"Population Health - Putting Concepts into Action"

Final Report

by Dr. H. Zöllner and S.Lessof

World Health Organization - Regional Office for Europe August 1998

The Canadian government is strengthening the population health concept recognizing that it is a major component of the new Health for All Policy for the 21^st Century. This report is intended to facilitate the translation of the population health concept into action. It has been compiled following a review of evidence (see Annex 1) and consultation with a team of collaborators (see Annex 2) which included a seminar and teleconference. It is divided into six sections (A-F) which seek to answer the questions:

• What is population health?

• How does the Health for All for the 21^st Century policy (HFA) add to the population health concept?

• What are the prerequisites for implementing population health and HFA approaches?

• What strategies should inform actions?

• What actions might the relevant actors take?

• What should be done in the future?

Canada has been at the forefront of moves to shift the emphasis of thinking about health and health sector expenditure away from the narrow perspective that revolves around health care delivery. Canadian academics and policy makers have been instrumental in developing a broader understanding of what health and wellbeing mean and how government might attempt to enhance the health of the population as a whole. There is a need now to further consolidate and to translate advances in thinking into further action, informed by a shared conception of population health.

Table of Contents

• SECTION A: What is population health?

• SECTION B: How does Health For All for the 21st Century add to the population health approach?

• SECTION C: Prerequisites for implementing population health and HFA approaches

• SECTION D: Strategies for putting population health into practice

• SECTION E: Actors and actions

• SECTION F: Looking Ahead

• ANNEX 1: References

• ANNEX 2: Contributors

Section A: What is population health?

It is not easy to agree a single definition of population health. Certainly it has at its heart an understanding that health and wellbeing are far more complex than anything that can be captured by medical definitions revolving around illness and disease. It is absolutely explicit in stating that socio-economic conditions and the social and physical environment are key in determining people's health and wellbeing. It is clear that inequalities account for differences in health status so that the poorest and the least powerful experience worse health.

Decisions to adopt health-enhancing behaviour like healthy eating or taking exercise illustrate this difference. These choices are often constrained by the physical, social and cultural environment of the person exercising the choice. Wholefoods may be expensive or there may be no outlets stocking healthier food choices in poorer neighbourhoods. Gym membership may also be less accessible to poorer people or to women from particular cultural or religious groups.

Moreover population health demonstrates that it is not just a question of a difference in absolute levels of wealth or power giving rise to differences in health status. Rather (and critically) the differences or inequalities themselves impact on health and wellbeing.

Population health also makes clear that investment in the health care system alone cannot provide people with health and wellbeing. It sees the most effective response to the inequalities that impact on health as socio-economic policies which address inequity. There has been some suggestion that this justifies diverting resources from the health sector to support economic development. This report does not subscribe to such an interpretation of population health thinking. It is necessary to ensure that those people who experience sickness and disability are fully supported. Investment in economic growth may produce long-term health gains but it does not offer an opportunity for short-term savings. However, it is also clear that significant amounts of new resources will not be ploughed into the issues of health and wellbeing. Instead opportunities must be sought to modify investments in other sectors so that they achieve their key objectives but in ways which are more supportive of a healthy society.

Population health is also portrayed as being at odds with health promotion or 'the new public health'. Without wishing to gloss over their points of difference, this report sees the contributions these schools of thought have made as being complementary. The following description of the evolution of population health thinking may clarify this approach.

One of the first attempts to think about health as the outcome of combination of biological, lifestyle and environmental factors was the health field approach. It built on the ideas of Thomas McEwan and was championed by Lalonde, who was successful in making a wide audience reconsider how health was created and maintained. Policy responses included concentrated efforts to encourage behaviour change by individuals. The model though did not include the social, economic and political context in which people made lifestyle choices and so came to be seen as blaming the victim.

Health promotion, having focussed initially on individual choices, began increasingly to address the social determinants of health and call for broad, multi-disciplinary responses. The Ottawa Charter for Health Promotion was very much in keeping with this approach and extended the ways of understanding health as the upshot of many inputs. Furthermore it began to focus on the role of populations as the owners of health and to emphasise strategies for intervening in the processes through which health is determined, in the settings where health is experienced. These initiatives further refocused the debate about health and wellbeing.

Subsequent developments saw the definition of a model of population health which distinguishes between disease, health and function, and wellbeing. It recognised that social and physical environment and genetic endowment impact on disease and are themselves affected by prosperity. These elements all affect the individual and their responses both in terms of behaviours and biology. Individual responses then go on to affect disease states, health and functioning and sense of wellbeing in a dynamic process.

In common with health promotion, population health believes that the delivery of health care is only a part of what properly constitutes health. It goes on to describe the ability of the health care component to influence health and wellbeing as increasingly limited in a developed society. It makes clear that differences in wealth and status are key determinants of health and functioning and sees a diminishing return on investment in individually oriented health care once the basic package of provision is in place.

Beyond this point there is increasing divergence between health promotion and population health proponents. Health promotion is sometimes seen as being suspicious of the suggestion that the most effective way to enhance wellbeing, at least in the context of growing concerns about public expenditure, might be investment in broader issues rather than in health care. In the literature there is also some disagreement around the importance of epidemiology, genetics, how to measure cause and effect and the extent to which population health may be used to advocate the withdrawal of welfare services.

Despite this both schools advocate a broad understanding of the determinants of health and a multisectoral response to population needs. Both assume that all interventions that centre on people's health and wellbeing are underpinned by three continua that run end to end, side to side and top to bottom, where end to end implies across life cycles, side to side indicates the influences across and between population groups and top to bottom refers to the macro and micro dimensions of policy and practice. Both would reject claims by the health care sector for primacy in policy or decision making and both would highlight the need for health to be regarded as one of several factors that inform policy making. Both would acknowledge the importance of communication, consultation and the building of partnerships across departments and sectors.

The conclusions that this report reaches about the ways that population health and the new Health for All for the 21^st Century Policy can be strengthened draw on the areas of common ground and should present no difficulties for advocates of either school.

Section B: How does Health For All for the 21^st Century add to the population health approach?

The global Health For All (HFA) policy statement develops and advances those themes first set out in the 1978 Alma Ata Declaration on Primary Health Care and in subsequent discussions on policies for health, wellbeing and social development at international and United Nation's conferences. In the European Region, the European HFA policy takes into account the rapidly changing political, economic and social environment and the need for clear targets in the formulation and execution of programmes.

It also recognises explicitly that most of health is determined outside the health care sector. It seeks to inform the way that health issues can underpin and contribute to all policy debates without seeking to annex to health and health policy makers all powers and decision making. It makes health a responsibility to be shared by all sectors.

