Population Health Mobilization: A Regional Strategy - June 1999

Table of Contents

Executive Summary

I. Introduction

II. From Health Promotion to Population Health

III. The Strategy

Scope
Desired Goals
Approaches and Activities

1. Approach: Broaden Work on Determinants
2. Approach: Focus on Populations and Sub-populations
3. Approach: Collaborate Across Sectors
4. Approach: Knowledge Development
5. Documenting Experience of the Population Health Approach

Planning and Priority-Setting

Checkpoints
Entry Points
Priority-setting

IV. Opportunities

Criteria/Checklist

V. Next Steps

APPENDIX A - List of References and Resources
APPENDIX B - Population Health Activities Underway in the Regions
APPENDIX C - Mobilization Grid
APPENDIX D - Showcasing Regional Initiatives
APPENDIX E - Mobilization Strategy Work Plan

Executive Summary

This paper outlines the emerging strategy that will be used to steer the regional mobilization of the population health approach, for which the Regional Directors of the Health Promotion and Programs Branch have assumed the role of champion. It provides background information and reviews health promotion activities in the regions in relation to the population health approach. As well, it outlines key approaches and activities, entry points, provides suggestions for how to analyze health issues and set priorities, and finally, identifies opportunities and next steps.

The basic elements of the strategy were developed at a meeting of Regional Directors and regional Population Health Managers in August 1998. It draws upon all the work that has been done to articulate the nature and scope of the population health.

Five Approaches

The Mobilization Strategy proposed by the regions includes five key approaches. The first three, to broaden work on determinants, focus on populations and sub-populations and collaborate across sectors are external in focus. Approaches four and five, knowledge development and documenting the experience of the population health approach, are internally focused.

Priorities

Priorities for mobilization will be based on work at a multi-sectoral level and in particular, work which draws in non-traditional health care sectors to:

Increase the focus on the broader determinants of health such as income and social status, employment, social environment and health services;

The Blueprint to Promote a Population Health Approach in Canada has identified two building blocks or short term outcomes for mobilization: increasing skills needed to use a population health approach and increasing intersectoral and intergovernmental action. Regional priorities will directly address these outcomes. Mobilization initiatives are also intended to influence a number of the mid term outcomes identified for population health in the Blueprint. These outcomes include more integration across sectors/government, the development of healthy public policy, more supportive environments, and an increase in community action.

Next Steps

The Regional Population Health Managers' Forum has taken on the task of coordinating the further development of the Regional Mobilization Strategy. Future steps include the following:

During the initial implementation period, a portion of regional resources will be set aside for specific mobilization activities in order to protect them from the pressures that other funding programs and issues can put upon Branch resources. At the same time, work will continue to shift the delivery of all programs and resources so that they increasingly reflect the population health approach.

Introduction

This paper outlines the emerging strategy that will be used to steer the regional mobilization of the population health approach, for which the Regional Directors of the Health Promotion and Programs Branch have assumed the role of champion. It provides background information, reviews health promotion activities in the regions in relation to the population health approach, outlines key approaches, activities and entry points, provides suggestions for how to analyze health issues and set priorities, and identifies opportunities, and next steps.

The basic elements of the strategy were developed at a meeting of Regional Directors and regional Population Health Managers in August 1998. Neither they nor the steering group that subsequently worked on the strategy started from "scratch". The paper draws upon work that has been done to articulate the nature and scope of the population health approach and its implementation. A number of documents provided important analysis and recommendations and they are referred to directly in the text, as well as listed in Appendix A.

It is intended that this strategy document will assist regional staff and other Blueprint champions as the implementation of the population health approach continues over the next one to three years.

Population Health

The Health Promotion and Programs Branch adopted a population health approach to guide its work almost two years ago. Since that time, work has been done on a number of fronts to develop and implement this strategic approach. It is being used as a macro framework to analyze health issues and to make decisions about how best to invest resources to improve health status. The definition of the population health approach is evolving and may change with experience.

