The National Health Forum

The National Health Forum
Building A Population Health Evidence Culture
Defining Evidence-Based Decision Making
Health Status Indicators

Among the multiple benefits gained through the National Forum on Health in 1997, a national consensus emerged to support the need for evidence-based policy development and decision making. The Forum dedicated one of its reports to describing how health professionals and administrators can use the most solid information available to make their decisions, and to ensure that these decisions reflect the values and principles of Canadians regarding health and health care.

Multiple initiatives have emerged from the Forum. The two most critical initiatives for evidence have been the Canadian Health Information Roadmap Initiative and the 1999 Budget Announcement of the Canadian Institutes for Health Research.

1. The Canadian Health Information Roadmap Initiative

The Canadian Health Information Roadmap Initiative is an important contribution to building a comprehensive national health information system and infrastructure. It will provide Canadians with the information they need to maintain and improve Canada's health system and the population's health. The initiative was developed jointly by the Canadian Institutes for Health Information (CIHI), Statistics Canada, and Health Canada.

Implementation of the Canadian Health Information Roadmap Initiative responds to the needsexpressed in the Speech from the Throne, in which the federal government committed to "work with its provincial partners and other interested parties to improve Canadian health information systems to improve decision making about health and health care across the country". The federal Health Minister's Advisory Council on Health Infostructure has reinforced the need for a comprehensive national health information system in order to provide better health information for the better health of Canadians.

The goal is to build a secure, consistent, relevant, integral, flexible, and user-friendly accessible health information system that can answer two fundamental questions:

• How healthy is the health care system?
• How healthy are Canadians?

Canadian Population Health Initiative (CPHI)

The Canadian Population Health Initiative (CPHI) is a central element of the Canadian Health Information Roadmap Initiative. The CPHI was proposed by the National Forum on Health as one instrument to improve decision making in the health domain.

The CPHI is funded through the Roadmap Initiative, as a result of the 1999 federal budget. In this budget, the Government of Canada announced a series of measures to strengthen health care in Canada, improve the health of Canadians and enhance health information and health research. The CPHI is one way in which the Canadian Health Information Roadmap Initiative addresses the Forum's recommendations for emphasis on the social determinants of health.

CPHI will create new knowledge and enhance Canadians' understanding about health and its broad determinants. It will support the undertaking of policy relevant research. It will also stimulate debate and dialogue leading to improvement of the health and well-being of Canadians.

CPHI functions:

• Generate new knowledge on the non-medical determinants of health.
• Contribute to the development of a national population health information system and infrastructure.
• Develop reports on aspects of the health of the nation and stimulate public debate and dialogue through outreach activities.
• Support analysis of policy options, for the medium and long term, in the public, private and voluntary sectors.

2. Canadian Institutes of Health Research (CIHR)
The second important initiative to emerge from the National Forum on Health is the Canadian Institutes of Health Research.

The 1999 federal budget recognizes the importance of health to Canadians through significant investments in research by existing federal agencies. Expanded funding for the health research we need is a central part of government's commitment to health, one that builds on increases in support for Canadian research and our research infrastructure in recent budgets.

The federal government recognizes that spending more on health research is only part of the solution. The research enterprise needs to be reorganized and modernized to support cooperative, collaborative research ventures involving researchers working in different fields and in different parts of the country. This is why the government has announced that it is willing to facilitate the transformation of the structure that supports much of Canada's health research. How this new reality should be taken into account in the governance, funding and execution of health research was the focus of a task force which came into being in 1998. The Canadian Institutes of Health Research (CIHR) concept emerged from the work of this task force.

The task force, representing the diversity of Canada's health research community, recognized that the present system is highly fragmented. Participants identified better ways to support the integrated, collaborative and multi-disciplinary approaches that Canada needs to solve the complex and difficult health challenges it faces.

Participants also saw the need to generate knowledge and to encourage investigators to apply their insights and imaginations to important health challenges. They understood the need to support deeper interaction between researchers in many disciplines. They recognized the value of faster adoption of effective technologies, products and practices to improve the health of Canadians and the quality of the health care system. And they understood that the science of the new millennium will identify new ethical challenges that can only be addressed through a broadly-based dialogue across Canadian society.

The Federal, Provincial and Territorial Advisory Committee on Population Health (ACPH)

Concurrent to the National Forum on Health, Canada, through the Federal, Provincial and Territorial Advisory Committee on Population Health, was engaging in the promotion of the population health approach. This approach emphasizes the role of a series of determinants on the health of Canadians. The Advisory Committee on Population Health identified very specifically the following determinants:

• Income and Social Status
• Social Support Networks
• Education
• Employment and Working Conditions
• Physical Environments
• Biology and Genetic Endowment
• Personal Health Practices and Coping Skills
• Healthy Child Development
• Health Services

To engage Canadians in a broad discussion on health evidence, the Advisory Committee on Population Health produced two reports on the health of Canadians.