Values and HFA

Critically, it adds to the debate by making absolutely explicit that values underpin the whole discussion of health. HFA makes clear that those policies that deal with the allocation of health services and those which impact on the determinants of health are underpinned by values, where values are understood as having a clear ethical component.

The specific values and principles that inform HFA in Europe are equity, participation, solidarity, sustainability, accountability, ethics and sensitivity to gender issues. These in turn are supplemented by a set of action principles which are the precursors of programme work, namely evidence based practice, the assignment of accountability, value for money, empowerment and participation. The role of values and principles in guiding action are set out in Figure 1.

Fig. 1 Values and principles underpinning HFA that can inform population health approaches

HFA, a shift in emphasis

The updated HFA policy (which will be adopted in final form by the European Regional Committee in September 1998) builds on the experience of WHO and population health theories, often as first set out in Canada. The policy is complex and detailed and can only be described in the briefest form below.

Thus in comparison with 1984 and 1991 the HFA places greater emphasis on the population health agenda expressed as:

1. creating health, at the roots of health and disease, including social and environmental determinants as key factors;

2. improving health over the entire lifecycle, which includes addressing life events and inter-generational equity ;

3. improving health in the settings which give them context i.e. at home, work, school and play;

4. taking action across sectors and in partnerships that go beyond those boundaries typically thought of as health related to unlock resources for health;

5. measuring the success of health strategies and actions at all levels, in terms of health outcomes.

i) Creating health: the roots of health and disease including the key social and environmental determinants

Health For All is imbued with an understanding of the wider determinants of health and begins to address the way health status interfaces with differential income and social status. In addition to calling for initiatives to address poverty and exclusion, it includes the following steps i.e. to:

• analyse the contribution to health of socio-economic variables through improving and enhancing the information systems that record them;

• assess all public policy with respect to equity and gender sensitivity;

• prioritise disadvantaged groups and mobilise all sectors to protect them;

• adjust fiscal and other policies to ensure access to education and social services does not depend on income;

• identify the respective roles of the public and private sectors and encourage all sectors of society to bear responsibility for the reduction of inequity.

ii) Improving health over the entire lifecycle

HFA for the 21^st Century strongly advocates the adoption of a life course approach to developing policies and programmes for health. Health capital, when viewed as the complex of factors contributing to health (i.e. biological endowment, social and physical environment, economic conditions, support networks etc.), will accumulate and diminish over time and through chance, circumstance and choice. An exclusive focus on separate age groups will overlook the complex interaction of those factors that underpin health. Equity is also a factor across lifecycles, and differences between generations can be just as pronounced as those between social-economic groups. Increasingly the very young are relatively poor while the older population has reserves of capital and is relatively affluent.

Significant life events include entries to and exits from education and employment, moves in and out of relationships, bereavement and so on. The impact of each particular event and of critical transition periods can be catastrophic but again will be mediated by socio-economic status, age and gender, and the community resources which people can access. Life events are also part of the dynamic across a lifetime and will impact on the 'health capital' of the individual and their health status which in turn will effect their position on experiencing subsequent life events. A life course approach will ensure that health and other services intervene appropriately at times when people are in need of support i.e. when they lose a job or start a family, so ameliorating any negative consequences experienced. Notwithstanding which, early investment in health protection, promotion and maintenance should be encouraged as it pays dividends long term.

iii) Improving health in real settings

HFA for the 21^st Century also relies on a clear understanding that health and wellbeing are experienced in a wide range of complex settings. Health is not something that can be confined to a hospital or doctor's consulting room. HFA calls for greater opportunities for people to live in a healthy physical and social environment and to enjoy improved conditions in the home, at school, at work and in their communities. It also understands that settings may be psychosocial as well as physical. However, the HFA is conscious that health and the health lobby are not pre-eminent and cannot control all settings in which life is experience. Rather it sees health as having a contribution to make in partnership. Strategies for achieving these objectives include:

• introducing mechanisms for people to influence the design of their living and working environments and to contribute to local strategies for promoting health and well being;

• increasing access to social organizations and community coping organisations;

• developing an effective infrastructure for environmental health protection;

• supporting schools' efforts to promote health for staff, pupils and their families;

• promoting initiatives and legislation to encourage healthy workplaces and work practices;

• encouraging healthy cities through attention to urban planning and management;

• fostering integrated work across sectors to further healthy agendas.

These actions place people at the centre of population health as empowered actors, contributing to policy making as well as, as the recipients of health and health services.

iv) Taking action in partnership to unlock resources for health

HFA is clear that although health and wellbeing are of primary importance the health care sector cannot claim primacy in policy or decision making Like the population health and health promotion schools, it highlights the need for health to be regarded as one of several factors that inform policy making. It demands that health advocates work in partnership with representatives of other sectors and adopt genuinely collaborative work practices. HFA is also realistic about the restraints on expenditure experienced globally. The call for more health and wellbeing is not simply a call for more resources to spent in the health sector or on wellbeing initiatives. It believes instead that those resources being devoted to employment initiatives, to industry, housing, road building or transport systems could all make a contribution to levels of wellbeing. With minor changes in the way these monies were administered and with better communication and consultation there would be a real benefit for the health of the population, and resources now 'squandered' could be 'unlocked'.

v) Measuring outcomes and accountability

Assessing health status, measuring health gain and seeking to track outcomes of health strategies and actions in terms of health outcomes will always be complex. This is because of the multi-factoral determinants of health, the time that may elapse between interventions and outcomes and the difficulties around attributing causation. Nonetheless HFA requires performance targets or outcome measures for all initiatives whether they are aimed at any given stage of the lifecycle (health at the start of life, health of young people, healthy ageing) or at specific conditions (improving mental health, reducing communicable and noncommunicable disease, reducing injury). This is in order to ensure clarity about objectives, allow monitoring and, above all else, provide for accountability, since without adequate information actors cannot be held to account.

HFA also calls for the development of effective mechanisms to assess the health impact of actions by other major (non-health) sectors. This is to ensure that actors, whether or not they are perceived as being directly involved in health, accept responsibility for health protection and are held accountable for their actions. In order to do this the following must be achieved:

• agreement of instruments for health impact assessment;

• setting up of incentives and legislation to hold actors accountable;

• social and economic policies which place greater priority on health promotion and protection;

• health audits to review the progress of all sectors;

• encouraging public participation through open enquiries, hearings and information exchange;

• all health providers to take responsibility for health promotion and protection;

• education, information and research to focus on the responsibilities of individuals and the collective for health promotion and practice.