The population health approach is characterized by:

Taking Action on Population Health describes a set of principles to provide guidance for analyzing health issues and designing interventions. Readers are referred to this document for full descriptions, examples of actions and key questions. For reference, the guiding principles are listed below:

Altogether, these principles make up the population health approach. Acting on just one or two of them would not reflect it, but rather, it is their combined effect that fulfills the approach.

The Blueprint

As the Branch explored the implications of adopting the population health approach, a Blueprint, or plan, was developed to ensure that the necessary thinking and action takes place to implement it effectively. It is comprised of the following components: theory, policy, evidence, marketing, mobilization and institutionalization. Taking Action on Population Health and Moving Ahead on the Theory and Policy Components both offer descriptions of each of these components.

A Branch champion has taken the lead on each component of the Blueprint. Together the champions act as an informal board of directors, providing a sounding board for one another and reviewing progress on each of the components. Individually, they are responsible for developing plans and making sure that progress is made on their component. The Major Projects Directorate acts as a resource to the champions.

The Regional Directors have agreed collectively to take the lead on mobilizing population health in the regions and to participate in the champions' forum. Regional staff will participate in the work of each of the Blueprint components, providing another mechanism to link the mobilization of population health in the regions with the other components. Challenges and opportunities have been identified with respect to the relationships between the mobilization and the other components and will be raised with the champions in the course of working on the various Blueprint components.

Mobilization

The Mobilization component puts the population health approach into action. It refers to intersectoral collaboration on population health initiatives across sectors (e.g., business, labour, social and health) and levels of government (e.g., local, provincial). It is about the doing of the approach - acting on health issues in a way consistent with the guiding principles and characteristics of the population health approach. There is a relationship amongst all the components of the Blueprint, and the experience gathered through mobilization should inform and augment the work of the other components and vice-versa. Mobilization is critically important to the success of the population health approach because it puts theory into practice and will generate evidence about the usefulness of the approach. Regional mobilization will build support for the population health approach "from the ground, up".

Mobilization is about stimulating, developing and implementing population health initiatives across sectors and levels of government in a collaborative way. Expected products are mechanisms, models and tools that enable and support intersectoral planning and decision making, development of program tools and approaches that reflect a population health perspective, sharing of resources and information about best practices, etc. The Mobilization component should generate experience and information that can be fed back to the Theory component in an iterative process to refine the theoretical framework, and to the Policy component to refine policy decision making. It could also generate information to be used in Marketing.

(From Moving Ahead on "Theory" and "Policy" Components of the Population Health Blueprint: A Proposed Strategic Approach, by Diane McAmmond and Associates, June 1998)

II From Health Promotion to Population Health

Before the concept of Mobilization was articulated as part of the Blueprint, action was already underway in the Regions to implement the population health approach.

One key step to undertaking the population health approach was to understand it in comparison to health promotion, the paradigm under which HPPB's programs had been operating for many years previously. Québec and Atlantic Regions carried out analyses that identified the differences between the two frameworks by examining health promotion projects "through a population health lens". The key findings common to both Regions, and largely confirmed by informal analysis in other regions, are described below.

With respect to the determinants of health, the three determinants most frequently addressed were personal health practices and coping, social support networks and social environments. The three determinants least frequently addressed were income and social status, employment and education.

With respect to their impact on populations, many health promotion projects provided support to individuals and to community development. Some projects influenced policies or programs with a focus on local impact.

With respect to intersectoral collaboration, the partners most often involved in project collaborations were from the health, social services and community sectors.

Regional staff understood that building on the health promotion work of the past and present to mobilize the population health approach would primarily require expanding the range of determinants that are acted upon, using interventions to affect populations and collaborating with a much broader range of sectors. They also saw the need for a shared understanding within the Branch about the role and impact of community level interventions on populations and sub-populations.

There is a continuum of population health initiatives underway in the Regions of HPPB. At one end are those measures that were undertaken to support staff to work effectively on population health and which create the necessary structures to carry out the work. At the other end are collaborative initiatives involving many partners, across sectors, working on a number of determinants of health at the macro level. These are described more fully in Appendix B.

