Proceedings of the Subcommittee on Population Health
Issue 7 - Evidence, June 5, 2008
OTTAWA, Thursday, June 5, 2008
The Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 10:54 a.m. to examine and report on the impact of the multiple factors and conditions that contribute to the health of Canada's population — known collectively as the social determinants of health.
Senator Wilbert J. Keon (Chair) in the chair.
[English]
The Chair: Honourable senators, we are delighted to have an excellent panel before us this morning: Dr. Marcia Hills, from the University of Victoria; Dr. Maria De Koninck, from Laval University; Dr. Shanthi Johnson, from the University of Regina; and Mr. Richard Prial, from the Ontario Ministry of Health and Long-Term Care.
[Translation]
Maria De Koninck, Professor, Department of Social and Preventive Medicine, Laval University: Mr. Chairman, thank you for allowing us to speak on social inequalities in health, a question of considerable interest to us. I will focus solely on the problem of research, since that is my field of expertise. The purpose of my presentation will be to emphasize points concerning research needs in Canada to enable us to address social inequalities in health.
Social inequalities in health — I have seen the report you produced — are amply documented. They do indeed exist and have a significant impact on population health. Social inequalities have become a public health priority. The director of the Public Health Agency of Canada will soon be preparing a report on the issue.
Although we know the situation, we lack the necessary knowledge for a better understanding of how these inequalities are created and especially how they last. The situation is so chronic that it is perpetuated in certain social groups from generation to generation, with children born in poverty also bringing children into the world in poverty. We need to understand how the phenomenon works so we can take action and reduce these inequalities.
Our needs go beyond the need for a description. I will place considerable emphasis on this point. We must go much further than merely describing inequalities. We must understand and start acting by experimenting, particularly with approaches that must be evaluated. When we talk about approaches, that includes public policies and their impact so that we can adjust them.
In the document that has been distributed to you, I provide a theoretical model on health determinants that comes to us from England. This is probably the most widely used model right now. It clearly shows how public policies go through various conditions to reach the health of individuals. In this theoretical model, the emphasis is placed on the set of conditions that act on the health of individuals. To understand how inequalities are created between individuals, it is important to take this set of determinants into account. This is an absolutely enormous challenge.
I also have a slide that was presented by Dr. Hillary Graham. She is a very well-known British researcher who has been working on inequalities for a long time and who is increasing the agreement among researchers in emphasizing that we must now focus on the determinants of determinants, that is to say go upstream from what we call the determinants of health to understand the basis of the creation of inequalities among us. We need research that enables us to grasp the complexity of the situation, and, to do that, we need research that involves many types of expertise, that is to say multidisciplinary research, particularly in the social science research field, to enable us to understand how social conditions and social organization act on inequalities and population health.
We also need to do research on intervention and living environments, action research so that, from the outset, we can start putting in place ways of working to reduce inequalities and prevent them from recurring.
Here I have a brief text that summarizes our research work. In the Quebec City region, we conducted a study on three areas in the region. We found life expectancy differences within those areas. We saw differences of up to 10 years between environments within downtown Quebec City, for example, which is very big. That gives you an idea of the need to go much further in order to understand how this type of situation is possible and how we can act.
We need research that makes room for complexity and involves many types of expertise. It is important, and this is somewhat the message I am giving you today, to start seeking a change in culture at the agencies that fund our research. The agencies that fund our research want quick results. The agencies that fund our research do not seem to understand that basic social research is as important and requires as much time as basic biomedical research. The criteria are not the same. Social research is the poor cousin, and yet we know that it has become truly necessary to understand what is going on in an opulent society such as ours when we observe utterly unjustifiable inequalities. Furthermore, in the community organizations, they try to obtain results using a linear causality, whereas, when you work on social realities, the causality is not necessarily linear.
Last, the current trend is toward strategic programs, that is to say that research topics are suggested to researchers. This is increasingly the case, as a result of which intellectual innovation, ideas and intuitions that researchers may have are now virtually never funded.
The slides I have presented to you contain some passages from a study by a group that, for a number of years, has been requesting that Canada establish a longitudinal survey using household panels. A number of countries are doing this and the type of data that this kind of survey produces can really be very useful, first in monitoring population health, and second in gaining a clearer understanding of the complexity and all the elements that go into creating the social inequalities of health.
In closing, I would say to you that it is important for us to recognize that social inequalities are a priority for population health, that we need research that affords a better understanding of how inequalities are created and how they recur. We need evaluative research that will support social experimentation to reduce inequalities and, ultimately, infrastructures that will enable us to produce data, what is called complex data corresponding to human and social reality.
[English]
Shanthi Johnson, Saskatchewan Population Health and Evaluation Research Unit, University of Regina: I am delighted and honoured to be representing the Saskatchewan Population Health and Evaluation Research Unit. The 10-member team of dedicated researchers focuses on community-engaged and policy-relevant research in understanding health disparities. The three main areas that we focus on are Aboriginal and northern health, healthy children and rural health. I have been privileged to work with this unit over the last year, when I moved to Saskatchewan in January 2007 from Nova Scotia.
My comments today will reflect on my experiences not only in Saskatchewan but also in Nova Scotia and Ontario prior to that, which was my first home in Canada when I came to pursue my graduate doctoral studies in health.
I want to make five specific comments. The written submission that I made was quite lengthy, so I had to cut down quite a bit. I hope I did not throw out the baby with the bathwater when I was doing that.
The five points I want to make are, first, the need for building capacity through education and training opportunities. SPHERU has been a leader in providing opportunities for postgraduate students through thesis work, mentoring, partnerships, and most recently through a CIHR-funded program called the Community and Population Health Research Training Program, CPHR. Through this program, we have trained about 26 PhD students, master's students and post-doctoral fellows within the last five years. This is a huge accomplishment for a smaller province and also in a specific, focused area of population health. We have students from various disciplines — geography, history, kinesiology and arts — so it is a truly multidisciplinary program.
While these programs provide opportunities for current graduates, we need education and training opportunities to build capacity for those already in the workforce. We need training opportunities such as workshops, online educational modules and so on for people in the health sector and people in other sectors that are important for population health.
There have been quite a few interesting models. In the work that I did in Nova Scotia, Annapolis Valley Health was a leader, offering education sessions for their employees in the health sector and in the community health board, which is the grassroots organization of community volunteers and at the senior level management as well. Through that, there was quite a bit of incorporation of population health into the health planning process.
