Proceedings of the Subcommittee on Population Health
Issue 7 - Evidence, June 18, 2008
OTTAWA, Wednesday, June 18, 2008
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 on the impact of the multiple factors and conditions that contribute to the health of Canada's population — known collectively as the social determinants of health.
Senator Wilbert J. Keon (Chair) in the chair.
[English]
The Chair: Honourable senators, we do not have a quorum but we are duly constituted. Therefore, we will begin with testimony from Louise Saint-Pierre, Project Manager, Centre de collaboration nationale — Politiques publique et santé.
[Translation]
Louise Saint-Pierre, Project Manager, Centre de collaboration nationale sur les politiques publiques et la santé (National Collaborating Centre for Healthy Public Policy): First and foremost, I wish to thank you for your invitation. To begin, allow me to remind you that Quebec's Centre de collaboration nationale sur les politiques publiques et la santé is one of six collaborating centres funded by the Public Health Agency of Canada. The Centre de collaboration sur les politiques favorables à la santé is a translation of the expression ``healthy public policy'', better known in English. The centre's mandate is to support the efforts of Canadian public health actors in promoting healthy public policy throughout Canada. It is in this context that the centre works to synthesize and transfer knowledge and to make stakeholders aware of the most appropriate strategies to promote healthy public policy. For this reason, the National Collaborating Centre for Healthy Public Policy is interested in health impact assessment (HIA), which has been identified as a highly promising strategy to further the implementation of healthy public policies.
Since the centre's creation in 2006, we have undertaken a review of literature on HIA. In 2007, we conducted a fact- finding mission in England, Wales and Switzerland. We also organized a national roundtable on this topic, which shed light on how Canadian actors perceive the health impact assessment approach. We are monitoring with interest the use of HIA in Quebec. Therefore, our comments will be based on this information.
We congratulate the subcommittee on its report and interest in population health. Like all public health actors, we believe that improving population health in Canada can only be achieved by reducing social inequalities in health and ensuring more effective interaction among the different non-health sectors. In fact, in your report, you indicate that 60 per cent of health factors are non-health-related. This is why, for the first time, we have created a centre dedicated to promoting healthy public policy in Canada. We hope to contribute to the strategy.
For this evening's meeting, the subcommittee is seeking input on two important questions. The first is whether or not it is necessary and realistic to make HIA a requirement at the federal level. If it is, what would the role of the various support agencies and authorities be?
By way of response, we would like to point out that in 1969, the United States was the first country to institutionalize environmental impact assessments. It was based on this success that interest for health impact assessments grew, particularly in Europe, where the approach is much more well known than in the U.S. or Canada.
Many stakeholders believe that it is time to apply this approach to population health, as it is an issue which concerns all population segments across the board, as does the environment. If we have reached a point in the environmental arena where industrialized countries have in the main institutionalized environmental impact assessments, many observers now believe that it is time for a similar phenomenon in the field of population health.
However, our literature review and the meetings we held provided insight into conditions that are conducive to the introduction and implementation of a mechanism such as HIA at the government level, and the challenges it presents. These conditions and challenges fall into three main categories. The first is strong leadership and political support. We know that such an approach requires cultural changes and embracing different methods. Second, institutional adjustments, particularly within government departments, must be made. Third, support for knowledge and capacity development is necessary. I will go over these points briefly and we will then have an opportunity to discuss them.
With respect to the first main category, strong leadership and political support, you will already have concluded from the international literature review concerning experiences in other countries that it is highly important to maintain a clear position at the highest level, which provides a solid foundation giving legitimacy to the efforts of promoters and champions of this approach. To this effect, we have identified four methods in the literature review. In your own document, you talk about institutionalizing practices, as a way of ensuring the approach's sustainability, even in the absence of its advocates. For example, in British Columbia, champions and promoters have been able to apply HIAs at the government level. But once the government changed and the champions left, the approach was less frequently used.
Regulation or institutionalization can ensure a certain level of sustainability. Based on the experience of British Columbia, Quebec decided to institutionalize HIA by reintroducing it in a piece of legislation.
A second method which we have identified, which I believe you also highlighted in your work, is the existence of a body charged with accountability and the responsibility for following up on implementation.
Once again, this watchdog body would ensure that the necessary change comes into effect.
Another measure, which to our mind is effective, is a clear position at the highest authority, that being the federal government, expressed through a public statement to provide a solid foundation. Such official statements have been made in the United Kingdom, and by the European Commission with the Treaty of Amsterdam.
The fourth category, strong leadership, would mean setting population health goals based on a long-term vision. This was one of the major conclusions drawn by a group commissioned by Health Canada in 1996, that sought to understand how the HIA could be implemented. The group concluded that without a long-term vision, it is very difficult to achieve goals because the approach is a difficult one; a long-term and broad health vision must be strictly adhered to.
We have observed that the introduction of HIA requires adjustments within departments, in the relationships between departments and in the relationships between departments and legislative bodies. The two main adjustments identified in the literature are, firstly, the implementation of interdepartmental mechanisms or integration of responsibility for HIA into existing mechanisms, which we have already observed in some countries. Secondly, there must be consideration of the burden placed on the different departments as a result of the proliferation of impact clauses. This has occurred to some extent in the Quebec experience, where there is a host of impact assessments regarding health, the economy, and aboriginal persons. We must be sensitive to this.
Last, as has been observed once again in the Quebec experience, a clearly defined mechanism must be established to allow administrative and legislative branches to work together. Much can be done at the administrative level within the department to adopt new approaches. Sometimes, there are changes in the legislative branch and not everyone factors in this concern, the need to take health considerations into account when making decisions.
Finally, and I will conclude on this comment, the third measure which seems imperative is supporting knowledge and capacity development.
