Proceedings of the Subcommittee on Population Health
Issue 1 - Evidence, March 5, 2009
OTTAWA, Thursday, March 5, 2009
The Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 10:45 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 have an important hearing this morning on intergovernmental and intersectoral collaboration for population health. We will get started right away with Neil Bradford from the University of Western Ontario, who has written extensively on this subject. Without further ado, Mr. Bradford, we would like to hear your presentation.
Neil Bradford, Associate Professor, Political Science, Huron University College, University of Western Ontario: It is a pleasure to join your group for these important deliberations on population health matters. My brief remarks today will be perhaps a bit broader in terms of setting a context for thinking about governance and policy development in this field, perhaps in a sense setting a framework for some of the more focused presentations that will follow. I would like to highlight five themes here, as set out on the slide show, related to what has come to be known as place-based, community-driven approaches to public policy and population health. These five themes are identifying some of the new policy knowledge; discussions of a new policy model or innovation framework; some of the comparative experience with these approaches in the European and American contexts; suggest to you that Canada is now at a moment where we can learn and take advantage of some of the work that has been done in other jurisdictions; and then some brief ideas about moving forward.
In terms of this context and the new policy knowledge, the interest in place-based, community-driven approaches really reflects a growing awareness and understanding of so-called wicked policy problems, those that are complex, deep-rooted, interwoven, territorially-specific and beyond the reach of any single actor to solve. Some major research streams are converging around this understanding of wicked problems and what the policy implications are. I am highlighting three for us: the social determinants of health, work on neighbourhood effects and area-based empowerment. Each of these bodies of research suggests not only how the problems are increasingly spatially concentrated but also how they require community involvement and engagement in order to make progress.
The Harcourt report on cities and communities really summarized the essential message here: We need locally appropriate solutions to issues of national consequence playing out at the local level. The recent Ontario Report on the Roots of Youth Violence reinforced and elaborated this message on the importance of the place-based, community- driven policy strategies.
In terms of some of the features of this new policy approach, there is a strong consensus in the research literature that this strategy brings together governments and communities in a new and different relationship beyond the traditional categories of centralization and decentralization toward thinking about horizontal and vertical collaboration for multi-level, joined-up decision making focused on strategic outcomes that cross individual mandates but align priorities. Involved as well is a harnessing of the kind of local knowledge that is available at the community scale, leveraging those networks and assets for problem solving and improved policy-making and thinking about preventative, upstream investments to deal with root causes as well as promote longer-term well-being.
There is the concept of working with and through often quite innovative local governance bodies or collaborations, such as community hubs. Certainly in the population health field we have seen across the provinces a variety of regionally based collaborative arrangements, such as the local health integration networks in Ontario and the federal Community Action Program for Children and so forth.
I would go further to say that when we look at the progress on this community-based model, over the past two decades we have seen some really interesting developments across the countries in the Organisation for Economic Co- operation and Development, OECD, that are seeking to test out and institutionalize these kinds of strategies. There are two countries that serve as interesting reference points for Canadian policy communities as we move forward: England and the United States. They are notable for the particular pathways that each has followed in moving on the community-driven, place-based community approach.
In England, we have seen an extensive investment in what is known as joined-up government, the National Strategy for Neighbourhood Renewal, the Social Exclusion Unit linked to local strategic partnerships — a whole range of government structures to try to address these localized problems in a more collaborative way.
The research and evaluation literature is interesting with respect to the English approach. There has been clear acknowledgement that the U.K. has elaborated a national and comprehensive model, although in some sense it may be too top-down and prescriptive in the way it deals with local communities, and that there has been a centralization of the indicator and target or outcome process that has limited discretion and creativity at the local level.
One might summarize to say that in the British case they have been very good at the horizontal dimension of relationship-building and less robust in their approach to the vertical community-building side of things.
The United States is, in a sense, the mirror image of that English model. With community building, there is a long history in the United States through things like community development block grants, community empowerment programs, the work of national foundations, building a community-based infrastructure for joining up. The strength of the local and decentralized approach in the United States also has the consequence of perhaps being a bit too bottom- up and fragmented, and many of the community-based actors are situated in the absence of a broader supportive national policy framework that leaves communities trying to go it alone.
You might summarize that the American experience has been stronger on the vertical relationships down to community level but less robust in framing them through supportive national horizontal policies.
Where does Canada fit? The literature or consensus seems to be that in Canada we have been a bit ad hoc and lagging — slow to start, if you like, in embracing these innovations.
The literature identifies a variety of important obstacles or challenges on the intergovernmental front in terms of the relationships between federal, provincial and territorial governments that remain difficult and contested — a bureaucratic culture that is characterized as vertical departmentalism that is rooted in important ministerial accountabilities but is still a kind of barrier to this sort of collaborative work, and then a hierarchical policy culture as well that has limited community and municipal capacity and engagement with local actors, not giving them that seat at the table.
In comparison to England and the United States, it is fair to summarize that Canadian progress has been quite modest. I would add that a tremendous amount of research has been done on issues like horizontality and collaboration across departments, but that has not really translated into a national framework for policy activity. I would suggest here that there is a kind of latecomer's advantage that now presents itself to Canadian policy communities. We can learn from others about trying to find that appropriate mix of top-down and bottom-up policy models, balancing local flexibility with national accountability.
We can certainly learn from our own ongoing experiments, and I have listed a few of these here that are quite exemplary. We can learn from our own broader pan-Canadian political frameworks that have been initiated in the past few years.
I would say by way of summary with these points that all of these initiatives in some measure and in varying degrees are trying to find framework agreements for governance structures that will identify strategic outcomes, roles and responsibilities; are trying to find ways to integrate service delivery at the community level; are trying to find ways to pool funding and develop contribution agreements that focus the commitments of different departments; are trying to develop standardized reporting relationships for community actors in the different departments involved; and, in turn, are working on shared accountability frameworks and evaluation processes. This is not to say that any of these experiments or models underway in Canada have put the package together, but there are certainly important lessons to draw from these various innovations that are underway and experiments in our own jurisdiction.
I suggest that, as we move forward to think about possibilities for learning from these ongoing experiences, thinking about appropriate accountability and evaluation frameworks that, as I put here, are patient and shared, respecting the complexity and the longer-term nature of this sort of policy work, we learn to leverage more our success stories, finding out what works best so that we are not left with a series of one-off, short-term pilot initiatives but are identifying those practices and innovations that work and ought to be more fully integrated into our policy approaches.
Then there is this linking, building our knowledge cumulatively across these different experiences, working on knowledge transfer across the different sites of localized collaborative policy-making, to foster a community of Canadian research and practice. The other two jurisdictions I mentioned are quite a way ahead of us on this. In the United Kingdom, the Academy for Sustainable Communities was created to bring together the different actors in this collaborative policy work. In the United States there has been a long history of national foundations that have done similar kinds of intensive action research and have disseminated knowledge about what the most appropriate institutions and strategies would be.
I would close then with thinking about these issues in terms of leadership and more broadly with respect to Canada's moving forward, and that we recognize that there is an important federal leadership role that we can think about here. In these place-based, community-driven approaches, responsibilities are shared across numerous jurisdictions and sectors. They do play out in a whole host of places from the smallest rural communities to some of the larger neighbourhoods in our urban centres. No single actor owns the problem, but there is a need at this point for the kind of national leadership that can move things forward.
I would suggest here that much of the substantive policy work will be done at the provincial level when we think about these sorts of complex, wicked social policy challenges. That is where the jurisdiction does reside, but that is not to say that there is not still a need for this kind of catalytic convening and coordinating role. The great opportunity for the federal government is to demonstrate that kind of leadership and work on these integrative opportunities.
I would close by noting that in the context of the current economic situation where there will be a substantially larger amount of money in the context of a stimulus package flowing out to cities and communities, these lessons may be increasingly important because there will have to be capacity on the ground to receive these funds and work in creative and constructive ways to roll out programs and, in turn, put in place frameworks to be able to assess and account for those monies.
This agenda speaks to our current challenges.
