Proceedings of the Subcommittee on Population Health
Issue 3 - Evidence, February 27, 2008
OTTAWA, Wednesday, February 27, 2008
The Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:16 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 have some problems today. The Senate is meeting as we meet and, should there be a bell, we have to immediately leave and vote. The meeting may get truncated. That is life around here.
In any event, we have before us Jim Ball from the Public Health Agency, from the Treasury Board of Canada, Indian Affairs and Health division, we have Sally Thornton, and from Finance Canada, we have Yves Giroux. Ms. Thornton and Mr. Giroux will not provide presentations, but they will answer questions.
Please proceed, Mr. Ball.
Jim Ball, Director General, Strategic Initiatives and Innovations, Public Health Agency of Canada: Good afternoon, honourable senators, guests and fellow panellists. I am pleased to be back to speak to this important issue that you are addressing.
I am now the Director General of Strategic Initiatives and Innovations in the Health Promotion and Chronic Disease Prevention Branch of the Public Health Agency, and I am pleased to be here to speak to you about actions taken, associated barriers as well as models and mechanisms to advance population health and the population health approach across departments and among jurisdictions.
I have also noted the tabling of your two reports yesterday. Congratulations. These analyses of international experiences will be of strong interest and value, not only to your subcommittee but to a spectrum of stakeholders working to advance population health and health inequalities in Canada.
I am working through the slide deck that you should have in front of you. On the second page, essentially, my plan is to respond to the three questions that you have provided to us and which have been noted on the slide.
Over on slide three, this is essentially an overview of how my presentation will flow. There are six slides that speak to some of the highlights and selected examples of experiences in advancing population health policy, models and approaches taken at the federal as well as the FPT, federal-provincial-territorial, and provincial and territorial levels that provide learnings for potential future work.
I have also identified some of the barriers that have been observed in advancing cross-departmental and inter- jurisdictional population health policies and will end by identifying evidence from international experiences that we have seen that speaks to the requisites and enablers for successfully advancing the social determinants of health. This latter information has been the result of work undertaken in the context of the WHO commission on the social determinants of health.
Turning to slide 4, although it may seem basic, an important step in this work is to develop a common understanding of what we mean by population health and the population health approach.
Over the years, particularly during the 1990s, we put a great deal of effort into building this understanding. Your subcommittee has provided a succinct overview or definition, if you will, which is very helpful as you move forward in your work, through your consultation process toward the development of your final report.
The population health approach I can safely say is now well accepted and applied in the health sector. Some examples of this include a number of the issues that are being addressed by federal and national strategies. They include actions to influence key determinants. For example, our tobacco control strategy and its promotion of healthy public policies leading to smoke-free environments is an example of how a strategy has picked up on a population health approach and made headway in terms of changing environments that impact on health.
Population health is integrated into a set of core competencies for public health practitioners, and this has been recently agreed to by federal-provincial-territorial governments at the deputy minister level. We are now seeing various forms of public health included more and more in university curricula. We are seeing schools of public health being established, including an emphasis on the determinants of health and the role of public health in addressing those underlying factors.
Population health has been adopted at the municipal government level — to mention a few, Sudbury and Waterloo have developed frameworks and organizational units specifically to address the social determinants of health in the context of their public health programs.
In 1997, the Government of Canada adopted the population health concept at the cabinet table. In Health Canada, a population health business line was developed. Ministers across the government agreed to this approach, but there was no substantive follow-up in terms of advancing population health through such tools as health impact assessments undertaken across the various departments at that time.
In general, I would say that population health policies since then have been more issue-specific and developed on the basis of windows of opportunities that have presented themselves. In other words, we have built in a determinants approach to the way an issue or a priority has been addressed versus looking at the range of upstream investments that are possible and focusing on those that would produce the greatest population health gains.
There are two important exceptions to this. One is the investment in children's initiatives, which, as you would know, involves a range of policies and initiatives across a number of different departments and have been in place for a number of years, given early childhood development as an important fundamental determinant of health. That would be one of the key exceptions.
