Health care in Canada has long been a source of national pride.

Known as medicare, the system is publicly financed but privately run, it provides universal coverage and care is free at the point of use. Canada has a long history of universal health coverage. In 1944, Saskatchewan led the way, being the first of the provinces to introduce universal hospital insurance. By 1971, all Canadians were guaranteed access to essential medical services, regardless of employment, income, or health (Kraker, 2002).

The 1984 Act also defines and solidifies the principles of medicare, including: comprehensiveness (provinces must provide medically necessary hospital and physician services), universality (100 per cent of provincial residents are entitled to the plan), accessibility (there should be reasonable access to services, not impeded by user charges or extra billing), portability (protection for Canadians travelling outside of their home province), and public administration (provinces must administer and operate health plan on a non-profit basis) (Klatt, 2002). The Canadian healthcare system is funded primarily by tax dollars. The federal government makes cash transfers to the provinces, but the provinces may levy their own taxes to help defray the costs. Alberta and British Columbia require a health insurance premium, and other provinces have instituted employer payroll taxes (Klatt, 2002). In 2004, $91.1 billion or 70% of total health spending was by the public sector. Private sector spending totalled $39.2 billion in 2004, or 30%. In 2004, total health expenditure was estimated at $130 billion, about 10 per cent of GDP (Ibid). This is estimated to be around $4,078 per person. Latest OECD figures on spending per person is for year 2002, when it reports Canada spent $2,931 per person using purchasing power parities (PPPs), up from $2587 as used in report. This was the third highest, below the USA and Switzerland. Private insurance plans are not allowed to cover core services and may only cover non-core services. As a result, the role of private medical insurance in Canada is limited to supplemental care. Healthcare providers are predominantly private, but are funded by public monies via provincial budgets. Hospital systems are largely private non-profit organizations with their own governance structures (usually supervised by a community board or trustees) (WHO, 1996) that receive an annual global operating budget from the provinces (Klatt, 2002). Physicians are mostly in private practice and remunerated on a fee-for-service basis (with an imposed cap to prevent excessive utilization and costs) by the provincial health plan (WHO, 1996). By Benedict Irvine, Shannon
Ferguson and Ben Cackett

public and private sector participation in health care. Generally speaking, Canada has a mixed public-private system a system where the private sector delivers health care services and the public sector is responsible for financing those services. The Canadian system, however, is not completely consistent with this model. Canadian governments exercise considerable authority over the delivery of services by the private sector.

Health Care Delivery

Within this patchwork of provincial systems, health care in Canada can be divided into two basic elements: delivery and financing. These distinctions are important when one turns to the question of public and private participation in the health care system, as each sector plays very different roles in the delivery and financing of medical services. Health care delivery refers to the manner in which medical services are organized, managed, and provided. Central to health care delivery are the professionals who provide medical services to Canadians. In 2009, the health industry was the second largest employer in Canada, employing approximately two million people. This represented almost 12 percent of Canadas total employment for 2009. (It is important to note that these statistics include health and other social assistance professionals.) Health care delivery refers to the manner in which medical services are organized, managed, and provided. In this regard, Canada has a system with a strong mix of public and private involvement. In most cases, private individuals and organizations are responsible for delivering medical services to patients. Nevertheless, provincial governments exercise considerable authority over the manner in which these private entities deliver services. Moreover, while governments fund the large majority of services, the private sector does play an important, albeit secondary, role in health care financing.

Health Care Financing

The second basic element of any health care system is its financing that is, how medical services are paid for. Generally speaking, in western industrialized countries, health care tends to be financed by two key sources: out-of-pocket payment and health insurance. Out-of-pocket payment occurs when the patient must directly cover costs associated with a medical service. This type of financing may be further distinguished by complete payment and cost-sharing. Complete payment occurs when the patient must bear the full cost of the medical service. This can result

