Proceedings of the Subcommittee on Population Health
Issue 2 - Evidence - March 12, 2009
OTTAWA, Thursday, March 12, 2009
The Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 10:47 a.m. to examine and report on the impact of the factors and conditions that contribute to the health of Canada's population — known collectively as the social determinants of health.
TOPIC: Strengthening Community Action for Population Health
Senator Wilbert J. Keon (Chair) in the chair.
The Chair: Honourable senators, we are delighted to have with us this morning Katherine Scott, Vice-President, Research, Canadian Council on Social Development; Bob Gardner, Director, Policy and Research, Wellesley Institute; and Connie Clement, Executive Director, Health Nexus.
Who will go first?
Bob Gardner, Director, Policy and Research, Wellesley Institute: It is a pleasure to be here. I should tell you that in my own background, I had a number of years in your world. I was the Director of Research and Information Services at the Legislative Assembly of Ontario. For those of you who have been around for a while, I was the Ontario Hugh Finston.
We all think you are doing tremendous work that has real potential. I should also tell you that I have been doing work with one of your research consultants, Ms. Laura Corbett, who is doing a project with the Ontario Ministry of Health and Long-Term Care on how to create a cross-ministry, collaborative, cross-sectoral social determinants' planning framework.
You are dealing with the critical issue of addressing pervasive health disparities, and how to take the broader social determinants of health into account in government policy and programs. I think that is possible. There have been many interesting community level initiatives and many interesting examples from other countries that show that a difference really can be made.
I would like to quickly focus on how that can be done. I will look at your fourth report entitled Population Health Policy: Issues and Options, and try to concretely outline a few directions that might help in moving towards building action on social determinants of health.
Your challenge is digesting such a huge topic. I will have to be brief and I am happy to follow up with your research staff and clerk to give you any further information.
The first point is to start from the big picture and that is the work that you and your sister committee that Senator Eggleton chairs have been doing; that is to try to think of what is an overall policy framework that can advance the social determinants of health and help to join up government in a concerted and focused way.
I think there is tremendous value in developing that kind of overall framework. It is symbolic in the sense that it provides a government commitment that health disparities and social determinants are serious and that governments are committed to acting on it. In a more on-the-ground way, it is enabling. If there is an overall framework from governments, it allows the various departments and ministries to work together in different ways to create different coordinating forums. It is also enabling beyond governments; it allows and encourages partnerships with service providers, community agencies and with on going initiatives across the country.
One of the big themes is that there is an enormous amount of imagination, enthusiasm and momentum across the country. One of the tasks of public policy and of governments is to both tap into that enthusiasm and to encourage and nurture it.
I have done the usual thing for any policy analyst. I have given a little 12-point plan of what might be a roadmap for health equity. You have been looking at the best from other jurisdictions and you know there is an awful lot of interesting stuff happening.
On that big-picture issue, there is a danger of being paralyzed by the scope and the challenge of the social determinants of health. We can all sit and think about where we will start. We need affordable housing, we need to reduce poverty and have upstream health promotion. We cannot do everything at once.
My simple message is to start somewhere: Make the best guess. I suppose I would call it strategic experimentation. If you are a decision maker, make the best guess in the most promising avenues for action and experiment. Then rigorously evaluate and build on what is working. Gradually, we will have a better sense of what works and we will build up a coherent overall strategy.
Part of that is restructuring how governments work. Your work will be followed carefully at the federal level and at the other orders of government, as well. That is not just internal. It means forging different partnerships with community and other stakeholders. It means doing things differently. Again, looking for insights and experience from other jurisdictions, we know there are many interesting cross-ministry coordinating forums. We know that they work in the sense of bringing people together to identify common issues. We know serious targets are important and that tools are important. Perhaps we can come back and talk about that in more detail.
My outfit is doing work with the Toronto Central Local Health Integration Network, (LHIN), and with the Ministry of Health and Long-Term Care in Ontario to pilot a health equity impact-assessment tool.
With your broader view, the subcommittee will be interested in those cross-government collaborations. My reading of other jurisdictions is that there is real potential for secretariat-kind of functions, to ensure that everyone knows what is happening. The Public Health Agency of Canada has been doing a good job of that and can be enabled and encouraged to do more. There needs to be important coordination mechanisms.
Deputy ministers and assistant deputy ministers are getting together on social policy and economic policy at various meetings of regular forums. This committee could recommend health equity and health impact as part of the mandates on the most appropriate cross-sectoral committees.
The other thing is a clear lesson from England, Sweden and the jurisdictions that are really moving on health equity and social determines. The lesson is that it has to be driven from central authority. There needs to be a champion at the top. Someone at the top, like our equivalent of the Privy Council Office or Department of Finance, has to drive cross-government action. We can have all the committees in the world but if somebody is not driving it, it will not happen.
There are some interesting examples from across the world you can look at and recommend. I am happy to talk about that in more detail.
One of the critical things of the potentially successful big strategies from other jurisdictions is that they deal with high-level, macro stuff — they deal with economic policy, housing and anti-poverty but also enable and invest in local action.
