Proceedings of the Subcommittee on Population Health
Issue 2 - Evidence, December 5, 2007
OTTAWA, Wednesday, December 5, 2007
The Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:05 p.m. to examine and report upon the impact of the multiple factors and conditions that contribute to the health of Canada's population — known collectively as the social determinants of health.
Senator Wilbert J. Keon (Chair) in the chair.
[English]
The Chair: Honourable senators, we are delighted today to have with us two expert witnesses. Ms. France Gagnon is principal researcher and professor in the labour, economics and management teaching unit, Télé-Université de l'Université du Québec in Montreal. She is also Co-chair of the Groupe d'étude sur les politiques et la santé. Her field of research and expertise is the management of health care systems and the development of population health policies. Ms.Gagnon is also familiar with Quebec's Public Health Act and is able to discuss some of the implications of section 54 of the act.
Ms.Nicole Bernier, PhD, is an assistant professor of research in preventive medicine at the University of Montreal and a scientific consultant with the National Collaborating Centre for Public Policy and Health. Her research focuses on government policies that influence health and social disparities. Given her expertise, she can offer a comparison of the population health policies adopted in Quebec and those in other jurisdictions. We are looking forward to hearing what she has to say.
Please proceed.
[Translation]
France Gagnon, Professor and Co-chair, Groupe d'étude sur les politiques et la santé (GEPPS): Mr. Chairman, as a representative of the Groupe d'études sur les politiques publiques et la santé (Study Group on Public Policy and Health), I am pleased to respond to the invitation from the Subcommittee on Population Health of the Senate of Canada. We wish to thank the members of the subcommittee for this opportunity to raise awareness of the research we have conducted since 2005 into public policies conducive to health.
My presentation will address the following three points: the issue surrounding the implementation of section54 of Quebec's Public Health Act; our main observations on the implementation of section54, five years after its adoption; and the Act to Combat Poverty and Social Exclusion. May I first remind you of the content of section54, which states that:
"the minister is by virtue of his or her office the advisor of the Government of Quebec in any public health issue? The minister shall give the other ministers any advice he or she considers advisable for health promotion and the adoption of policies capable of fostering enhancement of the health and welfare of the population.'' This means that when statutory and regulatory measures that could have a significant impact on the population's health are being drafted, he or she must be consulted.
Let us now turn to its implementation. The findings of a study conducted in2003 on the perception and implementation of section54 in the various departments and agencies of the Government of Quebec, and scholarly papers assessing the impacts on health, allowed us to identify three main problems as a starting point for our research.
First, the difficulties experienced by the various departments and agencies in identifying the impact of their actions on public health and welfare; second, the difficulties for the organizations in question of incorporating within government departments and agencies an assessment process as regards the impact on health; and finally, the difficulties for those developing public policy of assessing potential positive or negative impacts on health and welfare. In order to better understand and address some of these problems, or at least attempt to partly address them, we have focused on three areas in our research: the decision-making process; the prospective assessment of the impact on health; and the process of knowledge transfer and acquisition.
To document these processes, we conducted retrospective case studies in four departments, including the Department of Employment and Social Solidarity, which is responsible for the Act to Combat Poverty and Social Exclusion. The rest of my presentation is based on the findings of these case studies, and on an investigation conducted by Jacques Bourgault, co-researcher at the GEPPS, on the conditions for success of interdepartmental provisions adopted by the various provincial governments in Canada in the development of horizontal public policies.
I would now like to move on to my second point, the main observations on the implementation of section54. I will begin with the findings on other ministries' perception of health and its determinants. Studies conducted in the public service of Canada and Quebec pointed to the gap between economic and social departments in their awareness of the potential impact of their actions on public health and welfare.
For economic departments, the links between their actions and the impact on public health and welfare is not a concern. This is a concern to the other departments, including the MSSS. The findings of our case studies in various departments tend to confirm this finding, with some qualifications.
In practical terms therefore, each department sees the problem primarily from the perspective of its own mandate. Impacts on health are addressed to the extent that this is relevant to the department's institutional vision. But in any given area of intervention, there are often conflicting understandings of the problem, especially as regards potential solutions. At the Quebec Department of Agriculture, Fisheries and Food, for instance, there are three concurrent views on the Act Respecting Commercial Aquaculture. Some divisions of the department focus on the economic aspect of aquaculture development while another division is more interested in food safety. Public health stakeholders, for their part, see this as an opportunity to introduce omega 3s in hatchery fish production.
A more detailed analysis of the dynamics between the stakeholder groups shows that in each case, the stakeholders' vision of the problem and most often of potential solutions relate to economic, environmental, safety or administrative visions.
In short, it is difficult to maintain the interest of departments and agencies in the potential impacts that their actions could have on health and well-being when there are factors more closely related to their own mission to consider.
Furthermore, the consideration of health and well-being determinants is rather implicit in the formulation of public policies. I would now like to make some observations on the development and implementation of interdepartmental mechanisms. Within the MSSS, steps have been taken to develop an intragovernmental health impact assessment process. These initiatives include the creation of a committee of departmental sponsors; the dissemination of an information bulletin; the preparation of a practical health impact assessment guide, an issue I will revisit in the next section of my presentation; and the publication of a document to raise awareness about the determinants of health, again for the use of other departments.
According to MSSS data, the number of opinions requested and/or consultations received and processed by the department with regard to proposed laws and regulations increased in 2006-2007.
A number of these requests came from the cabinet committee on social, educational and cultural development of the Executive Council Secretariat. Even before the adoption stage, a brief on the proposed action has already been drafted by the department or agency in question and submitted to the Executive Council Secretariat. The brief that you have been given provides you with more in-depth information, particularly on the committee of departmental sponsors. In order to keep within the time that has been allocated to me, I will end this section with a few final comments on conducting health impact assessments, commonly referred to as HIAs.
