Mobilizing intersectoral action to promote health: the case of ActNow

in British Columbia, Canada

Bamako Forum 2008

Robert Geneau, PhDGayle Fraser, MABarbara Legowski, B.Sc.Phm., Pharm.DSylvie Stachenko, MD, M.sc.

World Health Organization Collaborating Centre on Chronic Non-Communicable Disease Policy

Key lesson from the field of tobacco control

• Success stories have a common feature– Intersectoral action

Debate • Should jurisdictions develop an umbrella or

integrated NCD strategy in order to

increase coordination between risk factor

specific or disease specific strategies and

initiatives?

– Working “integratively”?•This is not a new idea:

–Promoted by WHO, PAHO…

Integration• An integrated approach on the largest

scale means simultaneously targeting

(multiple) risk factors, underlying

determinants of health and

opportunities for disease prevention

common to major CDs. The approach is

strategic by delivering an impact on

more than one disease.

Does it work?

• … maybe I am wrong, but

we still don’t really know

if integration is better.…

We know anecdotally that

it is better…

Integration

• Opportunities & Challenges

– Make the business case/advocacy– Implementation– Evaluation- Measuring Success

ActNow BC TargetsPhysical Activity – To increase by 20% the proportion of the B.C. population (aged 12+) who are physically active or moderately active during their leisure time.

Healthy Eating – To increase by 20% the proportion of the B.C. population (aged 12+) who eat the daily recommended level of fruits and vegetables.

Tobacco Use – To reduce by 10% the proportion of the BC population (aged 15+) that use tobacco from the current prevalence rate (2003) of 16.0% to 14.4%.

Overweight/Obesity – To reduce by 20% the proportion of the B.C. population (aged 18+) currently classified as overweight or obese by 2010.

The case of ActNow

• “ActNow is not just an umbrella for how the government interacts with the public, but it is about how it interacts internally in and of itself (…) so it is holistic in terms of a government approach”. (KI- 27)

ActNow BC

Horizontal Dimension: -Whole-of-government Initiative

Vertical Dimension BC Healthy Living Alliance Regional Health Authorities Municipalities Private Sector

Agenda Setting…• Benefit of integration

– Make it not only a health story but also an economic story

•Not only about one disease/one risk factor but about NCDs

100.0%

41.6%

53.6%

71.3%

27.0%27.0%

27.0%

-0.6%

16.6%

28.4%

-10%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

04/05 05/06 06/07 07/08 08/09 09/10 10/11 11/12 12/13 13/14 14/15 15/16 16/17 17/18

Year

Percent

Total

Health

Education

Other

The Business Case- ActNow BC

Revenue Growth – 3%Education Growth – 3%Health Growth – 8%Balanced BudgetOther spending reaches zero by 17/18

The Business Case• Making it an economic story:

•“… it became an economic story, not a health story, and that was what really captured the imagination, there was a “killer” slide (…) And that captured the imagination of government and all the ministries as well and that was the turning point” (KI-13).

ImplementationHorizontal Dimension

• Increasing coordination/integration– Governance and Stewardship to give direction

• Leadership (Political and Public Service) • Goals/Targets

– Mechanisms• Minister of State• Incentive Funds• ADM Committee• Logic Models• Accountability Framework

Political Leadership

• “The key to ActNow is the political will”.

• “…over time the “one of” disappeared

and it became “the healthiest”

jurisdiction [to ever host the Olympic]…

which is fine, I mean that’s what

politicians do”. (KI-12)

(Stretch) Targets

• Pros– A decision had to be made– It pushes people to do more

“Without them setting or reaching for those targets, we would probably still be arguing about them today” (KI-13)

• Cons– if you don’t attain it, then you undermine everything that

you are trying to do (…)

Minister of State for ActNow

• Consensus: “It’s a fabulous idea”– Pros:

• Minister of Health is too busy to make this a priority (not because he doesn’t think that ActNow is important… )

• This is a full-time job- making people accountable:

– the Minister was able to go into Cabinet and he was able to go and twist the arms of the other ministries and say “you guys aren’t doing what you should be doing, this is the Premier’s and the government’s initiative, not Ministry X initiative”. (KI-12).

Incentive Fund• $15 million over 3 years (2005-2008)

– Criteria: cost-sharing, contribute to health, something “new”

• Benefits– Generated out-of-the-box thinking &

innovative projects (e.g. health education in a dental clinic in downtown Vancouver).

• “We committed that funding (…) to help change the behavior and thinking of senior government officials [from other ministries] and I think it did” (KI-2).

Assistant Deputy Minister (19) Inter-Departmental Committee

• Early days: – Back to Population Health 101:

• “I have got to be honest with you, the committee meetings got off to a slow start. They had to be convinced. They had to really work and it goes back to the work that actually started out here probably 15 years ago on the broader determinants of health. Getting them to understand what that was all about was not an easy task” (KI-12).

Logic Models For Each Ministry

• First piece of an accountability

framework

Accountability Framework(for population health)

• Still a work in progress…

• Locating accountability:– Premier/Cabinet– Ministries

• Ministers, Deputy Ministers, ADMs– References to ActNow in Service Plans

Measuring Success-What kind of results count as outcomes?

• Contribution analysis• Outcome Mapping

– Outcomes as behavioural change• People and Organizations

Measuring Success

• Is ActNow changing the way government does

business?

Evidence of change

“I give this government full points for setting

targets and trying to get us all thinking about

things like service plans. It really is a discipline

that wasn’t particularly well-embedded in

government prior to this administration…” (KI-7)

Research gap- Integration

• “… research on governance and

accountability has been neglected so

far and only limited knowledge and

understanding is available to inform

policy and practice”… Alliance of

Health Policy and Systems

Research…

Future Challenges

• Address the Social Determinants of

Health/Health Disparities Issue– Some respondents strongly feel that this

component should be stronger/more visible on the government’s agenda

• Some suggested that a “stagist” approach was needed- that it would have been too risky/difficult to start with this component.