I think a major difference on social determinants of health and reducing health disparities comes at the community and local level. It is a critical role of governments to both invest in local community efforts and ensure there is a vibrant local community sector. My colleagues will talk about that. They should also create the cross-sectoral planning forums so the community and the governments and everyone are talking to each other and can learn from each other. I emphasize that point.
You have tremendous influence and can advise the government on what should go into its budget. Let us make sure there are social stimulus as well as economic stimulus; let us invest in community infrastructure as well as the obvious infrastructure projects.
I did some work for the Toronto Central LHIN, which is Ontario's version of regional health authorities. We tried to do two things at once; we tried to build equity into all health planning — and this would apply to other social worlds, as well — but also target some proportion of your investment and initiatives into particularly health-disadvantaged communities or populations or a particular barrier — language, low-income or literacy barriers. That is probably not a bad model to consider for wider action on social determinants; in other words, working simultaneously at those two levels.
One of the problems we often come up against is a lack of data. For example, if we want to ensure that a particular language community is well served by social and health services, we do not have the data to match race, ethnicity and ethnocultural background to services or demographics.
I think an interesting recommendation this subcommittee could consider would be to get the key players together at a national level, with all the provincial players to try to think of common definitions and a common data platform.
I want to do is go back to that idea of local interventions. I think if one is targeting a particular population or a really under-served community, that happens locally. The impetus can come from a national or provincial government, a regional health authority or a municipality but that happens on the ground in communities.
We know there is an enormous amount of enthusiasm and interest in these issues and I gave a few examples in my paper of neat stuff happening across the country. I think your task, as decision makers, is to think of ways to enable and to nurture that community action.
One of the challenges is that most of these community agencies are funded here and there by one-time funds and they are living hand-to-mouth. That means they do not have research capacity, so they cannot evaluate their own programs in the lessons-learned or in the practical sense. Demonstration projects or that sort of thing is another area this subcommittee might consider and what good applied service evaluation is. I do not just mean the accountability and value for money. Obviously, there are reporting and accountability mechanisms.
I can say I think this is neat. I gave the example of the Edmonton Multicultural Health Brokers Co-operative. How do we know it is working well and how do they translate that in Quebec City and Sudbury? That needs applied research.
Once we have those pockets of innovation going all over the country, how can we ensure they share what is working? That is innovation or knowledge management. The Public Health Agency of Canada and the national collaborating centres are doing some of that job and doing a good job with it.
That area could be expanded and should be community-based. They are people that know what is happening on the ground. They can develop easy-to-use forums and infrastructure to share what is working to ensure we are not reinventing the wheel every time we address a service challenge. However, keep in mind how stretched community agencies are.
Katherine Scott, Vice-President, Research, Canadian Council on Social Development: I would like to echo and pick up on some of the themes that Mr. Gardner talked about in his session. Thank you for the opportunity to address the committee. I understand you will be framing your final report so it feels like a timely opportunity.
I come from the Canadian Council on Social Development. We are not formally a health organization, but are very much involved in social development and understand the determinants of health as a key part of our mandate. We are involved in the community sector. Where the rubber hits road in population health policy is at the community level and with the ability of communities to react, adapt and innovate around the challenges they face.
Communities vary in their capacity across the country. They all share a common commitment to pursuing the well-being of their own members. They face similar barriers when it comes to resourcing their activities, reaching out, and learning from other organizations, et cetera.
A piece of research we did a number of years ago at the council spoke about the types of funding challenges that community organizations face. I would like to relate to that particular piece of work as we move into this current economic climate. The ability of communities to sustain and move forward with the innovation in which they are engaged is challenged, certainly around some of the social determinants of health. Funding and administrative challenges are an important architectural piece as we talk about a broader framework and the ability of communities to continue participating in this type of innovation.
I would like to make the case that the current funding practices are systematically undermining some of the community activities. This is something on which I would like to make some recommendations at the end that hopefully will find resonance with the work you are doing.
Civil society and community organizations are a vital part of Canadian communities across the country. We know from a large survey on non-profit organizations done a number of years ago, that there are roughly 5,000 community-based health organizations outside of the hospital sector in Canada. This sector employs thousands of Canadians. These are organizations that work in conjunction with hospitals and the big institutional players.
Health organizations are active in communities and are important players. They, like other community organizations, are facing particular funding challenges. The research I did a number of years ago documented the experiences of communities through the mid-1990s when revenues were climbing. However, we had seen a shift in how organizations were funding away from sources of organizational support to short-term funding-based mechanisms that are highly targeted, unpredictable, dependent, and with increasingly onerous reporting requirements.
Effectively, funders were becoming frequently reluctant to fund administrative functions in community organizations, while at the same time; administrative requirements were increasing exponentially. Community organizations were running faster to do more with fewer resources and experiencing high levels of staff turnover and volunteer fatigue.
This shift to project funding is the way governments and other funders support much community level programming. It has been a feature of the funding climate that continues to undermine community organizations. Mr. Gardner talked about some of the amazing community innovation. You will see and hear about fabulous projects or pilots that happen. However, invariably, they are one-offs because it is project funding or short-term and no evaluation is taken into account with little support for administration. These types of funding mechanisms all curtail the potential for this type of work.
