Health Care in Canada Has Long Been a Source of National Pride

8/4/2019 Health Care in Canada Has Long Been a Source of National Pride

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Health care in Canada has long been a source of national pride. Known as medicare, the system

is publicly financed but privately run, it provides universal coverage and care is free at the point

of use.Canada has a long history of universal health coverage. In 1944, Saskatchewan led the way,

being the first of the provinces to introduce universal hospital insurance.

By 1971, all Canadians were guaranteed access to essential medical services, regardless of

employment, income, or health (Kraker, 2002).

The 1984 Act also defines and solidifies the principles of medicare, including:

comprehensiveness (provinces must provide medically necessary hospital and physician

services), universality (100 per cent of provincial residents are entitled to the plan), accessibility

(there should be reasonable access to services, not impeded by user charges or extra billing),

portability (protection for Canadians travelling outside of their home province), and public

administration (provinces must administer and operate health plan on a non-profit basis) (Klatt,

2002). The Canadian healthcare system is funded primarily by tax dollars. The federalgovernment makes cash transfers to the provinces, but the provinces may levy their own taxes

to help defray the costs. Alberta and British Columbia require a health insurance premium, and

other provinces have instituted employer payroll taxes (Klatt, 2002). In 2004, $91.1 billion or

70% of total health spending was by the public sector. Private sector spending totalled $39.2

billion in 2004, or 30%. In 2004, total health expenditure was estimated at $130 billion, about 10

per cent of GDP (Ibid). This is estimated to be around $4,078 per person. Latest OECD figures on

spending per person is for year 2002, when it reports Canada spent $2,931 per person using

purchasing power parities (PPPs), up from $2587 as used in report. This was the third highest,

below the USA and Switzerland.

Private insurance plans are not allowed to cover core services and may only cover non-core

services. As a result, the role of private medical insurance in Canada is limited to supplemental

care.

Healthcare providers are predominantly private, but are funded by public monies via provincial

budgets. Hospital systems are largely private non-profit organizations with their own governance

structures (usually supervised by a community board or trustees) (WHO, 1996) that receive an

annual global operating budget from the provinces (Klatt, 2002). Physicians are mostly in private

practice and remunerated on a fee-for-service basis (with an imposed cap to prevent excessive

utilization and costs) by the provincial health plan (WHO, 1996).By Benedict Irvine, Shannon

Ferguson and Ben Cackett


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public and private sector participation in health care.

Generally speaking, Canada has a mixed public-private system a

system where the private sector delivers health care services and the

public sector is responsible for financing those services. The Canadian

system, however, is not completely consistent with this model. Canadiangovernments exercise considerable authority over the delivery of

services by the private sector.

Health Care Delivery

Within this patchwork of provincial systems, health care in Canada can be

divided into two basic elements: delivery and financing. These distinctions are

important when one turns to the question of public and private participation in

the health care system, as each sector plays very different roles in the delivery

and financing of medical services.

Health care delivery refers to the manner in which medical services are

organized, managed, and provided. Central to health care delivery are the

professionals who provide medical services to Canadians. In 2009, the health

industry was the second largest employer in Canada, employing approximately

two million people. This represented almost 12 percent of Canadas total

employment for 2009. (It is important to note that these statistics include health

and other social assistance professionals.)

Health care delivery refers to the manner in which medical services are

organized, managed, and provided. In this regard, Canada has a system with a

strong mix of public and private involvement. In most cases, private individuals

and organizations are responsible for delivering medical services to patients.

Nevertheless, provincial governments exercise considerable authority over the

manner in which these private entities deliver services.

Moreover, while governments fund the large majority of services, the

private sector does play an important, albeit secondary, role in health

care financing.

Health Care Financing

The second basic element of any health care system is its financing that is,

how medical services are paid for. Generally speaking, in western industrializedcountries, health care tends to be financed by two key sources: out-of-pocket

payment and health insurance.

Out-of-pocket payment occurs when the patient must directly cover costs

associated with a medical service. This type of financing may be further

distinguished by complete payment and cost-sharing. Complete payment occurs

when the patient must bear the full cost of the medical service. This can result


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from having no health insurance or receiving services that are covered by the

health care users insurance plan. Cost-sharing, by contrast, includes out-of-

pocket payments where the patient is required to cover only a portion of his/her

medical services. A common example is insurance deductibles, where a patient

pays a fixed amount to his/her insurance plan before any payment of benefits

takes place. Another example is user fees, requiring that the patient pay a smallfee to the healthcare provider (e.g. the hospital) upon receiving medical service.

The second key source of health care financing is health insurance. In broad

terms, insurance is a means by which individuals pool the risk of incurring

medical expenses. Instead of paying for their medical services directly from their

own pockets, individuals or groups participate in a collective fund that covers

their health care costs. Health insurance can be organized in different forms,

with a basic distinction being public versus private insurance schemes. Public

health insurance refers to schemes covering the community as a whole (or

large segments of the community) which is imposed and controlled by a

government unit. Private health insurance, by contrast, refers to schemesthat are controlled and administered by non-governmental or private entities,

and which usually cover only a small portion of the general population.