The second point is the need for a national population health framework. Given the extent and significance of health disparity that we have seen throughout Canada, I think broader scope focus is needed to begin to address this. A national framework will be very important to set the stage and to lead the way, to provide direction and inspiration, to work with the provinces to further this agenda. This framework will have to have short- and long-term goals, of course, objectives and targets, plus adequate funding to resource the strategies that are developed.
The third point is the coordinated integrated health information infrastructure. We are really blessed to have extensive databases in Canada. We have the Canadian Community Health Survey and several other population surveys. However, it can take a bit of improvement. We do not have as much longitudinal data. The longitudinal family dynamic survey that was mentioned by Ms. De Koninck is important, and I know the Canadian longitudinal study of aging is being developed. Those are important surveys that are needed.
We also need community-level information. Many of these national surveys only provide regional-level information. When you look at one region, such as the Regina health region, it is so diverse. You have Regina, which is a major centre, but you have communities that are very small. How do you identify health needs when it is all put in one pot? We need a breakdown.
We need further work on indicators. We traditionally use indicators such as life expectancy, mortality and morbidity, but what are important indicators for local communities? SPHERU has worked with several Aboriginal northern communities to come up with culturally relevant indicators that are important to the communities. These kinds of indicators should be incorporated into national and provincial surveys.
I want to also make a point about the evaluation and evidence. As population health researchers, we cannot emphasize enough the importance of evaluation in any strategy or framework development. I have to commend you on the work you have done on the scoping paper looking at population health policy. I notice that on pages 7, 17, and 28, there is discussion about development and implementation of policy or framework, but there is no mention of evaluation as part of it. I want to encourage the committee to consider thinking about and putting in an evaluation framework as part of the process.
As the earlier speaker mentioned, we need further research into understanding the complex interaction of various determinants of health. CIHR, through its Institute of Population and Public Health, has been providing funding, but the success rate in the CIHR competition is very small, given the funding limitation. That means that many of the really interesting and important research questions go unanswered for lack of financing and funding. We need to encourage targeted and enhanced funding opportunities to promote innovative research that is meaningful to the communities.
On the point of prioritizing, the scoping document beautifully lays out seven areas of disparities, with the possible recommendation of action in two — Aboriginal health and child health. This is a very limited scope, because we know disparity affects us all throughout our lifespan and we really need to have a multi-sectoral and life-course perspective in addressing disparities; otherwise we will not make a big dent in the huge disparity we see in Canada.
In my written submission, I provide an example from a nutritionist. I am a dietician by training. Are we what we eat? The question raises issues about: Is it the knowledge, attitudes and beliefs we have or is it the societal issues that we see in childhood obesity, food insecurity, people not being able to afford foods, the increasing incidence of chronic diseases that start earlier and earlier in life? What are the indicators we are using? Is it just the nutritional intake or is it the food additives we have to worry about, the trans fats and the sodium content of food?
We need educational opportunities. I am quite familiar with many of the nutrition programs in Canada, and they do not offer population health courses. They are still focused on individual behavioural change, on the assumption that if you provide knowledge, the attitudes will change and it will bring about a change in behaviour. Based on research in social determinants of health, we know that is not the case, so we need capacity-building and training opportunities for students and for people in the profession.
With that, I will finish my comments. I am pleased that this committee is looking into this significant and important issue in Canada.
The Chair: Thank you very much. I was happy to hear you confirm our structural framework that we are working with fundamentally, which is a population health platform and then looking at the life cycle in its entirety, built on that platform. You just confirmed the need for that, so thank you.
Marcia Hills, Director, Centre for Community Health Promotion Research, University of Victoria: I would like to begin by saying how pleased I am to have the opportunity to speak to you today. I apologize for being late. I am in Athens, Greece. If any of you have been here, you will understand that the people here have a different concept of time than we have in Canada. I was misinformed about how long it would take me to get here.
I want to commend you on taking up this important work. I was pleased to read your reports and to spend some time reading some of the transcripts of other witnesses.
I will be brief in my comments, because I am hoping that the technology will stay working. I think that the discussion and the question-and-answer period are very important.
I have worked for over 20 years in the area of health promotion and community-based research and evaluation. The core issue of equity in health outcomes has been at the forefront of my own work, but is also foundational in terms of being the heart of health promotion in the originating document of the Ottawa Charter for Health Promotion. This very much guides our work in health promotion.
When I am speaking to you today, although I am a director of the centre at the University of Victoria, I also feel I can represent some of the views of the Canadian Consortium for Health Promotion Research, which is a non-profit organization, as I am the president of that organization.
I will limit my points to three. First, we need more population health research. I want to focus particularly on what we call intervention research and evaluation. I was pleased to hear the speaker before me mention that as well. I want to end by talking about complexity, context and the problem of synthesizing evidence. I will give you a couple of examples of ways that the consortium is working with the Public Health Agency of Canada to address some of these issues.
We need more population health research, but we just do not need more of the same. We have to shift to more social epidemiology. We cannot continue to just collect the evidence about things we already know about. We need more collaboration between traditional health research and social sciences.
We need more funding, again, not just to keep doing what we have been doing, but also so we create more innovation and less redundancy. I think it was Monique Begin who said we are a country of pilot projects, and it is time to invest in more long-term, sustainable research.
We need more data on what we call the complex causal mechanisms that underlie health disparities. I heard this mentioned also — the idea that when you are looking at social determinants, it is not straightforward that B follows A. It is complex. Also, communities are very complex social interactions between many people and organizations. There is a level of complexity there that I will address in a few minutes.
We also need to shift, especially with communities, from our exclusive focus on deficits to focus more on assets. There is wonderful work happening now with the Venice office of the World Health Organization. They are taking up the Commission on the Social Determinants of Health and they are working on this idea of assets rather than deficits. It is the idea that all communities have assets and we should build on their strengths rather than continuing to identify their weaknesses.
We say we need to double our investment over the next five years, and we must shift to more intervention research as a proportion of population health research. I do not know the exact figures. CIHR supports population health research, of course, but it is about 10 per cent when you look at it compared to medical research. Of that, only another 10 per cent is dedicated to intervention research.
Basically, the idea behind intervention research — and if you heard Sir Michael Marmot speak from the commission, or Monique Begin or Stephen Lewis, they are saying the same thing — we have a lot of information and research on health disparities. We know what they are, we know where they exist and we also know what causes them. However, we have very little intervention aimed at reducing or eliminating these disparities. We feel strongly that this is where the focus of our work has to be.