Conclusion

Health For All then sets explicit goals and targets for the achievement of its superordinate

objective, that of achieving health and wellbeing for whole populations. It sees health as a human right, but one which implies responsibilities. It makes health and wellbeing the ultimate aim of social and economic development. The health of the population is central to HFA, and HFA builds on and advances population health approaches.

It can be described through a dynamic model which places people at its centre. The model is value laden and sees people as more than passive recipients of health care. Instead they are actively involved in health and health creation across lifecycles and in different settings. It implies that people feel the direct impact of the wider determinants of health and experience the secondary health and wellbeing consequences of these factors. Thus people as individuals, collectives and communities are entitled to a voice, which will allow them to enter the 'feedback loop' and to influence more actively the context in which they experience health. This in turn will encourage them to take further responsibility for their own health (see Figure 2).

Fig 2. People and determinants of their health and wellbeing

Section C: Prerequisites for implementing population health and HFA approaches

Health For All can usefully strengthen the practice of population health policies in Canada and support attempts to integrate health promotion, disease prevention and primary health care into a single overarching framework able to address the issues of the health and wellbeing of the whole population in the settings where health happens. Implementing a population health approach based on HFA will, however entail change. If efforts to:

1. work in partnership and at a variety of levels

2. build in accountability and

3. make policy choices informed by evidence are to succeed then there will need to be

4. a reallocation of resources including of power and authority.

i) The need to work in partnership and at a variety of levels

Partnerships must be built across levels of government and between institutions, departments and sectors if resources for health are to be unlocked. Joint work with business, schools, communities and citizens should also be encouraged, as a step towards the empowerment of people and the creation of a society which regards quality of life as a core concern owned by all members of the society.

Partnerships, if they are to succeed, must be covered by clear guidelines on openness, communication, defining expectations and accountability.

ii) The need to build in accountability

Accountability is a key requirement that is central to empowering people and allowing them input into their own health. It means using performance measures to identify outputs or the achievement of process targets and assigning accountability clearly. It is a way of providing the information that people need to hold actors in all sectors to account.

Indicators should be chosen to measure the health and wellbeing of the population rather than of individuals. Given the time frames involved monitoring may need to be of process rather than outcome but ongoing research and feedback should endeavour to measure population health gains and to develop information systems able to disseminate findings. An awareness of the settings in which both health and health related interventions take place should also inform the monitoring process so that mapping of emerging issues is facilitated.

iii) The need to make policy choices informed by evidence

Undertakings need to be based on evidence both of need and of effectiveness, but robust approaches to research should be accepted where the scale of the intervention so merits.

It must be understood that different constraints will operate, when attempting to address health of the population issues across the various levels of organisation and of society. While at the macro level of the country or province, it may be easy to instigate change, evidence of success in affecting population health indicators may be more difficult to secure. However, despite clear evidential support for particular interventions at the micro or community level, implementation may be more difficult both in terms of securing funding and compliance (see Figure 3).

Fig. 3 Macro and micro; challenges for population health

	Macro	Micro
Implementation	Easier	More difficult
Providing evidence	More difficult	Easier

iv) The need to reallocate resources

Population health initiatives need to be informed by evidence, undertaken in partnership and to build in accountability. None of these can be achieved without a real shift in resources when the relevant resources are understood in the broadest sense i.e. as including assets in housing, transport, economic infrastructure and so on. These must be harnessed without alienating actors from other sectors or seeking to take them over. There will also be a need for a shift in the resources of power and of status which will be challenging for members of the medical professions and for planners, politicians and policy makers.

The reallocation of resources has powerful political implications. Furthermore, any shift in resources to address the determinants of health will only have measurable outcomes in the long term. In the short term demands for health services and equitable access to such services will continue and can be expected to exert a powerful influence on politicians. There will need to be a conscious effort to achieve a balance between short term needs and a long term strategy of shifting investment to reflect a broader population health and wellbeing agenda. The experiments on Prince Edward's Island suggest that a community when empowered may be willing to take a longer term view, which addresses the complex roots of health, but that this is not a foregone conclusion. Advocates of population will therefore have to engage with the population and politicians in resolving this issue.

The population health approach also creates new challenges for health care providers who may require support in adapting their practice. It creates a new awareness of the social, physical and economic context of the disease presenting, the circumstances of the individuals concerned, and the opportunities for promotion and prevention. Thus it changes the perspective of health care, especially primary health care and shifts power in the care giving relationship.

Likewise a shift in power is implied in the public health sphere. Although public health as a discipline retains a key role informing the public and health care professionals and acting as an interface between planners and actors, the health of the population increasingly becomes the responsibility of all people and professionals across sectors.

It follows therefore, that those making health policy and seeking to encourage healthy public policy will have to engage with varied groups in an attempt to balance competing demands and integrate differing approaches to population health. The health care system, health promotion and private prevention agencies can all contribute to, and should all be involved in, supportive partnerships. Their different approaches should be seen as part of a spectrum and the role that each can play in furthering the agenda of a healthy population recognised and valued.

Conclusion

HFA and population health approaches demand a change in the balance of power and represent an opportunity to act on aspirations around partnerships, accountability and evidence based practice. However there are also risks associated with acting on principle.

Population health initiatives must be reviewed to ensure that in seeking to formulate a coherent programme they do not overly simplify the complexity of health and wellbeing dynamics or tend towards a too narrow interpretation of reality. There is a danger that lifecycle interventions will focus too closely on the individual, while work on the socio-economic roots of health and disease may tend towards top-down social engineering. Likewise, the use of "settings" to frame interventions can be limited to idealised conceptions of homes, communities and workplaces, excluding depressed and less "neat" arenas in which many people live or work.

This is not to suggest that interventions aimed at enhancing the health of the population will not need to take a focussed pathway. Attempts to be all encompassing can be paralysing. However, it is important that population health initiatives should be conscious of the multiplicity of relevant dimensions even when they chose to focus on a single strand.

Section D: Strategies for putting population health into practice

There is clearly enormous scope for collaboration between a range of actors and stakeholders to enhance social and economic wellbeing. Such efforts might usefully be informed by a strategic focus on key issues and in particular the following areas:

1. leadership for population health, securing a champion

2. building partnerships across the public sector

3. engaging the private sector

4. putting public health to work

5. looking for evidence and monitoring success

6. making population health attractive

7. raising the stakes towards accountability.

These themes are consistent with the Health for All Policy as it applies to population health.

i) Leadership, securing a champion

The implementation of any major change programme requires successful dissemination and popular support, but as importantly it will depend upon high level backing and leadership. If population health concepts are to translate into action then the population health approach will require a powerful champion. This is all the more so since the health and wellbeing of the population depends on such a complex interaction of factors and is effected by so many different agencies. The champion must be legitimate, credible and able to work across boundaries.