First, I would like to point out the ambiguousness of the expression "significant impact'' used in section54 of the act and, in particular, the application problems resulting from this ambiguity. What criteria or standards are used to determine whether an impact is significant?
That is why the MSSS developed a practical guide for HIAs. This guide contains the basic information needed to perform this type of assessment, as well as screening and scoping tools. This assessment, which is intended to be strategic in the sense that it focuses on screening for and identifying potential impacts, is voluntary. Furthermore, the INSPQ, Quebec's institute for public health, is currently developing a methodology for the drafting of reports on public and health policies, with a view to standardizing the opinion and knowledge summaries prepared for the Minister of Health or the MSSS.
In short, the ability to document the impact and quality of the data are determining factors in carrying out health impact assessments.
To respond to the subcommittee's question regarding the Act to Combat Poverty and Social Exclusion, no formal coordination exists between the measures relating to section54 and those relating to section20 of the Act to Combat Poverty, which states that each minister must give an account of proposals of a legislative or regulatory nature that he considers could have impacts on the income of persons who live in poverty.
However, it is the Advisory Committee on Combating Poverty and Social Exclusion, struck in 2006, that has an oversight role on government policies having impacts on poverty and social exclusion. The Act to Combat Poverty and Social Exclusion, passed in December 2002, is a framework law that sets out key principles to guide government actions.
Pursuant to the act, the Department of Employment, Social Solidarity and Family Welfare introduced the government action plan to combat poverty and social exclusion in April 2004.
A case study was carried out on the action plan, and I would be happy to discuss it during the question and answer session if that would be of use to you.
In conclusion, section54 certainly provides significant leverage to encourage the development of public policies conducive to health. However, although it is technically the law, section54 is more of an incentive, since there is no formal sanction for non-compliance. In general, there is a great deal of work to be done on the transfer and appropriation of knowledge on the development of public policies conducive to health from the MSSS and INSPQ to the departments and agencies and in cooperation with the academic community.
Health and welfare determinants, the carrying out of impact assessments and the review of policies implemented elsewhere are all matters of concern in this regard.
The Chair: Thank you, Ms.Gagnon.
[English]
I was very interested in what you had to say and recognize that, from a public health point of view, Quebec is well ahead of the rest of Canada.
Is any feedback available between the population health status of people and the policies that combat poor health, such as poverty and sanitation for example? Is there any connectivity between the information you gather from a population experiencing poor health and the policies and measures implemented in the health care system or even more broadly from a social point of view to combat poor sanitation and housing, et cetera? We are looking for that type of information somewhere in Canada and I thought Quebec may be ahead of the rest of the country.
[Translation]
Ms.Gagnon: I am afraid that I am going to have to disappoint you as the passage and implementation of section54, as part of the Public Health Act, is a relatively recent event: section54 was only implemented in June 2002. The government is in the process of ensuring that it is respected in the various departments and organizations. It is still too early to evaluate the impact on population health.
The same is essentially true of the Act to Combat Poverty and Social Exclusion: As it was adopted in 2002, it too is fairly new. I do not have exact figures as to poverty levels in Quebec but thus far the focus has not so much been the impact of the legislation on population health, but, rather, the political and administrative machinery available to ensure that departments other than the MSSS give consideration to the impact of their activities on health and welfare.
We know that health determinants, such as the physical and social environment, have a more significant impact on population health than do factors such as the health care system.
The real aim of section54 is, therefore, to ensure that other departments, such as the Department of Transport and Department of the Environment, think about how their activities impact upon population health. This is a challenge that has been with us for a number of years.
[English]
The Chair: To follow up on your response, Sweden is beginning to get connectivity between their pockets of poor health and the implementation of social programs such as you mentioned. Initially, you said there was not much connectivity, but in your answer you mentioned that planning relating to environment and sanitation in the communities must link with public health. If you are doing that, you are the first place in Canada to get public health approval for any kind of community or provincial program. Could you enlighten us on that?
[Translation]
Ms.Gagnon: Perhaps I misunderstood your question. When you talk about public health, I assume you mean public health stakeholders and their role in the process?
You are undoubtedly aware that public health in Quebec is structured differently than it is in other provinces. In recent years, public health has been built up centrally to a rather large degree, within the Public Health Branch at the department and at the Institut national de santé publique. At the regional level, there are public health branches, and locally, efforts are also underway to redefine the role of public health through health and social services centres.
As regards the application of section54, the ministère de la Santé does indeed have close ties to stakeholders at the Institut national de la santé publique. The public health institutes play an important role in documenting all aspects of what we call "health impact assessments.'' They are defining a method to produce opinions and analyses as systematically as possible, to document the positive or negative impact that certain measures may have on health.
I do not know if that was the thrust of your question, but public health stakeholders play an important role in putting in place and developing policies that promote health.
Moreover, in an exploratory study conducted in 2006, we attempted, somewhat naively perhaps, to put together an inventory of public health initiatives based on policies that promote health, for the period from 1995 to 2005. Our study shows that most initiatives focused on environmental and lifestyle determinants. The stakeholders we met told us that in the years to come, greater emphasis should be placed on social determinants and that that aspect of social determinants was often difficult to document.
[English]
The Chair: Yes.
In the old days of medicine, there were fundamentally two determinants of health, genetic and environmental.
Now we talk about a dozen determinants of health, and we are making progress. Thank you for your answer.
Senator Eggleton: Just to follow up on that question, poverty is a major social determinant of health. There is a public health act attempting to follow a population health approach. There is an act to combat poverty and social exclusion. Obviously, poverty comes within the interest of both of those areas.
While you say the economic departments do not seem to have much of an interest in public health or welfare concerns, quite obviously poverty is an economic issue as well.