We have to recognize the different nature of population health and health promotion interventions from classical medical interventions; they are very different. These differences demand a different approach to intervention research and evaluation. We absolutely must have citizen engagement and community participation in both the interventions and in the evaluation.
I also heard this alluded to earlier, and I want to make a strong point about it because it is our byline. We say you must link policy practice and research. You may be surprised to hear me say this as a researcher, but researchers cannot dictate either the research question or the research process. We need to be more aware of what the policy needs are if we want to bring about change.
One of the questions that I noticed you were interested in is where should this research funding come from? Again, in light of linking policy, practice and research, we think the funding should come both from independent funding research institutions like CIHR, and from the relevant government departments. I know this is beginning to happen with the Public Health Agency of Canada. They are working with CIHR to start to do some of this intervention research.
I will talk briefly about complexity context and the problem of synthesizing evidence. Population health and health promotion interventions are complex; they are social actions taking place within complex social systems. This means that evaluating the effectiveness of these interventions requires understanding how each intervention interacts with its context to produce certain outcomes. We want to focus on the outcomes, but we want to know what is the context under which intervention works and does not work. We do not know that right now. Therefore, we have a dilemma. How do we analyze individual contexts and synthesize across diverse contexts in order to arrive at conclusions — in other words, in order to know the effectiveness of specific interventions?
Traditional models of synthesizing evidence have not been able to solve this dilemma or they have simply ignored it. In most ways of synthesizing evidence right now, they use the random controlled trial as the gold standard. This is completely inappropriate for trying to do anything with community interventions. It simply does not work. What happens as a result is lots of excellent best practices are ignored or do not make it into the literature because they do not meet the criteria of having control groups. Moving forward requires more investment and innovative approaches to synthesizing evidence on the effectiveness of these interventions.
I want to give two examples of one of the things we are trying to do right now, because I think there is some hope in this. The Public Health Agency of Canada has been working with the Canadian Consortium for Health Promotion Research for the last four years to develop a framework so that we can look at federally funded community initiatives. We should be able to look across these programs. I am referring to pan-Canadian programs — things such as the HIV/ AIDS strategy, the nutrition strategy, diabetes and the parenting programs.
We have been looking at these programs and looking at the evidence of their effectiveness in promoting health. We are trying to test the idea of looking at complex mechanisms and contexts and linking them to population health outcomes. Previous research provided a logical framework that presents a results chain, looking from short- to medium- to long-term outcomes. This work also exemplifies the point I was making earlier about the model of collaborative research between researchers, policy-makers and practitioners.
The other program that we are working on now is the healthy living strategy. This is an excellent example of the work that we should be doing. These are the interventions that we should be looking at. The difficulty lies in evaluating them and asking the right questions in the evaluation so that you can roll up the evidence across the programs. I think this is very difficult. I commend the Public Health Agency of Canada and CIHR for introducing this kind of work, but we need more of it.
Richard Prial, Director, Strategic Alignment Branch, Ontario Ministry of Health and Long-Term Care: Thank you very much for this opportunity to contribute to this committee's deliberations on a topic that some of us in Ontario have come to appreciate is a matter of pressing urgency and certainly one of great social importance.
I am back in Ontario. I indicated earlier that I was ill recently and just managed to read some of the work of this committee. Having had my head deep in the sands of trying to move this issue in Ontario, I am both excited and encouraged. It is critical that this is happening at the national level.
Perhaps it is not a bad idea to give you a sense of my background and what I can bring to bear on today's discussions. First, I am not an academic like the others, but I strongly endorse virtually everything I have heard this morning. As a public servant with 20 years experience, I bring a different perspective. I have been working in the bureaucracy in Ontario for most of my career as a ``horizontalist specialist,'' if you will. If I have any expertise to bring to bear today, that is probably where it is. I have come to be known as a director of impossible missions in Ontario; health equity happens to be the latest of them. Prior to that, I was director of results in our cabinet office as the McGuinty government sought to come to terms with some of its broad results in the health care, education and economic arenas. I have the gospel about the horizontal aspects. I also know by dint of hard experience and by the many bruises on my back, and elsewhere, which make clear the challenges associated with working horizontally.
I provided a brief slide deck overview to the committee. I focused on what we have tried to do in the area of health equity over the past year or so and what we plan to do over the next few months. I should note that I do not use the terms ``population health'' or ``social determinants of health'' — not only because the latter is difficult but also because the approach we have taken has been very much influenced by the European secondary literature and we have focused on health equity.
Health equity, or inequity in health, is recognized as an important issue across the health sector in Ontario. Recently, it has become part of the government's strategy for the health care system. It is a strategy that we have been seeking to ground in research over the past while. As it became a strategic priority for the province, the then cabinet secretary of Ontario sought to launch several initiatives to build up the policy capacity in Ontario. That is an issue at the federal government level as well. We proposed health equity as a focus for developing policy capacity.
Preliminary research allowed us to draw a couple of interrelated conclusions. First, our researchers quickly revealed that this is less an issue of health policy or narrowly understood health care than it is a matter of broader social policy, so we knew that we had to engage our ministries. Second, we realized that this is not really an issue of access to health care as such — although that is a significant issue — but, rather, an issue of health and well-being. That is a matter not exclusively within the purview of the Ministry of Health or any other ministry but, in a fundamental way, a broader outcome served by all governments.
The research project's objectives were to put in place a foundation for working horizontally and to provide a set of practical tools — that is, because we are very practical people as bureaucrats — for ministries based on evidence of what works. We are here very much influenced by the policy agenda of the Blair government between 1997 and 2003, when most of the progress on health equity was made.
We duly established the usual interdepartmental apparatus; that is, an ADMs committee that oversaw the work executed under the direction of a group of directors from the 10 concerned ministries. We have all the ministries. We have the Ministry of Finance because the funder is a critical component. All report into a committee of deputy ministers who are responsible for social policy. It was my job to drive this process and to ensure the delivery of a number of products.
We also recruited an expert panel. One thing that is characteristic of my experience of public policy-making is that we have a very disparate community of policy advice. There are think-tanks, academic institutions and then government. We knew that if we were to get the evidence that we needed, we would have to bring all three together. That is our public policy capacity, and not just here in government. Given that we are dealing with a wicked problem, namely, health equity, there is no way that any ministry or any government will have all that capacity inside to address these difficult issues to which Professor Hills, for example, referred. That is, the whole question of complexity; the subtleties associated with causation; and the difficulty of attribution, which is one of the major problems that confronts all those who seek to put in place a regime of metrics.
