 MODELS FOR POPULATION HEALTH 

Maynard AJ, ed. Being Reasonable About 12. Gold MR, Muenning P. Measure- chological, and biological pathways. Ann Health Promotion: An Integrated Model of
the Economics of Health. Cheltenham, En- dependent variation in burden of dis- N Y Acad Sci. 1999;896. Population Health and Health Promotion.
gland: Edward Elgar; 1997:322–349. ease estimates. Med Care. 2002;40: 16. Drummond M, Stoddart G. Assess- Ottawa, Ontario: Health Promotion De-
260–266. ment of health producing measures velopment Division; February 1996.
9. Summarizing Population Health Di-
rections for the Development and Applica- 13. Berkman L, Kawachi I. Social Epi- across different sectors. Health Policy. 20. Epp J. Achieving Health for All: A
tion of Population Metrics. Washington, demiology. New York, NY: Oxford Uni- 1995;33:219–231. Framework for Health Promotion. Ottawa,
DC: Institute of Medicine, Division of versity Press; 2000. 17. Lavis JN, Ross SE, Hurley JE, et al. Ontario: Health and Welfare Canada;
Health Care Services; 1998. Examining the role of health services 1986.
14. Keating DP, Hertzman C. Develop-
10. Wall R, Foster R. Beyond life ex- mental Health and the Wealth of Nations: research in public policy making. Mil- 21. World Health Organization
pectancy. Health Policy Res Bull. 2002; Social, Biological, and Educational Dy- bank Q. 2002;80:125–154. (WHO). Ottawa Charter on Health Pro-
1:32–33. namics. New York, NY: Guilford Press; 18. Lomas J. Using “linkage and ex- motion. Copenhagen, Denmark: WHO
1999. change” to move research into policy at Regional Office for Europe; 1986.
11. Erickson P, Wilson R, Shannon I.
Years of Healthy Life. Bethesda, Md: Na- 15. Adler N, Marmot M, McEwen B, a Canadian foundation. Health Aff. 22. Frank JW. Why “population
tional Center for Health Statistics; 1995. Stewart J. Socioeconomic status and 2000;19(3):236–240. health”? Can J Public Health. 1995;86:
Statistics note no. 7. health in industrial nations: social, psy- 19. Hamilton N, Bhatti T. Population 162–164.

The Contribution of the World Health Organization

to a New Public Health and Health Promotion
The author traces the de- | Ilona Kickbusch, PhD
velopment of the concept of
health promotion from 1980s
policies of the World Health Or- IN 1986, AT AN INTERNATIONAL institutions, epistemic communi- maintaining a more egalitarian ap-
ganization. Two approaches conference held in Ottawa, On- ties, and actors at the “health” end proach in all health matters.”7
that signify the modernization
tario, Canada, under the leader- of the disease–health continuum, In its Health for All strategy,
of public health are outlined in
ship of the World Health Organi- a perspective that had been la- WHO positioned health at the
detail: the European Health for
All targets and the settings ap- zation (WHO) (and with a strong beled the “salutogenic approach” center of development policy and
proach. Both aim to reorient personal commitment from then by Aaron Antonovsky.6 In over- defined the goal of health policy
health policy priorities from a Director General Halfdan coming an individualistic under- as “providing all people with the
risk factor approach to strate- Mahler), a broad new under- standing of lifestyles and in high- opportunity to lead a socially and
gies that address the deter- standing of health promotion lighting social environments and economically productive life.”3 It
minants of health and em- was adopted. The Ottawa Char- policy, the orientation of health proposed a revolutionary shift in
power people to participate in ter for Health Promotion has promotion began to shift from fo- perspective from input to out-
improving the health of their since exerted significant influ- cusing on the modification of indi- comes: governments were to be
communities. ence—both directly and indi- vidual risk factors or risk behav- held accountable for the health of
These approaches combine
rectly—on the public health iors to addressing the “context their populations, not just for the
classic public health dictums
debate, on health policy formula- and meaning” of health actions health services they provided.
with “new” strategies, some
setting explicit goals to inte- tion, and on health promotion and the determinants that keep Lester Breslow, the father of the
grate public health with gen- practices in many countries.1,2 people healthy. The Canadian Alameda County study and one
eral welfare policy. Health for The work on this document was Lalonde report is often cited as of the world’s leading epidemiol-
All, health promotion, and pop- spearheaded by the WHO Euro- having been the starting point of ogists, had argued in 1985 that
ulation health have contributed pean Regional Office and was this new development. Recently “the stage is set for a new public
to this reorientation in thinking developed over a period of 5 the director of the Pan American health revolution.”8 The Ottawa
and strategy, but the focus of years of intensive research and Health Organization, Sir George charter echoed this challenge as
health policy remains expen- debate. It was based on the Alleyne, reflected on this issue, well as the link to public health
diture rather than investment. “Health for All” philosophy,3 the stating that “it is perhaps not acci- history in its subtitle, “The Move
(Am J Public Health. 2003;93:
Alma Ata Declaration,4 and the dental that the impetus for the Towards a New Public Health.”
383–388)
Lalonde health field concept.5 focus on health promotion for the Fourteen years later, in a com-
The Ottawa charter initiated a many should have risen in Can- mentary published in the Journal
redefinition and repositioning of ada which is often credited with of the American Medical Associa-

