February 2006
Towards a
POPULATION
HEALTH PROMOTION
APPROACH
A Framework and Recommendations for Action
EXECUTIVE SUMMARY
Population health is an approach to health that aims to improve the
health of the entire population and to reduce health inequities among
population groups. In order to reach these objectives, it looks at and
acts upon the broad range of factors and conditions that have a strong
influence on our health (from the Public Health Agency of Canada).
A population health approach has the potential to not only improve health status, but to
contribute to the overall sustainability of the health care system. This method requires
action in four areas:
This involves recognizing the existence of a health issue or health disparity
and assuming a responsibility to redress it.
LEADERSHIP >
Responding to health issues often requires action across more than one
jurisdiction, requiring inter-sectoral strategies. Partnerships are essential components of a
population health strategy and facilitate the creation of health promoting environments
and conditions for the population.
PARTNERSHIPS >
Advocacy is an effective strategy for addressing the social determinants of
health. This strategy often calls for a visible leader or spokesperson that can raise awareness
and represent the need to the public, media and political bodies.
ADVOCACY >
Healthy public policy is a critical component in the move to shift
health care from an illness driven model to one that focuses on the health status of the
population. Policy development can be a key outcome of advocacy and lobbying efforts and
can be addressed at a number of levels.
POLICY DEVELOPMENT >
A series of recommendations have been developed to implement a population health promotion
strategy in Vancouver Coastal Health. These include population health promotion workshops
for members of leadership groups; the creation of a population health promotion leadership
position; the creation of a population health surveillance unit; an annual VCH Population
Health Report; a Population Health Promotion Collaborative; and, support for community
based health promotion initiatives.
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BACKGROUND
Vancouver Coastal Health (VCH) delivers an array of programs through three service networks
— acute care, community care and primary health care. Although these services have an
impact on the health of the VCH population, significant improvements can also be made
through illness avoidance strategies and the creation of programming/policies directed at
vulnerable population groups. The cost of providing health care services is staggering and
will continue to escalate with the advent of newer, complex and expensive technologies and
pharmaceuticals. Sustainability is a key issue for the health system. Through an investment
in population health promotion, and a corresponding reduction in the burden of illness,
VCH can strategically contribute to a more sustainable health care system. Each avoided
illness can potentially translate into avoided diagnostic and treatment services.
In addition to the impact on people’s health and the direct costs of the health care system,
population health and public health strategies produce a significant return on investment
from a broader economic point of view. Interventions to prevent disease and disability can
have a significant impact on future healthcare costs. As seen in the chart below, the costs
for providing Diabetes care can be reduced through the promotion of healthy lifestyles
(i.e. healthy weights).
Estimated Actual and Projected Health Service Costs for Persons with Diabetes,
Under Varying Assumptions as Population Control of Overweight in 10 Years, B.C.
1993/94 to 2011/12
Prevalence of
Overweight
$1,200
45%
Constant 1999 $
Current Year $
$1,000
Costs
(millions)
30%
$800
15%
0%
$600
$400
$200
2011/12
2010/11
2009/10
2008/09
2007/08
2006/07
2005/06
2004/05
2003/04
2002/03
2001/02
2000/01
1999/00
1998/99
1997/98
1996/97
1995/96
1994/95
1993/94
$0
Year
The term population health promotion is used in this paper to encompass a broad range of interventions. These include population
health strategies that focus on multi-sectoral actions to address the determinants of health, as well as more targeted health service interventions such as health promotion aimed at building community capacity reducing health risks in specific populations or changing
individual health behaviors.
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DEFINITION
Population health is an approach to health that aims to improve the health of the entire
population and to reduce health inequities among population groups. In order to reach these
objectives, it looks at and acts upon the broad range of factors and conditions that have a
strong influence on our health (from the Public Health Agency of Canada).
