School of Public Administration, Faculty of Management, Dalhousie University, 6100 University Avenue, Halifax, Nova Scotia, B3H 4R2, Canada.
Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, 6100 University Avenue, Halifax, Nova Scotia, B3H 4R2, Canada.
Hum Resour Health. 2018 Aug 13;16(1):38. doi: 10.1186/s12960-018-0299-3.
Primary care in Canada is the first point of entry for patients needing specialized services, the fundamental source of care for those living with chronic illness, and the main supplier of preventive services. Increased pressures on the system lead to changes such as an increased reliance on interdisciplinary teams, which are advocated to have numerous advantages. The functioning of teams largely depends on inter-professional relationships that can be supported or strained by the financial arrangements within teams. We assess which types of financial environments perpetuate and which reduce the challenge of medical dominance.
Using qualitative interview data from 19 interdisciplinary teams/networks in three Canadian provinces, as well as related policy documents, we develop a typology of financial environments along two dimensions, financial hierarchy and multiplicity of funding sources. A financial hierarchy is created when the incomes of some providers are a function of the incomes of other providers. A multiplicity of funding sources is created when team funding is provided by several funders and a team faces multiple lines of accountability.
We argue that medical dominance is perpetuated with higher degrees of financial hierarchy and higher degrees of multiplicity. We show that the financial environments created in the three provinces have not supported a reduction in medical dominance. The longstanding Community Health Centre model, however, displays the least financial hierarchy and the least multiplicity-an environment least fertile for medical dominance.
The functioning of interdisciplinary primary care teams can be negatively affected by the unique positioning of the medical profession. The financial environment created for teams is an important consideration in policy development, as it plays an important role in establishing inter-professional relationships. Policies that reduce financial hierarchies and funding multiplicities are optimal in this regard.
加拿大的初级保健是患者需要专科服务的第一站，是慢性病患者的基本护理来源，也是预防服务的主要提供者。系统压力的增加导致了一些变化，例如增加对跨学科团队的依赖，人们提倡跨学科团队有许多优势。团队的运作在很大程度上取决于专业间的关系，而团队内部的财务安排可以支持或紧张这种关系。我们评估了哪些类型的财务环境会加剧，哪些会减轻医疗主导地位的挑战。
我们使用来自加拿大三个省的 19 个跨学科团队/网络的定性访谈数据以及相关政策文件，根据两个维度，即财务层次和资金来源的多样性，来构建财务环境的类型学。当一些提供者的收入是其他提供者收入的函数时，就会产生财务层次。当团队资金由多个资助者提供并且团队面临多条问责线时，就会产生资金来源的多样性。
我们认为，随着财务层次的提高和资金来源多样性的提高，医疗主导地位会得到延续。我们表明，三个省份创造的财务环境并没有支持减少医疗主导地位。然而，长期存在的社区卫生中心模式显示出最低的财务层次和最低的资金来源多样性——这是最不利于医疗主导地位的环境。
跨学科初级保健团队的运作可能会受到医疗行业独特定位的负面影响。为团队创造的财务环境是政策制定的一个重要考虑因素，因为它在建立专业间关系方面发挥着重要作用。在这方面，减少财务层次和资金来源多样性的政策是最优的。