March 2003, Vol 93, No. 3 | American Journal of Public Health Kickbusch | Peer Reviewed | Models for Population Health | 383
  MODELS FOR POPULATION HEALTH 

tion, Breslow deemed the Ottawa the health of populations: (1) the objectives in the United States,11 United States can be understood
charter the document that has development of healthy public which involved commitment to a only by keeping in mind the
best captured the essence of the policies (policies supportive of focus on individual behavior strong link between public health
third public health revolution by health in sectors other than modification. and social reform in European
conceptualizing health as a “re- health), (2) the need to ensure en- Finally, 2 sets of “lifestyles” public health history—the work
source for living” and shifting the vironments supportive of health, targets were developed, one fol- of Villermé, Virchow, Chadwick,
focus from disease prevention to (3) the importance of personal lowing the US “reduction of dis- and Engels, to name but a few—
“capacity building for health.”9 In skills, (4) community action, and ease” model and the other fol- and the role of the state in the
many parts of the world, influ- (5) the challenge of reorienting lowing a “social model of health” provision of health and social
enced in particular by WHO and health services. A new mind-set approach. An advisory group of services in the European region.
the Pan American Health Organi- and professional ethos are pro- WHO European member states This decision built as well on in-
zation, health promotion has posed for health professionals; decided to move ahead with the tellectual traditions in the social
come to be understood not only their new role is to “enable, advo- latter, and the compromise was a sciences, particularly Max
as an approach that moves “be- cate, and mediate.” This ap- package of 5 lifestyles and health Weber’s understanding of
yond health care” but also as a proach to health promotion targets that addressed healthy lifestyles as a collective social
commitment to social reform and found its dissemination and appli- public policy, social support sys- category and Emile Durkheim’s
equity. The Pan American Health cation through a number of chan- tems, knowledge and motivation, understanding of the social de-
Organization included the cate- nels. Here I focus on 2 of these positive health behavior, and terminants of health as devel-
gories of the Ottawa charter in its channels: the European health health-damaging behavior. While oped in his classic 1970 study,
2001 annual report, and the di- targets and the settings approach. still addressing individual behav- Suicide. Recently this under-
rector’s message stated: “For an iors, the advisory group zeroed standing of lifestyles as residing
organization devoted to health, THE WHO “HEALTH FOR in on the interactions between in- at the intersection between per-
such as ours, the main strategies ALL” TARGETS dividuals and their environments sonal and social factors10 has
of health promotion can find ap- and on the political instruments been further expanded and de-
plication in almost all aspects of The most important avenue needed to address health deter- veloped as “collective lifestyles”
our work.”7 for the spread and recognition of minants. The group aimed to ex- by Frohlich and Potvin.14 They
The Ottawa charter frames a broad understanding of health pand the territory of health into too argue that collective lifestyles
