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

3.3.1 How the determinants of health are addressed

This initiative grew primarily from a social development orientation rather than a health perspective. At the 1998 think tank, the embracing of a focus on social and economic exclusion originated in a shared realization that the notion of "child poverty" is inadequate to capture the range of factors that produce the negative and inequitable outcomes associated with poverty, and particularly the mediating role of policy in producing the conditions of exclusion. While all the players agree that the main results of their work will encompass improvements in population health, the collective definition of population health emphasizes societal change towards increased social justice and for many, health outcomes (in the sense of reduced morbidity, improved life expectancy and functional status) are but a few among a host of benefits to be reaped from making social and economic policies more inclusive. For their part, Health Canada staff were quick to recognize the consistency among the concepts inherent in social inclusion/exclusion and the health determinants framework, and to push for further development of the inclusion/exclusion model as means of mobilizing the population health approach. The main strategy has been focussed on the development of healthy public policy, with a rather long-term outlook, on the understanding that: "The possibilities of short-term failure are high."

As a result of the decision to embrace multiple frameworks rather than emphasizing the population health framework, all players in the initiative are comfortable with the population health vocabulary, and recognize their shared aims, as well as shared interest in marginalized populations. The population health framework is thus seen by all partners as a perfectly compatible, convenient and timely companion to the mobilization of social justice concerns in Atlantic Canada. As one respondent remarked, it has provided "a venue for this approach to evolve," with the overall aim, as stated by another respondent, "to create a social environment where health can be appropriated."

In terms of the determinants addressed, of particular interest are social and economic policies related to income and social status, as well as related issues that affect women and children who live with social and economic exclusion: for example, violence, teen pregnancy and single parenthood. The analysis of the range of determinants and their interactions (1A) was therefore based on existing studies of the relationship between socioeconomic status and health outcomes for women and children, produced in the context of policy initiatives and advocacy around the issue of child poverty. While it is clear to participants in this initiative that all the determinants of health interact (1B), most see poverty as the key factor in exclusion, with consequences for all other determinants (education, family functioning, employment, etc.).

According to some participants, the adoption of the inclusion/exclusion framework within the health determinants perspective has made dealing with poverty more palatable and less threatening to governments. This shift in focus to systemic factors away from individual blame is seen as having opened new ears within government, and helped to redress what some respondents see as an imbalance between social and economic development.

In terms of gaps in knowledge of the determinants that hinder ability to respond (1C), two main knowledge deficits were identified by participants. The first is related to the perceived need to increase diversity and the presence of "First Voices" - a gap in understanding the experience of exclusion among some groups who have not had ways to be heard in policy-related fora. The second gap is in terms of analysis frameworks for anticipating the impacts of policies on social and economic inclusion and exclusion.

3.3.2 How the focus is placed on the health of populations

This initiative developed from concern about the health and well-being of women and children living in poverty. That population has remained a focus throughout the work of the initiative. However, the initiative essentially attempts to enable policy makers and other key stakeholders to view populations through a social and economic exclusion lens (focussing on policies, structures and practices) rather than a poverty lens (focussing on individuals). The range of populations addressed (2A) thus embraces any sectors or groups who are directly or indirectly excluded from developing their full social and economic potential. The initiative is driven directly by a concern for inequities between sub-populations, with a focus on equity of access to full social and economic inclusion. In particular, there is focus on "First Voices," or ensuring that people whose voices have traditionally not been audible in policy fora are heard. Examples of such groups are found among the Black community, urban Aboriginal families, women in fishing communities and female caregivers over the lifespan.

While it is clear that the social and economic inclusion initiative addresses what are conventionally referred to as "high-risk populations," the players in this initiative prefer to avoid ths terminology. This focus on inclusion/exclusion rather than risk locates the causal factors (2B) for social and health inequities within social and economic institutions rather than within individuals. In this sense, the initiative addresses aggregate populations and particularly the opportunities and frustrations for populations presented by social and economic policies.