Health impact assessments, particularly at the highly complex policy level, require a thorough knowledge of evaluation methodologies and impact analysis methods. Under this approach, a prospective analysis of the impacts on health of a given policy must be carried out, policies that do not have health as their primary objective. Therefore, there are methodological approaches to develop. A lot of knowledge has now been amassed, but not all public health actors are equipped with the necessary training to carry out this analysis.
Once again, through the literature review and practical experience, we have identified three conditions to foster skill and capacity development for stakeholders: firstly, the contributions of external organizations involved in the development of knowledge pertaining to analytical methods, the politico-administrative process and public health data — I believe this was also one of the findings of your subcommittee. Second, there must be an ability for organizations to train and support skills development. In Canada, many of these abilities must be brought together in a quest for synergy. Third, there must be increased financial resources. At times, assessments of attempts to implement this approach have revealed a lack of financial support to launch pilot projects and impact assessments.
Perhaps my colleagues would like to add a few comments on this subject.
With respect to support, I believe in development, in support, and in the use of HIA. It is worthwhile mentioning the case of Quebec. You are most certainly aware that the Quebec government has implemented HIA. Departments and non-health organizations are responsible for initiating health impact assessments, and the Department of Health supports other departments.
By passing this clause to amend the Public Health Act and implement HIA, the government has taken measures such as the creation of two full-time positions in the provincial Department of Health and Social Services. There is a service agreement with the Institut de santé publique du Québec, which provides highly technical expertise, and scientific opinions; something not possible within the Department of Health and Social Services. There is also a rather significant research project which is funded accordingly. Therefore, the Department of Health has developed a consortium of two research funds in health and in culture to support research activities with a view to better understanding the politico-administrative process that I referred to earlier — I believe that you met with France Gagnon from that research group — but also to better understand health impacts.
In conclusion, we believe that the HIA is a powerful and necessary tool to spur cultural change because population health is important and the Government of Canada can act to reduce inequalities. However, HIA alone is not enough. It must be complemented with various measures to ensure better follow-up, assessment and support. And I believe that several of these measures are contained in your recommendations.
I do apologize for having exceeded the time allotted for opening statements. I would be pleased to answer your questions.
[English]
The Chair: Thank you, Ms. Saint-Pierre. Mr. Smith, please proceed.
John Smith, Director, Legislative and Regulatory Affairs, Canadian Environmental Assessment Agency: Thank you, Mr. Chair, for the opportunity to address the committee. I am joined by Tim Smith, Senior Policy Advisor, Canadian Environmental Assessment Agency. He has a particular focus on strategic environmental assessment.
We understand that part of the work of the subcommittee is to consider the potential use of health impact assessment in the development of federal policies and programs. We would like to spend a couple of minutes providing an overview of a process currently in place to examine the environmental impacts of policy, plan and program proposals at the federal level. We provided the committee with a short deck, which I will walk through with the committee.
There are two major elements of the federal framework for environmental assessment. The first element concerns legislative requirements that apply to projects for which the federal government has a decision-making role. When we talk about projects, we are talking about infrastructure, mines, hydro-electric developments and so on. Under the Canadian Environmental Assessment Act, an environmental assessment has to be conducted for any proposed project that requires federal funding, federal land, federal authorization or where the federal government is the proponent of the project.
The second element to the framework is probably more relevant to today's discussion and is called strategic environmental assessment, or strategic EA. Strategic EA deals with proposed policy, plan and program proposals and is governed by a cabinet directive that has been in place since 1990. The goal of this process is to provide decision makers with the best available information on the potential environmental implications of those proposals and thereby help to avoid downstream costs that might arise from potential environmental liabilities resulting from those programs or policies.
The next slide talks about the key elements of the cabinet directive. It is required when a policy, plan or program proposal requires minister or cabinet approval and when the implementation of the proposal will result in either positive or negative environmental effects.
The key parts of a strategic EA include assessing the nature and scope of the potential environmental effects of the various options considered in the proposal. I would emphasize that the directive requires organizations to look at both positive and negative effects. The requirement is to identify the need for mitigation of adverse effects and how to do that or identify opportunities to optimize positive impacts. Finally, the strategic EA evaluates the importance of the final environmental effects and enhancement measures and looks at how important those effects are.
Whenever a strategic EA of a proposal is conducted, there is a requirement under the cabinet directive for the government to issue a public statement on the results of that strategic EA.
The next slide deals with the roles and responsibilities. Under the cabinet directive, all federal departments and agencies are responsible for undertaking a strategic EA of their own policies, plans and proposals whenever required. The department or agency is also responsible for ensuring that the findings of the strategic EA are integrated into their analysis of the various options and the recommendations presented to a minister or to cabinet. It is what we call a self- assessment approach that is intended to promote the integration of environmental considerations into the policy development process and the decision-making process across government.
The Canadian Environmental Assessment Agency provides support through training and guidance to other federal departments on the implementation of the cabinet directive. We are involved in policy development to further the practice of strategic EA.
Another important player in the process is the Privy Council Office, which has a role to ensure that departments and agencies are compliant with the directive when they review proposals going forth to cabinet. As well, Environment Canada has a role in providing expert advice.
In 2004, the Commissioner of the Environment and Sustainable Development conducted an audit of the federal government's performance in implementing this cabinet directive. Recently, they did a follow-up audit to look at progress in relation to the previous audit. The scope of the original audit looked at 12 departments, at our agency and at central agencies.
The results of the audit are summarized on the fifth slide. The Commissioner of the Environment and Sustainable Development identified some significant gaps in the application of the directive. The factors identified included insufficient senior management support for implementation, lack of central ownership and support, limited integration of considerations and decision making, and a lack of transparency. The commissioner made several recommendations, one being a request that the government undertake an evaluation of the cabinet directive.