Second, I would mention seniors policy and interventions. There are indicators of improved well-being of seniors that have coincided with the introduction of the pension plan, as well as other initiatives, such as the New Horizons for Seniors Program that was introduced at that time as well, which reflected a social determinants approach. Seniors and seniors policies and investments you could say are one of the population health success stories in Canada. Since the pension plan was introduced in 1978, we have seen the poverty rate among seniors drop. Improvements in seniors' health have coincided with improvements in their economic situation in recent decades. The prevalence of some important chronic conditions, notably heart disease, high blood pressure, arthritis, depression, et cetera, has declined amongst seniors since the 1970s. While we cannot say that it is cause and effect, there is a strong association, temporally at least, with the introduction of those measures and the improvement of the health and well-being of seniors.
Turning to slide 5, models and approaches, at the federal level we have engaged in a number of horizontal population health initiatives, some led by the health portfolio in the federal government and some by other departments. Among those, no one approach stands out as the best way or the most appropriate way to go, but each of these different models and approaches provides lessons, challenges that were faced, and opportunities that we can identify, to inform future efforts.
In the interests of time, I will point out just a few examples. The national security policy, which is currently in place, while not a population health example, per se, is a model worth looking at. It is a policy objective that was at the outset driven by a Government of Canada priority. It resulted in a suite of coherent and integrated policy initiatives around security. The mechanisms that were formed ensured that that would happen and that they would be managed in that way. Committees at the deputy level, the ADM level were put in place to move this forward in an integrated way. In essence, it shows how a centrally driven priority seen as an urgent issue or an important issue can result in the needed horizontal work that would be required to effectively address the issue.
Second, I would mention the family violence initiative, because it has been within the health portfolio to lead a cross-government effort, and in fact was designed at the outset as an interdepartmental approach, and included and still includes dedicated funding for work across departments, so that there is support for this interdepartmental effort. There is a committee structure tied to that that provides the opportunity for collaborative decision making, integration of various initiatives and collaboration on the application of the funds that have been provided to address family violence, all the way from the determinants of family violence to mitigating the effects of this issue.
Over on slide six, on the inter-jurisdictional front and at the provincial-territorial level, there are a number of efforts of note. I know you will be publishing a report in terms of provincial-territorial activities in this area, and I know as well that you have heard from some other witnesses on some of these. I will focus on a few that you perhaps may not be as familiar with.
The first one I would mention is a committee that is no longer in existence but had an awful lot to do with the development of the population health approach in Canada. That was the Federal, Provincial and Territorial Advisory Committee on Population Health. It consisted primarily of ADMs. responsible at the federal and provincial-territorial levels for work in this area. Essentially, together, it articulated the population health approach and published documents on the broader determinants of health, including the identification more recently of what are the health sector roles in advancing the social determinants of health through intersectoral work. It really provided the foundation for FPT work on population health. This effort led to the establishment of the federal-provincial-territorial public health network, the Pan-Canadian Public Health Network, which is now in place. It is governed by a council that consists of a chief medical officer of health for a given jurisdiction or a senior ADM responsible for public or population health. All jurisdictions are represented. It is an effective mechanism that is engaged in developing collaborative policy and initiatives. The advantage over the Advisory Committee on Population Health is that the Pan- Canadian Public Health Network has a mandated capacity to facilitate the implementation of this collaborative policy that is developed at the federal-provincial-territorial level.
The committee reports to a conference of federal-provincial-territorial deputy ministers who, in turn, report to the ministers of health across the country. There is strong potential to build on this work and to engage the Public Health Network further on addressing population health or the social determinants of health.
Some provincial-territorial initiatives of note: Quebec, you have heard from directly, so I will move west to Manitoba. The Manitoba child health initiative — Healthy Child Manitoba — is very interesting in that it is a cross- government initiative governed by a ministerial coordinating committee that is spearheading an intersectoral, interdepartmental strategy that is multi-facetted in nature. It is aimed at the improving the health and well-being of children and adolescents in Manitoba. It is quite an interesting model and an initiative that has achieved tangible results as a result of the cross-departmental engagement that it has achieved.