from having no health insurance or receiving services that are covered by the health care users insurance plan. Cost-sharing, by contrast, includes out-ofpocket payments where the patient is required to cover only a portion of his/her medical services. A common example is insurance deductibles, where a patient pays a fixed amount to his/her insurance plan before any payment of benefits takes place. Another example is user fees, requiring that the patient pay a small fee to the healthcare provider (e.g. the hospital) upon receiving medical service. The second key source of health care financing is health insurance. In broad terms, insurance is a means by which individuals pool the risk of incurring medical expenses. Instead of paying for their medical services directly from their own pockets, individuals or groups participate in a collective fund that covers their health care costs. Health insurance can be organized in different forms, with a basic distinction being public versus private insurance schemes. Public health insurance refers to schemes covering the community as a whole (or large segments of the community) which is imposed and controlled by a government unit. Private health insurance, by contrast, refers to schemes that are controlled and administered by non-governmental or private entities, and which usually cover only a small portion of the general population. Public insurance schemes can be further distinguished by the manner in which they are funded. One approach is through insurance premiums, where individuals pay regular premiums into a public insurance fund to receive benefits. This is commonly referred to as social security financing. Another approach is through taxation, where the insurance plan is funded by the government through taxes paid by citizens and residents. Public insurance schemes can also take a mixed approach, funded by both premiums and general taxation. Private insurance schemes are usually funded through premiums, which may be borne by the individual and/or his/her employer. Moreover, private plans can be either non-profit or for-profit. In non-profitschemes, the private insurer only seeks to collect premiums and other fees necessary to cover the costs incurred by the insurance fund, such as payment of benefits and administration costs. In for-profit schemes, the private insurer operates the insurance fund as a business, seeking to generate a profit by generating revenues above what is necessary to cover costs. More information on health care financing is included later in this article.

Financing Health Care in Canada

Predominantly public with some private participation Like health care delivery, health care financing in Canada is a mix of public and private participation. The mix associated with financing, however, differs significantly.

Health care delivery is characterized by private individuals and organizations providing medical services, albeit with considerable government regulation and control. Health care financing, by contrast, is characterized by direct government participation through funding for health care facilities (i.e. hospitals) and mandatory, universal public health insurance plans. ublic health insurance plans also represent a significant avenue of public sector financing. Each province and territory in Canada has mandatory and universal health insurance plans, to cover basic medical services. These are public insurance schemes insofar as they are administered by provincial/territorial governments and funded almost exclusively through taxation. This includes general provincial/territorial taxes and the annual federal fiscal transfers (referenced earlier). Some provinces have experimented with the idea of levying health care premiums, charging provincial residents regular fees for health care services. In addition, some provinces have also experimented with user fees (a flat fee patients pay per medical visit) and extra-billing (allowing physicians to charge extra fees above what they bill public insurance plans). Nevertheless, these alternative forms of funding represent only a small fraction of public sector spending on health care. As indicated in the above table, public health care premiums in Canada totalled just over $2 billion in 2007. General government funding, by contrast, totalled $107 billion. Provincial/territorial health insurance plans are mandatory and highly monopolistic. Canadians are required to participate in the public financing of these plans through general government taxation and health premiums. Moreover, private insurance is not available (or is very limited) for those services covered by public plans. It is important to note, however, that public health insurance is not completely comprehensive in its coverage. Also, while coverage differs from one province or territory to another, it tends to cover only basic or medically necessary services. This includes most primary and secondary care services, such as visits to the family physician and specialized hospital care. Medical services that fall outside the scope of public insurance plans must be financed privately, either through direct, out-of-pocket payments or private health insurance (see below for more information). Another way the public sector finances health is through direct program funding. The largest of these initiatives tend to relate to hospitals and other health facilities. As discussed above, hospitals in Canada are typically operated by private community or voluntary boards. Their operating and capital costs are largely funded through annual government budgetary allotments. Governments also spend directly on other programs such as health protection (i.e. antismoking campaigns) and health research Chronic diseases, sometimes referred to
as noncommunicable diseases or NCDs, account for the highest causes of death in Canada and the world. NCDs include a variety of chronic diseases such as arthritis, diabetes, cancer, cardiovascular diseases, respiratory diseases, and mental illness.

The Public Health Agency of Canada (PHAC) supports the WHO Collaborating Centre on chronic noncommunicable disease policy. PHAC provides public health practitioners in Canada and worldwide with data, analysis, web tools and technical advice that support policies, programs and public health interventions for chronic disease prevention. PHACs Strategic Plan 2007-2012 promotes a strong international public health infrastructure and helps to reduce the risk factors leading to chronic illnesses by sharing Canadas leadership and expertise in NCD health policy development. Through strategic global partnerships, international cooperation and dialogue, we also learn about successful initiatives in other countries. The WHO Collaborating Centre on chronic noncommunicable disease policy delivers onPHACs objectives by working in an international context to share Canadas expertise to promote health policy planning, implementation and evaluation to combat global noncommunicable diseases. First designated in 1994 [with successful subsequent redesignation every four years by the World Health Organization (WHO) ], the Centre is recognized as a worldwide centre of excellence in the development, implementation and evaluation of NCD public health policy. The WHO Collaborating Centre reports activities annually to World Health Organization Headquarters (WHO HQ) and its regional body, thePan American Health Organization (PAHO) and around the world. Through PHACs policy initiatives as a contributing member of WHO, public health policymakers and practitioners in Canada and worldwide can find essential information about chronic disease health policy research, training, evaluation, capacity building and partnership initiatives. to advance NCD prevention and control policies in Canada

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What We Do
At the Public Health Agency of Canada (PHAC), the WHO Collaborating Centre on chronic noncommunicable disease policy promotes leadership and innovation to combat noncommunicable disease (NCD) through public health policy planning, implementation and evaluation activities. In Canada and around the world, the WHO Collaborating Centre shares leading-edge knowledge and practical tools pertaining to policy monitoring, policy research, policy

training and capacity building, policy dialogue, policy partnership initiatives, policy outreach, and policy legislation development.