How does all this get coordinated, or does it? Will it all be a happy coincidence that it comes together? Is there some coordination and where is it? Is there coordination from the top, at the cabinet level? Is there a political will to coordinate this?
[Translation]
Ms. Gagnon: You have raised several important questions. In my brief, I raised those aspects and I am going to come back to that. For starters, section54 stipulates that departments must consult, but there are no real formal constraints. For the time being, the ministère de la Santé has chosen to use an incentive-based approach. It has selected three strategies: first, the impact assessment process within government, secondly, the creation of links with the Institut de santé publique to document knowledge about impact assessments, and thirdly, investments in research.
As regards the development of an intergovernmental process, I will go back to my brief, if I may. Various steps have been taken including the most important one which is closest to your question, and which is the creation of an interdepartmental committee called a network of respondents.
The ministère de la Santé created this network of respondents. The impact assessment guide is being developed. An outreach document on health determinants is also being published. If we focus on the network of respondents, on studies that have been conducted, we can say that the network of respondents from the departmental committee is variable. Of course it does seem that when they are closer to the deputy minister's office or the departmental secretariat, they have an easier time disseminating the information. The issue of turnover among the respondents involved remains. Most of the respondents questioned, although they did not have a formal mandate, did go to great lengths to distribute the information in their departments.
Moreover, links have been created between the team at the ministère de la Santé responsible for section54 and the Executive Council to ensure that the evaluation grids are sent to the department when a draft memorandum or regulation is tabled. They indicate whether or not there is an impact on health. If the information has been taken into account, the evaluation grids are sent to the Ministère de la Santé so that it can take a look at the impact assessment process. I do not know if that answers your question.
Senator Pépin: Thank you, I am very happy that you have come. You were just talking about the impact. You say that there is a practical guide, and so on. If I understand correctly, the ministère de la Santé is in charge and provides that. Yet there seems to be an economic side. It seems that departments with an economic focus are having some difficulty coordinating their involvement in health.
You then told us that the practical guide does not contain formal constraints regarding assessments. I think section54 is very good, but there seems to be a lack of coordination that means on the one hand, you have people who do want something for health, but for them, the issue is the absence of disease, not prevention. It is very difficult to reconcile the two. Has the government been able to create a group or a system to apply that? In Sweden, they began with regional groups, the government, and different aspects. Did Quebec do that before trying to coordinate, so that people on the economic side came on board and said: of course, we must spend or take action to prevent disease and poverty, and so on?
Ms. Gagnon: There were several parts to your question.
Senator Pépin: There were very clear objectives.
Ms. Gagnon: For starters, section54 clearly targets the provincial level first and foremost. Moreover, initiatives are underway in the regions, in Quebec, through the National Collaborating Centre for Healthy Public Policy, which was set up by the Public Health Agency of Canada. Efforts are underway to develop initiatives like that in the regions.
As regards the involvement of departments with more of an economic focus, I would not want to imply that nothing is being done. If we look at the policy, in other words the Act to Combat Poverty and Social Exclusion, I went over that part quickly. Several steps have been taken. An oversight committee has been created and includes participants from several departments including some with a social focus, but also some with an economic focus.
The ministère des Finances does not necessarily participate in this oversight committee, but there are nonetheless a number of diversified departments that do participate in it to assess the impact of the Act to Combat Poverty and Social Exclusion on an annual basis.
So there is that aspect. There is another point, for example, in the case studies we have done. I told you about what is being done at the ministère de l'Agriculture et des Pêcheries et de l'Alimentation, at the ministère de l'Emploi et de la Solidarité. We have taken a look at the work done at the Ministère de l'Environnement and at the ministère des Transports.
It is the same at the ministère des Transports; we know, par example, that the accident toll is a very important aspect. At the Ministère des Transports, health promotion work is being done with a view to reducing the accident toll.
For example, an issue table was created in recent years, and the various public health stakeholders have participated. So we know that some very specific action has been taken in various sectors. It takes the shape of coordination tables and oversight committees involving departments from various sectors. In Quebec, not everything being done in terms of public health policy is strictly linked to section54. It is important to emphasize that.
SenatorPépin: Various means have been used to reduce disparity and inequality in health, for vulnerable groups, including Aboriginal families, pregnant women, and immigrants. In Quebec, what would be the corner stone or the essential strategy for improving health and reducing disparity among the various groups?
Ms.Gagnon: That is a highly complex question.
SenatorPépin: In your view, is the government, namely through its projects, spending enough time looking at this aspect? Will this issue be considered, if it has not yet been studied?
Clearly, as you have said, the process has just begun. So we will have to wait a year or two for the results.
Ms.Gagnon: Public health stakeholders often refer to section54 as a lever. That way, movement and interest in an issue is generated, which raises awareness in people outside the Ministère de la Santé. That is an important point.
Various public health stakeholders are attempting to systematically document impacts and to acquire to knowledge necessary to measure the impact of all actions on health. In fact, for departments, section54 means changing the way they work. Departments are accustomed to using a vertical approach. We are now asking them to adopt a horizontal one.
This approach is already used in certain sectors where we work with issue tables and oversight committees. However, we cannot make issue tables mandatory. We must start with the practices that are already in place. For departments, that means changing the corporate culture.
A similar section was adopted in Switzerland, and it recently came into force. In the life of an institution, five years is hardly enough to measure impacts on health.
For our part, we have not focussed as much on health impacts as we have on ways of insuring that health becomes a frontline concern within government and the administration. Stakeholders in health should not bear the weight of these concerns alone, the others departments must do so too. This is more or less the process that we are attempting to understand in all its dimensions.
The use of knowledge is fundamental. The knowledge is often enough available, however, it is not always used.
The work must be done in the medium and long term. Some public policy models require observing changes over a ten-year period. Consequently, I believe that it will take some time before we see the results.