In British Columbia, I think you have heard something about the ActNow BC initiative. It is as a government-wide effort with an ADM committee with representatives from multi-departments. Plans are developed and a contribution is made to the priority of the premier to some stated objectives that include the goal of being the healthiest population ever to host an Olympic games. More important, this initiative was also driven by concerns over projections that they made out over a number of years in terms of the cost of their health care system. Those projections demonstrated that it would leave the province in a position of having only the capacity to cover its health care budget, a flat-line budget for education and no funding left for anything else that the provincial government would want to be engaged in. This was a strong impetus for moving forward on an initiative that would hopefully reduce the pressures through improved health status of the citizens of British Columbia.
ActNow BC is a good start. For it to be successful, it needs to continue to move on the underlying conditions or the determinants of healthy choices. At this point, it is in the early days. It is probably more focused on some of those lifestyle factors, but, hopefully, in the future it will be a model that more strongly addresses the underlying conditions and the determinants of health.
At the bottom of this slide, you will see the intersectoral efforts at the community level that are worth looking at. Often, these initiatives have included investments by the federal government and the provincial-territorial governments, as well as municipal governments. I point to the Vancouver agreement, which was signed in 2000, as possibly the best example that engages all three levels of government. It has been evaluated positively by the Auditor General. It started with a focus on drug use in the Downtown Eastside and has moved to addressing social and physical conditions. The current agreement commits all levels of government to coordinate resources to implement a comprehensive strategy supporting economic, social and community development.
The results are beginning to show. There is less crime, reduced substance abuse, new businesses are emerging in that particular area of Vancouver, and there are overall safer conditions for the citizens.
Moving to slide 7, ``Barriers to Advancing Population Health,'' which is one of your questions, from a health sector perspective, we can work on population health within our sector through policies and programs that target issues and address risk factors and other conditions. Often, though, we are mitigating. We are mitigating the effects of more powerful drivers of health or of ill health. Many of the levers or the policy initiatives that would advance population health lie outside the purview of the health sector and the health portfolio in the federal government and within other departments in government and other sectors outside of government.
With these other departments focused principally on their own mandate, and with a finite set of resources, human and financial, in order to accomplish their mandate and their priorities, this is not a situation that is always conducive to collaborative work or horizontal work across government. The win-win in working together is not always clear. I will come back to this point in a few minutes.
As you know, working in a multi-jurisdictional environment — to comment on the last point on this slide — can be complex. Priorities and needs vary across jurisdictions. Some provinces and territories are more advanced in terms of addressing health and population health; others have less capacity in order to invest in this area. Different ideologies sometimes create challenges in finding common priorities and certainly common approaches to addressing some of these priorities are issues. In some cases, we run into difficulties where we need greater clarity on what level of government is responsible for what area.
For example, there has been debate around Aboriginal peoples living off-reserve. Sometimes they are on-reserve; other times they are off-reserve. It is a complicated situation federally and with respect to provincial and territorial roles and mandates.
On the next slide, we have made some international observations, as you have, and I think it is fair to say that there is international consensus among experts concerned about health for all citizens that suggests some considerations worth noting. While discussion of specific models and mechanisms for advancing population health policies is important, we need to remember to focus on the end goal, which is really creating and maintaining health for all, hopefully as a priority. Ensuring that this priority is included in macro- and specific policy initiatives at the outset is fundamentally important, and we see that those countries that are most successful in advancing this have adopted that kind of priority and value on health.
To accomplish this, we need to create the conditions for success as noted on the slide. Clearly, we must be able to measure and report on the determinants of health and health inequalities so that we know where we are and what kind of impact our policies and interventions are having or not having. We need to develop a capacity to work with others and collaboratively consider the impacts, whether they are positive or negative, of existing and proposed policies and investments on health. Building an understanding of the interplay and potential congruency between health and socio- economic goals would, I think, in turn lead to incentives for collaborative policy development if we understand the win-win relationships.