The key deliverables of our research initiative were a review of strategic lessons learned from other jurisdictions; a framework to guide policy development; a kit of policy levers and tools for ministries based on evidence of what works; and a framework for setting objectives and measuring success. We made progress on all fronts and continue to work towards our wrap-up report this fall. I have provided a summary of research to date before this panel. I am providing it in advance of having provided it to many assistant deputies in Ontario but I think it will not change much.
Although our public service colleagues were familiar with the notion of social determinants of health — and, I mean here talking across ministries — they were much less familiar with the notion of health equity and all that imports. Moreover, we discovered that at least some colleagues felt that this was just about health and asked: What has that to do with our business? Thus, there was an education job to do. That should not be underestimated.
In our first research report, we reported on lessons to be learned at the strategic level from the European nations that had made the most progress on this issue. I know this committee has been examining the same countries as well; it is the usual gang of suspects from Scandinavia and the U.K. Some of these lessons are summarized on page 5, but you have done formidable work in that area already.
Our second report proposed a goal of reducing disparities, essentially a modification of the goals proposed by the World Health Organization and the European Union, with policy action focused on levelling up the gradient. In response to the reasonable argument, from elsewhere in the Ontario public service, that this was all about health, we responded in two ways. First, relying on the work of Amartya Sen and the World Health Organization, we pointed out that health is a sensitive indicator of societal conditions. That is, health provides an entry point for policy. However, it is not the only one, because we can demonstrate gradients in other fields as well. Education is a good example of that. Since health is the entry point, the focus should be on social and economic policy domains, not exclusively on health policy domains.
Second, we subtly shifted the goal from achieving greater equity in health to achieving greater equity in health and being-well. The big lesson for us it that it is about health, not health care, and we are all responsible for enabling better health as a fundamental capability. This has very important implications for how government structures policy-making and policy execution.
Our research has generated lessons about horizontal policy-making. We in the public service talk about horizontality a great deal, but it is hard to do, and there are very few examples worldwide where it has been successful. The one in Ontario that we point to is the smart growth initiative, and there are some lessons to be learned from that. We do have a couple of home-grown examples; there is at least one in Ontario, and I am aware of others in Canada.
Our research has also generated lessons about performance measurements in this area. We know that measuring performance is important, but it, too, is hard to do — harder than most people will allow, in my my personal opinion, particularly where the relationship between investments and outcomes is subtle and hard to trace. You have had plenty of evidence to that effect.
My current job is in the rather mysteriously entitled Strategic Alignment Branch. The job is rather innovative. I am responsible for bringing together health outcomes and health investments much more effectively. Of course, the argument in the background is challenges to the fiscal sustainability of our health care system.
The difficulty with metrics in the health equity area, of course, is that attribution is a great challenge. There are people more expert in that than I, but the secondary literature is full of the subtleties associated with it. In Ontario, we tried to promote an input-output model put forward by the Swedish scholar Finn Diederichsen a few years ago. That will be in the research annals. The difficulty with talking about models tracing inputs and outputs is that it is almost impossible for anyone to understand what is going on. Imagine trying to explain that to a committee of cabinet.
Why is this? As I said earlier, among wicked problems that states have to deal with today, it is probable that health inequity is among the most wicked of all. Although we suspected the existence in Ontario of a social gradient in health that was pervasive and durable, we had no evidence of that gradient either, so we had to get that. On the final slide of my deck, I have provided a portrait of the gradient in Ontario produced by a study that the Ministry of Health has commissioned. The study has not yet been published, but I ventured to provide some of this. I was speaking about this initiative to a group of health executives about a year ago. I was on a panel with Noralou Roos, who has appeared before you. She was asked the question, ``How do you know there is a gradient in Ontario like there is in Manitoba? I need not to tell you what Noralou's response was to that.
We now have evidence of that and we are working to deepen the evidence, because we know that if we are going to be measuring these phenomena we need a baseline, we need some form of goal or target, and we need to have effective indicators that are telling us where we are going. In order to do that we need the kind of hard-nosed policy evidence to which my predecessor commentator referred to.
We now have the beginnings of a foundation for doing health equity work in Ontario, but we have a very long way to go. These are research initiatives.
I hope these remarks have set a useful foundation for your questions today.
The Chair: Thank you very much, Mr. Prial. We are waiting whatever information you can release. I am very much aware of this initiative. It is closely aligned to our thinking and what we intend to recommend, unless witnesses convince us otherwise. But we are moving towards a whole-of-government approach recommendation, because we feel there is no other workable approach.
I think Ontario can be a key player. Minister Smitherman was kind enough to give me an hour of his time and I discussed this with him about two months ago to be sure that we were moving in the same direction as Ontario is moving. Of course, he has the great capacity, as deputy premier, to push a whole-of-government approach.
I want to draw you out on this. I am being a bit verbose because this is tremendously important to our thinking. We have heard from many people that this cannot be headed by health. Health is already consuming close to half the provincial budget. Other cabinet ministers are defensive about health and any more health initiatives. It probably requires another ministry.
Paradoxically, it must come out of a health initiative, because we are talking about the health of the nation. Our final report will address health disparities and how to correct them. Despite the negatives of a health minister leading this, I am not sure there is much of a choice.
I know the British model. I am going there to study it in more detail. We have video conferenced them and have heard witnesses from there and so forth.
Would you please enlighten tell us what your thinking is after all your involvement and after your very long bureaucratic career. I was saying yesterday that the importance of a report is to get all the bureaucrats on board, because governments keep turning over. If a report is going to have life, you have to have the bureaucratic thinking behind you, because that is the foundation for any government. Please tell what you think about the construction of an all-of-government approach, starting at the top with the federal level, going down to provincial, civic, and community governance.
Mr. Prial: A whole-of-government approach has to come to terms with a number of fundamental barriers to that approach. We will call them key barriers to horizontality, if you will. I will talk about where the barriers are before getting into what we might be doing about them. This is based on a review of most of the literature on the topic of horizontality that has been published in a couple of languages, mostly English, over the last 15 years and, as I said, the scars on my back.
A key barrier is the way we organize the departments, as you know. All our major issues are not organized around departmental lines, but we are, and there is a certain type of relentlessness associated — a sort of steel trap of pre- existing conditions — with the structure of public finances that has no bearing on the way problems are organized and how solutions could be organized. There is the structure of decision making, more than 200 years of Westminster model; politics and power; and bureaucratic incentives. All of those have to be considered from different perspectives.
