7.3 Analyses: How This Initiative Illustrates The Mobilization Of Population Health

7.3.1 How the determinants of health are addressed

The ACHF was designed to embody the population health principles, consistent with the intersectoral action work in the broader provincial context. For example, in the funding application guidelines, five ACHF principles are described, with the indication that project and program activities must be delivered so that they address all of these:

• use of community development approaches
• use of health promotion strategies
• action-oriented partnerships involving all partners in the planning, delivery and evaluation of the programs
• use of a population health approach, working in a broad social context and addressing the determinants of health
• evaluation: in order to ensure learning from the experiences of community-based initiatives.

Those interviewed about the ACHF have a common understanding that the Fund is a mechanism for mobilizing the population health approach through its multi-layered approach. At the community level, the Community Planning Committees are intended to respond to community concerns and mobilize local energies around pressing issues, while ensuring a coherent, concerted and inclusionary approach. At the aggregate provincial level, the Population Health Consortium examines the overall funding picture using a population health lens. At all levels, partnerships ensure representation from all population sectors affected by HIV.

With respect specifically to the health determinants, although both previous funds had been in existence for some time before the population health approach became activated, accumulated knowledge about HIV trends in Canada left little doubt, by the time the ACHF was established, that health determinants such as income and social status, education, employment, social support networks, personal health practices and coping skills, culture and gender are related to HIV transmission risk factors as well as outcomes for people living with HIV. The importance of social contextual factors was reinforced during the consultations that led to the creation of the ACHF, through the experiential learning of the community-based groups and their communities.

The ACHF funding application guidelines for both operational and project funds state that, "organizations applying for ACHF funding must identify which determinants of health their program addresses. These determinants are factors and conditions that have an influence on the health of individuals and communities." In the application form itself, applicants are instructed to check off which of the determinants their program or project will address. In practice, representatives of the HIV Working Group stated that groups recognize the importance of the health determinants; their application forms tend to include a large number of determinants and emphasize their interconnectedness. This is consistent with the findings of the evaluation of the ACHF conducted in 1999 by Downie and Associates, where the population health approach as adopted by governments was seen as "legitimizing, in the eyes of the broader community, the holistic approach that was already in use."⁷

According to an interviewee in the present study, some of the HIV groups have developed a better understanding of the population health approach because of this emphasis in the funding process, and have begun to shift their thinking toward this new focus.

7.3.2 How the focus is placed on the health of populations

The purpose of the ACHF operational fund is to support both continuing local and provincial community-based responses to the existing and emerging issues associated with HIV, while the project fund supports unmet HIV needs and priorities. Within this broad framework, the evaluation criteria for proposals include needs as identified through the prevalence of people living with HIV, needs assessments, epidemiological evidence, literature reviews, and needs identified through consultations. Moreover, the funding guidelines stipulate that the ACHF will continue to prioritize community-based prevention initiatives that are targeted at populations known to be vulnerable to HIV, based on recent epidemiological and research evidence (2B).

In 2000/2001, operational finding has been provided to 17 operational sites and 25 projects, offering services and programs to a wide variety of HIV-affected populations (2A), including, for example, injection drug users, Aboriginal people, marginalized and transient youth, HIV-positive women, rural gay men, alcohol- and drug-using inmates, as well as staff and volunteers who work with these populations.

7.3.3 How upstream investment has occurred

The upstream strategies used in the initiative are both structural and process-oriented, aiming to enable an ongoing intersectoral focus that can become progressively more inclusive over time (3A). In terms of structure, the roles and mandates of each of the various committees, offices and working groups (Community Planning Committees, Provincial Stewardship, Working Group, Population Health Consortium) have been constructed so as to strongly encourage intersectoral collaboration, if not effectively require it, for actions to go forward. This ensures that at all levels, all voices have access to a mechanism for making themselves heard, and fosters the building of capacities for intersectoral collaboration. In addition, the multiple layers of partnerships can provide multiple feedback loops to each level, as a means of double-checking that significant population health issues are being addressed. From the bottom up, Community Planning Committees can put forward proposals in emerging areas as immediate responses to grassroots-level sentinel events, thus directing the attentions of the Working Group and Population Health Consortium to new risk factors, determinants or other contextual issues. From the top down, the Population Health Consortium can respond to new epidemiological and research evidence by ensuring that the funding mix best represents the current and future trends of the epidemic.

The division of funds into operational and project envelopes supports this mix between ongoing support and responsiveness to new issues. HIV organizations that receive operational support are not eligible for project funds. This stipulation reflects the growing awareness among HIV organizations at the time the new model was being created of the changing nature of the epidemic (being driven into increasingly more marginalized and disenfranchised populations): that they were no longer able to respond to all the emerging needs, and that resources would need to be set aside for those new needs.