First Report on the Health of Canadians(1996)
Released in 1996, the First Report on the Health of Canadians provided a general reporting framework on the health of Canadians. It described how to assess the health of the population.

Second Report on the Health of Canadians (1999)
Just released in September 1999, the Second Report on the Health of Canadians contains a wealth of information and is a good starting point for a reflection on evidence.

Toward a Healthy Future: The Second Report on the Health of Canadians, is a landmark public policy report that examines major factors or "determinants" that influence the health of Canadians at all ages. It draws on results from the National Population Health Survey, the National Longitudinal Survey on Children and Youth and numerous other sources, to provide a comprehensive picture of the state of the nation's health.

Toward a Healthy Future takes a population health approach in its organization and analysis. The goals of a population health approach are to maintain and improve the health of the entire population, and to decrease inequalities in health status among various population groups. It focuses on the interrelated conditions that most influence health, and applies evidence to suggest broad priority areas for action.

Toward a Healthy Future provides reliable information on the health status of Canadian men and women and its relationship to income; education and literacy; employment and working conditions; social support; violence; civic participation; child and youth development; the physical environment; personal health practices; health services; and biology and genetic endowment. Each chapter contains a summary of the highlights and discussion of the implications of the findings for policy, practice and research.
The report will serve as a valuable tool in identifying broad, comprehensive and collaborative actions at the federal, provincial and territorial level. It will also help engage all sectors of society in actions aimed at nurturing good health throughout life.

Building A Healthy Future (2000)
This document is intended to provide health intermediaries and the general public with key messages from Toward a Healthy Future: Second Report on the Health of Canadians. This plain-language popular version is one way of getting simple and compelling population health messages out to people who would not otherwise read the Report itself. It was produced by the Canadian Public Health Association and funded by Health Canada.

Building a Population Health Evidence Culture

In the vein of the National Forum on Health and the Federal, Provincial and Territorial Advisory Committee on Population Health work, a growing interest and capacity has been emerging across Canada. Among other initiatives, various research centres have been precursors and advocates for the emergence of the population health approach.

Three groups seem to have lead the charge: 1) the Canadian Institutes for Advanced Research, 2) the Canadian Policy Research Networks, and 3) the Health Statistics Division of Statistics Canada. We suggest you visit their web sites:

Canadian Institute for Advanced Research (CIAR)
The CIAR has research programs vital to human well-being (Human Development; Population Health; Economic Growth and Policy). The work of the Population Health Program has created a new awareness among health policymakers as to the preponderant influence of economic and other social determinants of health.

Canadian Research Policy Networks (CPRN)
CPRN's mission is to create knowledge and lead public debate on social and economic issues important to the well-being of Canadians. This site provides in-depth, innovative and integrated policy research. Publications are accessible online.

Health Reports from Statistics Canada
The site provides free tabular data on aspects of Canadians' health, including determinants, status and the use of resources.

Defining Evidence-Based Decision Making

The aim of evidence-based decision making (EBDM) is to ensure that decisions about health and health care are based on the best available knowledge. To use EBDM one must first assess what constitutes evidence, both in relation to health-enhancing interventions and to organizational or policy level decision making. One also needs to explore the availability and accessibility of reliable information and knowledge that identifies how interventions, practices and programs affect health outcomes.

A second use of EBDM is to explore what is preventing change from taking place in the health system (in practice and policy) when there is clear evidence that change is necessary and desirable. An EBDM framework also examines the length of time the health system takes to adopt existing information about the interventions that work, and their degree of success.

This definition is based on the National Forum on Health's Summary Report: Evidence-Based Decision Making: A Dialogue on Health Information published in May 1995. See EVIDENCE BASED DECISION MAKING: A DIALOGUE ON HEALTH INFORMATION

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Health Status Indicators

A population health approach recognizes that any analysis of the health of the population must extend beyond an assessment of traditional health status indicators like death, disease and disability. A population health approach establishes indicators related to mental and social well-being, quality of life, life satisfaction, income, employment and working conditions, education and other factors known to influence health.