3.3.3 How upstream investment has occurred

The upstream strategies used in the initiative can be described as follows:

• Identification and nurturing of a community of interest. Creating a "forum for like minds, a critical mass within the region" is seen as a necessary precursor to creating sustainable mobilization. As some events over the course of the initiative have demonstrated, the organizational and political structures to which the working groups have been attached are vulnerable to instabilities associated with political change. This vulnerability is exacerbated when, as is the case for many of the individuals involved in the initiative, they are highly placed. The creation of a broad base of the community of interest via the Reference Groups throughout the region has assured the initiative's stability. Like a tree with a large root system, while at times not growing very rapidly, it is less likely to topple in the winds of change.

An important step in consolidating the community of interest was the considerable effort dedicated to clarifying the language used. This has helped sharpen understanding of gaps among partners' positions, as well moving them toward greater mutual appreciation.

• Sensitization of increasingly wider circles of stakeholders to the notions of social and economic inclusion and exclusion and their consequences.
  At this point in the initiative, many of those interviewed feel that this has been its greatest success to date, although much remains to be done. Success has been attributed to the ability of the Reference Groups to take messages that are not easily conveyed and package them in ways that seize attention, engage discussion and stimulate action. Success is also attributed to the dedication and vigilance of the partners in spotting and using opportunities to influence thinking in their own spheres of action.

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

In the short term, the main accomplishment expected is increased sensitivity and attention to inclusion and exclusion as health determinants among all relevant sectors. For example, several partners interviewed affirmed that their participation in the initiative has directly affected work in their own spheres. For example, the Saint John Community Health Centre (in partnership with the New Brunswick Human Development Council, among others) has proposed a "one-stop centre" for teens founded on social investment concepts, and the Social Planning Unit in Newfoundland and Labrador has integrated indicators of inclusiveness in its structuring of regional steering committees. In general, one of the main changes in thinking believed to be occurring is a growing understanding of the benefits of social investment. The impacts of the initiative can thus be seen as extending well beyond the formal dissemination processes, but not in predictable ways: especially in the short term, the impacts will occur through non-linear, osmotic processes and the perspicacious exploitation of fortuitous events.

In the medium to long term (five to 10 years), the main accomplishments anticipated are changes in social and economic policies. Specifically, it is hoped and expected by all involved that these increasingly sensitized social circles will be enabled to translate the ideas raised by the Reference Groups into more inclusive social and economic policy. The entire policy system will be attuned to facilitate inclusion, and to be much more sensitive to the impacts of exclusion. This will involve realignment of allocation priorities on the basis of the new ways in which all people's voices will be allowed to be heard.

It is felt by most of those interviewed that while the phases up to the present have been concerned with setting the groundwork for the development and implementation of inclusionary social policy, the true test of success will not come until a policy change has been proposed around a specific issue and then successfully implemented. Part of the success will come not just from having achieved policy re-orientation, but also from the demonstration to skeptics that changes in social investment can make a difference in societal outcomes.

Some respondents at the community level noted that policy change will have to first be supported by community-level popularization and appropriation of the inclusion/ exclusion concepts, and that this is the direction the initiative should now turn, if possible in tandem with, or complementing or supporting ongoing community work. Some respondents also pointed out that the enormity of the task facing the initiative sometimes feels overwhelming. While the good ideas that have emerged from the processes have produced positive energies, in the long run the level of commitment required from individuals and from the organizations that support them - generally, outside their direct mandates, or as an adjunct to their regular work - may cause engagement to erode.

3.3.5 How multiple strategies are applied

As described above, the actions undertaken to date in the initiative (at the time of data collection) have concentrated on developing a common framework for collaboration, a shared vocabulary and the raising of critical consciousness around the issues of social and economic inclusion and exclusion, all in reference to a single change strategy ? public policy development and coordination. All partners are jointly responsible for this work. While it is not precluded that these policies act on the range of health interventions (health promotion, disease and injury prevention, risk management, medical treatment, rehabilitation, palliative care and health services), the focus is mainly on "social" interventions (for example, the Monquarters at Work case study, which aimed to develop community enterprises, or the Urban Core Support Network in Saint John, which aims to identify and address barriers experienced by people living in poverty). In the medium term, it is expected that the initiative will stimulate actions in the multitude of policy settings where social and economic exclusion occurs, addressing issues throughout the life span, for example, among rural Black women or among urban teens.

