Population Health in Canada: A Working Paper

VI. Issues in Health & Social Impact Assessments for Population Health

This section summarizes key issues surrounding the adoption, implementation and evaluation of a population health approach to program and policy decision-making in Canada. The issues are intended to stimulate discussion among participants at the National Conference on Shared Responsibility for Health and Social Impact Assessments. The list of issues is not exhaustive but does include attention to philosophical, methodological, political, logistical and scale considerations.

We are assisted in issue-generation by concepts taken from Rogers' (1998) discussion of the diffusion and rate of adoption of innovations by members of a social system, wherein we view the population health perspective as an increasingly popular innovation in Canada.

ISSUE 1
Definition of Health: Is a narrowly defined definition of health, that allows for clearer distinctions between health and its correlates, more feasible than a broader definition as proposed by the WHO, for example, and what would this mean for policy? A broader version may sell itself more readily to non-health ministries, but may also make the scope for attention unmanageably broad. It will also impact on the conduct of health and social impact assessments.

ISSUE 2
Values: The CIAR model of population health proposes to be value-neutral, but may not be. Critics have espoused values that are not in concert with the CIAR model. Poland et al. (1998), for example, are protective of the welfare state in contrast to Evans and Stoddart (1990) who, while recognizing the importance of income inequality, additionally emphasize wealth-creation. Zollner and Lessof (1998) suggest that certain values held by the Health For All (HFA) movement in Europe may be worthy of uptake in Canada as well: namely, equity, participation, solidarity, sustainability, accountability, ethics and sensitivity to gender issues. Action principles delineated by the HFA are evidence-based practice, assignment of accountability, value for money, empowerment and participation.

The question of values leads to the further question of "representation" or who can claim to speak for specific sectors of society (Jewkes and Murcott, 1996, 1998; Wiesenfeld, 1996). Substantive representation is defined by "who representatives look after and whose interests they pursue", not what the representatives look like (Metsch and Veney, 1976; Notkin and Notkin, 1970, Sawyer, 1995). Some representatives may have no idea for whom they speak (Morone and Marmor, 1981).

ISSUE 3
Fuller Models: Do policy-makers and programs planners require more detailed models with carefully delineated distinctions between proximal and mediating causes and speculation on the strength of causes and relations? Rogers (1995) suggests that the greater the complexity of innovations the slower the rate of adoption, and the frameworks are complex as they are. Saunders et al. (1996) call for a better understanding of the relative importance of different determinants and their interactions. Hertzman et al. (1994) claim it is difficult getting money for longitudinal studies and the problem is exacerbated by the fact that granting agencies often target one disease only. Is it too early to enact population health perspectives in policy, since focus upon the wrong determinants may be a waste of resources?

ISSUE 4
Time Frames: Identified time frames within population health models do not necessarily match political, policy-making and policy evaluation timetables. For example, incorporating concerns for environmental sustainability in health policy may mean several hundred years are required before changes to "causes" manifest changes in "effects" on health. Changing the nature of inequality in society could take some time, and effects upon childrens' development may only manifest results sixty years hence. These time frames do not coincide with political realities, for example, since governments must often demonstrate immediate positive effects of policies and allocate budgets according to impact. Can governments adjust to longer time frames? The question of time frames is also inherently tied to health and social impact assessments.

ISSUE 5
Responsibility for Decision-Making 1: Do the determinants of health, as presented by the population health perspectives and the various frameworks therein, demand collaboration among ministries and the adoption of the perspective by housing, environment, education, employment and taxation divisions, for example? Are changes to the nature of inequality, perhaps through economic reform, feasible and necessary? Can meaningful steps be taken within health-related divisions alone, and does this demonstrate sufficient societal commitment to health? We suspect the other divisions may resent the intrusion of health concerns in their mandated areas of responsibility ("health imperialism"). Besides, is government willing to make strong decisions? According to Lomas and Contandriopoulos (1994) there are two solitudes: government avoids responsibility so as not to encroach on medical decision-making and the medical profession avoids sharing responsibility for resource allocation.

ISSUE 6
Responsibility for Decision-Making 2: The appropriate level of government responsible for healthy public policy is open for debate. Would policy that incorporates various sectors work more efficiently at the municipal level, since the networks among individuals in government are denser and collaboration more easily facilitated? Or should we instead give power to federal, provinces and/or regional health authorities? Lomas and Contandriopoulos (1994) suggest that decentralization of decision-making may help intersectoral collaboration. It may also lead to increased participation of nontraditional stakeholders (e.g., the private sector). Finally, the issue of shared responsibility leads to awareness of the limits of potential action by individuals, communities and regions towards addressing individual or collective determinants of heath. A distinction must be drawn between self-responsibility and self-reliance. Individuals, communities and regions cannot be reliant upon resources (economic, social, environmental) they don't possess. In seeking to reduce health inequities population health must avoid the "victim-blaming" sometimes associated with lifestyle-oriented programs or policies (Allison, 1982).