Indicators are established to monitor health status and to help understand and evaluate the effects of current interventions and programs. In some cases, this information is available and just needs to be made more accessible. In other cases, new research will be required to generate the information needed. Currently Health Canada and Statistics Canada, jointly with the Canadian Consortium for Health Promotion Research, are planning to develop community health indicators. Other key national indicator projects include the following:

An Annotated Bibliography on Indicators for the Determinants of Health
One of the guiding principles of population health is that decisions must be based on sound evidence. For this reason, the shift towards population health planning has increased interest in monitoring progress and measuring the impacts and outcomes related to the conditions that determine the health of a population. This current interest in indicators in the population health field coincides with growing worldwide interest in the use of social indicators and indicators of sustainability. Both across the country and around the world, researchers have been developing, proposing and using indicators to monitor social and environmental conditions that determine health.

This annotated bibliography was developed in the winter of 1999 for the Atlantic and Manitoba/Saskatchewan Regional Offices of the Health Promotion and Programs Branch (now the Population and Public Health Branch) as an initial step in developing a system for assessing the impacts of their work. Although it was developed for internal use, it has now been updated, revised and translated for public distribution.

The bibliography was produced using documents provided by the two regional offices and supplemented by a scan of recent and significant initiatives. The intent was to capture the diversity of approaches and to create a menu of indicators that are being used for monitoring the determinants of health and related constructs, such as quality of life, social progress, healthy cities and social health. It was not an exhaustive search and was limited to documents available in English.

The study and use of indicators that relate to the determinants of health are widespread and have been developing over many years in the social and environmental sciences. Many relevant models, initiatives, networks, list-serves and web sites were found. An exhaustive literature review and annotated bibliography would have been more costly and time-consuming than originally anticipated, and much work in this area has already been done. For example, the Report on the Health of Canadians identifies many indicators for use at provincial, regional or national levels. Hancock, Labonté and Edwards synthesized literature on indicators for use at the community level, and the Ontario Healthy Communities Coalition reviewed many tools for monitoring progress at the community level in their "tool kit."

These and many additional documents are described in this bibliography, which provides an overview of the work done to date and sets the stage for future developments in this rapidly expanding field.

The Federation of Canadian Municipalities (FCM)
Through its Quality of Life project, the FCM developed a set of indicators to measure quality of life in Canada's cities. FCM's goal is to develop a global picture of living conditions within Canadian cities and identify trends and issues that might escape traditional measures of public policy outcomes. Working with a team of officials from 16 participating municipal governments from across the country, FCM developed a set of eight indicators of community well-being. These are:

• Community Affordability
• Quality of Employment
• Quality of Housing
• Community Health
• Community Safety
• Community Stress
• Community Participation
• Population Resources

Together, these indicators amount to a report card on the quality of life in urban Canada called the Quality of Life (QOL) Reporting System. A report on the quality of life is being developed through a multiphased approach. The first phase involved generating baseline quantitative measures of quality of life. Later phases will involve complementing and verifying these through a series of qualitative measures. The technical team will also review and refine existing indicators and incorporate new measures in the economic and environmental domains.

The goal will be to publish annual snapshots of social and economic conditions in Canadian cities. Taken together, they will provide a picture of quality of life in this country.

Environment Canada
Indicator work at the Indicators and Assessment Office of Environment Canada is guided by three principal environmental goals for sustainable development: assuring ecosystem integrity; assuring human health and well-being; and assuring natural resource sustainability. Environment Canada is developing 17 key environmental issues of national significance as part of the national set of environmental indicators. Based on consultations and cooperation with various federal partners, these issues are being scheduled for indicator development and improvement over the next few years, as progress is made towards reporting on the entire set. Issues related to human health and well-being include: urban green space; urban air quality; urban water: municipal water use and wastewater treatment; and freshwater quality.

Canadian Council on Social Development (CCSD)
The Personal Security Index is a new measure created by the CCSD. It combines data about Canadians' economic and physical well-being with custom polling on Canadians' perceptions about such things as their job security, access to health care, and exposure to crime. The 1999 edition provides the baseline by which changes in future years can be measured.

Social Indicators Site
This site by the CCSD provides a central repository for social indicator material on the Internet. Social indicators are measures of well-being which assess such things as school performance, life expectancy, or our population's health. They can provide important information upon which to base public policy decisions.

Centre for the Study of Living Standards (CSLS)
CSLS was established in August 1995 to undertake research in the area of living standards. The objective of the CSLS project, The State of Living Standards and the Quality of Life In Canada, is to address the following question: Has the standard of living and the quality of life of Canadians - while high from an international perspective - improved little or even deteriorated in recent years? The project will identify the various dimensions in economic and social well-being, document whether there has been improvement or deterioration in these variables, and put forward specific policies that will contribute to the betterment of the well-being of Canadians.

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