In terms of process, the Working Group model offers an example of an upstream investment in relationships founded on trust and openness, leading not only to improvements in the way funds are currently disbursed, but also to a state of preparedness to accept new challenges as a team and a commitment to work out differences rather than falling back on confrontation. In the often adversarial context of relations between community and government sectors in HIV, this is a remarkable platform on which future efforts for the HIV-affected community can be built.

7.3.4 What accomplishments are anticipated in the short, medium and long term

In the short to medium term, those interviewed felt that the main impacts would be seen in a greater awareness of population health, health promotion and health determinants concepts among the Regional Health Authority Boards and at the senior management level, because of the influence provided through the Population Health Consortium as well as the intersectoral action work. In the medium to long term, this could lead to increasing recognition of the need for healthy public policy and, and to the extent that senior staff have become sensitized, to direct policy shifts. According to one respondent, this increased groundswell of awareness may have a greater long-term effect than shorter- term mobilization strategies. Another short- to medium-term impact is seen in the securing of increased funding from provincial or other sources.

In the long term, some respondents expect to see changes in the health of populations due to more effective resource management, more coherent and coordinated interventions, and improved capacity to respond to community needs and population trends. However, others cautioned against looking for changes in indicators such as HIV rates, as these are not appropriate to assess the kinds of impacts that this initiative is likely to produce. Instead, long-term changes could appear in improved access to services and supports, greater continuity among services, and fewer crisis situations, when individuals have fallen through the cracks in the system.

7.3.5 How multiple strategies are applied

The ACHF identifies strategies for implementing the population health-driven approach to action on HIV, all of which are considered to be equally important. These are:

• Creating supportive environments.
  Eliminating or reducing social barriers that prevent those affected by HIV from accessing appropriate services. To create these environments, groups are encouraged to develop partnerships, coalitions and networks.

• Health promotion for people living with HIV.
  Including programming that helps them manage their condition and remove barriers.

• Prevention initiatives.
  Prioritizing vulnerable populations, as mentioned previously.

• Strengthening community-based organizations.
  Increasing the skills and abilities of all levels of community-based HIV action (board, staff and volunteers) in areas such as community development, fund-raising, evaluation and marketing.

• Harm-reduction initiatives.
  Focussing on reducing the negative consequence of high-risk behaviours, with a priority on short-term obtainable goals to ensure safety and survival.

The strategies used by the operational projects and the activities funded by the ACHF in 2000/2001 are summarized below, according to an ad hoc classification of project descriptors:

Strategy	No. of initiatives (Total possible 17)
Community outreach, community development	8
Education, information, training, strengthening organizations	7
Care and support services	6
Harm reduction	5
Housing	2
Volunteer support	2
Strengthening community-based organizations	2
Other	9

From this table, it can be seen that operational groups funded through the ACHF employ multiple strategies, and that the emphasis among these is shared between getting the message out and mobilizing the population, and providing targeted interventions to populations in greatest need of support.

7.3.6 How collaboration across levels and sectors has occurred

7.3.6.1 Nature and implications of collaboration

The basic partnership triumvirate in the new funding model - Health Canada, Alberta Health and Wellness and the community-based groups represented by the ACCH - had a long history of positive collaboration, predating the creation of the ACHF. It was felt by many of those present at the Working Group meeting as well as by others who were interviewed separately, that those prior relationships among a stable, core group of committed people in many ways made the funding model possible. The partnership embodied in the funding model is seen as extremely successful, resulting in an open and honest process. Over and above the pooling of funds and the creation of joint mechanisms, the model has brought a new delight in working together, in an atmosphere where everyone's insights are valued and there is a genuine feeling of shared ownership. Initial tensions were overcome through patience and humour. Working Group members report that they feel that the weight carried by their collective voice has greater impact in the policy sphere than previously, and in particular, that their coming together at a moment of need for redefinition of HIV funding was a significant accomplishment.

Participation in the ACHF has also brought a feeling of being connected to ongoing developments in the HIV area. Because the atmosphere is full of trust, members feel that they can communicate openly while at the same time listening with open minds to their colleagues, thus ensuring that all parties are aware of upcoming issues which may affect them, and have a chance to develop more coherent and measured responses. This is seen as benefitting the entire community, as well as providing a protected forum for the development of positive solutions to the problems that sometimes arise. Government partners, in particular, are careful to check in with each other in order to ensure that they do not put each other into awkward situations.

7.3.6.2 Resources brought by partners (5B)

The total amount of ACHF funds allocated to operational sites in 2000/2001 was $2,303,437, with an additional $230,150 going to project sites. Of this total, Health Canada contributed $665,000 through the regional ACAP envelope as well as $127,00 though the national HIV office in support of research and evaluation capacity building. The remaining funds, about $1,700,000, was provided through Alberta Health and Wellness.