Public insurance schemes can be further distinguished by the manner in which

they are funded. One approach is through insurance premiums, where

individuals pay regular premiums into a public insurance fund to receive benefits.

This is commonly referred to as social security financing. Another approach is

through taxation, where the insurance plan is funded by the government

through taxes paid by citizens and residents. Public insurance schemes can also

take a mixed approach, funded by both premiums and general taxation.

Private insurance schemes are usually funded through premiums, which

may be borne by the individual and/or his/her employer. Moreover,

private plans can be either non-profit or for-profit. In non-profitschemes,

the private insurer only seeks to collect premiums and other fees

necessary to cover the costs incurred by the insurance fund, such as

payment of benefits and administration costs. In for-profit schemes, the

private insurer operates the insurance fund as a business, seeking to

generate a profit by generating revenues above what is necessary to

cover costs. More information on health care financing is included later

in this article.

Financing Health Care in Canada

Predominantly public with some private participation

Like health care delivery, health care financing in Canada is a mix of public and

private participation. The mix associated with financing, however,

differs significantly.


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Health care delivery is characterized by private individuals and organizations

providing medical services, albeit with considerable government regulation and

control. Health care financing, by contrast, is characterized by direct government

participation through funding for health care facilities (i.e. hospitals) and

mandatory, universal public health insurance plans. ublic health insurance

plans alsorepresent a significant avenue of public sector financing. Eachprovince and territory in Canada has mandatory and universal health insurance

plans, to cover basic medical services. These are public insurance schemes

insofar as they are administered by provincial/territorial governments and

funded almost exclusively through taxation. This includes general

provincial/territorial taxes and the annual federal fiscal transfers (referenced

earlier). Some provinces have experimented with the idea of levying health care

premiums, charging provincial residents regular fees for health care services. In

addition, some provinces have also experimented with user fees (a flat fee

patients pay per medical visit) and extra-billing (allowing physicians to charge

extra fees above what they bill public insurance plans). Nevertheless, these

alternative forms of funding represent only a small fraction of public sectorspending on health care. As indicated in the above table, public health care

premiums in Canada totalled just over $2 billion in 2007. General government

funding, by contrast, totalled $107 billion.

Provincial/territorial health insurance plans are mandatory and highly

monopolistic. Canadians are required to participate in the public financing of

these plans through general government taxation and health premiums.

Moreover, private insurance is not available (or is very limited) for those services

covered by public plans. It is important to note, however, that public health

insurance is not completely comprehensive in its coverage. Also, while coverage

differs from one province or territory to another, it tends to cover only basic or

medically necessary services. This includes most primary and secondary care

services, such as visits to the family physician and specialized hospital care.

Medical services that fall outside the scope of public insurance plans must be

financed privately, either through direct, out-of-pocket payments or private

health insurance (see below for more information).

Another way the public sector finances health is through direct program funding.

The largest of these initiatives tend to relate to hospitals and other health

facilities. As discussed above, hospitals in Canada are typically operated by

private community or voluntary boards. Their operating and capital costs arelargely funded through annual government budgetary allotments. Governments

also spend directly on other programs such as health protection (i.e. anti-

smoking campaigns) and health research Chronic diseases, sometimes referred to

as noncommunicable diseases or NCDs, account for the highest causes of death in

Canada and the world. NCDs include a variety of chronic diseases such as arthritis,

diabetes, cancer, cardiovascular diseases, respiratory diseases, and mental illness.


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ThePublic Health Agency of Canada (PHAC)supports the WHO Collaborating Centre

on chronic noncommunicable disease policy. PHAC provides public health

practitioners in Canada and worldwide with data, analysis, web tools and technical

advice that support policies, programs and public health interventions for chronic

disease prevention.

PHACs Strategic Plan 2007-2012promotes a strong international public health

infrastructure and helps to reduce the risk factors leading to chronic illnesses by

sharing Canadas leadership and expertise in NCD health policy development.

Through strategic global partnerships, international cooperation and dialogue, we

also learn about successful initiatives in other countries.

The WHO Collaborating Centre on chronic noncommunicable disease policy delivers

onPHACs objectives by working in an international context to share Canadas

expertise to promote health policy planning, implementation and evaluation to

combat global noncommunicable diseases. First designated in 1994 [with successful

subsequent redesignation every four years by theWorld Health Organization

(WHO) ], the Centre is recognized as a worldwide centre of excellence in the

development, implementation and evaluation of NCD public health policy.

The WHO Collaborating Centre reports activities annually to World Health

Organization Headquarters (WHO HQ) and its regional body, thePan American Health

Organization (PAHO) to advance NCD prevention and control policies in Canada

and around the world.