3.3.6 How collaboration across levels and sectors has occurred

3.3.6.1 Nature and implications of collaboration

The initiative has involved active collaboration among the community sector, university sector, all four Atlantic provincial governments, and Health Canada (5A). Their level of involvement has varied, with some partners being more active contributors than others, according to their interest and availability. The approach used to build and maintain partnerships has been one of open acceptance, rather than strict expectations: "When people can commit they are welcome: we are creating opportunities, and waiting for people to come to them." For all of those partners consulted, the key to the success of the initiative has been the strength of the relationships developed. The extent of trust developed over the course of the initiative as experienced by most partners is quite extraordinary.

The approach to partnership and intersectoral collaboration in this initiative has been founded on the development of ties among individuals who, first and foremost, support the fundamental concerns with social justice which underlie all the work (5G, 5H). While these individuals represent their organizations, the approach to involving organizations and sectors has been to locate and recruit like-minded individuals who are respected within their organizations and also have an appropriate combination of knowledge, intersectoral and other skills, power, passion and commitment. This approach, based on natural affinities, has had several important consequences:

• As mentioned above, a striking feature of how partners in the initiative describe their experience of intersectoral collaboration is their emphasis on the genuine trust that exists among the partners. Those involved emphasize that barriers to collaboration that have existed (and in other areas, may continue to exist) between their organizations (for example, between federal and provincial governments, between provincial governments and the community sector) have dissolved, being replaced by a shared conviction that the individuals involved have and will act in the best interests of social and economic inclusion.
• In exploring with participants how this trust developed, some insights emerged. According to those interviewed, the building of relationships was an evolving process, with some difficult moments at the outset, particularly due to lack of a common language. The key foundations of this process seemed to be a combination of individual factors, the cross-sectoral membership, and the relaxed and accepting approach to partnership communicated by the flexible and supportive arrangements provided by Health Canada and enacted by the Maritime Centre. In addition, the processes of interaction themselves created a safe space for open and transparent discussion among participants. On this foundation, the shared development of a critical consciousness about social and economic inclusion and exclusion has bound the partners to each other and to their common cause.
• Another consequence is that individuals have continued to maintain involvement in the Reference Group activities even when their own organizational landscape has been altered by political events, organizational restructuring or career developments. This has ensured a continuity among the players in the initiative, and has also in some cases enabled work to continue where it might have foundered. As well, in cases where key individuals have found themselves within new circles of influence, it has allowed the initiative to expand its network of contacts.
• In some cases, this affinity-based approach has meant that individuals who were asked to assume a role within the initiative on behalf of their organization but whose value orientations or priorities diverged from those behind the initiative, became less involved over time.>
• The approach has led to the explicit recognition of the importance of identifying and working with "bridge people," or key like-minded individuals with personal capacities to make connections between organizations and systems.

The collaborative work within each of the Reference Groups has been jointly managed on a consensus basis (5G). The Maritime Centre held an initial face-to-face meeting with each Reference Group, during which the aims of the project, expectations for partnerships, and the types of support to provided through the Centre were discussed. After that initial meeting, the Groups began to organize their own work and meetings, with the Centre's facilitator as a resource. In all the Reference Groups, there was a strong ethic in place around ensuring that all voices were heard and recognized in the documents, so that the ideas contained in them would be collectively owned. In order to facilitate the actual production of the documents, a writer was identified for each of the groups, who assumed the task of ensuring that all views were reflected in the final products.

3.3.6.2 Resources brought by partners (5B)

The organizational status of participants in the Reference Groups has been a deliberate focus of the initiative, in the sense that it is hoped that partners will be able act on the thinking which emerges from the initiative and use their own spheres of influence.