Second, we in government frequently have a hard time having a clear idea of our objectives. We need much greater clarity in what we are trying to accomplish. Of course, that is been a major focus in all the European jurisdictions. They resort to legislation. However, I am a lawyer by training, so some of my legal work in the past has involved how to get governments out of situations in which they do not really obey their own laws. Legislation is not a panacea; it is a tool, along with many other tools that are available.
Clarity around goals is elusive, and that is why it is critically important to achieve, if we can, a national consensus on what it is we are trying to accomplish. The issue, as we have heard, is complex, but just to say it is complex should not preclude the articulation of what it is we want to achieve.
Third, measuring performance is critical, but it is much harder than most people allow. It is very resource intensive. The biggest issue is attribution, and particularly in dealing with the complexities of reporting on performance, that crosses department lines and fields of expertise.
Professor Johnson referred to the importance of allowing for evaluation. I was at one time responsible for launching a program evaluation in the Ontario government. I learned in that process just how difficult it is to evaluate programs. It is a very costly enterprise, even if you develop, as we did, short-cut approaches to manage costs. When we fund programs in government, we never fund them beyond what we think we can get away with. They are never funded so that you can actually evaluate them. I have sought to get, from time to time, funding for evaluation in itself, because it is costly. There are strong reasons why governments do not want programs evaluated, and I can leave it to your imaginations.
Horizontal coordination of policy formation is a challenge. Some of that has to do with the way we structure bureaucracies, the old charges of specialism — the stuff that goes back to Niskanen — specialism, segmentation of expertise. The response to that is incentives, education, communication and overall commitment to a common set of goals.
The fifth challenge is horizontal coordination of execution. One example is in Great Britain and all these local area- based policies. Many of these were launched between 1998 and 2001, and by the time you get to 2002 and want to evaluate what these area-based policies have achieved, you realize that they are all bumping into one another. There is lack of effective governance at the local level.
The final challenge is a lack of consensus in what we mean by accountability and the presence of a strong audit culture, no risk-taking. That has to do with ways we conceive of policy, or that affects how we conceive of policy.
The British experience, in our view, suggests that one important approach is to experiment, try what works. If we are talking about working based on evidence of what works, you do not know what works until you test it, and that means a rather different approach to how we conceive of implementing government policy.
I hope that gives some sense of the results of our experience.
Senator Callbeck: Thank you very much for coming this morning. Carrying on with the question that Senator Keon asked, was there any thought given to finance spearheading this initiative.
Mr. Prial: The best way to answer that question is that health started it. That is why we are in the driver's seat. However, we understood we needed finance to be on board. First, although they hold the money, this is really a question of broad policy, and so I would question the wisdom of just saying that Treasury, because it holds the financial reins, is the right place to situate responsibility.
Senator Callbeck: You mentioned having 10 departments involved and that the ADMs have a committee. Now you have had to educate those people. Are you satisfied that all 10 departments have bought into this initiative?
Mr. Prial: The short answer is no. I am impressed by the dedication of my fellow public servants in discharging their duties. The reality is that most of my colleagues are overloaded, so when we add on another initiative, another request from the centre, or a request from a line ministry, such as mine, to help work on some common objective, what do you think a reasonable person would do in those circumstances? Do you choose what you have to do, your urgent day-to- day needs, or will you somehow give up on that and invest time in an initiative for which you are not getting any credit? That is a simple fact of life. When you are working horizontally, it takes capacity and, to some extent, a bit of redundant capacity and governments do not do that. We are funded very tightly.
Senator Callbeck: When was the first meeting of the 10 departments? How long have you been at this?
Mr. Prial: We have been on this particular initiative for about a year. The first meeting was: What is this all about, why am I here and how can I justify my time? The second meeting was: What is this all about, why am I here and how can I justify my time? Those are really good questions. It is not a question of competence or blame or the fact that people do not want to work together. People do want to work together. In my experience, everyone is well motivated. I ask, what infrastructure and what superstructures do we have to support and enable the initiative?
Senator Callbeck: You are optimistic about this structure?
Mr. Prial: I am always optimistic. I am a public servant.
Senator Callbeck: Ms. Hills, you mentioned the need for more innovation and less redundancy when you were talking about research. What is the best way to get at this redundancy? How do we deal with that?
Ms. Hills: We have to pay attention to what we already know. We know a lot about disparities, but we do not take risks. We do not know what will work if we do not test it. It is easy to stay with what we already know and what we already do. It is really easy to do traditional research that is run by a researchers' own initiative. It is difficult to do research when you are partnering with a policy person who has a totally different agenda. We have learned much by working with policy people.
One of the initiatives right now is around this whole-of-government approach, which is quite interesting. You will know that in B.C. they have taken up this approach. CIHR, in collaboration with the government, has said that this is innovation, but we need to evaluate it; we need to know what is working and what is not. There are some interesting nuances, such as that it is not in the Department of Health any more, and it used to be. What does that mean? It will answer some of the very questions that Senator Keon was asking.
Regarding the idea of partnership and working together, we will never be successful if we cannot get education. Look at what occurs with youth in the schools. If you do not have education on board, how do you even have access? Earlier I was talking about nutrition and various programs. We have a huge dilemma around this intersectoral collaboration.
Senator Callbeck: You mentioned in your comments that researchers should not dictate the research questions or the process. Who should take the lead?
Ms. Hills: The community, the policy person, the person who has the issue should take the lead. It has to do with your question. If I am going to do policy research, there is no point in me, as a researcher, saying what I am interested in because I will never be able to satisfy your questions. I also think people who work with policy have very different questions than researchers have. We are trying to look at return on investment. We fund community initiatives and we need to know what the return is.
Senator Callbeck: You mentioned a project between the Public Health Agency and the Canadian Consortium of Health Promotion Research. Is that an ongoing project? Is there a specific time frame on that?
Ms. Hills: We have worked on it for the past four years and there is new funding for another three years. This time, it will be related to policy and creating a policy index of effectiveness. We know about the return on investment, so we will have much more of a focus on that. It will be presented to Treasury Board next spring, as I understand.
Senator Callbeck: You have three-year funding in place right now?
Ms. Hills: Yes.
Senator Callbeck: Will it be presented to Treasury Board for ongoing funding?
Ms. Hills: I have to back up for a minute because the whole reason this project was funded in the first place was because federally we fund these community initiatives, all kinds of them, hundreds of them, and we spend a lot of money doing so. However, the auditor's report asked: What are we getting out of this? We did not have good evidence that there was an impact on health. That is why the project was started. After four years of development, we are now ready to tackle the more difficult policy questions.
