Promoting Health in Canada

An Overview of Recent Developments & Initiatives

• 1.0 Introduction
• 2.0 Background: The Canadian Context
• 3.0 Achievements Since 2000
  • 3.1 Knowledge Development, Exchange and Capacity Building
  • 3.2 Policies and Actions
  • 3.3 Evaluation and Accountability
• 4.0 Moving Forward

1.0 Introduction

This document outlines key developments and initiatives in Canada since the Fifth Global Conference on Health Promotion, in Mexico (June, 2000). It is intended to serve as background information for the Chile Forum on Health Promotion: Enabling and Empowering Partnerships being held in Santiago, Chile in October 2002. The document addresses developments in a some key areas such as knowledge development, exchange and capacity building; policies and actions; evaluation and accountability; and considers challenges and opportunities for the future.

2.0 Background: The Canadian Context

The landmark Lalonde report, A New Perspective on The Health of Canadians (1974), broadened the understanding of factors that contribute to good health. It introduced the concept of health promotion and led to a number of government policies focussed on lifestyle - seat belt legislation, exercise, nutrition and smoking cessation. Since that time, Canada has continued to play a leading role internationally in developing a comprehensive understanding of health promotion over the last thirty years.

The Ottawa Charter for Health Promotion was released at the International Conference on Health Promotion (1986) under the auspices of the World Health Organization (WHO), Health Canada and the Canadian Public Health Association (CPHA). About the same time, the Government of Canada released Achieving Health for All (1986). These documents expanded the emphasis in health promotion from factors that can be controlled by individuals to societal factors and conditions. This led to many innovative initiatives such as the World Health Organization's (WHO) Healthy Cities and Healthy Communities, which originated in Canada. http://www.who.dk/healthy-cities/

The population health approach was adopted in Canada through the endorsement of the Federal/Provincial Territorial Ministers of Health in 1994.
(http://www.phac-aspc.gc.ca/ph-sp/pdf/strateg-eng.pdf).
This approach focuses attention beyond the individual and recognizes that there are many determinants of health, among them: social, economic and physical environments, early childhood development, personal health practices, individual capacity and coping skills, human biology and health services. It emphases the broader determinants of health and related interventions to address root causes of health and factors for addressing health inequalities.

The support for a population health approach and the evidence required to develop and sustain this approach was further strengthened by the recommendations of the National Forum on Health. The Forum' s final report, Canada Health Action: Building on the Legacy (1997) concluded that: Canada needed to: develop an evidence-based health system with decisions made on the basis of quality evidence; establish a nationwide population health information system; and develop a comprehensive research agenda.

Some examples of policy initiatives that integrate economic, social and health policy at different levels include:

• National Child Benefit (1998): a collaborative tax policy which aims to prevent and reduce the depth of child poverty in Canada, promote labour market attachment by ensuring that families will always be better off as a result of working, and reduce overlap and duplication by harmonizing program objectives and benefits across jurisdictions. http://www.nationalchildbenefit.ca/
• National Children' s Agenda (NCA) (1999): an intersectoral and intergovernmental policy to ensure that all Canadian children have the best opportunity to develop to their fullest potential. The NCA provides a shared vision and four goals for all children: good health, safety and security, success at learning, social engagement and responsibility. http://www.socialunion.gc.ca/nca_e.html
• Social Union Framework Agreement (1999): a collaborative framework which lays out the principles and process for achieving integrated social policy development with the federal and provincial governments. http://www.socialunion.gc.ca/

These and other initiatives demonstrate that the health and well-being of Canadians has been and continues to be one of Canada' s most important public policy objectives.

3.0 Achievements Since 2000

Overall, Canadians are in good health. In 2001, 87 % of Canadians reported that they were in excellent or good health with 13% rating their health as fair or poor. This represents one of the highest levels of self-rated health among developed nations.