On the last slide, in summary, as we look across different models and approaches in advancing population health policy and initiatives through horizontal action at different levels in Canada, as well as experiences in other countries, six characteristics or factors seem to be common in identifying successful work. These are noted on the slide.
Support from the centre of government or the highest levels helps to establish buy-in and ensure sustainability of an initiative. Clear directives for collaborative work also promote action, but it would be preferable rather than to have directives to have recognition of the mutual gains that the players in any intersectoral effort could accrue.
An example of a win-win, I think, would be working on literacy. Literacy can lead to increased employability and a better skilled labour force. It can also contribute to health literacy, leading to better health outcomes. An example of the importance of that is that low health literacy is strongly correlated with the incidence and prevalence of Type II diabetes. Improved health literacy, on the other hand, recent analysis suggests, can in fact improve overall literacy. There is a nice win-win relationship in terms of investing in literacy and the outcomes that can be achieved in terms of employment, productivity, et cetera, as well as what it might do to improving health outcomes, including the ability of Canadians to more efficiently and effectively use the health care system. For the majority of Canadians, their health literacy levels are not as high as they should be in order to navigate their way through competing messages about health promotion, disease prevention and some of the complications that arise in dealing with a highly sophisticated health care system.
The other points on this slide refer to some obvious things, such as the need for dedicated human and financial resources to work on horizontal and interdepartmental efforts. Accountabilities need to be in place and based on clear roles and responsibilities of various partners in a particular initiative. Internationally, something that can facilitate intersectoral and interdepartmental work is that, rather than creating new mechanisms where they are not needed, making effective use of existing mechanisms. Some of those are in place, at least within the federal government. There are mechanisms with respect to federal-provincial-territorial collaborative policy work in population and public health that could be used effectively to address the determinants that we are concerned about.
To conclude, a key aspect of the population health approach is addressing inequalities in health. These inequalities affect all Canadians and result from many factors. It will take many departments and many sectors working together to change this reality — hence, the importance of today's session and discussion on advancing horizontal and inter- jurisdictional policy and action.
The Chair: Thank you, Mr. Ball. Honourable senators, Mr. Giroux and Ms. Thornton will be happy to answer questions in regard to finance as it relates to horizontal initiatives, which we are talking about.
Let me start with you, Mr. Ball. As you know, our objective is to produce a report on the tremendous number of initiatives that have occurred in Canada over the years, and leading back to the Lalonde report, at the federal level and provincial levels, from NGO initiatives and so forth. We now have also tremendous resources with the new Public Health Agency and its integration with the provincial agencies and so forth and CIHI with its population health initiatives, just to mention a few. There are literally hundreds of initiatives, many of which are very good.
I want to bring you to something you did not mention, and that is the reason we went to Cuba. It was my impression that the federal-provincial initiatives targeting the general population have really been very good, such as the anti- smoking program, and I suspect the anti-obesity initiative will catch up before long.
In addressing health inequities, however, I do not think we have the structure. About 10 years ago, Health Canada identified about 136 regions in Canada where comparative studies, analyses and models could be applied. That has not happened on the ground.
Fundamentally, in addressing health inequities, we would be searching for a way of providing a structural framework on the ground at the local level or at the municipal level. The work may have already been done for us with the regions that were identified by Health Canada — which preceded the Public Health Agency of Canada. However, we are searching for a structural framework that can harness the tremendous resources and bring them in on a horizontal basis to address the local health inequities.
What do you think of that approach? We are gradually working towards that.
I think our fundamental platform will be maternal and child health. The major accomplishments in population health will come from healthy mothers and healthy children, who can take the advantage of early childhood development. However, let me bring you back to the ground because I think that is what has been missing, despite the tremendous amount of good work that has been done.
Mr. Ball: I think you are making a very important observation. Clearly, there are roles that need to be played by all levels, including the federal and provincial/territorial levels. However, the community level is absolutely vital.
I look at the community level in terms of three capacities. In some communities, these have been brought together, but in others they have not. Perhaps there are models from which we could learn. Certainly, we have municipal councils making, probably on a weekly basis, fundamental decisions about the determinants of health — they call them the determinants or not. For example, decisions about transportation planning, urban planning, land use planning, et cetera, are all important considerations in a determinants of health approach.