health as a resource that is cre- promotion was the adoption of other policy arenas and high- should be conceptualized as a
ated in the context of everyday 38 Health for All targets by the lighted the complex political and group attribute resulting from
life and defines health promotion member states of the European social processes necessary to the interaction between social
as “the process of enabling people region of WHO in 1984.3 In achieve changes in health. This conditions and behavior.
to increase control over, and to essence, these targets followed approach was strengthened in The European Health for All
improve their health.” It defines the Lalonde health field concept5 subsequent revisions of the tar- targets provided the new resource-
health as “a resource for everyday with one important distinction: gets in 1991 and 1998.12,13 based health promotion ap-
life, not the objective of living.” It the section on “lifestyles and As a matter of policy and prin- proaches a visibility far beyond
adds that “health is a positive con- health” did not focus on lifestyles ciple, the 5 lifestyle targets were the individual program and proj-
cept emphasizing social and per- as individual behavior changes always grouped as a “package,” ects. Through these targets,
sonal resources, as well as physi- but opted to integrate several and a new division was created health promotion gained legiti-
cal capabilities.” Following in the components of the Lalonde con- within the organization to support macy and influence and created
footsteps of the best traditions of cept in a composite approach. A their implementation. The work- the positive political environment
public health and social medicine paper presented at the 1983 ing group preparing the lifestyles for the adoption of the Ottawa
and making full use of the re- meeting of the WHO Regional targets also exerted considerable charter in 1986. To date, 27 Eu-
search on the impact of social fac- Committee of the European Re- influence on the nature of the Eu- ropean countries have formulated
tors on health, it links the produc- gion had already made the point ropean target document by pro- health targets using the WHO
tion of health explicitly to that lifestyles needed to be un- posing—as early as 1982—targets policy as a starting point, as have
“prerequisites for health” such as derstood as collective behaviors for social determinants of health. regions, provinces, and cities.15,16
peace, income, and housing and— deeply rooted in context.10 This These targets were not included The most recent such attempt
most important—defines health thinking was very different from in the final document, but the at the national level upholds the
promotion as a process of empow- the second major influence on group did succeed in gaining sup- original orientation developed in
erment and capacity building. the work of the WHO Regional port for an equity in health target. the Ottawa charter and the
The charter outlines 5 key ac- Office, the “management by ob- The decision to move in a di- WHO policy. A report published
tion areas that reinforce one an- jective” approach applied in the rection that was quite different in 2001 by the Swedish National
other with the goal of improving Healthy People 2000 goals and from the approach chosen in the Committee for Public Health17 (a

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  MODELS FOR POPULATION HEALTH 