ISSUE 7
Impact Assessment: We noted the importance of evaluating the impact of programs and policies, but evaluation of programs and their effects are not integral components of the population health frameworks thus far. Saunders et al. (1996) note that studies of etiology are more common than studies of interventions or programs outside of health care. They claim a need for further population-based surveys to measure trends and assess results of societal-level interventions. The time frames implicit in the population health perspective make measures of change in health difficult, and trialability (the degree to which an innovation may be experimented with on a limited basis) and observability (the degree to which the results of an innovation are visible to others) (Rogers, 1995) are not easily amenable to population health. Can programs be evaluated with respect to other standards, and what standards could be used (e.g., social, economic, environmental impact assessments)? What should programs look like and what kind of outcomes are expected? Will the budget be tied to outcomes? Should regulations be imposed, with both a carrot (incentive to participate) and a stick (punishment for non-participation)? Is regulation the way to ensure continuity in policy across government divisions?

Evidence from the Healthy People 2000 initiatives suggest that tying the achievement of health goals and objectives to line-item budgeting through government regulations may be an important factor in the sustainability of these initiatives over the past 20 years. It also appears to foster state and regional participation in a federally-driven initiative.

ISSUE 8
Making Population Health Popular: Governments are guided by public opinion. How can we generate among the public a more balanced understanding of both social and health care investments in health (Lomas and Contandriopoulos, 1994:253)? So far the public cannot keep up with developments in the population health perspective (Hayes and Dunn, 1998). Zollner and Lessof (1998) suggest securing charismatic champions in government and business to represent the perspective. A few provinces have already developed public information materials to help inform the public about the broad determinants of health, and a national initiative could use these as a starting point (Strategies for Population Health, 1994:35). Use of the information highway, the Internet, may be one vehicle for dissemination of ideas to the public.

ISSUE 9
Paradigms: Do policy-makers in Canada require a logically coherent population health model to craft policy or would they prefer a multiplicity of perspectives? A common culture and working relationships, such as those advocated in the integrated health research agenda envisioned by the proposed Canadian Institutes of Health Research (CIHR), may assist in generating a common paradigm. The contribution of multiple stakeholders from diverse sectors to the creation of a coherent population health paradigm is a also key question.

ISSUE 10
Structural Constraints: Rutten (1995) describes several elements of policy implementation that pose specific challenges for adoption of a population health approach in decision making including: conceptualization, complexity, bounded rationality, play of power, bureaucratization process, organizational specialism and policy networks. The notions of conceptualization and complexity are inherently interwoven and suggest that important stakeholders may find population health concepts difficult to operationalize and manage on a day-to-day basis (see issues 1 and 6 above). Rutten's interrelated concepts of the bureaucratization process, organizational specialism and policy networks highlight the fact that existing systems are inherently bureaucratic. Representatives of key sectors and expert stakeholders tend to operate through well-developed networks and tend to focus on, and feel most comfortable in, executing familiar tasks and responsibilities.

ISSUE 11
Accountability: Across Canada, policy makers and program planners are faced with a public demanding greater accountability for public resources. This concern has contributed to the emergence of a focus on "evidence-based decision making and the development of a plethora of accountability frameworks. The notion of "accountability" also begs the question of who will be accountable (to whom?) for taking action on specific determinants or combinations of the determinants of health and for what outcomes program planners and policy makers will be accountable.

ISSUE 12
Relations Between Health Sector Participants and Other Stakeholders: The involvement of non-health sectors in population health decision-making suggests both a shift in the role of traditional government stakeholders and health professionals and an emergence of new partnerships. With a shift to greater intersectoral participation, the role(s) of health professionals in population health may become unclear. Tensions emerge as health professionals feel threatened by an uncertain future and a reduction in their influence. The change in the role of health professionals is analogous to what has happened to the role of academic researchers involved in participatory research with communities.

ISSUE 13
Resources to Facilitate and Strengthen Population Health: Program planners and policy makers who seek to address the broad determinants of health are faced with a range of complex tasks and decisions. They require data and information in a timely, useable form that supports their decision making (Schwartz et al., 1993). As lay people, they may lack the technical training and expertise with which to judge sophisticated health data (Burr et al., 1995). As such, the data must be triaged by supportive health professionals and researchers. It falls to centralized governments to assure some degree of equity in the distribution of resources for population health across other levels of government (e.g., provincial/state, regional, municipal) (Whitehead, 1990).

ISSUE 14
Sustainability of Population Heath Initiatives: Once created, mechanisms and structures for addressing the determinants of health making must be appropriately nurtured and sustained (Altman, 1995). Three potential approaches to the sustainability of outcomes of population health can be found in the literature: the institutionalization approach; the community competence approach; and the Healthy Communities approach. The institutionalization approach considers outcomes in terms of structural changes and is useful for measuring sustainability within an organizational context. This approach may have some relevance to the ongoing function of health programs; however, it may offer little towards measurements of community or regional-level outcomes such as increased community competence/capacity (e.g., social capital).

Distinct but not mutually exclusive of the institutionalization approach is the community competence approach, which considers outcomes from a more functional perspective (Eng and Parker, 1994). Increased community competence is a major intent of many community-based health programs and policies. The place of enhanced "community competence" as an (expected) outcome of population health remains an open question.

The third approach is drawn from the Healthy Cities/Communities movement (Boothroyd and Eberle, 1990). While this WHO-initiated approach to public health has grown significantly, many questions remain as to the definition and measurement of a "healthy community". The evolution of the movement is such that its philosophy and rhetoric often outstrip the reality. Others have noted the difficulties inherent in attempting to identify Healthy Community indicators (de Leeuw and O'Neill, 1992; Elaskari et al., 1998; Hancock, 1993; Hayes and Manson-Wilms, 1990).

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