As an approach, population health focuses on the interrelated conditions and factors
that influence the health of populations over the life course, identifies systematic
variations in their patterns of occurrence, and applies the resulting knowledge to
develop and implement policies and actions to improve the health and well-being of
those populations. (Federal/Provincial/Territorial Advisory Committee on Population Health)
This definition makes it clear that to influence the health outcomes of a population, it is
essential to have an understanding of the interrelated conditions and factors that influence health – the
determinants of health. Some examples of the determinants of health include education, employment, income, housing, adequate nutrition, social supports, social networks, and access to
health care services. In addition to identifying these determinants, it is also necessary to
have the will to develop and implement policies and actions that will lead to improved health and,
most importantly, eradicate the disparities in health across population groups.
The Vancouver Coastal Health Vision statement commits to “supporting healthy lives in
healthy communities with our partners through care, education, and research”. VCH currently
approaches this commitment primarily through an individual patient/client based perspective.
In contrast, a population health approach focuses on the health influencing factors that exist
outside of individuals. These may occur both within and between groups of individuals,
including families, neighborhoods, communities or geographic regions.
Population health is not synonymous with targeted health interventions aimed at specific
sub-populations, such as a prevention program for people with mental illness. Population
health is about systems changes (i.e., education system, housing, recreation system) in the
context of the population and the communities where people live. Population health is also
not synonymous with ‘public health’, although there are many population health strategies
that are advanced through public health actions. Consequently, the public and community
health programs being offered by VCH, while valuable, are not solely able to address the
broad scope of health determinants identified above. It is important to understand that a
commitment to improve population health does not always demand a ‘service’ or ‘program’
type response to the need. However, it does demand that VCH recognize when and where
there exists a need to improve health status or reduce inequities. This recognition should
result in action to bring awareness, understanding and ultimately a resolution to the issue.
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KEY POPULATION
H E A LT H P R O M OT I O N E L E M E N T S
Canada is considered a worldwide leader in population health. The model of population health
promotion shown in the following figure was developed to show the inter-related components
that make up a population health promotion approach. As shown in this model, these include:
Re-orienting health services
Developing personal skills
Creating supportive environments
Building healthy public policy
Strengthening community action
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This is a powerful framework that provides a foundation for the design of a population health
promotion approach. Implementation of the framework is dependent on some key strategies
that must be a cornerstone of a population health approach within VCH. As one of the largest
health authorities in Canada, VCH has the potential to be a national leader in population
health. Population health based actions require: leadership, partnership, advocacy, and policy
development—all factors that influence the inter-relationships between individuals within
populations.
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LEADERSHIP > This involves recognizing the existence of a health issue or health disparity and
assuming a responsibility to redress it. Actions may include developing alliances, coalitions
or partnerships, particularly for issues that are cross-jurisdictional such as those involving
local governments or politicians. For example, this strategy has been successful in addressing housing issues and issues of harm reduction through the vibrant Four Pillars approach
in Vancouver’s Downtown eastside. The success of this approach was dependent on the
proactive leadership shown the by the mayors of Vancouver, leaders in the Vancouver/
Richmond Health Board and members of the Vancouver Police Department.
VCH is
currently working with
the Healthy Living Alliance,
the BC Recreation Council and
municipal parks and recreation
departments to champion
Political leadership is often critical to the success of these approaches.
A central facet of this strategy is the development of leaders and
champions within communities. If leadership from within the health
sector is not practical, possible, or desirable, then the Health
Authority can work to cultivate a champion and leader from within
another sector of the community.
healthy active living
initiatives.
PARTNERSHIPS > Partnerships are essential components of a population health strategy that
facilitate the creation of health promoting environments and conditions for the population.
Responding to health issues often requires action across more than one jurisdiction, requiring inter-sectoral strategies. A Health Authority can also play the role of
an ‘instigator’ of a partnership if it recognizes a health issue
where the resolution rests outside its formal jurisdiction.
Across VCH, there
are numerous examples
of partnerships ranging from
the Vancouver Agreement to
Richmond’s substance abuse
strategy to the North Shore’s
homelessness
strategy.