The Chair: Thank you very much, Mr. Bradford. That is highly relevant. We will dig into that in some depth a little later.
Perhaps we can move on to Trevor Hancock, who has written extensively about population health, and in particular organizations at the community level, where we can get some of our thinking to the ground.
Dr. Trevor Hancock, Health Promotion Consultant, as an individual: It is a pleasure and an honour to be here. I did write a fairly extensive response to your fourth report, which I believe you got back in the summer, and I am hoping you got the speaking notes I put together for this morning. I will not go through everything that is here because it would take me more than the five to seven minutes I have. In many ways, my speaking notes reiterate, strengthen and focus what I said in my response back in the summer.
There are three areas I would like to explore. I noticed your interest in framing today's discussion in mechanisms, models and principles. I wish to start with three principles and explore each of those briefly.
The first principle is that people must be at the centre. I have given speeches that I have called "It's the people, stupid,'' which is a takeoff on the famous Bill Clinton presidential campaign quote, "It's the economy, stupid.'' My response at the time was always no, it is not about the economy; it is about people. People must be at the centre.
The second principle is that we are all in this together. There are costs that everyone in society bears when we do not do a good job of human development and improving population health, and there are benefits that everyone shares when we do a good job of it.
The third principle picks up on some of the topics that Mr. Bradford addressed, which is that community matters and place matters. Fundamentally, we need to address these issues in the places where people live, learn, work and play, which is the guiding principle behind the healthy cities and communities movement that I was involved in developing back in the early 1980s. As Senator Eggleton knows, we did some pioneering work in Toronto when he was mayor, which continues to this day.
First, in terms of people being at the centre, I would argue that the raison d'être should be — not necessarily is, but should be — human development, that we should be in the business of developing people. How do you develop human capacity, human ability and human potential? How do you develop people? That is the business we should be in at all levels of government, whether federal, provincial, territorial, municipal or Aboriginal.
I have come over the years to shift my focus to a broader picture, not just of population health but to locate population health within an even broader paradigm of human development, and that is what we are about. Issues such as social and economic development have, as their purpose, human development. It is not about developing the economy. It is about developing society, but really the purpose of that, again, is the development of individual people.
I am sure we will discuss these topics later, but one of the mechanisms that occurs to me is the notion of ministers or departments of human development. It is quite strange that we do not have cabinet committees, for the most part, on human development. We have cabinet committees on economic development, on resource and sustainable development and on social development, but not on the development of people.
There is the idea of some sort of national council or commission that would bring together national leadership. By "national,'' I mean the various jurisdictions — federal, provincial, territorial and municipal — but also the private sector, the NGO sector and the community sector.
One of the ideas Mr. Bradford spoke about concerning human development and cross-government policy is the notion of conducting human impact assessments. Again, we conduct economic impact assessments and sometimes social and environmental impact assessments, but for some reason we do not conduct health impact assessments or, even more broadly, human impact assessments.
Some of the processes involved in conducting these assessments include explicit human development plans with goals and targets, and reporting back, in relation to some of the accountability issues that Mr. Bradford spoke about regarding reporting back on human development. At a national level, we need that big, overarching framing and leadership around human development and population health.
My second principle, as I said, is that we are all in this together, whether we are talking about government or private sector, or community or municipal. There are benefits that we all share in from better human development — to begin with, healthier, happier people; less pain and suffering; healthier communities; fewer social costs; and improved productivity.
The role of the private sector here is interesting. I commend the Conference Board of Canada on its recent report Healthy People, Healthy Performance, Healthy Profits, which begins to look at why the private sector should be looking at and investing in population health and the determinants of health. That is very positive.
Tied to that is a notion from years ago, back in 1984. For the centennial of the Toronto Board of Health, we organized a conference called "Beyond Health Care.'' Senator Eggleton was present as the Mayor of Toronto. We began to talk about the notion of healthy public policy.
In more recent years, I have also come to talk about the notion of healthy private policy — issues like portion size, which is an important issue around obesity and the amount of food we are offered and then eat. I cannot see governments stepping in and starting to regulate portion size. I think that will remain a private policy. How do you then work within the food sector to make that a healthier private policy than it currently is, which is that bigger is better and more is good?
To see us as all being in it together, the notion of multi-sectoral leadership groups applies. I mentioned the idea of some sort of national commission or council on human development and population health.
I was impressed by the work that went into the Premier's Councils in Ontario back in the late 1980s and early 1990s that tried to bring together health, economic and environmental factors. It was an interesting model. The councils were chaired by the premier. A third of the members were ministers, a third were from the sector that was the focus and a third were civic leadership across sectors. It was an interesting model of how to bring those elements together.
Our all being in it together is also about community participation and democracy. Some years ago, soon after the Iron Curtain came down, we did work, funded by the Danish Democracy Fund, on how to do healthy city work in Eastern Europe. The Danish Democracy Fund funded the work because they understood that learning how to make a city healthier was also learning about democracy. There is a strong community-based, participatory democratic process to this.
I will quickly highlight my final point, because I realize time is short. Community matters and place matters. In health promotion, we have what we call the settings approach. If you want to improve population health, you have to deal with it in the settings where people lead their lives: homes, schools, workplaces, hospitals and neighbourhoods.
In my notes I have laid out another notion — I will not speak to it in any detail now — of how we bring together national efforts around healthy homes, schools and workplaces. There is a national Healthy Schools Network, but it could certainly be strengthened. I do not see anything similar for healthy workplaces yet, not in the broad sense that I am talking about, with regard to healthy homes and communities.
Back in the early 1990s, we had a Canadian Healthy Communities Coalition. It died in the budget cuts in 1992 and has never been resurrected, but I think it needs to be.
If any place in the community should be the healthiest workplace, where you get the best food and a good night's sleep, it should be the hospital, but we know it often is not. How do you create healthy, environmentally responsible hospitals that are healing workplaces?
All of these elements form part of what makes for a healthy community, and so the overarching issue is how to create healthy communities and how, as Mr. Bradford said, to address these wicked problems, as he called them, at a national level and a local level. That is where many of the answers lie, and that also means looking at the role of municipal government and how to strengthen it.
I will stop there and I would be happy to engage in discussion with you later.
The Chair: Thank you very much indeed, Mr. Hancock. You have been a tremendous help to us so far, and we will look to you for more help.
Our next witness is David Hay, who also has an extensive background in writing about and researching population health. Mr. Hay, we would like to hear from you.
David Hay, Principal, Information Partnership: Thank you all for the invitation; it is certainly a pleasure to be here.
I have done a lot of work over the past 20 or 25 years, broadly speaking, in the population health area. There has always been, as part of that work, this issue of decision making: how decisions are made, who makes the decisions and what are the structures and institutions that support that decision making.
Certainly, I applaud your focus on governance and on these issues of how to get a whole-of-government approach as you have written in your report to address these issues of population health. It is a critical issue that has been increasingly researched. Mr. Bradford and Dr. Hancock described better examples, but we are still behind. Mr. Bradford described the U.K., the U.S. and other jurisdictions in terms of our ability to promote collaborative governance.
My comments today are related to this topic of collaborative governance, and I will talk about some of the current realities, challenges and continuums and then about a couple of points in moving forward. This is a very big area and we are touching only on a few issues here. Hopefully, we can get into these more deeply in the question period.
I want to talk about four things: my definition of collaborative governance, some current realities, some challenges to address, and a couple points about moving forward.
I am currently doing some work with the federal government through the Policy Research Initiative. About a year ago, the Policy Research Initiative, jointly with the Public Policy Forum, held a workshop on collaborative governance and produced a report. It is on the Public Policy Forum website. It was about defining the federal role in collaborative governance. If you have not seen that, I would recommend it as a worthwhile publication to review. It addresses many of the issues you are examining.
There they talk about collaborative governance as a non-hierarchical relationship between governments and non- governmental actors. I would add also within and between governments and non-governmental actors, because a number of issues about collaboration exist that need to happen within organizations themselves or within particular levels of government, since there are many purposes for collaboration.