parliamentary committee estab- In 1998, WHO’s Regional Of- the preferred US terminology)— regions, companies, schools, pris-
lished in 1997) identified 6 main fice for Europe published a de- at whatever level of governance, ons, and hospitals, to create net-
areas of strategic intent that, in tailed report exploring the inter- from organizational to interna- works of commitment and diffu-
effect, set both a health promo- section between population tional—is one mechanism of sion. These networks carried the
tion and a health determinants health and the Health for All agreeing on common goals and new health policy message to a
agenda: (1) strengthening social strategy.21 It underlined that the direction, providing a “common range of collaborators in other
capital, (2) ensuring that children common ground between popu- context of interpretation” and sectors, organizations, and all lev-
grow up in a satisfactory environ- lation health, Health for All, and broadening the legitimacy base els of governance. Through a
ment, (3) improving workplace health promotion resides in the for critical choices in health. The myriad of meetings, consulta-
conditions, (4) creating a satisfac- recognition that the majority of target development process in it- tions, publications, and other for-
tory physical environment, health determinants reside out- self, if broadly conceived and im- mal and informal mechanisms,
(5) stimulating health-promoting side the health sector and drew plemented in partnerships be- an international learning process
life habits, and (6) developing a attention to the strategic compe- yond the health sector, produces was set up for the new concept
satisfactory infrastructure for tence and experience that health “bridging capital.”22 Commitment of health promotion.26–30
health issues. Gunnar Ågren, di- promotion is able to bring to the to collaboration becomes a “cate- The key strategic point of the
rector-general of the Swedish Na- table. The more recent target gorical imperative,” and, as a settings approach was to move
tional Institute of Public Health, documents of WHO have rein- consequence, new strategic roles health promotion away from fo-
described the essence of the forced the commitment to ad- emerge for public health depart- cusing on individual behaviors
Swedish targets as being oriented dress health determinants and to ments, health agencies, and and communities at risk to devel-
toward health determinants seek strategic entry points out- health professionals. This is a oping a strategy that encompasses
rather than health behaviors.18 side of the health sector. For ex- point repeatedly underlined in a total population within a given
This “new order” was, to a cer- ample, according to WHO’s re- comparative analyses of health setting. This followed the thinking
tain degree, a response to Leo- cent Health 21 document13: targets.12 One such challenge, for of Geoffrey Rose31 that an effec-
nard Syme’s19 repeated chal- example, is how to transfer tive and sustainable public health
[W]hether one is a government
lenges for a new categorization minister, city mayor, company knowledge regarding what cre- strategy must lower the risk of the
of health action not based on dis- director, community leader, a ates health and how to organize majority of individuals, not only
ease categories. parent or individual, Health 21 collective learning regarding how those at the tail end of the distri-
can help develop action strate-
It must be kept in mind, gies that will result in more to produce health as an overall bution. The target of the interven-
though, that while the charter democratic, socially responsible systems goal, not just a responsi- tion therefore moves from individ-
and its “ecological” orientation and sustainable development. bility of the health sector. Gover- uals or groups of individuals to
Health is a powerful political
were widely adopted, the practice platform. nance theories stress the impor- their environments, the “settings
of health promotion frequently tance of “meso” institutions and of everyday life.” The strategic ob-
continued to focus on individual At the same time, the Euro- mediating structures, which allow jective becomes the strengthening
behavior change, in part because pean document has strengthened the dialogue between all parties of resources for health. The inno-
its institutional base tended to be the commitment to values such to evolve and serve as a center vation of health promotion has
in health education. Many propo- as equity, participation, solidarity, of social learning.23 been to include the participatory
nents of health promotion as a sustainability, and accountability, This shift in orientation and process and empowerment as
“new public health” based more a point often considered a weak- purpose found its strategic ex- part of the strategic objectives. In-
on social determinants were ness of the population health de- pression in the settings approach, deed, Rootman et al.32 claimed
therefore encouraged when the bate, which focuses on an eco- the second major innovation in- that “unless empowerment is part
population health movement nomic rather than a humanistic troduced by the WHO European of the strategy it cannot be called
emerged in Canada at the begin- rationale. A subtle change can Regional Office in the field of health promotion.”
ning of the 1990s, because it pro- also be seen in the new Healthy health promotion.24,25 This ap- In 1987, the WHO Healthy
vided strong arguments for a People 2010 goals and objectives proach spearheaded a number of Cities project was launched with
focus on social and economic de- of the United States, which now initiatives that sought to engage the explicit aim of localizing the
terminants and for investments in include goals related to support- other actors in health, and it did Health for All strategy by involv-
the sectors that “produce health,” ive environments. so by creating a new dissemina- ing political decision makers in
such as education, income, and tion strategy through networks. cities throughout Europe and by
housing.20 But population health, THE SETTINGS In the early 1980s, the WHO building a strong lobby for public
as the “next new thing,” included APPROACH European Regional Office began health at the local level. What
very little mention of health pro- to work with cities and local au- began with 11 designated WHO
motion, and the chance to forge a Developing health targets (or thorities, universities, and profes- cities soon became a widespread
strong alliance was lost. health goals and objectives, in sional organizations, along with “new public health movement” in

