A population health approach maximizes its potential by directing efforts and investments “upstream” to address root causes of health and illness.
What are upstream investments?
Upstream investments are interventions aimed at the root causes of a population health problem or benefit. Root causes are often identified by determining the most immediate and direct causes, and working backwards from there. In many cases, upstream action addresses social, economic and environmental conditions.
The population health approach is grounded in the notion that the earlier in the causal stream action is taken (i.e. the more upstream the action is), the greater the potential for population health gains and health-related cost savings. It is often true, however, that these root causes are more difficult to change, requiring more time, more resources and more will.
Because of this, upstream interventions may not be the most appropriate choice; the context, timing, resources, mandate and available evidence must be considered. The choice should be based on the best evidence, not just on an article of faith that “further upstream is always better.”
Resources to Increase Understanding:
What are upstream investments?
- The Case for Prevention: Moving Upstream to Improve Health of All Ontarians – Health Nexus (formerly the Ontario Prevention Clearinghouse)
- a) What is the best balance of investments?
- b) Who will provide support and what will it be?
A) What is the best balance of investments?
A population health approach recognizes the tension between short and long term goals. Health problems have to be treated immediately, but at the same time, upstream investments are needed to keep people healthy. Furthermore, upstream investments need sustained support to have a real impact.
The population health approach strives to strike a balance between investments of three types:
- Short term, e.g. responding to citizen concerns about the quality and accessibility of health care, food and drug safety, and emergency response procedures
- Medium term, e.g. programs that favour equity, such as redistribution of resources, and programs that invest in children, such as responding to windows of developmental opportunity
- Long term, e.g. investment in alternative energy sources and other technologies that reduce stress on the physical environment.
B) Who will provide support and what will it be?
Taking upstream action on the social, economic and environmental health determinants requires influencing how multiple sectors of government assign their resources. In this Key Element, it is important to identify what investments by what partners outside health are required. To generate this list, consider all the sectors whose mandates impact upon health determinants and focus on those that are most relevant.
How are upstream investments increased?
4.1 Balance short, medium and long term investments
The decision-making framework presented in Key Element One can help with this process. More specifically, this means:
- Identify potential interventions
- Generate criteria to guide investment decisions and to help reach agreement among the investor groups that seek to advance health
- Identify the anticipated positive health outcomes and estimated costs, so as to assess cost-effectiveness to the greatest degree possible.
- Select priorities for investment based on the results of a strategic assessment process. The assessment process allows comparisons of different choices based on their ability to improve health outcomes.
4.2 Influence investments in other sectors
A broad intersectoral range of support is important for upstream population health work, since health and health promotion ministries do not have lead responsibility for many determinants of health such as education, environment, housing, etc. An ongoing communication strategy to make the case for upstream investments to all relevant stakeholders (e.g. political leaders, medical professionals) should be implemented. This will help explain and justify the investment patterns that underpin a population health agenda.
To do this, decide who will say what to whom and how, making sure to address perceived barriers, since investing resources to address these upstream broader determinants of health can challenge the established interests of political leaders, some medical professionals, and other groups that benefit from the status quo.
Evidence to Support Decision-Making:
What sources of data can inform decisions about the best point on the up/downstream continuum to focus to make the most impact on a given audience and health issue?
- A Census of Economic Evaluations of Primary Prevention Interventions in Population Health – University of Calgary, Centre for Health and Policy Studies
- Economic Evaluation Across the Four Faces of Prevention: A Canadian Perspective – Centre for Health Economics and Policy Analysis
Resources that Build Capacity:
What decision-making frameworks or guides can help guide efforts to influence decision-makers in health and other sectors, to make upstream investments for health?
What do you have at the end of Key Element 4?
- A shortened list of potential interventions, which strikes a balance between long, medium and short-term considerations.
- A wish list of contributions from stakeholders from multiple sectors.
How does this Key Element relate to the others?
- It provides a lens through which to sort and prioritize the list of potential interventions (Key Elements 3.5 and 5)..
- It identifies roles for other sectors, thus setting the stage for intersectoral collaboration (Key Element 6)
Why is this Key Element important?
- It has the potential to achieve the greatest influence on population health.
- It can result in great savings, as prevention tends to be less expensive than treatment.
Examples Illustrating Application:
What is an example of a group, organization or government that has supported the adoption of evidence-based approaches and interventions?