Through PHACs policy initiatives as a contributing member ofWHO, public health

policymakers and practitioners in Canada and worldwide can find essential

information about chronic disease health policy research, training, evaluation,

capacity building and partnership initiatives.

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What We Do

At thePublic Health Agency of Canada (PHAC), the WHO Collaborating Centre onchronic noncommunicable disease policy promotes leadership and innovation to

combat noncommunicable disease (NCD) through public health policy planning,

implementation and evaluation activities.

In Canada and around the world, the WHO Collaborating Centre shares leading-edge

knowledge and practical tools pertaining to policy monitoring, policy research, policy
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training and capacity building, policy dialogue, policy partnership initiatives, policy

outreach, and policy legislation development.

Policy Monitoring

Monitoring NCD public health policy strengthens the national and global roadmap

that guides how best to take action in reducing chronic disease at the practical level.

. Policy Training and Capacity Building

Policy training and capacity building enlarge the field of expertise to prevent and

controlNCDs through the dissemination of methodological approaches and technical

tools.

Policy Dialogue

Policy dialogue is a method that allows research evidence to be considered together

with the views, experiences and knowledge of those who will be involved in or

affected by policy decisions. Policy dialogue promotes the continuous exchange of

emerging NCD public health policy information and initiatives at the country or sub-

regional level (e.g. the Caribbean, Central America) to help policymakers and

practitioners to formulate effective development, implementation and evaluation of

strategies to reduce NCDs.

Policy Partnership Initiatives

Policy partnership initiatives encourage the sharing of knowledge and resources

between participating partners and promote cross-disciplinary, cross-sectoral and

cross-cultural perspectives to stimulate action that changes risks to populations and

health determinants.

Policy Outreach

Through outreach activities such as presentations and publications,

the WHO Collaborating Centre disseminates recent developments in chronic disease

policy research and best practices. The state-of-the-art knowledge that is shared

assists policymakers in making effective and informed public health policy decisions,

in Canada and around the world.


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Policy Legislation Development

Legislation is the enactment of public health policy compelling specific actions for the

prevention and control of chronic or noncommunicable diseases. The enforcement of

supportive health measures, such as banning smoking in public places, together withconsequences for failure to comply, are cornerstones in controlling the risk factors

that contribute to chronic disease.

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Benefits to Canadians

ThePublic Health Agency of CanadasWorld Health Organization (WHO)

Collaborating Centre on chronic noncommunicable disease policy works nationally

and internationally through collaborative initiatives, partnership frameworks, grants

to support research and distribution of emerging chronic disease policy knowledge.

Public health policy is the roadmap that guides how best to take concrete action in

reducing chronic disease at the practical level. National health policy informed by

global best practices promotes effective action at the community and individual

level. Improving the lives of individuals through effective global health policy is in

Canadas health interest.

A Globalized World

Canadians live in an increasingly globalized world with interconnected economies and

health challenges. Our partnerships provide access to breakthrough scientific

research and developments in the field of chronic disease prevention and treatment.

Collaborative, multilateral action is key to tackling the many components that

contribute to chronic disease.

A Foreign Policy Priority

The Americas are and will remain a foreign policy priority (Government of

Canada, Canada and the Americas: Priorities and Progress, 2009). Canada, as a

country of the Americas, plays a special leadership role

through PHACs WHO Collaborating Centre on chronic noncommunicable disease

policy as a co-lead with the Pan American Health Organization in the CARMEN Policy

Observatory. (CARMEN is a network of 32 countries in the PAHO region committed to
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shared solutions in reducing chronic diseases through integrated, evidence-based

prevention and control programs).

Creative Solutions

Working across political and professional boundaries through intersectoral

collaboration promotes a strong knowledge base and new approaches to reducing

chronic disease mortality and morbidity rates.

Cost-Effectiveness

Contributing to the development and dissemination of internationally recognized best

practices helps improve cost-effectiveness by promoting sound investments in high-

impact interventions. Collaborating helps strengthen our approach to reducing the

burden of chronic disease in Canada while ensuring good value for money.

Canadas Reputation

Canada is known internationally for its advanced public health systems and plays a

leadership role in tackling chronic diseases for Canadians and for the world.

Development of advanced chronic disease policy monitoring, research, intervention

and evaluation through global health networks is in Canadas best interest.

A Fundamental Value

Canada promotes key Canadian values such as equitable access to health care

through its participation in international organizations. Promoting healthy living and

reducing chronic disease is a public health priority for Canada. Canada is committed

to developing and sharing tools and best practices to help build capacity for all

nations through its partnership with theWorld Health Organization (WHO) .

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Building momentum to tackle the global healthchallenge of the 21st century

By 2015 it is projected that more than 40 million people will die annually from

chronic diseases. Chronic diseases impose a much greater burden on poor countries
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and poor populations than on richer economies and must be tackled as a

development issue.

