II Past Processes
III Current Process
--by Connie Clement, Executive Director, Ontario Prevention Clearinghouse
By this time next year, Canada should have new public health goals approved at the Federal level.
Last September, as part of developing a pan-Canadian health strategy, the First Ministers agreed to "set goals and targets for improving the health status through a collaborative process with experts." (1) The intention is that common goals will provide a framework to enable federal, provincial, and territorial governments to align their individual and joint public health efforts. The goals will come into their own when, at the next step, each jurisdiction establishes related targets by which to monitor action related to their respective mandates, capacities, and priorities. The Federal/Provincial/Territorial (F/P/T) process is being led by the Honourable Carolyn Bennett (Federal Minister of State for Public Health) and the Honourable Theresa Oswald (Manitoba Minister of Healthy Living).
From the last week in March into the summer, a series of invitational consultations will be held: regional roundtables; issue or theme roundtables (e.g., a youth summit, aboriginal issues, and round-tables co-hosted by the new Public Health Agency Collaborating Centres); and, at a slightly later stage, citizen roundtables. Concurrently, an electronic citizen engagement process similar to that used by the Romanow Commission is getting underway. All Canadians are invited to use the goal-setting website, workbook, survey, and dialogue spaces to share their ideas. Members of Parliament have been asked to hold local consultations. Ideally, public health units, community health centres, and other health promoting organizations will also engage directly in holding townhalls and consultations or encouraging community participation.
A national meeting will be held in the autumn to ratify the goals and provide advice to First Ministers regarding how to advance the next phase of the process, including establishing targets to monitor progress towards achievement of the goals.
II Past Processes
Today's public health goals initiative echoes earlier work undertaken in Canada during the past 20 years, with varying success. In 1994, the F/P/T Advisory Committee on Population Health (ACPH) initiated a project to develop national health goals. The Committee reviewed then-existing provincial and territorial goals for congruency and in 1996 identified 14 challenges (which read a lot like goals) in the First Report on the Health of Canadians. These challenges were aimed upstream to address determinants of health. In 1997, the challenges were followed up with strategic directions; in 2000, the Deputy Ministers updated the strategic directions and adopted a minimum set of indicators.
Most provinces and territories have also developed goals. In Ontario, in 1987 the Panel on Health Goals for Ontario, chaired by Robert Spasoff, recommended seven health goals. These were to
* achieve equity in health opportunities,
* enable Ontarians to achieve their health potential,
* increase the health expectancy of Ontarians,
* provide environments which support health,
* encourage behaviours which support health,
* provide health services which support health, and
* establish public policy which supports health.
The panel recommended related objectives and strategies and recommended actions to achieve the goals.
Similar processes have been carried out in other countries:
* England began by targeting five health conditions in the early 1990s. Today, the United Kingdom has a single overriding public health commitment to reduce health inequalities. This goal is accompanied by two national targets (one geared towards improving children's health and one geared to geographical districts with lowest life expectancy).
* Sweden's two-year old public health policy seeks to integrate public health into social policy. The overarching aim is to create "the conditions for good health on equal terms for the entire population." (2) Eleven public health goals address upstream determinants.
* The United States' Healthy People 2010 process defines two overarching goals: to increase equality and years of healthy living and to eliminate health disparities. These goals are supported by numerous objectives and associated targets. Nearly all US states have established Health People plans.
There is significant variation across countries and provincial jurisdictions in terms of goal types and consultation and approval methodology. Yet, there is high congruency in terms of the health improvements sought. In Canada, the various goals and challenges approved within the past 15 years show that government staff -- at both senior and support levels -- understand and demonstrate a commitment to determinants of health. The ACPH observed that the goals development processes themselves have been important in building understanding about determinants of health. Precisely because there has been so much agreement about health goals in Canadian jurisdictions previously, the current process is able to build on this foundation rather than starting from scratch. Accordingly, this consultative process is focused and rapid.