Policy Monitoring
Monitoring NCD public health policy strengthens the national and global roadmap that guides how best to take action in reducing chronic disease at the practical level.

Policy Training and Capacity Building

Policy training and capacity building enlarge the field of expertise to prevent and controlNCDs through the dissemination of methodological approaches and technical tools.

Policy Dialogue
Policy dialogue is a method that allows research evidence to be considered together with the views, experiences and knowledge of those who will be involved in or affected by policy decisions. Policy dialogue promotes the continuous exchange of emerging NCD public health policy information and initiatives at the country or subregional level (e.g. the Caribbean, Central America) to help policymakers and practitioners to formulate effective development, implementation and evaluation of strategies to reduce NCDs.

Policy Partnership Initiatives

Policy partnership initiatives encourage the sharing of knowledge and resources between participating partners and promote cross-disciplinary, cross-sectoral and cross-cultural perspectives to stimulate action that changes risks to populations and health determinants.

Policy Outreach
Through outreach activities such as presentations and publications, the WHO Collaborating Centre disseminates recent developments in chronic disease policy research and best practices. The state-of-the-art knowledge that is shared assists policymakers in making effective and informed public health policy decisions, in Canada and around the world.

Policy Legislation Development

Legislation is the enactment of public health policy compelling specific actions for the prevention and control of chronic or noncommunicable diseases. The enforcement of supportive health measures, such as banning smoking in public places, together with consequences for failure to comply, are cornerstones in controlling the risk factors that contribute to chronic disease.

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Benefits to Canadians
The Public Health Agency of Canadas World Health Organization (WHO) Collaborating Centre on chronic noncommunicable disease policy works nationally and internationally through collaborative initiatives, partnership frameworks, grants to support research and distribution of emerging chronic disease policy knowledge. Public health policy is the roadmap that guides how best to take concrete action in reducing chronic disease at the practical level. National health policy informed by global best practices promotes effective action at the community and individual level. Improving the lives of individuals through effective global health policy is in Canadas health interest.

A Globalized World
Canadians live in an increasingly globalized world with interconnected economies and health challenges. Our partnerships provide access to breakthrough scientific research and developments in the field of chronic disease prevention and treatment. Collaborative, multilateral action is key to tackling the many components that contribute to chronic disease.

A Foreign Policy Priority

The Americas are and will remain a foreign policy priority (Government of Canada, Canada and the Americas: Priorities and Progress, 2009). Canada, as a country of the Americas, plays a special leadership role through PHACs WHO Collaborating Centre on chronic noncommunicable disease policy as a co-lead with the Pan American Health Organization in the CARMEN Policy Observatory. (CARMEN is a network of 32 countries in the PAHO region committed to

shared solutions in reducing chronic diseases through integrated, evidence-based prevention and control programs).

Creative Solutions
Working across political and professional boundaries through intersectoral collaboration promotes a strong knowledge base and new approaches to reducing chronic disease mortality and morbidity rates.

Cost-Effectiveness
Contributing to the development and dissemination of internationally recognized best practices helps improve cost-effectiveness by promoting sound investments in highimpact interventions. Collaborating helps strengthen our approach to reducing the burden of chronic disease in Canada while ensuring good value for money.

Canadas Reputation
Canada is known internationally for its advanced public health systems and plays a leadership role in tackling chronic diseases for Canadians and for the world. Development of advanced chronic disease policy monitoring, research, intervention and evaluation through global health networks is in Canadas best interest.

A Fundamental Value
Canada promotes key Canadian values such as equitable access to health care through its participation in international organizations. Promoting healthy living and reducing chronic disease is a public health priority for Canada. Canada is committed to developing and sharing tools and best practices to help build capacity for all nations through its partnership with the World Health Organization (WHO) .