The challenge of chronic disease worldwide requires the reduction of economic

disparity between global citizens and effective access to healthy lifestyle and

preventative medical care. There is a new and urgent global priority to address

chronic diseases and the risk factors that impede effective reduction and control,

namely poverty, hunger, social exclusion, discrimination and inequality. In order to

empower populations through the promotion of positive lifestyle choices, there must

be sustainable access to education, health services and availability of health food

choices for consumers.

It also requires a collaborative approach between public health policymakers, non-

governmental agencies and private sector entities. Recent high level policy

discussions -- and subsequent commitment to multisectoral collaboration to address

rising rates of chronic disease -- have stimulated significant international

momentum.

Canada works at the frontlines through PHACs WHO Collaborating Centre on chronic

noncommunicable disease policy through its participation at key junctures in the

emerging rise of addressing chronic disease as a global priority.

September 2007

Uniting Against Chronic Diseases:

The CARICOM Summit on Healthy Living and ChronicDisease

Port of Spain, Trinidad and Tobago

The heads of thirteen Caribbean national governments met in Port of Spain, Trinidad

and Tobago under the umbrella of the Caribbean Community (CARICOM) Secretariat

in September 2007 to work together strategically by sharing knowledge and

resources to combat together the effects of chronic diseases and risk factors on their

respective populations.

The Summit was organized in partnership with thePan American Health

Organizations (PAHO) Chronic Disease Unit in conjunction with

the CARMEN Policy Observatory, including support from PHACs WHO Collaborating

Centre on chronic noncommunicable disease policy. (CARMEN the Collaborative

Action for Risk Faction Prevention and Effective Management of Noncommunicable
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Disease, is a network of 32 countries in the Americas, which form one of five major

geographical areas of the World Health Organization).

The successful summit marked the convergence of several components. First, the

summit was a direct consequence of the advent of a collective Caribbean

Cooperation in Health approach to shared health priorities among the member states

of CARICOM as a political integration framework. It was also based on the

recognition that Caribbean populations are the most seriously affected by the social

and economic burden of chronic diseases as a sub-region

within PAHOs CARMEN network.

The summit was also based on a model of cooperation between health, social,

legislative, education, agriculture, trade and fiscal sectors, pointing the way to

integrative public health policy initiatives where collaboration is the key to successful

intervention.

April 2009

Fifth Summit of the Americas:

Securing Our Citizens Future by Promoting Human

Prosperity, Energy Security and Environmental

Sustainability


At the fifth meeting of the member countries of the Americas, a new Declaration of

Commitment was drafted including two important articles addressing the

commitment to reducing the burden of chronic disease.

Article 28 calls for the promotion of comprehensive and integrated preventive and

control strategies at the individual, family, community, national and regional levels.

It also reiterates the critical need for innovative collaboration of the public sector,

private sector, media, civil society organizations, communities and relevant regional

and international partners.

Article 29 specifically instructs the inter-American Ministers of Health to work with

the Pan American Health Organization (PAHO) to incorporate the surveillance of

chronic disease and associated risk factors into existing national health information

reporting systems by 2015.

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November 2009

Commonwealth Heads of Government Meeting (CHOGM)

Partnering for a More Equitable and Sustainable Future


The Commonwealth Heads of Government Meeting (CHOGM) is the collective body of

54 Commonwealth countries representing 2 billion people. It is convened every two

years to review global, political and economic developments and to conduct a

strategic overview of the Commonwealths work in support of the interests of

member countries.

In November 2009, the theme of the meeting was Partnering for a more Equitable

and Sustainable Future. Although the main topic of discussion was addressing

climate change as a global challenge, chronic disease as a global health tsunami,threatening the economic and social development ofmany Commonwealth countries

was positioned as a worldwide health priority. A special statement was issued

affirming CHOGMs commitment to addressing the burgeoning incidence of

noncommunicable diseases (NCDs), and to increasing the ability of our countries to

respond to this emerging health crisis.

May 2010

Commonwealth Health Ministers Meeting

Geneva, Switzerland

At the Commonwealth Health Ministers Meeting, it was agreed that chronic disease

indicators would be tabled at the 2010 Millennium Development Goals (MDGs)

Review Summit, taking place at the United Nations General Assembly in September

2010 in preparation for the 2011 high level summit on preventing chronic disease.

The meeting sought to identify elements of a possible Commonwealth Programme of

Action, pursuant to the call by Heads of Government for the consideration of a UN

Summit on NCDs. It also provided countries with an opportunity to examine the

status of the MDGs in the Commonwealth and the challenges and opportunities that

face member nations.
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November 2010

CARMEN Policy Observatory Meeting on Chronic

Noncommunicable Disease Policy


In preparation for the September 2011 UN Summit on chronic

disease, PAHO members, including PHACs WHO Collaborating Centre on chronic

disease policy as a key member, met to prepare to ensure involvement of Heads of

State (through Ministries of Health) by sharing examples of

how PAHO/WHO contribute to chronic disease policy development and by

supporting WHO in coordinating the summit. PAHO will provide leadership by

showing how whole government and whole society approaches create effective

multisectoral collaboration.

