Rio Political Declaration on Social Determinants of Health: A Snapshot of Canadian Actions 2015
Table of Contents
- Canadian initiatives/tools at-a-glance
- 1.0 Introduction
- 2.0 Canadian actions across the five Rio Declaration themes
- 2.1 Rio Declaration theme: To adopt better governance for health and development
- 2.2 Rio Declaration theme: To promote participation in policy-making and implementation
- 2.3 Rio Declaration theme: To further reorient the health sector towards reducing health inequities
- 2.4 Rio Declaration theme: To strengthen global governance and collaboration
- 2.5 Rio Declaration theme: To monitor progress and increase accountability
- 3.0 Conclusion
The Public Health Agency of Canada would like to recognize these groups for their support, and thank them for their contributions:
- British Columbia First Nations Health Authority
- Canadian Council on Social Determinants of Health
- Canadian Institutes of Health Research - Institutes of Gender and Health, Population and Public Health, Aboriginal Peoples' Health
- Canadian Medical Association
- Department of Foreign Affairs, Trade and Development
- Inuit Tapiriit Kanatami
- Mental Health Commission of Canada
- National Collaborating Centre for Determinants of Health
- National Collaborating Centre for Healthy Public Policy
- New Brunswick Economic and Social Inclusion Corporation
- Pan-Canadian Public Health Network
- Public Health Ontario
The Canadian initiatives or tools profiled in the report were informed through input from the Pan-Canadian Public Health Network and the Canadian Council on Social Determinants of Health. The Canadian Council on Social Determinants of Health also provided advice on initiative/tool selection criteria.
The purpose of this report is to showcase Canada's recent actions that contribute to the advancement of the Rio Political Declaration on Social Determinants of Health (Rio Declaration), a non-binding pledge which calls on World Health Organization Member States to improve/influence the working and living conditions that affect health and well-being. In the lead up to the World Health Organization reporting on Member State implementation of this pledge at the World Health Assembly in May 2015, Canada compiled a selection of recent initiatives undertaken across sectors and levels of government and with non-governmental actors, which aligns with the five themes of the Rio Declaration.
Since reporting on actions aligning with the Rio Declaration in 2013, Canada has made advancements across each of the five Rio Declaration themes and across different levels of government and sectors. The 29 initiatives profiled here demonstrate actions to advance health equity and fall under the following groupings:
- To adopt better governance for health and development:
- Experiences in applying health impact assessment
- Work across sectors to reduce poverty, improve social protection, advance key determinants, such as housing
- To promote participation in policy-making and implementation:
- Reforming government processes to increase openness of data, transparency and participation, and engaging citizens
- Providing approaches to engage and empower Aboriginal peoples for self-governance
- To further reorient the health sector towards reducing health inequities:
- Integrate equity, including gender-related considerations, into the design and delivery of programs and services
- Provide capacity and tools to advance health equity
- To strengthen global governance and collaboration:
- Provide financial contribution to countries and international organizations
- Foster North-South support in information sharing and technical expertise
- To monitor progress and increase accountability:
- Strengthen monitoring systems and methods to report on health inequalities
- Share evidence to inform policy and action
This report intends to stimulate exchange of promising practices to advance health equity within Canada and with other countries.
Canadian initiatives/tools at-a-glance
|To Adopt Better Governance for Health and Development||To Promote Participation in Policy-Making and Implementation||To Further Reorient the Health Sector Towards Reducing Health Inequities||To Strengthen Global Governance and Collaboration||To Monitor Progress and Increase Accountability|
Support Development of Healthy Public Policies
Work Across Sectors to Combat Poverty and Improve Social Protection
Collaborate Across Sectors to Address a Key Social Determinant of Health
Open, Transparent and Engaging Governments
Engage and Empower Communities to Participate in Decision-Making
Empower Aboriginal Peoples for Self-Governance
Strengthen Health Systems Through Health Sector Leadership for Health Equity
Integrate Equity, Including Gender-Related Considerations, into the Design and Delivery of Programs and Services
Provide Capacity and Tools to Advance Health Equity
Provide Financial Contribution to Countries and International Organizations
Foster North-South Support in Information Sharing and Technical Expertise
Strengthen Monitoring Systems to Report on Health Inequalities
Provide Methodologies for Monitoring and Reporting on Health Inequalities
Share Evidence to Inform Policy and Action
In May 2012, Canada and other United Nations Member States endorsed the Rio Declaration. This declaration sets out actions to address health inequities in five areas: to adopt better governance for health and development; to promote participation in policy-making and implementation; to further reorient the health sector towards reducing health inequities; to strengthen global governance and collaboration, and; to monitor and increase accountability. The World Health Organization reported on regional and Member State action on the Rio Declaration since 2012 at the World Health Assembly in May 2015.
Following the endorsement of the Rio Declaration by the World Health Assembly in 2012, the Government of Canada documented Canadian actions in the five themes of the Rio Declaration by releasing a 2013 report, which profiles evidence-based Canadian action on social determinants of health and health equity across various sectors, within health and public health systems, and within research institutes.
In May 2014, Canada and other United Nations Member States endorsed the resolution: Contributing to Social and Economic Development: Sustainable Action Across Sectors to Improve Health and Health Equity. This resolution calls on nations to coordinate and align action across sectors and levels of government in pursuit of health and development, and health inequity reduction as a shared societal goal. It builds on and aligns with the Rio Declaration theme: to adopt better governance for health and development, which calls for action across sectors for health and health equity.
1.2 Report purpose
The purpose of this report is to demonstrate Canada's concrete actions aligning with the five themes of the Rio Declaration, undertaken since 2013. It provides a point-in-time snapshot of the diverse spectrum of activities undertaken across levels of government and sectors to advance health equity and address social determinants of health in Canada.
The initiatives profiled in this report will be of interest to regional and local authorities, national governments and non-government organizations, academic organizations, and professional and civil society organizations working to advance the social determinants of health in Canada and internationally. This report intends to support global and domestic exchange of concrete approaches undertaken by a variety of stakeholders to advance health equity and illustrate how they are making a difference.
1.4 Canadian context
Canada is a large, culturally, geographically and linguistically diverse nation with the majority of Canadians reporting overall good health.Footnote 1 However, health inequities in Canada continue to persist or are growing among certain populations. For example, Aboriginal peoples, Canadians with low income and education, and residents of rural and remote communities experience patterns of poorer health, whereas new immigrants to Canada are more likely to face various barriers to accessing health care services. Various health differences are also noticeable when considering sex and gender.
Canada is a nation with a federated, parliamentary democracy, in which the federal government and provincial/territorial governments have unique responsibilities for the delivery of health and social services, with the provinces/territories playing the greatest role in their delivery.
Canada has a well-established social protection system which includes publicly funded, universal health care coverage for medically necessary services; public pensions; supports for workers who lose their jobs or are injured, and; income assistance for those temporarily or permanently unable to work, disabled persons, families with children and low wage workers; primary and secondary education, and some child care and early education services.
Selection criteria were developed and used to capture the recent, diverse and multiple Canadian initiatives or tools demonstrating action across the Rio Declaration themes, with advice from the Canadian Council on Social Determinants of HealthFootnote 2.
