Question

Discuss five (5) factors and relationships that lead to inter-organizational collaboration in public health interventions.

Answer 1

Primary care [PC] and public health [PH] are viewed as distinct sectors within the health systems of western societies including Canada [1]. Canadian researchers propose that better integration between PC and PH is necessary for a more effective primary health care system to improve health and social outcomes [2]. Other nations have similar aims [3, 4]. In 2012, in the U.S., a report was released calling for better integration of primary PC and PH services arguing that:

the integration of primary care and public health could enhance the capacity of both sectors to carry out their respective missions and link with other stakeholders to catalyze a collaborative, intersectoral movement toward improved population health. [5] p.1.

Most discussion papers that promote greater integration and collaboration between PC and PH maintain that the goals of each sector can be supported by the other. PC can act as a source of critical data and clinical observation that can highlight health issues of potential consequence to PH and its mandate to promote health and prevent disease as well as improve population health. PH, through its assessment of community and population health risks and needs can inform PC practitioners of things to look for in their patients, subsequently assisting in differential diagnoses and improved patient care [2, 6, 7]. Others acknowledge synergies in health promotion that can occur when education within PC settings aimed at behavioural changes to promote health is combined with PH strategies for creating supportive environments that enable healthy life styles and reduce environmental risks [8]. DeVoe and colleagues [9] discuss opportunities for PC and PH collaborations to jointly address the social determinants of health.

In 2013, a special issue of the journal HealthCare Papers indicated a continuing interest by influential leaders in Canada for building stronger collaboration between PH and PC sectors [10, 11]. Various influences that impact collaboration between PC and PH sectors presented within the international literature are discussed within a scoping review [12]. However, within this discussion there is limited substantive evidence about the important influences on successful PC and PH collaboration, how these influences relate to each other, and the mechanisms occurring within these relationships.

We report here on one of five studies conducted in a program of research [13] – Strengthening Primary Health Care through Primary Care and Public Health Collaboration. The program of research was guided by an ecological framework [14] describing three categories of determinants for inter-organizational collaborations including systemic, organizational, and interactional levels. This paper focuses specifically on factors that influence PC and PH collaboration at the organizational level in the Canadian context. Our results can inform collaboration in countries with similar health care systems. Here, organizational level influences refer to influences at the local or regional level within the context of an organization, large or small. Whereas, systemic level influences are at a national or provincial level such as ministry policies, strategic directions, and funding.

Organizational influencing factors can be thought of as operational attributes, processes or conditions within an organization. Organizational factors affecting collaboration can include, “structure and philosophy, team resources and administrative support, as well as communication and coordination mechanisms” [14] p.138. Our scoping literature review identified five major organizational influences on collaboration between PC and PH [12]. They included: lack of a common agenda; knowledge and resource limitations; leadership, management and accountability issues; geographic proximity of partners; and shared protocols, tools and information sharing. No research papers were found in our review that specifically explored influences on PC and PH collaboration. However, we extracted factors from results and discussions of papers reporting on collaboration. The present study contributes new knowledge by validating our previous review findings and delving deeply into factors explicitly influencing organizational influences on PC and PH collaborations supported by experiences of key informants in PC and PH. It also explores mechanisms that help to explain relationships between influencing factors.

Within Canada, the organizational environment of PC and PH varies depending on the province or territory. For example, Ontario (ON) has public health units while Nova Scotia (NS) and British Columbia (BC) have regional health authorities that provide public health programs and services. There are a variety of PC delivery models in each province [15,16,17]. In ON, there are 11 models of primary care delivery, such as solo physician practices, community health centres, nurse practitioner-led clinics, and family health networks. In BC, PC is mostly provided by physicians in solo and group family practices with some integrated health networks, and less commonly, health authorities also delivery PC through community health centres, and specialized clinics (e.g., youth health, STI diagnosis and treatment) often by nurse practitioners. NS predominantly has solo and group physician practice models but there are a growing number of interdisciplinary teams, particularly in rural areas. Furthermore, in some instances, PC and PH working spaces and regional reporting accountabilities are shared, while in others, each sector is visibly and operationally its own entity [6, 15]. This diversity creates a rich naturalistic opportunity for further defining the organizational factors influencing PC and PH collaboration. This paper explores: what structures and processes do PC and PH stakeholders perceive influence successful collaboration between PC and PH? Table 1 provides our definitions of PC, PH, and collaboration.

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