Despite these figures, inequalities continue to exist in the health status of different groups within the population. Those with relatively low incomes and levels of education suffer more illnesses and die earlier than those with higher incomes and levels of education. The Second Report on the Health of Canadians (1999) for example, documents that Canada' s Aboriginal people are at higher risk for poor health and early death than the Canadian population as a whole.
www.phac-aspc.gc.ca/ph-sp/phdd/report/index.html

It is recognized that an effective approach to improving health and reducing health inequalities requires a long-term plan. The Governments of Canada have invested in a variety of initiatives at the community, regional and national levels. Selected initiatives can be grouped under three key themes as identified below. These are developed throughout the paper.

• Knowledge Development, Exchange and Capacity Building. A sound knowledge base with a forward research agenda to address gaps and help deal with emerging issues. Effective exchange of knowledge to policy and practice. The development of capacity to apply new knowledge.
• Policies and Actions. Public polices and actions that focus on the broader determinants of health as well as interventions to reduce and/or delay the impact of more proximal determinants related to chronic and infectious diseases.
• Evaluation and Accountability. A strong commitment to accountability including monitoring and evaluation to assess effectiveness of interventions and establish priorities for future investments.

3.1 Knowledge Development, Exchange and Capacity Building

Given the complex array and interaction of the factors related to the health of the population, continued expansion of the evidence base and exchange of this knowledge is essential to inform policy future development and action. Canada' s recent strategic investments in population and public health research, knowledge development and capacity building include the following:

Canadian Institutes of Health Research (CIHR)
The Federal Government launched the CIHR in June 2000 to better address the health needs and priorities of Canadians. A series of virtual institutes were created to link biomedical research, clinical research, health systems and population and public health research. Several institutes, including the Institute of Population and Public Health, the Institute of Aboriginal Health, and the Institute of Childhood and Youth Health will directly address inequalities in health.

Canadian Population Health Initiative (CPHI)
CPHI was established to generate new knowledge on the determinants of health; build research capacity in population health; enhance Canada' s population health infrastructure; synthesize and analyze population health research findings from Canada and internationally to identify "what we know" and "what we don' t know"; and transfer new knowledge to decision-makers and the public. CPHI focuses on two program areas: research; and policy analysis and knowledge exchange. The three priority themes for the policy program are poverty, aboriginal people' s health and obesity.

Centres of Excellence for Children and Women' s Health
The five Centres of Excellence for Children' s Well-Being are under development. The Centres, once operational, will advance knowledge, disseminate information and influence future policy and program decisions to meet health needs of children. Each Centre will focus on a different issue; child welfare, communities, early childhood development, special needs, and youth engagement.

The major aim of the five Centres of Excellence for Women's Health is to inform the policy process and narrow the knowledge gap on gender and health determinants. A Research Bulletin was launched in 2000 to increase access to the research being generated by the five Centres for other researchers, policy and decision-makers, health care providers, academics and interested members of the public.

Canadian Consortium for Health Promotion Research
The Consortium is a collaboration of 14 university-based research centres across Canada that partners with various stakeholders including governments, NGO' s and community groups. The Consortium links research, capacity development and information dissemination to enhance health promotion research, policy and practice. Some recent activities of the Consortium include: training - summer schools in health promotion; framework development and approach to "best practices" in health promotion called the "Interactive Domain Model" (www.utoronto.ca/chp); and the publication by WHO-EURO of a book on evaluation in health promotion supported in part by Health Canada and led by a Canadian (www.who.dk).
http://iuhpeconference.org/consortium/

National Aboriginal Health Organization (NAHO)
NAHO is an aboriginal designed and controlled body dedicated to improving the physical, mental, emotional, social and spiritual health of Aboriginal Peoples in Canada. It has successfully launched three priority Advisory Committees: health policy, capacity building and public education; health research and health information; and traditional health and healing. Each committee is linked to the broader objectives of: improving health and promoting health issues; facilitating research partnerships; and fostering recruitment and retention of aboriginal people in health delivery.
http://www.naho.ca/

There have been investments in a large number of health promotion and population health initiatives in Canada to facilitate the exchange and application of new knowledge. These initiatives support the development of collective capacity-building of individuals and organizations to take action on promoting health. The following are of particular note in communicating knowledge and health information to stakeholder organizations and to Canadians.