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ADVOCACY > Advocacy is an effective strategy for addressing the social determinants of health.
This strategy often calls for a visible leader or spokesperson that can raise awareness and
represent the need to the public, media and political bodies. Social, political and
Through advocacy,the
primary health care principles
economic factors are all potential areas of advocacy for political action and
policy change. Advocacy can be one of the most effective population
of equity and accessibility are
taken into account and actively
health/ health promotion strategies, with the end result being the
development and implementation of policy that directly impacts health
outcomes on a sustained basis.
promoted in the development of
needed resources for the
disadvantaged.
POLICY DEVELOPMENT > Healthy public policy is a critical component in the move to shift
health care from an illness driven model to one that focuses on the health status of the
population. Policy development can be a key outcome of advocacy and lobbying efforts and
can be addressed at a number of levels. At both micro and macro levels,
healthy public policy should focus on population health with an
emphasis on health status, equity, and multi-disciplinary and
The policies of the VCH
multi-sectoral elements consistent with the principles of
Primary Health Care Network are an
primary health care.
example of internal policy development
that can influence the health of the population.
Through these policies, the Network is
undertaking the development of an infrastructure that will support individuals in
These approaches are relevant to all levels and
assuming more responsibility for their
members of the Health Authority. It is only through the
recognition and acceptance of responsibility for the health
own medical conditions
and care.
status of our community and population that any meaningful
progress will be made. The path to be avoided is to assume it is
someone else’s job or domain and they will look after it. Equally undesirable is to
maintain that it is everyone’s job, making responsibility so diluted as to lack focus,
and to fail to assign accountability for an outcome.
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VC H P O P U L AT I O N H E A LT H
PROMOTION STRATEGIES
Vancouver Coastal Health has grouped its services into three interconnected networks —
acute care, community care and primary health care. VCH is currently developing a population
segmentation strategy to complement its three service delivery networks. The goal of this
strategy is to identify key target populations that have similar needs and where system-wide
strategies and population health approaches may be particularly beneficial. Once defined,
VCH wants to ensure that there are formal processes for the defined populations to have
involvement in the networks, thus allowing consumer/community needs to help shape the
priorities and framework for service delivery. The population groups identified can also be
used as the foundation for the strategies outlined in the VCH Population Health Framework.
By building on the creation of a population focus within the service delivery networks, VCH
can create a resource for community partnerships that can address the broad determinants of
health that are beyond the sole ability of the Health Authority to address.
An initial set of recommendations have been developed to implement VCH’s Population
Health Promotion Strategy. These include:
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P O P U L AT I O N H E A LT H P R O M OT I O N WO R K S H O P S FO R L E A D E R S H I P G R O U P S
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In order to increase the understanding and capacity of key VCH leadership groups (i.e.,
VCH Board and Senior Executive Team) around population health priorities and strategies,
workshops can be developed as part of regular planning activities. The workshops are an
interactive opportunity for the VCH leadership to familiarize themselves with, and discuss,
the important and complex set of strategies that form a population health promotion
approach. The workshop is not designed as a didactic exposé of current VCH population
health promotion initiatives. Rather it is an opportunity to understand and explore the
critical role of senior leadership in population health and the importance of strategies such
as policy development, advocacy and political partnerships in improving people’s health.
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L E A D E R S H I P P O S I T I O N — P O P U L AT I O N H E A LT H P R O M OT I O N
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A new leadership position has been created for population health promotion. Currently the
responsibility and accountability for population health is diffused throughout VCH at the
level of program directors within HSDA’s, medical health officers and the Primary Health
Care Network. While this diffusion has very real advantages and need not be eliminated, it
is important to have a leadership focus to accomplish several outcomes. Responsibilities for
this position will include: taking leadership of a Population Health Promotion Collaborative;
coordinating internal efforts; facilitating provincial and national collaboration, and initiating
advocacy efforts around population health issues.