We have begun work on that evaluation as recommended and as the government agreed to do. The intent of the evaluation is to review compliance with the cabinet directive across government and, perhaps more important, how effective it has been. It will review the extent to which environmental considerations are integrated into the development of policies, plans and programs and whether and how that integration has impacted the outcomes of those policies, plans and programs.
We are hoping that the evaluation will result in recommendations that will both strengthen and measure the implementation of integration of environmental considerations into policies, plans and programs. We expect the final evaluation report in March 2009 to include recommendations on improving the performance of the directive and the measurement that I mentioned.
We see some general similarities between the process of strategic environmental assessment and proposals and discussion around health impact assessment. Both are mechanisms for evaluating the impact of policies, plans and programs. For most departments, assessing the environmental or health impacts of a proposed policy likely requires the consideration of impacts that go beyond the department's regular mandate. The challenges of developing whole-of- government approaches and ensuring clear accountability, enforcement and transparency, which we have seen through the work of the Commissioner of the Environment and Sustainable Development, we expect would also be challenges in health impact assessment. Ms. Saint-Pierre touched on some of those issues.
Both the report of the Commissioner of the Environment and Sustainable Development and our upcoming evaluation of the cabinet directive could provide valuable lessons learned from our processes. That could inform future development of a federal health impact assessment.
The Chair: Thank you. We will move to questions.
[Translation]
Senator Pépin: Discussing health impact assessments raises the question of whether or not it is realistic to conceive HIA as a permanent element in all legislation and in all new federal programs. Do we have the necessary resources, capacity and knowledge to roll out such a program? What would be the approximate cost of this program?
Ms. Saint-Pierre: Is it realistic to think so? I believe that at least one province has already done so.
Senator Pépin: Quebec.
Ms. Saint-Pierre: Certain countries have implemented it, as well as certain cantons of Switzerland. This is exactly why we made a point of reminding you of the environmental impact assessment. The environmental assessment impact has been implemented in all countries, in all jurisdictions. All industrialized countries have systematically implemented the environmental impact assessment. This is why we are saying that political will must be set as a first condition.
Senator Pépin: You talked about leadership. Which brings us back to the Quebec model. How many departments have adopted HIAs in Quebec? Is HIA integrated in all proposals, or strictly in political proposals? How does it work? Are there departmental officials who are in charge of this? How are things coordinated?
Ms. Saint-Pierre: Under the public health act, departments and organizations are required to make sure that their laws and regulations will not have any detrimental impact on health. The Department of Health is responsible for making sure that this provision in the act is complied with. It was decided that departments and organizations would be responsible for taking the first step, the screening stage, and for ensuring that the assessment, laws and regulations do not have a negative impact. The Department of Health provides very significant support to all departments and organizations, and has developed a five-step guide.
The beauty of the HIA approach, which has been considerably developed in Europe, as I mentioned earlier, is based on several years of experience with the environmental impact assessment. There are tools, guides and methods that have been developed and are available on the web.
The Department of Health and Social Services of Quebec has developed a guide for departments. It has also set up a network of respondents. At the request of the minister or cabinet, each department delegates one person per department to participate in the network. It is a network, rather than a committee, because the goal is to raise awareness and inform people of the impacts and determinants of health. It is not a ``go'' or ``no go'' approach.
This program is, rather, about education, exchange and sharing. Departments and organizations must comply with the provisions of the act. In actual fact, in some departments health objectives are more closely aligned with their respective mandates than in other departments, and the former are more inclined to carry out a health impact assessment.
Senator Pépin: Mr. Smith, when we look at the whole process that brought in environmental impact assessments, we see that it has been a success. Your documents tell us that it has been a success. Could we see a similar process used to introduce the health impact assessment?
[English]
Mr. John Smith: On one level, the basics of the process are fairly simple. In other words, when you are developing a policy, a plan or a program that requires ministerial or cabinet approval, it is required, as a matter of good policy development, to consider the impacts of that proposal in a number of areas, looking at whether it will achieve the results that you have set out to achieve, whether it will solve the problem you are trying to solve and to look at costs and impacts on society.
One element of that analysis has to be the impacts on environment. The cabinet directive requires that, as part of your broad analysis that should be done as part of good policy development, one of those elements is consideration of the effects on the environment. On one level, it is simple. Is it reasonable to implement? As I mentioned, our cabinet directive has been in place since 1990. Is it effective? That will be the subject of the evaluation that we are undertaking.
The report from the Commissioner of the Environment and Sustainable Development has indicated that the reality of the implementation is that there are problems in some areas. The application of the directive and the quality of the assessments, we suspect, are rather uneven. We know there are some good examples where it has been done reasonably well.
Regarding the methodology, over the years there has been a great deal of information about methodologies for considering environmental impacts, whether of projects or policies developed. The challenge is to ensure that it is done early, that it is done well and that it becomes an integral part of policy and program development.
[Translation]
Senator Pépin: Under the Quebec legislation, the minister can give orders to other ministers, he or she can be proactive. Do you think that ultimately, this could be done in the federal government?
Ms. Saint-Pierre: I do not know if I can answer that. In fact, I would say that one of the paragraphs of section 54 — there are 2 — gives the health minister this power to notify his colleagues. I believe that this type of exchange is possible when ministers are sitting down together making decisions, and everyone can see the impacts involved.
To implement this section of the act, the Minister of Health is required to have solid information based on conclusive evidence. I believe that health impact assessments are in keeping with this type of public policy that is based on information derived from research and conclusive data. This is why, through the agreement with the Institut de santé publique du Québec, we are developing public health directives upon the request of the Department of Health.
The Department of Health consults other departments to learn of their concerns and raise awareness concerning the health impacts of their decisions, be they related to housing or transportation. Knowledge-based concerns are raised.
