Jean- Louis Denis Professeur titulaire École nationale d administration publique 1 er février 2014

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1 Jean- Louis Denis Professeur titulaire École nationale d administration publique 1 er février 2014 Canada Research Chair in Governance and Transformation of Health Organizations and Systems

2 To identify trends and challenges in the governance of contemporary health care systems Provide some illustrations of trends and challenges based on the experience of the Canadian health care systems To raise some hypothesisfor the practice of governance within health systems in South America

3 Composante externe Législations Règlementation Culture politique et administrative Institutions Financement, allocation des ressources et système d incitations Composante locale Rôles et habiletés incluant le leadership Information et indicateurs Connaissance des enjeux Capital de relations Stratégie pour l amélioration des soins et services Allocation des ressources et système d incitations

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5 Network governance: a more distributed and differentiated health policy systems Policy instruments: more indirect and exogeneous approach to control, performance management and accountability (eg COAP; WB approach to governance) Governmentality: exogeneous & endogeneous approach to governance where the shaping of roles, practices and knowledge play a key role in governing health systems

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7 Growing recognition of policy, organizational and clinical networks to realign health systems according to needs and broad policy goals (LINH in Ontario, local health networks in Quebec) Greater reliance on a variety of policy instruments (P4P/Excellence for care act in Ontario for health care organizations and providers) Governmentality projects and regimes in the domain of quality and safety of care and prevention/health promotion (new professional roles & ethos, new institutions like Quality council, new knowledge like «science of improvement» in health care, greater role to organizations (Denis & Forest, 2012)

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9 Paradox: high level of resources but persisting major care deficits Misalignment of the system to health needs and policy goals (home care, mental health for examples) Persisting transactional mode in attempts to better align the system (more resources, more money for smaller changes with some promising initiatives however!) Need a variety of policy instruments with the goal of creating a new experience of the system by providers, organizations and citizens/users Policy instruments design and implementation within the political economy of the system

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11 Constant attention through proper monitoring and incentives has to be paid to the allocation and utilization of resources. Resources are easily captured in health care systems by particular interests, Governance of health care systems relies on distributed capacities (existing or to be developed) at all decision- making levels of the system from the policy to the clinical one. Most systems need to invest more deliberately and strategically in capacity development at the delivery and local levels of governance and also at others levels of governance.

12 Governing health care systems means constantly playing with a broad diversity of policy instruments/levers for change, adaptation and performance. Systems with the monitoring capacities to understand how new policies or policy instruments modify the dynamic of the system are in a better position to consolidate through time.

13 Policy consensus is certainly a virtue but it may be difficult to achieve in a world of sectorial interests. Governments can not push for the development of public health care systems or for systems that provide better coverage without confronting these interests.

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