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

6.3.1 How the determinants of health are addressed

The Partnership model addresses all possible health determinants and their interactions, based on partners' knowledge of research and practice in population health and health promotion and the social and environmental conditions in the province or in their populations of interest. New knowledge about determinants as well as about effective means of addressing them, constantly flow through the Partnership, as members share everything they are able about new information sources, population health resources, and their own formal and experiential learnings.

6.3.2 How the focus is placed on the health of populations

The Partnership addresses the entire Saskatchewan population, with specific emphasis on Aboriginal populations. Its focus is on supporting and strengthening the provincial capacity in population health promotion; that capacity can then be applied to any sub-population or risk group, according to health status or other indicators of need.

6.3.3 How upstream investment has occurred

The Partnership is in and of itself a fundamental upstream strategy. By increasing population health promotion capacity, it supports the ability of practitioners and organizations to reorient social and economic structures and policies that can redress the root causes of health problems:

• By strengthening links with key players at all levels of government and other policy stakeholders in the province, the Partnership is designing a network of influence that will allow it to reach the policy environment related to all health determinants.

• These levels of government include the province's Aboriginal governments.

• The focus to date has been on working with governments and organizations most directly linked to the health sector. In its next phases, as identified in its Strategic Plan, the Partnership will expand these links into other sectors - but at a pace which will allow for the same quality of relationships to develop, and with attention to the effectiveness of partnering: "We are not looking for members, we are looking for opportunities."

• The Partnership enacts the population health approach in the way it carries out its work, by creating and protecting a collective space for interactions that embody principles of inclusiveness and mutual support and that give primacy to members as people. This provides a model-in-action for the influence the Partnership hopes to have both inside and outside the health sector. It also facilitates candid communications and efficient sharing of knowledge. At another level, it maintains a power equilibrium among the partners. This is an upstream approach to ensuring maximum reach for the regional mobilization of population health.

• By focusssing on networking and capacity building in an intersectoral collaboration mode, the Partnership adds to the resources that individuals, organizations and communities can draw upon in their own drive to improve population health. The Partnership has supported major training and development initiatives throughout Saskatchewan, and provided resource materials and access to other forms of support to a very broad cross-section of health and other professionals in the province. Whether the issue is diabetes, mental health or some other concern, the Partnership acts to equip those concerned with the tools for effective local or issue-specific action.

• The Partnership opens multi-directional communication channels, allowing many voices to be heard in the collective planning processes. Partners representing specific sectors (for example, rural communities, Aboriginal communities) see it as their responsibility to educate the partnerships about the issues and problems facing their communities. The Partnership is thus able to act further upstream, by being directly responsive to those issues.

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

In the short term, the Partnership members see their efforts as increasing local capacities to work from a population health perspective, by providing tools, training and networking opportunities to all of the province's health districts as well as First Nations and Métis Nation communities. The impacts of this are already being seen in how health districts are carrying out their mandates and working with local partners. This increased population health literacy among practitioners is also expected to have medium- to long-term impacts on the creation of policy environments which are supportive of population health principles, and eventually lead to healthier public policies. Also in the long term, the Partnership aims to support the integration of the population health vision in provincial health reform and the further development of an integrated services delivery model. This influence is expected to bear out in funding allocation criteria and decisions.

6.3.5 How multiple strategies are applied

The population health practice model developed through the Partnership and disseminated through its training activities and funding programs is founded on the necessity of using multiple strategies and settings. For example, in the diabetes prevention demonstration program, projects are encouraged to put more emphasis on strategies other than individual skill development (build healthy public policy, strengthen community action, create supportive environments, re-orient health services). The supporting resources provided to sites are intended to stimulate multiple strategies; for example, in the Practice Guide, for each of the three main health issues to be addressed in the sites (increasing physical activity, achieving and maintaining healthy body weights and improving diets), examples of traditional individual approaches are contrasted with examples of multiple alternative strategies, in a variety of settings such as food producers, retail food suppliers, community-based organizations, workplaces and schools.