There are integrating functions where you want to bring finance, policy and program people together. There is collaboration across jurisdictions to join those actors and to address particular policy problems. There is collaboration between disciplines and departments; when we talk about "horizontality,'' those are generally the kinds of things we are thinking about. Collaboration is also necessary in integrating sources and types of information, such as quantitative and qualitative research information, and whether we take information from censuses, sample surveys, case studies, and so on. There is a necessity to collaborate there and bring information together as well. There is collaboration between sectors and between interests. In social policy terms, we talk about the family, communities, community organizations, government and business as sectors. They are broad definitions and they overlap, but those sectors need to find ways to collaborate as well to address problems.
Another important area that sometimes is not talked about as much is that it is necessary to collaborate between perceptions, attitudes and values — dialogue. We do not always come to the table with the same perceptions of a particular problem. Therefore, there is a necessity to collaborate and share there as well.
Governance relations also have to be purposeful relations where there are shared understandings of the policy challenge and the goals to achieve in addressing that challenge. It is the purpose that brings people around the table and helps them to focus and integrate in all those ways I described to solve those particular problems.
Some current realities are necessary to highlight the current tensions. Mr. Bradford has written about characterizing federalism in the current and previous governments. He described previous governments as practising deep federalism where the policy goal demanded that both horizontal and vertical collaboration be made.
The current government has described itself as open federalists respecting more the constitutional division of powers and not treading on people's constitutional turf. It is difficult, obviously, from the federal government's perspective to work in the area of health when constitutionally it is provincial jurisdiction and authority to act in those areas. Where we are in terms of federalism and how we approach it will depend on a government's perspective on issues it will support or challenge and how problems are addressed.
Where are we on the continuum of leadership or unilateralism? Leadership is always necessary, but sometimes it is simply unilateral and autocratic. Hence, there always needs to be reflection when we talk about leadership. Is it leadership within a partnership or leadership to ensure you get what you want out of any particular partnership or collaboration?
Another issue is who we answer to in policy decision making. Are we truly respecting triple bottom lines? Are we ensuring that we have lenses of social, economic and environmental decision making that go into decisions? Sometimes social policy writing has been characterized as "fiscalization,'' where the goals of efficiency and affordability essentially override goals of equity and social justice. In such cases, there is less of a balance and more of a push for economic bottom lines.
Is there information overload or inadequate information? We live in a world where we have so much information we do not know how to deal with it. However, access to information is not equal, shared or supported. For many community organizations, this has improved greatly over the last number of years, but they do not have access to the same type of information that politicians, bureaucrats and federal public servants have. There are inequalities in access to information.
In discussing our realities, do we have an innovation gap? Are we lacking ideas to solve problems or do we have gaps in supports for innovation? When Thomas Homer-Dixon came out with his book a few years ago on the ingenuity gap, I engaged in an email exchange with him saying it was less an ingenuity gap and more a gap in the structures and institutions that support ingenuity and innovation, incubate it and allow it to develop. There are many structural barriers to that.
What are some of the challenges to collaboration? If I take a perspective of the federal government, organizational culture itself is a challenge. The federal government is generally risk-averse. There are not many rewards for pushing the envelope and trying to do things differently. Many times, in partnership or collaboration initiatives, the federal government is seen as the big brother and the one directing things rather than truly acting as a partner.
Regarding vertical authority and accountability, there is much discussion and writing on "horizontality.'' However, a large barrier to getting things done is simply the very direct lines of vertical authority and accountability. That characterizes the way and your ability to work horizontally. It is difficult if you have to go away from your partnership initiative every time and return to where you come from, to your vertical structures, to ensure decisions are stamped there as well.
Our whole public accountability regime is quite rigid. It is important, obviously, to make sure that public dollars are spent properly, but it has put a constraint on the public service's ability to act. The administrative burden is terribly unwieldy and takes many person hours and money away from getting the job done.
There is a challenge in support networks, institutions and engagement. Many informal networks exist, but there are no good hub-and-spoke models of support to make sure there are information and decision-making channels. Mr. Bradford spoke to that as well.
I spoke about information gaps, so information infrastructure is also a challenge and needs work.
Many of these collaboration initiatives do not happen unless there is money on the table either to be used in shared decision making or for people to take bits of and work on their own initiatives. We did a report when I was with the Canadian Policy Research Networks looking at the management structure for children's programs, what they called the joint management infrastructure for the Canada Prenatal Nutrition Program and the Community Action Program for Children, and we found that one of the main reasons people came around the table to collaborate, although there are other successes, strengths and weaknesses from that model, was money. They said explicitly that when the money changed and when the early childhood development initiatives came in subsequently, much of the energy behind that whole model dissipated and left.
Moving forward, certainly leadership is required and champions are needed. There are a lot of talk and good sense behind this whole business about collaborative governance in the complex world we live in and the constitutional division of powers, but you need supported leadership not just from the top but from everywhere, and champions need to advocate this. As I said before, if we do not get champions in the federal government, generally you cannot see initiatives going forward without that leadership.
As I touched on earlier, in order to move forward, you need clearly defined and goal-oriented policy problems in order to promote collaboration. There is a lot of activity in the country now, particularly amongst provinces and communities and doing things around poverty and addressing the issue of poverty in Canada, and it is the focus on the issue that helps to build the collaboration.
As far as secretariats or hubs, over the years, many of the institutions that brought people together and promoted networks and shared understandings have gone by the way. Many of them were in the non-profit sector. Some were creatures of government, such as the Economic Council of Canada and the Law Reform Commission of Canada. They have disappeared, and performing that networking and integrating function is very important.
I would say in summary that there are two critical issues to address. One is obviously the governance, as I have described, and the other is these challenges that need to be addressed, as mentioned by Mr. Bradford and Dr. Hancock, in the business of capacity development to ensure that the citizens of this country have the capacity to engage meaningfully in these types of exercises. Thank you.
The Chair: Thank you very much, Mr. Hay.
We will be taking a break at 11:30 to bring in some witnesses from British Columbia over television, but we have five minutes, so let me exploit all three of you for five minutes. The other senators will be questioning you later on when we have everyone aboard.
Our objective in doing this report was to try to elevate the status of health, well-being and productivity in Canada, which is at a very low rate considering all of the resources we have and our educational status and our health care delivery system. The testimony has led us down the road to believing that the emphasis has to be on the building of healthy communities. However, because we have such great Canadian diversity, top-down organizations will be very hard to apply to, for example, the Chinese community in Vancouver, in the Chinese community in Toronto, in the Indian community in Toronto and some of the communities in Montreal, and, of course, in some of the rural communities and smaller provinces. Nonetheless, as you have just said, Mr. Hay, there has to be leadership. We have been groping for how to package this.
We want an all-of-government approach, but how can we involve everyone? We do not want top-down administration of the system. It has to be bottom-up, from the community. I want to hear your comments, but I am trying to lead you. I cannot beat around the bush any more. I have not mentioned this to date, but I think time is running out. We have to write our report, so I will spring this on you. My own feeling is that we need a federal minister of human development and we need a corresponding minister in every province. We need a corresponding officer in every major city, and we need a corresponding person in each community, but the communities have to organize themselves. Tell me how wrong I am.
Dr. Hancock: Well, I would not say you are wrong. When I have talked with communities, I have often talked about it being both top down and bottom up. It is the nutcracker phenomenon, and a nutcracker has two arms, top down and bottom up.
As Mr. Hay mentioned, that would work only if resources are applied at the local level. You cannot get this for nothing. Those resources have to be applied from the federal, provincial and territorial levels, both to and with municipal governments and also with communities, because they are not necessarily the same, and obviously they need both to be working together.
To a certain extent, those resources have to come without strings attached. It drives communities absolutely nuts, particularly if you get away from the very big cities and down to smaller communities, to get all of these stove-piped contributions coming in, all of them for a specific purpose defined by people "up there,'' none of whom have talked to each other before the contribution came into place, and the communities are running around trying to respond to all these different things. What they really need is a pot of money with the freedom to decide their issues and priorities and how to use it. That is not the way we normally do business. It is risky, and Mr. Hay talked about the risk-averse nature of decision making, but in order to get this kind of innovation, you have to take some risk and recognize that not everything works. We also have to understand that "failure'' does not mean that it was a failure. You learn by mistakes as much as you learn from success, and we need a higher tolerance of failure in order to make those learnings.