Initiatives or tools included:
- aligns with at least one or more of the five themes of the Rio Declaration
- was published in 2013 or after
- profiles Canadian action / showcases Canada's value added:
- national, provincial/territorial and/or federal/provincial/territorial collaborative efforts
- public, non-government organizations, or private sector efforts
- intersectoral partnership efforts
- may profile a compilation of Canadian experiences from different jurisdictions, including local level
- profiles proven, promising or innovative action (ideally, the initiative or tool should demonstrate the evidence base of evaluation results/its impact)
- profiles action and not position statements/recommended actions
- underwent an appropriate review, for example, a peer-review process, approval process or is informed by evaluation data
- is publicly accessible, i.e. posted on the internet (preferable)
Efforts were also made to:
- profile a balance of upstream and downstream interventions improving health and advancing health equity
- profile Aboriginal populations (First Nations, Métis, Inuit)
- apply a common definition of health equityFootnote 3
- reflect Canada's commitment to gender equity
1.6 Report organization
Canada's actions are presented as a selection of recent (2013 or after) summaries with web links to exemplary Canadian initiatives or tools. For each of the five themes of the Rio Declaration, a theme summary and a collection of example initiatives or tools are presented. Canadian actions under each of the Rio Declaration themes are further categorized into groupings of similar type of activity being undertaken in Canada. Taken together, these groupings provide a flavour of the diverse and multiple types of action undertaken at different levels of government and with non-government actors. Some examples of initiatives or tools fit under more than one Rio Declaration theme. An at-a-glance visual of Canadian actions across the five themes of the Rio Declaration in 2015 can be found here.
2.0 Canadian actions across the five Rio Declaration themes
2.1 Rio Declaration theme: To adopt better governance for health and development
This theme highlights the need for:
- effective cross-sectoral partnerships across levels of government and various sectors;
- policy design and delivery that takes into consideration vulnerable populations;
- research programs that inform policy;
- tools and capacities to reduce health inequities;
- universal access to health and social services, and;
- collaboration with the private sector, while safeguarding against conflict of interest, to develop policies on social determinants of health.
Canadian actions related to this theme:
- Support development of healthy public policies
- Work across sectors to combat poverty and improve social protection
- Collaborate across sectors to address a key social determinant of health
- Provided an opportunity for various Canadian jurisdictions (federal, provincial/territorial) to share information about implementation and use of Health Impact Assessment;
- Identified conditions that can support the incorporation of health and health equity considerations in all policies.
On April 18, 2013, the National Collaborating Centre for Healthy Public Policy (NCCHPP) hosted a meeting of public health officials from 11 Canadian provinces and territories and the federal government (deputy ministers responsible for public health, chief medical officers of health and directors of population health) to discuss the implementation and use of health impact assessment at the provincial/territorial level. This was the second such meeting convened by the NCCHPP to address this subject. The first meeting took place in 2009.
The objectives of the 2013 meeting were to share knowledge and experiences regarding the implementation of health impact assessment strategies as a mechanism for integrating health in all policies including conditions for success, barriers, strategies and models envisioned by the various jurisdictions.
Considering the diverse institutional, political and cultural contexts across Canadian provinces and territories, the means chosen to promote healthy public policy can vary. The initiatives presented in this workshop nevertheless shed light on certain conditions that can facilitate such policies, including:
- A strong link between health impact assessment proponents and higher levels of authority;
- A rapid impact assessment process (to address decision-making needs) that generates reliable results;
- An approach that relies more on incentives than on coercion;
- An approach based on supporting other sectors in achieving their goals, thus gaining their commitment to the process;
- A legal basis, which constitutes a powerful incentive, and;
- A prospective approach, aimed at seizing opportunities to influence the policy development process as early as possible.
Alberta's Social Policy Framework, 2013
- Provides a comprehensive framework to guide development of policies and programs that influence determinants of health underpinning population vulnerabilities;
- Applies across sectors (including, but not led by, health) and includes reduction of inequalities as a priority social policy goal.
More than 31,000 Albertans took part in the development of Alberta's Social Policy Framework, including Aboriginal Elders, business leaders, communities, non-profit organizations, service delivery agencies, municipalities, elected officials, and Government of Alberta staff. The resulting framework is being used to clarify Albertans' common goals, plans, and roles and responsibilities; coordinate and align activities across government departments and with other stakeholders, and; influence planning and decision-making across sectors.
Communities, non-profit organizations, government, and businesses use the framework as a lens to evaluate and target supports and services to achieve the identified four key social policy goals: reduce inequality, protect vulnerable people, enable collaboration and partnerships, and create a person-centred system of high quality services. Health is one of several social policy outcomes identified (others include safety, inclusion, health, education, training, recreation, and cultural opportunities), with the health outcome described as 'achieve the highest attainable standards of health and well-being'. Early childhood development initiatives, a poverty reduction strategy, and a renewed partnership with First Nation, Métis and Inuit communities to address underlying causes of recognized inequalities were among eight priority initiatives identified in the framework.
- Select provincial/territorial poverty reduction strategies/poverty reduction plans:
- Newfoundland and Labrador Poverty Reduction Strategy, 2014
(Government of Newfoundland and Labrador)
- Overcoming Poverty Together: The New Brunswick Economic and Social Inclusion Plan, 2014-2019
(Economic and Social Inclusion Corporation)
- Saskatchewan Poverty Reduction Strategy, 2014Footnote 4
- Collaboration for Poverty Reduction Act, 2013
(Government of Nunavut)
- Government of Northwest Territories Antipoverty Action Plan, 2014
(Government of Northwest Territories)
- Promote and strengthen universal access to social services and social protection;
- Represent policies targeting the entire population with specific attention to vulnerable groups and high-risk areas;
The Rio Declaration calls on Member States to bring together actors, who have accountability for determinants of health, with non-governmental organizations and civil society to improve the living and working conditions of those affected negatively by unequal distribution of resources. Globally, good health varies in a stepwise gradient with income, making income among the most important determinants of health. In Canada, nine provinces and three territories have announced or implemented poverty reduction strategies/action plans, which aim to reduce poverty and mitigate its effects on quality of life and, by extension, improve health.
The example strategies and plans from Newfoundland and Labrador, New Brunswick, Saskatchewan, Nunavut, and the Northwest Territories represent different stages in implementing plans which unite sectors and engage citizens to influence this important determinant of health.
The province of Newfoundland and Labrador was among the first provinces to launch a poverty reduction strategy (2003) and action plan (2006) and has recently released a report on progress. Highlights of progress include a reduction in the number of people living in poverty from 63,000 in 2003 to 27,000 in 2011; median family income has increased by 26%, while at the same time the number of families relying on social assistance decreased from 36,700 in 2003 to 29,650 in 2013.Footnote 6Footnote 7
New Brunswick's Overcoming Poverty Together: The New Brunswick Economic and Social Inclusion Plan, 2014-2019, is the second of such plans, the first of which was launched in 2009. The plan is led by the Economic and Social Inclusion Corporation and is governed by a board of directors which includes members representing government, business, non-profit community organizations, and individuals who have experienced poverty. The plan includes four pillars:
- Community empowerment, includes actions addressing community development, communication and networking, and volunteerism;
- Learning, includes actions addressing child and youth education and adult education, training, and preparation for work;
- Economic inclusion, includes actions addressing participation in the labour market and business activity, and;
- Social inclusion includes actions addressing food security and healthy food availability, housing, and transportation.
