Organising for health equality: assessing contexts for implementing integrated health access

Abstract

Abstract Background Social inequalities in health are complex and vulnerable people therefore need cross-sectoral initiatives that provides integrated access to different sectors of the health system. However, specialization makes systems fragmented, and health organization is an important but overlooked determinant of social inequalities in health. The Flexible Assertive Community Treatment (FACT) model offers integrated health access to people with severe mental illness, through interprofessional teams across health and social services. This study aimed to assess the organizational contexts that shape the implementation of this model of integrated care. Methods The study applied the theory of the Organizational Fields to identify the specific mechanisms by which organizational contexts influence the implementation of the FACT model. We analysed political and administrative documents at national, regional, and local levels to assess relevant contexts. We complemented with semi-structured interviews with managers and health professionals in three municipalities and the region in Denmark that implemented the model. Results Overall, this study found that the contexts for implementing FACT are highly complex both horizontally, between the health and social care sector, and vertically, between the national, regional, and local level. This leads to conflicting demands on the implementation of FACT in the municipalities. Local cultures of collaboration may nonetheless offer a lever to handle these demands, although this varies across municipalities. Conclusions For health systems, it is challenging to organize integrated health access as contexts are complex both horizontally and vertically. Assessing these contexts is therefore highly important to identify key determinants for successful implementation of models such as FACT. This may in turn reduce social inequalities in health through more coherent and accessible care. Key messages • Vulnerable people need integrated access to different sectors of health systems to secure health equity, but this is challenging to organise as health systems are complex horizontally and vertically. • Assessing the contexts of health sytems is key to identifying the determinants for successful implementation of initiatives to reduce health inequalities through more coherent and accessible care.