In terms of the financial resources brought by partners to the initiative, direct funding in the amount of $75,000 per year has been supplied by Health Canada to the Maritime Centre to support the coordinating work and the costs of face-to-face meetings. Health Canada staff (two program consultants and their manager) also participated directly in the working groups, providing contributions of time as required. Each partner organization has provided the time for its representatives to participate in Reference Group meetings, by telephone or face-to-face. Although those interviewed maintain that it is inappropriate for them to estimate the not inconsiderable amount of time that they have spent on the initiative, as it tends to overlap with their other work, it is possible to document the time spent in formal meetings during the production phases of the initiative. According to information provided by the Maritime Centre, each Reference Group had at least one additional face-to-face meeting after an initial start-up session, while some had two or three additional in-person meetings. Each Group also had 10 to 15 conference calls spread out over the 12-month period of the writing of the papers and the planning for the regional workshop. One paper had five drafts, another had nine drafts and the third had eight, all of which were discussed by telephone or in person by the Group members, with the writer present to note revisions.

3.3.6.3 Involvement of specific sectors (5C, 5D)

University sector
The Maritime Centre of Excellence for Women's Health has played a key role in the initiative, over and above its role as coordinator. First, in terms of its positioning among the networks of partners, the Centre's university setting in conjunction with its credibility within the social development community provided the initiative with a coordinating nexus in neutral relationships with the governmental and other players involved (especially important in terms of federal-provincial and interprovincial relationships). Second, the provision of dedicated and effective staff within the Centre has provided an invaluable resource base to facilitate discussion and production. The coordination required to essentially have groups of individuals in several locations co-write numerous drafts of deeply thought-out papers over a period of a few months cannot be underestimated; the resources provided through the collaboration of the Maritime Centre kept the work progressing. The Maritime Centre also provided a central node point for the numerous contacts and connections involved in the network, keeping track of changes not only in literal but also ideological coordinates in the social policy cartography of the Atlantic region. And not least, the Centre was vigilant to ensure that partners' contributions in time and effort were acknowledged with courtesy and respect.

Provincial governments
As respondents pointed out, provincial governments have both much to lose and much to gain from their involvement in this initiative. Provincial policies and programs, notably in areas such as social welfare, health services organization and housing, are linked very directly to inclusion/exclusion outcomes. The roles of individual provinces in the initiative have varied among each other and across time, according to factors within each province. An added complexity is present in the need for the initiative to maintain a balance between garnering the advantages of a regional activity (sharing across provinces, developing interprovincial networks of social policy expertise), and remaining sensitive to autonomy issues for each government.

• Newfoundland and Labrador.
  The social and economic inclusion initiative has dovetailed closely with work being undertaken in the provincial government on the development and implementation of a Strategic Social Plan. This Plan was put forth in 1998 by the Social Policy Advisory Committee to help deal with the major economic upheavals in the province and the restructuring of its health and education systems. In the Plan's implementation phase, its staff became aware of the social inclusion initiative and saw its potential to become a catalyst for community engagement. The production of the Reference Group's paper involved the participation of provincial representatives from the Social Planning Unit, enabling links with the implementation of the Plan through regional steering committees.

• Nova Scotia.
  The government of Nova Scotia has been involved with the social inclusion and exclusion initiative mainly through the Public Health and Health Promotion Division of the Department of Health. The Division works within a population health perspective, advocating for population health within the Department and through the delivery of regional services. A change in government and its orientation in facing a health system in crisis have limited the momentum on the initiative within the Department and the government.

• Prince Edward Island.
  The Reference Group initially set up in Prince Edward Island experienced difficulties in mobilizing, and was later combined with the Nova Scotia group. Although the initiative is still active through the work of Reference Group members who are building alliances through issue-specific groups, they are not in position to advance the work within the provincial government at this time.

• New Brunswick.
  The New Brunswick government is currently involved in the social and economic inclusion/exclusion initiative through the unofficial participation of the Premier's Health Quality Council, which has a mandate to reform and renew the health system. Prior to this, the New Brunswick Reference Group had been connected with a Social Policy Renewal Initiative, attached to Cabinet and supported by a Cabinet committee. This group had undertaken extensive consultations with New Brunswickers in the social sector, finding shared philosophies with the inclusion initiative. This ideological foundation is still present, and as the community-based momentum of the initiative is very strong, the provincial government is, in the view of its partners, an important player in it.