These funding issues came to the attention of the federal government and have been an issue of the voluntary sector for a long time. The first report on funding and funding reform in the non-profit sector was from the Panel on Accountability and Governance in the Voluntary Sector, the Broadbent panel, in 1999. Some of you may remember it. Subsequent to that the government launched the Voluntary Sector Initiative and funding was an important theme in that work as well. In 2005, there was the Task Force on Community Investments, which was spearheaded at Human Resources and Skills Development Canada. More recently, this particular government launched the Blue Ribbon Panel chaired by the head of the United Way in Toronto, Frances Lankin. That committee reported back in 2007.
All of this work reiterated the importance of looking at the mechanisms for funding community-based organizations. The inter-sectoral and macro-level policy work was fine, but unless it strengthened the relationships with community through these fundamental, institutional, funding relationships — contracts, reporting requirements, et cetera — much effort was lost.
The Blue Ribbon Panel reported back making 32 recommendations captured in four directives. There was a fundamental directive to respect the community sector: the government should be recognizing and entering into relationships with non-profits as equitable partners engaged in the task of promoting well-being at the community level.
The panel suggested that the government look at dramatically simplifying reporting in the accountability regime and design new vehicles to promote innovation. Current funding regimes and accountability actually work to curtail innovation. No one will take risks in a funding environment where you are punished by scooping up year-end dollars. There are ways in which the funding vehicles work systematically to thwart innovation. That is a concern to a committee such as this promoting population health.
As Mr. Gardner said, there was a fundamental lack of good data and evaluation in this sector. The government should better service non-profit organizations in this regard.
In the spring of 2008, the government released its first action plan and is considering redoing its transfer payment policy. It is an administrative reform. They are talking about simplifying reporting requirements, streamlining applications for funding, et cetera. This particular plan did not address central issues around lack of administrative support or lack of funding for organizational support — core funding — for organizations.
One issue raised repeatedly is that government non-profit funding relationships has systematically underfunded community organizations to the tune of 15 per cent. One recommendation put forward the principle of full cost recovery and therefore, if you enter into a contract for service or some particular activity that the government commit to paying the full cost of that service.
We have now have information suggesting government is fundamentally undercutting or underfunding those services. The government plan released last year did not address these central funding issues, so they remain a source of weakness in the government/non-profit relationship.
It is important to address these issues in this context because, as I said at the outset, the vitality of the community sector is really what will drive the population health agenda forward. We can craft, at the most intricate, macro-level, intersectoral policy development forums, but if that does not connect to a vibrant community sector — which is now, of course, struggling within the context of fewer resources going into many of these agencies — we will be hamstrung; we will not be able to make effective change. We will not be able to replicate the fabulous innovation that exists now; it will not translate. We will not take that great example in Edmonton and realize it in Quebec City.
There are many pieces involved, but one we can focus in on to look at the funding relationship and to put it on the right track. This is the recommendation from the federal government, as well as from other orders of government and other funders. What is emerging, as we talk about communities of practice and sharing best knowledge is that the funders are now talking to each other. This is an interesting development.
I did a piece two years ago looking at innovative funding practice from the funder's perspective and the challenges they face. Funders do have a variety of important challenges they face in crafting funding programs.
What is happening in the philanthropic sector in the United States is that there are new strategies for capacity development, financing and making available social loan equity to community organizations. Funders are now talking to each other, whereas they used to compete with each other. In Ontario, for instance, arts funders are convening their own round tables, talking and sharing their best funding practice ideas.
As part of a non-profit organization, I think that is great, because that will improve my relationship. The good practices will rise to the top and you will start seeing change. You see funders approaching the issue of core support differently and realizing that they cannot expect the organization to function effectively if they only give 10 per cent for administration. No private-sector business would fund their administrative costs at 10 per cent. I have never particularly understood the expectation that non-profit organizations are able to do this. We come up with these rigid formulas and the result is to erode the capacity of the organizations to do their work.
Some tremendous funding innovation is going on right now. It would be an interesting complement to the work of the committee to consider some of those models. I am happy to provide additional information about that. I will leave it at that and turn it over to Ms. Clement, who will talk about community engagement.
Connie Clement, Executive Director, Health Nexus: I am thrilled to be here. It is really an honour.
Health Nexus, Nexus Santé is a charitable bilingual organization that builds health promotion capacity. It is Ontario-centric, not Ontario limited. We were particularly pleased to be recognized, in one of your earlier papers, for our contributions to population health, particularly being a small organization.
I have submitted a paper to you. I will focus on the community engagement aspect. I have named six challenges. One challenge is to find the right terminology. Health excludes, by terminology, all of the partners who work in social issues and do not think about what they do as health related. We need to find what is that wording and commonality.
There is the concept of movement upstream. Everyone across sectors gets the idea of not the clinical term of prevention, but being upstream before bad events happen further downriver.
With regard to political will and willingness, I think you know far more than I do how often population health and health equity have been addressed in reports, over and over.
We face the challenge of building commitment across all sectors, building public awareness, and what I call sustaining the demand by communities and the public. This is when I actually talk about engagement.