The federal government is perhaps the only body that can hold this position in the first instance and effectively review activity across different sectors, tiers of government and departments to take a consistent and committed stand on health and wellbeing. Its mission therefore must be to:

• take on the role of champion of a broad health and wellbeing agenda;

• assign responsibility for furthering this agenda to a named agency, ministry or official of federal government;

• give a clear and consistent voice to the agenda, building support for it and mobilising resources to further its ends;

• review its own practices to ensure they are consistent with the population's health and wellbeing so that it can lead by example.

ii) Building partnerships across the public sector

The population's health and wellbeing cannot be secured by the efforts of health ministries nor of federal government alone. Rather it will need to draw on the efforts and resources within other areas of the public sector through a series of partnerships that respect the autonomy of different departments and tiers of government yet seek to involve them in the health and wellbeing agenda. There must be a strategy that covers:

• working with partners at the level of provincial and local government;

• working with government departments that don't yet see themselves as contributing to health but have a major impact on wellbeing, including the ministries of finance, employment, education and transport;

• unlocking resources that are earmarked for other areas yet which might so easily contribute to social and economic wellbeing at the same time as meeting their primary purpose;

and that:

• avoids making the debate so narrow and so 'health' focussed that it is easily dismissed as the exclusive concern of health care professionals and health care services;

• avoids appearing overly 'imperialistic' and like an attempt by the medical world to annex all other public services.

iii) Engaging the private sector

In a pluralistic economy the government, the private sector and non-governmental or not-for-profit organisations all contribute to socio-economic development. In Canada the private sector contributes enormously to the environment in which people live and in which wellbeing is created and diminished. Private companies create employment, goods and services and generate tax revenues. They provide a livelihood for many and influence the patterns of consumption of all. Some enterprises market products that are hazardous or pollute their surroundings while others have unhealthy or stressful working practices. If population health is to be integrated into the wider world the agents championing the approach must;

• engage with the private sector in ways that acknowledge the objectives of business and the constraints it faces;

• highlight the business case for population health approaches identifying the contribution that they make to profitability and their potential as a marketing tool;

• challenge the approach whereby employers merely fix what is broken rather than looking upstream at ways of avoiding problems in the first place;

• encourage the emergence of a group of business leaders who will lead the way in championing population health as part of the business agenda;

• support the private sector in building health and wellbeing issues into all their strategies for the future.

Just as private companies are key, so the voluntary sector too must be engaged in this enterprise as an employer, a provider of services, and a public advocate.

iv) Putting public health to work

Population health approaches cannot work without being focussed on the people themselves. Initiatives to enhance wellbeing must be tailored to meet the needs and preferences of the population concerned. This means identifying the people involved and the settings in which they experience wellbeing or the lack of wellbeing. There can be no genuine constituency for change without meaningful consultation; and without popular consent there can be no legitimacy in attempts to influence the actions of either public or private sector agencies. In guiding the implementation of a broader based conception of health it will be essential to:

• acknowledge that people experience health and wellbeing in a variety of settings that include the workplace, the home and schools and that these settings are complex;

• be aware of the changing experience of people over a life cycle and in particular the crucial role played by key life events (e.g. entering employment, marriage, bereavement, redundancy);

• recognise the importance of individual experience even while formulating public policy and develop responses at a population level to the needs of individuals;

• seek to empower people and make them increasingly important in determining the agenda for population health and wellbeing.

v) Looking for evidence and monitoring success

It is essential to the development of any programme that there be a yardstick against which to measure progress and set targets for the future. Similarly it is key to selecting a line of action that it be based on evidence of effectiveness. There should therefore be a strategy in place which provides for the collection of information on project work, health status and wellbeing, and policy and practice. The strategy should provide for the monitoring and updating of that information and for:

• the creation of a comprehensive index of health and wellbeing

• research to identify levels of and gaps in health and wellbeing

• a clear statement of the starting point and desired end point of any intervention

• the establishment of health and performance indicators that allow progress to be measured

• the dissemination of results indicating progress or lack of progress to ensure accountability is possible.

There is also a need to support research that covers the whole spectrum of issues that affect health and wellbeing. Research should range from the biochemical markers that might be early indicators of disease through to macro economic modelling that could illuminate the workings of policy on populations.

vi) Making population health attractive

As people and organisations have often proved reluctant to take responsibility for health matters, it is essential that the move to strengthen population health approaches captures the popular imagination. Just as the environment and all matters 'green' have bedded themselves down in the way people think so health and wellbeing should become part of a new mindset which will redefine public expectations. The championing of health and wellbeing must include an awareness of media and social marketing and:

• attempt to capture the essence of what has made the green/environmental lobby so successful - the ability to insert health and wellbeing into the public's consciousness and make it a matter of fashion and style as well as of legitimate concern;

• ensure that the private sector see health and wellbeing as positive features which are valued by their clients;

• make health and well being sufficiently attractive to people that successive generations will value them and reinterpret them so that they are always relevant and self-sustaining concepts.

vii) Raising the stakes towards accountability.

Accountability is a fundamental value that underpins health for all and population health thinking. It is central to empowering people, monitoring progress and fixing concerns about wellbeing in the public's consciousness. Population health approaches that are genuinely accountable have a far greater chance of becoming sustainable and successful. Impact assessments for environmental projects and National Environmental Health Plans (NEHAPs) have shown the way that accountability can be used as a practical tool. Health and wellbeing impact statements could extend these models into all areas. Strategies must:

• distinguish between the level of accountability appropriate to undertakings: where health is a clear objective (i.e. health services, health related products), where products are marketed despite known hazards to health, and where health consequences (whether positive or negative) are by-products;

• work over time to extend accountability across the full range of actors and actions and until it is seen as the norm;

• assign accountability to named parties and provide them with the necessary authority, skills and training to exercise that authority;

• ensure sufficient information is recorded and disseminated to allow effective monitoring and feedback.

Over time responsibility can be moved out to communities and the population itself can be encouraged to ask for accountability and to expect policies and practices which support population health and wellbeing.

Section E: Actors and actions

The previous section sets out a series of strategies that might underpin the implementation of population health focussed policies. These strategies need to inform concrete actions. What follows includes a range of ideas and interventions that might usefully be considered if they are not already in place. They are meant to provide a starting point for discussion and are not intended to be in any way definitive. The scope, feasibility and detailing of tasks will need considerable analysis and development in consultation with partners at the various levels of government, in different government departments and from the private and voluntary sectors.