By lawFootnote 8, the plan must be renewed every five years through a public engagement process.
The Government of the Northwest Territories Antipoverty Action Plan builds on the territory's first antipoverty strategic framework released in 2013 and was developed through input from the Northwest Territories Anti-Poverty Round Tables engaging representatives from all sectors in every region and under the leadership of an Anti-Poverty Advisory Committee. The action plan outlines actions for the Government of Northwest Territories in five areas to address poverty:
- Children and family support;
- Healthy living and reaching our potential;
- Safe and affordable housing;
- Sustainable communities;
- Integrated continuum of services.
In May 2013, Nunavut passed the Collaboration for Poverty Reduction Act to affirm the commitment of the Government of Nunavut to participate as a partner with Nunavut Tunngavik Inc., Inuit organizations, other governments, non-government organizations and businesses on the Nunavut Roundtable for Poverty Reduction. The Nunavut Roundtable for Poverty Reduction is co-chaired by the Government of Nunavut and Nunavut Tunngavik Incorporated and recognizes the right of Inuit, as set out in Article 32 of the Nunavut Land Claim Agreement, to participate in the development of social and cultural policies, and in the design of social and cultural programs and services, including their method of delivery. Through a public engagement process, a shared approach to poverty reduction has been developed in the territory focused on eight areas for action:
- Working together;
- Community decision-making;
- Local economies;
- Healing and wellbeing;
- Life-long learning;
- Food security (a food security strategy and action plan have been developed);
- Income assistance;
Based on this shared approach, the Roundtable is working to finalize the Makimaniq Five Year Poverty Reduction Action Plan and to develop indicators to measure progress in reducing poverty.
Saskatchewan is among the most recent provinces to announce an antipoverty strategy (October 2014). In Saskatchewan, an advisory group on poverty reduction consisting of community leaders and government officials was formed by the provincial government to review the work done to address poverty in Saskatchewan and identify any gaps where more work is needed. For more information on the role that the health sector played in informing the development of the Saskatoon antipoverty action plan see summary of Toward Health Equity: Canadian Approaches to the Health Sector Role (section 2.3.1).
- Provides a framework to reduce barriers to a key determinant of health within challenging contexts and conditions;
- Reflects a collaborative partnership between health and the education, culture and employment sectors;
- Prioritizes system integration and collaboration as a specific goal.
The Northwest Territories Framework for Early Childhood Development guides its programs and initiatives to support healthy development of all children from birth through the first years of life, within the diversity of the Northern context. The Departments of Education, Culture and Employment and Health and Social Services partnered in its development, which included a comprehensive public engagement process involving parents and caregivers, community members, elders, early childhood experts, and Northern leaders. The framework's goals are:
- Increased accessibility and participation in early childhood development programs, services, and supports for children and families;
- Enhanced quality of early childhood development programs, services, and supports, and;
- Improved integration and collaboration at all levels of the early childhood development system.
- Demonstrates how a randomized trial design can measure the effectiveness of a multisectoral intervention to address chronic homelessness;
- Reflects an approach that both engages sectors in its development and delivery, and contributes to a shift in demand away from acute services toward community-based services.
The Housing First (HF) model provides immediate access to permanent housing along with community-based supports to people with histories of chronic homelessness without requiring treatment for mental illness or substance abuse as a condition of participation.
In 2008, with federal funding, the Mental Health Commission of Canada and stakeholders initiated a five-year randomized controlled field trial to test HF in five Canadian cities. More than 2,000 participants were engaged for two years, with half randomly assigned to receive HF and the other half continuing in a treatment as usual condition. Those randomized to HF were provided with permanent housing and then assigned community support at one of two levels of intensity depending on an individual's need of these services. Researchers studied the program's impact on their housing stability, service use and costs, community functioning, and quality of life in comparison to others who received 'treatment as usual'.
Results showed that the HF model can be effectively implemented in a range of local-level contexts, and that having a place to live with supports can lead to other positive outcomes beyond those provided directly. They also showed that HF contributed to appropriate shifts away from many types of (higher cost) crisis, acute, and institutional services towards more consistent community and outreach-based services.
It was also found that to fully address the complexity of chronic homelessness, strong leadership and partnerships across departments, sectors, government and communities are needed to bridge across fragmented systems and programs.
2.2 Rio Declaration theme: To promote participation in policy-making and implementation
This theme speaks to promoting participation in policy-making and implementation by:
- optimizing citizens' influence in informing government policies which have direct impact on them;
- promoting inclusive and transparent health governance across all sectors and levels of society;
- empowering communities and the public, including Indigenous populations, in policy-making and implementation, and;
- promoting health equity by sharing good practices on effective participation in policy decision-making.
Canadian actions related to this theme:
- Open, transparent and engaging governments
- Engage and empower communities to participate in decision-making
- Empower Aboriginal peoples for self-governance
- Select Canadian initiatives on open government:
- Increase access to data for decision-making;
- Improve engagement of citizens in decision-making;
- Improve transparency of government.
The Government of Canada has developed its second Action Plan on Open Government (Action Plan) as part of its Open Government Partnership commitments, which aim to make governments more open, accountable, and responsive to citizens. The Action Plan was developed in consultations with citizens, civil society organizations, and the private sector to contribute to more responsive, innovative and effective governance. The Action Plan consists of 12 commitments that fall under the following three streams: open data, open information, and open dialogue. It aims to engage citizens in decision-making using innovative technologies by providing access to government data and information and accelerate progress on the delivery of more responsive and cost-effective services for Canadians.
Similarly, guided by the principles of transparency, accountability, participation and collaboration, the province of Newfoundland and Labrador launched an Open Government Initiative (OGI). OGI aims to improve access to information and data; provide meaningful opportunities for dialogue with the residents of Newfoundland and Labrador, and; bring government, partners, organizations and communities together to achieve common goals through collaboration. Its Office of Public Engagement, the lead department for the OGI, is conducting dialogue sessions to provide meaningful opportunities for citizens and stakeholders to participate in developing an action plan that is high-quality, relevant and publicly-supported.
- Empowers communities and citizens to communicate the importance of action on determinants of health.
To improve Canadians' level of knowledge of how broader economic and social factors affect their health and well-being, this Canadian Council on the Social Determinants of Health report presents the results of research into the latest ideas and insights on how to effectively and broadly share information about social determinants of health. Report findings emphasize that effective messaging requires clear and plain language, the use of concrete examples, stories or images to bring the information to life, and an open conversational approach. Customizing or adapting messages to the values, experiences and worldviews of the target audience is also critical. This can include 'priming' an audience by beginning with a message or idea that is likely to resonate with their outlook. The report supports health and public health professionals, researchers, community organizations, and other social determinants of health leaders from health and non-health sectors, in crafting effective and clear messages that will increase understanding and help to mobilize action.