I would agree with you, and I would add that maybe that is where all of these offices would come together, the notion of a commission of some sort that was a bit at arm's length, that was set up by statute so that it cannot disappear at the whim of the next government, whoever that is, but brings together the private sector leadership and the community sector leadership. You have to get them involved as well.
Mr. Bradford: I would certainly support what Dr. Hancock has said and echo what Dr. Keon said. There could be three functions for such a ministry. The first would be to deal with the money question. The American experience with community development block grants is interesting. A combination of national standards or goals is rolled out to allow for flexible integration and tailoring based on community priorities and inputs. We did some of that with the federal gas transfer tax: there were broad goals but then diversity was allowed at the local scale.
The second point for that ministry could be research. There is a real priority on greater understanding of both the administrative challenges and also the sorts of wicked issues that are being dealt with here. There is a real need for this kind of knowledge exchange and research activity.
The third point would be to link it to action through the kinds of demonstration and pilot projects that we in Canada are good at. The gap in Canada is learning and leveraging from the range of experiments and the five-year projects that we have running now on homelessness and in population health, in urban development agreements. Having a ministry that would be a coordinating point for those kinds of pilot and demonstration activities and systematically learning the lessons would be a terrific start for that kind of institution.
Mr. Hay: It is a good idea. I would suggest some sort of priority agenda to guide that. You need to come out with some sort of focus on what the policy problems are, and to simply suggest taking a whole-of-government approach to human development as defined as a narrow set of issues would be important. The vertical integration that would come as a result is very good.
There is lots of experience. My first job out of graduate school was at a social planning council in British Columbia. I worked with people who had years of experience working as community developers in cities from federal funding envelopes in the 1960s and 1970s. These things have been done before, although perhaps not directly tied in a line as you described.
The research is important, but information infrastructure is also important, which means access to information broadly and publicly and no cost or low cost, in a sense. There are research skills in the community. People want the information to work on in their communities for their purposes rather than have it done by somebody else. I know that is not what Mr. Bradford meant, but it is a matter of bringing those two together.
The Chair: Thank you. Joining us now from Western Economic Diversification is Ms. Michelle Neilly, Director General, BC Operations; and from Vancouver Agreement, Ms. Christine Lattey, Executive Coordinator.
Ms. Neilly, please proceed.
Michelle Neilly, Director General, BC Operations, Western Economic Diversification Canada: Thank you. I hope to give you a short history of the Vancouver Agreement, the context and its strategic directions.
Statistically speaking, the Downtown Eastside of Vancouver has a population of approximately 16,000 and is considered one of the poorest postal code communities in Canada in terms of income per capita. It is important to note that the community also includes the historic neighbourhoods of Chinatown, Gastown, Strathcona, Victory Square, and the areas near Oppenheimer Park and the Port of Vancouver. This area was once a vibrant commercial core of the region. It had many leading retail stores, manufacturing plants and tourist attractions. One of the flagship stores at the time was Woodward's, which closed in 1993.
Median income levels in the area are approximately $12,000, and the majority of the population is considered low income. Approximately 6,000 residents living in the community rely on government assistance. Despite the many weaknesses that this neighbourhood has, the community has a strong sense of community. There is an active network of community organizations. Many events, festivals and celebrations take place, and it is a culturally rich community. Over 50 per cent of the population is Chinese, 11 per cent are Vietnamese, and almost one third speak a language other than English.
Between 1997 and 1999, there were rising rates of HIV infection and death rates. Local authorities declared that the Downtown Eastside was in a public health crisis. There was a call for better coordination of programs and services among different levels of government, which were largely operating in silos separate from one another. As the popular saying goes, a crisis is a terrible thing to waste, so the City of Vancouver played a leadership role. They went well beyond their mandate and urged both the Province of British Columbia and the Government of Canada to join with the municipality to collectively take action.
The key objective of this action and of the Vancouver Agreement is to have more effective government and community performance in specific neighbourhoods and on specific city-wide initiatives, and to improve the conditions for individuals, businesses and communities as a whole. During the summer of 1999, the Government of Canada, the Province of British Columbia and the City of Vancouver signed an urban development agreement called the Vancouver Agreement. The purpose of the Vancouver Agreement was to coordinate and maintain an effective response to economic, social and public safety challenges in Vancouver's inner city. This also includes health and housing. The urban development agreement is a multi-year, cost-shared, tripartite agreement. The original Vancouver Agreement was for five years; then it was renewed and extended to March 31, 2010.
Through the Vancouver Agreement, all levels of government have agreed to focus on four outcomes: first, a growth in number, size and diversity of local businesses and increased and diversified employment opportunities for local residents; second, improved health outcomes for local residents; third, improved safety and security; and fourth, improved housing options that include affordable rental housing and supportive and transitional housing.
The Vancouver Agreement has six key principles that guide its direction. The first one is informed decision-making, ensuring that decisions are linked to sound strategic planning. The second is innovation. The agreement promotes and supports innovative ways of addressing issues and delivering service. The third one is respect for diversity. Many communities belonging to the inner city of Vancouver have diverse interests and needs to be understood, supported and balanced. The fourth principle is community engagement to ensure that members of the community and stakeholders are engaged in the process. The fifth is collaboration. The Vancouver Agreement works with other institutions, the not-for-profit sector, education institutions and the private sector. The sixth principle is accountability for public funds.
The Vancouver Agreement supports but does not replace the goals or the accountabilities of public agencies. The implementation of the Vancouver Agreement strategies is undertaken either by individual public agencies or through agreements with public agencies and the not-for-profit sector. Through a series of committees, project teams and interdepartmental communication within all three levels of government, the Vancouver Agreement helps public agencies to work toward the common vision and common four outcomes.
These relationships build upon an agency's respective responsibilities. While each participating organization in the Vancouver Agreement adheres to its respective existing programming and accountability requirements to deliver service, the Vancouver Agreement provides an opportunity for the groups to work together and to identify joint initiatives.
The Vancouver Agreement has been able to address some of the complex socio-economic problems with a comprehensive approach. Governments are better able to coordinate and collaborate now on programming and services.
On slide 5 you can see the summary of where things were in the late 1990s and some progress that has been made. Crime rates have decreased by 14 per cent from 2000 to 2005. Income levels have increased for men and for women. Business activities have expanded. There has been a significant amount of development in this area. There are now 3,600 market housing units being built or already built, and there has been $500-million worth of private and public real estate investment. Death rates due to alcohol, drug use and drug overdose, HIV/AIDS and suicides are no longer at epidemic levels. There has been improved collaboration between all levels of government.
In June 2005, the Vancouver Agreement was one of eight recipients worldwide to receive the United Nations Public Service Award for improving transparency, accountability and responsiveness in public service.
Not all of the relationships in the Vancouver Agreement are the same. Mandates, programs and other considerations influence the level of participation and the interest of any given department or agency.
The governance structure of the Vancouver Agreement is outlined in the actual agreement, and it includes three main committees. There is a governance or policy committee, which includes a minister from the Government of Canada, the Province of British Columbia and the Mayor of Vancouver.
The Vancouver Agreement includes a management committee, which is compromised of an assistant deputy minister, again, from the Government of Canada and the Province of British Columbia, as well as the city manager for the City of Vancouver. This committee is responsible for the tripartite intergovernmental relations, the facilitation of staff participation in the agreement and the funding decisions.
There is also a planning committee comprised of staff, such as Ms. Lattey and me, staff from all levels of government, and we work to support both the management committee in making their funding decisions and also the project teams in their identification and planning of projects.
The Vancouver Agreement has created an effective platform to leverage private sector support. Bell Canada announced in 2005 that it would direct $2 million towards investment over the next four years for Vancouver Agreement-supported economic initiatives. We have also been able to leverage $100,000 from a local credit union to support economic initiatives in the Downtown Eastside.