Before I go into how we engage people, the piece of public awareness is very important. When Canadians stop to think about health equity, they tend to understand and to care. There is a piece about helping to translate these complex ideas into simpler ways.
In Ontario, we have been involved with three social marketing campaigns over the last decade, with partners. I gave Barbara Reynolds, your clerk, copies of two of the campaigns, a set in English and a set in French. There have been posters, radio and, in one case, television advertising. With social marketing, it is always hard to tell how someone's values or behaviour has changed, but in all of those campaigns we had very good recall later and people did notice them. It is important to note that you will still find these posters in social services and health organizations all over Ontario, many years after their campaigns.
In the paper that I presented, I named a number of different mechanisms that could be used to help increase public awareness. I want to focus on the challenge you named in your issues and options paper, namely, that as you build community engagement and help fund the kind of community organizations that Ms. Scott and Mr. Gardner have spoken about, how do they do their work and how do you ensure you are getting good results for that commitment?
I will provide two examples of engagement and then move on to how you know you are getting response.
I want to start with Ontario's work around tobacco. This is quite different from what we are talking about, but it is highly respected around the world. The tobacco work was successful in Ontario because Ontario invested in building local and provincial structures, assigned specific accountability and created clear goals. We used multiple strategies with intersectoral partners. We included education, services such as cessation, and influencing policy. The focus on policy was central to the success of that work and it emphasized local intervention, such as municipal bylaws, and it emphasized federal intervention, such as market regulation.
Interestingly enough, the early work in tobacco in Ontario skipped the provincial level, which made it much safer for the province to fund it, if that makes any sense to you. The provincial work came later, and that work was built in and important.
The local action, which both Mr. Gardner and Ms. Scott spoke about, was critical. We funded local coordinating committees, we demanded youth engagement around tobacco so that there were youth action projects, and we taught youth how to grow into active citizens through their tobacco work.
What is important there is that the investment was what we would call an "effective dose" for community prevention. The emphasis was on access, availability and social modifiers, all of which are translatable to health equity.
At Health Nexus, we have been working for the last few years with an engagement model that we call connecting the dots: How do you connect different ideas and different people to build partnership that brings together individuals from community services and across different sectors? Most of our work with this model has been in chronic disease prevention. We have been bringing together people from health care, from primary prevention right through to acute and long-term care, with community partners. In most cases, they had never talked to each other. In many cases, the acute care people had never talked to the primary care people. What is important about the model is that we are not trying to form new, long-standing, formally structured alliances or networks. We are trying to generate new relationships and amplify existing relationships to create a space for enhanced partnership. We create the mechanisms for visioning and identification of common interest, common solutions and how they will work together.
We did this process in one region and it takes about a year to work with a community through this process. About seven to nine collaborative initiatives grew out of that 10-month commitment. We are now working with that region to research the nature of the collaborations that evolved so that we can identify those strengths and weaknesses.
Mr. Gardner talked about tools. I think you could create a whole list of mechanisms and methods for community engagement, for example, coalitions, coordinating committees, peer leadership and champions. The piece that makes it challenging to evaluate, even if the community groups have evaluation money, is that, by its nature, these kinds of methods vary by setting, by issue and by time. It makes the piece that we are always seeking of replication and transferability a little challenging to measure.
Even so, when you look at the international literature, more and more research is finding what I call level 1 and level 2 evidence; that is, research that shows a causal relationship between an intervention and the outcome that you want. Level 2 is where you have very good methodology and you see a probable influence. We are seeing more and more impacts that we can measure from interventions.
One of the questions you asked in your fourth report on issues and option was how to balance space for community creativity and specificity with accountability. Scotland has established national standards for community engagement, and they have developed principles and indicators. Community projects funded by the Scottish government are expected to measure involvement, support, planning, methods, working together, sharing information, working with others, improvement, feedback, and their own monitoring and evaluation. It is an important model because they are measuring functions and the impact or capacity of those functions. They are not measuring the content detail of kids' engagement in recreation, for example. I do not think they have been using it long enough to fully evaluate it, but it is a good model for us to look at.
One of the pieces that excites me in our community engagement work is how quickly our knowledge of what I call purposeful network development — that is, how you actually build, support and sustain networks — is growing rapidly. Much of that attention is coming from research. In Canada, there has been a fair bit of work. The Canadian Council on Social Development has been involved in looking at the network of networks; the Canada Public Health Agency is looking at network models for civil society engagement around health equity; and there is rapidly escalating knowledge about communities of practice and how you support that.
We are doing a piece of research at the moment where we are working with some software that helps us deepen the understanding of existing networks so that the members of that network actually help to identify who is an innovator or a leader, who is the grunt worker, who is the person who has many or few relationships, who is the person who champions externally, who is the person who amplifies someone's quieter voice internally, and who is the one who makes referrals. I do not have results for you yet; we will be at that point in about three weeks. I could talk to you about them then. They have been using this software now in the U.S., including in the private and the non-profit sector.
The point that amplified with me was that a large city bank in the U.S. that was doing this kind of research realized that one of the reasons that they were failing to get clientele from the Hispanic communities was that their only relationships were with Hispanic men in business, but the leaders in the Hispanic community were all women. They needed to shift their practice. They started to figure out how to link with community-based female leaders. I think we have a lot to learn from that research.
