Reorienting Health Systems: Putting the PUBLIC back into Public Health

1
Reorienting Health SystemsPutting the PUBLIC
back into Public Health

• Conférence mondiale de lUIPES
• Vancouver, B.C.
• le 14 Juin, 2007
• Carolyn Bennett M.P.

2
IUPHE Fantasy
Le rêve de lUIPES
3

• Empowered patients
• Effective advocates
• Engaged citizens

4
Principles of Womens HealthWomens College
Hospital

• The Empowerment of Women
• Accessible Programs
• Broad Definition of Health Care
• Our definition of "health care" includes the
  prevention of disease and the promotion of
  health.
• High Quality of Care
• Collaborative Planning
• Innovative and Creative Approaches

5
The Em PHA sis is on the wrong syl
LAB le

6
Goal of Medicare Tommy Douglas

• Sharing risk
• getting people the health care they need when
  they need it.
• Keeping people well not just patching them up
  once they get sick

7
Fleeing the Medical Model,Embracing the Medicine
Wheel
8
Blame Hippocrates?
9
Affirm Hygeia
HYGEIA Goddess of Health
10
Learnings..

• Cuba
• Chile President Lagos
• Vietnam. VSF
• Thailand the Xray system..

11
Reorienting Health Systems from Health Care to
Health
12
Health CARE Magnetic North Pole
13
We need a strong opposing force for HEALTH
14
We need
Empowered Citizens
15
Health Care
Health CARE
Empowered Citizens
HEALTH
16
Empowered Citizens
HEALTH
17
Rx Civil society insisting on healthy public
policy

• Health literacy
• Civic efficacy
• Enlightened leadership
• Change in attitude
• respect for Bottom up solutions
• Democracy BETWEEN elections

18
Health Care or a Real System for Health

• Patchwork quilt of non- systems
• Focus on sicknessand the repair shops

19
Citizens have to get it

• More health less health care
• Service contract ??????
• Or longer warranty ????

20
The Tyranny of the Acute

• As long as citizens think of the sickness care
  system whenever they hear the word health we
  are not going to be able to reorient health
  systems.

21
Health is Politics

• If you want to move healthy public policies
  forward, you have to have political dynamite
• Dr. Halfan Mahler

22

• HOWEVER
• Public policy usually follows public opinion.
• BECAUSE.
• Doing the right thing is very difficult is the
  people arent onside
• Father knows best not great politics

23
CYNICISM
Meaningful citizen engagement must cynicism
not
24
Political Will to do the right thing

• Dramatically improves with an educated public
  health literacy
• Illiteracy for Afghan women - blind
• Cant see whats going on
• Citizens pulling healthy public policy. Civic
  efficacy

25
Values... Versus public opinion

• Public opinion ?
• sometimes very shortsighted
• Whats in in for me ?
• What we see in polling data
• Need to drill down to values
• Deliberative dialogue
• Empowerment
• taking the time to educate and listen
• speaking plain language
• 2 way accountability

26
Health literacy Civic Efficacy

• Ottawa Charter.
• Deconstructing the Deconstruction ????
• Or
• Get citizens the ammunition they need to help us
  .

27
Health Literacy Quizversion 1

• Is surveillance ?
• Pattern of disease
• cameras in school corridors
• Is Accessibility
• Getting the businessman to work from the suburbs
• Ramps and closed captioning
• Chronic Disease management
• What or who is being managed ?
• Isnt this about the health care providers too ?
• Why are we blaming the patients ?
• How many specialty clinics should one human have
  to attend ?
• Primary Care provider, setting
• Have you ever heard a real person say these words
  ?

28
What we have here is a failure to
communicate Cool Hand Luke 1967
29
The solutions are complex

• For every complex human problem, there is a
  neat simple solution, its just that its wrong
• HL Mencken
• Tax cuts
• More cops
• More prisons
• another MRI machine being used 9-5

30
Complex doesnt fit into a 7 second sound
bite..or on a bumper sticker

• We must fiercely defend the complex solutions for
  the complex problems ..
• BUTwe need simpler messages
• PLAIN LANGUAGE
• Myth busting data
• Paint the picture.
• beautiful GIS maps !!!!

31
Health Literacy Quizversion 2

Empowerment
Pulling Healthy Public Policy
Putting the Public back into Public Health
32
Public Health 101
33
1.Do you think we should have a

• A) strong fence at the top of the cliff
• B) state of the art fleet of ambulances and
  paramedics waiting at the bottom ?

34
1. Croyez-vous que nous devrions avoir 

• une solide clôture au sommet de la falaise?
• B) un parc dambulances moderne et des
  ambulanciers en poste en bas?

35
2. Would you prefer

• A) Clean air
• B) Enough puffers and respirators
• for all

36
2. Préféreriez-vous

• A) de lair pur?
• B) suffisamment de pompes et de respirateurs pour
  tous?