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Building momentum to tackle the global health challenge of the 21st century
By 2015 it is projected that more than 40 million people will die annually from chronic diseases. Chronic diseases impose a much greater burden on poor countries

and poor populations than on richer economies and must be tackled as a development issue. The challenge of chronic disease worldwide requires the reduction of economic disparity between global citizens and effective access to healthy lifestyle and preventative medical care. There is a new and urgent global priority to address chronic diseases and the risk factors that impede effective reduction and control, namely poverty, hunger, social exclusion, discrimination and inequality. In order to empower populations through the promotion of positive lifestyle choices, there must be sustainable access to education, health services and availability of health food choices for consumers. It also requires a collaborative approach between public health policymakers, nongovernmental agencies and private sector entities. Recent high level policy discussions -- and subsequent commitment to multisectoral collaboration to address rising rates of chronic disease -- have stimulated significant international momentum. Canada works at the frontlines through PHACs WHO Collaborating Centre on chronic noncommunicable disease policy through its participation at key junctures in the emerging rise of addressing chronic disease as a global priority.

September 2007 Uniting Against Chronic Diseases: The CARICOM Summit on Healthy Living and Chronic Disease Port of Spain, Trinidad and Tobago
The heads of thirteen Caribbean national governments met in Port of Spain, Trinidad and Tobago under the umbrella of the Caribbean Community (CARICOM) Secretariat in September 2007 to work together strategically by sharing knowledge and resources to combat together the effects of chronic diseases and risk factors on their respective populations. The Summit was organized in partnership with the Pan American Health Organizations (PAHO) Chronic Disease Unit in conjunction with the Collaborative the CARMEN Policy Observatory, including support from PHACs WHO Collaborating Centre on chronic noncommunicable disease policy. (CARMEN Action for Risk Faction Prevention and Effective Management of Noncommunicable

Disease, is a network of 32 countries in the Americas, which form one of five major geographical areas of the World Health Organization). The successful summit marked the convergence of several components. First, the summit was a direct consequence of the advent of a collective Caribbean Cooperation in Health approach to shared health priorities among the member states of CARICOM as a political integration framework. It was also based on the recognition that Caribbean populations are the most seriously affected by the social and economic burden of chronic diseases as a sub-region within PAHOs CARMEN network. The summit was also based on a model of cooperation between health, social, legislative, education, agriculture, trade and fiscal sectors, pointing the way to integrative public health policy initiatives where collaboration is the key to successful intervention.

April 2009 Fifth Summit of the Americas: Securing Our Citizens Future by Promoting Human Prosperity, Energy Security and Environmental Sustainability Port of Spain, Trinidad and Tobago
At the fifth meeting of the member countries of the Americas, a new Declaration of Commitment was drafted including two important articles addressing the commitment to reducing the burden of chronic disease. Article 28 calls for the promotion of comprehensive and integrated preventive and control strategies at the individual, family, community, national and regional levels. It also reiterates the critical need for innovative collaboration of the public sector, private sector, media, civil society organizations, communities and relevant regional and international partners. Article 29 specifically instructs the inter-American Ministers of Health to work with the Pan American Health Organization (PAHO) to incorporate the surveillance of chronic disease and associated risk factors into existing national health information reporting systems by 2015.

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November 2009 Commonwealth Heads of Government Meeting (CHOGM) Partnering for a More Equitable and Sustainable Future Port of Spain, Trinidad and Tobago
The Commonwealth Heads of Government Meeting (CHOGM) is the collective body of 54 Commonwealth countries representing 2 billion people. It is convened every two years to review global, political and economic developments and to conduct a strategic overview of the Commonwealths work in support of the interests of member countries. In November 2009, the theme of the meeting was Partnering for a more Equitable and Sustainable Future. Although the main topic of discussion was addressing climate change as a global challenge, chronic disease as a global health tsunami, threatening the economic and social development of many Commonwealth countries was positioned as a worldwide health priority. A special statement was issued affirming CHOGMs commitment to addressing the burgeoning incidence of noncommunicable diseases (NCDs), and to increasing the ability of our countries to respond to this emerging health crisis.

May 2010 Commonwealth Health Ministers Meeting Geneva, Switzerland

At the Commonwealth Health Ministers Meeting, it was agreed that chronic disease indicators would be tabled at the 2010 Millennium Development Goals (MDGs) Review Summit, taking place at the United Nations General Assembly in September 2010 in preparation for the 2011 high level summit on preventing chronic disease. The meeting sought to identify elements of a possible Commonwealth Programme of Action, pursuant to the call by Heads of Government for the consideration of a UN Summit on NCDs. It also provided countries with an opportunity to examine the status of the MDGs in the Commonwealth and the challenges and opportunities that face member nations.