Mr. Gardner talked about enthusiasm. For me, the challenge is to find out what we can invest in to help amplify the passion of the few to become the passion of many. When Canadians are taught about the inequity that exists in health, there is a huge value of fairness and of belonging in Canada. I will give you an example from Saskatoon, where the regional health authority surveyed local residents about priorities and health. On the first round of that research, the list was what you would expect; the focus was more on health care, and so on. They then took the time, by phone, to explain local ways that health is not equitable in Saskatoon. In affluent neighbourhoods in Saskatoon, 93 per cent of children are immunized according to schedule. They chose an issue like immunization and children. Only 44 per cent of children in the poorest neighbourhoods in Saskatoon are immunized. This is a medical aspect of universal health care.
When people knew that, they said that was not fair. They actually said, "Yes, we would like more money in prevention. We would like more money to go to population health. We would like that enough that you could even take away a little bit from medicine and treatment." That is the first time I have ever seen research where someone did not want an add-on but started to say, "Yes, we can do a bit of financial shifting." I think it comes from that concept of fairness.
As we engage communities, I encourage that we do so around those issues so that we can build passion.
The Chair: Thank you very much indeed, all three of you. The senators have questions for you, but first, as one of you mentioned in your presentation, we are now at the point where we are trying to frame the final report.
Consequently, I passed out this diagram to you; I think all three of you received a copy. We are recommending a whole-of-government approach so that everyone is included in an intersectoral approach.
We have been consulting extensively with the information technology world. We have a round table coming up in a couple of weeks. They tell us that they can wire this diagram. Our concept of population health that we would like to "wire," so to speak, would be based on a platform of population health with about 50 per cent coming from the socio-economic determinants, 25 per cent from the health care delivery system, 15 per cent from genetics and biology and 10 per cent from the physical environment. We are anxious to emphasize that we must look at the human life cycle. If we are to effect population health, then we cannot take pot shots at various steps along the road of life. We must look at the full human life cycle. Once that system is wired, it would be of tremendous benefit to researchers like you, because you can look at information and analyze the outcomes that have been achieved, which are various interventions.
I have a question for all three of you.
We know we are recommending the whole-of-government approach and intersectoral approach, but we do not how to make that effective and, so to speak, get money to the ground. The community model is based on this concept. Whether that comes from a Tony Blair idea, cabinet committee, or a special minister such as a minister of human development, we believe the first ministers have to buy this. I am making an all-out effort to speak to them all.
However, we feel that, first ministers have to buy this, and then they have to designate somebody in their framework to be the champion, to provide the continuity for this whole-of-government approach. Of course, municipalities similarly have to buy it, but the leadership of the municipalities is enthusiastic at this point.
If you were king of the world, how would you organize this whole-of-government approach, federally, provincially, municipally and community-wise? That is an easy question.
Ms. Clement: I would lean towards something more like a Tony Blair approach than a separate minister. I am very worried that a separate minister can be, for all of the good intention, the portfolio can be diminished. You need to have a model that avoids that competition, and I would look back at Toronto's healthy communities initiative when it was the leadership, and Senator Eggleton will remember those days as well. The Healthy Communities in Toronto office reported to the equivalent of first ministers as a committee of heads. It had much greater, full-city impact than most other cities and communities in Canada where it was headed by public health because the engagement of public works was immediate.
That would be the piece for that horizontal piece. I would certainly encourage that. I think Britain has a strong model.
The vertical engagement is more challenging, but I think that municipalities have a huge role to play, more so than provinces because of the community nature of their jurisdiction.
Mr. Gardner: The trick will be to build on already well-established and well-respected institutions. Two of the bodies within health that have taken a broader population health and a social determinants perspective are regional health authorities in most of the provinces and public health departments, to varying degrees. The regional authorities are creatures of the province; the public health departments, in most provinces, are within the regional health authorities, and some, such as Ontario, are within the municipalities. Whatever you do, you get some constitutional and jurisdictional problems.
The Canadian tradition has been to either try to bulldoze through those, which does not tend to work too well, or to sidestep them. To sidestep them through, as you are doing senator, one needs almost informal discussions with the leaders in the other provinces, other orders of government and the communities sectors to see to do all of this together. If for example, every province was to say that it would make a serious commitment to reducing health disparities in its area; we will make a serious commitment to work with our federal colleagues and our next-door provincial colleagues and with our municipal and community colleagues, it would take a different form in the different provinces, and that would not matter so much as long as there was a serious commitment. Underneath that, there is the nitty-gritty of the civil servants of the various provinces finding some coordinating mechanisms. Again, there are various FPT committees and task forces that, if they were given the political push from the leadership and the political direction that population health and social determinants are a priority, they could run with that.
Nobody is empowered to require that. However, that was a key lesson from England and other jurisdictions; they had targets in each department. Childcare and employment had targets and when it boiled down to the municipal and local level, they all had targets, and the targets were reported on and monitored. If the various orders of government were able to make those commitments and build on existing mechanisms or set up others for the coordination, it think that is doable. As the model suggests, we must make a strong recommendation that every province says that there will be a vision and an ending to reducing some targets.