SenatorPépin: Let's say that it is a wonderful opportunity.
Ms.Gagnon: Indeed.
[English]
Senator Callbeck: Thank you for coming here today. I wanted to ask about coordination. The minister, of course, is responsible. You mentioned many different committees, but with regard to the question on coordination, you mentioned interdepartmental committees. However, there is not a cabinet committee. Is that right?
Ms. Gagnon: No.
Senator Callbeck: Has any thought been given to that?
[Translation]
Ms.Gagnon: Unfortunately I have no way of knowing that. The current respondents committee is located within the Department of Health. The Executive Council Secretariat has closer ties with the Premier's Office. That is the level at which all of these actions take place. To my knowledge, there is no particular committee in charge of clause54.
In Quebec, this type of provision is called an impact clause. There are many such impact clauses in Quebec. There is one on poverty and one on health. We also pay special attention to the regions and to economic development. We have quite a number of impact clauses.
We are taking a closer look at this issue so that the health impact assessment might become part of a more comprehensive framework. This entire movement, including the health impact study, arises out of the environmental impact study. There has been a trend in some European countries to integrate the health impact assessment with the environmental impact assessment and the social impact assessment in order to avoid duplication and to make the best use of the impact assessment resources.
With respect to clause54, the ministère de la Santé takes the lead, along with stakeholders from the Institut national de santé publique.
[English]
Senator Callbeck: I wanted to ask you about those powers. It says that it gives the minister a power of initiative toissue proactive advice to other ministers in the aim of promoting health and supporting the adoption of policies that foster the health of the population.
Since the Public Health Act has come into force, how many times has the minister issued proactive advice? Do you have a rough estimate? Has it been several times?
[Translation]
Ms.Gagnon: According to the department data, there was an increase in the number of requests that were received and processed. There were some 40requests in 2006-2007 compared to about 30 in previous years. This seems to be an increase in the number of requests and notices received by the department.
Unfortunately, I do not have all of the health department data. However, in our research, we are working closely with the health officials. According to the information that we have, there has been an increase in the requests and therefore a greater awareness among the other departments.
[English]
Senator Cochrane: My question begins with the Government of Quebec. What objectives and targets has the government set out with regard to population health? There must be targets. When this was established, you had objectives as to the direction, whether there was an evaluation method in place and indicators in order to be accurate as to what has been achieved over a period of time.
[Translation]
Ms.Gagnon: As I said, for clause54, this is something that is starting to come together. You are no doubt well aware of the health and well-being policy that the Quebec government adopted in 1992; it involved a set of objectives, and was evaluated in 2005. It is essentially the health and well-being policy.
In this particular case, I would like to tell you that it is being implemented. However, I am just an outsider looking in. Eventually, the impact of this clause will be assessed, but at this point in time I do not think that any indicators have been defined. I believe that the impact of this provision on the health of populations will be assessed during a second phase, according to various sectors or various determinants.
[English]
Senator Cochrane: How long will it take before you are able to measure the results?
[Translation]
Ms.Gagnon: I cannot really tell you how many years, it might take another five or six, it all depends. I would be tempted to say that it depends on the initiatives that are implemented and policies that are adopted. I understand your concern, but at this point we are evaluating what has already been done. However, your comments are quite relevant. There will have to be an evaluation made after the fact. Currently, we are looking ahead in order to improve the decision-making process down the line. We will have to examine the impact, but for the time being, I cannot tell you when we will be evaluating the outcome of clause54.
As I said earlier, we must not forget, in relation to Quebec's public health system— which is structured—that there is a national public health program to define these objectives; but it is another opportunity to act in the area of the health of populations. We must understand that clause54 is a special tool with specific objectives, but there is an entire other public health structure in Quebec. I believe that it was possible to apply clause54 in Quebec because the province already has this public health structure which is different— and my colleague did more work in this area— than that of the other provinces.
[English]
The Chair: I would ask Ms. Bernier to proceed with her presentation.
[Translation]
Nicole Bernier, PhD, Assistant Professor, University of Montreal: Mr.Chairman, it is an honour for me to be able to contribute to the work of the Senate Subcommittee on Population Health. Thank you for having invited me. I am an Assistant Professor of Research at the Université de Montréal School of Public Health. My training is as a political scientist, and I have become a specialist in the field of public policy analysis.
For a number of years now, my research has focused on public health policy analysis. I strive to understand what is involved in the transformation of public action with respect to population health, who are the people involved in effecting this transformation, why and how it occurs, and what the effects are. Therefore, it is a somewhat different approach than that of my colleague, whose work deals more specifically with clause54.
This research enabled me to examine Canada's and Sweden's experience and also to get an idea of what is happening in other countries. My observations have also focused on three provinces: Ontario, Alberta and Quebec.
In this preliminary statement, I would like to tell you about the basics of what I have learned thus far from my research into public health policy. I will use very broad brush strokes, at the risk of over simplifying somewhat.
How have things changed? The transformation of public action as it affects population health is an international phenomenon that has surfaced in a number of heavily industrialized countries over the past two to three decades. Since the end of the 1970s, public action on population health has two key features. First, national governments got involved in health promotion and in developing a central national policy on population health. There is a long tradition of local and territorial public action in the field of public health, but health promotion was introduced late in national welfare state public programs following the war. Then, at least in terms of the official line, health became everybody's business. All government departments and no longer simply departments of health are responsible for public health. Those are the two new aspects.