Currently the Institut de santé publique is being asked to develop solid directives. This could take several months, and these directives are then handed over to the Department of Health, which uses them when needed.
[English]
Mr. John Smith: Similar to what Ms. Saint-Pierre said, in the development of policies or plans that go to cabinet, there is an opportunity for sharing and discussion amongst various departments and to bring various opinions to the table to affect the policy.
Your question strikes at the heart of the process as it is set up as a self-assessment process. Is it better to have a self- assessment process? The advantages are that the organizations that are developing the particular policy know their business, know the policy, the results they are trying to achieve and the area they are dealing with. There are also advantages to integrating the environmental considerations to all of the thinking they do in developing their policy. There are advantages to the self-assessment process.
As I mentioned, the Commissioner of the Environment and Sustainable Development has pointed to concerns about lack of central ownership. A process where a single minister or a single organization was responsible for doing that assessment perhaps might have some advantages in being able to develop some expertise in the assessment, but then that minister or organization would be applying their expertise in many different policy areas that they were less familiar with, and there are also questions about responsibility for decision making. I do not think there is one clear answer. What should be taken into consideration are the relative merits of both systems, perhaps, looking for a system where there is a body that has the expertise that the other departments can rely on to ensure the quality of their assessments.
Senator Callbeck: Ms. Saint-Pierre, you mentioned British Columbia. I believe they had an assessment from 1993 to 1999, and they have not got it now. Does the system in Quebec differ from the assessment they had in British Columbia?
[Translation]
Ms. Saint-Pierre: It is quite similar because this approach is in line with promoting population health. It is similar.
In fact, the idea is to make sure that when public policies are being developed, health is taken into consideration, they are examined from the health impact angle, just as the economic impacts of policies are considered, among others. This is what I know, because it lasted for several years; the same approach was used. In British Columbia, there is no law that obliges all departments to take such action.
[English]
Senator Callbeck: You therefore feel legislation is essential, then.
Ms. Saint-Pierre: Yes.
Senator Callbeck: That is one of the lessons that we learned.
Ms. Saint-Pierre: Yes.
Senator Callbeck: Did we learn anything else from British Columbia?
[Translation]
We also drew another lesson from the presence of champions. This is another different approach. It is innovative. During a meeting held on the 22nd, with people from British Columbia, we learned certain things. Not only government leaders, but academic leaders and NGO leaders set out the broad outlines, the significant lessons. Together, they sent several messages to create one single discourse and make sure that as many people as possible subscribed to it. There was a lesson to be learned.
Another lesson was the establishment of broad health objectives. At the time British Columbia was developing its population health program, based on a long-term vision, with broadly defined health objectives.
These are positive points which led to the acceptance of this approach by the government. I refer to one difficulty that was also noted by an observer, that pertaining to methodology. This approach is based on the environmental impact assessment on physical health, direct causes, such as dump sites and the release of toxic emissions. One can easily make the link between health and the population.
From a social perspective, it is very difficult to draw the same linear, cause-and-effect relationship as it is with exposure to a substance and health. Therefore, the approach did not enjoy any scientific credibility, as did the environmental impact assessment. Difficulties arose when the government tried to evaluate the effectiveness of this approach and concluded that it would be ineffective in modifying population health. It was unrealistic to come to such a conclusion over such a brief period of time.
That is one the reasons why the approach did not last over time.
[English]
Senator Callbeck: I want to come back to this proactive advice of the Minister of Health. Is that in legislation, that the Minister of Health has that power?
Ms. Saint-Pierre: Yes.
Senator Callbeck: Is the Minister of Health supposed to give that advice after the impact study is done?
[Translation]
Ms. Saint-Pierre: Yes, that is why we have an agreement with the Institut de santé publique.
[English]
Senator Callbeck: Mr. Smith, with regard to the environmental input assessment, what have been the major problems or challenges in implementing this?
Mr. John Smith: I would point to what the Commissioner of the Environment and Sustainable Development had done, which dealt with what the commissioner felt was lack of leadership and central support. One of main issues was lack of central ownership and leadership to ensure that the findings of the assessments were followed through on.
Senator Callbeck: You said the Privy Council oversees departments to ensure that they are following the directives. Is that right?
Mr. John Smith: It has a general oversight role in terms of policy and programs coming to cabinet, and so it looks at all of the memoranda and policies coming to cabinet to ensure that the analyses and recommendations are appropriate for cabinet consideration.
The Chair: I would like to ask both of you to address the following: Our report is unfolding now. It will be out in December. We have done four preliminary reports, as you know. We are headed — at least at this point in time, until we are convinced to change directions a bit by people like yourself — to recommend a whole-of-government approach, even though we have met many naysayers who say we cannot do this. However, other countries are doing it, some provinces are doing it, and even Ontario is doing it now. We intend to recommend that at the very beginning there be a whole-of-government approach to population health.
We will have a tremendously strong emphasis on the correction of health inequities, which are huge in Canada and often indefensible. In fact, even though I am on public transmission, I would say they contravene human rights, I believe.
We will be fairly forceful with regard to the need to address and correct this. We will be emphasizing that we think health impact analysis is possible, can be done, and should be implemented across the country. We will be recommending an information highway, so to speak, for population health that will link community, civic data banks, provincial data banks, federal data banks, and any other data banks that are relevant, and it will involve Statistics Canada, the Canada Health Infoway, the Canadian Institute for Health Information initiative, and so forth.
Fundamentally, that is what we want to see. We are very impressed with this program in Newfoundland, thanks to Senator Cook, who talked us into going there because she is from Newfoundland. They have at their fingertips information on the well-being of every community in Newfoundland. However, more than that — which is truly impressive — they can display the change in well-being for each community of Newfoundland.