Ms. Scott: The other feature about the British example is that when they established targets for the different departments they renegotiated the employment contracts with the deputies of those departments and integrated them in performance measures into those contracts. That has been a very powerful impetus. They ran it through finance, which was another thing that was important about the British model, but they made it real to the participating departments by writing it into the employment contracts of their chief administrators.
The other piece that was interesting, and I know this from the poverty work in England, is they made a huge investment in data. They developed a deprivation measure. They report deprivation indices for 32,000 geographic units in the U.K. It is unbelievable in terms of what has been done to build this infrastructure. It takes on a bit of a life of its own. It is now wholly electronic, on the web. Communities can access their profiles on an annual basis, and communities mobilize around it. Realtors use it. It is an extraordinary thing. It has made very concrete and real that "I live in Sandy Hill," or whatever community you are working with, the characteristics of those communities, and it helps tell the story of communities, whereas data seems like one of the academic "out there" situations. Through the British initiative, they have made it real to local communities and made it accessible. For example, a small business owner in Toronto or Calgary could use this data to understand the local area, the community in which they operate. They can also track and see the disparity. They work. That generates more interest and action. It has been a fascinating way and an important component of the British model. The accountability starts percolating up and becomes concrete and real and helps create that passion.
The Chair: We have been successful in getting the government to pump a huge amount of money into information technology. The people on the ground and the people with their fingers in the computers think they will have electronic records for 50 per cent of Canadians in two years. That means that this part of this diagram is wired from the electronic record.
The next thing that has to be wired is across here, but we already have the health care delivery sector wired because we have enough people wired that we can get meaningful data in longitudinal studies and so forth.
Some of the other stuff will be wired from medical records. The connectivity that has to come is here across in the social determinants, but, again, the electronic pundits do not think it is that big a problem.
Ms. Clement: The wiring challenge is to move from individual data to obtaining community data that is as strong. We have wonderful community data, but it is not consistent and it is not coherent. We have an early child development index from certain provinces and not others. When we try to do health status reports that include all of the determinants, we can only do them in a smaller number of locations rather than the larger number of locations.
You can add your voice to the individual data as well to ensure that we amplify and deepen some of the medical record data. In Ontario, for instance, we are having a debate because we have a new 18-month screen for children that coincides with the last immunization. The electronic record simply says, "Have you done it?" It can be ticked off if they just immunized, but we are trying to do a deepening of social screening and there is no difference in the electronic record yet.
Senator Eaton: This question is to you principally, Ms. Clement, but others please feel to comment.
I am interested in the grassroots. It will be largely a federal initiative from the top down and meeting, hopefully. You are talking about your tobacco campaigns as being very successful. With population health, we have to deal with several factors. Once the report comes out and it states goals and perhaps targets, if you were to start an awareness program, how much can you give the public to absorb? Do you start with one, say, obesity, or preventative early childhood health care? How do you begin? How long does it take the public to begin to absorb the information and how much can you give them at once?
Ms. Clement: The community educational challenge about population health is to help build the concept of community well-being and that community well-being is associated with individual well-being; and that it varies depending where you live, what your family education was and so forth. Many Canadians still have the concept that genetics are associated with health. You know this, the narrow view of health.
One of the first educational pieces is to help them understand that breadth because then the willingness to see dollars go into affordable housing becomes different. The willingness to see income adjustment policy becomes different. There are ways to do the obesity work or the lifestyle piece that includes an equity component.
Our largest program at Health Nexus is about early child development, preconception to preschool, and we integrate equity and determinants issues into almost every aspect of that work. It is very unusual for community health promotion campaigns or work to include those. You will find very little of those in obesity work. The obesity work will be mostly about individual eating and exercise, not enough about access to food, recreation and built environment.
At the campaign level — and actually at every level — part of the challenge is to coordinate so that part of this piece gives us a frame to help coordinate.
Mr. Gardner: It is important in this kind to work to pick issues that are both hot and winnable, or at least that can build some momentum.
You are going to do a fantastic report and it will have many things you want in it, but you know it will not be adopted all at once. How do we move forward?
In the health field, we know that chronic disease prevention and management are important on all kinds of levels, obviously to all of our well-being but also to the sustainability of the system.
Diabetes, for example, is perfect for this kind of lens because its incidence, impact and severity vary tremendously along the social gradient. It is very much influenced by social determinants of health. If the project was to work with health planners to lead to better prevention and management of diabetes, you would inevitably have to be talking to folks in schools, social agencies, ethnocultural organizations and all over the place. It is very concrete because you are not just giving a lecture on diet and another on diabetes, you are saying to folks, and everyone knows this, diabetes is a critical issue — or pick the issue in the community. Whatever the issue is, you pick it in the community and that is the key thing. It will vary by community. Then you build it up and build the stakeholders around it. Inevitably, if we want to be successful, we build a broad tent to bring non-health people together to do this kind of planning. The health system in Canada is tremendous, but it will not solve our health problems because of these wider determinants of health.
It is ground level, step-by-step, but strategic. You are well placed here to think of what those hot issues will be.
Senator Eaton: It would be strategy. How do you get them to start eating a little bit instead of the whole?