- Select YouTube videos mobilizing action on social determinants of health:
- Promote participation in policy-making and implementation by raising public awareness of the range of factors and policies affecting health, using social mobilization technology.
The city of Sudbury's health unit produced a short video Let's Start a Conversation About Health… and Not Talk About Health Care at All to raise awareness of the impact of social and economic conditions on health. The video tells a story about the root causes (social determinants) of a theoretical citizen's health issues, drawing on local data and context, and shows what can be done to mitigate them in practical ways. The video has since been adapted by provincial and local health authorities across Canada, and in communities in the United States and Australia, to mobilize action among non-health sectors and encourage the public to engage in a dialogue on the impact of social determinants of health on health and well-being.
Similarly, the Montréal Public Health YouTube video illustrates the effects of social inequalities in health in the city of Montréal. Using theoretical statistics which compare the impact of social inequalities on health between underprivileged and affluent population groups, it shows an individual's potential life trajectory depending on the population group the individual belongs to. It can be used to educate and engage various health and non-health sectors and the public on the impact of social and economic factors on health and well-being.
- Provides practical guidance to public health practitioners on how to engage community members in addressing health equity and social determinants of health.
Community members increasingly expect to be engaged in decisions that affect them, and evidence suggests that effective community engagement can improve client satisfaction and provide information to adapt interventions to community specific needs. This guide from the National Collaborating Centre for Determinants of Health (NCCDH) provides public health practitioners with practical information on how to incorporate community engagement in their work, focusing specifically on frameworks that address health equity and social determinants of health. The guide is intended to assist practitioners in selecting, adopting or revising a community engagement framework that is appropriate to their projects.
The guide is informed by an analysis of frameworks that include a focus on health equity and social determinants of health. Profiles of 16 Canadian and international frameworks are provided, with summary information on principles, tools, barriers, success factors, and considerations for evaluation. This guide will help public health practitioners to effectively incorporate health equity and social determinants of health focused community engagement into their work.
- Update on British Columbia Tripartite Framework Agreement on First Nation Health Governance - (Government of British Columbia, Government of Canada and BC First Nations) - Establishing the First Nation Health Governance Structure in British ColumbiaFootnote 10
- Enables First Nations in the province of British Columbia (BC) to participate fully in the design and delivery of health and wellness services by creating a new First Nations Health Governance Structure;
- Brings decision-making closer to home by recognizing and involving First Nations decision-making and service delivery processes and structures at local, regional and provincial levels;
- Supports the creation of a more integrated and responsive health system that reflects the cultures, values and perspectives of BC First Nations.
The framework agreement sets out new roles and relationships amongst BC First Nations and federal and provincial governments and the four parts of the First Nations health governance structure, including the First Nations Health Authority (FNHA), First Nations Health Directors Association (FNHDA), First Nations Health Council (FNHC) and the Tripartite Committee on First Nations Health (TCFNH).
As of October 2013, the FNHA assumed full responsibility to plan, manage, design, deliver and fund the health programs and services previously provided by Health Canada. Through the First Nations health governance structure, BC First Nations are better positioned to work with service partners across the provincial health system to design and deliver health and wellness services in a manner that respects the diversity, cultures, languages and contributions of BC First Nations. It is through this new way of working together that the partners aim to improve the quality, accessibility, delivery, effectiveness, efficiency and cultural appropriateness of health and wellness services accessed by BC First Nations, and eliminate the disparities and inequities in the health status between BC First Nations and other residents of BC.
The FNHA maintains a unique position within the provincial health system with a focus on improving community-based services, improving access to, and integration with, mainstream services by leveraging regional and provincial partnerships, and addressing the underlying determinants of health. After just one year of operations, the FNHA, BC Ministry of Health and Health Canada can point to success with the integration of services and the pairing of new investments with the health and wellness priorities of BC First Nations.
- Considers the particular social determinants resulting in persistent health inequities for indigenous people, and promote meaningful collaboration with them in the development and delivery of related policies and programs;
- Empowers the role of communities and strengthen civil society contribution to policy-making and implementation.
It is widely recognized that Aboriginal peoples in Canada face significant and persistent inequities that affect the health and well-being of individuals and communities. Consistent with the Rio Declaration commitment to promote participation in policy-making and implementation, this report produced by the Canadian Council on Social Determinants of Health explores the experiences of five Aboriginal groups in Canada that have successfully pursued greater self-determination to target the structural causes of inequity. These five examples demonstrate that many Aboriginal communities are successfully pursuing self-determination in many different ways. However, all of the approaches profiled in the report are grounded on a strong commitment to maintaining Indigenous cultures and values, and a willingness to create and adopt new approaches outside of the models provided by broader Canadian society to address the root causes of inequity. The positive experiences documented in this report can provide examples for other Aboriginal communities and populations.
2.3 Rio Declaration theme: To further reorient the health sector towards reducing health inequities
This theme highlights the need for the health sector to advance health equity by:
- developing and maintaining public health policies which reduce health inequities;
- providing equitable access to health care and health promotion and disease prevention services;
- building public health capacity for intersectoral action on social determinants of health;
- promoting changes within the health sector through collaboration and building capacity and tools to reduce health inequities, and;
- exchanging successful practices, tools, and approaches on how to reorient the health sector towards reducing health inequities.
Canadian actions related to this theme:
- Strengthen health systems through health sector leadership for health equity
- Integrate equity, including gender-related considerations, into the design and delivery of programs and services
- Provide capacity and tools to advance health equity
- Promotes a range of health sector approaches in, for example, building health equity capacity, using data to engage across sectors, and fostering a supportive organizational culture, which have been proven or are promising to advance health equity.
This report, prepared by the Public Health Agency of Canada as part of Canada's contribution to the 8th Global Conference on Health Promotion, illustrates Canadian experiences and lessons learned in advancing health equity within health sector policies, program and practice at the federal, provincial/territorial and regional levels.
To illustrate how health equity is integrated within the Canadian health sector, the report profiles the mandates and roles of three organizations at different levels of government: the Federal Health Portfolio (Public Health Agency of Canada, Health Canada, Canadian Institutes of Health Research, at the national level); Alberta Health Services (the provincial/territorial level), and; Saskatoon Health Region (the local level). The report is framed around three themes that emerged during consultations with leaders and practitioners from various health sector organizations at the federal, provincial/territorial and regional level: build a strong foundation for action, establish and use evidence, and collaborate with others outside the health sector.
The report presents a few key lessons learned about promoting equity within the health sector organizations outlined in the report. Some of the lessons learned revolve around:
- The important role of governments as demonstrated in the federal example in providing data and evidence base and testing and sharing best and promising practices;
- The benefit, as illustrated in the described provincial experience, of leadership and internal capacity to routinely consider health equityFootnote 11 within public health organizations;
- Local-level use of health data to inform action to combat poverty can influence and inform policies on the social determinants of health.
Lessons learned within different jurisdictions in Canada point to the importance of strong organizational culture and priorities, as well as participation and engagement of marginalized or disadvantaged populations, the media, and policy makers across various sectors.