Regions are already mobilizing the population health approach. The next necessary step is to develop a strategy which will ensure that this work is effective and contributes to the overall understanding of population health.

III The Strategy

Scope

The strategy is being developed for use by HPPB Regional Offices, rather than as a tool for the whole Branch; although it may well inform a national mobilization strategy. The work being done in the Regions can provide a significant contribution to the emerging understanding of the population health approach by demonstrating how to "do" population health and by generating evidence about its effectiveness. The strategy is a work in progress. It will build upon the work already underway and provide additional coherence to regional planning and priority-setting.

The following sections cover goals, approaches and activities, checkpoints for analyzing health issues and a process for setting congruent regional priorities. The strategy will be updated and amended regularly to reflect emerging priorities, progress and learning.

Approaches and Activities

This section outlines broad approaches to mobilize population health and specific activities related to each approach. These are not exhaustive and, over time, approaches and activities will expand and/or be refined as experience provides important feedback about their relative effectiveness. On acceptance of the strategy, examples of specific regional initiatives will be added to the strategy to illustrate the activities described below.

There are five key approaches. The first three, to broaden work on determinants, focus on populations and sub-populations and collaborate across sectors are external in focus. Approaches four and five, knowledge development and documenting the experience of the population health approach, are internally focused.

1. Approach: to Broaden Work on Determinants

Activities:

a) Continue to develop new and support existing initiatives, which expressly address the multiple determinants that contribute to a particular health issue;

b) Support public and professional education about the determinants of health. This is part of the continuum of activities to develop understanding of the approach amongst staff, colleagues in other departments, our partners and the public;

c) Influence research agendas of other decision-makers at the regional level to investigate the determinants of health;

d) Focus on how Regions can have an impact on employment, income and education determinants, those that have been furthest from HPPB direct influence;

e) Examine current programs, projects and initiatives to develop a new understanding of the influences and interactions of the determinants of health underlying key health issues. Where possible, influence or support action on determinants that have not been addressed; and

f) Encourage current partners to consider the importance of the determinants of health and support them to address or influence them.

2. Approach: Focus on Populations and Sub-populations

Activities:

a) Develop experience at influencing programs, policies, services and infrastructure - these are the tools that will have an impact on the health of a population;

b) Work with communities and organizations to enable them to influence policies and programs;

c) Increase involvement in regional/provincial forums and activities that are already organized around health issues in order to influence them to focus on interventions that will have an impact on populations;

d) Develop or participate in multi-faceted initiatives, (one activity or strategy is unlikely to be powerful enough to have an effect on a population); and

e) Be a partner in national strategies. Implement regional sub-strategies to contribute to national population health initiatives.

3. Approach: Collaborate Across Sectors

Activities:

a) Include partners who have an interest in or influence on key determinants. Potential partners are other federal departments, provincial departments and agencies, local governments, community groups, the private sector, representatives of affected populations, labour, education, academic institutions, foundations, voluntary sector, media and others;

b) Use participative processes with partners to ensure joint setting of priorities and directions;

c) Develop expertise at working in partnership with different sectors by seeking out opportunities to work with them. Document and share partnership experiences. In particular, focus on partners that have an influence on determinants such as income, employment and education, areas in which HPPB may wish to develop more expertise;

d) Review current collaborative efforts for opportunities to include new sectors, such as the business sector, in partnerships. This could include review committees and consultations, as well as projects and initiatives;

e) Bring regional strengths to the partnerships, for example, success in working with the community, supporting capacity building and being the enabler;

f) Identify different levels of partnership in intersectoral collaboration, e.g., lead role, funder, catalyst; and

g) Build on opportunities to mobilize population health where regional priorities are of wider societal concern and have currency with the public and decision-makers.