However, the ACPH also found that the various goals developed previously "have not been directly integrated into the planning, decision-making, and accountability mechanisms to any significant extent in most provinces." Thus, we run significant risk of creating goals that won't achieve what they are intended to do -- to serve as a basis for coordinating planning, policy, and program initiatives.
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III The Current Project
What will ensure that the 2005 public health goals accomplish what we need them to do?
1) Our 2005 public health goals must be broad and upstream.
2) The approval process must gain all-party endorsement and commitment and bind the current and future governments. Further, the goals must be supported with structures that ensure accountability on the part of all ministries and F/P/T.
3) The process of developing our new public health goals must strengthen the public health infrastructure, have high community and professional participation, and integrate education about public and population health and determinants of health.
Canada has chosen to frame the forthcoming goals as public health goals, rather than as health goals. An advantage of this is to clearly address population health, determinants of health, and well-being, rather than needing to create goals that encompass treatment, cure, and care. Focusing specifically on public health goals creates central leadership roles for the newly created Public Health Agency of Canada, the recently created Minister of State (Public Health), and one of the few provincial-level new ministers with a special population health mandate. This leadership must be complemented by a supportive and interested public, health professionals, and politicians who understand the extent to which healthy public policy is created by cross-ministerial and cross-jurisdictional cooperation.
A risk of narrowing the goals to just public health is that without adequate political will and community drive, the new goals will be marginalized -- along with the rest of public health -- to being addressed only by the 2 or 3% of the health budget that funds public health. If this happens, the goals will not be able to adequately influence the breadth of social policy -- such as income and taxation reform, housing, education, and early child development and learning -- required to ensure population health and to narrow inequities in health. In England, lead roles to address inequity in health are shared by the Prime Minister and the Minister of Finance -- the Minister of Finance is obligated to consider health impact as part of his financial assessment of all proposed policy.
To date, developed goals have had minimal staying power as governments change. Although in all jurisdictions goals were developed by government staff with significant public and expert consultation, the end products appear to have been treated as partisan and linked to government platforms rather than being accepted as a standing commitment developed with all-party support. If the initiative can carry forward long enough for provinces and territories to develop objectives and indicators, pan-Canadian public health goals may become a long-lasting health management tool.
Is this worth doing? Yes. But to succeed and have lasting impact, the process of establishing goals must be designed and carried out in ways that strengthen Canada's public health infrastructure and use citizen engagement approaches to build popular -- as well as political and professional -- understanding of and commitment to the determinants of health underlying the improved health of Canadians.
So, what's this summer's consultation about? The current Canadian consultation proposes six themes for consideration. (The consultative process stays one step back from proposing goals by removing action from the proposed areas for consideration.) The themes put forward to start the consultations are
* opportunities for healthy development and learning throughout life;
* supportive communities and healthy working environments;
* sustainable, diverse, and safe environments;
* vulnerable populations;
* supports for personal choices, skills, and capacities that enhance health; and
* an integrated, supportive health system.
Already, the discussions at the first consultations make it clear that the final goals will diverge from these starting themes. For instance, the first consultations suggested replacing vulnerable populations with a theme about equity and participants put forward concerns about gaps (e.g., mental health) and ideas to change a number of themes (e.g., separate community from work environments).
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The success of this project rides on high participation. Here are some ways you can contribute:
* Visit http://www.healthycanadians.ca to find tools and references.
* Post a link on your organization's website.
* Request fliers and distribute them widely.
* Put a brief article in a community newspaper.
* Host a community meeting.
* Put this item on the agenda of your board or advisory group and submit input.
* Encourage community partners to do the same.
* Promote the activities you undertake on the health goals website.
Do it now, and you'll know that you and yours helped to define goals that will guide the reform and growth of public health and thus help society achieve "health for all."
1 Office of the Prime Minister, News, "A 10-year plan to strengthen health care," http://pm.gc.ca/eng/news.asp?id=260. Accessed April 15, 2005.
2 Goverment of Offices of Sweden, Public Health, "Public Health Objectives," http://www.sweden.gov.se/sb/d/2942. Accessed April 15, 2005.