- Select Canadian provincial/territorial wellness plans/wellness strategies:
- Provide comprehensive wellness strategies, wellness plans or guiding frameworks for public health focusing on a planned approach to lifelong health and well-being (in majority of initiative examples);
- Promote collaborative multisectoral work, championed by the health sector (in majority of initiative examples), to advance health equity.
In Canada, several provinces/territories have developed wellness strategies, wellness plans or guiding frameworks for public health (for example, Yukon, Alberta, New Brunswick). These documents guide jurisdictions in how to reduce the gap between the most and least healthy through collaborative partnerships with various sectors and the public. They focus on health and the determinants of health, and help governments measure improvements in the health and wellbeing of their people now and into the future.
For example, the territory of Yukon developed On the Path Together: Wellness Plan for Yukon's Children and Families, which combines the science of prevention and the wisdom of Yukon people to promote well-being, prevent illness and reduce health inequities. The strategies in the plan reflect the complex interplay of factors at the individual, family, community and society levels that impact health. The plan sets out the following three pathways for lifelong health and well-being:
- Getting a good start in life with nurturing adults and safe, stimulating surroundings;
- Raising kids who flourish by creating opportunities for children and young people to develop confidence, interests, and positive relationships;
- Healthy living for all by making healthy choices easier and equipping all people with information, skills and opportunities to make good decisions.
The plan is a roadmap for action on wellness for multiple sectors, such as governments, community organizations, businesses, and faith communities, and is a framework for measuring progress to improve health outcomes for children and families.
Alberta's Strategic Approach to Wellness lays out an overarching vision, principles and strategies for achieving wellness in the province of Alberta and provides a starting point for further discussion, action and change, and a rationale for focusing proactively on health and the determinants of health. It shifts the dialogue from the delivery of health care to a discussion about Albertans' health and wellness. The document forms the foundation upon which multiple sectors, such as governments, non-governmental organizations and businesses, and the public can collaborate to improve the health and wellness of Albertans.
The province of New Brunswick's Wellness Strategy 2014-2021 is championed by the New Brunswick Department of Healthy and Inclusive Communities, which is outside the health sector. The strategy is a road map for action on all dimensions of wellness and determinants of health, and supports work across and within all levels and sectors of government, and with community organizations and the public. The strategy builds in an equity focus as one of its three key guiding principles, which guides decisions and actions on improving the wellness of New Brunswickers. The strategy measures progress on wellness by different determinants of health, such as geography, gender, age, Aboriginal status and income, by the same token emphasizing that addressing the wellness gap will positively impact population health outcomes. The strategy promotes a comprehensive approach consisting of five key actions one of which is promoting evidence informed practice, therefore creating mechanisms that allow for the exchange of promising and best practices.
Ontario Public Health Standards, 2008, updated 2014
(Ontario Ministry of Health and Long-Term Care)
- Establishes requirements for integrating equity into the design and delivery of public health programs and services.
In Canada, some provincial governments (Ontario, Nova Scotia) have developed public health standards which set minimum requirements for provision of public health programs and services and provide direction on public health action at the provincial and/or local-level. The Ontario Public Health Standards (OPHS) and incorporated protocols outline expectations of Ontario's 36 boards of health, which are responsible for providing public health programs and services that contribute to the physical, mental, and emotional health and well-being of all Ontarians.
To ensure that boards of health design, deliver, and evaluate public health programs and services to meet the needs of various populations, the OPHS requires that board of health initiatives be guided by principles of need, impact, capacity, partnership and collaboration. The OPHS mandates, for example, that boards of health monitor food affordability, increase awareness of health inequities that contribute to chronic disease, and work with boards of education to support healthy policies and the creation or enhancement of supportive environments to promote healthy behaviours such as healthy eating; tobacco control, and; physical activity.
- Serves as a guiding document for the public health system, integrating equity into the design and delivery of public health policies, programs and services.
Promote, Protect, Prevent: Our Health Begins Here. BC's Guiding Framework for Public Health (Guiding Framework) is the province of British Columbia's (BC) high-level directional document for the public health system which aims to improve the health and well-being of British Columbians. The Guiding Framework sets the stage to better align health promotion and protection policies, programs, services and resources to establish a long-term vision for the public health system. The Guiding Framework establishes a vision of "vibrant communities in which all people achieve their best health and well-being where they live, work, learn and play" and promotes improved health equity across all population groups, such as recent immigrants, Aboriginal peoples, women, men, children, youth, and seniors. The Guiding Framework also supports a population health approach and the public health role in health equity through information, education, leadership for healthy public policy and multisectoral approaches, and partnerships across all levels of government and within communities.
The Guiding Framework identifies seven visionary goals for the public health system: healthy living and healthy communities; maternal, child and family health; positive mental health and prevention of substance harms; communicable disease prevention; injury prevention; environmental health, and; public health emergency management. Together, these goals represent the key areas of focus for BC's public health system over the next ten years. Each of the goals organize existing provincial strategies and identify objectives for the health system which inspire action to address the burden of disease and injury in collaboration with key health and non-health sector partners. Work across all visionary goals consider the settings that affect people and the unique needs of different population groups, such as differences in culture, gender and age. Each goal also has a set of performance measures to help measure progress and motivate action. There are also a set of overarching measures, which are intended to measure system performance and are indicative of important changes in the overall health and well-being of the population.
The Guiding Framework reinforces the importance of strategic partnerships and collaborative efforts. To support the implementation of the Guiding Framework, the BC Ministry of Health and local health authorities work with partners, such as the First Nations Health Authority and Tripartite partners, community organizations and schools, to design and deliver policies, programs and services that respond to specific needs of target populations.
- Reorients health research to support gender equity.
Responding to inequities in health requires a good understanding of the state of and trends in inequalities, an understanding of how they come about, and research into effective approaches to reduce them. The 13 Canadian Institutes of Health Research make important contributions to the evidence base to support health sector reorientation in several areas: supporting routine consideration of sex and gender influences in research to ensure that the outcomes are equitably applicable to the health of men and women, girls, boys and gender diverse populations; understanding the pathways through which inequities are created and impact of policy on health, and; testing and scale up of effective interventions to address health inequities experienced by Aboriginal Peoples (the latter two are summarized in section 2.5.7).
Consistent with this Rio Declaration commitment, the Canadian Institutes of Health Research-Institute of Gender and Health fosters research excellence regarding the influence of gender and sex on health, and applies these research findings to identify and address pressing health challenges facing men, women, girls, boys and gender diverse people. The Institute of Gender and Health plays an important leadership role in advancing knowledge, building capacity for gender, sex and health research across disciplines and career stages, and accelerating the application of evidence in the real world.
The Institute of Gender and Health launched a five-year strategic plan in 2013, which focuses on integration (building consideration of sex and gender into research granting and review processes), innovation (development and use of methods and instruments to support sex and gender sensitive research), and; impact (making sex and gender evidence more available, in useful forms and ways to inform policy and practice).
For example, the Institute of Gender and Health was instrumental in the establishment of the Canadian Institutes of Health Research requirement that all grant applicants respond to mandatory questions about whether their health research designs include gender and/or sex considerations. Applicants who indicate that they are considering sex and/or gender are required to explain how, and those not taking up sex and/or gender are required to justify why not. Since then, the Canadian Institutes of Health Research has seen an increase in grant applications which include sex and/or gender considerations.
