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Wednesday, December 15, 2010

Social Determinants of Health - Pamela Fralick Responds

Pamela Fralick, President and CEO, Canadian Healthcare Association

Health Council of Canada’s Stepping it Up:Moving the Focus from Health Care in Canada to a Healthier Canada

On the bottom shelf of a bookcase at home I have, among other relics, three dusty and tattered original documents – prized possessions, actually. They are the seminal 1974 A New Perspective on the Health of Canadians, the internationally acclaimed 1986 Ottawa Charter, and the groundbreaking F/P/T Agreement on Determinants of Health, signed in Victoria, BC in 1994. And now, we have the Health Council of Canada’s report, Stepping it Up.  Will this be the one that nudges us precipitously towards the tipping point where action will actually take place?

As a matter of course, I review a great number of papers on a wide variety of “hot” health system topics.  Most are informative and well presented. This report, however, actually got me excited – something to say for a serious tome!

This paper brings together all of the past and present proclamations on determinants of health in a non-emotional, professional way, yet manages to light a fire.  For instance, highlighting Senator Wilbert Keon’s statement:  “increased expenditures on health care are likely impacting negatively on the general health of our population by virtue of diminished investments by other areas like education...” frankly causes me to wince, as I reflect on how true this statement is, and how little we collectively have done.

And compelling statements such as “...our analysis confirms what the literature has already told us: research and analysis about health promotion and the determinants of health are not being translated into public policy and program  action in Canada to the degree that was expected,” add to the ‘wince factor’.  More than a fire, this should create a blaze!

The report is filled with provocative sidebar snippets, quotes from all of the major reports, and evidence/data that can only allow us to conclude ‘there must be something to this’. Even the challenging cost-benefit question is taken on, allowing the reader to understand progress made and questions remaining.

How is it then, when we know so much, that efforts to change our approach have been so relatively futile?

The Health Council calls into play the “wicked question” concept. True enough. But fortunately, the Health Council doesn’t use that ‘excuse’ to let us off the hook; there is the hint of a path to action. For instance, the report identifies the existing bodies it feels are well positioned to lead action. The Health Council also proposes a whole-of-government approach as necessary for change, or success, and cites the September 2010 declaration of the country’s Health Ministers as reason for optimism.

But this declaration is heavy on prevention and promotion, lighter on determinants of health and too new to prove successful in terms of concrete action.

In the end, although tantalizingly close to ‘next steps’ recommendations, the report frustrates in its lack of pointed direction for the future.  Given the challenges and failures of past decades, perhaps that was too much to expect. Perhaps the most important message to take away is that we all must find our role as change agents, and put that in motion. Now.

For our part, CHA recently approved a new six-point plan for its advocacy efforts in the coming years. Several of the plan’s points will incorporate a determinants of health approach, particularly within the illness prevention/health promotion focus area. We, too, can do more to move our work from health/healthcare-specific to health-determining. And must.


Ms. Pamela C. Fralick is the President & CEO of the Canadian Healthcare Association. She also acts as co-chair of the Health Action Lobby, a coalition of 37 national health associations and organizations, co-Chair of the Canadian Coalition for Public Health in the 21st Century, and Chair of the Quality Worklife-Quality Healthcare Collaborative.

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