Working with community and businesses, we have sparked additional partnership opportunities to better coordinate services among the various levels of government. For example, we have a Vancouver Agreement Economic Revitalization Plan in which all three levels of government participated in the cost of research for two years. That plan included 11 meetings with stakeholders and open public houses that were attended by 200 residents and 200 economic development representatives. The plan was finalized in the year 2004 and was adopted by the city council and all of the partners.
In 2005, the Vancouver Agreement was one of three federal horizontal initiatives that were selected for review by the Office of the Auditor General. During that review, the Auditor General concluded that the Vancouver Agreement had a promising governance model, with the involvement of provincial, municipal and federal governments working together to meet the needs of the community.
However, the Auditor General never leaves without making a recommendation, and one of the recommendations was for us to develop a federal accountability framework. We did not have a formal framework in place that outlined the respective roles and responsibilities.
We have a study under way right now. We are using a technique called a linear responsibility chart, which is helping us to examine the roles and responsibilities of the various participating departments and agencies in the agreement in terms of planning, monitoring, reporting and communication.
We are working with departments and agencies, and there are various levels of involvement. You may be responsible for decisions, you may be in the capacity to approve decisions, you may only be interested in being informed, or you may want to only be supportive or consulted. We are working together to put an accountability framework in place, taking into consideration the various levels of participation.
That is a quick overview of the Vancouver Agreement. Ms. Lattey, would you like to add anything?
Christine Lattey, Executive Coordinator, Vancouver Agreement: No, that was a great description. I will wait to hear what the senators wish to discuss.
Ms. Neilly: We would be pleased to answer any questions you have.
The Chair: Thank you very much, Ms. Neilly.
Senator Eggleton: Thanks to all of you for being here. This is one of the most important parts of our deliberation on population health. The social determinants of health cross over many jurisdictions and departments within each government level, and governments are not particularly known for being able to do horizontal links very well. We have been trying for ages to do that.
Having been a minister once myself, I understand the stovepipe or vertical system that we operate under and the desire of the people who are part of that system to ensure their minister always knows the answers and is not caught off guard. It is the old accountability question. It is very difficult to get these horizontal links unless you get commitment and leadership right from the top.
What you have all said today is valuable. I certainly subscribe to what Dr. Hancock said in terms of principles, and to what Mr. Bradford said about the place-based and community-driven programming and policy. Mr. Hay, of course, has further amplified on the collaborative approach.
In our last presentation, we have a good example of how this might be done; or is it the kind of example we should use? It has obviously worked in Vancouver. It works for the Downtown Eastside. I have been through that area, and I can appreciate how the Vancouver Agreement has worked well there. There is another initiative in Winnipeg, and maybe some others of varying kinds, but it certainly is a collaborative approach, bringing all levels of government and the community together to deal with specific issues.
How broadly can we use that approach in the population health context? Is it a good model? What are the dos and don'ts? What have we learned that is good about it and not so good about it? Do you think there is anything else that might also be an application of bringing about all these horizontal links? That question can be addressed to all five witnesses.
Dr. Hancock: Mr. Bradford spoke about the pilot study nature, and I think it was Monique Bégin who said Canada is a nation of pilot studies. I am not sure that doing it on a city-by-city, agreement-by-agreement basis is the way to go. It might work when you have half a dozen or a dozen big cities, but how do you then take that approach to Bradford or Kelowna or Fredericton? How do you systematize the approach so that you do not have to negotiate a separate agreement for every city? I do not think that in the long term it would be an effective way to go.
Also, how do you ensure that within the federal government, for example, that same collaborative approach is modelled across the different departments who have to work together around this? I am not sure I have answers to that, but I would be concerned that it not become a series of special-case, one-off situations.
Senator Eggleton: One size does not fit all.
Dr. Hancock: That is certainly a piece of it. Each community is different. I think you can apply some principles and overall processes, but trying to manage this top down or to manage this as we did it here in Vancouver, saying this is the way you have to do it in Fredericton, will not work.
At the same time, you do not want to have to negotiate 300 separate agreements across the country, so somewhere in between. Discussing with people from the Federation of Canadian Municipalities, FCM, how they would approach it would be valuable.
Senator Eggleton: Okay.
Ms. Lattey: I will make a couple of comments in response. I think your first point about leadership from the top is very important. Given our political system in Canada, where federal, provincial and municipal governments change, you lose the continuity. The reason the Vancouver Agreement was so successful in its first years was because there was a strong commitment from all three levels of government, from high-up political leaders. As soon as governments change, they tend to disregard many of the initiatives of the previous government, and then you lose that commitment. Some way for continuation must be built in; otherwise you get stop start, stop start. That is a key point, and without that, I do not think it can be successful.
The second point you made was about how broad this should be. One difficulty we have experienced in the Vancouver Agreement is that it is very broad. It covers social, economic, health, safety and security. It is very difficult for one group to address all those issues and to coordinate with all the federal, provincial and municipal governments on all levels on all those initiatives. You need a scope that is much more clearly defined.
One of the previous speakers talked about Canada's being an expert at carrying out experiments. Each one of these is, indeed, an experiment that we can learn from. It would be taking on an awful lot to implement something like this across Canada with all sorts of communities. You would have to pick and choose some places where you wanted to give it a try.
Ms. Neilly: I would add to Ms. Lattey's comments that you still need to have a holistic approach. That is why it is challenging. You cannot focus on housing without thinking about the health needs of the individuals in the housing. How are they spending? How are they connected with the community? Do they have friends? Do they have a meaningful employment or volunteer opportunity to go to during the day? You still need to take a holistic approach.
Mr. Bradford: I might take brief issue with Dr. Hancock's notion here. If we are thinking about principles and human development, the strength of this urban development agreement model is that you do get the three levels of government at the table with the different resources they can bring to these complex problems. You also engage the community.
Western Economic Diversification has piloted five of these across the Western provinces dating back to 1981 or 1982. The other regional development agencies in Eastern and Central Canada might also begin to think about what would be an appropriate kind of model for the Toronto area around issues like immigrant settlements and so forth, where there are particular challenges that define that place or community.
One can imagine rolling more of those out in urban centres; they complement very nicely the Community Futures program, which does a similar kind of integrative activity in towns and communities of less than 100,000 people. We have 268 Community Futures development corporations across the country. They are doing precisely this kind of integrative work in the rural parts of the country.
There might be an interesting complement between an urban development framework for the larger cities and Community Futures on the smaller scale, if we could encourage a dialogue across the two about best practices. That is where we are doing the kind of systematic work that we have seen in places like England or the United States, as they think about place and community and public policy.
Dr. Hancock: I do not disagree. I was trying to get at the question of how do you systematize it. That is a very good idea.
Mr. Hay: I was going to take issue with Dr. Hancock too, because I think the city-by-city approach — with leadership and resources, et cetera — represents an opportunity. It is a ground-up opportunity. If there are provincial and local leadership and champions, build on where the energy and the activity is and build a system from the bottom up.
Senator Keon's notion about a particular federal ministry and associated vertical responsibility right down to the community would be a good addition at the same time because it would help coordinate those things.
There are many systems, institutions and, broadly speaking, infrastructure to build on without having necessarily to go into a community and say we need to create an urban agreement. There is already knowledge and at least a high- level, shared understanding in most of those regions and communities about particular problems and challenges, and particular organizations and structures are addressing them.
From the population health perspective, the Chief Public Health Officer's report sets a range of priorities in the public and population health area. You can take those into your work to make suggestions about the governance structures and models, the particular policy priorities. Then you have an agenda to build on the various structures.
Maybe some more formal things need to be worked out, like an urban agreement. Maybe they already exist and you can just modify and build on those. However, I think a city-by-city approach could be a way to go if there are not sufficient resources and leadership for something grander that comes from the national leadership, which potentially could be perceived as being imposed from the top down. You have a number of conflicts.