March 2003, Vol 93, No. 3 | American Journal of Public Health Kickbusch | Peer Reviewed | Models for Population Health | 385
  MODELS FOR POPULATION HEALTH 

which several hundred cities on institutional change, and cre- together to improve the health of For example, a recent English
around the world engaged in ate space for innovative health the setting. The settings projects health target document42 (al-
new types of public health ap- action. Diffusion of knowledge have caught the imagination of though its targets are structured
proaches.33 The leaders of the and exchange of information many actors in many countries, around disease categories) pre-
project ventured that health was were ensured through regular with and without WHO support. sents itself as an intersectoral
not something separate to be im- meetings of all European cities in- What they achieve does not fit challenge for the whole of gov-
plemented by public health de- volved in the project, as well as easily into an epidemiological ernment, not just the health sec-
partments, and they challenged through national and regional framework of “evidence” but tor. It regards health as a “na-
each social actor in the commu- networks. Cities were supported needs to be analyzed in terms of tional contract” and a 3-way
nity, the private sector, the non- in developing indicators and poli- social and political processes. partnership between individuals,
governmental sector, the faith cies, and a mechanism called the Ways in which to approach communities, and the govern-
community, and the various sec- “multi-city action plan” was intro- the evaluation of settings pro- ment. The document then clearly
tors of city government to con- duced that focused on priority grams have been outlined in a lays out the responsibilities of
tribute to health and work with health issues such as equity, traf- number of recent publica- each partner under each respec-
others in an “organized commu- fic, tobacco, the elderly, mental tions.25,32,39 Such projects fulfill tive target. The health promotion
nity effort,” as expressed in the health, and AIDS care. many of the criteria for “promis- approach advocated by the Ot-
definition of public health of The project continues to this ing interventions” developed in tawa charter implies that health
C. E. A. Winslow.34 day. There is now a strong focus the recent Institute of Medicine is produced in the dynamic ex-
Anthony Giddens, the British on cities in Central and Eastern report focusing on health promo- change between people and their
sociologist and recent director of Europe, and the practical experi- tion.40 Strategically, their environments. Social determi-
the London School of Econom- ence accumulated in the cities achievement has been to move nants are considered central to
ics, coined the phrase “life poli- has become a source of inspira- health out of the professional ac- health creation, but at the same
tics” to refer to this kind of inte- tion for local health action tion frame into organizations and time people are recognized as so-
grative approach. He postulated around the world. WHO has en- the community (“the context of cial actors who can effect
that we cannot continue to di- gaged in regular project evalua- everyday life” in the language of change. Indeed, the very process
vide the way we do politics into tions and reviews.33 The ap- the Ottawa charter) and to frame of involvement is considered
vertical streams of action: sepa- proach has been particularly health in terms of relevance to health promoting in that it cre-
rating, for example, social policy, successful in the Americas, people and communities. ates (for example) self-esteem, a
health policy, and economic pol- where, with the encouragement This active role of citizens and sense of worth, and social capital.
icy.35 According to Giddens, the of the Pan American Health Or- the community is central to the
question faced in 21st-century ganization, a strong “healthy mu- settings approach. The Ottawa THE THIRD PUBLIC
politics is “How do we want to nicipalities network” has evolved charter definition of health pro- HEALTH REVOLUTION
live our lives?” Accordingly—and that includes hundreds of cities.38 motion—“the process of enabling
following the WHO definition of In the United States, the Coalition people to increase control over The first public health revolu-
health—the 11 qualities of a for Healthy Cities and Communi- their health”—partly took its lead tion addressed sanitary conditions
healthy city developed by the ties (http://www.healthycommu- from the health definitions of the and fought infectious diseases; the
project are related to well-being nities.org) has based its work on major social movements of the second public health revolution
and quality of life.36 the WHO approach. 1970s and 1980s (e.g., the wom- focused on the contribution of in-
To be recognized, cities had to Following the Healthy Cities en’s health movement, the self- dividual behaviors to noncommu-
fulfill a number of conditions set project, other settings approaches help movement, and the gay nicable diseases and premature
by WHO37; for example, they were developed by the WHO Re- rights movement). Some authors, death. The third public health
had to commit to a health plan, gional Office for Europe: health- for example Petersen,41 contend revolution recognizes health as a
create an intersectoral committee promoting schools, health- that this is not a move toward key dimension of quality of life.
for health, establish a Healthy promoting workplaces, health in empowerment but an increased Health policies in the 21st cen-
Cities office and appoint a coordi- prisons, healthy universities, and privatization of risk. However, Pa- tury will need to be constructed
nator, develop a city health pro- health-promoting hospitals. In all quet23 argues that the new health from the key question posed by
file, and involve citizens and com- of these projects, the key inten- governance is only possible as a both the health promotion and
munity groups. The project tion has been to gain a “political” new type of social contract be- population health movements:
advocated partnership and net- commitment to improving the tween the “strategic state” and “What makes people healthy?”
work-based approaches of change health of the entire organization “active citizens,” which in turn re- Health policies will need to ad-
management to allow creation of (a systems approach) and devel- flects an understanding of health dress both the collective lifestyles
political commitment, generate oping strategies that allow all as a co-produced good within the of modern societies and the social
visibility for health issues, embark parts of the organization to work structure of everyday life. environments of modern life as

