Letter to the Editor – Eulogy for the Canadian health-promoting hospitals movement

J. Ross Graham, MSc, MPA^{Author reference 1}; Shannon L. Sibbald, PhD^{Author reference 2,Author reference 3,Author reference 4}

https://doi.org/10.24095/hpcdp.39.2.04

Author references:

Correspondence: Shannon L. Sibbald, Arthur and Sonia Labatt Health Sciences Building, Room 334, London, ON  N6A 5B9; Tel: 519-661-2111 x 86258; Email: ssibbald@uwo.ca

The Health-Promoting Hospitals (HPH) concept and movement grew out of the fifth priority action area of the Ottawa Charter (Reorient Health Services) nearly 30 years ago.^{Footnotes 1,Footnotes 2,Footnotes 3,Footnotes 4,Footnotes 5} As a setting for health promotion, hospitals were a natural focus since they represent the largest concentration of health care system resources. Unfortunately, this work has had limited influence on health care delivery in Canada today.^{Footnote 1,Footnote 3,Footnote 4} Few Canadian hospitals have been meaningfully “reoriented” toward health promotion. The Ontario HPH network is defunct, and the Québec HPH network is headed in the same direction^{Footnote 6}—there have never been HPH networks in other provinces or territories. It is rare to find a Canadian hospital that adheres to either the five standards of the International HPH Network or to Health Canada's Framework for Health Promotion in Healthcare Facilities.^{Footnote 7,Footnote 8} This leads us believe that the HPH movement is failing and may soon be dead.

In preparation for the death of the Canadian HPH movement, we respectfully submit this eulogy:

Popularized in Canada in the 1980s, following the Beyond Healthcare Conference and publication of the Ottawa Charter, the HPH movement sought to help hospitals “develop a community conscience rather than an institutional loyalty.”^{Footnote 9(p.23)} HPH prioritized prevention and the promotion of health with patients, with hospital staff and in the community, in tandem with the treatment of illness and injuries. In Europe, the HPH concept continues to be investigated and refined, and the movement is supported by the World Health Organization's Regional Office for Europe.^{Footnote 10} In turn, the HPH movement is popular with European and Asian hospitals, and we know more about HPH than ever before. This includes recent publication of the largest-ever study conducted on HPH with 159 European and Asian hospitals.^{Footnote 11} Study results indicated that hospitals with any of the following in place had considerably higher chances of sustained implementation of health promotion activities:

• regular implementation of health promotion projects and organization-wide programs; or
• an established health promotion team and system; or
• integration of health promotion into hospital quality standards.

While there was initial enthusiasm for HPH concepts in Canada, the movement never had much traction. In 1989, Lalonde characterized the response of Canadian hospitals to health promotion as “let somebody else do it; we already have too much to do.”^{Footnote 12(p.40)} However, studies indicate this was not the whole story. Many Canadian hospital leaders have reported a desire to increase health promotion activities in their settings over the past 30 years.^{Footnote 13,Footnote 14} Unfortunately, HPH activities have seen limited uptake and support for HPH networks has ceased.

The cause of death was likely multifactorial, but evidence points to the main cause being longstanding financial and accountability disincentives within provincial/territorial health care systems.^{Footnote 3,Footnote 4} These disincentives have made health-promoting activities prohibitive for hospitals dating back to at least 1986, when despite calls from Health Canada and the Canadian Hospital Association to support hospital reorientation toward health promotion, provincial Deputy Ministers of Health unanimously indicated that Canadian hospitals would not be reimbursed for health promotion activities, because this was the responsibility of public health.^{Footnote 2} The unsurprising result of their position has been that hospitals direct energy toward the activities for which they are remunerated.

The HPH movement is survived by a number of exciting concepts that it helped to create. Most notable are the notions of environmentally conscious health care delivery, a population health lens in hospital decision-making, clinical population health practice (or clinical health promotion), and the notion that hospitals are anchor institutions in their communities and should be accountable for community benefit beyond provision of medical treatment.^{Footnotes 15,Footnotes 16,Footnotes 17,Footnotes 18}

Condolences can be sent to the countless individuals who worked to reorient Canadian health care systems through HPH – most being grassroots health promotors and public health leaders.

Rest in peace Canadian HPH movement.