4. Approach: Knowledge Development

Activities:

a) Provide opportunities for staff to develop knowledge and understanding of the determinants of health and the key concepts and principles of the population health approach, through ongoing discussion of learnings and best practices. Organize think tanks and seminars, and contribute to national knowledge development initiatives. This is part of the continuum of activities to develop understanding of the approach amongst staff, colleagues in other departments, our partners and the public;

b) Provide opportunities for staff to enhance skills: analysis, relationship building (with external partners), influencing, etc.;

c) Conduct research regionally which provides knowledge about our programming with respect to the implementation of population health;

d) Build upon national research by applying findings to regional situations and by identifying national implications of regional research; and

e) Identify intersections between work on population health and work in other fields, from the points of view of both action and theory.

5. Documenting the Experience of the Population Health Approach

Activities:

a) Develop a common evaluation framework in collaboration with other Blueprint champions;

b) Demonstrate the population health approach by example. Develop, implement and evaluate models. Contribute results to Branch population health marketing efforts;

c) Track, analyze and document activities. Ensure that experience and learnings are shared with other components of the Blueprint as appropriate; and

d) Study national and regional examples of other intersectoral federal initiatives such as Crime Prevention, Health and Environment and Rural Health.

Planning and Priority-Setting

Checkpoints

A methodology for analyzing health issues was developed by the BC regional office and then modified during the pilot project on knowledge development. Regions may want to use this analysis to ensure a consistent approach to understanding and taking action on health issues.

Entry Points

Entry points are places to start the analysis of a health issue or a set of issues. They can include demographic groups, diseases or causes of death, hazards to health, settings, behaviors or lifestyle actions and determinants of health. Entry points are just that: places to begin to consider particular health issues, contributing factors and their respective effects on the health of a population. Regions use them as starting points as they analyze health issues and to lay the groundwork for setting strategic priorities.

Priority-setting

Regional Population Health Managers were tasked with identifying how regions have and will identify priorities for mobilization. They have agreed that in general terms, priorities will be based on work at a multi-sectoral level, and in particular, work which draws in non-traditional health care sectors to:

These priorities reflect HPPB regional offices strengths and capacities developed over the past 20 years in the field of health promotion. Regional offices are well placed to:

Inputs for the determination of regional priorities will come from several sources:

Priorities for the mobilization will be established through inter-regional consultations and decision-making, based on the strengths of individual regions and on opportunities presented across the country. While priorities may vary between regions as a result of unique features, the entire range of activities and actions supported will form the basis for the analysis of the mobilization function.

The Regional Population Health Managers' Forum has taken on the task of coordinating this approach. They have identified a process to review existing and planned regional examples of mobilization, identify common outcomes, characteristics and benchmarks, and to develop a framework for documenting and analyzing population health approaches and activities. This will build upon the Approaches and Activities analysis described in this paper. Part of this analysis will be a description of the value added inputs which regional offices bring to Taking Action on Population Health and which aid in the establishment of priorities. The Forum will also develop outcomes, benchmarks, time lines and accountability references to describe and measure the effectiveness of this process for setting of priorities.

During the initial implementation period, a portion of regional resources will be set aside for specific mobilization activities to protect them from the pressures other funding programs and issues put upon Branch resources. At the same time, work will continue to shift the delivery of all programs and resources so they increasingly reflect the population health approach.

IV Opportunities

Discussions in August about population health mobilization afforded regional participants a chance to look at the opportunities ahead.

While the understanding of the determinants is growing, communicating the approach continues to be a challenge. Regions are encouraged by the efforts to define population health and look forward to incorporation of the regional work, which will help focus a clear and succinct definition of the population health approach, one that can be used to rally staff and communicate effectively with potential partners.

Criteria/Checklist

In order to move forward meaningfully to mobilize the population health approach, a key question needs to be answered for staff: "How do we know when we are doing the population health approach?" or conversely, "How do we know when we're NOT doing it?". Because of a practical need for a tool that can help to answer this question, a number of parallel efforts have been undertaken in the Branch:

• Individual Regions have developed criteria or checklists to conduct analysis, to set priorities and to ensure their activities use a population health approach;
• The marketing component of the Blueprint has developed a success stories framework;
• and Taking Action on Population Health contains guiding principles, most of which could be considered criteria. There may be other efforts underway.