Recognizing the fundamental role of municipal governments and the nature of decisions made there is important. I think that needs to be brought together with the role of the local public health units and the medical officers of health who can provide an additional source of expertise and perspective through the full spectrum of the functions of public health. That includes everything from immunization to advice on healthy public policies in terms of smoke-free environments or the manner in which you undertake land use planning, et cetera.
The third cluster of organizations is those community-based groups concerned with issues that are really determinants of health. Addressing issues such as poverty and vulnerable populations at the community level is important. If you can find the models at the community level where you can harness all of those capacities and expertise, then, while we cannot dictate a particular structure, we can articulate an integrated approach that could be aspired to organizationally and from a planning perspective at the community level. That approach, as I say, would be more integrated and ensures that all of the capacities are brought to bear on the issue.
The Chair: I want to bring the financial people into this to ensure an integrated discussion. I thing there are about 58 horizontal initiatives from Treasury Board.
Can you envision a financial structure that would allow this horizontal integration of the 12 most important determinants of health at the community level? It may be 15 by the time our report comes out. Can you see a way of dealing with this financially?
[Translation]
Yves Giroux, Acting Director, Social Policy, Department of Finance: Mr. Chairman, one important issue that would be worth considering is that of the respective roles and responsibilities of the provinces, municipalities and the federal government. There are a host of population health determinants. Most of these determinants fall under provincial or municipal areas of responsibility. Mr. Ball alluded to transport. This is mainly a provincial issue, as well as a municipal issue in large part.
The issue of revenue is a shared area of jurisdiction between the federal government and the provinces. It is one of the areas in which the federal government has the most important role to play regarding the health of the population, that of helping to decrease revenue gaps.
There is an old saying according to which it is better to be rich and healthy than poor and sick. I think that is an area that the federal government has a part to play in.
To respond briefly to your question regarding whether a financial mechanism exists which would take into consideration these 12 or 15 factors, I do not think such a mechanism exists which could credibly or effectively take into consideration all of these factors. Measures are already in place through tax transfers, enabling provinces to have access to comparable revenue in order to deliver similar services.
Aside from these very general application or revenue distribution measures ensuring that the provinces have the same resources, I do not know of any simple and easy mechanism which would take into consideration these 12 to 15 factors.
[English]
Sally Thornton, Indian Affairs and Health, Treasury Board of Canada: Given everything my colleague from Finance Canada said with respect to roles and responsibilities and some of the difficulties in transferring funds, often at a community level you can enter into a results-based accountability framework to which all parties agree and which allows for some movement. It is an area where Treasury Board provides guidance. However, it is a collaborative arrangement where they identify common goals to enable them to start to speak the same language and work towards the same goals and the roles and responsibilities of each. They can indicate how much funding they will be contributing. They can also talk quite clearly about what they want to achieve. They can focus on results and everyone can take some ownership of those results. They can also agree to performance measurement indicators and a way of actually measuring them and reporting on those results.
This requires commitment from all parties, a clear governance structure and funding for the administration as well as for the actual delivery of the initiatives. That is a tool that can help bring a range of partners together. We use it interdepartmentally and between governments, and we have used it with community partners.
[Translation]
Senator Pépin: In Sweden, we know that the minister for public health is responsible for intersectoral collaboration when it comes to population health. In 1997, the Government of Canada took an important step in improving population health. Cabinet adopted a population health approach and Health Canada was chosen as the lead department.
What does the Public Health Agency of Canada think of the idea according to which government departments and agencies must consider the effect of their actions on population health? Is the Public Health Agency of Canada able to play this coordination role in a similar way to what is done in Sweden?
[English]
Mr. Ball: As I mentioned in my opening remarks, to advance significantly on the socio-economic determinants of health, we must work collaboratively within the federal government. The government obviously has a number of objectives, not just health. However, we do need to think about health in all the different policies and measures that we put forward so that we can ensure that the best possible outcomes for all objectives are achieved.