• The Population Health Website (www.population-health.com) was launched in 2000 to increase understanding and implementation of the population health approach, health promotion and prevention. It provides access to newly developed resources and tools.

• The Population Health Template: Key Elements and Actions That Define A Population Health Approach outlines the procedures and processes required to implement a population health approach.
  www.phac-aspc.gc.ca/ph-sp/phdd/pdf/discussion_paper.pdf  

• Case Studies of The Regional Mobilization of Population Health and Creative Spice: Learning From Communities About Putting The Population Health Approach Into Action    - inform practice in the field and provide communities a better understanding of the benefits and challenges of using a population health approach.
   

• The federal government' s International Network for Mental Health Promotion is the first on-line network for people working in mental health promotion. Individuals can describe their work, connect with others, and learn what people around the world are doing to promote mental health.

3.2 Policies and Actions

Examples of recent achievements in health program and policy development in Canada reflecting health promotion and population health principles follow.

Health Promotion in Health System Reform

A number of significant reviews have been undertaken in recent years as part of ongoing efforts to reform Canada' s health system. The reviews listed below highlight the importance of health promotion and prevention as part of health system reform in Canada and point to challenges related to the balance of investment in population health, promotion and prevention initiatives; and the integration of population-based health strategies into the health care system.

• The Commission on the Future of Health Care in Canada will release its recommendations on the publicly funded health care system in late 2002, including recommendations on an appropriate balance between investments in prevention and health maintenance and those directed to care and treatment. The Commission' s interim report acknowledges the need to focus on the determinants of health; includes population health approaches when discussing innovative new approaches to the delivery of health care across Canada; and acknowledges the need to better weave disparate elements of prevention, promotion, and health care delivery into a more coherent and integrated system.

• The Standing Senate Committee on Social Affairs, Science and Technology is examining the role of the federal government in Canada' s health care system. Options recommended in its interim reports include: a population health strategy to guide delivery of services to Aboriginal peoples; an agency or body, such as a health commissioner, to screen all federal policies through a population health filter; and more attention, effort and resources to the development and implementation of population health strategies.

• Several provincial initiatives mandated to advise governments on health reform were completed in 2001, including the Alberta Premier' s Council on Health, the Saskatchewan Commission on Medicare  and the Quebec Commission of Study for Health and Social Services. While the major focus of these initiatives is the health care system, all reports acknowledge the value of upstream initiatives (health promotion, disease prevention, and the importance of population and public health) to the longer-term sustainability of the health care system.

National Strategies

Canada has an array of health promotion initiatives, at national, provincial/territorial and local levels. These initiatives range from intergovernmental accords and advisory groups, to comprehensive strategies that address health issues, population groups or settings. Comprehensive strategies often include research, education and capacity building, partnerships, intersectoral collaboration, project funding at the community level and evaluation. Increasingly, instead of addressing only one issue at a time, integrated strategies are being developed, that consider the root causes and risk factors that lead to a wide range of health problems.

To increase their effectiveness in addressing health issues and the determinants of health, these initiatives strive to be collaborative in many ways: to involve different levels of government; to include different disciplines and types of health organizations(research, community, professional); and to collaborate with non-health sectors (social services, business, recreation, transportation, education) whose policies have a strong impact on health. Some of these initiatives are highlighted below.

National Health Accord and Early Childhood Development (ECD) Agreement The Health Accord affirms a commitment by all governments to strengthen and renew Canada's publicly funded health care services. Health Promotion and Wellness is one of the eight priorities of the Accord' s Health Action Plan, and includes the development of strategies that recognize the determinants of health, enhance disease prevention and improve public health.