P O P U L AT I O N H E A LT H S U R V E I L L A N C E U N I T
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Central to population health is the ability to analyze the population’s health status, burden
of disease and emerging health issues through surveillance and intelligence gathering.
These capabilities guide the development of appropriate and timely interventions, as well as
providing measurements on the impact of population health strategies. With the increasing
sophistication and availability of data sets both nationally and provincially, there is a wealth
of information that is not being fully utilized to facilitate evidence-based decision-making
in population health. A dedicated unit modeled on that currently operating in VIHA,
would enhance the analysis of existing databases, as well as ensuring that appropriate surveillance and intelligence gathering was occurring across VCH. The unit would also support
the work of the Collaborative (see below) and the development of an annual report on the
population health status of VCH. VCH is working with the Provincial Health Services
Authority to develop the capacity required to support population health surveillance.
I S S U E A N A N N U A L VC H P O P U L AT I O N H E A LT H R E P O R T
The nature of many population health issues do not lend themselves to discrete, easily
identifiable or measurable indicators. Often, population health initiatives require long-term
monitoring before outcomes of success are observable. Further, population health measures
demand a narrative or descriptive method supported wherever possible by both intermediate
and long-term indicators. An annual report under the auspices of the Medical Health Officer,
and patterned after the Provincial Health Officer’s report, will summarize the population
health of VCH and will assist in identifying areas for strategic policy and partnership
development. It will also establish important annual benchmarks for the accountability and
performance assessment of VCH in improving the health status of the region’s population.
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A P O P U L AT I O N H E A LT H P R O M OT I O N CO L L A B O R AT I V E
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The formation of a Population Health Promotion Collaborative will not only signal the
strategic importance of population health initiatives, but will also provide leadership for
a forum where participants from across VCH can come together to identify issues, define
measurable outcomes and select actions. The Collaborative, modeled after similar VCH
initiatives, would require the same support that has been intrinsic to their success including
mentoring and coaching, IT systems support, communication support and other resources
as required.
S U P P O R T FO R CO M M U N I T Y B A S E D / I N I T I AT E D
H E A LT H P R O M OT I O N P R O G R A M S
A cardinal tenet of population health promotion programming is that it must reflect the
needs of the community and foster various avenues for community participation. In this way,
VCH can be responsive to community ideas and reflect diverse values and views on proposed
solutions. As one strategy, VCH has at its disposal the community health promotion fund—
the SMART Fund, which supports community based health promotion initiatives. Funding
has been allocated to expand the SMART Fund.
Sources of Information
Anderson, E. T. (1996). Community as Partner: Theory and Practice in Nursing. Philadelphia: Lippincott.
Epp, J. (1986). Achieving Health for All: A Framework for Health Promotion. Ottawa, ON: Minister of Supply and Services.
World Health Organization (1986). Ottawa Charter for Health Promotion. Ottawa: World Health Organization, Health and
Welfare Canada & Canadian Public Health Association. Available: www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf
Public Health Agency of Canada: Population Health Approach.
www.phac-aspc.gc.ca/ph-sp/phdd/
Shah, C. P. (1998). Public Health and Preventive Medicine in Canada, 4th Edition. Toronto: University of Toronto Press.
Stewart, M. J. (2000). Community Nursing: Promoting Canadians’ Health.Toronto, W.B. Saunders Company.
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CONCLUSION
Population health promotion has the potential
to improve the health of the people we serve
and the sustainability of the health care
system. It requires leadership, commitment,
a clear mandate and resources to sustain a
comprehensive range of strategies. It also
requires linkages with the community and
populations in need. The evidence about the
return on investment in this approach suggests
that efforts to expand population health
promotion will reap benefits into the future.
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For more information, contact:
Ted Bruce
Executive Director
Primary Health Care Network
11th Floor, 601 West Broadway
Vancouver, BC
V5Z 4C2
Tel: (604) 875-4673
Fax: (604) 875-4388
Email: [email protected]