September 2011

United Nations General Assembly

New York, USA

The increasing visibility of chronic disease as the worlds leading cause of death, and

moreover, the leading cause ofpreventable death has resulted in a UN resolution to

discuss strategies as an urgent priority for the 2011 meeting.

The resolution builds on Objective #1 of theWHO NCD Global Strategy Action Plan

2008-2013 which calls on global development initiatives to take into account the

prevention and control of chronic diseases and raise the priority accorded in

development work at global and national levels.

All UN member countries are now engaged in preparing surveillance, intervention

and policy evaluation activities in preparation for the global summit to address

chronic disease, the first time the rising pandemic of noncommunicable disease

around the world will be specifically addressed by the international body of heads of

government.
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2013

World Health Organization Health in All PoliciesMeeting

Helsinki, Finland

Health is largely determined by factors outside the health care domain. It is widely

recognized that decisions made by many sectors can help to influence the conditions

that shape the health of the population. Efforts to integrate health considerations

into societal policy-making with the aim to improve population health and avoid risk

factors of chronic diseases are being considered almost everywhere, at the

community level as well as at the national, regional and local levels.

PHACs WHO Collaborating Centre on chronic noncommunicable disease policy has

committed to work with WHO HQ in preparation of the 2013 Health in All Policies

(HiAP) summit to be held in Helsinki. The collaboration will focus on case studies thatpromote intersectoral policies in battling chronic disease:Mobilizing Intersectoral

Action to Promote Health: The Case of ActNowBC (2010)marks the first case study

report and accompanying backgrounder in this series.

Top of Page

Policy Development in Action

TheWorld Health Organization (WHO) has encouraged nations to work togetherto reduce the burden of chronic disease around the world. As the personal and

national costs of living with chronic diseases continue to rise, WHO is committed to

motivating transformational change and measurable improvements through

innovative international and intersectoral partnerships.

By sharing challenges and solutions, emerging proven approaches to public health

policy, implementation and evaluation will lead the way for all to significantly reduce

disease and the impediments that produce health inequities. Two leading agencies

dedicated to reducing chronic diseases have joined forces to address chronic

diseases in the Americas together:

The WHO Collaborating Centre on chronic noncommunicable disease policy is theonly chronic disease policy collaborating centre in the world. A vital part of

thePublic Health Agency of Canada (PHAC), this WHO Collaborating Centre is

recognized as a global authority in the analysis of policy development,

implementation and evaluation.
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ThePan American Health Organization (PAHO) is an international public healthagency working to improve health and living standards of the countries of the

Americas. It serves as the specialized organization for health of the Inter-

American System and as the WHO Regional Office for the Americas.

Together, PHAC and PAHO lead groundbreaking initiatives to mobilize a higher, more

effective level of strategic planning and interdisciplinary critical thinking to drive

national health policies.

Top of Page

CARMEN Policy Observatory

The Americas are and will remain a health policy priority for Canada. Canadians have

much to gain by being involved in the region, and they also have much to contribute.

Canadas government has made it clear that re-engagement in the Americas is a

critical international priority for our country Canada is committed to playing a

bigger role in the Americas and to doing so for the long term.

Prime Minister Stephen Harper

July 17, 2007

The WHO Collaborating Centre on chronic noncommunicable disease policy

at PHACconducts the CARMEN Policy Observatory jointly with PAHO to promote theexpansion of effective systematic chronic disease policy development and

implementation using both qualitative and quantitative methodologies. (CARMEN is a

network of 32 countries in thePAHO region committed to shared solutions in reducing

chronic diseases through integrated, evidence-based prevention and control

programs.)

The key areas of activity for the Policy Observatory are policy monitoring and

analysis, policy dialogues, policy research, outreach, capacity building and training.

The Policy Observatory's broad mandate includes the review of public policies

affecting chronic disease prevention, risk factors and risk conditions, as well as

relevant legislations and regulations. The Policy Observatory has been successful in

boosting the technical capacity of policy analysis in a number of countries of the

Americas, and around the world.
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Two recent collaborative initiatives between PAHO and PHACs WHO Collaborating

Centre on chronic disease have yielded groundbreaking results, harnessing strategic

planning to immediate action.

The Canada-Chile Technical Cooperation on chronic

disease policy

In 2006, Canadian and Chilean public health policy delegates attending the annual

Pan American Health Organization (PAHO) Directing Council Meeting forged an

ambitious technical cooperation initiative focusing on prevention and control of

chronic diseases, a priority for both countries.