Mr. Gardner: Senator Keon mentioned that the federal government has committed a lot of money and attention to information highways. That is good at all levels. For health, it is critical in the purely medical area of electronic health records. This has tremendous potential for better health care. If you add this stuff at the bottom, all of the sudden you have a good planning tool.
Imagine if you were in a local municipality or planning authority and you knew that people whose first language was Mandarin were not being served in the local hospitals. If you had that kind of real-time data you could work with the Mandarin-speaking community and the hospitals. It may be as simple as having more interpretation services. Probably there has to be more grassroots community work in that particular community, but the advantage of having that kind of data is tremendous. Then you do your programs and you see that next year we had better have more Mandarin folks coming into that hospital and we had better have Mandarin folks' diabetes levels going on. When they do, you have learned how to do a successful program and apply it somewhere else.
The Chair: As you know, health, well-being and productivity run parallel. As a matter of fact, Mel Hurtig said to us a few weeks ago that, when it comes to productivity, all roads lead to population health.
We asked the Conference Board of Canada to do a business plan for us, which they did, but the interesting spinoff of that is that some major companies that were involved in this have now introduced a population health agenda in their corporate structure.
Since you have had connectivity in communities, how do you see us selling that at the corporate and at the community level? There is a tremendous payoff for you here.
Mr. Gardner: Each of us has been involved with the Conference Board projects, and that is one way to do it. They are well placed to make the business case to other business leaders.
We can also look at other jurisdictions. There are always carrots and sticks in public policy. In Germany, the requirements in the fairly complicated health insurance schemes are that quite a small proportion of the spending on health insurance goes towards health promotion and community-based health promotion.
When I say quite a small proportion, I mean pennies, but that adds up to a huge amount of money. That money is funnelled into community ground level work that can be path-breaking. From your vantage point and that of the government, there could be a decision that "X" percentage of Ministry of Health funds, or in Ontario we have a Ministry of Health Promotion, or social services or finance, wherever it may come, will go to population health-driven types of initiatives. I would imagine that a relatively small proportion, quite a liveable proportion in budget terms, would make an enormous difference on the ground and then, as you have been saying, you partner off with community people.
To go back to Ms. Clement's example of Saskatoon, when communities are themselves involved in talking about the issue of particular neighbourhoods and particular types of people in our communities who have such lower standards of care or such poor health, then they get together and start to think about how to do something about it.
Ms. Scott: The model that comes to my mind is the training scheme in Quebec, where a portion of monies are set aside. The commitment is made for employers to invest in training and for those who either have small workplaces or do not, they are taxed a small amount to contribute to a global fund that underwrites workplace training.
Canada has low levels of private sector investment in training. This was an effort by the Quebec government to try to turn that around and, again, it is the same type of model; creating a social pool to underwrite a common public good that will be of benefit to a large number of citizens. This is in a similar sense what you are talking about.
Coming from the social development sector, is that we drift into campaign. There is something about population health that all of a sudden you are talking about eating well, there is an obesity campaign, we are in Saskatoon or this community, how will we do better outreach? All of a sudden, we are in social marketing. I believe that is because we have an extraordinary history in Canada — a 30-year-old history in Canada — right back to ParticipACTION. The frame in population health is around campaigns and personal behaviour. What struck me reading your report, certainly at the end, is that tension about getting out of that box.
Coming back to Senator Eaton's question about what type of strategic choices do you want to make; diabetes is probably a good one because it is not obesity. It is not something that people fundamentally believe is an individual responsibility.
How do you make those choices? If you came out with another healthy eating campaign as where to start, I think you would have nailed the coffin on the report and said this is not going anywhere because it does not stretch people to think about the system issue.
If you came out and said that you think this new money set aside for population health absolutely has to go into affordable housing that would do it. If you said we have absolutely impoverished income security programs for working-age Canadians. The structure of our EI program right now is a disaster. If you said we need population health, we need money to support Employment Insurance, that would be because it is fundamental to the population health of our country, based on our research, which would be an extraordinary statement.
I am not necessarily making that recommendation, there are many other things, but I do think that picking an issue that forces people to think system and not the individual will be really critical to the success of promoting your message as well as the efficacy of your initiative down the road.
Senator Eaton: When you are talking about breaking out of the box and I look at housing as one of the social determinants of health I think, and am I right, Senator Eggleton, they are rebuilding Regent's Park from the ground up. Was population health taken into account when they decided to rebuild that area?
Ms. Clement: Yes; absolutely. It is an exciting initiative and it broad social policies, community population, population health kind of issues were considered.
Senator Eaton: Could that be used as a model, as an awareness to other communities across Canada?
Ms. Clement: Yes; absolutely. In Regent's Park, they have set up a temporary organization simply to support coordination, communication and engagement. The redesign is to try and say how we are helping our physical environment; how are we helping our early childhood development; how do we have the school embedded right inside; what are the working employment supports that we need within the community; how do you support it multiculturally. You can go right across the list. They have dealt with it all. It is very exciting.
Senator Eaton: That could part of an awareness program as well.
Ms. Clement: Yes.