The points raised are set out under three headings which crudely describe the actors and stakeholders in society, for example:

• people in their communities

• the private sector and

• government.

Clearly none of these groups can be taken in isolation but it may be helpful to think about ways of addressing their needs separately. Given that health and wellbeing are a common good it is most appropriate that government continue to act as a focal point for addressing their needs. It would be helpful, however, if government would work in consultation with the private and voluntary sectors, perhaps establishing a working party for each group listed above with members from a variety of backgrounds who could further activity in each area and coordinate between areas.

These working parties could seek ways of improving the health of the population through influencing the multitude of factors that affect health. They should not assume that large amounts of extra resources will be available nor should they see the population health approach as an opportunity or excuse to cut government expenditure on health and welfare.

1. People and Communities

Federal, provincial and local government and its partners can exert a positive impact on people and their communities not just through the provision of health services or indeed by supporting economic policies that generate wealth and employment but by addressing the power differentials in society and by:

1. actively promoting equity and working to minimise inequality in access to housing, education, employment and wealth;

2. acknowledging people's rights to make active choices about health and foster structures and information networks that might encourage them to make positive choices;

3. developing policies that are supportive of families, neighbourhoods and communities which contribute so much to people's experience of health and wellbeing.

i) Actively promoting equity

Macroeconomic policies have a powerful influence on the socio-economic context in which people live. Shifts in policy should consider the implications for equality between groups and report on them. Likewise all decisions taken at provincial or local level with regard to housing, education or employment should make explicit their implications for differentials in wealth and access to resources.

Box 1: Equitable policies and healthy policies

A number of Ministries of Health and Presidents of Parliament have invited the European Office of WHO to undertake an in-depth audit of their national approaches to planning, policy and investment. The audit covers all relevant aspects of policy and both governmental and non-governmental programmes and sets out their implications for health and wellbeing as well as identifying new opportunities to promote the health of the citizens. The audit also allows mutual learning across conventional boundaries and encourages consensus building around healthy priorities.

ii) Acknowledging and informing people's rights to make choices

If people are to be at the centre of population health then they must be respected and given the right to make choices. If they are to make healthy choices then the value of those choices must be clear to them which means providing information and access to information networks as well as helping them develop the skills they need to utilise the information given. It also means allowing for the fact that different individuals have different notions of health.

Box 2: Making informed choices

People cannot monitor the impact of policies or interventions without clear information on the 'base level' of health and wellbeing and without regular and accurate updates on progress. They need:

• clear information on the population's health and its socio-economic determinants, publicised in an easily accessible format;

• easy to understand reports of the levels and cost of diseases linked to environmental hazards, smoking and other collective risks;

• reporting requirements to be built into work undertaken by government or its partners so that the impact of their actions on health can be audited;

• population representatives or citizen's panels to have an input into the formulation of policy on health and the wider areas of policy which clearly impact on health (fiscal, employment, housing, welfare and others).

iii) Supporting families, neighbourhoods and communities

In order to create the kind of society that minimises inequalities and maximises health and wellbeing it will be necessary to acknowledge the importance of families, neighbourhoods and communities. This implies:

1. taking account of the complexity of settings where people experience health and wellbeing;

2. acting to ease the burden faced by individuals at particular points in their lifecycle;

3. backing initiatives that are supportive of community networks;

4. encouraging and enabling proactive citizens (alone, collectively and in conjunction with the voluntary sector) to demand health and wellbeing.

a) Settings

The settings in which people experience health are made up of a complex interaction of the physical environment, the actors involved, the dynamics and so on through all of which the impact on health and wellbeing is mediated. Acknowledging the above will not be sufficient. As a rule of thumb, all health or wellbeing initiatives aimed at individuals and their communities should state explicitly the setting in which they will be launched and the implications of that setting for the programmes objectives.

Box 3: Healthy Cities and Health Promoting Schools

These WHO initiated schemes seek to focus on factors which impact on health and wellbeing seen in the wider context. Schools and cities are clearly highly complex yet they can present opportunities to address health and wellbeing issues in the settings in which they take place and in an environment which is authentic.

Canada already has examples of best practice up and running and could extend the model to promote real partnerships that would support community life in ways that were experienced as positive by the individual and enhanced the health of people, including the vulnerable.

b) Life cycles

The life cycle (or life span) denotes the experience of the individual from birth to death. Clearly the position of any individual will change over time and their experience of health and wellbeing will fluctuate. Particular episodes in a person's life (e.g. entering employment, marriage, job loss or bereavement) can all have a crucial impact on health and socioeconomic wellbeing.

While population health will continue to emphasize the general rather than the particular and ought not to focus on the individual, there are means of systematically acknowledging individual experience in public policy which will be beneficial to populations as a whole. Strategically a multidisciplinary, multi-agency approach will be the most effective.

Box 4: Intervening in times of life crisis

Schemes that target children, older people or the vulnerable can provide the social support which contribute to health and wellbeing.

• Telephone help lines can counsel the bereaved preventing isolation and its consequences.

• Volunteering projects that provide opportunities for those recently retired or made redundant can contribute to the wellbeing of the volunteer and of those helped through the project's activities.

• Programmes supporting new mothers benefit women, whose lives have undergone profound upheaval, as well as the newborn child.

c) Networks

Isolation is a risk factor and it has been clearly demonstrated that linkage into effective networks can mitigate the effects of risk factors on health. Networking for individuals and for disadvantaged communities is, therefore, a desirable goal that should be fostered in a systematic way (without institutionalising the networks to a point where they are no longer owned by people). Initiatives should be conscious of the fact that peoples' identities are complex, and that they play cross-cutting roles and will belong to a number of different groups and act in a number of different settings and have different expectations in terms of health and wellbeing.

Networking also implies the establishment of links at the community level and an extension of bilateral alliances and partnerships between sectors with a focus that goes well beyond a single dimension of health but seeks to capture the totality of the experience of wellbeing.

Box 5: Building on existing networks

• Single issue groups like lunch clubs for the elderly, parent and toddler centres can be encouraged through small scale grants and/or in partnership with the voluntary sector.

• Groups that focus on more conventional health issues i.e. patients undergoing dialysis or families of patients with mental health problems, may be funded through medical budgets and will offer far wider benefits.

• Groups may also seek to bring diverse people together by mobilising a local population or addressing a general interest (i.e a resident's group or sports club) thus extending networks across boundaries.

Efforts should be made to coordinate the support offered so it acknowledges the interaction of life events, group membership, age and other factors particularly as these affect women, members of First Nations and Inuit communities, young men and people retiring. There may also be scope for schemes that pair people up to allow one-to-one rather than group support.