- Identifies roles for physicians in contributing to health equity.
The Canadian Medical Association is a national, voluntary association of physicians that advocates on behalf of its members and the public for health and high-quality health care and provides leadership and guidance to physicians.
For several years the Canadian Medical Association has been active in identifying and supporting roles for physicians in influencing action on social determinants of health and contributing to health equity. Noting a gap in the literature on this issue, the Canadian Medical Association undertook interviews with physicians from across Canada to identify strategies and practice being undertaken in this regard. The most common roles being undertaken were linking patients with supportive community programs and services; asking questions about a patient's social and economic circumstances and integrating relevant considerations into treatment planning (i.e. cost of medications); adopting equitable practice design (i.e. flexible office hours, convenient practice location); providing practical support to patients to access the federal and provincial/territorial programs for which they qualify, and; advocating both for individual patients and for changes to support improvements in the social and economic circumstances of the community. Many of these strategies were incorporated into an online Continuing Medical Education module: Social Determinants of Health - What Physicians Can Do About Poverty in Practice, which was launched in May 2014.
- Develops and applies a tool which supports routine consideration of how health risks, protective factors and barriers to access, are experienced by different sub-groups of the population.
Developed by the Ontario Ministry of Health and Long-Term Care in partnership with local health care authorities, the Health Equity Impact Assessment tool helps users to identify unintended potential health equity impacts of a policy, program or initiative (positive and negative) on specific population groups; supports equity-based improvements in policy, planning, program or service design; embeds equity in an organization's decision-making processes, and builds capacity and awareness about health equity throughout the organization.
Based on the steps of health impact assessment (scoping, potential impacts, mitigation, monitoring, and dissemination), Health Equity Impact Assessment calls on users to think through how a proposed initiative could have positive or negative effects on such population groups such as the homeless, Aboriginal populations, linguistic communities, ethno-racial communities or sexual orientation populations; to develop and disseminate mitigation strategies, and; to raise awareness about health equity within an organization. Health Equity Impact Assessment is intended for application by organizations and health services providers who have an impact on the health of Ontarians.
It includes prompting questions about whether an organization's policies, programs, and initiatives take opportunities to improve equity, or whether they result in widening health disparities amongst vulnerable and marginalized populations. For example, Health Equity Impact Assessment assists local-level public health units in Ontario in meeting the Ontario Public Health Standard requirements, which outline expectations for the planning and delivering of health equity focused programs and services (for more detailed description of Ontario Public Health Standard see page four of the Health Equity Impact Assessment Public Health Unit Supplement). Health Equity Impact Assessment also supports improved targeting of health care investments. The tool is free and publicly available, in English and French and is designed to be adapted and used by many organizations within and outside of Ontario's health care system whose work can have an impact on health outcomes. Application of the tool is also supported by training.
- Dedicated human resources and training for health equity application in select Canadian provinces/territories and select federal government departmentsFootnote 12
- Builds capacity among public health practitioners to identify and address health inequities and influence determinants of health;
- Provides tools and training to support routine consideration of reach and impact of health sector interventions among disadvantaged populations.
In Canada, several jurisdictions have dedicated human resources to building organizational capacity to understand and take action on determinants of health and health inequities. For example, Ontario has hired 75 public health nurses under the Social Determinants of Health Nurses Program to act on issues of health inequity and social determinants of health within the context of program and service delivery. These positions (the first of their kind known in Canada), provide enhanced supports to public health programs and services to address the needs of locally determined priority populations impacted negatively by social determinants of health.
The provinces of Alberta, Manitoba, and Nova Scotia, as well as the federal Public Health Agency of Canada each have staff who lead or coordinate the application of a health equity 'lens' to interventions undertaken to promote and protect health in their jurisdictions. In addition, several jurisdictions have hosted training sessions to build staff capacity in several areas such as how to integrate analysis of health equity and social determinants of health into their day-to-day work (Population Health Equity Unit in Manitoba), diversity competency trainingFootnote 13Footnote 14Footnote 15 (Fraser Health Authority, British Columbia; Guysborough Antigonish Strait Health Authority, Nova Scotia; Health Prince Edward Island), and Indigenous Cultural Competency trainingFootnote 16 (BC Provincial Health Services Authority). In addition, Public Health Ontario has dedicated time to train their staff in the application of health equity impact assessment (also refer to summary of Ministry of Health and Long-term Care's Health Equity Impact Assessment in section 2.3.7).
Through these investments of dedicated staff time, and provision of training and tools, Canadian jurisdictions are improving reach and impact of their interventions by assuring consistent consideration of health equity in the types of interventions undertaken, the populations targeted, and the methods used to make interventions accessible, acceptable and appropriate for populations disadvantaged socially, economically or geographically.
2.4 Rio Declaration theme: To strengthen global governance and collaboration
This theme speaks to the importance of international collaboration to take action on social determinants of health by:
- building capacity of national governments by providing resources, training and expertise to advance health equities;
- fostering North-South and South-South collaboration by building capacity and providing technical expertise, and sharing promising and best practices on initiatives advancing health equities;
- preventing and controlling non-communicable diseases through the health equity lens;
- providing support to the World Health Organization in its leadership role of global health governance.
Canadian actions related to this theme:
- Provide financial contribution to countries and international organizations
- Foster North-South support in information sharing and technical expertise
- Builds capacity of national governments by providing resources, training and expertise to reduce global health inequalities in maternal and child health;
- Fosters North-South and South-South collaboration by building capacity and providing technical expertise, and sharing promising and best practices.
The Rio Declaration calls on nations to 'support national governments, non-governmental entities and others to tackle social determinants of health as well as to strive to ensure that efforts to advance international development goals and objectives to improve health equity are mutually supportive'.
Improving maternal, newborn and child health is Canada's top development priority. In May 2014, Canada hosted the Saving Every Woman, Every Child Summit, renewing its financial commitment to maternal, newborn and child health from 2015 to 2020.
As part of this renewed commitment, Canada is placing a strong emphasis on deepening and expanding existing and new partnerships. In November 2014, Canada launched the Partnerships for Strengthening Maternal, Newborn and Child Health call for proposals to support the initiatives of selected Canadian organizations that will help to end the preventable deaths of mothers and children and improve women's and children's health in targeted developing countries.
In September 2014, Canada joined the United States, Norway and the World Bank Group to launch the Global Financing Facility in support of Every Woman, Every Child. Canada is providing funds for the facility to help developing countries to sustainably finance maternal, newborn and child health initiatives by streamlining financing and reducing inefficiencies. The facility will also help developing countries to build and strengthen their civil registration and vital statistics systems, so governments can ensure that all children are registered and have access to health care.
In February 2015, Canada announced support for the innovative work of 20 implementation research teams made up of Canadian and African researchers aimed at identifying, testing, and delivering high impact interventions to improve the primary health care needs of mothers and children in 13 countries across sub-Saharan Africa.
- Examines different governance, legislative and other institutional frameworks to better understand enabling factors that contribute to the identification of implementation strategies of Health Impact Assessment.