Dr. Hancock: Maybe I can clarify, because I do not think we are disagreeing that much. For example, the Vancouver Agreement is focused on the Downtown Eastside. It is not about the whole city of Vancouver.
Senator Eggleton: True.
Dr. Hancock: That is a very different thing; and some of those agreements that are designed to solve a specific problem in a specific area within a city are very different from what would be an agreement for all of Vancouver.
While there clearly has to be tailoring to every city if you are going to do this, or every community — let us get away from just cities and go down to those communities of 10,000 or 20,000 or 30,000 people — you do not want to have to reinvent the wheel every time you do it. What are the generic principles you can apply across all of those communities? Then you can tailor specific agreements if you need to.
That is where the leadership and the national and systemic approaches need to come from. What are the generic rules and approaches that you apply across all communities? They all need some sort of support at a local level to do things. It obviously has to be locally relevant and locally directed, but there are some overarching issues you can approach as well. It is not either/or; it is both/and.
Senator Eggleton: For my last question, I would like to ask Ms. Neilly about other agreements that come under Western Economic Diversification. Mr. Bradford mentioned that there are some, and I do know the one in Winnipeg. How different are they? Are they working well?
Ms. Neilly: Winnipeg, Regina and Saskatoon have other agreements, each one being different. The Winnipeg Agreement has been in place for about 25 years, I believe, which makes it the oldest. In all cases, the partners have agreed that a comprehensive and coordinated approach to their particular issues has worked well.
Senator Champagne: I will broach a small point within the entire spectrum of population health. Dr. Hancock, you opened the door to this for me when you talked about healthy hospitals. Will there be a day when all those socio- economic problems will disappear? I know well what I am talking about because I became ill with septic shock from meningococcal bacteria. Fortunately, I was spared infection from Clostridium difficile, commonly known as C. difficile. How and when will we be able to make our hospital healthy places?
Dr. Hancock: That is a big question. The bugs will always be with us, so we will never be free of such infections. How do you minimize that? There was a period 30 years ago when we thought we had overcome bacterial infection, but we have not done so and we never will. The bacteria are more adaptable than we are and more able to respond. They will not disappear, so we need to determine how to minimize their presence. That is an important part of making a healthy hospital a safe place to be, but it involves much more than that.
How do you create a healing environment for patients beyond the basic necessities of being safe, so that they are getting a good night's sleep and feeling at ease and relaxed? How do you make it a healthy workplace for staff? Curiously, hospitals are unhealthy work places for a variety of reasons. How do you make it environmentally responsible? I was one of the founders of the Canadian Coalition for Green Health Care. We have been working on that for more than a decade, and gradually it is catching on. How do you reduce the environmental impact of the health care sector, which amounts to 10 per cent of the Canadian economy? It has a large environmental impact and we have not paid much attention to that until recently.
Certainly, the issue of infection exists and it will not disappear. The question is how to minimize it.
Senator Champagne: I do hope that resources, research, information and action will improve this. Three septic shocks within a three-week period is not recommended for any grandmother.
Senator Cook: Mr. Bradford, I am preoccupied with the concept of pilot projects. It seems that this nation exists on pilot projects. What happens after a pilot project ends? What percentage would integrate into a system? I will give you an example of the Heart Health Program. In the province of Newfoundland and Labrador, my daughter finished her graduate studies, became the one-person project and landed her first job. It was a marvellous experience for her. I became familiar with it, but after five years, the funding was gone. It was a federal program, administered by the Province of Newfoundland and Labrador. The provincial health caregivers they needed were seconded and everything was in place. Unless there is some oversight built in and monitoring to acknowledge that something needs to happen, are such pilot projects counterproductive? What do they cost in Canada?
Mr. Bradford: Thank you for the question. I do not have the figures or the percentages of those pilot programs, so I would not want to claim to have knowledge of that. To your broader question of whether they are counterproductive, no, they are not. Rather, they represent the untapped genius of our federal system. This is a particular comparative advantage at the federal level in Canada that we are able to explore and launch these policy collaborations on wicked issues that fall mainly under provincial jurisdiction. As well, we are able to do it in an experimental-driven or learning kind of way. The major challenge and the reason that this is an untapped genius of our federal system is that we do not build-in the transition issues that inevitably arise. The federal government has to link that knowledge in experimentation to the hand-offs — the provincial governments, the municipal governments and the community organizations, such as the United Way, that they might have engaged in those pilot projects over the five years. You have to embed the transition thinking into the pilot planning. Then you will have a dynamic kind of interplay between federal, provincial and municipal governments, with the federal government playing that larger leadership role on leading-edge research and testing out new approaches. We are not there yet.
Senator Cook: Can we get there? Do you advocate us doing that? Another project had to do with nutrition for communities. The people who enter into such projects are usually the young who are just landing their first jobs and believe that anything and everything is possible. They pour all that they have into these projects and then there is nothing when the projects come to an end. What can we do to ensure that ongoing pilot projects become part of our lifestyle?
Mr. Bradford: For the proposed ministry of human development, one of the core elements of a mandate could be to ensure that we are world class at this kind of pilot project activity. We need to think up front about these issues of hand-off and ensure that the federal government is working with the various partners in the provinces and the municipalities to move things forward. That might involve transition funding, mentoring or knowledge transfer. We can be very good in this area. If we had an institutional focal point for leadership around this, the possibilities would be exciting.
Senator Cook: The Vancouver Agreement has done wonderful things. The fourth bullet of your presentation is about a strong sense of community. Surely if we had that element up front in any of those programs, it would be incumbent upon government to maintain that and to look after its well-being. There are all kinds of good things built into this pilot project as I look at the outcomes, but what can we do to ensure that it remains an ongoing, living document process? People will always need this kind of service. It is not a handout. It is a hand up.
Mr. Bradford: There are two ways to think about that. First, as Vancouver has done, you renew the pilot framework on a five-year basis. Winnipeg has done that four or five times. Second, try to think about how to hand off and institutionalize the urban development agreement as a policy model across the country, and there you have to build linkages into a new ministry for human development. You have to link it into the new deal for cities and communities. You therefore have a structured, departmental hand-off so that you really embed this as part of the Canadian approach to human and social development. We get beyond the pilots in that way.
In either case, good evaluation of successes, failures and how we learn from these agreements is critical, because you have to make the case for this kind of institutionalization.
Senator Cook: I commend them for their partnership benefits to business. I think that is the key.
I will state in my simplicity and sense of humour, being from Newfoundland, that the grocery store determines whether I will be healthy or not. That is where I go to buy my food. Canadians may or may not be able to afford to buy healthy foods, not only from a cost perspective but from a packaging perspective. The local grocery store I go to must think I am a strange woman; I live alone and always ask them to cut a cabbage in two.
It is the simplicity of caring for people in community. I think that our grocery stores or chains have to be an integral part of this if we want to move forward with a public health structure that will be comprehensive.
Mr. Hay: I certainly want to reinforce what Mr. Bradford has said. I very much agree with him.
I think there must be recognition that the governance and institutions and other things we have been talking about are tools and institutions to support problem solving. When you put a problem, such as inadequate nutrition or poverty, on the table, you need that focus in order to help legitimize, whether it is support through renewals of agreements or it eventually becomes institutionalized through the kind of planning and dedicated approaches that Mr. Bradford mentioned. All of that is very important.
One way to get there, and what you have written in some of your reports, is by setting goals and targets. If you want to do something about poverty, you must reduce it, I would assume, by a certain percentage by a certain time. That is another way, to some extent, to institutionalize the mechanisms — and here we are talking about collaborative mechanisms — to ensure that goal is met over that period of time. If a group is committed to that goal, its members will continue to work together to solve those problems or they will determine it is taking longer than they thought, so they have to find other ways by broadening their partnership or what have you.
There are ways both to legitimize and to focus on various ways to institutionalize and support through time, beyond mere pilot projects.
Dr. Hancock: Pilot projects may be the genius of the system, but they are also the tragedy of the system because they breed cynicism in communities. When they do something innovative and good, they run for three years and then the funding ends and they are dead in the water. Sometimes, particularly for those complex problems, it takes two or three years just to get up and running, and then you are ready to start making an impact and the pilot gone.