The Canada-Chile dialogue produced an innovative framework for sharing technical

expertise in the prevention and control of chronic diseases. Working as member

nations under the PAHO framework, they developed a three-phase project:

PHASE 1 (DECEMBER 2007): Canadian representatives from PHAC visitedcounterparts in Chile to learn about Chilean strategies for chronic disease risk

factors and determinants in reduction and control;

PHASE 2 (AUGUST 2008): Chilean representatives visited counterparts in Canadato learn how chronic disease is managed through public health policy at the

national and provincial levels.

PHASE 3 (SEPTEMBER 2009): The Ministry of Health in Chile hosted aninternational cross-sectoral dialogue with participating experts from Chile,

Canada, Paraguay and Brazil. The dialogues produced the blueprint for a new

national plan of action for Chile, and a model for other countries on how

international collaboration and knowledge exchange enhances the respective

strategic policies of each participant.

The Uniting Against Chronic Diseases Summit

In 2007, the heads of 13 Caribbean national governments met in Port of Spain,

Trinidad and Tobago under the umbrella of the Caribbean Community (CARICOM)

Secretariat to work together strategically by sharing knowledge and resources to

combat together the effects of chronic diseases on their respective populations.

The summit was organized in partnership with PAHOs Chronic Disease Unit in

conjunction with the CARMEN Policy Observatory with support

from PHACs WHO Collaborating Centre on chronic noncommunicable disease policy.

The successful summit established a framework for the complex intersection of

several progressive vectors:


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Activation of a collective approach to shared health priorities among the memberstates of CARICOM as an emerging political integration framework;

Recognition of Caribbean populations as most seriously affected by the social andeconomic burden of chronic diseases;

Collaboration between chronic disease public health policymakers with non-governmental agencies and private sector entities;

Strategically linking chronic disease prevention and control to empoweringpopulations through the promotion of positive lifestyle choices with access to

education, health services and consumer choice;

Prioritizing national mandates through public policy, legislation and fiscalmeasures to reduce the negative effects of risk determinants such as tobacco,

alcohol and unhealthy foods;

Intersectoral solutions involving the integration of health, social, legislative andfiscal sectors.

Top of Page

Sharing Lessons Learned

One of the most persistent challenges in combating chronic disease is linking the

creation of ambitious public health policies to the delivery of tangible positive effects

in actual populations.

Sharing the lessons learned from international dialogue is central to the mandate of

theCARMEN Policy Observatory. Through outreachinitiatives, PAHO and PHACs WHOCollaborating Centre on chronic noncommunicable

disease policy share the best practices of their past projects.

High level planning sessions, collaborative agreements and dialogues, shared

knowledge of best practices, and resources allotted to research and case studies are

only meaningful if they can be harnessed to transformational change with an

accountability framework to measure causal effects.

Traditionally, public health policy has depended on a linear planning process followed

by implementation and evaluation, founded on a singular methodological paradigmand supported by political commitment and a variety of resources.

Emerging cross-disciplinary perspectives and best practices case studies have

shown that maximum efficacy comes with greater awareness and understanding of

the complex and interrelated components required to produce positive change. Many

components must be considered together to reduce population mortality and


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morbidity statistics and produce real life improvements for individuals and

communities coping with chronic diseases.

Moreover, a more sophisticated understanding of achieving results must also

combine improving the determinants of health that affect chronic diseases (such as

individual lifestyle choices) together with the reduction of disparities between

population segments (such as reducing unequal access to education, resources and

health services).

Defining Project Objectives

At the outset of the project, it is necessary to define project objectives. These

objectives, in turn, form a key part of the project accountability framework by

providing specific performance indicators against which the effectiveness of the

community intervention can be measured. Identifying the objectives also serves topromote greater dialogue among project participants about the importance and

approach to measurement of effectiveness and to identify future stakeholders of the

eventual performance assessment, such as funding bodies.

Project objectives should reach deeper than achieving dialogue or tabulating

statistics. Action should deliver transformational change, measurably delivering

individual change, community change and systemic change.

Gathering Data

Prior to launching the project, gather and prepare evidence. Undertake research, if

necessary, to ensure that credible and timely information is available to support

project objectives.

Defining Methodology

The realist synthesis model developed by Ray Pawson provides a new innovative

perspective for evaluating community health interventions by seeking to identify the

specific social mechanisms that determine outcomes. The realist synthesis model

views health programs as context-dependent and evaluates transformational change

by linking the intentions of intervention designers to the complex real-world contexts

of how communities respond to programs.

What mechanisms drive an intervention forward successfully, for whom and under

what circumstances? It is from the sometimes complicated answers to these


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questions that forward momentum will be found to create truly effective health

programs tailored to best suit the given context. By carefully considering the variable

social, political, economic and cultural environments that are proven to foster

successful change, health policymakers can identify the transferability of program

elements into community programs with comparable contexts.