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  MODELS FOR POPULATION HEALTH 

they affect the health and quality ing public health with general toward health in the year 2000. Health operation and Development; 2001:
of life of populations. welfare policy. Health for All, Med. 1985;3:43–44. 183–208.

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for health, and increasing people’s European Health Promotion Series 4.
21st Century. Copenhagen, Denmark:
About the Author World Health Organization; 1999. 28. Pelikan JM, Garcia Barbero M,
capabilities to lead healthy lives. The author is with the Division of Global
Lobnig H, Krajic K, eds. Pathways to a
The development of tools such as Health, Department of Epidemiology and 14. Frohlich KL, Corin E, Potvin L. A
Health Promoting Hospital. Gamburg,
Public Health, Yale University School of theoretical proposal for the relationship
environmental, social, economic, Germany: Conrad Verlag; 1998.
Medicine, New Haven, Conn. between context and disease. Sociol
and, most recently, health “impact Requests for reprints should be sent to Health Illness. 2001;23:776–797. 29. Tsouros A, Dowding G, Thompson
assessments”43,44 (or the “Verona Ilona Kickbusch, PhD, Division of Global
15. Proceedings of the International
J, Dooris M. Health Promoting Universi-
Health, Yale University School of Medi- ties: Concept, Experiences and Framework
benchmark,” which relates to best Workshop on Target Setting, Brussels,
cine, Department of Epidemiology and for Action. Copenhagen, Denmark:
practices in partnership build- 8–9 March 1966. Brussels, Belgium:
Public Health, 60 College St, PO Box World Health Organization; 1998.
European Public Health Center; 1966.
ing45) underlines the fact that as- 208034, New Haven, CT 06520-8034
30. Whitelaw S, Baxendale A, Bryce C,
(e-mail: ilona.kickbusch@yale.edu). 16. Goumans M, Springett J. From proj-
sessments of accountability need MacHardy L, Young I, Witney E. “Set-
This article was accepted October 30, ect to policy—“healthy cities” as a mech-
to involve both cross-sector effects tings” based health promotion: a review.
2002. anism for policy change for health?
Health Promotion Int. 2001;16:
and externalities. Health Promotion Int. 1997;12:311–377.
339–354.
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March 2003, Vol 93, No. 3 | American Journal of Public Health Kickbusch | Peer Reviewed | Models for Population Health | 387
  MODELS FOR POPULATION HEALTH 