November 2010 CARMEN Policy Observatory Meeting on Chronic Noncommunicable Disease Policy Port of Spain, Trinidad and Tobago
In preparation for the September 2011 UN Summit on chronic disease, PAHO members, including PHACs WHO Collaborating Centre on chronic disease policy as a key member, met to prepare to ensure involvement of Heads of State (through Ministries of Health) by sharing examples of how PAHO/WHO contribute to chronic disease policy development and by supporting WHO in coordinating the summit. PAHO will provide leadership by showing how whole government and whole society approaches create effective multisectoral collaboration.

September 2011 United Nations General Assembly New York, USA

The increasing visibility of chronic disease as the worlds leading cause of death, and moreover, the leading cause of preventable death has resulted in a UN resolution to discuss strategies as an urgent priority for the 2011 meeting. The resolution builds on Objective #1 of the WHO NCD Global Strategy Action Plan 2008-2013 which calls on global development initiatives to take into account the prevention and control of chronic diseases and raise the priority accorded in development work at global and national levels. All UN member countries are now engaged in preparing surveillance, intervention and policy evaluation activities in preparation for the global summit to address chronic disease, the first time the rising pandemic of noncommunicable disease around the world will be specifically addressed by the international body of heads of government.

2013 World Health Organization Health in All Policies Meeting Helsinki, Finland
Health is largely determined by factors outside the health care domain. It is widely recognized that decisions made by many sectors can help to influence the conditions that shape the health of the population. Efforts to integrate health considerations into societal policy-making with the aim to improve population health and avoid risk factors of chronic diseases are being considered almost everywhere, at the community level as well as at the national, regional and local levels. PHACs WHO Collaborating Centre on chronic noncommunicable disease policy has committed to work with WHO HQ in preparation of the 2013 Health in All Policies (HiAP) summit to be held in Helsinki. The collaboration will focus on case studies that promote intersectoral policies in battling chronic disease: Mobilizing Intersectoral Action to Promote Health: The Case of ActNowBC (2010) marks the first case study report and accompanying backgrounder in this series.

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Policy Development in Action

The World Health Organization (WHO) has encouraged nations to work together to reduce the burden of chronic disease around the world. As the personal and national costs of living with chronic diseases continue to rise, WHO is committed to motivating transformational change and measurable improvements through innovative international and intersectoral partnerships. By sharing challenges and solutions, emerging proven approaches to public health policy, implementation and evaluation will lead the way for all to significantly reduce disease and the impediments that produce health inequities. Two leading agencies dedicated to reducing chronic diseases have joined forces to address chronic diseases in the Americas together: The WHO Collaborating Centre on chronic noncommunicable disease policy is the only chronic disease policy collaborating centre in the world. A vital part of the Public Health Agency of Canada (PHAC), this WHO Collaborating Centre is recognized as a global authority in the analysis of policy development, implementation and evaluation.

The Pan American Health Organization (PAHO)

is an international public health

agency working to improve health and living standards of the countries of the Americas. It serves as the specialized organization for health of the InterAmerican System and as the WHO Regional Office for the Americas. Together, PHAC and PAHO lead groundbreaking initiatives to mobilize a higher, more effective level of strategic planning and interdisciplinary critical thinking to drive national health policies.

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CARMEN Policy Observatory

The Americas are and will remain a health policy priority for Canada. Canadians have much to gain by being involved in the region, and they also have much to contribute. Canadas government has made it clear that re-engagement in the Americas is a critical international priority for our country Canada is committed to playing a bigger role in the Americas and to doing so for the long term. Prime Minister Stephen Harper July 17, 2007 The WHO Collaborating Centre on chronic noncommunicable disease policy at PHACconducts the CARMEN Policy Observatory jointly with PAHO to promote the expansion of effective systematic chronic disease policy development and implementation using both qualitative and quantitative methodologies. (CARMEN is a network of 32 countries in thePAHO region committed to shared solutions in reducing chronic diseases through integrated, evidence-based prevention and control programs.) The key areas of activity for the Policy Observatory are policy monitoring and analysis, policy dialogues, policy research, outreach, capacity building and training. The Policy Observatory's broad mandate includes the review of public policies affecting chronic disease prevention, risk factors and risk conditions, as well as relevant legislations and regulations. The Policy Observatory has been successful in boosting the technical capacity of policy analysis in a number of countries of the Americas, and around the world.

Two recent collaborative initiatives between PAHO and PHACs WHO Collaborating Centre on chronic disease have yielded groundbreaking results, harnessing strategic planning to immediate action.