Box 6: "Mentoring" and "buddying" schemes

The isolation and stress of the individual can be addressed through encouraging their involvement in networks or by allowing for a person with more experience or resources to support someone who finds themselves at a relative disadvantage. Those who have been through (and survived):

• particular disadvantage or exclusion from society

• retirement or redundancy

• serious illness, caring for someone with serious illness or bereavement or

• drinking or substance misuse

may be able to help others going through similar difficulties.

d) Proactive citizens

If progress is to be made and sustained, people must be encouraged to take increasing responsibility for the way public priorities are set and for decisions about health and wellbeing in society. This means action groups, academia and government working to present their messages in an attractive and comprehensible way that makes people value health and wellbeing.

Box 7: Making health and wellbeing attractive

Campaigns must be tailored to reflect the interests of the target group and the settings in which they may be reached so that:

• credible figures address the risks young men face;

• the issues that interfere with women's ability to respond to health messages are tackled head on; and

• information on ageing encourages commitment rather than anxiety.

It also means working with people to provide them with the skills and information to demand an environment (and public policies) which support the quality of life they would like to enjoy.

Progress can be made in the short term by taking steps to encourage people to use health services well. In the longer term it is to be hoped that the information to monitor the behaviour of government departments and private sector firms will be widely available and widely used, so that people and communities can mobilise their civic and economic power to ensure all services, conditions and products promote wellbeing and the public's health.

Box 8: The skills to demand healthy products and services

People need skills and confidence to take an active role in monitoring actors and actions that impact on health, particularly if they are going to demand real accountability. Capacity building steps might include:

• Skills training for community groups and individuals to help them formulate the right questions about health and wellbeing and monitor data from health audits.

• Workshops on communication and advocacy skills.

• Providing health and community facilitators when needed to demand accountability on behalf of excluded groups and transfer skills to them.

• Training of existing public networks and consumer groups to give them the skills to review the health implications and dimension of all products, policies and practices.

The voluntary sector also makes a significant contribution to the health and wellbeing of the population as an advocate and in seeking to support the most vulnerable. The public sector should acknowledge the difficulties inherent in large bureaucracies communicating with the individual or individual communities and should seek to work with and through the voluntary sector to enact the ideas set out above.

2. Private Sector

The private sector has a significant role to play in advancing socio-economic wellbeing. At the outset businesses may need some encouragement to become involved but government should build alliances and persuade them that creating healthy consumers and a healthy workforce serves their own interests. Although on occasion government may need to legislate, it will always be preferable to work in partnership and encourage voluntary compliance. Over time business may be convinced that being able to demonstrate a good track record on health and wellbeing issues is a marketable selling point and good for productivity and competitiveness. In striving to create such a climate government and business should seek to develop tools to:

1. enhance the profile of 'healthy producers' and 'healthy employers'

2. minimise harmful employment and production practices

3. encourage business leadership to take on responsibility for future initiatives.

i) Healthy producers and healthy employers

A healthy producers/employers scheme would offer firms an opportunity to have themselves 'certified' as making healthy products, having healthy employment conditions and/or contributing to the health of the community. The scheme would apply to all employers (public, private or voluntary sector) and offer a 'seal of approval' like those granted by vegetarian or environmental societies. This would allow firms to demonstrate their levels of achievement (in health and wellbeing terms) and advertise on that basis. Factors that might be reviewed are shown in Box 9. A levy of manufacturers could cover the costs of such a project and it might be owned by industry, a consumer's association, the voluntary sector or government.

Box 9: Healthy producer/employer recognition scheme

To include a review of whether:

• production processes are non-polluting;

• the product is as harmless as possible in terms of emissions, components etc.;

• there are safe means of disposal for the spent product;

• firms support research into improving the above.

To monitor whether all or any of the following are in place:

• checks on the safety of the work environment and the promotion of safe practices (including no smoking and/or healthy eating policies and stress reduction);

• screening and/or prevention programmes.

• Counselling services or support for staff facing challenging life events and/or policies that support parents and families;

• Induction and mentoring for new staff and clear exit strategies for leavers;

• Outreach work with the community or with the local unemployed;

• a programme to reengineer work processes to maximise the benefits for health and wellbeing as far upstream as possible.

A scheme like this would create clear incentives for the private and not-for-profit sectors to address health issues as an integral part of management practice. Membership could be expanded from a voluntary basis and target companies whose commodities are marketed for health benefits, then firms using healthy imagery as a marketing tool and then encourage widespread participation as public expectations change. Large firms should be encouraged to work with their sub-contractors and suppliers to promote healthy practices downstream and to facilitate the participation of small firms and employers.

It will also be important to give full credit to employers who invest in the health of their workers and to protect them form freeloading perhaps through a monitoring or passport scheme (Box 10).

Box 10: Monitoring employers' contributions to wellbeing

• Agree a 'passport scheme' which logs the benefits provided for staff, assigns a monetary value to the investment made and encourages staff moving through the labour market to carry their log book with them.

• Carry out periodic audits of employers with publication of results so that they can see whether their investment in staff who leave is offset by the value attached to the staff they hire and to expose freeloaders.

• Provide grant support to cover investment in people new to employment where the employer is already, demonstrably a net contributor.

ii) Minimising harmful employment and production practices

Where companies are not inclined to participate in voluntary schemes, it may be necessary to consider legislation to force compliance with healthier standards. While environmental protection is already enshrined in law further schemes might be considered (Boxes 11 and 12).

Box 11: Regulating polluters

Federal government could examine international experience of pollution limitation and taxes i.e. initiatives in the Ruhr and San Francisco piloting property rights to pollution and risk sharing. These could include (taking the example of environmental pollution):

• Establishing total limits on emissions with new entrants having to show that for every unit of pollutant or noise they add to the environment they will remove an equivalent amount of the same from the total burden (property rights in pollution);

• Extracting payment of a proportion of the clean up bill in respect of pollutants in proportion to pollutants emitted by any given plant or industry (risk community);

• Or in terms of population health, demanding a payment of a proportion of the costs of conditions linked to emissions i.e. cancers or asthma (polluter pays externalities).

Government could publicise polluters and clean firms which will influence companies' behaviour and raise the expectations of the general workforce and the public so creating pressure for good practice. This might also be adapted for harmful work practices.