And who is involved? There are many, but those involved in this transformation have been, first of all, the central public authorities themselves. The main dynamic is a top-down process, to use an English term. What I mean is that the national governments took on an official mission to improve population health through multisectoral public health action. Nowhere was there a mass mobilization asking national governments to develop public programs to address the social determinants of health and to find solutions. However, there was a secondary grassroots type of dynamic, but only among government and professional organizations. Local and regional governments are asking the national authorities for a national intervention framework. They feel that a national form of public action would be a way of dealing with the problems that have arisen from geographically limited public action, for example, the fact that some public health programs and services are available in one region but not in another, which gives rise to inconsistent public action. By demanding standards from the central government, some regional governments hope to be able to remedy these territorial inequalities. But it is always a very sensitive matter for a national government to impose national standards on all regions and sophisticated ways of doing so are required.
Central governments will have to find sophisticated ways of doing so. Also, an international movement of health care professionals in the world of academic research can be considered as stakeholders supporting central governments in the area of public health.
Likewise, international agencies are involved with national governments in a self-reinforcing and mutually influential interactive dynamic. The World Health Organization (WMO) comes immediately to mind, but one must not forget the influence of other agencies like the OECD, the IMF and the World Bank, which are also international public health stakeholders. An important thing to remember is that national governments are the initiators and catalysts of the change in direction in public health policies.
Now, why has government action to address population health and the social determinants of health at a given point in the history of modern welfare states become a common concern in many highly industrialized countries? It is no accident that the concerns of national authorities have arisen precisely when highly industrialized governments were striving to implement systematic ways of controlling growth in public spending.
The beginning of a process of national government disengagement vis-à-vis health and welfare and the crumbling of their legitimacy and authority are the key reasons to explain this. These major transformations created a specific form of political dynamics characterized by increased tensions in the field of health services, including tensions between medical authorities and the State. For some groups, the growth of public health provided new opportunities to improve and consolidate their professional position. This is clearly the case for nurses. Greater strength for certain occupational groups within the health sector as diluted the power of medical associations and contributed to a relative strengthening of the position of the State.
Clearly, the attention paid to social health determinants represents a governance tool ensuring that the public health system continues to work despite tensions that are exacerbated by reduced financing strategies. In the same vein, this disengagement poses questions as to the legitimacy of governments while efforts to promote health based on the social marketing of good lifestyles are highly valued by public authorities, it is not because they are particularly effective. It is rather because such efforts allow public authorities to refurbish their legitimacy. They offer a high level of electoral visibility at low cost.
As for the other levels of government, the financial disengagement of national governments was manifested, as we know, by an administrative decentralization giving sub-national governments responsibilities for service delivery. Whereas national governments were reducing their contributions to public health and protection, they were finding it difficult to continue imposing their authority. With reduced financing, there was a need for national governments to find new ways to underscore their political authority over sub-national governments.
In sum, why this phenomenon? National public health policies make it possible to reduce the tensions associated with the financial disengagement of central governments. They allow them to reaffirm their legitimacy and authority at a time when they are profoundly redefining their role in social protection and health.
How did this phenomenon occur? How have the official policies manifested themselves thus far? In three ways: first of all, through the development of an official line of expertise based on a broad national strategy; the development of new population health data bases through the creation of national research infrastructures and the development of a community of social health determinant researchers.
Second, through coordination. This involves the main policy stakeholders: provinces, political parties, unions, employers and occupational groups, depending on the context, in large national forums. These forums generally extend over several years. The process involves major national forums to negotiate the objectives of public health, but they usually forget to prescribe ways of achieving these objectives. The coordination process also involves representation from the health sector vis-à-vis other departments. We see it here in the case of section54. The health sector brings in other departments and has them review their role as it relates to public health, thereby contributing to the dissemination of the health standard throughout all government activities.
Third is the institutionalization of standards within the machinery of government. For example, the establishment of public health agencies in Sweden in 1992 or agencies that promote concerted action on the social determinants of health and policies to promote health in Canada, in 2004. It can also be effected through legislation, in Quebec and Sweden, for example, those factors in public health in areas of intervention other than health. Lastly, it can be effected through the introduction of new government management technologies such as impact assessments of health and the strengthening of a decision standard surrounding the adoption of legislation and programs that are supported or often justified by convincing data.
In short, to answer the question as to how this is done, government action on the social determinants of health has to date been mainly an official-expert line that is solidly supported by the scientific community and widely disseminated to the major policy players and other areas of intervention. Concrete action can be summarized as the development of an official, expert line on population health, a vast coordination process with all the political stakeholders, and the institutionalization within the machinery of government of standards for public action on the social determinants of health.
Who are the winners and who are the losers in this? We will not talk about the interests of the central governments, which have already been discussed. Such a policy has genuine repercussions on the positioning of the policy players, and the health sector gains legitimacy in relation to other areas of intervention. This is because making a multisectoral vision of public health a reality requires that the actions of all departments become subordinate to public health standards and to health impact assessments.
The health standard requires special status in government programs by taking precedence over competing government standards and helping to strengthen the position of health policy players in relation to other policy- makers. Major social problems such as unemployment, poverty or social exclusion are virtually re-expressed in health terms and broken down into micro-problems by a technical and scientific bureaucracy for health. The ability to mobilize data and articulate traditional social problems in terms of their effects on public health becomes an essential ingredient in negotiating those in government between departments and administrative levels and in the social sphere between the government, unions, employers and NGOs, for example.
The players who are in the best position to translate social issues into health terms most often come from the health sector itself. Clearly, beyond the national authorities— compared to infranational authorities— the winners are the players in the health sector. The losers are groups in society whose social resources did not enable them to describe their social problems using the language of the social determinants of health.
In conclusion, I would like to draw the members' attention to the symbolic aspects of public policy due to the social determinants of health. Despite official initiatives and the major efforts undertaken, I do not think these policies will be implemented effectively, or even that their objective is to improve population health. I say this for the reasons I have just mentioned and which I could develop.
