The social nature of health policy implementation – an empirically-grounded reflection on the implementation of integrated care in the fields of mental health and chronic diseases.

摘要

This paper introduces an empirically-grounded theory of change in health care systems. It draws on three research projects focusing on the implementation of a mental health care reform. These projects include two evaluation studies commissioned by Belgian public health authorities and a scientific, PhD research supported by the Belgian National Fund for Scientific Research. They are based on qualitative methods, including document analysis, semi-structured interviews and focus groups. The generalisation of these research findings has recently started through ongoing projects devoted to the implementation of an integrated care model in the field of chronic diseases. This paper first draws on a realistic approach to health policy implementation (1). A particular attention is consequently paid to the context of implementation and to identify explicit and implicit mechanisms combining to give a particular direction to the change process. Moreover, the theory of change outlined in this paper importantly borrows from system and process theories (2). It emphasises the pivotal role fulfilled by repeated sequences of interactions, most of which take the form of meeting communication, between differentiated and interdependent social systems. Belgian policymakers started supporting a shift from an institution-based towards an integrated care model in the field of mental health in 2010. This shift was expanded to the field of chronic diseases in 2015. The Belgian health care system combines characteristics of the Bismarkian and Beveridgian models. It is decentralised, highly differentiated, and recognises the autonomy of health care providers and professionals. Moving towards integrated care is all the more challenging in that context. This challenge explains the preference of Belgian policymakers for soft regulation mechanisms, that is, pilot projects making room for local adaptations and depending on a phased approach to organisational change. In this framework, local coordinators are responsible for steering the implementation process, in a way to ensure consistency between local translations and global policy objectives. In-depth analysis of the mental health reform implementation evidenced a significant discrepancy between the policy programme and local adaptations. Professional cultures, organisational strategies and ideological pillars specific to the Belgian society have been identified as the main factors accounting for these discrepancies. Furthermore, inter-organisational meetings emerged as the very spaces where such influential logics of action are expressed and articulated with one another. In this respect, the main challenge lies in the stakeholders’ ability to create hinges (3), defined as visions of the situation which enable to coordinate the action of different systems, without preventing them from preserving their cognitive structure. Coordinators, acting as boundary spanners (4), play a strategic role in organising and reporting on these meetings. However, coordinators lack power, managerial skills and knowledge of innovation process to cope with social influence in a way consistent with policy objectives. Therefore, this paper outlines a theory of health system transformations which put professional culture, organisational strategies and social ideologies at the forefront. It argues that assuming the social nature of these transformations would enable to improve both the design of health policy and the training of change managers.