The report of knowledge development sessions with staff recommends the development of an easy to use checklist and/or set of probing questions which could be used by staff across all the functions of the Branch. The Regional Directors, as mobilization champions, have tabled a recommendation with the Blueprint champions that such a tool be developed and endorsed by the Branch. Most significantly, they recommend it be used by the Branch to assess all of its work: to set priorities, develop new initiatives, review national strategies and initiatives for congruence with the population health approach and to evaluate mobilization efforts. This kind of tool is necessary for the branch to move forward collectively to mobilize population health.

V Next Steps

Appendix A: List of References and Resources

Appendix B: General Descriptions of Population Health Activities Underway in the Regions

Appendix C: Mobilization Grid

This form is designed to assist staff in regional HPPB offices to develop and describe their planned initiatives for population health mobilization. During the initial implementation period for mobilization, a portion of regional resources will be set aside for specific mobilization activities to protect them from the pressures that other funding programs and issues can put upon Branch resources. At the same time, work will continue to shift the delivery of all programs and resources so they increasingly reflect the population health approach.

In fiscal year 1999/00, it is anticipated each region will implement 2-3 initiatives that address the mobilization approaches and regional priorities described in the document "Population Health Mobilization: A Regional Strategy".

Please use this document to describe each of your planned initiatives. The completed forms will be used to develop a national synthesis of regional mobilization plans. This synthesis will help identify further opportunities for regional collaboration and analysis. In addition, it could stimulate the development and implementation of interregional projects and initiatives.

Appendix D: Showcasing Regional Initiatives

The purpose of showcasing specific regional initiatives is to demonstrate how to mobilize people, communities and institutions to use the population health approach and to demonstrate the early results of the use of this approach. Learning from these initiatives will help develop knowledge about best practices and contribute to the evidence base regarding which interventions are the most effective. It is intended that this will lead in the long term to outcomes such as healthy public policy, increased citizen engagement, and improved health status. There is a multiplicity of effort in the regions to mobilize the use of the approach, but it has been decided to chose just one initiative from each region upon which to focus attention, largely because of the anticipated additional effort required to adequately monitor, analyze, evaluate and report on these initiatives. There are, therefore, six initiatives in total. They were chosen to address the mobilization strategic priorities -

They fall into one or more of the following categories:

The six initiatives are summarized in chart form on the following pages and fuller descriptions are appended.

The regional Population Health Managers will oversee the development of a common analytical framework in order to provide a consistent approach to analysis and reporting on the initiatives. The development of this framework will be coordinated with related work going on in the Branch.

Regardless of the specific elements of the analytical framework, it is likely that regions will collectively be able to report on the learnings about the following at an appropriate time in the future:

Summary of Regional Mobilization Initiatives

Appendix E: Mobilization Strategy Work Plan:

Objective To document what regions have learned and accomplished in mobilizing a population health approach.

To use the knowledge gained through the mobilization strategy to inform the theory and practice of population health internally and externally.

Approach Regional offices of the Health Promotion and Programs Branch will highlight what they are learning and contributing to the Branch's population health approach by documenting and analysing case studies drawn from each of HPPB's six regional offices. Each region will select one key initiative that addresses the following priorities that have been identified for mobilization:

Increase the focus on the broader determinants of health such as income and social status, employment, social environment and health services;

Although the initiatives will be diverse, a common analytical framework and reporting tools will be used by each region. The framework and tools will reflect the approaches, activities and priorities that are described in the document Population Health Mobilization: A Regional Strategy.

Regions will submit reports on a yearly basis. A national synthesis document will be prepared each year. In addition, other strategies will be developed to disseminate the learnings from these initiatives.

The work plan is broken down into the following four components:

The table below summarizes the work to be done on the first three components. The dissemination and marketing plan will be developed at a later stage.

Important Notices