When that is coupled with some of the initiatives we see in Saskatchewan, Manitoba, Quebec, Ontario and some of the data banks on the native reserves — I mean the good data banks — I do believe that Canada, collectively, is coming into a position to address and correct health inequities. It will not happen overnight, but I believe that we, as a nation, cannot dodge the bullet any longer, and that is fundamentally what our report is all about.
Ms. Saint-Pierre, you had experience with this at the provincial level. Mr. John Smith, you have had experience with the attempted whole-of-government approach in the environment. Tell us about the foibles of our plan and how you would do it if you were doing it.
Ms. Saint-Pierre: Your question is what we think about your plan; is that correct?
The Chair: Yes. Tell us what is defective in the plan, and what will work and what will not work.
[Translation]
Ms. Saint-Pierre: In fact, I believe your position is very much in line with the majority of countries, where ways in which the health of populations can be improved are being considered. You are quite right to say that in Canada, there are many resources we are not necessarily aware of.
Two things come to mind: The idea of having data banks and information is no doubt the cornerstone upon which we can build projects, and especially be able to determine what needs to be done, regardless of the strategies that we choose to monitor improvements in population health. I am sure that is no doubt the first step.
What we have been very happy to note, at the National Collaborating Centre for Healthy Public Policy, which is a pan-Canadian and horizontal organization, are the initiatives that have been undertaken, very diverse in nature, in each of the provinces; we also see a lack of awareness of these initiatives from one province to another.
You were talking about Newfoundland; the centre is relatively new, and we are not yet entirely familiar with all of the initiatives. But the people of Alberta would no doubt be very interested in hearing what happens in Saskatchewan, and vice versa.
This is one of the roles of the collaborating centres, to develop this networking and a better understanding from province to province. Because you are quite right, there is a lot of networking already underway and we are beginning to also see more pan-Canadian public health infrastructures.
And I am thinking about the public health schools. The six public health schools that are being set up will definitely contribute to fostering improved knowledge and information-sharing.
[English]
Mr. John Smith: There are a couple of things to consider. You mentioned that your report will be saying health impact analysis is possible. The lesson from strategic environmental impact assessment would be that yes, it is possible. The concept is relatively simple. The lesson from our experience in terms of the environmental impact assessment process is ensuring there is a clear definition of responsibilities and accountabilities.
I had mentioned earlier some pros and cons of a self-assessment approach and a centralized approach, but fundamental to whatever approach is taken in terms of responsibilities is to ensure that there is adequate availability of expertise, whether it is in a variety of departments or in one department, and regardless of decision making to make sure that the expertise is there.
It is interesting that you mentioned the information highway for population health and linking data banks. Many parallels are being worked on in the area of environmental impact assessment, using, in this case, geographic information systems to link together information in data banks and web bases to try to get a picture of what is happening in one particular location.
When we are assessing in the area of project environmental assessment and you look at a project in one particular location, robust tools like that that can let you access all of the information about the physical and the environmental conditions of the area, of other projects that are going on, is invaluable. That kind of work is perhaps in its early days. A lot of work is being done in Canada and in the United States.
That is a useful approach. There is a lot of information there and it is feasible. I am not a computer expert by any means, but from what we have seen, it is feasible to relatively easily define systems that can pull in all of that disparate information from a variety of sources and give a single snapshot. Having that kind of information available would be invaluable.
Senator Cook: My first question will have the element of risk in it, at least for me. In relation to developing policy, we have a health impact assessment and we have an environmental assessment. For our purposes, is it possible to be practical and to amalgamate this when we are looking at data banks, collections of knowledge in provinces and attempting to build a prototype, if you will? Is it possible to meld the two with all the common elements in it? I am afraid I do not know very much about environmental impact assessments in relation to health. I want to know from a practical point of view whether it is possible.
Mr. John Smith: If we look at the current requirements, both under our legislation for project assessment and under the cabinet directive in dealing with strategic environmental assessment, there is currently some consideration of health impacts in those processes, but it is only some. It deals with the way the directive and the legislation are framed. It deals with situations where there is a change in the environment that then causes health impacts. There is some consideration of health impacts, but it is certainly not as broad as the wide range of determinants of health that would be looked at in a health impact assessment.
That is the current situation. Is it possible to amalgamate the two? I would say it is possible. One consideration from the point of view of environmental impact is whether by amalgamating them we would lose a clear and definite focus on the environmental issues. In other words, would the environmental issues be overwhelmed by all of the potential health issues that might come along?
From a strictly environmental viewpoint, there may be some benefit in keeping them separate to make sure you do not lose that focus. When a policy and program are being developed, there are other issues that need to be looked at as well, and an integration of sorts does occur at one point when you are coming up to the final decision, so many different areas do get integrated. There may be some benefit in specifically highlighting the separate areas that need to be looked at so that one does not overwhelm the other.
Senator Cook: That is my angst. I do not want to overwhelm the system. I want to have a clear definition. If we are developing something at a federal level, I want something that is user-friendly from a provincial perspective. More especially, we are building a pyramid. I do not want it to be overloaded at the bottom so at the top will be the healthy person.
We would be recommending to provinces that they share or take out of this what is needed. At what point should we have enabling legislation from a federal point of view to ensure that the elements are protected?
I will tag the other question that is running through my head, and that is the evaluation process. What would be the time lapse from the time of an impact assessment study in place and then going out and asking for an evaluation? In Newfoundland, I believe it is two years.
Ms. Saint-Pierre: In Newfoundland does it take two years?
Senator Cook: They are out now. In their strategic plan they are in year two and they were going into the field when we were there in May and that has been two years. They have started their evaluation process. They report annually to the legislature through their cabinet committee, but Newfoundland has a strong leadership component with adequate funding.
I am trying to see where this fits on the scale. Where do you put the impact assessments? In B.C. it was mandatory and it went someplace else, but we need legislation. How do we get some practical legislation to make sure that those essential things are there, if health and environment need to be separate? I do not want to overload the system so that it is not user-friendly when we get to that point. However, I want to ensure that some things are not optional. That is what I am trying to get at.