The Accord' s ECD Agreement affirms a commitment by all governments to invest in early childhood development (age 0 to 6). For example, to improve the well-being of Aboriginal children, the federal government has provided funding to enhance child care and Aboriginal Head Start programs. Programs to reduce the incidence of fetal alcohol syndrome and to increase support for children on reserves who have special needs at school are also being intensified. http://www.scics.gc.ca/cinfo00/800038004_e.html

Federal/Provincial/Territorial Advisory Committee on Population Health(ACPH)
The ACPH is comprised of representatives of the federal health department, provincial and territorial governments and include selected non-governmental representatives. Its mandate is to develop and provide policy advice to the F/P/T Conference of Deputy Ministers of Health on current and future population health (including public health) issues of national significance. ACPH is collaborating in areas such as: immunization; harm reduction associated with injection drug use; healthy child development; and strengthening public health infrastructure.

Recent ACPH reports include:

• Reducing the Harm Associated with Injection Drug Use in Canada (2001)
  This report provides a framework for multi-level strategies and coordinated action plans to address injection drug use and the associated harms.
  
• The Opportunity of Adolescence: The Health Sector Contribution (2002)
  The paper describes the current health status of adolescents and identifies areas where some youth have greater needs for information and support. It identifies how the health sector can build on ECD investments to promote adolescent health.

Healthy Living
In September 2002, Canada' s Health Ministers announced plans to develop a Pan Canadian Health Living Strategy. The Ministers will work together on short, medium and long-term ‘healthy living' strategies that emphasize nutrition, physical activity, and healthy weights. The aim is to promote good health and reduce the risk factors associated with diabetes, cancer and cardiovascular and respiratory diseases, and the burden they place on health care. This work will be anchored by the underlying factors and determinants of health such as, genetics, bio-physical environment, socio-economics, behaviours and the health care system. By addressing underlying factors, the strategy is also expected to contribute to a reduction in other chronic and infectious diseases. A national symposium will be held in Winter 2003 to bring together health and other sectors of government, non-government organizations, health specialists, First Nations and Inuit, business and other stakeholders to set out specific initiatives to support healthy living in the context of healthy communities.

Integrated Approaches to Chronic Disease Prevention
The Conference of Deputy Ministers of Health in June 2002 approved an integrated approach to reducing the burden of chronic diseases in Canada. This approach focuses on four elements: addressing common risk factors; addressing the relationship between lifestyle choices and social conditions; consolidating prevention efforts within life settings; and engaging partners within and across the systems that impact health. National actions to advance an integrated approach to chronic disease prevention include: developing and disseminating best practices; further research to fill knowledge gaps; and the continued development of networks to facilitate collaborations and integration of efforts in chronic disease prevention.

Chronic Disease Prevention Alliance
The federal health department is partnering with the Chronic Disease Prevention Alliance, an initiative started by national non-governmental organizations concerned with chronic disease prevention such as the Heart and Stroke Foundation, the Canadian Diabetes Association, and the Canadian Cancer Society. This group is developing a national, common, coordinated approach to the prevention of diseases that share risk factors by integrating current efforts around specific risk factors (such as nutrition and physical activity) and conditions (such as diabetes and cancer).

Voluntary Sector Initiative (VSI)
Under this accord between the Government of Canada and Canada's voluntary sector, announced in June 2000, a partnership with 200 national voluntary health organizations on health policy and program development has worked to strengthen the sector' s capacity to work together with the public and health professionals and deliver targeted health programs and services. Working Together on Policy Development: A Code of Good Practice is being developed to provide mechanisms for consultation and incorporating the issues and concerns of the diverse voluntary sector in the policy development process.
http://www.phac-aspc.gc.ca/vs-sb/index-eng.php