Federal government
Health Canada has been the lead federal player in mobilizing population health through this initiative. Its partners praise it for its flexible, open and outcome-driven approach, that has extended beyond the traditional role of a funding agency, to that of a true partner with creative and committed input to the development of the processes and outputs. Moreover, community-based respondents emphasized that because their own arguments were also being pronounced by prominent institutions such as Health Canada, they were lent considerable strength. For some partners, Health Canada's work in this initiative has increased the department's overall presence in the province. While many partners insist that Health Canada must retain its leadership role in order provide balance to the catalyzing role played by community organizations as well as to the challenges sometimes experienced by the provincial governments, its representatives feel that it should remain a full partner but not be the power holder (5F).

Some partners interviewed stressed that Health Canada's role in this initiative could serve as model for other federal departments, which could enhance the inclusiveness of their actions and policies. Although other departments, notably Human Resources Development Canada, were approached, they have not so far expressed interest in collaborating in this initiative, possibly because of their own efforts in similar areas. However, it is believed that there is greater potential for collaborative success with some smaller federal departments, such as Status of Women Canada, Canadian Heritage and Statistics Canada.

Community-based sector
The community sector is a fundamental part of all of the activities conducted through the initiative, as well as in the working groups. A variety of organizations and coalitions have been involved in the different groups, bringing different issues, cultures and geographies into the discussions. A major challenge for some of these groups, according to their representatives as well as some provincial government representatives, has been to develop ways for the community and government sectors to communicate. In the past, community groups have lacked the skills to navigate government decision-making processes, and governments have tended to respond reactively to community groups on a single-issue basis. The initiative has allowed these sectors to understand each other's constraints more fully, and therefore to develop a more trusting relationship based on the knowledge that they are pursing shared social goals. However, some respondents acknowledge that the community sector, which has in the past opted for an advocacy rather than a partnership stance with governments, must continue to be concerned that advocacy remain an option when necessary.

3.3.6.4 Gains and challenges from intersectoral collaboration

Many of the partners involved in this initiative cite the opportunity to share with counterparts in other provinces as a key gain from their participation: "It's important not to feel isolated and that we always have to be reinventing the wheel." Shared experiences are also a major gain: "We learn from everyone around the table, and we can bring our members' views to the table, and then bring the tables' discussion back to our members." For the community sector, another main gain has been in the development of a greater understanding of how policy comes to be written and implemented, and of increased sensitivity to the constraints faced by governments in that process. This has led to an appreciation of the need to build spheres of influence, not only among the public, as has been their traditional focus, but also within government and the corporate world. This has led to efforts to identify natural allies within all of these groups, as a first step in the influence chain.

According to those consulted, one challenge to maintaining the levels of collaboration necessary to collectively evolve thinking and produce collective outputs has been the instability of personnel within the government sector (especially in some provinces). Continuity is seen as a requirement for success in intersectoral collaboration, as the possibility of collaboration is determined by the strength of the ongoing relationships among group members, their mutual respect for each other, and their mutual appreciation of each other's perspectives.

Another remaining challenge to intersectoral collaboration in the initiative is breaking down the silos among government departments, and replacing bilateral relationships with sustained collective interaction. Both provincial and federal government representatives see this as true within their own levels of government. At the federal level, for example, the presence of departments such as Human Resources Development Canada, Canadian Heritage and the Atlantic Canada Opportunities Agency in the roster of active partners in the initiative would be beneficial.

3.3.6.5 Sustainability (5E)

By the nature of their long-term commitment to the development and implementation of inclusionary social and economic policy, all partners in the initiative will be actively involved in creating the conditions for its sustainability. This will take several forms:

• through the securing of funds in support of local/sub-regional/provincial projects and activities which model or enact the ideas and principles identified through the Reference Groups' work
• through continued sensitization and consciousness raising, in their respective settings and jurisdictions, of their other partners
• through the integration of social and economic inclusion as an organizing principle in the programs and activities of their own organizations.