Senator Eggleton: What did you say about the British model? That model worked because it had political will, firm priority and commitment from the top two people in that government. That is an extraordinary combination. Even if you can get it in one government, governments change. Even within the same party when governments change you get a different sense of priorities and political wills. I like what Ms. Scott said about employment contracts. We say mandate letters around here, but either one will do.
I am sorry; I caught part of one presentation and missed both the other two presentations. We have emergency meetings crop up around here and in fact I have another one I have to go to in a minute.
However, I did get a chance to read this summary report entitled, Funding Matters: The Impact of Canada's New Funding Regime on Nonprofit and Voluntary Organizations. I noted that it was published in 2003, so I was wondering what was new but then I see in your presentation today that you have said revenues have been climbing again but core funding is still the same old issue. This is key to it, too.
We are talking about the federal government or the governments in total being a key part of this and the need for political will. There is the need for horizontal links et cetera, but much of this policy has to come from the ground up and it has to be delivered by organizations at the ground level. These organizations include volunteer organizations and many not-for-profit organizations that are working in our communities. That brings me back to this report.
I understand that the Treasury Board Secretariat is into a three-year study. They are consulting with stakeholders with respect to transfer payment policy, which includes a wide range of organizations but would include these kinds of organizations, the not-for-profits and community groups.
How is that coming? Is that going to start to address this core funding issue? What is the way to get around this thing because I recognize there has to be accountability about this core funding, about administration. There has to be efficiency, effectiveness in how it is used, but we could not cannot ignore it because organizations going from pillar to post, from one funding project to another funding project, having to shape the project in accordance with the government plan is no way to operate an organization.
How do you see this process going? For a community organization to be able to get into the population health thing, what kind of improvements do we need?
Ms. Scott: The current Treasury Board process is, as you mentioned, ongoing. They are doing outreach and consultations. I set this in the context of having been involved in these consultations for upwards of 10 years now and there is a certain level of fatigue I would say in the community sector.
Treasury Board is looking at this transfer payment policy and looking at the idea of having service directives that will be instituted in departments like Health Canada. They will be instituted whereby if you submit an application for funding you will not wait for six months and have to lay off all your staff. You can only see how that happens. If there are service standards that the Government of Canada adopts in its funding relationships this will certainly help move the administrative bar and reduce the burden.
Those are positive steps. However, as I had mentioned they steered away from any of the funding piece, the idea that organizations need administrative support. They steered away from the idea of full cost recovery or any of those sorts of things. They are focusing on the technical administrative piece, which is not unimportant but it is a series of first steps.
It is good that Treasury Board Secretariat is doing it but how that actually flows out to other departments and then flows down because much of the funding decisions are made in communities in regional offices and so forth. That architecture needs to be addressed. However, it is positive that the government is taking certain steps and much more must be done on that score.
That is why I am pointing to evidence of other philanthropic funders that are looking at re-forging the relationships and trying to create that traction.
I appreciate there is only so much the federal government can do. There are only so many organizations it is in touch with. That is what makes it interesting. Through the homelessness initiatives — Supporting Communities Partnership Initiative, SCPI, and the like, and the Urban Aboriginal Strategy, UAS, — there are some interesting models that the federal government has developed to do that direct linkage with the community sector. Those models include respectful funding relationships and more meaningful engagement in the process. That is the other thing, if you undercut funding in the relationship, you are actually debilitating the ability of community groups to plan and be engaged in your policy development. You are cutting the plant in half, in a sense.
What the UAS has done has been more successful in having meaningful engagement. There are some models of how to ramp that up, replicate and spread it.
Senator Cook: When you talk about structures, have you heard of the Internet-based Community Accounts in Newfoundland and Labrador?
Ms. Scott: Yes, it is brilliant. They are doing it in Nova Scotia now, and there are other similar types of initiatives perking up across the country.
Senator Cook: They are into New Brunswick now. You would endorse that concept and see it as a working model?
Ms. Scott: It is a tremendous model.
Senator Cook: The strength of that one — to go back to what Senator Eggleton just said with government accountability — they have enshrined that concept into legislation with accountability at budget time that gives the protection that you could ever hope to have.
Ms. Scott: Someone in Twillingate can click on their computer and pull up their community profile, which is an amazing thing. We do not have that in Ontario, I can tell you.
Senator Cook: You see it as a workable program?
Ms. Scott: Yes, it is excellent. Alton Hollett is a terrific person.
The Chair: We are convinced as well. He will be part of our armamentarium.
Senator Cook: It helps to get an endorsement.
Ms. Clement: In your model, the one thing that I would like you to think about adding is that not everyone goes from school into work life. Therefore, even though everything somehow is community, I think there is a nice space here where you could place community life; that sense of both neighbourhood life, but also communities of interest.
The Chair: Thank you.
Ms. Clement: It would just deepen and not change it.
The Chair: Thank you very much.
Mr. Gardner: I would also like to add a friendly amendment, as we say here. What I think would be worth doing to the whole model is to explicitly state that one of your goals is to reduce the gaps in health and well-being across the spectrum. You are about not just improving overall health through this kind of tremendous framework, but reducing the gradients.
The Chair: Thank you. Those are two very good points.
(The committee adjourned.)