Health Canada also provides staff time, through the ACAP designation, for support of the community-based programs funded by the ACHF. Additional resources are contributed by the members of the ACHF Working Group in terms of their time and energies in managing the funding review process. This group meets face-to-face at least four times per year. Health Canada covers the costs of travel for the ACCH and the HIV-positive representatives, while all other representatives' organizations cover their travel expenses. The Population Health Consortium meets twice per year.

7.3.6.3 Involvement of specific sectors (5A, 5C, 5D)

Provincial government
The Alberta government is involved with the initiative through the Population Health Strategies Division of Alberta Health and Wellness, taking the leadership role in the Working Group. Within the provincial health system, the role of the Division is to support the delivery of services through the 17 Regional Health Authorities, whose core activities include health promotion, and injury and disease prevention. The Division provides support to the Action for Health Initiative, implemented in 1995 in all the Health Authorities and aimed at involving communities in identifying issues and proposing solutions. It is also carrying out the departmental business plan, in which inter-governmental and inter-ministerial collaboration is emphasized. It is thus clear that population health mobilization has been at the forefront of the Division's mandate for some time. Indeed, as one interviewee put it, "We have been working this way for a very long time, before anyone else thought it was good idea!" Working within this framework in the ACHF is a natural extension of a well-travelled road.

Health Canada
In this initiative, Health Canada acts as a full partner and important support, without necessarily assuming the leadership position in any decision-making mechanisms: "We don't want to come across as health imperialists, but want to stimulate without being a leader." Through the ACAP program consultant role, it provides important ongoing support to the ACHF fundees. Its partners emphasize that they have always had a strong relationship with the regional office, and this has been capitalized on in the new funding model.

Community-based sector
As described above, the community-based sector is also a full partner in this initiative. As the Steward for the federal and provincial funds, the ACCH holds a key symbolic and practical, if sometimes unfamiliar, role in managing the fund disbursements and the various accountability requirements. Through its representation of local HIV organizations, it also provides to its government partners the necessary link to grassroots action in HIV and the social conditions that surround it.

Non-health sectors
A challenge that is currently facing the initiative is gaining the full partnership of sectors outside of health. While the Population Health Consortium has representatives from several agencies and departments outside the health sector with mandates relevant to the determinants of health in the context of HIV, Working Group members and other interviewees reported feeling that HIV is still seen mainly as a health issue by these partners, and that they have not yet embraced it as an issue which should be squarely part of their own business plans.

7.3.6.4 Gains and challenges from intersectoral collaboration (5G, 5H)

For all of those interviewed, the main gains from intersectoral collaboration in this initiative have come from the streamlined funding procedures and improved coordination for HIV organizations and services. This means that the monies allocated to HIV can go further than they used to in reaching out to communities and individuals touched by HIV. Applicants have an increased sense of security that the funders are working together in an overall strategy, and that their application will be dealt with by understanding and knowledgeable colleagues, rather than a "faceless bureaucrat."

The collaborative funding model has removed the previous context of "them vs. us." All partners have a shared accountability and responsibility for the effectiveness of their actions. It has increased awareness among the participating organizations of each other's goals and constraints, making it easier to interpret their actions. Moreover, when difficult decisions have to be made, especially about continued funding or similar issues, they are no longer perceived as "top down" but as having emanated from a collective joint process.

For the community-based sector, a main gain from collaboration in the ACHF process has been in the opportunity to directly influence the funding process. On the other hand, this has brought new challenges: "There is a price to pay: we have more influence, but now there are more discussions and arguments." (Or, as a government representative put it: "The community is now a funder - an interesting shift.") The Working Group says it is sometimes hard for the community-based sector to maintain the balance between their government partners on the one hand, and their community constituents on the other.

There is a consensus, among those who spoke to this issue during the interviews, that a challenge still remains in terms of attaining the critical mass necessary to truly mobilize a population health approach for HIV outside of the health sector. While some departments, such as Justice, have become champions of the population health approach and have made policy shifts in light of their new understandings, many of those interviewed feel that efforts need to be targeted at other federal and provincial departments and agencies related to the human services as well as those involved in economic development. In addition, some of those interviewed feel that despite the complexity of their relationships with Alberta Health and Wellness, additional effort needs to be invested toward working more closely with Regional Health Authorities, especially in some areas. The Population Health Consortium is building its ability to work in an integrated fashion, and spillover into the Health Authorities would be a desirable result of this.

Another challenge for government Working Group members has been in finding the balance between flexibility in their responsiveness to the Group's direction while at the same time being able to deal with accountability requirements within their level of government. While the allocation process is now seen as more inclusionary and fair, it also presents more conundrums, throwing up new issues that require constant renegotiation of the parameters of flexibility.