37
3. Would you prefer that wait-times were reduced
by

• A) a falls program to reduce preventable hip
  fractures
• B) private orthopaedic hospitals and more
  surgeons

38
3. Préféreriez-vous que les temps dattente
soient réduits grâce à 

• un programme de prévention des chutes pour
  réduire le nombre de remplacements de hanches?
• B) des hôpitaux privés de soins orthopédiques et
  davantage de chirurgiens

39
4.Should we invest in

• A) early learning, child care, literacy,the
  early identification of learning disabilities and
  bullying programmes
• B) increase the budget for young offenders
  incarceration

40
4. Devrions-nous investir dans

• lapprentissage, la garde, lalphabétisation et
  le dépistage des troubles dapprentissage chez
  les jeunes enfants, les programmes contre
  lintimidation.
• B) augmenter le budget pour les jeunes
  contrevenants?

41
5.Should we

• A) assume that the 'grey tsunami' will bankrupt
  our health care system
• B) include our aging population in the planning
  of strategies to keep them well

42
5. Devrions-nous

• croire que le tsunami gris ruinera notre
  système de santé?
• B) tenir compte de la population vieillissante
  dans des stratégies visant à en garantir le
  bien-être?

43
6. Is the best approach to food security

• A) food banks and vouchers
• B) Income security,affordable housing, community
  gardens and community kitchens and a national
  food policy

44
6. La meilleure approche concernant la sécurité
alimentaire réside-t-elle dans

• A) les banques et les bons alimentaires?
• B) La securité financière, le logement abordable,
  les jardins communautaires et les cuisines
  communautaires?

45
7. Pick the one that is NOT correct

• Pandemic Preparedness should focus on
• Tamiflu for all
• Working with the vets to keep avian flu a disease
  of birds
• Making sure people wash their hands especially
  the doctors and nurses
• Research on vaccines
• Community care plans for our most vulnerable

46
7. Choisez-vous lun qui est incorrect

• Les prepréparation doivent avoir le focus de
• Tamiflu pour tous
• Travailler avec les vétérinaires pour assurer que
  la grippe aviare reste une maladie des oiseaux
• Assurer lavage à la main
• La planification communautaire pour les plus
  vulnérable.

47
7.Governments should boast about

• how much they spent on the sickness care system
• the health of their citizens, leaving no-one
  behind

48
8. Les gouvernements devraient-ils se vanter

• du montant dépensé dans le système de soins aux
  malades?
• B) de la santé des citoyens ne laissant personne
  derrière?

49
teachable moments

• 2003
• Canada 44 died of SARS
• France14,000 died in the heat wave
• 2005..Katrina, Kasheshewan

50
Beyond borders. SARS as a teachable moment

• Beyond silos
• Departments
• Disciplines
• Beyond jurisdictional squabbling
• Germs dont respect borders
• Neither do the social contagions
• Nor the humanitarian imperatives

51
Social Determinants of Health vsChoose
Health(modifiable risks)
52
The Causes of the Causes

• Versus
• The Causes

53
Evolution of the Healthy Canadians Tree
54
(No Transcript)
55
Progress

• First MoS Public Health 2003-2006
• Public Health Agency of Canada
• Chief Public Health Officer
• Public Health Network for Canada
• Health Goals
• National Collaborating Centres
• Knowledge Networks for the SDOH Commission

56
CommuniquéFMM September 2004

• In addition, governments commit to accelerate
  work on a pan-Canadian Public Health Strategy.
  For the first time, governments will set goals
  and targets for improving the health status of
  Canadians through a collaborative process with
  experts. The Strategy will include efforts to
  address common risk factors, such as physical
  inactivity, and integrated disease strategies.
  First Ministers commit to working across sectors
  through initiatives such as Healthy Schools.

57
Health Goals for Canada

• As a nation, we aspire to a Canada in which
  every person is as healthy as they can be
  physically, mentally, emotionally and
  spiritually.

58
Next step

• Indicatorsfor each goal ?
• Canadian Index of Wellbeing
• Atkinson Foundation .very interesting

59
Changing the way we do things..

• Good Governance Ursula Franklin
• Fair
• Transparent
• Takes people seriously

60
Changing the way we do things..

• Measurement
• Process
• Structure

61
Changing the way we do things..Managing for
results..

• Whole of Government results.
• Health outcomes NY State. Hb A1C reportable
• Health system performance readmission rates
• The Causes (modifiable risks)
• The Causes of the Causes (SDOH)
• Transparent, comparable and understandable
• Newfoundland and Labrador Community Accounts
• Measuring Quality of Life The Use of Societal
  Outcomes for Parliamentarians
• 2001, Library of Parliament, Canada
• GIS invaluable..
• http//www.statcan.ca/english/freepub/82-221-XIE/
  2007001/maps/maps.htmdt

62
With the Public Health Map Generator, you can
produce high quality, detailed maps of your own
health data, in combination with extensive
geography from our spatial data warehouse
63
The Public Health Map Generator is a secure,
web-based mapping application, accessible only to
clients registered with the GIS Infrastructure at
the Public Health Agency of Canada.
GIS User

All of the Infrastructures services, including
the Public Health Map Generator, are available at
no cost to all public health professionals in
Canada.
64
The mobilization of shameIrwin Cotler

Management 101 If its measured it gets
noticed, if its noticed it gets done
65
Process .