Analyzing Context

Prior to designing an intervention or program action, it is critical to define and assess

the many factors that form the total project context. These can include social,

cultural, physical, environmental, economic, political, and gender factors. It is critical

to undertake this analysis each time at the onset of a project, as subtle fluctuations

within any single or cluster of factors will affect program effectiveness. These

drivers determine critical decisions in defining resource allocation, target

populations, methodology, timing and scope.

Top of Page

Defining Framework

To truly achieve transformational change by reducing chronic disease in populations,

and reducing the inequities to achieve health for all, a holistic framework is required.

This framework needs to link immediate, intermediate and long-term health

outcomes with external contexts and with the proven process components needed

for a successful community intervention.

With each community-based intervention, the framework has to be adjusted to

consider the particular external contexts that will influence the project parameters.

These include social, cultural, physical, environmental, economic, political and

gender exigencies. As these contexts are always in flux, assessments and

adjustments are critical to create an intervention that can thrive.

Implementing the Process

Moving from intervention planning to action depends on clearly defining the process

components and the underlying drivers or mechanisms to power the process.


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Collaborative Planning Mechanisms

Transformational change works best when the power of strategic partnerships is

harnessed to expand scope, resources and reach. Collaborative planning mechanisms

include:

Meaningful participation of all stakeholders Engaging in critical dialogue Sharing power and responsibility Planning and evaluating project actionCommunity Organization and Action Mechanisms

Effective interventions depend upon strong project governance and vigilance over

the process:

Evolving leadership Sustained mobilization of resources Critical reflection and systematic monitoring Ongoing educational and training opportunitiesTransformational Change Mechanisms

Community-based interventions should seek to achieve transformational change,

that is individual change, community change and systemic change. The mechanisms

for transformational change include:

Developing and attracting champions Generating public awareness of evidence-based project successes Influencing public policy and decision-making bodies Working with relevant social movements, private sector organizations and

advocacy groups

Improving knowledge exchange and community-academic partnershipsEvaluating Impact

Designing and delivering interventions are only part of the equation. These have to

take root in the community and improve both health indicators and reduce health

disparities between communities. These impacts or outcomes are linked to the

project objectives established at the outset of the project. In planning evaluation,

objective and subjective indicators must be defined as well as methods for

quantitative and qualitative data collection.


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Evaluation is the key to measuring success. An analytical method assigning relative

values to each mechanism has been developed by PHAC s WHO Collaborating Centre

on chronic noncommunicable disease policy in collaboration with theCanadian

Consortium for Health Promotion Research synthesizing all intervention process

mechanisms into an impact index. This impact index is correlated to an outcomes

index and the final score is weighted by the local context.

The impact index looks backward as an accountability measure gauging the success

of the investment in community-based interventions and also forward providing

guidance on future policy and funding decisions.

Top of Page

Our Partners

PHACs WHO Collaborating Centre provides leadership in chronic or

noncommunicable disease policy development, implementation and evaluation

through active collaborative projects, through collaboration with strategic partnership

networks and initiatives:

WHOs The Global Noncommunicable Disease Network (NCDnet)

The World Health Organizations2008-2013 Action Plan for the Global Strategy for

the Prevention and Control of Noncommunicable Diseases 2013 specifically calls

upon international partners, Member States and WHO to promote partnerships for

the prevention and control of noncommunicable diseases (NCDs).

NCDnet is a resource for the global health policy community providing practical tools

and resources to support monitoring and evaluation in the prevention and control of

chronic or noncommunicable diseases (NCDs). PHACs WHO Collaborating Centre is

leading the evaluation of the success of NCDnet as a partnership vehicle and plays a

vital role by assisting in the performance measurement of the implementation

of WHOs Global Action Plan.

Pan American Health Organization (PAHO)

PHACs WHO Collaborating Centre is a contributing partner in the Pan American

Health Organization public policies on noncommunicable diseases (NCDs). PAHO is

an international public health agency with more than 100 years of experience in

working to improve health and living standards of the countries of the Americas. It

serves as the specialized organization for health of the Inter-American System. It
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also serves as the Regional Office for the Americas of the World Health Organization

and enjoys international recognition as part of the United Nations system.

PAHO has aRegional Strategy and Plan of Action on an Integrated Approach to the

Prevention and Control of Chronic Diseases . One of the approaches is to create

multisectoral partnerships and networks for chronic disease, creating thePartners

Forum . PHACs WHO Collaborating Centre is a pillar of the regional NCD strategy.

Canadian Best Practices Portal for Health Promotion and Chronic Disease

Prevention

A central and early component of the Canadian Best Practices System, the Portal

provides relevant and accessible best practices information to enhance decision

making.

Canadian Coalition for Global Health Research (CCGHR)

The Canadian Coalition for Global Health Research is a not-for-profit organization

governed by a volunteer Board. The Coalition began in 2001 as an informal network

and has evolved through generous support from theCanadian International

Development Agency , theCanadian Institutes of Health Research ,Health

Canada , theInternational Development Research Centre and other

foundations. The Coalitions primary focus is on research to improve health in low-

and middle-income countries (LMICs) in Africa, Asia and Latin America.

