Improving the health of our children and youth: The power of partnerships and questions

“What you see but cannot see over is as good as infinite.”

–Thomas Carlyle, 19th century Scottish philosopher

In his 2002 Commission Report entitled Building on Values: The Future of Health Care in Canada (1), Roy Romanow stated that the goal of our health care system is to make Canadians the healthiest people in the world. To reach this goal, we must improve the health of our vulnerable and marginalized citizens, particularly those populations whose health lags behind the majority, such as the poor, the Aboriginal, the immigrant and refugee, the rural remote, the incarcerated, the mentally ill, the homeless and the addicted (2). Children and youth can be found within each of these groups.

While our health care system has evolved extensively since the 1960s, when Premier Tommy Douglas led the drive for universal health care, the current configuration and areas of emphasis have been much influenced by the perspectives of health professionals, and most attention has been paid to acute care. This system serves a wide swath of Canadians and, in general, it serves them well, particularly in their time of acute need. Unfortunately, it frequently falls short in meeting the health needs of those at highest risk for poor health as noted above. Furthermore, the health needs of many of our children and youth with serious chronic problems, such as obesity, physical and mental handicaps, depression and addiction, may not be well addressed. As health professionals, we have failed too often to see health care delivery issues through the eyes of those most in need. When we fail to recognize their issues, we cannot see beyond them to find the perspectives needed to reshape our health care system into one that can meet the needs of all Canadians, including our marginalized and vulnerable children and youth.

A good starting point for changing our perspective comes from the work of Charles Boelen of the World Health Organization. In his 2000 report entitled Towards Unity for Health (3), he articulates the rationale for focusing health care systems on the needs of people and not on the convenience of health care providers. He notes that five groups are critically important for developing a health care system that is centred on people’s needs: communities, health professionals, academic institutions, health administrators and policymakers. Note in Figure 1 that health professionals are neither at the centre nor in a more prominent position than any of the other groups. Partnership and unity for health are key, hence the pentagram for health.

Figure 1.

Partnership pentagram. Adapted from reference 3

Boelen also presents a four-point health compass (relevance, quality, equity and cost-effectiveness) for reviewing our current health system and for charting a new course (Figure 2). When one point on the health compass dominates, the system may be driven in that direction to the detriment of the others. Balance is key. For example, when one looks at the American health care model, one sees that quality, including choice, is most highly valued, while equity, cost-effectiveness and relevance appear to be much less important.

Figure 2.

Health compass. Adapted from reference 3

In Canada, we have not addressed the issues of relevance, equity and cost-effectiveness very well. This flaw is easily seen if one looks from the perspective of Aboriginal health needs and concerns. There is much to be learned here about identifying the most important needs and concerns and determining how our system could be reshaped to better meet those needs. That Aboriginal health needs are indeed different, important and must be addressed has long been recognized (1,4–6). Unfortunately, health care professionals and administrators have tended to apply traditional methods of problem solving to arrive at traditional solutions with limited or no input from the involved Aboriginal communities. Not surprisingly, many of these solutions have met with little success. However, when native concerns are addressed from a native perspective, with emphasis on collaboration and partnership, more appropriate health care can be provided with more success (7). Partnership means unity for health.

Not only do we need new, more inclusive perspectives for dealing with the health issues of our Aboriginal population and other marginalized groups, but we also need new techniques for finding solutions because our traditional ways are not working. We can do better.

Complexity theory offers a new framework for thinking about problems (8). Table 1 presents a very brief overview by Zimmerman of York University in Toronto, Ontario (8,9). Health system problems are indeed complex, not simple or complicated, whether they are in the acute care arena or not. Despite this fact, over and over again we have chosen to apply either simple solutions to problems (eg, throwing money at it) or complicated ones, such as the regionalization of the health care system. At the same time, there have rarely been any significant changes in what is actually done. Despite this, we continue to be surprised when these actions fail to improve health. Partnerships and relationships are key for successful changes that can lead to improvement in health. Too often, these have been ignored in our haste to find a quick fix.

TABLE 1.

Overview of complexity theory

Simple: Following a recipe	Complicated: A rocket to the moon	Complex: Raising a child
The recipe is essential	Formulas are critical and essential	Formulas have only limited application
Recipes are tested to assure replicability of later efforts	Sending one rocket increases assurances that next will also work	Raising one child gives no assurance of success with the next
No particular expertise; knowing how to cook increases success	High level of expertise in many specialized fields + coordination	Expertise can help but is not sufficient; relationships are key
Recipes produce standard products	Rockets similar in critical ways	Every child is unique
Certainty of same results every time	High degree of certainty of outcome	Uncertainty of outcome remains

Adapted from reference 9

The complex problems of health care require a new approach and new perspectives, in which partnerships and relationships are valued and appreciative inquiry is applied. Appreciative inquiry (9,10) means asking questions not to find the problems or gaps, but to find out what is working and why. The basic premise is to find situations and settings where better-than-expected results have occurred, to identify the assets or preconditions that have helped create the context for these results, and then to find ways to support these assets or preconditions in other settings.

Finally, as stated by Cooperrider et al (11), “human systems grow towards what they persistently ask questions about”. We, as health professionals who care for children and youth, must continue to ask questions. By asking questions, we draw attention to the problems, help reshape health priorities and help change the system to better meet the needs of all of our children and youth. We need to ensure that we have listened well to patients, to their families and to communities. We must improve our understanding of their perspectives and the perspectives of the other partners in the pentagram for health (Figure 1). We must work to bring together all five groups in the pentagram to work collaboratively to find new ways to address the health needs of our children and youth. We need to be respectful of our vast geography, cultural diversity and differences in access to resources. We must focus on what has worked better than expected and how we can translate that experience into improved health for others most in need. This approach is the only way to achieve the goal of making Canadians the healthiest people in the world. We cannot leave any of our children and youth behind.