The Canadian Diabetes Strategy
In collaboration with partners, work continues on the four components of the Strategy: an epidemiological surveillance system, the Aboriginal Diabetes Initiative, prevention and promotion and a national coordination system. An important landmark for the prevention and promotion component was the 2001 national diabetes symposium, where 250 Canadian diabetes stakeholders achieved consensus on a national framework for action. Planned activities include raising public awareness; developing a child and youth strategy for diabetes; a progress report on diabetes in Canada and expansion of the National Diabetes Surveillance System coverage to all provinces.
http://www.diabetes.gc.ca

National Framework for First Nations and Inuit Fetal Alcohol Syndrome and Fetal Alcohol Effects Initiative (FAS/FAE)
This new initiative enhances activities in a number of areas including: public awareness and education, surveillance, early identification and diagnosis, FAS/FAE training with front line workers and communities and strategic project funding. It strengthens already existing work in this area undertaken by the Government of Canada. For example, strategies related to FAS/FAE are integrated into community-based programs such as the Canada Prenatal Nutrition Program, the Aboriginal Head Start Program, the Community Action Program for Children and the National Native Alcohol and Drug Abuse Program.
http://www.hc-sc.gc.ca/english/for_you/aboriginals.html

Canadian Strategy on HIV/AIDS
National leadership in HIV/AIDS research, surveillance, prevention, care, treatment and support continues, including:

• identification, through the efforts of 125 HIV/AIDS experts, of ten broad strategic directions to guide future work
• community-based responses through the AIDS Community Action Program (ACAP). For example, ACAP funding enabled the Prisoners AIDS Support Action Network to identify gaps in services for women living with HIV/AIDS and to identify the HIV/AIDS prevention needs of women in prison
• development of a framework which responds to the home care needs of Aboriginal people with HIV/AIDS with the Aboriginal Nurses Association of Canada http://www.anac.on.ca

The Vancouver Agreement
In March 2000, the three levels of government, with community input, signed the five-year Vancouver Agreement. This was in response to a public health crisis due to high rates of HIV/AIDS and Hepatitis C largely caused by injection drug use. The initiatives developed over five years will form a continuum of support that runs from prevention to intervention, including work towards changes in basic social and economic conditions having an impact at the level of the individual and the community. One example is the Partners in Economic and Community Help Fund (PEACH). This is an initiative that coordinates funding from the Vancouver Agreement partners for economic and community development initiatives.
http://www.city.vancouver.bc.ca/commsvcs
/planning/dtes/agreement.htm

National Strategy to Reduce Tobacco Use in Canada
In September 2002, the federal, provincial and territorial Ministers of Health released the second annual report on the National Strategy to Reduce Tobacco Use in Canada. This report concentrates on prevalence and consumption statistics and provides examples of progress made by the wide variety of initiatives carried out across the country. The first progress report, released in 2001, provided an overview of tobacco control in Canada.
http://www.hc-sc.gc.ca/hl-vs/pubs/tobac-tabac/tcbc-rmtc/index_e.html

Healthy Environments and Settings

In Canada, there are a variety of initiatives underway at all levels of government to improve the sustainability and health of our environments and settings. These efforts focus on a range of issues in a variety of settings including at schools, workplaces and in communities. Examples of recent developments are noted below.

National Workplace Health Agenda
The National Workplace Health Policy Agenda is being developed to link the impacts and benefits of healthy workers and workplaces to Canada' s productivity and competitiveness, the health care system, and sustainable development. Key activities of this policy framework include: a comprehensive research program; a Canadian Network of Workplace Health Promotion; workplace health models of best practice; public consultations with stakeholder groups; a social marketing campaign; intersectoral collaboration and capacity building.