Part of what must happen, as Mr. Bradford said, is the transition. Thinking must happen at the beginning, but if a pilot is working, it presumably is doing something better than the way we were doing it before. There must be some commitment to transfer the funds from what was not working to what is working. There must be an actual transfer of funds, and that is how you can allow it to be continuous.
Senator Eaton: I am grateful that you are all here; it has been very interesting. I was doing a bit of reading over the weekend. My goodness, it is frustrating; how long have population health issues been present? In the 1990s, we had Canada Health Plan 201. Thank goodness Dr. Keon is here, and maybe we can do something.
To bring up something Mr. Bradford and Senator Keon mentioned with respect to a ministry of human development, what strikes me is the lack of continuity. Governments change, minorities happen, priorities change. Instead of having a minister of human development, could we not have an advisory panel of human development that would be depoliticized and federal and to which wonderful things like the Vancouver Agreement could feed their data and that perhaps could be a force that provincial and municipal people could use? It really worries me when I see population health being politicized by having a minister at the federal level.
The other thing I think about is whether the federal government should soon start making Canadians aware of what population health goals should be. I was alive in the days of the campaigns I am about to mention, and I hope everyone else was as well. If you remember, ParticipACTION got everyone talking. There was also the anti-smoking campaign. Neither of those campaigns had a ministry, but the awareness that we provided Canadians helped them. Do you feel programs like those would be helpful?
Mr. Hay: I think programs such as those are definitely helpful. I think discussion is needed on your idea of advisory councils versus ministries. I certainly understand the concern or even fear of politicization of some of these processes, as was mentioned by Dr. Hancock and Mr. Bradford, this business of mandates and how things can change and go off track.
With respect to political bodies or advisory bodies, legitimate authority needs to be expressed, particularly when you are trying to change governance arrangements. You can certainly have educational activities, such as through ParticipACTION, around physical activity and smoking cessation, educating people about the dangers of second-hand smoke and such issues. It must be part of the process, and there will always be a network of community organizations, government bodies, private sector interests, et cetera, that will contribute to that educational debate.
However, in order to move people from one place to another, not simply in terms of behaviour but in terms of something more difficult, we actually need decision-making systems that will help to support those shifts. I think in that area there is a little more need for some sort of legitimate authority. A ministry of human development, as described, would be a contributor to that and not the silver bullet that solves that problem. It is always a mix of these things rather than it being one or the other.
Senator Eaton: If you have a ministry, it depends on who the Prime Minister is, what priority he assigns to it and whether the minister assigned is a junior minister or a senior minister. Would it be better to be a Crown corporation with certain rights?
Mr. Hay: As Senator Eggleton said earlier, the leadership is critically important. I made the same remark earlier.
A federal minister would have all the concerns and issues exactly as you described, Senator Eaton. A vertically integrated system also has a horizontal mandate and horizontal accountability, broadly speaking. No matter what happens with the Prime Minister or the federal government or the shifting of priorities, you have that whole other system already working on stuff that has already happened and bringing up activity at the community level. The opportunity is to make the links from the top to the bottom, so the bottom sometimes will very much drive the top.
The Honourable Monique Bégin was on the advisory council for the population health report I completed when I was at the Canadian Institute for Health Information, CIHI. She made the issue very clear when she asked who you respond to. Of course as a minister you respond to the Prime Minister and the direction from cabinet. However, you very much respond to the public. That was the point Monique Bégin made to me over and over again. This bottom up is primarily responding to activity on the ground and to the public. Therefore, an integrated system cannot take care of all issues you suggest, but it can help to maintain momentum across the system.
Senator Eaton: Do you feel that Canadians are aware of how bad population health is?
Mr. Hay: No, I do not think they are. At the CIHI, we did public opinion research on determinants of health and understanding health. The awareness was good about behavioural issues — about smoking and physical activity and those things — but very limited about broader social determinants of health. That research was five years ago.
Monique Bégin said we should be celebrating because, in a generation, we have the awareness around the Lalonde report and now the awareness of all the behavioural determinants. However, it will take another generation to push out to the public this understanding of these broad social determinants and their complex interrelationships.
Senator Eaton: How can you say we are aware when the number of obese school children is soaring?
Mr. Hay: As Senator Cook outlined, it is also a structural problem in terms of the foods available, the education and the family settings that allow it. Again, a chapter in our report, Improving the Health of Canadians, talks about that range of issues. There is also a chapter on obesity.
Senator Eaton: However, we have not addressed it since your report.
Mr. Hay: Again, it is a broad set of issues. Dr. Hancock could discuss the many activities in British Columbia and elsewhere to address these kinds of issues.
Dr. Hancock: Perhaps I can pick up on three points. First, I would like to think that a minister of human development is every bit as essential to Canada as a minister of defence or finance and that it is not a peripheral ministry that comes and goes at the whim of government. It is a central agency.
Senator Eaton: You are more idealistic than I am.
Dr. Hancock: I have always been idealistic. I am a believer in having a vision, even if you do not know how to achieve it. That may be the level of commitment one is looking for. The problem with advisory councils is that they can come and go easily at the whim of the Prime Minister, a minister, or cabinet order. That is why I talked about the notion of a commission established by statue that cannot disappear when the government, the Prime Minister or a minister changes.
Though symbolism is also important, it is more than symbolism that you have a minister of human development and that it is established that this is a priority for the nation that we need to maximize the level of human development.
With respect to public awareness and understanding — and I do not think I am telling tales out of school — we had a presentation a couple of weeks ago from Diana MacKay from the Conference Board of Canada in a follow-up to the report I mentioned. The Conference Board is floating the idea of developing what it is calling "Determinaction,'' which is a sort of ParticipACTION-type model but focused on the determinants of health to raise public awareness and show that it is more than lifestyle; that it is all these other broader determinants. I think it is an interesting idea and worth following up on.
With respect to the issue of obesity, you have to go back to where we were with smoking 30 or 40 years ago. Thirty years ago, there would have been ashtrays on this table and people smoking in the room and in the building. We have changed the social norm about smoking to such an extent that it has become a minority behaviour now. That is not to say it is not still a problem, because clearly it is, but there has been a huge shift. However, it has taken a generation.
We are at the early stages in that process with obesity. There is an awareness, just as there was in the 1970s with smoking, but we are at the start of that process and it will take 10 or 20 of 30 years, just as it has with smoking.
Let us remember the days in Toronto when Senator Eggleton was the mayor and we were bringing in at a municipal level some of the early legislation about smoking in the workplace. That was a huge fight at the time and a huge shift in social norms. Now no one thinks twice about it; you do not smoke in the workplace and, of course, cities have bylaws. It will be the same process with obesity.
You have to understand that the Heart and Stroke Foundation of Canada and the Canadian Cancer Society are all looking at obesity now. The Canadian Cancer Society is putting on a conference in a couple of weeks around the built environment and the role it plays in physical activity. The Heart and Stroke Foundation has funded research in this area.
There is a fundamental principle in health promotion that you have to make the healthy choice the easy choice. Too often as a society through our policies — both public and private — we make the unhealthy choice the easy one. Take portion size, for instance. If you are presented with a large portion, you will eat it because we have been taught to clean our plates. If you create environments in which the unhealthy choice is the easy choice, you should not be surprised when people make unhealthy choices. We have to change social norms.
Senator Eaton: It seems to me we are not trying very hard. I appreciate what you are saying.
Dr. Hancock: There is a lot happening. It is early.
There is not a good enough understanding of the level of inequalities in health within society and the role that social determinants and environmental determinants play in those inequalities. I think that is a huge issue. We are not even where we are with obesity on that one.
The Chair: I think it comes back to building healthy communities. Look at the terrible population health programs we have in some pockets of our country, including with some of our Native peoples and so forth; some of them have overcome that by building healthy communities. They have looked at the panacea and they are changing things and doing so with their own initiatives. It is a question of putting a structural framework in place to allow them to do their thing, to do what they want to do, as opposed to somebody coming in and telling them what to do.
