Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
BMJ Open. 2023 Dec 11;13(12):e079268. doi: 10.1136/bmjopen-2023-079268.
In Aotearoa New Zealand (NZ), integration across the healthcare continuum has been a key approach to strengthening the health system and improving health outcomes. A key example has been four regional District Health Board (DHB) groupings, which, from 2011 to 2022, required the country's 20 DHBs to work together regionally. This research explores how this initiative functioned, examining how, for whom and in what circumstances regional DHB groupings worked to deliver improvements in system integration and health outcomes and equity.
We used a realist-informed evaluation study design. We used documentary analysis to develop programme logic models to describe the context, structure, capabilities, implementation activities and impact of each of the four regional groupings and then conducted interviews with stakeholders. We developed a generalised context-mechanisms-outcomes model, identifying key commonalities explaining how regional work 'worked' across NZ while noting important regional differences.
NZ's four regional DHB groupings.
Forty-nine stakeholders from across the four regional groupings. These included regional DHB governance groups and coordinating regional agencies, DHB senior leadership, Māori and Pasifika leadership and lead clinicians for regional work streams.
Regional DHB working was layered on top of an already complex DHB environment. Organisational heterogeneity and tensions between local and regional priorities were key contextual factors. In response, regional DHB groupings leveraged a combination of 'hard' policy and planning processes, as well as 'soft', relationship-based mechanisms, aiming to improve system integration, population health outcomes and health equity.
The complexity of DHB regional working meant that success hinged on building relationships, leadership and trust, alongside robust planning and process mechanisms. As NZ reorients its health system towards a more centralised model underpinned by collaborations between local providers, our findings point to a need to align policy expectations and foster environments that support connection and collegiality across the health system.
在新西兰（NZ），医疗保健连续体的整合一直是加强卫生系统和改善健康结果的关键方法。一个关键的例子是四个地区 DHB 分组，从 2011 年到 2022 年，要求该国的 20 个 DHB 在区域内共同合作。这项研究探讨了这一举措的运作方式，考察了区域 DHB 分组如何为改善系统整合和健康结果和公平性而共同努力，为谁以及在什么情况下共同努力。
我们使用了真实主义评估研究设计。我们使用文件分析来制定方案逻辑模型，以描述每个四个区域分组的背景、结构、能力、实施活动和影响，然后对利益相关者进行访谈。我们开发了一个广义的背景-机制-结果模型，确定了关键的共性，解释了区域工作如何在新西兰“发挥作用”，同时注意到重要的区域差异。
新西兰的四个地区 DHB 分组。
来自四个区域分组的 49 名利益相关者。这些人包括区域 DHB 治理小组和协调区域机构、DHB 高级领导层、毛利人和太平洋岛民领导层以及区域工作流的首席临床医生。
区域 DHB 的工作是在已经复杂的 DHB 环境之上进行的。组织的异质性和地方与区域优先事项之间的紧张关系是关键的背景因素。作为回应，区域 DHB 分组利用了“硬”政策和规划流程以及“软”关系为基础的机制的结合，旨在改善系统整合、人口健康结果和健康公平。
DHB 区域工作的复杂性意味着成功取决于建立关系、领导力和信任，以及强有力的规划和流程机制。随着新西兰重新调整其卫生系统，以更以中央化为基础的模式为支撑，建立在地方提供者之间的合作基础上，我们的发现表明需要调整政策期望，并营造支持整个卫生系统连接和合作的环境。