Business Case for Active Living at Work
The Business Case for Active Living at Work is the most recent initiative undertaken by the federal government to improve the physical activity levels of Canadians (following the launch in 1998 of Canada's Physical Activity Guide to Healthy, Active Living and Canada's Physical Activity Guide for Older Adults in 1999). It was developed in partnership with the Canadian Council for Health and Active Living at Work and provides research results, best practices and a template for practitioners to use in developing a business case for active living in their own organizations. http://www.activelivingatwork.com

Health Promoting Communities: Surrey - The Active City
Surrey, British Columbia is one of the many Canadian communities and municipalities that have developed specific initiatives to promote health. The city will be recognized by WHO at the Health Promotion Forum in the Americas, October 20-24, 2002 in Chile for its exceptional work in protecting its open areas for recreation and providing diverse programs and activities to promote physical activity. In late 1998, the Mayor and Council made "Active City" one of their six major priorities and asked staff to develop a plan to reduce the number of inactive people in Surrey by 10% by the year 2005. Formally launched in 1999, there are five major components: increasing awareness; changing physical activity behaviour; supportive environments; partnerships; and employee wellness.
http://www.surrey.ca/default.htm

3.3 Evaluation and Accountability

There is now a strong focus in Canada on accountability generally, and growing interest in accountability for health outcomes. This priority is reflected in a number of ways, for example: accountability for public reporting is built into agreements between the federal and provincial governments; governments are producing regular, comprehensive public reports on the progress, impact and outcomes of health programs; and there are reports on a wide variety of health issues and populations.

Evaluating the impact of policies and initiatives and reporting on outcomes is a critical step in best practices related to reducing health inequalities and improving the health of the population.

The evidence base demonstrating the effectiveness of population health approaches is growing. However, given that health promotion involves multiple interventions - often for prolonged periods of time - and relies on action at several levels and across a number of sectors, evaluation of its effectiveness is complex. Key challenges for strengthening the evidence base include the following issues:

• the nature of evidence and methods used to generate it
• the role of various evaluation methods (effectiveness and cost-effectiveness)
• the set of health indicators available.

Examples of achievements and recent developments follow.

Community Action Program for Children (CAPC) / Canada Prenatal Nutrition Program (CPNP) Project Renewal 2000
This evaluation at national, regional and project levels indicates that both of these community based programs are making a difference. It captures the learnings, policy implications, opportunities for improvement and actions to be taken over the next three years. In addition to the full report, a summary version has been developed for communities and other stakeholders.

Health Indicators

• The National Accord on Health contains a reporting framework that all levels of government have agreed to use to report to the public. Governments will now report on progress towards health goals in each of fourteen indicator areas. These comparable indicators will address health status, health outcomes, and quality of service. This will also serve to document progress toward reducing health inequalities. To facilitate comparability, the Canadian Institute for Health Information (CIHI) will be making a website with data for all jurisdictions publicly available. http://www.cihi.ca

• The Health Indicators Project aims to support Regional Health Authorities in monitoring the health of their population and the functioning of their local health system. A core set of indicators relating to the health of the population and the health care system has been developed, including the major non-medical determinants of health in the region. Consultations continue with provincial and regional health authorities to refine and expand the initial list of indicators first confirmed at a consensus conference in 1999. http://www.cihi.ca

• The first cycle of the 2000/01 Canadian Community Health Survey has been conducted by Statistics Canada. The Survey focuses on indicators of community health to provide regular and timely cross-sectional estimates of health determinants, health status and health system utilization for 136 health regions across the country.
  http://www.statcan.ca/english
  /concepts/health/ccshinfo.htm

Effectiveness of Interventions

• In 2000, Health Canada and Veterans Affairs Canada launched a four year pilot initiative in three Canadian regions aimed at developing evidence about effective falls prevention interventions directed to community-dwelling veterans, seniors and their caregivers. This initiative funds sustainable community-based projects with the primary objective to promote independence and improved quality of life by preventing the number of , or reducing the severity of falls.
  http://www.phac-aspc.gc.ca/seniors-aines/pubs/Falls_Prevention
  /falls_fundedprojects/falls_vac_e.htm

