Health and Health Health and Health Care:Care:

Reorienting our Reorienting our health care systemshealth care systems

into integrated and accountableinto integrated and accountablesystems for healthsystems for healthWith a little glance at CUBA With a little glance at CUBA

Honourable Carolyn Bennett MD, MPHonourable Carolyn Bennett MD, MPChiefs of Ontario ForumChiefs of Ontario Forum

February 23, 2011February 23, 2011

►Empowered Empowered patientspatients

►Effective Effective advocatesadvocates

►Engaged citizensEngaged citizens

►Patient as PartnerPatient as Partner►Doctor MultidisciplinaryDoctor Multidisciplinary►Hospital CommunityHospital Community►Social Determinants of HealthSocial Determinants of Health

Poverty, violence, environment, shelter, Poverty, violence, environment, shelter, equity, educationequity, education

Sir Michael MarmotSir Michael MarmotChair, WHO Commission on Social Determinants of Chair, WHO Commission on Social Determinants of

HealthHealth

““The worst thing for a physician is to The worst thing for a physician is to help someone get well and then send help someone get well and then send them straight back into the situation them straight back into the situation that made them sick in the first place”that made them sick in the first place”

““Paternalism Paternalism has been a total failure”has been a total failure”

Nellie Cornoyea, ‘Speaking Together’ Nellie Cornoyea, ‘Speaking Together’ 19751975

First Woman Premier, NWT

“Politics in Canada has always been the art of making the necessary possible.

Therefore deciding what’ necessary IS

political

Peter C. Newman

“Good public policy is developed when the policy-makers can keep in their mind’s eye the people affected.”

Jane Jacobs

Ongoing health CARE DilemmasOngoing health CARE Dilemmas

The The urgenturgent at the expense at the expense

of the of the importantimportant..

The politics of FEAR……The politics of FEAR……

Canadian Institute for Advanced Research

25% health attributable to health care system

15% biology and genetics 10% physical environment 50% social and economic environments

HEALTH VS HEALTH CARE

Health literacy Health literacy + +

Civic efficacy Civic efficacy = =

Political WillPolitical Will

PublicPublic policy usually follows policy usually follows

public public opinion….opinion….

BECAUSE…….BECAUSE…….

Doing the right thing is very difficult Doing the right thing is very difficult is the is the publicpublic isn’t onside… isn’t onside…

““Father knows best” not great politicsFather knows best” not great politics

Political Will Political Will to do the right thingto do the right thing

dramatically improves withdramatically improves with

►Health LiteracyHealth Literacy ‘‘tyranny of the acute’tyranny of the acute’

►Civic efficacy Civic efficacy Citizens pulling healthy public policyCitizens pulling healthy public policy

AttitudeAttitude 2+2=52+2=5

Knowledgeable Stakeholders Knowledgeable Stakeholders

+ + Committed Politicians Committed Politicians

==Better Public PolicyBetter Public Policy

ChronologyChronology

► Turn of century …. urbanizationTurn of century …. urbanization► 1918 Spanish flu1918 Spanish flu► DepressionDepression► Tommy Douglas – goal of medicareTommy Douglas – goal of medicare► ‘‘tyranny of the acute’tyranny of the acute’► Lalonde Report 1974Lalonde Report 1974► Ottawa Charter 1986Ottawa Charter 1986► Failed attempt at Health Goals… 1992 ?Failed attempt at Health Goals… 1992 ?► SARS 2003SARS 2003► Health Goals for Canada 2005Health Goals for Canada 2005► WHO Commission for SDOH 2005-2008WHO Commission for SDOH 2005-2008

Goal of Goal of Medicare… Medicare…

►Sharing riskSharing risk getting people the health care they need getting people the health care they need

when they need itwhen they need it

►Keeping people well not just Keeping people well not just patching them up once they get sickpatching them up once they get sick

Lalonde Report 1974Lalonde Report 1974►Followed by Followed by

Series of reports on `risk factors` by long range Series of reports on `risk factors` by long range health planning directoratehealth planning directorate

Series of targeted population reportsSeries of targeted population reports►Nutrition, Physical Fitness, Children etc.Nutrition, Physical Fitness, Children etc.