Beyond compliance with standards on public policy by all of the political players, a genuine implementation of public programming geared to the social determinants of health is extremely complex, if not impossible, even when the standards are institutionalized, as they are in Quebec and Sweden. An approach of this type involves a significant transfer of resources and authority between the intervention sectors and the administrative levels.
I wanted to give you my general observations. I am sure that during our discussion, I will be able to highlight some of the aspects that interest you in particular.
[English]
The Chair: Thank you very much, Ms.Bernier. You raise some very important issues. Are you satisfied that you are capable of measuring population health and that your measurements are proper?
[Translation]
Ms.Bernier: We would have to see what epidemiologists would have to say in this regard. Social epidemiology is the science that might have the answers to the questions that seem to be of concern to the committee— namely the question as to whether these policies work.
I think these policies are so broad that their effects are diffuse, and I do not know either how or when they could be measured. However, if there were some social epidemiologists here, they might tell you something different. I do not want to answer for them. It is a little like asking what impact Keynesianism and liberal policies have had on population health. The effects are so diffuse that I do not see how we could someday come up with an answer that everyone would find clear and satisfactory.
[English]
The Chair: I have always thought that Quebec was in the ideal position to establish a health system on a population health basis because a number of years ago they established the CLSCs. Perhaps they have not been used adequately as research tools, but certainly you have CLSCs in downtown Montreal where the people are rich and healthy. You have CLSCs in parts of rural Quebec where people are poor and unhealthy. It would seem to me that if the public health agency could harness the CLSCs as a research and implementation tool we could get some hard measurements. I do not know which one of you would care to wade into that, but maybe both of you.
[Translation]
Ms.Bernier: I have nothing to add regarding the measures. You mentioned the CLSCs. The interesting thing about the Quebec policy, which is unique in Canada, is the relative integration of social policy with health policy. As you know, in Quebec, we have a department of health and social services. That created a special dynamic for policy development. The policy is already incorporated into this department. There are two areas of activity within the department, but this has been crucial to the development of the policy we have today.
I am going to go off track a little, but I will do so in an effort to respond to your concerns. Many questions have been asked about the links between the anti-poverty policies, the Public Health Act and public health programming. What you should know is that the Act to Combat Poverty and Social Exclusion in Quebec already promotes health to a significant extent. It was designed with that in mind. The person who ran the department of employment and social solidarity at the time was none other than Dr.Jean Rochon, who was a public health expert. Since there was a social movement in Quebec, he wanted to implement an act to fight poverty and social exclusion. The social movement existed, but the public health players were crucial in developing this legislation. For example, there was a regional public health branch that piloted the research that led to the legislation to fight poverty and social exclusion. So the links have already been established, both by the CLSCs and by the networks.
I would like to make one final point about integration. Since the public health program was introduced in the mid- 70s at Laval University and the Université de Montréal, they have trained between 700 and 800public health professionals who work in government and are located throughout the various departments. So they have a genuine impact on public programming in Canada, not just in the health field.
That is what I meant to say with regard to integration; it holds true for local community service centres, but it also applies to the department, and generally speaking to Quebec's social policy.
Ms.Gagnon: I think we are going in the same direction with regard to the measures. We must consider the actual measures taken under these policies.
As my colleague said, it is very important to remember that the Act to Combat Poverty and Social Exclusion was born of a social movement which began in 1998, and at the time, it was the former Minister of Health, who was with the Ministry of Employment and Social Solidarity.
In the course of our case study, we realized that not only was the Minister of Health involved, but also a former deputy minister of health and a person who worked in health promotion, and that all of these people were already aware of the situation. So this would have made a difference. These are the people who carried the issue forward, because you can well imagine the first reaction people would have to a minister tabling a bill born of the efforts of many people wanting to fight poverty. Then the minister must sell the bill to his colleagues and convince them of the merits of fighting poverty through legislation. There were negotiations between all the people behind the bill and the department, which led to a compromise that eventually allowed the bill to be tabled.
With time, the act became operational. At the beginning, it was a strategy. It then became an act and a plan of action. When the time came to develop the plan of action, people disagreed about the types of measures to be taken. On the one hand were those who believed that it should be an economic approach focused on the short-term integration of people into the labour market, and on the other hand were people who believed it should be a social approach focused on training people to help them overcome chronic, long-term poverty. The measures which were adopted focused on the short term. Therefore, it is important to know whether these measures were indeed effective.
[English]
The Chair: Senator Pépin wants to leave, but before she does, I want to follow this up. Both your presentations were very interesting. However, it is a very interesting phenomenon because politicians do not seem to be afraid to talk about health equity — that is, equal health for all. Nobody would dare talk about financial equity— not since Joseph Stalin, right. I believe the social conscience of the whole country is dedicated to relief of poverty, and that kind of thing, but financial equity will not occur.
However, health equity may be an achievable goal. I was fascinated, Ms.Bernier, when you were speaking. You said that because there has been such an emphasis on health, some of the other departments are getting a bit tired of hearing about it; that there is too much emphasis on it; and that there should be more emphasis on some of the other things.
I would think that certainly in the province of Quebec, with the organization you have as well as I know it— and I do not know it anything like you two do, but I know about it— you certainly have the medical infrastructure to address health equity. How far down the road are you in doing this? I know also that you have some terrible pockets of ill health in the province.
Apart from the policies up there at 30,000 feet, what is happening on the ground at a CLSC that happens to be a pocket of very ill health — that is, bad maternal health, bad early childhood development and that kind of thing?
[Translation]
Ms.Bernier: I am afraid I cannot answer your question because that is not my area of expertise, so I can only talk about maternal or infant health in very general terms, which is not what is being discussed here today. I did not say that the other departments are sick of having to meet the health standard. That is not at all where I was going. The health standard is also applied to other sectors. It reflects a profound change in the approach taken by the welfare state, where health is becoming a much more important sector, and as a result, it influences social policy and the area of social protection. This has happened slowly over time. It became a clear trend in the middle of the 1990s when federal transfer programs were redefined and there were deep cuts to federal transfers to the provinces. So what happened? The health care standards were maintained; in other words, the five conditions related to federal transfers to the provinces in the area of health care. But the other conditions were eliminated, except the one which applied to welfare programs.