The World Health Organization defines Health Impact Assessment (HIA) as a combination of procedures, methods and tools to systematically evaluate the potential effects of policies or programs on the health of a population, including the distribution of these effects. Consistent with commitments to strengthening global health governance in the Rio Declaration, there is growing interest internationally in the potential of Health Impact Assessment to evaluate the health impacts of non-health policies. Supported by the Public Health Agency of Canada, the World Health Organization examined different governance, legislative and other institutional frameworks to support HIA in order to better understand enabling conditions, barriers and effective strategies. Based on the experiences of key informants from nine countries and the European Union, the report recommends embedding HIA within normative systems, clearly defining HIA, developing implementation guidelines, building capacity for HIA practice, and improving cooperation across sectors. Also included are recommendations for the role of the World Health Organization in continuing to advance the use of HIA. The learnings presented in this report provide important guidance for jurisdictions interested in advancing the use of HIA to support policy and program decision-making.
- Provides an overview of methods and data needed to monitor health inequalities in low- and middle-income countries to help identify impact of policies and programs.
Determining whether policies and programs are accomplishing their stated goals is important for strengthening global governance in the health sector, and a theme in the Rio Declaration. Developed with support from the Public Health Agency of Canada, this World Health Organization Handbook explores the methods and data needed to monitor health inequalities, with specific emphasis on the application of these concepts in low- and middle-income countries. Health inequality monitoring requires data on health indicators, and on the population or other subgroups for which these indicators are assessed. The report discusses the advantages and disadvantages of various types and sources of data in low- and middle-income countries as well as also reviews basic (such as rate differences and ratios) and complex (such as slope, concentration indices and mean difference) measures of inequality and factors affecting the selection of appropriate methods. A case study of the Philippines provides concrete examples of each of the steps involved in the health inequality monitoring cycle. By helping to build capacity for health inequality monitoring, the Handbook supports the broader inclusion of health inequality in planning and decision-making.
2.5 Rio Declaration theme: To monitor progress and increase accountability
The commitments under this theme highlight the need to:
- develop and strengthen monitoring systems that provide disaggregated data;
- establish and implement evidence-based measures of social well-being;
- promote research;
- share evidence and trends;
- increase access to monitoring and research results, and;
- use Health in All Policies approach, as one of several intersectoral mechanisms, to address health inequities.
Canadian actions related to this theme:
- Strengthen monitoring systems to report on health inequalities
- Provide methodologies for monitoring and reporting on health inequalities
- Share evidence to inform policy and action
Pan-Canadian Baseline Reporting on Health Inequalities, 2015Footnote 17
(Pan-Canadian Public Health Network, Public Health Agency of Canada, Statistics Canada, Canadian Institute for Health Information)
- Establishes a pan-Canadian platform for monitoring health inequalities.
Following recognition by federal, provincial, territorial governments of the importance of health inequalities in Canada and the health sector role in reducing them, the Pan-Canadian Baseline Reporting on Health Inequalities initiative was developed to strengthen monitoring and reporting of these inequalities in Canada. The initiative is being implemented in three phases with the following objectives: increase accessibility of data on health inequalities in Canada; report on a selection of key health inequalities, and; facilitate measurement of progress on reducing health inequalities over time. This work aligns with the open data stream of Canada's Action Plan on Open Government 2014-16. Products will include an online data portal and an upcoming report synthesizing findings for a subset of key indicators. The report will describe key inequalities in Canada and help to focus the efforts of public health and related sectors to reduce health inequalities.
Baseline reporting focuses on over 55 indicators which measure premature mortality, quality of life, disease outcomes and select determinants, and a subset of approximately 15 key indicators drawn from comprehensive analysis. Where possible, results for each indicator are disaggregated by: sex, age, income quintile, education, employment status, occupation, rural/urban residence, cultural/racial origin, immigrant status, Aboriginal status, disability, and sexual orientation. Products for research, practice and policy users will describe and assess selected key inequalities observed to inform future action to reduce health inequalities in Canada.
Trends in Health Inequalities in Canada, 2015Footnote 18
(Canadian Institute for Health Information)
- Describes trends in income-related health inequalities in Canada over time and shares promising interventions for reducing income-related health inequalities.
Monitoring health inequalities over time can provide insight into where action is needed for reducing health inequalities and where improvements may have occurred. To this end, the Canadian Institute for Health Information (CIHI) is carrying out a project titled Trends in Income-related Health Inequalities in Canada. This project examines 16 indicators by income quintile and reveals that income-related health inequalities have largely persisted, and in some instances increased, over the past decade in Canada at the national and provincial level. This project also describes examples of promising interventions for reducing income-related health inequalities.
The indicators included in this project were selected to reflect the complexity and continuum of factors that affect health inequality, as informed by the World Health Organization's Conceptual Framework for Action on the Social Determinants of Health. These included indicators of material circumstances, early-life experiences, individual behaviour, the health system, and health and wellbeing outcomes. A variety of absolute and relative measures of health inequality were calculated to summarize the magnitude of income-related inequality and its variation over time. For each indicator, an intervention was selected and summarized with the goal of ultimately providing an overview of the range of approaches that currently exist for addressing income-related inequalities.
- Monitors progress over time on health inequalities and determinants.
In Canada, efforts are advancing to develop and maintain systems which will monitor progress in reducing avoidable health inequalities. The Chronic Disease and Injuries Indicator Framework, developed by the Public Health Agency of Canada and updated annually, is a comprehensive pan-Canadian data resource on the burden of chronic diseases and associated determinants intended for policy and program decision-makers. The framework and its related products support evidence-informed decision-making by allowing decision-makers and practitioners at all levels of government to identify which Canadians are at risk for and suffering from chronic disease, and the relationship between chronic disease and the state of key determinants of health.
The framework includes a core set of 41 indicators and specific measures which are grouped into six core domains: social and environmental determinants, early life/childhood risk and protective factors, behavioural risk and protective factors, risk conditions, disease prevention practices, and health outcomes/status. The tool is web-accessible and provides up-to-date data disaggregated by province/territory and by key socio-demographic characteristics (e.g. sex, age group, urban/rural, income status, immigrant status, Aboriginal status, occupation, and ethnicity) and time trends. The framework can help improve reach and effectiveness of interventions for populations experiencing social, economic or geographic disadvantage.
- Describes key determinants affecting a sub-population experiencing significant health inequalities, including statistics on key indicators to enable measurement of relative change over time;
- Shares knowledge about initiatives that show promise in Inuit-specific contexts (e.g. Harvester Support Programs help finance hunting equipment and sewing supplies to benefit both livelihood and food security).
Inuit Tapiriit Kanatami (ITK) is the national Inuit organization in Canada, representing the 60,000 Inuit living in 53 communities across the Canadian North. ITK led the development of the Social Determinants of Inuit Health in Canada report to support public health activities and respond to the disproportionate health challenges Inuit face compared to non-Inuit Canadians, including lower life expectancies and higher rates of infant mortality, infectious disease, and suicide. Collaborators included representatives from each of the four Inuit regions, the Chief Medical Officers of Health from the governments of Nunavut and Northwest Territories, Labrador Grenfell Health, and federal, provincial and territorial public health officials.