Senator Callbeck: That is funded now for three years and then you have to go back to Treasury Board. Is that right?
Ms. Hills: Yes.
Senator Callbeck: Ms. Johnson, you talked about a national strategy and that we need national leadership. Do you suggest that the Department of Health take the lead?
Ms. Johnson: Because this is a health issue of society, as Senator Keon mentioned earlier, I think health should take the lead, but it should be intersectoral. We have talked about the challenges associated with working horizontally.
If organizations such as CIHR, in partnership with the Public Health Agency of Canada, could take the leadership with perhaps subcommittees or a provincial working group in order to get a feel for what is happening and to integrate the framework, that might work well. Someone must take leadership, and the Department of Health seems to be the obvious choice, at least in my mind.
Senator Callbeck: I have one other question on the Institute for Population and Public Health. You mentioned the funding. Has funding increased or decreased or has it stayed about the same over the last few years?
Ms. Johnson: The funding has increased slightly, but the capacity of researchers and the number of applications has gone up tremendously, so that has brought the equation down in terms of success rates. It is a matter of not enough increase in funding and quite an increase in the number of researchers.
Senator Callbeck: It has gone down immensely.
[Translation]
Ms. De Koninck: Research needs are absolutely not being met right now. It was mentioned that it is extremely difficult to get funding for research in the social sciences and health. And when the research institutes were established in Canada, there had to be considerable openness to the social sciences; there was a little. As I said earlier, if you compare biomedical research with research in the social sciences, communities, health promotion and so on, no comparison is possible. I want to emphasize that because we talked about health costs. It is increasingly acknowledged that people who wind up in hospital represent a high cost; a large part of the work can be done before that, which costs a lot less.
Without talking about social justice, equity and all our great principles, talking strictly about costs from a pragmatic standpoint, everything that is invested in prevention and addressing the social inequalities of health prevents us from paying 10, 15, 20 times the costs we will have in the health system.
In that regard, and this somewhat addresses your concern as a person working in the public service, the world of health, medicine and health care must be made aware of the social aspects of the creation of health problems. It can be understood that, if health people sit around a table and you talk to them about the social field, community organization, help with children's homework and even public nutrition, those people may wonder: what am I doing here? An enormous amount of work must be done, and that has to start with training for health professionals.
At Laval University, we have a new medical program, a new course for which I am jointly responsible and which is called Doctors, Medicine and Society. Starting in the first years of medicine, they will hear about social inequality and social determinants. If doctors, nurses, nutritionists, all those who work in the public service in health, are enabled to gain a better understanding of the genesis of health problems from a social and economic standpoint, they will definitely be more convinced that their work has an impact on health and will be involved to a much more significant degree.
[English]
The Chair: Ms. De Koninck, I would like to comment on what you have said. We have asked the Conference Board of Canada to develop a business case for population health and to tell us why we should embark on a major initiative in population health. They will be doing that for us.
The short answer was what you just said. For each dollar invested in population health and correction of health inequities, there is probably a savings to the health care delivery system of $20 to $25.
That brings me back to all four of you for your guidance here, because despite the fact that there is tremendous resistance on the part of other ministries to let health lead an all-of-government approach to population health, the big financial driver and the big initiative is seen in health. The Minister of Finance has to get his head around this as well. It is really seen in health that there can be a direct link drawn.
I think the initiative has to come out of Health Canada but we need advice on that and soon.
Senator Cook: Thank you all for appearing. Thank you for challenging us once again this morning on the journey we are setting out on.
Ms. De Koninck, you talked about the social aspect of research. What do you think you will find if you go upstream?
[Translation]
Ms. De Koninck: Are you talking about my comments on the determinants of determinants, upstream? Increasing emphasis is being placed on this in research in Europe. If we want to address the problems in a sustainable way, we have to go upstream from the determinants. So you must understand that social relations and the social dynamic of conditions lead individuals to experience unequal situations.
For example, housing and employment policies will have an impact on conditions that will have an impact. It is really a chain. If, for example, you address housing, but without considering and without anticipating what can cause negative housing developments, it will be a short-term solution.
For example, you can select people and give them an acceptable place to live, but if you do not go upstream to really plan housing policies to ensure, on a sustainable basis, that people have an acceptable roof over their heads, you can only come up with short-term solutions. That is why we are increasingly talking about determinants. So it is always a medium- and long-term perspective.
What my colleagues have emphasized is that, when you think and want to put approaches like this in place, first, those approaches absolutely have to be anchored in the communities in order to take into account all the dynamics, but, second, there has to be an evaluative process enabling us to monitor and put things in context. That is extremely important in the evaluation. I believe my colleagues will agree with that; the evaluation must always be put in context. You can have an approach in a community that will have certain results, and results will be different elsewhere.
[English]
Senator Cook: That leads me to my conversation with Ms. Johnson. In the Province of Newfoundland in the 1990s, the fisheries collapsed and our way of life collapsed forever. The working population left in search of jobs. Canada was the beneficiary of that population shift, in particular Alberta. The government of the day was very innovative and asked what could be done. They knew what needed to be done but not how to do it. They developed an IT program called, Community Accounts. It is free of charge and can be viewed on the Internet. It is fully funded through the Newfoundland and Labrador Department of Finance. The premier determined that he needed to do what was best for his people. The program was developed at Memorial University in cooperation with Newfoundland and Labrador's Statistics Agency.
The result of the program was a kind of prototype that collected the profiles of what we were as a people. We are a small province of course, making it easier perhaps. The profile of each area was added to the Community Accounts. They gathered their information from Statistics Canada and elsewhere. The database is online and whoever wishes to access it, for whatever reason, may do so, such as the police, justice officials, school lunch programs, the poverty reduction strategy, and others. It is designed at the community level.
I would like your opinion on such a prototype. Is it possible? I realize that the funding is at the provincial level, which is not an issue in my province.
Do you see such a program being offered to the provinces across this nation? Are you doing something like that in your Province of Saskatchewan?
Ms. Johnson: I am proud of Community Counts and the way in which the database is set up. I used that database when I was in Nova Scotia, after Newfoundland developed the model called Community Accounts.
The information provided a wonderful start to the regional district health authorities to be able to draw on the information that provided community-level information. We found that although it was important and useful, it was limiting. It did not have some of the indicators and information that community health boards were looking for in terms of identifying community needs, for example, information related to health literacy. Through focus groups, the communities identified that as an important issue, but they did not have any data to support it. They had educational level, but that is not a good overall indicator of health literacy. There are other contexts. An immigrant's language skills are also an indicator of literacy. I was an immigrant so people tend to speak loudly and slowly, assuming I do not understand English.