One very important aspect of this is that it encouraged reform of the social protective system, while keeping the health care system intact. As for health care costs— while, though income security programs were reformed, the government did not succeed in properly controlling health care spending. As you know, health care costs are continuing to grow as a percentage of GDP. In 1970, health care costs accounted for 7percent of GDP. In 2005, that figure had risen to 10.4percent. That means the costs increased. Health care spending is growing more quickly than the GDP. What effect does that have? It takes money away from other public programming. The balance changes.
I am quite far from maternal health policy, because it is not my field and unfortunately I cannot talk to you about it. If we undermine social policy, that will certainly have an impact on the social determinants of health. If we put less money into social assistance, and make the shift to ambulatory care, like Quebec did and as we have seen in other parts of the health care system, but do not have the funding for social services down the line, we can say all we want about working on social determinants of health and population health, we can establish all the legislation and public health care programs we want, but the system will not work. That is more or less my answer. Sorry, but this is the area in which I am working.
Ms.Gagnon: I am also a political scientist, so I cannot answer your question specifically for a given health sector. When you talk about the importance of equality in health, I feel I should say that what we are really talking about is investment in disease. That is the driver that increases health care costs, because we have increasingly developed technology and all kinds of other things. Often, we invest in disease— and everything that we invest in that sector is not only not invested in the social sector, but also not invested in education, in parks, or in cycling trails. That is where investing everything in health care becomes dangerous.
Can we make other departments more aware, to help them understand the impact of their actions, to the point where they will be more careful and come out the winners because they will be reinvesting in health? I do not have the answer to that today. It is a way of saying let us invest less in health care and let us try to see in advance how we can better allocate funding so that the general population is in better health. I consider that very important. This is not something we can impose through legislation. It will need both the political will from political authorities, and more awareness and understanding among Canadians so that more initiatives are started up locally. Intervention is needed at both those levels. You need the grassroots movement, but you also need the political will from a government that wants to restore a balance to the system.
Stakeholders in the public health system are very aware of the so-called "health imperialism'' issue. They are trying to get away from the reputation they might have in Quebec. In some cases, they were called the ayatollahs of health. For example, take the issue of advocating the Tobacco Act, which was passed. Take the interest in obesity. That remains an important issue as well. Do we go as far as allowing a public health system to impose standards and tell individuals how to behave in their day-to-day lives? That is another important issue. Public health stakeholders are well aware of that role, and that of label as health dictators in what they are trying to present to other stakeholders and government departments.
[English]
Senator Cook: I will confess at the outset that I know very little about the health programs in the province of Quebec. Help me to understand this: You say in your paper that currently section 54 is an incentive to consider impacts on health and well-being but that there is no legal obligation to do so.
Then you go on to say that the assessment, which is intended to be strategic in the sense that it focuses on screening for and identifying potential impacts, is voluntary. I am preoccupied with your possible outcomes, given that you work in that particular environment. I am concerned about best practices or evidence-based information.
I also hear you say that laws will not do it, that there must be a political will — and that sometimes can take on a life of its own.
What is the value in consensus when we talk about population health amongst all the parties?
[Translation]
Ms.Gagnon: You have raised a number of points. Impact assessment is not mentioned in the legislation at all. That is a way of implementing section54.
Health impact assessment, as I was saying earlier, is very well developed in the U.K. and other places. In some practices, health impact assessment is believed to require participation by the population. In Quebec, we have not yet integrated population participation into this, but we do it elsewhere, for example through consultations or forums of various kinds.
At present, active participation by the population in an impact assessment is not formally incorporated. I do not know if that is what you meant with your question. There is no official mechanism that requires their active participation. We could see this happening in the future— and we should bear in mind that it is an important consideration.
However, it is not the only consideration that must be taken into account. Active participation can complement a study and provide another point of view, but there is still a debate about impact assessment generally and the data we should take into account. Earlier, I said that the Public Health Agency of Canada is in the course of developing a method. It has drawn inspiration from the procedure used by NICE, a U.K. institute, that takes more conclusive data into account.
However, we are more open to other kinds of qualitative data because it is quite possible that in some cases we may not have conclusive data. If we have no probative data, must we necessarily exclude all other kinds of data? Are there no other data that might prove useful, for example data from case studies, interviews or other sources? We just have to remain aware of the kind of data we are using. That is what matters. The issue that is raised with respect to health impact assessment concerns the use of data, and the quality of the assessment as such.
[English]
Senator Cook: Ms. Bernier, would you like to comment, or have I confused you as well?
Ms. Bernier: Maybe you could rephrase your question.
Senator Cook: I am trying to understand within my head an element that carries no legal obligation and is voluntary. I am concerned about the outcomes. I tend to think black and white, plant trees in rows, and that kind of thing.
I am trying to understand how effective that method could be. I understand that laws will not cut it. There is an element there that I am not focusing on or understanding.
[Translation]
Ms.Bernier: Let us go back to the macroscopic view. That is true for Quebec's policy, and I know that is something you have looked at particularly carefully. However, when I finished my remarks, I said that there was a very symbolic function to public health policy. This is not unique to Quebec. There are no sanctions. There is no specific instruction as to how we are to implement programs, the policies we establish, or legislation. We are talking as experts. We vote for legislation, we institutionalize standards, yet implementation does not follow. I was also saying that policy is not necessarily fully intended to be implemented, it may be intended rather as a symbolic reform of social policy.