This report updates an earlier discussion paper that was submitted to the World Health Organization Commission on Social Determinants in 2007. Drawing from current data sources and consultation with Inuit organizations, agencies and governments, the report highlights the key social determinants of health that are relevant to Inuit in Canada including: quality of early childhood development, culture and language, livelihoods, income distribution, housing, personal safety and security, education, food security, availability of health services, mental wellness and the environment. While summarizing the key challenges that exist for each of these areas, the report also highlights practices that have resulted in positive outcomes. This report is an Inuit-specific resource designed to support public health activities across the Inuit regions in Canada and to function as a reference for organizations and governments working within the Canadian health and social services sector. While progress is being made, substantial work is still required to address the conditions that lead to poor health outcomes for Inuit. Fact sheets summarize current statistics on key indicators for each determinant, comparing Inuit data to other Canadians.
- Select reports providing methodologies for monitoring and reporting on health inequalities:
- Allows for more precise identification of local population needs by proposing methods to strengthen evidence-based measures for monitoring and reporting of health at the provincial and local-level.
The Institut national de santé publique du Québec developed a report which recommends a strategy and indicators for monitoring health inequalities in Québec. The report provides useful methodological concepts and recommendations for a measurement approach and outlines 18 indicators which can be used to monitor health inequalities, including ten covering the health status of the population and eight for health determinants. One interesting feature of inequalities monitoring in Québec is the recommended use of the deprivation index which allows material and social deprivation to be quantified and mapped by geographic area. The report recommends that the indicators be cross-referenced with the deprivation index and tracked at provincial and regional levels over approximately two decades, making it possible to systematically monitor inequalities in health and its determinants in the province.
Similarly, Public Health Ontario, a crown corporation, whose work it is to enable informed decisions and actions that protect and promote health and contribute to reducing health inequities in Ontario, released a report which describes methodological approaches to quantify health inequalities, and is intended for a technical audience. It provides a discussion of concepts related to health inequalities, measures of socioeconomic status in the population, and the scientific and technical basis for using five summary measures of inequality described in the literature. The report outlines methods of calculation as well as possible advantages and disadvantages of the five summary measures, providing an outline that can be used by public health practitioners determining the existence of inequalities in the population. As in the Québec report, these methodological approaches can be used at the provincial level in Ontario as well as by local public health units to inform program priority setting for targeted populations.
- Illustrates data on health and social factors on local maps to identify areas of deprivation/vulnerability and inform action;
- Establishes monitoring systems which illustrate relationships between health outcomes and determinants at a local level.
The Rio Declaration calls on countries to monitor progress and increase accountability of policy makers for health and social outcomes. In Canada and elsewhere, maps are becoming increasingly popular as research, communication and monitoring tools. Maps can be an especially effective way to present information on social determinants of health because they allow for the display of health, social, economic or other data on a single image. Recognizing this potential, the Canadian Council on the Social Determinants of Health supported research on the use of mapping technologies to support action on the social determinants of health in Canada. This report highlights how two communities use integrated health and social data mapping to identify targets, mobilize action, and track progress on health determinants at the local level. The two case studies developed in the report are: the Espace montréalais d'information sur la santé in Montréal, Quebec and the Community View Collaboration in Saskatoon, Saskatchewan. Both initiatives focus on the ways in which data sharing and mapping tools can contribute to evidence-based decisions for intersectoral action. The practical information provided in this report can support other communities interested in using mapping as a tool to support local planning and action.
The Canadian Institutes of Health Research: Federal investments in health inequalities and health equity researchFootnote 20Footnote 21Footnote 22Footnote 23
(Canadian Institutes of Health Research)
- Shares evidence on complex interactions of determinants of health to inform policy and action through research investments.
Research into the complex interactions of determinants of health is vital to understanding the health of individuals, communities and global populations. Since 2000, the Canadian Institutes of Health Research (CIHR) has funded research initiatives specifically addressing health inequities as they relate to poverty and income inequality.
CIHR's Pathways to Health Equity for Aboriginal Peoples program, announced in 2012 as a Roadmap Signature Initiative, funds research projects, chairs and teams aimed at increasing understanding of how to implement and scale up interventions and programs to improve health equity across diverse Aboriginal communities. The initiative focuses on four specific areas identified as priorities by Aboriginal communities, organizations, and federal/provincial/territorial governments: suicide prevention, tuberculosis, oral health, and obesity/diabetes. Funded projects will be co-led by researchers and Aboriginal community partners.
In 2011, the CIHR-Institute of Population and Public Health funded 11 teams through the Programmatic Grants to Tackle Health and Health Equity to support research that contributes new knowledge to improving health and health equity at a population level; interdisciplinary collaborations involving researchers and knowledge-users in public health and other sectors in Canada and with other countries, and; effective knowledge translation approaches to informing decision-making in public health and other sectors.
This research has health and economic impacts through the study of large-scale intersectoral policy interventions and their influence on health, health equity, and social outcomes. The research teams have studied topics such as the differences in long-term health and social outcomes from: participation in full day kindergarten across different socioeconomic groups; impact of seniors' pensions on food security, and; stakeholder perspectives on health equity, vulnerability and ethics in response to the Haiti earthquake.
A 2014 mid-term evaluation revealed that all teams were on track toward achieving objectives. For every $1 CIHR invested in this funding program, the teams have yielded an additional $2.74 in research grants, suggesting a substantial return-on-investment and providing evidence of the quality of their research. In addition to producing several peer reviewed journal articles and technical reports (close to 160) and conference presentations (over 150), the teams have produced a number of policy briefs and guidelines for policy makers (18).
- Supports the identification and sharing of evidence based and promising practices to reduce health inequities;
- Provides guidance on reorientation of public health programming to advance health equity.
The Public Health Agency of Canada's Canadian Best Practices Portal (Portal) showcases promising or best practice interventions to help health professionals, public health decision-makers, and researchers plan and choose interventions for promoting health and preventing diseases for populations and communities. The Portal is used as a source of information to support evidence-informed decisions in promotion and prevention on a range of topics including mental health and healthy living.
The Public Health Agency of Canada recently developed criteria to identify interventions which are effective at improving the health of socially, economically or geographically disadvantaged populations. These interventions also act on one or more key determinants of health at the organizational, institutional, community, or population level in order to promote health equity. Any intervention featured on the Portal will meet rigorous effectiveness requirements and interventions that pass the equity criteria will be identified as 'equity sensitive'. Using these criteria a compendium of equity-sensitive interventions has recently been included on to the Portal, including those focused at maintaining healthy weights and promoting mental health.
This compilation of recent Canadian actions demonstrates how Canada has concretely advanced work on the determinants of health across each of the five Rio Declaration themes across different levels of government and various sectors since 2013. Key developments include further reorientation of the health sector to reduce health inequities and initiatives to monitor progress and increase accountability.
This snapshot of Canadian actions to advance health equity will be used to stimulate exchange and uptake of promising practices within jurisdictions in Canada and with other countries. Canada will also continue to explore opportunities to further advance the social determinants of health and health equity including the implementation of the 2014 resolution: Contributing to Social and Economic Development: Sustainable Actions Across Sectors to Improve Health and Health Equity.
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