The Canada-Chile Technical Cooperation on chronic disease policy

In 2006, Canadian and Chilean public health policy delegates attending the annual Pan American Health Organization (PAHO) Directing Council Meeting forged an ambitious technical cooperation initiative focusing on prevention and control of chronic diseases, a priority for both countries. The Canada-Chile dialogue produced an innovative framework for sharing technical expertise in the prevention and control of chronic diseases. Working as member nations under the PAHO framework, they developed a three-phase project: PHASE 1 (DECEMBER 2007): Canadian representatives from PHAC visited counterparts in Chile to learn about Chilean strategies for chronic disease risk factors and determinants in reduction and control; PHASE 2 (AUGUST 2008): Chilean representatives visited counterparts in Canada to learn how chronic disease is managed through public health policy at the national and provincial levels. PHASE 3 (SEPTEMBER 2009): The Ministry of Health in Chile hosted an international cross-sectoral dialogue with participating experts from Chile, Canada, Paraguay and Brazil. The dialogues produced the blueprint for a new national plan of action for Chile, and a model for other countries on how international collaboration and knowledge exchange enhances the respective strategic policies of each participant.

The Uniting Against Chronic Diseases Summit

In 2007, the heads of 13 Caribbean national governments met in Port of Spain, Trinidad and Tobago under the umbrella of the Caribbean Community (CARICOM) Secretariat to work together strategically by sharing knowledge and resources to combat together the effects of chronic diseases on their respective populations. The summit was organized in partnership with PAHOs Chronic Disease Unit in conjunction with the CARMEN Policy Observatory with support from PHACs WHO Collaborating Centre on chronic noncommunicable disease policy. The successful summit established a framework for the complex intersection of several progressive vectors:

Activation of a collective approach to shared health priorities among the member states of CARICOM as an emerging political integration framework; Recognition of Caribbean populations as most seriously affected by the social and economic burden of chronic diseases; Collaboration between chronic disease public health policymakers with nongovernmental agencies and private sector entities; Strategically linking chronic disease prevention and control to empowering populations through the promotion of positive lifestyle choices with access to education, health services and consumer choice;

Prioritizing national mandates through public policy, legislation and fiscal measures to reduce the negative effects of risk determinants such as tobacco, alcohol and unhealthy foods;

Intersectoral solutions involving the integration of health, social, legislative and fiscal sectors. Top of Page

Sharing Lessons Learned

One of the most persistent challenges in combating chronic disease is linking the creation of ambitious public health policies to the delivery of tangible positive effects in actual populations. Sharing the lessons learned from international dialogue is central to the mandate of theCARMEN Policy Observatory. Through outreach initiatives, PAHO and PHACs WHOCollaborating Centre on chronic noncommunicable disease policy share the best practices of their past projects. High level planning sessions, collaborative agreements and dialogues, shared knowledge of best practices, and resources allotted to research and case studies are only meaningful if they can be harnessed to transformational change with an accountability framework to measure causal effects. Traditionally, public health policy has depended on a linear planning process followed by implementation and evaluation, founded on a singular methodological paradigm and supported by political commitment and a variety of resources. Emerging cross-disciplinary perspectives and best practices case studies have shown that maximum efficacy comes with greater awareness and understanding of the complex and interrelated components required to produce positive change. Many components must be considered together to reduce population mortality and

morbidity statistics and produce real life improvements for individuals and communities coping with chronic diseases. Moreover, a more sophisticated understanding of achieving results must also combine improving the determinants of health that affect chronic diseases (such as individual lifestyle choices) together with the reduction of disparities between population segments (such as reducing unequal access to education, resources and health services).

Defining Project Objectives

At the outset of the project, it is necessary to define project objectives. These objectives, in turn, form a key part of the project accountability framework by providing specific performance indicators against which the effectiveness of the community intervention can be measured. Identifying the objectives also serves to promote greater dialogue among project participants about the importance and approach to measurement of effectiveness and to identify future stakeholders of the eventual performance assessment, such as funding bodies. Project objectives should reach deeper than achieving dialogue or tabulating statistics. Action should deliver transformational change, measurably delivering individual change, community change and systemic change.

Gathering Data
Prior to launching the project, gather and prepare evidence. Undertake research, if necessary, to ensure that credible and timely information is available to support project objectives.

Defining Methodology
The realist synthesis model developed by Ray Pawson provides a new innovative perspective for evaluating community health interventions by seeking to identify the specific social mechanisms that determine outcomes. The realist synthesis model views health programs as context-dependent and evaluates transformational change by linking the intentions of intervention designers to the complex real-world contexts of how communities respond to programs. What mechanisms drive an intervention forward successfully, for whom and under what circumstances? It is from the sometimes complicated answers to these

questions that forward momentum will be found to create truly effective health programs tailored to best suit the given context. By carefully considering the variable social, political, economic and cultural environments that are proven to foster successful change, health policymakers can identify the transferability of program elements into community programs with comparable contexts.

