Mobilizing intersectoral action to promote health: the case of ActNow in British Columbia, Canada Bamako Forum 2008 Robert Geneau, PhD Gayle Fraser, MA Barbara Legowski, B.Sc.Phm., Pharm.D Sylvie 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 dont 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 Targets Physical 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

The Business Case- ActNow BC Revenue Growth – 3% Education Growth – 3% Health Growth – 8% Balanced Budget Other 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).

Implementation Horizontal 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 thats 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 dont attain it, then you undermine everything that you are trying to do (…)

Minister of State for ActNow Consensus: Its a fabulous idea –Pros: Minister of Health is too busy to make this a priority (not because he doesnt 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 arent doing what you should be doing, this is the Premiers and the governments initiative, not Ministry X initiative. (KI-12).

Incentive Fund $15 million over 3 years ( ) –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 wasnt 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 governments agenda Some suggested that a stagist approach was needed- that it would have been too risky/difficult to start with this component.