• Article 54 in PQ
• HIA. All MCs , budget, TB guidelines
• Gender Based Analysis
• Disability lens
• Triple bottom line. NWT
• UKChildrens Commissioner.
• impact on children of all policies
• Bias-free framework Mary Anne Burke, Margrit
  Eisler Global Forum for Health Research

66
Structure Gridlock
horizontal departments
vertical - jurisdiction
67
Structure

• Silo- busting - Horizontality
• Ministries or Ministers
• ACTNOW B.C.
• Seniors, Children, Women
• Multicultural/Settlement
• UK Minister of Joined-Up Government
• Cabinet committees
• Paul Martins Aboriginal Affairs Kelowna
• Manitoba Cabinet Committee on Children
• Parliament
• Status of Women
• Persons with Disabilities.

68
Structure

• Jurisdictional squabble
• SARS . Naylor report..
• Collaboration
• Cooperation
• Communication
• Clarity of who does, what, when

69
Disability Supports and Services
70
Public Sector All different departments Agencies
Voluntary Sector
Private Sector
National
Provincial/State
local
71
Public Sector All different departments Agencies
Voluntary Sector
Private Sector
National
Provincial/State
local
Healthy Public Policy
Empowered Citizens
72
Population Health Keeping Canadians healthy.

• Citizen centered federalism
• bottom up
• Strong common purpose.
• Local wisdom, local knowledge to get it done
• Aligning all levels of government and all
  government departments to what is determined in
  communities.

73
InternationalWHO NGO Advisory Group Health
Promotion

• Clear they need to be included
• Clear they know its politics
• strengths
• Respond to needs in community
• Identify policy gaps
• Advocacy and consensus building
• Resource mobilization

74
Mahler

• All I learned was from developing countries.
• Learned the word Empowerment
• Community Empowerment
• Family Empowerment
• Individual Empowerment
• NB dynamic centre is the family

75
Ministries of Diseases Dr. Harry Jeene

• Mirroring the way Northern countries are
  structured, developing countries also fund health
  as a set of diseases.

76
Health Promotion in partnership Dr. Harry
Deene

• There is not much profit to be made in Health
  Promotion, certainly not for the Pharma, fast
  food and entertainment industries,
• Neither for the donors who require quick wins,
  direct attributions and an increasing preference
  for commodities.
• There is even little in it for the formal health
  care providers, including those in primary health
  care
• Major shifts in thinking are required, and these
  can only be driven by communities working as full
  and equal partners with the formal health system,
  especially at the Primary Care level.

77
Dr. Harry Deene

• We have missed our Alma Alta
• 2000 targets
• We are missing our 2015 MDG targets
• (and where are health promotion, chronic
  conditions, mental health and trauma in these
  MDG's'anyway ?)
• Civil Society will have to exercise much more
  pressure to get health promotion on the agenda,
  North and South.

78
The Policy Makers

• As most decision makers are male, female health
  issues are particularly hard to get on the agenda
  
• (Some female health ministers, not enough female
  finance ministers)
• Dr. Harry Jeene

79

Putting the poli back into Politics ( policy
!)

• The art of making the necessary possible
• Deciding what is necessary is political..
• We need great people to run for public office.
• We need great people to want to be civil
  servants.
• They need to be believers in bottom up

80
No time for pessimists
81
Sir Michael Marmot

• Evidence is not enough. There has to be the
  desire, the political will for change. Given that
  will - a big given but I am an optimist - the
  evidence of what works will be a great help.

82
Research.Learning Culture

• Evidence-informed practice
• Practice-informed evidence
• Courage to fund what works
• Courage to stop funding what doesnt
• Complex adaptive systems

83
We need enlightened leadership too !!
HEALTH
84
Dr. John Hastings M.O.H. Toronto on the
occasion of his Presidency of the APHA,1918

• Every nation that permits people to remain under
  the fetters of preventable disease and permits
  social conditions to exist that make it
  impossible for them to be properly fed, clothed
  and housed so as to maintain a high degree of
  resistance and physical fitness and, who
  endorses a wage that does not afford sufficient
  revenue for the home, a revenue that will make
  possible the development of a sound mind and
  body, is trampling on a primary principle of
  democracy.

85
Reorienting Health Systems


Healthy Public Policy
Empowered Citizens
Enlightened Leadership
86

• The care of the public health is the first duty
  of a statesman."
• Benjamin Disraeli
• Aspiring to become a statesman should be the
  first duty of every politician