Analyzing Context
Prior to designing an intervention or program action, it is critical to define and assess the many factors that form the total project context. These can include social, cultural, physical, environmental, economic, political, and gender factors. It is critical to undertake this analysis each time at the onset of a project, as subtle fluctuations within any single or cluster of factors will affect program effectiveness. These drivers determine critical decisions in defining resource allocation, target populations, methodology, timing and scope.

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Defining Framework
To truly achieve transformational change by reducing chronic disease in populations, and reducing the inequities to achieve health for all, a holistic framework is required. This framework needs to link immediate, intermediate and long-term health outcomes with external contexts and with the proven process components needed for a successful community intervention. With each community-based intervention, the framework has to be adjusted to consider the particular external contexts that will influence the project parameters. These include social, cultural, physical, environmental, economic, political and gender exigencies. As these contexts are always in flux, assessments and adjustments are critical to create an intervention that can thrive.

Implementing the Process

Moving from intervention planning to action depends on clearly defining the process components and the underlying drivers or mechanisms to power the process.

Collaborative Planning Mechanisms

Transformational change works best when the power of strategic partnerships is harnessed to expand scope, resources and reach. Collaborative planning mechanisms include: Meaningful participation of all stakeholders Engaging in critical dialogue Sharing power and responsibility Planning and evaluating project action

Community Organization and Action Mechanisms

Effective interventions depend upon strong project governance and vigilance over the process: Evolving leadership Sustained mobilization of resources Critical reflection and systematic monitoring Ongoing educational and training opportunities

Transformational Change Mechanisms

Community-based interventions should seek to achieve transformational change, that is individual change, community change and systemic change. The mechanisms for transformational change include: Developing and attracting champions Generating public awareness of evidence-based project successes Influencing public policy and decision-making bodies Working with relevant social movements, private sector organizations and advocacy groups Improving knowledge exchange and community-academic partnerships

Evaluating Impact
Designing and delivering interventions are only part of the equation. These have to take root in the community and improve both health indicators and reduce health disparities between communities. These impacts or outcomes are linked to the project objectives established at the outset of the project. In planning evaluation, objective and subjective indicators must be defined as well as methods for quantitative and qualitative data collection.

Evaluation is the key to measuring success. An analytical method assigning relative values to each mechanism has been developed by PHACs WHO Collaborating Centre on chronic noncommunicable disease policy in collaboration with the Canadian Consortium for Health Promotion Research synthesizing all intervention process mechanisms into an impact index. This impact index is correlated to an outcomes index and the final score is weighted by the local context. The impact index looks backward as an accountability measure gauging the success of the investment in community-based interventions and also forward providing guidance on future policy and funding decisions.

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Our Partners
PHACs WHO Collaborating Centre provides leadership in chronic or noncommunicable disease policy development, implementation and evaluation through active collaborative projects, through collaboration with strategic partnership networks and initiatives: WHOs The Global Noncommunicable Disease Network (NCDnet) The World Health Organizations 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases 2013 the prevention and control of noncommunicable diseases (NCDs). NCDnet is a resource for the global health policy community providing practical tools and resources to support monitoring and evaluation in the prevention and control of chronic or noncommunicable diseases (NCDs). PHACs WHO Collaborating Centre is leading the evaluation of the success of NCDnet as a partnership vehicle and plays a vital role by assisting in the performance measurement of the implementation of WHOs Global Action Plan. Pan American Health Organization (PAHO) PHACs WHO Collaborating Centre is a contributing partner in the Pan American Health Organization public policies on noncommunicable diseases (NCDs). PAHO is an international public health agency with more than 100 years of experience in working to improve health and living standards of the countries of the Americas. It serves as the specialized organization for health of the Inter-American System. It specifically calls upon international partners, Member States and WHO to promote partnerships for

also serves as the Regional Office for the Americas of the World Health Organization and enjoys international recognition as part of the United Nations system. PAHO has a Regional Strategy and Plan of Action on an Integrated Approach to the Prevention and Control of Chronic Diseases Forum . One of the approaches is to create multisectoral partnerships and networks for chronic disease, creating the Partners . PHACs WHO Collaborating Centre is a pillar of the regional NCD strategy.