Box 12: Publicising polluters, harmful practices and clean companies

Those companies with poor standards will be least inclined to comply with voluntary schemes making information available. Legislation might be an appropriate long-term step to expose polluters and ensure clean or healthy companies receive credit. Publicly listed companies might be required to report to their annual general meeting and publish in their annual report a statement on the population health implications of their activities, including:

• an environment statement about pollution or emissions;

• a healthy products statement of the health implications of what they make;

• a healthy staff statement listing the impact of their employment practices on the physical, social and economic wellbeing of their staff.

iii) Building business leadership

The business community would, ideally, get actively involved in pursuing a health and wellbeing agenda. Certainly it would be desirable for the business community to take on responsibility for future initiatives and to get involved in innovation. Senior figures from the private sector could be galvanised so that they champion both a population health perspective and a business input into those economic and employment policies which contribute to health and wellbeing. Extending the private sector's responsibilities in this area does not mean privatising it though. It will remain an integral part of government's role to look to the health of the population and monitor and regulate the factors that impact on health and wellbeing. Rather government should support and facilitate the emergence of business leaders willing to contribute.

Box 13: Business as a champion of population health

Business in the Community is a UK initiative which was founded by a senior business figure. It has worked to encourage corporate social responsibility through a number of schemes including the fostering of public, private and voluntary sector partnerships. It has encouraged senior business people and leading companies to contribute expertise as well as money to urban regeneration programmes, the development of small and medium sized enterprises, and schemes that support women in the workplace.

It has also worked with the Princes Trust and a series of business partnerships to develop initiatives that promote healthy working practices, progressive models of employment and links with local communities all of which are redefining the role of the private sector in contributing to a healthy society.

It has proved effective in capturing the imagination of the private sector and harnessing its energies to wider public goods.

3. Government

Government at all levels is in a unique position to address health and wellbeing issues. It is charged with protecting the public good and so has the legitimacy to act. It also possesses legislative and regulatory powers and has comprehensive reach across the country and the various sectors of the economy. It has a clear role (or rather number of roles) to play in promoting quality of life, health and wellbeing. These include :

1. working to create links within the public sector between tiers of public administration and different government departments

2. acting to unlock resources that will minimise inequity

3. collecting and disseminating information and using it to plan for the future

4. working with other sectors to develop co-operative partnerships

5. running campaigns and programme work

6. legislating and regulating and

7. acting responsibly as a major employer and as a significant economic player.

i) Partnerships within and across government

Government potential can only be fully realised if all tiers of government are committed to action and if they are able to co-ordinate their activities. Central, provincial and local government need to establish a modus operandi which will allow them to respect each others' spheres of authority and champion change appropriate to their jurisdiction.

Box 14: Partnerships across levels of governments

Local and central government in Italy have established pilot partnerships to further health and wellbeing. Work is done in accordance with principles that stress the need to:

• identify named partners within each level of government;

• respect the autonomy of local decision makers;

• secure the involvement of all parties through discussion of shared concerns and encouragement and not by edict;

• ensure the information and knowledge held at local level genuinely informs the approach of the all initiatives.

There is also a tendency on the part of organisations and governments to atomise the world and deal with it in distinct sections that correspond to the configuration of functional departments. Wellbeing cannot be assigned to a single Ministry to deliver, rather it must be a shared responsibility where the inputs of a range of actors and stakeholders are recognised, valued and co-ordinated. However, this is not simply a matter of ensuring that 'health' is part of everyone's agenda, particularly since this runs the risk of appearing to be a bid by health professionals for primacy over all other issues. Rather there needs to be more alliance building with government seeking to encourage the acknowledgement of shared responsibility for wellbeing across departments. This also represents an opportunity to unlock resources held elsewhere within government which could effectively contribute to health understood in its broadest sense.

Box 15: Partnerships between government departments

Strategies that will facilitate the building of alliances across tiers of government and between departments might include:

• making agreements at a ministerial level between health and housing, education, employment, industry and so on clearly acknowledging the contribution that each partner makes towards socio-economic wellbeing;

• setting explicit guidelines to govern joint working which chart standards of communication, ethics and so on;

• encouraging all government departments to build into their planning cycle an annual statement on the health and wellbeing implications of their existing work, their development proposals and their employment practices

ii) Addressing inequalities and unlocking resources

Population health research has demonstrated that it is not just the absolute conditions in which people live that affect their health but the relative differences in their life experience. All tiers and departments of government must, therefore, attempt to remedy inequity whether it is at a national, provincial or community level. As importantly government must recognise that it is not just inequalities in wealth that affect people's health but also differentials in security, authority and power. Public policies which seek to minimise these differences and put people in control of their own circumstance will do much to enhance population health and wellbeing.

While it may not be possible to divert extra monies into the area, a commitment to equality and empowerment of people by the whole of government could lead to the unlocking of resources for health. Public expenditure in areas like housing, education and transport could so easily be rethought to provide people with a sense of security or self-esteem at the same time as meeting their primary purpose at little or no extra cost.

Box 16: Unlocking resources that contribute to equality

• Public housing that has been designed in consultation with the people who will live in it gives them a sense of self-determination and thus wellbeing. Architects in Berlin have worked with communities to design living space which is well lit, protects from noise pollution and has shared spaces that meet the needs of women. Money that would have been spent anyway has been tailored to people's needs, so benefiting their health at little extra cost.

• Grants to new industries to encourage them to locate in areas of particular deprivation are routinely made through the European Union. These are properly understood as part of the budget that addresses inequities and harmonising these awards with consideration for the pollutants emitted, the working conditions created and the work practices of the companies concerned would ensure the maximum benefit for the same expenditure.

iii) Collecting and disseminating information and using it to plan for the future

Information on health status, wellbeing, existing policy and practice and the monitoring of that information will be key to attempts to engage with various levels of government, departments and sectors to achieve change. Government should lead the way in the routine collection of information and in disseminating it widely before requiring other bodies to follow suit.

Routine monitoring of information would also allow for a tangible measurement of the base line position before any intervention and for the mapping of improvements, which will be a powerful tool in persuading actors from different sectors to commit themselves to particular programmes.

It will also allow planners and policy makers to understand the existing context and identify likely trends so that their decisions about the future are informed by a sense of the relevant judgements, values, interactions and feelings.

Box 17: Auditing activity

• All government policies (federal, regional and local) should contain an explicit statement on the implications of that policy for the socio-economic wellbeing of the individual, the community and the population as a whole.

• There should be an annual review of the allocation of all government resources in terms of their impact on health and wellbeing.

• The periodic updating of the position of Health for All Policies is used to review progress and record the extent to which implementation has taken place. This can help inform comparisons with the Canadian position.

iv) Co-operation with other sectors

The need to work with both the private and voluntary sectors is detailed earlier in this report but it is clearly the role of government to pursue these links in the interests of health and wellbeing.