Fraser & Wigle - first thinking on potential Fraser & Wigle - first thinking on potential years of life lost formula.....economic costs of years of life lost formula.....economic costs of dying prematurely from preventable diseases dying prematurely from preventable diseases

Maureen Law as DM... Health Goals processMaureen Law as DM... Health Goals process Killed before Health Ministers Meeting Killed before Health Ministers Meeting

►Dx: Dx: HEALTH IMPERIALISMHEALTH IMPERIALISM

““Reorienting health systems”Reorienting health systems”

FROMFROMa health a health CARECARE system system

TOTOa true system for a true system for HEALTHHEALTH

Ottawa charter 1986Ottawa charter 1986

The Em The Em PHAPHA sis sis

is on the wrong is on the wrong

syl syl LABLAB le le

Minister of HandwashingMinister of Handwashing

Fleeing the Medical Model,Fleeing the Medical Model,Embracing the Medicine WheelEmbracing the Medicine Wheel

Blame Hippocrates?Blame Hippocrates?

Affirm Hygeia

HYGEIA: Goddess of Health

Oath of Hygeia, an oath of health care providers

I swear by Hygieia, the goddess of health making her my witness that I will fulfill according to my ability and judgment this oath and covenant: I affirm that the ultimate goal of all health providers is to promote health, prevent disease and injury whenever possible.

Minister of State (Public Minister of State (Public Health)Health)

► Sworn in December 2003Sworn in December 2003

►20032003 Canada… 44 died of SARSCanada… 44 died of SARS France…14,000 died in the heat waveFrance…14,000 died in the heat wave

►2000 WHO Report2000 WHO Report France #1France #1 Canada #30Canada #30

Beyond borders…. Beyond borders…. SARS as a teachable momentSARS as a teachable moment

► Beyond silos Beyond silos DepartmentsDepartments DisciplinesDisciplines

► Beyond jurisdictional squabblingBeyond jurisdictional squabbling

► Germs don’t respect bordersGerms don’t respect borders

► Neither do the social contagionsNeither do the social contagions► Nor the humanitarian imperativesNor the humanitarian imperatives

Teachable MomentsTeachable Moments

Kasheshewan Reserve . . . Dr. HillKasheshewan Reserve . . . Dr. Hill Hurricane Katrina Hurricane Katrina

The 2003 heat wave in FranceThe 2003 heat wave in France

The 1995 Chicago heat waveThe 1995 Chicago heat wave►Heat Wave: A Social Autopsy of Disaster in Heat Wave: A Social Autopsy of Disaster in

Chicago Chicago by Eric Klinenberg by Eric Klinenberg

VictimsVictims

►The PoorThe Poor: who either had no working : who either had no working air conditioning or could not afford to air conditioning or could not afford to turn it on. turn it on.

►The ElderlyThe Elderly: who were hesitant to open : who were hesitant to open windows and doors at night for fear of windows and doors at night for fear of crime. crime.

►African AmericansAfrican Americans: many blacks lived : many blacks lived in areas of sub-standard housing and in areas of sub-standard housing and less cohesive neighborhoods.less cohesive neighborhoods.

SurvivorsSurvivors

►HispanicsHispanics: had an unusually low death : had an unusually low death rate due to heat. Hispanics at the time rate due to heat. Hispanics at the time lived in places with higher population lived in places with higher population density, and more social cohesion. density, and more social cohesion.

►Elderly womenElderly women: who may have been : who may have been more socially engaged, were less more socially engaged, were less vulnerable than elderly menvulnerable than elderly men

The Tyranny of the AcuteThe Tyranny of the Acute

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

Citizens have to ‘get it’Citizens have to ‘get it’

►More More healthhealth …less …less health carehealth care

►Service contract ??????Service contract ??????►Or longer warranty ????Or longer warranty ????

The Grey Tsunami ?The Grey Tsunami ?

R.O.M.P.R.O.M.P.

CollingwoodCollingwood

April 24, 2008April 24, 2008

Dr. Carolyn Bennett M.P.Dr. Carolyn Bennett M.P.

The Grey The Grey Tsunami ?Tsunami ?