Canadian Institutes for Health Research

Canadian Institutes of Health Research (CIHR) is the major federal agency

responsible for funding health research in Canada. It aims to excel in the creation of

new health knowledge, and to translate that knowledge from the research setting

into real world applications. The results are improved health for Canadians, more

effective health services and products, and a strengthened Canadian health care

system.

Canadian International Development Agency

Canadian International Development Agency (CIDA) is the lead player in delivering

Canadas official development assistance program. Its mission is to support

sustainable development in order to reduce poverty and to contribute to a more

secure, equitable and prosperous world.

Canadian Society for International Health
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The Canadian Society for International Health (CSIH) is a national non-governmental

organization that works domestically and internationally to reduce global health

inequities and strengthen health systems.

The CARMEN Policy Observatory

The CARMEN Policy Observatory is a joint initiative

between PHACs WHO Collaborating Centre on chronic noncommunicable disease and

the Pan American Health Organization (PAHO). The purpose of the Observatory is to

promote the expansion of effective systematic NCD policy development and

implementation using both qualitative and quantitative methodologies. The

Observatory also fosters strong international and pan-sectoral NCD-prevention

collaborations and shares its findings through a variety of channels including

publications, websites and international policy dialogues and conferences.

Top of Page

Centers for Disease Control and Prevention (USA)

CDCs National Center for Chronic Disease Prevention and Health Promotion is at the

forefront of prevention and control chronic diseases. The CDC conducts studies to

better understand the causes of these diseases, supports programs to promote

healthy behaviors, and monitors the health of the nation through surveys. Critical to

the success of these efforts are partnerships with state health and education

agencies, voluntary associations, private organizations, and other federal agencies.

Together, the center and its partners are working to create a healthier nation.

Chronic Disease Prevention Alliance of Canada

The Chronic Disease Prevention Alliance of Canada (CDPAC) is a networked

community of organizations and individuals who share a common vision for an

integrated system of chronic disease prevention in Canada.

Chronic Diseases and Injuries in Canada Journal

Chronic Diseases and Injuries in Canada (CDIC) is a quarterly scientific journal

focusing on current evidence relevant to the control and prevention of

noncommunicable (chronic) diseases and injuries in Canada. The journal publishes a

unique blend of peer-reviewed feature articles by authors from the public and private

sectors that may include research from such fields as epidemiology,

public/community health, biostatistics, behavioural sciences and health services.
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Economic Burden of Illness in Canada

Health Canada first published the Economic Burden of Illness in Canada (EBIC) in

1991 and again in 1997. The overwhelming response to these original reports and

continued requests for more detailed cost-of-illness information indicated the need

for an up-to-date revision that would provide even more detail than the first two

reports.

National Collaborating Centres for Public Health

The purpose of the Centres is to foster linkages throughout the public health system.

A key function is to connect, co-operate, collaborate and communicate with all

stakeholders in the public health community, including the provinces and territories,

international experts, academia, non-governmental organizations, the research

community and health practitioners.

World Bank

Since 1945, Canada and the World Bank have worked together, with other member

governments, to create a world based on a common vision. As our knowledge and

understanding of the world have changed and grown over the last sixty years, so has

that vision. Today, we continue to work together to finance projects, design policies

and deliver programs in an effort to eliminate poverty and create a world based on

the principles of sustainable development.

World Health Organization (WHO): European Regional Strategy

In the WHO European region, 86% of deaths are caused by noncommunicable

diseases a group of conditions that includes cardiovascular disease, cancer, mental

health problems, diabetes mellitus, chronic respiratory disease, and musculoskeletal

conditions. This broad group of disorders are largely preventable and are linked by

common risk factors, underlying determinants and opportunities for intervention.

Through the Deputy Chief Public Health Officer, PHACs WHO Collaborating Centre

coordinates an international working group on noncommunicable disease policy. It

provides social science methodology support to the development of both

the WHO European Regional Strategy and the Pan American Health

Organization NCD action plans.

World Health Organization (European Office) Chronic Disease and Health

Promotion
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WHOs regional office for Europe encompasses a region made up of 53 countries,

with over 880 million people. The sheer size of the European Region means an

incredible diversity of people and health situations. The Member States share a

common goal: ensuring that the European Regions citizens enjoy better health.

World Health Organization (WHO): Headquarters

PHACs WHO Collaborating Centre is a contributing partner in the World Health

Organizations public policies on noncommunicable diseases (NCDs). Of the 35

million people who died from chronic disease in 2005, half were under 70 and half

were women.

World Health Organization Headquarters (WHO HQ) Chronic Disease and Health

Promotion Department

Leadership and direction for urgent global, regional and national efforts to promote

health and to prevent and control major chronic diseases and their risk factors.
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Documents

Health Care in Canada Has Long Been a Source of National Pride