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Evolution of the Determinants of Health, Health Policy, and Health

Information Systems in Canada
The history of health deter- | Sholom Glouberman, PhD, and John Millar, MD, BSc, MHSc, FRCP(c)
minants in Canada influenced
both the direction of data
gathering about population IN CANADA, THE NOTION OF vices resulted in increased de- dition, it proposed health educa-
health and government poli- determinants of health was de- mand. McKeown argued that tion and social marketing as the
cies designed to improve rived from the work of Thomas there were a large number of in- tools to persuade people to adopt
health. Two competing move- McKeown, who influenced 2 fluences on health apart from tra- healthier lifestyles.
ments marked these changes. somewhat different movements ditional public health and med- Health promotion advocates
The idea of health promo- that together are now referred to ical services and that these quickly recognized that an exces-
tion grew out of the 1974 as “population health.” Health influences should be considered sive emphasis on lifestyle could
Lalonde report, which recog- promotion, the earlier of these in framing health policy and in lead to a “blame the victim”
nized that determinants of movements, was first articulated any efforts to improve the health mentality. Smoking, for example,
health went beyond traditional
by Hubert Laframboise in the of the population.3 was not merely a matter of per-
public health and medical care,
widely circulated Lalonde report sonal choice but also a function
and argued for the importance
of socioeconomic factors. Re- of 1974.1 The second, research HEALTH PROMOTION of one’s social environment. As a
search on health inequalities focusing on inequalities in health, result, physical and social envi-
was led by the Canadian Insti- grew out of the efforts of Fraser The Lalonde report marked ronments were differentiated,
tute for Advanced Research in Mustard and the Canadian Insti- the first stage of health promo- with growing emphasis placed on
the 1980s, which produced ev- tute for Advanced Research.2 tion in Canada. It used McKe- the latter. By 1996, as more dis-
idence of health inequalities Both have had a strong effect on own’s ideas to develop a frame- tinctions and additions occurred,
along socioeconomic lines and how health information is gath- work labeled “the health field the 4 determinants of health de-
argued for policy efforts in ered and disseminated in Can- concept” and applied this con- scribed in the Lalonde report
early child development. ada, but they have had a more cept to an analysis of the then had grown to 12.5
Both movements have
limited influence on health pol- current state of health among The Lalonde report called at-
shaped current information
icy. Here we attempt to describe Canadians. It concluded with a tention to the existing fragmenta-
gathering and the policies that
have come to be labeled “pop- these movements and their infor- large number of health policy tion in terms of responsibility for
ulation health.” (Am J Public mation and policy consequences. recommendations formulated in health. “Under the Health Field
Health. 2003;93:388–392) McKeown was a professor of line with this new approach. Concept, the fragments are
social medicine at the University brought together into a unified
of Birmingham in England dur- Determinants of Health whole which allows everyone to
ing the establishment of Britain’s To the best of our knowledge, see the importance of all factors
National Health Service. The ser- McKeown was the first to use the including those which are the re-
vice’s original promise of univer- term “determinants of health.”4 sponsibility of others.”1(pp33–34)
sal health care coverage to im- The Lalonde report identified 4 The report was ahead of its time
prove population health and major components of the health in identifying the need for inter-
eventually reduce demand on field concept: human biology, sectoral collaboration and recog-
services was not fulfilled; in- health care systems, environ- nizing that multiple interven-
creased access to medical ser- ment, and lifestyle.1(pp31–34) In ad- tions—a combination of research,

388 | Models for Population Health | Peer Reviewed | Glouberman and Millar American Journal of Public Health | March 2003, Vol 93, No. 3
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