6.3.6 How collaboration across levels and sectors has occurred

6.3.6.1 Nature and implications of collaboration (5G, 5H)

For all of the Partnership members, the key factor that supports their working together is the healthy, supportive human environment within the group. Members feel mutually valued and respected first and foremost as human beings, then as health promotion champions, and finally as members of other organizations or institutions with roles to play in population health mobilization: "When we go in, we shed our official titles." "The groups leave their power at the door." They understand their contributions to be critical and valued, but also understand that they are expected to contribute only what they are able to at any particular juncture: expectations of partners are realistic and adjusted as needed. Partnership members trust each other explicitly and implicitly, and frank discussions can be carried out without restraint or anxiety about disclosure.

Some of those members who have been involved since the beginning credit the pre-existing relationships among the major players for the quality of the relationships within the Partnership. However, more recently recruited members emphasize that the group has made conscious efforts toward the primacy of the relationships and to ensuring that new members feel sincerely welcomed.

The members of the Partnership provide mutual support to each others' specific activities as needed. For example, Partnership members sit on the review committees for Population Health Fund grants; and act as advisors to the Saskatchewan Heart Health Program - Dissemination Phase, carried out by the Prairie Region Health Promotion Research Centre and its partners.

6.3.6.2 Sectors involved in the initiative and their financial contributions (5A, 5C)

As described above, the organizations, agencies and government departments involved to date are concentrated within the health and social services sectors, including educational institutions with a role in the education of health promotion/population health professionals. Each partner organization is responsible for ensuring that members can attend meetings and devote time to Partnership activities: this is seen as part of the collective ownership of the Partnership. Over and above this, each partner may contribute financial or other resources to Partnership processes, according in part to the availability of funds, but also to the types of expenditures that the various administrations allow. This situation provides maximum flexibility for the Partnership to work out financial and administrative arrangements, and because of the level of trust in the group, these arrangements have been very effective. The nature and amounts of the contributions vary according to the specific initiative, but "things just get done ... who has the money is not the biggest issue."

However, in the larger landscape of population health mobilization in Saskatchewan, partners' contributions extend well beyond their contributions to the Partnership. An assessment of the total investment in population health that is oriented or influenced by the Partnership would have to include many of the ongoing activities of the member agencies, including Health Canada's Population Health Fund, Saskatchewan Health's Wellness Grants and other funding programs, a part of the resources of all health districts, and the Prairie Region Health Promotion Research Centre, to name a few. In this case, it makes more sense to examine the value added by the Partnership to the existing province-wide investment.

6.3.6.3 Role of Health Canada (5F)

Health Canada participates in the Partnership as a full partner and key player in population health in Saskatchewan, assuming leadership of specific ventures as required and actualizing the Partnership's population health promotion vision through ongoing programs such as the Population Health Fund and children's programs. It is expected that the renewal of existing projects through these programs as well as the design of any new programs (for example, hepatitis) will have the population health approach ingrained in them.

6.3.6.4 Gains and challenges from intersectoral collaboration

A main gain from the intersectoral collaboration in this initiative has been the continued visibility of population health at high levels within the participating organizations. The Partnership has created a kind of joint account for population health within the province, for which partners have assumed collective responsibility. In the absence of this entity, the momentum for maintaining a very high level on population health promotion may have been slowed, or stayed by ongoing crises in the health care system. In this context, the Partnership has also provided a source of support for health promotion professionals buffeted by the organizational implications of the health care crisis: "It started as an opportunity, then became a support system."

For many of the partners, participation in this initiative has provided access to a new vision of change processes based on a broader understanding of the complex interrelationships among social structures and forces: "Being on it helps to change our way of thinking, allows us to think across departments, with the idea the we all have common needs." For some, the Partnership model has expanded not only the network of partners, but also the interfaces that partners have with each other. According to those interviewed, prior to the Partnership, for example, the main interface between the Métis Nation and Saskatchewan Health had been though alcohol and drug services.

Within the Saskatchewan context, the current push for services integration has provided a ready opportunity to gain from intersectoral collaboration. The network of provincial departments involved in the Human Services Integration Forum is becoming connected to the Partnership's network. In this process, a common vision of intersectoral work is being discovered, and it is anticipated that many commonalities of approach and purpose will become apparent.