There are tools that one can use. Health-impact assessments are tools that are used by a number of countries. They are most successful in situations where it is not a directive to do a health-impact assessment on a particular policy or initiative but where there is an understanding on the part of all departments or sectors about health and how it can be best promoted and advanced so that it becomes a collaboration between, say, the health portfolio in the federal government and other departments as opposed to a directive to go through a series of questions or analyses, but working together. There are tools and there is expertise available within the health portfolio in order to provide that kind of collaborative support.
[Translation]
Senator Pépin: Training was provided in various departments and the Department of Health coordinated this training and was the lead department. It would seem there were some problems. To work at different levels, with different departments, currently it would be Health Canada. However, if another department coordinated these activities, like the Department of Finance for instance, would it make things any easier? Would it be easier from a leadership standpoint to ask another department to lead, considering the collaborative work that is done not only with federal departments but also with the provinces?
[English]
Mr. Ball: There may be a sense on the part of all departments that there would be, for example, a more neutral approach to this. I cannot speak for other departments, but if it were seen as a government-wide initiative, collaboratively undertaken or facilitated by a more neutral focal point, as I said before, that might create conditions for better collaborative work and consideration of health and well-being.
The Chair: In case you do not know Senator Eggleton, he has a lot of experience in horizontal integration, because he was the mayor of Toronto for three terms.
Senator Eggleton: I also tried to do it more when I was President of the Treasury Board. It is tough to do horizontal whole-of-government stuff in a system that is based on a lot of tradition and silos. Some of you are trying this.
Mr. Ball, you talked about the need for high-level championship. A very good example of that can be found in the U.K. The U.K. government has taken a strong leadership role — certainly they did on the basis of the previous Prime Minister, Tony Blair; as well, his Chancellor of the Exchequer, who is now the Prime Minister, was also closely involved with it. When you get the finance guy and the prime minister working in tandem with other ministers, you have a lot of leadership and championship from the top. That is a great example. Of course, they do not have the inconvenience of provinces, as I think the Finance Canada official would point out, so there is not a jurisdictional question.
There is that model, but then there is also one that you mentioned, Mr. Ball, with which I have some familiarity, and that is the urban development agreements. I only know of two of them — one in Vancouver and one in Winnipeg. I cannot remember what the one in Winnipeg is based on, but you have talked about the one in Vancouver. They are not the same kind of thing as the U.K. example. They are bottom-up examples where the municipality pulls all the players together. If we were doing population health on that basis, we would be dealing with many agreements across the country.
Could you comment on which one of those directions you see as producing the quickest results? Should we go to a more bottom-up approach or should we be getting the Government of Canada to take the top-down approach like the U.K. government?
Second, I wish to talk about the Aboriginal Horizontal Framework. Is that a model, maybe, here? It deals with some 360 programs and services. There are seven theme headings, including health, lifelong learning, housing, safe and sustainable communities, economic opportunities, lands and resources, and governance and relationships. It covers quite a lot. It may, in effect, cover population health — maybe not directly as a program but indirectly that seems like it could easily be all encompassed after that. Again, the Finance Canada official would say yes, but the federal government has that special responsibility for Aboriginals. This is one of the great problems, when you get into cross- sectoral issues with different levels of government.
Maybe that is a model we should be touting in this particular case. Does it work and is it a model?
Ms. Thornton: We can start with your last question about the Aboriginal Horizontal Framework. I am in the program sector within the Treasury Board Secretariat. I serve client departments, Health Canada and Indian and Northern Affairs Canada. I also have the lead on the Aboriginal Horizontal Framework.
First, I wish to clarify that we do not actually manage these horizontal initiative; we report on them. We seek to get good information about spending and results. The actual management of the initiatives lies elsewhere.
On the Aboriginal Horizontal Framework, we have been struggling with that. It was developed in 2004 to answer a simple question: How much are we spending on Aboriginal issues? We could not answer that. We are now coming up to our third report. We could not answer how much we are spending on Aboriginal initiatives as a federal government. We have begun doing significant work on our expenditure management systems to better identify strategic outcomes and to better clarify program definitions that will help us define that.