• Federal/Provincial/Territorial Early Childhood Development Agreement: Report on Government of Canada Activities and Expenditures 2000 - 2001
  To give a clear idea of the progress being made on this agreement and to help improve and expand early childhood programs and services, governments agreed to report regularly to Canadians. In keeping with this commitment, the Government of Canada has released its baseline report which provides a comprehensive overview of each activity, the approximate numbers of children and families served and the related financial expenditures.
  http://www.phac-aspc.gc.ca/dca-dea/publications/pdf/ecd_report_e.pdf   

• Across Canada there are shared interests in developing and applying better evidence of effectiveness of interventions in population health. The federal health department' s Health Policy Research Bulletin devoted its March 2002 issue to the theme of "Health Promotion: Does it Work?". This Bulletin represented the challenges and issues associated with measuring effectiveness and provided examples of how these challenges are being addressed in current programs and policy initiatives.

4.0 Moving Forward

As we enter the new millennium there are many successes upon which Canada can build. As noted earlier, we have made strides in conceptual development over the past 25 years as we progressed from the focus on the individual to a population health approach. More recently, there has been a major focus on knowledge development, especially by strengthening the health research infrastructure and developing research on the determinants of health and their interactions. As well, we have a strong foundation of collaborative health promotion programming at national, provincial/territorial and community levels.

Canadian governments and non-government organizations are poised at the outset of the new millennium to further advance the field of health promotion and population health. Some of the key challenges and opportunities that will define this next phase are summarized as follows:

Research/Knowledge Development: Building and Applying the Evidence Base
We continue to invest in strengthening the evidence base for prevention and promotion, especially evidence on the effectiveness of interventions, with a concerted effort to exchange knowledge and build capacity for its application. A stronger evidence base on the effectiveness of health promotion interventions to improve health outcomes will help to make the case for increased investment in the promotion of health and support the selection of the best mix of interventions to address a given situation. This requires the effective transfer and use of the evidence that already exists, as well as the generation of new evidence and tools, and models for applying it.

Health System Reform: Balancing Health Care and Health
An important challenge related to the health system in Canada is finding the appropriate balance between investments in health care and investments in keeping people healthy through prevention, promotion and action on the broader determinants of health. The attention paid to prevention and promotion in the recent provincial health system reports and the interim report on the Future of Health Care in Canada provides a foundation for further efforts to capitalize on the potential of prevention and promotion in the context of a sustainable and efficient health care system. Consultations carried out for the Commission of the Future of Health Care indicate that Canadians are supportive of a focus on keeping the population healthy, in conjunction with other important reforms to the health system.

Partnerships and Networks: Expanding Linkages and Collaboration
Governments and other stakeholders are taking steps to address the challenge of how to better link and integrate the elements of Canada' s health system in order to maximize our contribution to the health and well-being of Canadians. This includes strengthening linkages among the many stakeholders and parts of the system: across the different jurisdictions involved (at national, provincial/territorial and local levels) in delivering health services and programs; and improving the integration of health care and health promotion. For example, governments are already developing and testing innovations in primary care, including multi-disciplinary models with greater emphasis on prevention and promotion.

There are good, collaborative federal/provincial/territorial government relations and strong partnerships with key stakeholders in health promotion to build on that support increased integration of effort to address common health determinants or risk factors. The recent agreement to develop long-term pan-Canadian Healthy Living strategies is a positive advance. These strategies will focus on evidence-based and integrated approaches to improve health in Canada.

Finally, given that many of the factors and determinants of health lie outside the health sector, collaboration across sectors is critical. While progress has been made in Canada in terms of intersectoral collaboration to address specific issue areas, further attention is needed to establish intersectoral collaboration as a critical ingredient of public policy at all levels and to facilitate action on the broader determinants of health.

Summing Up

Since the commitment in Mexico in 2000, Canada has made progress in health promotion and population health. Looking to the future, there is a readiness among governments and other major stakeholders to meet our key challenges and capitalize on opportunities to make further gains in promoting the health of all Canadians.