Box 18: Partnerships across sectors

Further steps that government might take include:

• Introducing tax reforms to benefit healthy employers.

• Auditing worker compensation systems to encourage preventive measures.

• Working with manufacturers, service industries and other bodies to develop best practice statements on health and wellbeing.

• Developing a National Environmental Health Action Plan (NEHAP) which would draw together the public health and environmental sectors, industry, energy, transport, agriculture and tourism to address sustainable and healthy development.

v) Campaigns and Programmes

Government should be formulating campaigns and programmes that promote wellbeing and seeking the voluntary support and compliance of organisations and individuals for those initiatives. It will be crucial that all such campaigns are marketed effectively and in ways that are attractive to the target audience whether that is a group of employers or the general public.

Box 19: Making campaigns attractive

All population health messages need to capture the attention of people. This means learning from the successes of the environmental lobby and working in collaboration with relevant professionals with marketing skills.

• Policies should be labelled in ways that are appealing rather than off-putting.

• Policy makers should work with educators and health care providers to incorporate their insights into campaigns and materials produced.

• Campaigns should be supported by credible figures that are relevant to the target group.

• Programmes must be designed with clear reference to the setting in which they will take place.

vi) Legislation and regulation

Legislation and regulation should not be the main routes for implementing population health and Health For All approaches. Where there are clear hazards, existing legal measures should be enforced but where government wants to see a greater sensitivity to health and wellbeing issues then advocacy, persuasion and popular pressure are likely to prove more effective in winning support. Government (at the appropriate level) should retain the option to use legislation as a fall back position, perhaps making health auditing a long-term legal requirement, but it should not be the first port of call.

vii) Government as an employer and an economic force

The government sector in Canada is a major employer with a significant proportion of the Canadian people working for the various tiers of government. Indeed a significant number are employed in the provision of public sector health services. It is incumbent upon government to create conditions which will enhance the health and wellbeing of their own employees not least because they are likely to advocate that the private sector implements healthy employment practices. The scope for innovation is enormous.

Box 20: Government as employer

Government could do much to pilot healthy employment practices including:

• working with staff to modify their working environment to minimise stress;

• reengineering jobs so that they are sensitive to the needs of individuals for a degree of control over their own work and for some degree of autonomous decision making;

• creating supportive policies which acknowledge the whole person and the context of their lives and allow for the possibility of job-sharing, paternity leave, family-friendly hours and holidays and so on.

Government is also a significant economic player in terms of the contracts it awards and the purchases it makes. There is again scope for an adjustment in thinking which will create benefits for health and wellbeing without inflating public expenditures.

Box 21: Government as economic force

Government could insist that:

• all government contracts include a clear statement on health and wellbeing implications;

• all contractors demonstrate that they are implementing healthy employment practices;

• all contractors take on responsibility for monitoring the activities of their subcontractors with regard to their impact on population health and wellbeing.

Section F: Looking ahead

The benefits of enhancing population health are most apparent in the long term. It is necessary to invest now for future improvements. It will be key therefore, to:

• ensure that population health is always updated and informed by best practice; and

• demonstrate, using scientific evidence, that the basic approach is sound.

To this end it will be desirable to take the following steps:

1. Build international networks at the government and institutional level to promote the exchange of best practice across the countries of the WHO/EURO Region and those of the UN Economic Commission for Europe.

2. Build international networks at the community level to facilitate the exchange of information and best practice, in particular between groups representing excluded sections of society.

3. Pursue additional evidence for fostering equity between socio-economic and age groups and across gender through policy measures.

4. Commission conventional and implementation/action and dissemination research to provide evidence which can inform policy, including:

   • the impact of setting on message;

   • the effectiveness of initiatives sponsored where effective includes consideration of the logical coherence, face validity and conceptual worth of the initiative as well as attempts to measure its outputs;

   • the efficacy of different services offered;

   • the balance between factors in multi-variant interventions;

   • the wider application of quality-adjusted life years.

5. Take steps to develop an internationally accepted health production function or Gross Health Product (analogous to GDP), as a population level measure of the value of health capital and to allow the cost and benefits of the health dimension in all development plans to be made explicit.

Taking this agenda forward internationally will enormously strengthen the position of advocates of population health and HFA approaches. It will give a rational and credible basis to efforts to empower people and involve them in promotion and preventive measures.

Annex 1: References

Evans, R.G., Barer, M.L. & Marmor, T.R. (editors) Why Are Some People Healthy and Others Not? The Determinants of Health of Populations, Aldine De Gruyter, New York, 1994.

Frank, J.W., The determinants of health: a new synthesis, Current Issues in Public Health 1995, 1:233-240, 1995.

Horst Noack, R. Research for Health Promotion - A Challenge for the 21^st Century, Report for the Advisory Committee on Health Research of WHO Geneva, 1997.

Lalonde, M. A New Perspective on the Health of Canadians: A Working Document, Health & Welfare, Ottawa, Canada, 1974.

Marmot, M.G. & Elliot, P. (editors) Coronary Heart Disease, Epidemiology: from Aetiology to Epidemic. Oxford, Oxford University Press, 1992.

McEwan, T. The Role of Medicine: Dream, Mirage or Nemesis? 2^nd edition, Basil Blackwell, Oxford, 1979.

Robertson, A., Shifting discourses on health in Canada, Health Promotion International vol. 13 no. 2, 1998.

WHO. Health 21 - The Health for All Policy for the WHO European Region - 21 Targets for the 21^st Century, World Health Organization Regional Office for Europe, Copenhagen, draft of 18^th June 1998.

WHO. Consultation on Multisectoral Issues and the Draft Health Policy in Europe, January 1998.

WHO. Food and Agriculture Aspects of the Draft Health Policy for the European Region, March 1998.

WHO. Health For All in the 21^st Century, World Health Organization, Geneva, 1998.

WHO. Ottawa Charter for Health Promotion. World Health Organization & Health and Welfare, Ontario, Canada, 1986.

WHO. Social Determinants of Health, The Solid Facts, Centre for Urban Health, World Health Organization Regional Office for Europe, Copenhagen, 1998.

WHO. Town Planning & Health, World Health Organization Regional Office for Europe, Copenhagen, 1997.

Annex 2: Contributors

Internal WHO Contributors

Xavier Bonnefoy
May-Brit Hansen
Patsy Harrington
Rudiger Krech
Erio Ziglio
Herbert Zöllner (Co-ordinator)

External Contributors

Keith Barnard, Sweden
Suszy Lessof, United Kingdom (Rapporteur)
Gérard de Pouvourville, France
Greg Stoddart, Canada

For the Client

Heidi Liepold