Table 5 Influence of policy dialogues on policy implementation

 Evidence strength and quality

“So in my example, I think that’s certainly true where there has been no visible or no - at least what I’m aware of - significant discussion about the policy option. It may … be that the evidence … is so mixed that there isn’t a very strong case for taking it forward in a more practical or thinking about feasibility and implementation … it doesn’t mean there’s no impact [of the dialogue], it could mean that there was some impact.” [R1]

 Relative advantage

“There’d be a couple things that’d be helpful at the discussion. One is, it did help me, as a whole, to understand the relative importance of different mechanisms, or the relative likelihood of payoff of the different mechanisms.” [PPM1]

 Adaptability

“I don’t think we succeeded very well to try to imagine what would a social insurance model applied to healthcare look like in the Canadian context. We kind of keep defaulting back to countries where we observe that approach to financing healthcare and can’t seem to get to the point where we say, “Well, this is how you could construct something like that in the Canadian context whether you apply it to drugs, or mental health, or to the system as a whole.” So that one I think is really interesting. I don’t think the paper itself and by the dialogue … got us to where we could have gone.” [FPM1]

 Design quality and packaging

“… any given dialogue helps contribute to developing a compelling package of evidence that might incrementally, over time, contribute to the policy-making process and in turn, the opening of a policy window for potential reform.” [PPM1].

 Cost

“What is the opportunity cost? Which patient groups will lose out because the money for funding that has been taken from their account?” [R11]

 Knowledge and beliefs about the intervention

“It [the dialogue] probably just helped to nudge it along. I don’t think it’s hurt at all, the information was very useful - whether it was around strategy, tactics or system design - for certain individuals around the table. So I would say, if anything, it was again incremental, but generally that’s the way we make gains in our system. It is really incremental.” [NSO2]

 Self-efficacy

“Well, you have to remember at the time, it was 2011, and at the time all of these things, what happens is people start feeling, at the end of these things, they all feel good. You know what I mean? Most of these meetings, they’re designed to make you feel good about yourself. And within the context of what’s going on at the time, that’s important because people can tell they get a little bit more confident.” [PPM3]

  Patient needs and resources

“The difficulty to get traction on change around, and excitement about, a national pharma-care plan. If you talk to Canadians about what their big problem is in terms of healthcare coverage, pharmaceuticals isn’t the issue that comes up. It has to do with other issues about access to a doctor, access to an emergency room” [R12]

  Cosmopolitanism

“The dialogue creates such a face-to-face connection. I would say that I reached people in the various sectors when I needed to and it was easy to connect with them and ask them like, “Alberta, I remember you had this policy on long-term care. Can you refer me to someone that will be able to give me extra information on this and that? So it was more what I gained from those dialogues was more like a connection. I knew that … I could contact someone that would direct me to the appropriate person” [PPM4]

  Peer pressure

“I think it was a topic area [hospital funding] that was right for action because Canada is sort of behind in most of the other countries in the developed world in changing how hospitals are funded. Pretty much every other country in the world has moved away from the block funding system that predominates in Canada, and so this is the topic area that’s right for change since we’re sort of, we haven’t evolved the way the rest of the world has.” [FPM2]

  External policy and incentives

“The Federal Government has been less active, that’s a result of not engaging in the Accord. So that changing policy environment sort of had an effect of limiting the uptake of some of the-- but not eliminating, but it reduced the uptake of what was in the policy dialogues.” [FPM2]

  Structural characteristics

“…one of the things that I learned was the turnover in government, especially future government, is the half-life of those people is at least half of what it takes to make real change happen. So the turnover problem was huge. It was always huge, because new people have come who are in senior positions who I had to bring outside and educate, and just as soon as I’d finished doing that and they were outside, they were gone and somebody else came in and that was a constant problem.” [PPM3]

  Culture

“… but the thing that’s preventing change, frankly it’s fear. It’s fear of doing anything different. Because all those things contain a risk. Every time you do something different, there’s a risk involved. And we have a very risk-averse structure here. Both inside health care, and at the political level - highly risk-averse. And the risk involves two different risks. One is the risk of adverse publicity. … And even good news in health care can turn to bad news overnight depending on how it’s played in the media. And I think governments have figured that out, and that’s why they’re backing off with health care. At every level, governments they’re trying to just distance themselves from anything having to do with health care as much as they can, so to stay away from hot arguments” [PPM3].

 Tension for change

“So it’s not a shortage of knowledge. We don’t need to study what the problems are in health care, we actually have a really good idea of what the problems are, we know what most of the solutions would be, at least in a broad sense … [however] we won’t change health care dramatically until there’s a crisis because there’s no incentive to do so, and so health care at some point in time will fail catastrophically and what will come out of the other side will be worse for everybody, and I don’t think that’s going to be a surprise to anybody.” [PSO2]

 Relative priority

“You could see when it was a policy option that was … embraced, that there was incentives to put them in place as opposed to other options where…they could see there were more limitations.” [PPM4].

 Leadership engagement

“[the dialogue] … created this big buzz, and [province] got really attracted. The Minister … got really attracted. … It provides them also a momentum, which was really important for the Minister… they’ve been able to use this information … to move and to bring this to life.” [PPM4].

  Available resources

“If it had happened like four or five years earlier where we had a lot of money to put on the table for that stuff, it’s probably feasible if people really like that idea of gain sharing for example, that they would have put that on the table and say, ‘Can we try this maybe for some sort of Orthopedic wait time procedures.’ or something like that, that’s where I would have started. I think just the negotiations have been so antagonistic the last couple rounds that there was very little room I think, to experiment with any sorts of major transformations like that, and policy like that right?” [PPM2]

 Access to knowledge and information

“Also it was good reference because we were trying to implement funding policy. So, it wasn’t only about what it is, the alternative funding policy, but really how can we help the system going through the change and what [is the additional labour] that we need.. in order to make this things change.” [PPM4]

 Planning

“I was always taking out some information… to evaluate on what was missing or plan the future steps and trying to get everyone on board.” [PPM4]

 Opinion leaders

“…but the trouble with the policy dialogues is that they involve people who are already essentially committed to reform of kind or another. They may differ on the details. But they don’t get at the people who provide the money and the opportunities. So, I think the biggest barrier that I see now to real change is at the most senior level in government. And the reason is that A, they don’t actually have the time to understand the level at which it needs to be understood at. I mean, they just don’t have time. I feel really bad for the ministers. They’re just constantly putting out fires.” [PPM3]

 Internal implementation leaders

“I think [individuals name], many of you will know this, did a fantastic job when she was pushing down generic drug prices the last time. Basically she said, “Why are we paying so much? Here’s the evidence.” She was able, as [position], to really, very effectively move forward. She personally bore a really heavy risk, or heavy burden in doing that, but I think it was actually in this case it was very effective by appointing an executive director, a political appointment, who ended up taking the heat instead of a politician, was quite an effective strategy for moving forward.” [R5]

 External change agents

“… they’ve been able to use those information and put in place an expert panel - a three years expert panel - on the topic of activity based funding. To try to put-- to move and to bring this alive.” [PPM4]

 Reflecting and evaluating

“There’s the old saw that you can’t manage what you can’t measure. We’re ready to start measuring a lot of things, not at the level of precision, perhaps not at the level of accuracy that we’d all like but it won’t start to get better until we do. And so I think the whole question of measurement is central to any type of reform that we consider. But more important I think it’s critical to think about what it is we want to measure. You know our health system is a reflection of who we are as a country so we should be measuring the things that are important to us, it’s our health system is one of the ways that we actually define ourselves positively.” [PPM1]