Mr. John Smith: In the area of the strategic environmental assessment with the federal government, it is not optional. It is required by a cabinet directive. Various organizations have called for the requirement to be put in legislation. Whether or not that is an approach to take we hope will be informed by our upcoming evaluation. It has not been necessary up to this point.
One consideration is that the environmental impact assessment is to be done as part of developing policy and making options and recommendations to ministers and the cabinet. In one sense, to put the requirement in legislation means that you are legislating the policy development decision-making process within government, and that might pose some challenges.
As I said, putting the requirement in place and making it mandatory has been done through a cabinet directive. I mentioned that the Commissioner of the Environment and Sustainable Development pointed to the fact that ensuring that there is accountability is important to making sure it happens, and ensuring there is availability of expertise for departments to draw on is important.
As I said, legislation has been suggested, but I think some of the underlying processes are as important in ensuring that it happens. Does that answer your question?
You had a question about time frames for evaluation. The evaluation that we are doing is looking at the overall implementation of the cabinet directive. In other words, there is not an evaluation each time something goes forward. It is a one-time thing. Maybe there will be future evaluations, but this is being done now, and hopefully it will be done by next March. We are looking across the board at the implementation of the directive.
Senator Cook: The mechanism for reporting in my province is on an annual basis, so would it not follow that evaluation would have to be running parallel to that, if you are to be transparent with what you are doing?
Mr. John Smith: Currently, a public statement is required on the results of the strategic environmental assessment. It does not get into an evaluation, but there is a requirement that when a strategic EA is done, there is a public statement on the results of that.
Tim Smith, Senior Policy Advisor, Canadian Environmental Assessment Agency: I would add that in addition to the public statement, there is an expectation that where a department undertakes a detailed strategic environmental assessment, for example, there be some effort to follow up on the findings of that analysis; and if mitigation measures are proposed through that analysis, to make sure those have the desired effect on the policy outcomes. In a sense, I suppose that is a form of evaluation on a case-by-case basis.
Senator Cook: There are bound to be tensions in any system, because health is delivered provincially. My maternal instincts are to create a system that will be good, mandatory and proper, one that there is no opting out of, but one that is user-friendly so that the provinces will want to use it.
I would like your opinion. I have some understanding of the environmental impact, but I would like your comment on the health impact.
[Translation]
Ms. Saint-Pierre: Your pragmatic concern involving integration and deadlines are two important issues in the practice of health impact assessment, whether it concerns projects or is on the political level. Furthermore, the literature, particularly in Europe, reflects that. Should we move forward, is integration desirable in order to avoid the departments having too great a burden? As Mr. Smith was saying, there is always the risk of weakening the initiative. Health concerns are more difficult as far as the social aspects of health are concerned. This aspect is very difficult to assess.
Concern about the disparities in health is part of the health impact assessment approach, which is not necessarily the case in the environmental area. By attempting to integrate environment with health, we run the risk of eliminating those disparities in health care. At the same time, in order to be pragmatic and promote this practice within government, we must attempt to see how this integration could be achieved. In order to do this, a pan-governmental approach is required. One of the gains for the Quebec government has been a better understanding between departments. At the Department of Health, the public health stakeholders understand the interests and needs of the other departments a little better. This approach brings the departments a little closer.
An intensive study was carried out on the effectiveness of health impact assessment approaches in Europe. This study was done over a three-year period. Nineteen countries contributed to this assessment of the effectiveness of the approach. The study dealt with projects that were sometimes municipal, sometimes provincial or regional. The European office carried out this study. Generally speaking, the conclusion was that the approach was effective. The effectiveness was seen particularly in the ability of the process to influence decision-makers outside the field of health as concerns broader health determinants. The approach was also effective when policies had to be changed midstream and also to strengthen the administrative system. The latter then becomes more consistent, because the government is obliged to work less in silos and more horizontally.
There are many issues. The time factor is also important. Sometimes public policy is developed very quickly. It is therefore difficult to carry out rigorous analyses on health and to add scientific information in due time. There are therefore adjustments to be made by all stakeholders. Decisions are sometimes made without taking the time to research all of the considerations.
[English]
Senator Cook: Thank you very much. I will have to do my own analysis.
The Chair: Now I want to really exploit you.
I have been truly fascinated for the past few years by the analogy between the environment and population health, because neither is soluble without a whole-of-government approach; indeed, neither is soluble without an international approach on top of a whole-of-government approach.
I spoke about the afferent loop, about how we can gather information at the community level and wind it through civic governments and provinces and up to the federal level and so forth. Then, when we get it up there and we have defined the inequities — which we can define pretty well right now — but when we truly define them accurately, we have to come back through the efferent loop and correct them; otherwise, the exercise is a waste of time. In dealing with environment assessment, the analogy is close to health assessment. I cannot tell you how to deal with environment, obviously — you know a lot more about it than I do — but in dealing with the environment, you have to deal with everything from 747s flying from Vancouver to St. John's, Newfoundland, to a local community of 100 people that is contaminating the water table from the dump.
You have to correct all of that if you are to control the environment. Do you agree, Mr. Smith?
Mr. John Smith: Yes.
The Chair: In dealing with population health, we are in the same predicament. We cannot deal with pandemics at the provincial level. We can implement some changes and so forth, but to deal with a pandemic, we have to at least go to a national plan and probably even an international plan.
To deal with some of the other determinants of health that seem so eminently correctable, such as communities with unclean drinking water, inadequate food supplies, particularly in the North, inadequate schools and education, inadequate health clinics and that kind of thing, the correction seems relatively simple, even though it does take a lot of money, perhaps, or maybe not as much as we are spending the way things are now, because we are not dealing with the determinants of health.
