4]. |
Available resources
| “If it had happened like four or five years earlier where we had a lot of money to put on the table for that stuff, it’s probably feasible if people really like that idea of gain sharing for example, that they would have put that on the table and say, ‘Can we try this maybe for some sort of Orthopedic wait time procedures.’ or something like that, that’s where I would have started. I think just the negotiations have been so antagonistic the last couple rounds that there was very little room I think, to experiment with any sorts of major transformations like that, and policy like that right?” [PPM2] |
Access to knowledge and information | “Also it was good reference because we were trying to implement funding policy. So, it wasn’t only about what it is, the alternative funding policy, but really how can we help the system going through the change and what [is the additional labour] that we need.. in order to make this things change.” [PPM4] |
Process | |
Planning | “I was always taking out some information… to evaluate on what was missing or plan the future steps and trying to get everyone on board.” [PPM4] |
Opinion leaders | “…but the trouble with the policy dialogues is that they involve people who are already essentially committed to reform of kind or another. They may differ on the details. But they don’t get at the people who provide the money and the opportunities. So, I think the biggest barrier that I see now to real change is at the most senior level in government. And the reason is that A, they don’t actually have the time to understand the level at which it needs to be understood at. I mean, they just don’t have time. I feel really bad for the ministers. They’re just constantly putting out fires.” [PPM3] |
Internal implementation leaders | “I think [individuals name], many of you will know this, did a fantastic job when she was pushing down generic drug prices the last time. Basically she said, “Why are we paying so much? Here’s the evidence.” She was able, as [position], to really, very effectively move forward. She personally bore a really heavy risk, or heavy burden in doing that, but I think it was actually in this case it was very effective by appointing an executive director, a political appointment, who ended up taking the heat instead of a politician, was quite an effective strategy for moving forward.” [R5] |
External change agents | “… they’ve been able to use those information and put in place an expert panel - a three years expert panel - on the topic of activity based funding. To try to put-- to move and to bring this alive.” [PPM4] |
Reflecting and evaluating | “There’s the old saw that you can’t manage what you can’t measure. We’re ready to start measuring a lot of things, not at the level of precision, perhaps not at the level of accuracy that we’d all like but it won’t start to get better until we do. And so I think the whole question of measurement is central to any type of reform that we consider. But more important I think it’s critical to think about what it is we want to measure. You know our health system is a reflection of who we are as a country so we should be measuring the things that are important to us, it’s our health system is one of the ways that we actually define ourselves positively.” [PPM1] |
Thematic analysis
Dialogue features
Influence on capacity development
Influence on policy-making
Thematic synthesis, conceptual framework and pathways of influence
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Pathway A1: Policy dialogues build participants’ individual capacities for new thinking by seeding and socializing new ideas and providing a view of the landscape that contributes to policy ideas that shape problem definition in policy-making and organizational capacity for agenda setting.
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Pathway A2: Policy dialogues build participants’ individual capacities for mutual understanding and relationships that can foster a more cohesive policy community and face-to-face connection and may create greater will for change among interests that contribute to organizational capacity for agenda setting.
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Pathway A3: Enhanced empowerment interacts with these influences on ideas and interests over time to promote greater organizational level capacity to advance policy problems onto the agenda.
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Pathway B: Enhanced mutual understanding developed at policy dialogues can assist in shaping options for discussion, prioritizing options and creating a tighter consensus around ideas that can enhance organizational capacities over the medium-term not only for problem definition but also for formulation of policy solutions.
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Pathway C1: The evidence presented at policy dialogues can include information about the relative advantage, cost, adaptability and evidence strength of different policy options and package them in a way that may be more attractive for implementation.
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Pathway C2: Greater individual empowerment can lead to greater self-efficacy and enhanced organizational capacity for implementation.
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Pathway C3: Individual capacities for new thinking can enhance individual knowledge and beliefs about the options that enhance mutual understanding, contribute to a tighter consensus about policy ideas and shape organizational priorities, as well as organizational access to knowledge and information to support organizational capacity for implementation.
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Pathway C4: The relationships developed at the dialogue that create a more cohesive community can also foster greater cosmopolitanism and peer pressure that may contribute to tension for change, enhancing organizational interest in policy implementation.
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Pathway C5: The external policy context of organizations as shaped by the interacting forces of ideas, interests and institutions may influence the extent to which organizations are successful in advancing knowledge shared at policy dialogues at all stages of the policy cycle, including implementation.
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Pathway C6: Policy dialogues have the potential to influence implementation processes by engaging opinion and implementation leaders and external change agents and providing input to organizational processes of planning, reflecting and evaluating. Leadership engagement can also help to establish greater tension for change within organizations and engage organizational leaders as interests in policy implementation.
One element in an incremental process
Dialogues were described as contributing to a continuing conversation that may last many years within the public debate before any action is taken. One informant described the work as being “extremely influential” and “picked up by a lot of other people,” but that “…it's just overall, a whole lot of different pieces of work that come together to give you a picture” [R4].It's hard to really point to something really specific that this particular series of conversations gave rise to. These areas of policy, they change so slowly over time, and it's really kind of a building thing, an accumulation of pieces of work, of conversations, of positioning by stakeholders and governments, and you see movement over time. [FB11SI]
This temporal aspect is difficult to capture in the figures because the journey through the policy cycle is non-linear and may be disrupted as priorities shift, for example, due to external events, shifting political considerations, realignment among interests [17] or poor evaluation results that send a policy back to an early stage of the policy cycle.This involved a whole bunch of motivated people. We're taking some good pieces of research. We're talking about how those things influence decision-making, but at the end of the day, no one in government is going to stand up and say, It is because of - only because of - the discussion that was at this conference. [PPM1]