However, the framework, as it stands now, engages about 30 departments. We report on spending. We are able to track about $8 billion of federal government spending per year on that. We do it manually; we do not actually have the systems in place to pull those figures. Large departments such as Indian and Northern Affairs Canada have that capacity, but many of the smaller departments have to go through their programming and say, ``Half of this is related to Aboriginal; a third from that.'' We are hoping to improve that through expenditure management system reform. However, it is not yet a management tool. Right now it is a reporting tool. I have ideas on how to make it a management tool — but this will take several years.
We report on the Aboriginal Horizontal Framework about 18 months after the fact. Great work has been done, but it is not helpful at this stage as a management tool.
Senator Eggleton: You say you monitor it, that it is managed somewhere else. Who manages it?
Ms. Thornton: The leads for the different initiatives are in respective departments.
Senator Eggleton: Does someone chair it?
Ms. Thornton: No one actually manages the framework. I chair the committee that gathers the data, inputs it and tries to clarify.
Senator Eggleton: You are there to monitor it.
Ms. Thornton: We are there to report on the spending. Then, as Treasury Board submissions come forward, we try to monitor and challenge whether the results are being achieved.
The Chair: Senator Eggleton and honourable senators, we have just received bad news. We have to wind up. There is a vote in the chamber in about 20 minutes.
Senator Eggleton: Can I get the answer to my question first or will we wrap up right away?
The Chair: No, that is fine.
Senator Eggleton: I am trying to come up with a model here. If that is not Aboriginal Horizontal Framework, is it the Urban Development Agreements? What is it?
Mr. Ball: I do not think it is an either-or issue. I do not think there is a single model, whether it be top-down or bottom-up. I will say that the identification of population health as a Government of Canada priority would be a significant advancement as long as it had a focal point, and, therefore, a lead, within the government to facilitate or ensure that a cross-government effort, according to certain objectives or targets, was developed and implemented. I would say that, as part of that effort, you would want to have very close collaboration with provincial-territorial governments and, in turn, work with provinces and territories to develop the agreements that are necessary in major urban centres and rural regions that would bring to bear the policy levers and the capacities of both levels of government to the issues that are being faced in urban and other communities.
It will take a whole-system approach to address these issues. I think it would be worthwhile to be aware of the socio- economic gradient in health.
It is worthy of government-wide attention since it affects all Canadians. At every step downwards in income or education, we see a decrease in health status. Nothing illustrates that more than statistics today that show that lower- middle-class Canadians have double the rate of Type II diabetes than the highest-income Canadians.
Senator Cook: I will just take 30 seconds. I am from the province of Newfoundland. Are any of you familiar with the government's Strategic Health Plan? They started with a draft provincial charter. They listed their goals, their outcomes and their way of achieving. The plan is crosses various government departments and has a reporting mechanism.
Although we are a small province and can manage that kind of thing, I wondered if you have seen it. If not, I would be pleased to sends it to you. I would like your opinion on whether this could be a possible model that could be modified, even as the innovative community accounts — 10 components like household spending and whatever. An audit has been done. It is a comprehensive policy plan. It is in year three and it appears to be working.
Are you familiar with it?
Mr. Ball: We are familiar with the Newfoundland strategy. You mentioned the community accounts and I think that is a very interesting approach. It is one that could be useful for other regions and provinces.
For those who are not familiar with it, it is a system that collects and displays information on social, economic and health indicators at a community level. This data from the community accounts are used to inform social and economic policy at the provincial, regional and municipal levels. Therefore, it is a good example of how all of these different factors, which are essentially socio-economic determinants of health, are as a package considered in moving forward with the policies that are developed at the provincial level.
Senator Cook: It feeds into the provincial Ministry of Finance, which manages it.
The Chair: am sorry that we cannot continue this interesting discussion; I regret that we have not been able to utilize the witnesses fully. Perhaps there will be another opportunity. Thank you very much.
The committee adjourned.