The point I am coming to is whether you see the possibility of the linkages working, as I mentioned, for a population health information highway, from top to bottom. Do you see the possibility of the linkages working from top to bottom to correct health inequities, or is that a pipe dream?
Mr. John Smith: In terms of the information you talked about and the linkages working, there is tremendous possibility out there. The work that our agency is involved with in trying to hook into information systems related to decisions on the environment suggests that it is feasible to link this information to make greater amounts of information available, so that when somebody is making a decision on a specific issue, that information is readily available.
It is not necessarily easy to get everything that you need quickly, but I think the possibilities are there. There are so many information sources and data banks out there, and there are examples in the environmental area of how to pull all these together. Therefore, I believe the information part of it is feasible.
Your other question goes beyond my area of expertise, and I would defer to others regarding the challenges you have mentioned.
The Chair: Sorry, you are it. You are here on the environment.
Mr. John Smith: Trying to deal with environmental issues involves many issues and situations that are all kind of linked, and one of the challenges we face is trying not to ignore issues but ensuring that you break problems down into solvable issues, or you can get overwhelmed. That is one thing in the goal you described that needs to be kept in mind. With health issues, like with environment, everything gets linked; one thing links to the other, and one thing is connected and affects the other. One challenge is not losing sight of the linkages and the connections but not letting them overwhelm the goal and ensuring that the assessments that are done and the plans can stay focused on manageable chunks and make progress that way. I am not sure if that answers your question.
The Chair: It does. It is an encouraging answer.
Let me lead you into the legislative framework. In environment and population health, we could perceive a legislative framework that would work and is similar in both areas. You have federal legislation, provincial legislation, civic legislation and, in some of the smaller municipalities, appropriate bylaws and so forth.
I know that you are doing this, because I looked at it. You are controlling, for example, how the garbage is handled in tiny municipalities.
How did you go about setting that up from top to bottom?
Mr. John Smith: I am not sure, in one sense, that we are controlling how the garbage is handled in municipalities.
The Chair: You are right, and I do not want that on the record, so thank you for correcting me.
You have provided the incentive to make sure somebody is doing the job; is that right?
Mr. John Smith: Correct me if I am going off on the wrong tangent, but your question probably relates most to the assessments that are done of individual projects under the Canadian Environmental Assessment Act, and when assessments are done there, the role of the federal government or the federal process relates to federal decision making, and so we get involved in quite a variety of projects.
On any one of those projects, environmental effects can be identified and mitigation measures can be identified to deal with those effects. Those mitigation measures can be put in place through whatever federal decision is made on those projects. For example, if the project is being enabled by federal funding, then conditions can be attached to that funding to ensure that the environmental effects are dealt with. Through that process, whether through funding arrangements or lease arrangements, or to some extent, through federal permit approvals, a wide variety of environmental issues can be dealt with.
That process does not go so far as to give the federal government authority to regulate all of the areas with respect to the environment that are the responsibility of municipalities and provinces, but it can enable the federal decision to put in place various mitigation measures.
The assessments typically consider as well what is required on a project because the federal environmental assessment is not the only thing that affects what happens to it. There are a wide variety of provincial, municipal and other federal requirements.
The environmental assessment process is important and can deal with a variety of environmental situations, particularly those that may be unforeseen, but it does not set itself as being the overarching single way of pulling together all environmental legislation. It does not go that far.
The Chair: You need the goodwill and buy-in of provinces and so forth; correct?
Mr. John Smith: The federal process applies to federal decisions, so we can provide it through our process. The provincial governments have environmental assessment processes as well, so there is a lot of effort to ensure that the two processes work together and we cooperate on the assessment of specific projects.
The Chair: That is fundamentally what we are searching for in our structural framework here.
I want to come back to you, Ms. Saint-Pierre, because in health we are blessed with having the Public Health Agency of Canada and similar provincial agencies. We have public health officers in large cities and in the small communities and so forth. We already have a network to the ground.
We will be recommending in our report a major initiative to strengthen and indeed ramp up drastically the population health node in the Canadian Public Health Agency and a similar ramping up at the provincial level and, when we get to the polyclinics in the communities, a similar set of organizations, so that the public health officers can work with the health authorities and the municipal authorities that control the 12 or so determinants of health.
You have extensive experience in Quebec. Do you see what I have just said working in Quebec?
[Translation]
Ms. Saint-Pierre: I could add that I am happy that you mentioned this component because it truly is the role of the National Collaborating Centre for Healthy Public Policy. We work primarily with public health stakeholders working in public health at the regional, district and municipal levels. Health impact assessments are successfully carried out at the municipal level as well.
We participated in a meeting, among others, on February 22 last where there were representatives from various departments and from different levels of government, concerning the health impact assessment approach at the local level. We were asking them if they thought it was realistic to promote impact assessment at the local level, that is to say in public health with municipalities; the consensus was in the affirmative, because there are more public health stakeholders at the local level than at the provincial level; people felt that the various sectors, be it housing, transport or education, worked better through intersectoral collaboration.
As you were saying, there are public health resources at these levels. The disparities in health care are often better understood on the ground and municipal decision-makers are the closest to the effects of their decisions because they see them. Therefore, working at that level seems very productive.
The social determinants of health have structural causes, which often flow from provincial or federal decisions. Therefore, working at the local level alone is not enough, but the fact of working in synergy greatly increases the ability to have an influence on public policy or to further culture change.
To answer your question, this is somewhat like what is happening in Quebec. Health impact assessment is set up at the government level. Quebec's public health legislation also provides legislative levers to those responsible for public health in the regions, and recently at the local level as well. This legislation allowed for the introduction of pilot projects between the local level and health authorities — not just public authorities, but health authorities — who now have responsibilities in terms of population health in their area and their municipalities.