I think Senator Eaton's point is very good. That is a tremendous worry. I have been trying to grapple with that, which is why I have thrown out the idea of the minister today. We have to start someplace. I am not sure another royal commission is saleable at this point; nor am I sure it is the right idea.
We have to have some faith in our political system. Senator Eaton, I have a little more faith than you. I think our politicians are reaching the point where they are not satisfied that we stand somewhere around fifteenth in the world in health status, well-being and productivity. I asked the Conference Board of Canada to do for us the report Dr. Hancock referred to so that we could include it in our report. They were very kind to do that.
Even the business community is getting on the bandwagon. They are saying, "We cannot afford unhealthy workplaces. We cannot afford all this time off. We have to provide healthy work forces.'' Some companies, for instance, are providing daycare so that when the local daycare centre goes down, parents can bring their children to work.
I want to return to Senator Eggleton again. He has been jumping at the bit.
Senator Eggleton: Not quite. I simply want to ensure everyone else has had an opportunity to comment or ask questions.
I like your idea of the ministry that you talk about. Having sat at the cabinet table, I know you need to have the commitment from the top. The cabinet table is where the money flows from. The will to do things has to flow from the top.
You can have all sorts of structures on the way down to engage people at a community level and all orders of government, and that is important, particularly to find ideas. However, you need to have that commitment at the top, because if you do not have it at the cabinet table, it is out of sight, out of mind. There will be other priorities that will take over and rule the day.
I do not know that all of you will know the answer to this one but hopefully someone will. At the bureaucratic level, we had the Advisory Committee on Population Health between 1994 and 2004. Then, in 2005, it was replaced by the Population Health Promotion Expert Group. This is one of six expert groups advising a pan-Canadian public health network. As I understand it, this involves the federal and the provincial and territorial governments at the level of deputy minister and below.
I want to understand the implications of that change. Is this working better or about the same? Does anyone know where it is at?
Dr. Hancock: I co-chair the group you mentioned, which replaced the advisory committee. The Council of the Pan- Canadian Public Health Network is composed of medical health officers or assistant deputy ministers from each province and territory and the federal government. Its remit is in some ways wider than the Advisory Committee on Population Health because it is all of public health services. It includes infectious disease control. Much of the stimulus for that came out of the SARS epidemic and some of the other infectious disease outbreaks that led to the recognition that the public health infrastructure in Canada was weak.
The council and that whole network are finding their feet. It has been two or three years. They have gone through a review, and it is still early days in determining how effective that structure is. There is no question that good work is being done. Through our group, we are addressing issues of indicators of inequality and the health costs of poverty. We are linking with former Senator Kirby's Mental Health Commission. It is a very high level commitment to population health and it reports to the deputy ministers of health.
Senator Eggleton: It deals with the social determinants of health, not only infectious diseases.
Dr. Hancock: The expert group I co-chair does exactly that. That is our main purpose. The final report that came out from the Advisory Committee on Population Health was on the role of the health sector in reducing health disparities. We have taken that as our guiding document for the work we do in our expert group.
Mr. Hay: I would suggest that those activities are less transparent to the people not involved. There is an opportunity to open up those structures to inputs from a broader set of stakeholders, maybe not the public at large, but a broader set of stakeholders.
I do not think there was a change necessarily from the advisory committees to these new public health networks. However, increased participation could be brought, or at least getting a sense of what is on their agenda and shaping that agenda would be important.
Senator Eggleton: Thank you.
Mr. Bradford: To follow up briefly to Senator Eaton's and Senator Eggleton's points, I do not think these structural options or alternatives are necessarily one without the other. You could have an advisory council as part of your proposal. You could have a minister of human development or a ministry at the centre of this and you could also pay attention to the need for senior civil service innovation and commitment. For example, in the United Kingdom, Prime Minister Blair created the Social Exclusion Unit, which was mandated explicitly to work with central agencies and the cabinet office in the United Kingdom on these inter-ministerial cross-cutting issues.
We talk about building national policy capacity in these issue areas that are inherently complex and multi-faceted. You need a whole series of players around the table. A public advisory council, a ministry and a senior bureaucratic structure are all part of a viable and necessary package. We ought to think big and see them as part of an integrated approach.
Dr. Hancock: When I talked about a commission, I did not mean a royal commission. It is more than an advisory council. What I had in mind was something like the Premier's Council on Health in Ontario, which has joint political, civil society and sectoral leadership that came together. However, I am suggesting establishing something like that by statute. Whether you call it a commission, council or whatever does not matter. I did not mean a royal commission into human development. I meant an ongoing statutory body that brings together key leadership sectors from the country, not only political but certainly to include the political. That is what I had in mind.
The Chair: To tease you, the reason I dropped the idea today for the first time of federal and provincial ministers of human development is that I believe our governments cannot dodge this bullet any longer. This is a preventable situation in Canada. If we build the healthy communities we need, we will not have 50 per cent of the diseases coming into the health care system in the first place. We will elevate our productivity from number 15, hopefully, to number 1.
Senator Eaton: I wanted to ask our guests from Vancouver, Ms. Neilly and Ms. Lattey, have you been approached to share what you have learned with other communities?
Ms. Lattey: No. We receive requests from many researchers and media, but we have not been approached to share what we have learned as far as I know. We have not been approached by other communities. We have had interest from the U.K. However, that is the only party that has really approached us. Do you have any other information on that, Ms. Neilly?
Ms. Neilly: In 2004 or 2005, a group from Santiago, Chile, found out about the Vancouver Agreement on the Internet. They came to Vancouver, visited us and looked at the model. They have used some of our tools to work with youth and to steer youth toward meaningful activities. We have had international interest.
Senator Eaton: Was there one champion? Was there one person in your area or was it several of you around a coffee table? How did it start and who did you go to first? Was it the municipality, the federal government or the provincial government?
Ms. Lattey: I was not there at the start. However, from my reading, what I see is that there were a few very strong champions. The city manager in Vancouver was a strong champion and she secured the involvement of the mayor at the time and the subsequent mayor, who were both very strong champions.
The woman in charge of Western Economic Diversification in Vancouver at the time was also a strong champion. At the provincial political level, the MLA responsible in part for the Downtown Eastside also became a champion. Those people pushed the initiation of the agreement.
At the same time, the federal government had the structure of urban development agreements. It was very important that that was already in place. Some of the other people have spoken to the need for those institutional structures. The fact that you had those champions who pushed and who were powerful people in their own realm was vital to the initiative's getting started.
The Chair: Before we close, could I ask one or both of you, Ms. Neilly or Ms. Lattey, about your information system? You are now being held accountable. Were you able to build a robust information system that simplifies life for you or is it less than desirable?
Ms. Lattey: That is a key question. Frankly, yes, it is less than desirable. We have learned a lot about how to build these information systems from this initiative. The trick is that each level of government has their own information system, and in order to maintain their accountability, they must keep their own information systems however they are designed. Then this coordinating body, which would be the ministry that you proposed, or the minister, needs to have a system that reflects the systems of those three levels. Otherwise, going back and forth between government departments becomes very confusing as to what you are talking about and what the common terminology is. It is not that difficult to do, but it must be done at the very beginning, and it must recognize the integrity of each of the existing systems.
Ms. Neilly: I would agree with Ms. Lattey, and I would also agree with the importance of a joint information system. There is an information system that the Government of Canada and the respective provinces use to collectively deliver many of the infrastructure programs. Since we jointly share the same information system, it definitely adds value to the delivery of the program.
The Chair: Thank you both very much. We will have a round table on trying to design an information system that will come from the top to the bottom of this population health network. I may well be back to both of you.
In any event, for all five of you, thank you very much. This session has been tremendously helpful. We are at a point now in the report where the rubber has to hit the road. Your comments have been truly enlightening, and I have a major ongoing debate to have with Senator Eaton. Thank you all.
Ms. Neilly: Thank you for inviting us today and including us in your session.
(The committee adjourned.)