Because of the way the initiative has been structured and nurtured, through the founding of strong relationships based on natural affinities and the development of collective critical consciousness, these forms of sustainability are felt to be guaranteed as long as the partners remain available, either formally or informally, to participate in furthering the initiative's aims. The nature of the working relationships and the accepting stance toward partners' types and levels of participation provide safeguards to ensure that partners can continue to be available for the work, and that the initiative can adapt to changing circumstances. In the views of some respondents, the challenges faced in terms of finding allies to support and grow the initiative present challenges to sustainability within specific jurisdictions. For others, however, the initiative has already made an indelible mark in the thinking of a critical mass of players across the region, ensuring that alternative doors into those jurisdictions will be found.

See Table 1 in section 10 for a summary of the contribution of each sector/partner to the Atlantic social and economic inclusion initiative.

3.3.7 How mechanisms for citizen engagement are employed

As the previous section illustrates, many community-based and non-governmental groups are engaged as full partners in the initiative, and thus provide mechanisms for input from citizens. The list of involved groups covers a wide cross-section of foci and settings:

• Antigonish Women's Resource Centre
• Feminists for Just and Equitable Public Policy
• Canadian Mental Health Association, Newfoundland Division
• Muriel McQueen Fergusson Centre for Family Violence Research
• Centre de bénévolat de la péninsule acadienne
• New Brunswick Human Development Council
• Saint John Community Health Centre
• Urban Core Support Network
• Cooper Institute
• Maritime Centre of Excellence for Women's Health

Up until the time of the data collection, other types of actions to secure citizen engagement had not been widely initiated, although the concepts had undoubtably been integrated into local actions in which Group members were involved. However, this is clearly part of the eventual process of building inclusionary policy and will be part of future developments in the initiative.

3.3.8 How accountability for health outcomes is increased

Within both Health Canada and partner organizations, accountability and evaluation mechanisms have been mostly informal to date, based on the individual's assessment that their considerable time and personal investment has been worthwhile. No formal financial allocations have been made for evaluation to date, although the development of evaluation plans is on the agenda of both Health Canada and the Maritime Centre. It was suggested that a key indicator for success of the initiative is the continuing commitment of individuals and organizations to the process and its goals. Community-based organization representatives emphasize that they are accountable to their funding agencies, and so have to be able to demonstrate that their commitment to the initiative is in fact beneficial.

A difficulty for evaluation and monitoring is that the capacity for the initiative to assess its progress is limited by the availability of useful methods and indicators. As some respondents pointed out, there is a need to develop ways to define and measure social success. However, communities do not have the resources nor the expertise to develop these systems on their own. Evaluation work could be facilitated if there were a conceptual framework for evaluating intersectoral, healthy public policy.

3.3.9 How knowledge development has occurred

This social and economic inclusion/exclusion initiative has afforded many learnings about the mobilization of population health within the region:

3.3.9.1 About partnership and intersectoral collaboration

The importance of creating a safe and trusting environment in which partners feel free to share and participate openly cannot be underestimated. It is important that partners either come to the table with, or develop, authentic mutual respect. In this initiative, the work progressed only when mechanisms for creating and protecting this type of collaborative environment were in place.

In situations where there are pre-existing barriers to mutual respect, the involvement of a neutral partner (in this case, a university-based group) can provide a safe setting for the development of mutual trust.

The potential for successful collaboration is enhanced by the presence of individuals with the right combination of skills, qualities and resources. It is unreasonable to expect that every potential agency or group representative will be able to further the collaborative aims to the same extent, so success will be maximized if efforts are made to work with those whose fit is closest.

Instabilities within all partner organizations are to be expected, but their effects can be minimized through a flexible approach to partnership and a persistent effort to create a wide base of support.

3.3.9.2 About impacts on population health

Patience and a long-term view are necessary. The successful mobilization of population health toward the development and implementation of healthy public policy requires the careful laying of a foundation of relationships, common vocabulary and shared vision. As a first and ongoing step in the mobilization process, laying this foundation can be expected to take several years, and can also be expected to encounter slower periods during times of change or restructuring among key sectors or partners. It may be several more years before changes in public policy are seen as a result, and several more years after that before these policies can be expected to have an impact on population health, in terms of the health indicators now in place.

Frameworks and tools for understanding the impacts of social and economic policy and for measuring social progress are needed, so that smaller advances along the long road to population health improvement can be assessed and strategies adjusted accordingly.

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