Poland et al.'s paper raises the premise that there are calls for "healthcare providers and institutions to work closely with other sectors and players." They then go on to explore how hospitals can answer these calls. However, based upon the experience in Alberta, a more appropriate question is how can the health system respond? The differences in these underlying premises have important implications for understanding how the health system (not individual providers or institutions) can best effect change that will lead to healthier people in healthy communities. Hospitals are only one component of the system, albeit a major one. Other components include continuing care, rehabilitation, community and primary care, and public health. The system has both the provision of high quality care and the improvement of population health as its goals. In order to maximize the effectiveness of interventions, it is important to build upon the strength of each sector. While each sector has a contribution to make to community action, Poland et al. admit that the typical skill set of hospital staff does not support a comprehensive approach to health and its determinants.

In our experience, the leadership and expertise in population health comes from the public health sector. Addressing the determinants requires strong leadership with a broad knowledge of the community in order to develop an approach which encompasses all sectors in the health system, as well as community partners, and also establishes priorities for action. There is a need for expertise in assessing and synthesizing information on health status and health service utilization data, in identifying desired outcomes and developing evidencebased strategies to reach these outcomes.

For example, in our region, smoking behavior was identified as a priority. A coordinated response was developed with the support and involvement of all providers. It included advocacy for policies to reduce smoking (e.g., legislation to create more smoke-free spaces), school-based programs aimed at preventing the uptake of smoking by adolescents and enhanced opportunities for cessation programs for smokers, especially targeted at low-income smokers. Such a comprehensive approach would not have been feasible for an individual institution to undertake.

Poland suggests that hospitals and communities link in small units for the betterment of both. While such linkages may be useful for addressing issues like the responsiveness of hospital programs to the unique healthcare needs of their communities, our experience suggests that in a regionalized system, building upon the expertise of its public health/community health component, can best deal with the macro issues associated with determinants of health. It can do so in a comprehensive way across multiple provider and community partners.

Although it would be more challenging in a non-regionalized system, we suggest that a similar approach including the public health sector would optimize the effectiveness of interventions to address the determinants.

About the Author

Gerry Predy is the Medical Officer of Health for the Capital Health Region in Alberta, the largest integrated academic health region in Canada. He has over 25 years experience in Family Medicine and Public Health and has major responsibilities for health protection programs and monitoring and reporting on the health status of the population.

Penny Lightfoot is the Regional Manager of Population Health and Research for the Capital Health Region. She has a lead role in managing the implementation of Capital Health's three population health priorities of heart disease/stroke prevention, injury prevention and healthy aging.