FantasyFantasy

Health Literacy QuizHealth Literacy Quiz

►

Empowerment Pulling Healthy Public Policy

Putting the Public back into Public Health

Public Health 101 Public Health 101

1.Do you think we should 1.Do you think we should have a:have a:

A) strong fence at the top of the cliffA) strong fence at the top of the cliff

B) state of the art fleet of ambulances B) state of the art fleet of ambulances and paramedics waiting at the and paramedics waiting at the bottom ? bottom ?

2. Would you prefer:2. Would you prefer:

A) Clean airA) Clean air

B) Enough puffers and respirators B) Enough puffers and respirators

for all for all

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

A) a falls program to reduce preventable A) a falls program to reduce preventable hip fractureship fractures

B) private orthopaedic hospitals and B) private orthopaedic hospitals and more surgeonsmore surgeons

4.Governments should boast 4.Governments should boast about:about:

A)A) how much they spent on the sickness how much they spent on the sickness care system care system

B)B) the health of their citizens, leaving the health of their citizens, leaving no-one behindno-one behind

Social Determinants of HealthSocial Determinants of Health

vs vs

Choose HealthChoose Health(modifiable risks)(modifiable risks)

The Causes of the The Causes of the CausesCauses

VersusVersus

The CausesThe Causes

Evolution of the Healthy Canadians Evolution of the Healthy Canadians TreeTree

2005

CommuniquéCommuniquéFMM September 2004FMM September 2004

► ““In addition, governments commit to In addition, governments commit to accelerate work on a pan-Canadian accelerate work on a pan-Canadian Public Public Health StrategyHealth Strategy. For the first time, . For the first time, governments will set governments will set goals and targetsgoals and targets for for improving the health status of Canadians improving the health status of Canadians through a collaborative process with through a collaborative process with experts. experts.

ProgressProgress

► First MoS Public Health 2003-2006First MoS Public Health 2003-2006► Public Health Agency of CanadaPublic Health Agency of Canada► Chief Public Health OfficerChief Public Health Officer► Public Health Network for CanadaPublic Health Network for Canada► Health Goals for CanadaHealth Goals for Canada► National Collaborating CentresNational Collaborating Centres

(incl Aboriginal Health)(incl Aboriginal Health)

► Knowledge Networks for the SDOH CommissionKnowledge Networks for the SDOH Commission► Minister Aglukkaq…Nunavut Public Health Minister Aglukkaq…Nunavut Public Health

StrategyStrategy

Health Goals for CanadaHealth Goals for Canada20052005

As a nation, we aspire to a Canada in which every As a nation, we aspire to a Canada in which every person is as healthy as they can be – person is as healthy as they can be –

physically, physically, mentally, mentally, emotionally and emotionally and spiritually.spiritually.

Basic Needs(Social and Physical

Environments)

►Our children reach their full potential, growing up happy, healthy, confident and secure.

►The air we breathe, the water we drink, the food we eat, and the places we live, work and play are safe and healthy - now and for generations to come.

Health Goals for Canada

BBelonging and Engagement► Each and every person has dignity, a sense of belonging,

and contributes to supportive families, friendships and diverse communities.

► We keep learning throughout our lives through formal and informal education, relationships with others, and the land.

► We participate in and influence the decisions that affect our personal and collective health and well-being.

► We work to make the world a healthy place for all people, through leadership, collaboration and knowledge.

Health Goals for CanadaHealth Goals for Canada

►Every person receives the support and information they need to make healthy choices.

Healthy Living

Health Goals for Canada

A System for Health

►We work to prevent and are prepared to respond to threats to our health and safety through coordinated efforts across the country and around the world.

►A strong system for health and social well-being responds to disparities in health status and offers timely, appropriate care. Health Goals for CanadaHealth Goals for Canada

Health GoalsHealth Goals

►Choose indicatorsChoose indicators► Include stakeholder in choosing Include stakeholder in choosing

meaningful and realistic but bold meaningful and realistic but bold targetstargets

►Develop real strategies….Develop real strategies…. what, by when and howwhat, by when and how

““The mobilization of The mobilization of shame”shame”

Irwin CotlerIrwin Cotler

Management 101

“If it’s measured it gets noticed, if it’s noticed it gets done”

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Mental HealthMental Health

► Increasing mental health capacity Increasing mental health capacity internationallyinternationally