It is important to gather additional information that is perceived as important at the local levels. For example, in an Aboriginal Northern community, availability of traditional food becomes important for community planning. We need to expand on that. It is a wonderful model but it is not used in other provinces. We do not have that model in Saskatchewan. It would be helpful to have it at the national level because then you could make provincial comparisons. For example, where does the immigrant population in Saskatchewan stand compared to the immigrant population in larger urban centres? Such comparisons would not be possible if the information is localized only and not coordinated and centrally available.
Senator Cook: It is my understanding that in my province an advisory group programs the required information into the system. Could we use this model as a basis and then add more specific data to it?
The other thing we heard was that while we have these wonderful research agencies across the country, there are barriers to access that prevented them from getting at it the information. That is why Newfoundland proceeded to develop its own database. I would like your opinion on access to information and the surrounding barriers. Should we use the prototype?
Ms. Johnson: I have used large data sets from CIHI and from Statistics Canada. As well, data are available from data initiative and regional data centres but they are not broken down to the community level.
Senator Cook: That was their problem.
Ms. Johnson: We experienced that problem as well.
Senator Cook: How do we get around that problem?
Ms. Johnson: The way would be to create more linkages and to work with CIHI. That is a wonderful starting place for us. We would look at the smaller innovative models that add value to locally needed information and then bridge the gap. We do not always have to go from top down. We can learn from the grassroots level and lead the innovation upward. It is extremely important that we have more coordination and integration.
Senator Cook: Ms. De Koninck, I heard you mention the need for curriculum or curriculum training. Would you see this as a possible model, whereby the data could be there and accessed? The users of this kind of model would be infinite. You input whatever you need.
I am interested in hearing where we should move on curriculum because if we are not teaching the deliverers of the system the skills that they need to know, then we will have failed. Do you have anything else to offer on that subject?
[Translation]
Ms. De Koninck: I would simply say that, before addressing the use that is made of data sources by people who provide health services, we must first take the first step, which is to achieve an awareness that health is not a strictly biological and behavioural outcome, but also a social outcome. You have to address the first stage before moving on to the second, and we have a lot of work to do in that regard.
Then, once the interest is there, of course if we can provide them with information that will help them in their work, to help reduce inequalities and improve social health, that is definitely welcome, but you have to go through a stage that I think is an enormous challenge.
That would help bridge the gap between health, health services and everything that represents people's work environment and family environment. Health workers find it hard to work hand in hand because it is difficult for them to understand how they can both work hand in hand in the health field. I think that is the challenge.
[English]
Senator Cook: It was the need that forced our people to work together, and I think it is a good start.
The Chair: You were speaking about literacy and here is the Senate's champion of literacy, Senator Fairbairn.
Senator Fairbairn: Thank you very much. I have been listening since I came in. I know my colleagues get a little weary of hearing this word as often as they do in this committee, and indeed the issues that we are talking about. I listened to all of you and the areas in which you are working, and most importantly the words you have been using in the last few minutes. This is very much a foundational issue for whatever else you want to build in social advancement in our country. I know all of you are very much aware of this and how it pops up.
There were comments about working with the provinces on some of these areas in which you are particularly engaged. We have lost a lot of that in recent times. Does this come up to you from your discussions with the provinces? Without that connection from the national and provincial level, you will not get down to the ground with the efforts where they are needed the most. I am wondering if you have thoughts on that and whether you have any advice to give to us. It is like a river going through almost everything we listen to.
Ms. Johnson: I do not have many years of experience in population public health. In my 10 years of experience in the three provinces, I have been fortunate to have been part of three strategy development processes: The Chronic Disease Prevention Strategy in Nova Scotia; the Immigrant Strategy; and I was part of the Saskatchewan seniors' injury falls strategy in Nova Scotia. As a community health board member and a member of the district regional health authority, I was also part of the Smoke-free Nova Scotia, the tobacco reduction strategy. I found if there was leadership from the federal level, having a national strategy, it really propelled the provinces to go forward and do more. The Integrated Pan-Canadian Healthy Living Strategy was instrumental for the provinces to take the lead on chronic disease and related issues of healthy eating in schools and keeping kids active and providing safer environments and so on. It propelled the agenda forward quite a bit.
I have been part of strategies where they start from the provincial level, but we do not have leadership at the national level. I see that in the seniors' injury strategies. We have one in Nova Scotia, and I was just at a meeting in Saskatchewan, where that province is in the process of developing a strategy on injury prevention. B.C. has a strategy on injury prevention.
Without the national coordination and national framework, it is difficult to find that continuity, to learn from the process. In Nova Scotia, it was such a struggle to find information for the strategy. In Saskatchewan, we are a little bit ahead in terms of being able to learn from the experiences of B.C. and Ontario. However, it would be wonderful to have a national framework on injury prevention to enable the provinces to work collaboratively to further the cause of the important issues that affect us all, population health and health disparities. Seniors' issues are very important. Falls are a leading cause of death in the elderly. I know there is another Senate committee on aging.
I think we need to coordinate those levels as well. We have had discussions and deliberations on population health, but those issues affect aging and aging populations. What is intersectorally there, horizontally at the national level, but also connect to the provincial issues as well. It is important to have it both ways, but to have the national leadership is key.
Senator Fairbairn: Any thoughts from others on the issue of literacy?
[Translation]
Ms. De Koninck: The Canadian health system reflects Canada's values, and we know it is currently under pressure. All the policies, all the tax measures that support values of fairness — when I think of fairness, I include values that concern the definition of overall health — and all the policies and orientations that can be proposed at the federal level are always very useful in enabling the provinces to implement initiatives.
In closing, I would say that it is in Canada that the research is done. That is where the money is, and that is where the major decisions on research orientations are made. The provinces subsidize research, but the major public institutions, such as the Canadian Institutes of Health Research, play a decisive role. The messages that can be sent are very important.
[English]
Senator Fairbairn: Ms. Hills, in your efforts over time, has this learning and understanding issue among all levels of our society been one that you have had an opportunity to take a deeper look at?
Ms. Hills: Yes, and I would say that most of the work has been done by Mr. Irving Rootman, my colleague at the University of Victoria. There is some interesting work happening here with the Canadian Public Health Association; there has just been an expert panel reporting on literacy and health. It is quite interesting. Mr. Rootman was CIHR chair in the area of health literacy.