And since it proposes a very structured way of doing things, which allows it to act in a more difficult context, between sectors, the health impact assessment approach is seen as a way of bringing together two different worlds: municipalities and public health.
And the collaborating centre exists not only in Quebec. In the consultations that we carried out in several provinces, we saw this interest in public health, a very clear will to work better with the municipalities who are making the decisions that have impacts on population health.
There is a research project underway in Saskatchewan that is attempting to better understand the decisions that municipalities make and the way in which public health could work. Therefore, that truly is another interesting avenue.
[English]
Senator Cochrane: Mr. Smith, do you have any positive results on any item to report to us, as a director within the Canadian Environmental Assessment Agency? Have you got anything like that to tell us about — something positive that you have accomplished and or the agency has accomplished that would be helpful?
Mr. John Smith: There are examples of positive things that we have accomplished. I am trying to think of something that is focused on these discussions.
Coming back to the cabinet directive on strategic environmental assessment, the responsibilities of implementing that directive is a self-assessment process. Our role is to provide training and guidance, so I would point to some of the activities that we have undertaken in developing training and providing it to departments. Mr. Tim Smith can talk a bit about the details.
Our role is fairly circumscribed, but we have had successes in offering training, and there has been a big interest in departments. Departments are interested in applying the directive appropriately and they come to us for training. We have done a reasonably good job in applying that.
Senator Cochrane: Tell us more about the training.
Mr. Tim Smith: We have a standard course offering for departments, for policy analysts to gain a better understanding of the cabinet directive and the principles of strategic environmental assessment. We offer that twice a year.
In addition, we develop, working collaboratively with an interdepartmental team, guidance documents — for example, how strategic environmental assessment relates to the concept of sustainable development, or what the intention was behind revisions to the cabinet directive in 2004 that incorporated the requirement for public statements on strategic environmental assessments.
These are the kinds of tools that we have worked with departments to develop to increase a more consistent application of the cabinet directive and address some of that unevenness that the commissioner identified in 2004 in the audit report.
Getting back to your question about successes as they relate to strategic environmental assessment, we play a role in monitoring cabinet business and encouraging departments to apply the cabinet directive fully. We have some insights into how departments are applying the cabinet directive. It is not without its challenges, but we have seen good examples as well.
Senator Cochrane: Could you give us some examples?
Mr. Tim Smith: One was the second round of funding for infrastructure programs, where early in the policy design process — and this is the element that I would like to focus on a bit — the interdepartmental table recognized that maybe this is the point where we should be taking environmental considerations into account. That led to a policy leveraging mechanism.
As you know, the second round of infrastructure funding deals extensively with issues related to waste water treatment, public transit, water treatment — those kinds of green municipal infrastructure investments. I would not want to suggest it was the cabinet directive alone that led to that policy leveraging function, but it contributed to some measure of success in that particular example. Where we have seen success in application of the cabinet directive is where environmental considerations have been addressed early in the policy design process.
Where it has been less successful is where it is applied in a more reactive stance, when policy measures have been designed and you are simply trying to understand whether or not they may have some impact on the environment and addressing those retroactively.
Senator Cochrane: Have you done any assessment on the impacts?
Mr. Tim Smith: No, and this is the process my colleague alluded to earlier — this evaluation of the cabinet directive that we are just embarking on. Hopefully, that will give us some clear insights into the impact that the strategic environmental assessment has had on policy outcomes.
Senator Cochrane: When do you expect to have that?
Mr. Tim Smith: We anticipate a report by the end of this fiscal year.
Senator Cochrane: Maybe we can get that, chair.
Does Mr. John Smith have anything else to add? I am looking at positive things here.
Mr. John Smith: I have nothing to add to what Mr. Tim Smith said.
Senator Cook: If I understand the conversation we have just had, the federal role is to provide oversight and to be proactive, but the implementation goes to the provinces. You work collaboratively with the provinces; is that correct?
Mr. John Smith: There are two main parts to the federal framework. The one that we have mostly been talking about today, the strategic environmental assessment, is focused on federal decision making and development of policies, plans and programs. It is focused on what the federal government develops and puts in place. Therefore, the assessment of the environmental impact, looking at the impact and at alternatives and, as Mr. Tim Smith pointed out, helping to make adjustments to what those are occur during development of those policies.
I referred to project-level assessments. Again, there are provincial mechanisms in place for doing environmental assessments of projects, and there is a federal mechanism as well. The federal mechanism is based on informing federal decisions that enable those projects to proceed; the decisions to provide funds, land, regulatory authorizations or, in the case where the federal is actually the doer or the proponent of the project, the environmental assessment informs the federal decision to provide those lands, funds or regulatory approval.
The intersection of that and the provincial process comes when the federal environment assessment and provincial environmental assessment are being done on the same project. The federal legislation is not implemented through or does not affect the provincial legislation. However, we come together when we are both active on the same project. At that point, there is a level of cooperation so that we try as much as possible to have one process to satisfy both levels of government. The interaction and the cooperation occurs at that level.
We do have agreements with many provinces that set out the general framework for cooperation to say that, on a project-by-project basis, we will cooperate and develop as much as possible joint processes. Where we do not have those agreements, that kind of cooperation can happen anyway, and very often it does. However, the legislation does not cascade. We cooperate at the level of individual assessments.
Senator Cook: Is Canada, therefore, still a country founded on projects supported by some cities?
The Chair: We have to close the discussion. Senator Cook, as you know, is from Newfoundland. You simply cannot cope with her.
Senator Cook: I am trying to understand. You have so much knowledge and I just want some of it. I have not even asked about climate change in relation to the environment. That will be for another day.
The Chair: We have to close the open hearing, honourable senators, because of the time constraint.
The committee continued in camera.