►Dr. Stan KutcherDr. Stan Kutcher Post tsunami, earthquake, volcanoPost tsunami, earthquake, volcano Non-medical modelNon-medical model Training hairdressser, taxi drivers, barbers Training hairdressser, taxi drivers, barbers

bartenders to identify those at risk – not bartenders to identify those at risk – not themselvesthemselves

Health Services

Community Development / Outreach

Administration & Financial Services

Community Services

Client

Emergency Preparedness

Non-Insured Health Benefits

Program Administration & Reporting

Activities to Promote Wellness

Cancer Awareness & Prevention

Cultural Awareness & ServicesPrevention Programs

Nutrition Awareness

Prenatal & Postnatal Activities

Chiropody/Foot Care

ChiropractorChronic Disease

ManagementElderly & Disabled Services

DieticianInfant & Child Development

Mental Health ServicesOccupational Therapy

Oral Health CarePrenatal & Postnatal Care

Primary Health Care Physiotherapy

Speech & Language ServicesTraditional Healing

Child and Family Services

Environmental Health

Home Care Services

Representation in Court for Child Welfare matters

Scotland – Honourable Andy Scotland – Honourable Andy KerrKerr

►Health outcomes down to postal codeHealth outcomes down to postal code►Letter from Family DoctorLetter from Family Doctor► InterventionsInterventions►Already paying offAlready paying off

WHO Active Aging

Health in CubaHealth in Cuba2009

Health in Cuba : Yesterday and Today

1959 20096286 medical doctors, most of them located in big cities and practicing private medicine. At the beginning of the Revolution half of them leave the country.Infant mortality rate higher than 60x1000 born alive.Life expectancy below 60 years old.Sanitary picture: predominance of communicable diseases, many of them preventable by vaccination.Only one School of Medicine

72 416 medical doctors, 47,83% of them are family doctors. 100% of the rural areas are medically covered.Infant mortality rate 4.7 x1000 born alive by the end of 2007Life expectancy 78 years oldSanitary picture with predominance of non-communicable diseases and an Immunization Program covering against 13 diseases.24 Schools of Medicine

Death

s in

ch

ild

ren

< 5

years

old

/10

00

bir

ths

(log

)H

ealt

h,

10

100

200

50

40

20

8

5

4

300300

30

60

6

3

80

Income, Gross National Income per capita, purchasing power in US dollar (log)

1 0001 000 10 00010 000 20 00020 000500500 2 0002 000 5 5 000000

50 00050 000

Somalia

Madagascar

richrichpoorpoor

Albania

Algeria

Angola

Antigua & Barbuda

Argentina

Armenia

Australia

Austria

Bahrain

Bangladesh

Barbados

Belgium

Benin

Botswana

Bulgaria

Burkina Faso

Cambodia

Cameroon

Canada

Cape Verde

CAR

Chad

Chile

Comoros

Costa Rica

Côte d'Ivoire

Croatia

Cyprus

Czech Rep

Denmark

Djibouti

Dominica

Ecuador

El Salvador

Equatorial Guinea

Eritrea

Estonia

Ethiopia

Fiji

Finland

Gabon

Gambia

Georgia

Greece

Guatemala

Guinea

Guinea-B

Guyana

Haiti

Honduras

Hungary

Iceland

Iran

IrelandIsrael

Italy

Jamaica

Jordan

Kazakhstan

Kenya

Republic of Korea

Kuwait

Kyrgyz Rep

Laos

Latvia

Lebanon

Lesotho

Lithuania

Macedonia

Malaysia

Mali

Malta

Mauritania

Mauritius

Moldova

Mongolia

Mozambique

Namibia

Nepal

Netherlands

New Zealand

Nicaragua

Niger

Norway

Oman

Paraguay

Poland

Portugal

Rwanda

Saudi Arabia

Senegal

Sierra Leone

Singapore

Slovakia

Slovenia

Solomon Islands

South Africa

Sri Lanka

St. Kitts & Nevis

St. Lucia

Sudan

Swaziland

Sweden

Switzerland

Syria

Tajikistan

Tanzania

Thailand

Togo

Tonga

Trinidad & Tobago

Tunisia

Turkey

Turkmenistan

Uganda

Ukraine

United Arab Emirates

Uruguay

Uzbekistan

Vanuatu

VenezuelaVietnam

Zambia

Zimbabwe

Panama

USAUK

Japan

France

Germany

India

China

Brazil

Russia

IndonesiaPhilippines Peru

Egypt

Azerbaijan

Pakistan

PapuaNG

Nigeria

Ghana

Cuba 2004

Iraq

Sub-Saharan Africa

Arab states

Europe

AmericasAsia & Pacific

Continents:

Population

10010

1 000

1

in millions

GrenadaColombia

Romania

Morocco

Samoa

Belarus

Cape Verde

Mexico

Bolivia

World Development Chart 2004Make sense of development by viewing UN statistics

with free software from www.gapminder.org

Afghanistan

Bosnia

West Bank & Gaza

Year 2002 data for 174 countries & territories with > 250 000 inhabitants. Source: WDI 2004, UNCDB 2004 & estimates in italic© hans.rosling@phs.ki.se, Karolinska Instintutet. Free to copy

Luxemburg

Burundi

Belize

Taiwan

Congo, Rep.Yemen

MalawiDRC

Dominican Rep

healt

hy

sic

k

Infant mortalityInfant mortality

20 x 1000 new born

American Region

4,7 x1000 newborn

Cuba

DispensarizacionDispensarizacion

►`the constant assessment of `the constant assessment of population and risk`population and risk`

►``We don`t expect people to get sick ``We don`t expect people to get sick and come to us``and come to us``

Pride in their resultsPride in their results

►Family doctors annual reportFamily doctors annual report Smokers,obese,sedentary,lipids,BPSmokers,obese,sedentary,lipids,BP

►Statisicians, Epidemiologists, Statisicians, Epidemiologists, PsychologistsPsychologists

►Accountability to Govt and LegislatureAccountability to Govt and Legislature Weekly meeting with Minister Weekly meeting with Minister

Integration of Health Professional Integration of Health Professional Education & CommunityEducation & Community

►health professional must be a professor health professional must be a professor and give tutorials to the students.and give tutorials to the students.

►`Polyclinics` - Teaching University`Polyclinics` - Teaching University► ► `̀We don`t train basketball players on a We don`t train basketball players on a

soccer pitch and vice versasoccer pitch and vice versa `̀

POLICLINICO UNIVERSITARIO PLAZA DE LA REVOLUCIÓN

Actividades con la comunidadActividades con la comunidad

► Círculos de abuelos.Círculos de abuelos.► Círculos de Círculos de

gestantes (clases de gestantes (clases de psicoprofilaxis).psicoprofilaxis).

► Círculo de lactantes.Círculo de lactantes.► Círculo de Círculo de

adolescentes.adolescentes.► Círculos de interés Círculos de interés

de escolaresde escolares

““... ... We are a small We are a small country, but we country, but we have been able to have been able to show how much show how much can be done when can be done when it is wanted to if it is wanted to if human resources human resources from any place from any place can be well used.can be well used.

Fidel Castro Ruz.Fidel Castro Ruz.

ResearchResearch

► Evidence-informed practiceEvidence-informed practice► Practice-informed evidencePractice-informed evidence

► Courage to fund what worksCourage to fund what works► Courage to stop funding what doesn`tCourage to stop funding what doesn`t

► Complex adaptive systems…Complex adaptive systems…

Sir Michael MarmotSir Michael Marmot

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

No time for pessimists

Research

Practice Policy

Research

Practice Policy

KT

Research

Practice Policy

KT

Political will

Research

Practice Policy

KT

Political will

Appliedresearch

Research

Practice Policy

ENGAGED CITIZENS

KT

Political will

Appliedresearch

““We are not tinkers, who patch and mend We are not tinkers, who patch and mend what is broken. We must be watchmen, what is broken. We must be watchmen, guardians of the life and health of our guardians of the life and health of our generation, so that stronger and more generation, so that stronger and more able generations may come after.”able generations may come after.”

Dr. Elizabeth Blackwell Dr. Elizabeth Blackwell first woman physician in North Americafirst woman physician in North America

Fleeing the Medical Model,Fleeing the Medical Model,Embracing the Medicine WheelEmbracing the Medicine Wheel

Miigwech