Health Impact Assessment as a Tool for Population Health Promotion and Public Policy

Recommendations

We offer the following recommendations for consideration in the development of health impact assessment as a tool for population health promotion and public policy:

1. The federal government should undertake, in collaboration with other major national organizations having a stake or a role in the determinants of population health, a systematic national goal setting process. Such a process should combine the evidence and experience already compiled and developed in the form of goals and objectives in the provinces and territories.

This single line of action on the part of the federal government would provide the major missing ingredients for an ongoing structure and process that would support continuous health impact assessment as a tool of population health promotion and health policy. It would also encompass most of the more specific recommendations that arise from the foregoing review. Thirdly, it would acknowledge and give national expression and support to the work that has been accomplished in virtually all of the provinces. Finally, it would put Canada on a par with the other OECD and Australasian countries that have adopted the WHO "Health for All" strategy of developing and following a public health management-by-objectives approach to the long-range planning and evaluation of population health programs and policies.

We recognize that the Ministers of Health did not adopt the 1994 report of the Federal/Provincial/Territorial Task Group on National Health Goals/Priorities (1994) prepared under the direction of the Federal/Provincial/Territorial Advisory Committee on Population Health. Much has happened in the two years since that report was presented in May 1994. The reorganization of the population health and health promotion units within Health Canada has given the federal government a greater capacity and organizational focus to provide the national coordination of the provincial efforts already completed. The provinces and territories that had only begun their goal-setting or their objectives and targets in 1994 have now completed them or have them well underway toward ratification. The three recommendations of the Advisory Committee on Population Health Report adopted at the Meeting of the Ministers of Health in September 1994 have been largely accomplished as a foundation for the deferred recommendations on goals, objectives and targets. We reproduce below those three recommendations for strategic directions as first steps to be completed and summarized in undertaking the goals, objectives and targets exercise:

1.1 Strengthen public understanding about the broad determinants of health, and public support for, and involvement in, actions to improve the health of the overall population and reduce health status disparities experienced by some groups of Canadians.

Since the September 1994 adoption of this recommendation, the public has become increasingly imbued with the understanding that there is more to health than health care. The public recognizes even more today than in 1994 the influences of lifestyle, stress, and the quality of their work and family life on their health, and the influence of employment, income, and educational disparities in determining these more proximal determinants of health. Public participation in formulating community health priorities and program or service allocations has been increasingly facilitated with the establishment of decentralized health boards, councils, and committees with lay representation if not control.

1.2 Build understanding about the determinants of health and support for the population health approach among government partners in sectors outside health.

Progress on this recommendation in the provinces and territories needs to be reviewed systematically for the lessons it holds and the implications for action needed at the federal and national level. Coordination among sectors at the local level will be impeded by inadequate coordination at provincial, territorial, or national levels. Coordination within federal government and between government and national organizations must be accomplished before health impact assessment and actions to address the determinants of health that lie so largely outside the health sector can be expected.

1.3 Develop comprehensive intersectoral population health initiatives for a few key priorities that have the potential to significantly impact population health.

The federal government has facilitated the unfolding of major national initiatives in tobacco control, "Brighter Futures" for children, family violence prevention, the Green Plan for environmental reform, the Seniors Independence Program, the National Breast Cancer Initiative, and other notable intersectoral efforts. The lessons from these efforts, including the successes as well as barriers and failures, need to be reviewed as a set of intersectoral intentions that may or may not have had the impact on determinants of population health, much less the health impact, that might have been expected of them. Their experience, however, can hold the keys to building toward the next steps in setting national goals, objectives and targets for population health and ultimately health impact assessment.

With the foregoing three analyses in hand, along with an update of the 1994 report of the Federal/Provincial/Territorial Task Group on National Health Goals/Priorities, an additional series of steps can be pursued to set in motion the development of national goals, objectives and targets for population health:

1.4 Return the Federal/Provincial/Territorial Advisory Committee on Population Health's (revised) recommendations on Health Goals for Canada to the Ministers of Health meeting for ratification in 1997, aiming for the formulation of national goals, objectives and possibly year 2010 targets by year 2000.

This recommendation assumes that the review and analysis of the first set of "strategic directions for national action" (1.1-1.3 above) have yielded the indications of feasibility needed to overcome the reservations the Ministers of Health had about national goals and objectives in 1994.

With the approval of the Ministers of Health to proceed with national goals and objectives, the next steps will be to select among the options for action offered by the May 1994 report of the Federal/Provincial/Territorial Task Group on National Health Goals/Priorities. We recommend:

1.5 Develop and expand the nonpartisan political commitment to the setting of comprehensive quantified national goals and objectives through consensus building and clarification of the long-term national benefits of doing so.

We base our choice of the more ambitious option 3 over the more focused option 2 recommended by the FPT Task Group in 1994 on the experience in other countries that a less comprehensive approach in which only "high priority" objectives are singled out for concentrated attention tends to undermine the broad base of support needed for the overall effort. When the federal government chooses a minimum set of priority objectives, it necessarily turns its back on other objectives that are high priority for some significant groups, often the very under represented groups whose needs are frequently missed in a political priority-setting process. The more comprehensive the approach, the greater will be the political "buy-in" by the multiple sectors and populations whose support and involvement will be needed to implement programs and pass policies in support of the overall health objectives program.

2. Develop objectives and targets in all areas regardless of the availability of data to confirm the estimates of baseline levels for the Canadian population at large or specific populations.

One of the most contentious issues debated in other countries in their national objectives process, especially among the health science and professional communities, has been whether to develop objectives only in those areas where adequate data exist to estimate the baseline levels and to project the trend lines to some targeted endpoints a decade or so later. We recommend from experience elsewhere that best estimates be used in the absence of data because setting objectives only on those things already measured means neglecting further those things that have been inadequately measured. These will be many of the most important determinants of health.

3. Develop monitoring and surveillance systems to track progress toward the objectives, and to provide a source of trend, baseline and follow-up data for assessment of health impact.

Established objectives with targets and comprehensive monitoring capabilities or systems will provide the built-in health impact assessment tools needed to make health impact assessment a routine part of policy and program decisions.

Finally, we have the following suggestions in the areas of research, funding and implementation of health impact assessment. The suggested actions provide possible steps for advancing the development and use of health impact assessment in Canada.

1. Health Canada should provide mechanisms to enable knowledge development relevant to health impact assessment (e.g., national conferences, research funding, needs assessment/survey of stakeholders at the federal, provincial and municipal levels).
2. Health Canada should involve various jurisdictions in achieving clarity and consensus regarding the purpose(s) of health impact assessments and mechanisms for public accountability.
3. Health Canada should recognize the existence of varying priorities for health impact assessments in different jurisdictions or areas of Canada.
4. Health Canada should foster environments that make involvement in health impact assessments available and accessible to a diversity of Canadians; particularly among high-risk or marginalized populations.
5. Health Canada should support research on validation/use of health impact assessments with specific groups, the theoretical bases for health impact assessments, and the cost-effectiveness, cost-benefits and opportunity costs of health impact assessment strategies.
6. Health Canada should build on emerging technology to create a communication network with persons and groups working on similar health impact assessments in various communities and jurisdictions.

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