Canadian Best Practices Portal for Health Promotion and Chronic Disease Prevention A central and early component of the Canadian Best Practices System, the Portal provides relevant and accessible best practices information to enhance decision making. Canadian Coalition for Global Health Research (CCGHR) The Canadian Coalition for Global Health Research is a not-for-profit organization governed by a volunteer Board. The Coalition began in 2001 as an informal network and has evolved through generous support from the Canadian International Development Agency Canada , theCanadian Institutes of Health Research , Health , the International Development Research Centre and other

foundations. The Coalitions primary focus is on research to improve health in lowand middle-income countries (LMICs) in Africa, Asia and Latin America. Canadian Institutes for Health Research Canadian Institutes of Health Research (CIHR) is the major federal agency responsible for funding health research in Canada. It aims to excel in the creation of new health knowledge, and to translate that knowledge from the research setting into real world applications. The results are improved health for Canadians, more effective health services and products, and a strengthened Canadian health care system. Canadian International Development Agency Canadian International Development Agency (CIDA) is the lead player in delivering Canadas official development assistance program. Its mission is to support sustainable development in order to reduce poverty and to contribute to a more secure, equitable and prosperous world. Canadian Society for International Health

The Canadian Society for International Health (CSIH) is a national non-governmental organization that works domestically and internationally to reduce global health inequities and strengthen health systems. The CARMEN Policy Observatory The CARMEN Policy Observatory is a joint initiative between PHACs WHO Collaborating Centre on chronic noncommunicable disease and the Pan American Health Organization (PAHO). The purpose of the Observatory is to promote the expansion of effective systematic NCD policy development and implementation using both qualitative and quantitative methodologies. The Observatory also fosters strong international and pan-sectoral NCD-prevention collaborations and shares its findings through a variety of channels including publications, websites and international policy dialogues and conferences.

Top of Page Centers for Disease Control and Prevention (USA) CDCs National Center for Chronic Disease Prevention and Health Promotion is at the forefront of prevention and control chronic diseases. The CDC conducts studies to better understand the causes of these diseases, supports programs to promote healthy behaviors, and monitors the health of the nation through surveys. Critical to the success of these efforts are partnerships with state health and education agencies, voluntary associations, private organizations, and other federal agencies. Together, the center and its partners are working to create a healthier nation. Chronic Disease Prevention Alliance of Canada The Chronic Disease Prevention Alliance of Canada (CDPAC) is a networked community of organizations and individuals who share a common vision for an integrated system of chronic disease prevention in Canada. Chronic Diseases and Injuries in Canada Journal Chronic Diseases and Injuries in Canada (CDIC) is a quarterly scientific journal focusing on current evidence relevant to the control and prevention of noncommunicable (chronic) diseases and injuries in Canada. The journal publishes a unique blend of peer-reviewed feature articles by authors from the public and private sectors that may include research from such fields as epidemiology, public/community health, biostatistics, behavioural sciences and health services.

Economic Burden of Illness in Canada Health Canada first published the Economic Burden of Illness in Canada (EBIC) in 1991 and again in 1997. The overwhelming response to these original reports and continued requests for more detailed cost-of-illness information indicated the need for an up-to-date revision that would provide even more detail than the first two reports. National Collaborating Centres for Public Health The purpose of the Centres is to foster linkages throughout the public health system. A key function is to connect, co-operate, collaborate and communicate with all stakeholders in the public health community, including the provinces and territories, international experts, academia, non-governmental organizations, the research community and health practitioners. World Bank Since 1945, Canada and the World Bank have worked together, with other member governments, to create a world based on a common vision. As our knowledge and understanding of the world have changed and grown over the last sixty years, so has that vision. Today, we continue to work together to finance projects, design policies and deliver programs in an effort to eliminate poverty and create a world based on the principles of sustainable development. World Health Organization (WHO): European Regional Strategy In the WHO European region, 86% of deaths are caused by noncommunicable diseases a group of conditions that includes cardiovascular disease, cancer, mental health problems, diabetes mellitus, chronic respiratory disease, and musculoskeletal conditions. This broad group of disorders are largely preventable and are linked by common risk factors, underlying determinants and opportunities for intervention. Through the Deputy Chief Public Health Officer, PHACs WHO Collaborating Centre coordinates an international working group on noncommunicable disease policy. It provides social science methodology support to the development of both the WHO European Regional Strategy and the Pan American Health Organization NCD action plans. World Health Organization (European Office) Chronic Disease and Health Promotion

WHOs regional office for Europe encompasses a region made up of 53 countries, with over 880 million people. The sheer size of the European Region means an incredible diversity of people and health situations. The Member States share a common goal: ensuring that the European Regions citizens enjoy better health. World Health Organization (WHO): Headquarters PHACs WHO Collaborating Centre is a contributing partner in the World Health Organizations public policies on noncommunicable diseases (NCDs). Of the 35 million people who died from chronic disease in 2005, half were under 70 and half were women. World Health Organization Headquarters (WHO HQ) Chronic Disease and Health Promotion Department Leadership and direction for urgent global, regional and national efforts to promote health and to prevent and control major chronic diseases and their risk factors.