A major challenge facing the Partnership as it carries out its current Strategic Plan is the expansion of the Partnership into other sectors. The rationale for expansion is being developed collectively, seeking to strike the right balance between addressing crucial sectors in terms of the impact on health determinants, and maintaining an effective, healthy partnership model. Within this challenge will be the challenge of developing a common language with the new sectors.

6.3.6.5 Sustainability (5E)

According to those interviewed, each member of the Partnership has a sustaining function in ensuring that their organization continues to see the need for participation. Moreover, although some district health boards are still struggling with the population health notion, it is becoming more widely accepted as a way of structuring actions in support of improved health and well-being. The complementary work being carried out through the Human Services Integration Forum, which aims to increase community capacity for the integrated local delivery of human services, will also provide a backdrop for sustainability. The general opinion among Partnership members is that it is indefinitely sustainable in its present form and is likely to remain in place until it is no longer needed or it evolves into a new entity.

See Table 4 in section 10 for a summary of the contribution of each sector/partner to the Partnership.

6.3.7 How mechanisms for citizen engagement are employed

The Partnership is most directly concerned with the infrastructure for population health mobilization, so citizen engagement has not been a primary focus and remains a challenge in an era when public attention is on the curative system. However, the population health promotion practice which it encourages includes citizen involvement as a key feature. For example, in the support materials for the diabetes prevention demonstration projects, it is stated, "For primary prevention of diabetes intervention to be successful, it must include ... community initiation of the program and continuous involvement with it." It is thus expected that projects grown as seedlings from the Partnership's approach will include mechanisms for citizen engagement through any of the tools which are appropriate within particular communities.

6.3.8 How accountability for health outcomes is increased

The Partnership is in the process of developing and refining a protocol for gleaning lessons learned from the Partnership's initiatives. This will consist of a series of reflective questions that Partnership members will pose to themselves as a group, to examine and reflect on any of its initiatives. The aim of this protocol is to generate lessons for the future. The reflective questions cover the following dimensions: context of the initiative, inputs, process, product and values. A brief description of the initiative in each dimension is followed by a series of critical sub-questions, concentrating on implications for future initiatives. This self-assessment procedure will require minimal resources to implement.

Other evaluation mechanisms are also used for specific initiatives, and the relevant information is brought to the Partnership for discussion and reaction. For example, the annual Health Promotion Summer School conducts an evaluation by questionnaire for participants and a summary of the results is presented to the Partnership. Evaluation is a requirement for the diabetes demonstration project pilot sites, and they have been provided with tools and supports to ensure that appropriate and useful evaluations are conducted.

Within partner organizations, accountability is maintained on a mostly informal basis; Partnership members must demonstrate to their respective organizations that their participation is beneficial to the organization and its clientele.

6.3.9 How knowledge development has occurred

This initiative is contributing to knowledge development about population health mobilization in a number of ways (8D). First, learnings from within the Partnership's broad sphere of contacts, resources and activities are shared and applied, so that population health in Saskatchewan is a vast, virtual learning organization. Second, the role of the Prairie Region Health Promotion Research Centre includes building research from practice, sharing that research with the wider research community, and learning from research conducted elsewhere. Through constant interplay between the two, theory is reintegrated into practice through the Centre's training and capacity-building activities.

In terms of additional supports which could have been useful, the approach taken by the initiative has been to work within the resources that were available (8B). The fact that the Partnership operates without a formal funding base has been both an advantage in terms of the increased agility and creativity it necessitates, and a disadvantage in terms of the need to regularly locate resources. However, the Partnership has deliberately chosen to operate in a low-key way, without calling attention to itself as a entity and without establishing a core funding base: its voice is heard through the voices of its partners. While the value of this approach has at times been difficult to explain to output-oriented managers and central agencies, it has on the other hand created a safe haven in which population health capacity building could be fed and cared for. In some ways, the Partnership has been a successful primary prevention venture, having filled a vacuum which could have been created by health crisis and reform with a vibrant and fertile population health promotion movement.

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