It was also pointed out that some of the thorniest challenges for intersectoral collaboration lie at the implementation and service-delivery levels, where the need to reach consensus on resource sharing, competing needs and competing mandates can be fraught with conflict. In particular, at the provincial level, the acute care system has consumed a lot of energy over the past few years, and this has not been helpful to the mobilization of population health within that system.

7.3.6.5 Sustainability (5E)

It is generally felt that the ACHF is fully sustainable, as long as both governments continue to commit funds to HIV in Alberta. It was noted that in the ways the funds are set up, the federal funding is more permanent and therefore less vulnerable to short-term pressures. Some of those interviewed expressed the hope that over time, more funding models for programs related to population health aims, but in other domains of wellness, would be able to adopt this collaborative, integrated model.

See Table 5 in section 10 for a summary of the contribution of each sector/partner to this initiative.

7.3.7 How mechanisms for citizen engagement have been employed

Citizen engagement in this initiative has been built in part through the partnership role of community-based groups. Over and above this, space has been made in all decision-making mechanisms for people living with HIV.

LEVEL OF ENGAGEMENT	CITIZEN ENGAGEMENT
	Population at large	Target group	Community-based organizations	Advisory committee	Other
Level 1: Inform, educate
Level 2: Gather information, views		People living with HIV consulted in development stages.	CBOs consulted in development stages.
Level 3: Public involvement through discussion or formal consultation		Public involvement through discussion or formal consultation People living with HIV consulted in development stages.	CBOs consulted in development stages.
Level 4: Engagement of public		People living with HIV participate in Working Group, CPCs and Consortium.	CBOs participate in Working Group, CPCs and Consortium.
Level 5: Facilitate capacity building

7.3.8 How accountability for health outcomes has been increased

Accountability mechanisms are a significant concern to all the players in the joint initiative, as each has to answer to their own central agency as well as to the collaborative body. The mechanisms that have been developed take into account the different needs of different players and have been very satisfactory for all concerned. Among those mechanisms are the evaluation requirements for each operational and project grant funded through the ACHF (7B). Each of these is required to have an evaluation component, and the funding guidelines provide some basic evaluation questions, focussing on processes and short-term outcomes. Projects may spend up to 10% of their budgets on evaluation (7C). They are also expected to provide information to be used in the evaluation of the Canadian AIDS Strategy.

In addition, all components of population health mobilization in Alberta have an explicit evaluation component at the federal level. The ACHF has already undergone one evaluation (by Downie and Associates in 1999), and its recommendations have been appropriated by the Working Group (7E). This evaluation essentially focussed on the implementation of the model according to the plan, and its perceived effects on the funding process and outcomes with recommendations for adjustments. Similarly, the findings of the evaluation of the Intersectoral Action Workshop have also contributed adjustments to the next planned workshop. A provincial evaluation of its contribution to the ACHF is being planned.

7.3.9 How knowledge development has occurred

Learnings about population health mobilization from this initiative are varied. First, with respect to intersectoral collaboration, the successful development of the integrated funding model shows that under the right conditions, inter-governmental and intersectoral collaboration can have a direct impact on the coordination and continuity of services to community-based organizations and the populations they serve. Those conditions seem to include:

• starting from strong pre-existing relationships - this suggests that relationship building should be a precursor to any formal collaborative attempts
• developing an atmosphere of mutual trust and acceptance, in a space where participants feel they can take risks but will be protected and can maintain an acute sensitivity to others' perspectives and potential difficulties (needing to always "listen with both ears")
• developing or articulating a common value base, so that although partners may work in a wide range of different systems, they can operate on the shared conviction that they are all heading for the same goals.

The experience of this initiative has taught that mobilizing partners outside the health sector, at least around the HIV issue, is a major challenge. This applies to potential partners at both the federal and provincial levels, and speaks perhaps to the need for targeted championing of the population health approach in key strategic or flagship locations.

Several learnings about moving intervention strategies upstream are also worth noting. First, it seems clear (although some of those interviewed had found it surprising) that through cautious nurturing in the process of providing support to community-based initiatives, a federal agenda, in this case population health, can influence the community- action agenda.

Second, adoption of a medium- to long-term perspective in the careful structuring of collaborative mechanisms and processes (for example, committee structures, decision rules for funding allocations) can pay dividends in terms of sustainability. To the extent that partners are confident that these mechanisms and processes have been developed to serve common interests, they will be willing to weather hard times and difficult discussions in order to keep the momentum going.

Finally, although impacts in terms of population health outcomes may be ultimately attainable through the systematic adoption of the population health approach, they should be looked for using appropriate indicators developed from reasonable expectations about the levels of change to be expected, and then only in the long term.

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7. Downie and Associates, Final report: Evaluation of the Alberta Community HIV Fund, 2000, p. 17.

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