We have a particular interest, probably because of my background in nursing, in health literacy as opposed to health and literacy, literacy and health. We are just doing something right now through the Canadian Council on Learning. They have set up a number of knowledge hubs across the country. University of Victoria has established a learning hub on health and learning. One of the main areas, of course, is health and literacy and health literacy. We are taking up the initiative around health literacy and creating a documentation centre around how health literacy influences self- management in chronic disease prevention.
I think there is a lot of work in this important area. If you have not talked to Mr. Irving Rootman yet, he is someone you should talk to, because he is one of the leading researchers in this area in Canada.
Senator Fairbairn: Mr. Prial, have you anything to add?
Mr. Prial: Not to this topic.
The Chair: Ms. Johnson as I mentioned in the opening, our concept of dealing with this issue of population health is the provision of a basic health platform drawn from the 12 determinants of health, even though there may be more. On top of that platform, is the human life cycle and the capability of wiring that, so to speak, to connect the existing information systems.
You mentioned a very important area, which is at the beginning of the life cycle. You have the special interest in healthy children and girls. Our report will start with parenting, then maternal health, then early childhood development and we will continue on to deal with healthy populations through the life cycle. As you mentioned, aging is very important. I am deputy chair of the Special Senate Committee on Aging so there will be continuity.
I want you to come back to girls. One of the real health disasters we have in some areas of Canada is poor maternal health. Children are being born with physical, mental and emotional disabilities. We still have children having children in Canada. The reason parenting is discussed first is, I believe, we have an obligation to educate young girls. We need to empower girls to know that they have control over their destinies and their bodies. Many of them, particularly in the poorer areas, may not realize that.
I would like you to comment on what you are doing about that concern.
Ms. Johnson: I have not done any work in terms of parenting. However, what Nova Scotia and Saskatchewan were looking at healthy children. We are working with the neighbourhoods in terms of resources to be physically active, to have healthy eating through the school system, et cetera. Those are the activities that we are doing in Saskatchewan.
In Nova Scotia, as well, through Active Kids, Healthy Kids, a health-promoting schools initiative, those things are happening at the behavioural level. That initiative comes under the umbrella of the social determinants of health. We are ensuring it is accessible and available to all.
One project I did in Nova Scotia looked at the nutritional risks of pregnant mothers. We had a toolkit we had developed that used card-sorting activities as to the understanding of consumption. We found that low-income mothers, who were younger, were not eating as healthily as they should. However, it was not a question of just food and availability; it was a broader question of poverty, the education level and all the other social determinants that underpin and propel the issue forward.
We need to work on the causes of the cause, which is repeated often, to understand the underlying causes. We need to provide more education opportunities and improve literacy. The social welfare system is another issue as well. We have done a couple of projects on affordability of food. The low-wage earners are not able to afford a healthy diet. That applies to pregnant mothers, as well; they are not able to afford a healthy diet for their own bodies or the development of their babies.
We need to look at it more multi-dimensionally as opposed to looking at parenting as consisting solely of being a bad parent and not eating the right food.
The Chair: Quite apart from the moral responsibility and the compassionate component, the economics of an unhealthy child are devastating. Some of them are born with disabilities they will carry throughout life, which may be a short life or one with reduced life expectancy. Regardless, during that life cycle, they will not have equal opportunities and they will be a tremendous burden on society.
Have you come across any information on the economics of unhealthy maternal situations and unhealthy children?
Ms. Johnson: I have seen a lot of literature on the consequences, such as the developmental issues, the social issues, and integration and being part and so on. However, I have not seen a lot on the economic consequences of early childhood development in terms of how much it costs and the additional burden to society.
We still rely on data such as life expectancy. Life expectancy does not tell us if a life is spent in good health or poor health. If the life expectancy is already compromised for those who did not have a good start in life, what portion of that is in good health and what portion is in poor health? Poor health is resource intensive and is a greater cost to the health care system.
There has been work among the elderly on that which shows that considerably high-percentage expenditure and health care access happens in the last 10 per cent of their lives; the expenditure rises quite a bit. However, I have not seen anything in children in that economic consequence part.
The Chair: Thank you.
[Translation]
Ms. De Koninck: You have raised an extremely important issue, the issue of children. That issue probably engages us to a high degree when we think of children.
Together with colleagues, we recently conducted studies on drug addict mothers, women who use drugs and become mothers. Among other things, these are women who give birth to children who are often exposed to tough conditions. What we found in our work is that the life histories of these young women could very well be explained by the fact that they use drugs. We came to the conclusion that this was the culmination of extremely difficult situations for the vast majority of them. A number of young women who start using drugs do so out of rebelliousness, but a very large number do so because they have had an extremely difficult childhood, spent in poverty, with violence and so on.
We always come back to the same question. If we could take action with families where there are these kinds of problems, these young women would not fall into substance abuse with all that entails. What is traumatic is that, when they have children — what is called ``a key moment'' — at the moment when they give birth, they often want to change their lives. They have hope, they suddenly see a child, someone they can take care of, whereas they have often been mistreated since childhood. However, we do not have available services; we do not invest enough to support these women so that they can take charge of their lives and raise their children properly. We know in advance that those children run a high risk of being placed elsewhere; so the cycle starts over.
As my colleague said, it is very important to change our approach to parenting. We must change our approach and look at the conditions in which people become parents and how we support them. A child who is born healthy, but is exposed to tough socio-economic conditions in the initial months, may be marked for life, even if the parents subsequently manage to do well. Colleagues from the Université de Montréal are doing research on that.
So we should always take this overall approach: children and their environment. A poor child has poor parents. So we look at the environment and we try to change the conditions if we want to avoid the poverty cycle and health problems.
[English]
Mr. Prial: I will mention research in Ontario conducted by the System-Linked Research Unit on Health and Social Service Utilization, which is affiliated with McMaster University. I do not know if you are familiar with that group. Although not specifically maternal and child health, a number of studies done seek to demonstrate the economic tradeoffs associated with the lack of provision of various other types of social supports. In particular, the benchmark study was When the Bough Breaks, published in 1999.
There have been subsequent studies. They have an interdisciplinary team, which includes a couple of professors of economics at McMaster who sought to do the analytics. Although the studies are small, because they like the notion of applying random controlled trials to social policy experimentation, they have a bit of rigour there that we have not seen in other areas. It is well worth looking at.
The Chair: Thank you all very much. Unfortunately, our time is up, but the good news is there is a free lunch jut outside the door. Thank you, honourable senators and panel.
The committee adjourned.