That is one example. Many programs are established world-wide and in the provinces. Alberta has established excellent public health objectives over a 10-year period, from 2003 to 2012, with no specific budget and with no accountability. That sort of attractive programming is very appealing to stakeholders, particularly those on the ground, but it is not necessarily implemented in the end. Even Sweden did not provide for strong mechanisms: yes, there are assessments— I believe that the first assessment report on the Swedish policy was published in 2005. But when I went there last year, I spent two weeks in Stockholm and talked to public health stakeholders who complained that the system did not really provide a genuine assessment. They said there was no real implementation. That is what came out of the interviews I conducted a year ago.
Central governments have to reconcile the expectation that standards must be established and the imposition of those standards in the regions. For example, in Sweden, it is very difficult for the government to impose central standards on authorities like the Stockholm County Council. It is very difficult, because the local authorities are very powerful. So the central governments cannot impose the standards. And the regions do not voluntarily indicate how they will go about establishing them. Nothing really happens if public health objectives are not met. There are no penalties.
Quebec is no exception to this. It is just that in Sweden and Quebec, standards are more institutionalized. However, it is still a process of cooperation. That is what I said in my remarks. Does that answer your question?
[English]
Senator Cook: I will have to think about it for a while, but my immediate conclusion is that an infusion from the public purse will drive that which you propose.
[Translation]
SenatorPépin: At present, governments want to assess the impact on health of their public policy. Many countries want a procedure that will apply to the environment. At that point, many countries will examine their policy and the potential impacts of the environment on health.
I am thinking about Ms.Bernier. Are you now talking about that redefinition of the welfare state? In what sector? Will it just be in the health sector?
Ms.Bernier: A lot of it is in the health sector, because the health sector is taking up an increasing share of collective public resources. As you are already well aware, that also applies to the environment sector and others. So I would say that what we are seeing is governance technologies being rationalized in the public sector so that they become more scientific and technical.
SenatorPépin: In practice?
Ms.Bernier: Perhaps, if we call it results-based. But those methods are aligned with a school of thought that no longer works well with the current public policy development process. The focus is on the decision. When we pass statutes and regulations, we want to know whether they have measurable direct impacts. Decisions are based not only on evidentiary data, but on a raft of compromises in a variety of sectors.
Obviously, people enter politics with ideals, but once they come to power— and I am talking to people who know this much better than I do— than they can no longer do what they want. Compromises must therefore be made with other sectors. But if we can succeed in saying that our decisions will be guided by public health considerations, that does give weight to the argument.
When the Harris government was elected in Ontario, that did have weight, that was important to the health sector, because the Harris government reduced the social protection people had. It reformed social assistance. It restricted access to social assistance in 1995. Social groups lost everything they were getting from the government. Many of them shut down very soon after the election. However, the public health system managed to keep channels of communication with the Harris government open by pointing out that cutting public health funds would cause long- term problems with the health care system. So the economic/health approach worked with the Harris government, when social arguments did not.
SenatorPépin: When we say that we are applying an environmental policy, do you believe that we should always look at the impact, and always try to make people aware of how important prevention is? In the long run, if we can do that for the environment, could we develop that approach further so that there would be a significant impact on health?
Ms.Bernier: If it is a useful means to improve health and well-being, why not?
SenatorPépin: It is the most direct way, is it not?
Ms.Bernier: For instance, if we can show that environmental policy has an impact on health, and so on, and that it is beneficial to the population's health and well-being, and if that is what we want, then let us go ahead with it.
SenatorPépin: We want to take something much closer to us to show the impact on health.
Ms.Bernier: It is an instrument that was developed by the central governments and that we can actively use.
SenatorPépin: To raise awareness?
Ms.Bernier: Yes. How do we go about developing a population health policy that works? As a government, and more specifically as a federal government, how can we successfully influence the social determinants of health?
Your questions clearly show that you are very interested in finding a solution and you are looking for models to follow. Have we any ideas from other provinces and other countries? We have some. Why should we not take advantage of them?
It is also important, at the same time, to get away from an overly idealistic approach to population health. It certainly has benefits, but it also has an impact on social redistribution, on social groups, and on the ways in which governments intervene. As we move ahead, we must evaluate the impact of our policies objectively.
Great changes are coming about and we do well to plan our way ahead, but at the same time, as we move on, we must evaluate the impacts.
SenatorPépin: I took note of your conclusion. In fact, to sum things up, I understand that you do not believe that the implementation has been effective. The health determinants are complex, etc., but it is important to transfer authority. How do you think we could transfer authority?
Ms.Bernier: Authority will change hands automatically, it is a natural process.
SenatorPépin: Yes, but currently, with the organization we have here, and in Quebec— ministers, various departments, etc.— what kind of transfer should there be to make things more efficient? If the determining factors are complex, how should we go about it?
Ms.Bernier: I have no silver bullet, but let me share an idea that I developed with a colleague in a recent article. I do not know if you have read it. In any case, with regard to Quebec as well as Canada and the federal government, we say that it is crucial for the central authorities to get involved. We mean Treasury Board, the cabinet, the central agencies of government, of every kind of government. The central authorities must absolutely get involved and provide guidance for the other departments.
This was done in Quebec, because we adopted legislation. Perhaps France knows more than I do about the central agencies in Quebec and their involvement?
To conclude, in answer to your question, I think that this is an essential condition, which applies everywhere, in Ottawa as well as in Quebec and in every country and every province.
SenatorPépin: The deciders!
Ms.Bernier: The central ones!
SenatorPépin: Ms.Gagnon, do you have anything to add?
Ms. Gagnon: I emphasize the fact that the authorities must be involved.
[English]
The Chair: Thank you, Ms. Bernier and Ms. Gagnon. You gave us two full hours. We deeply appreciate you coming here and providing us your expertise.
The committee adjourned.