Risk Management & Population Health

Case Study of Canada

Prepared By:- Mohammad Abu Mahfouze Master Security of Information System AABFS Supervised By;- Dr. Loai Tawalbeh

Introduction
Health policy development has focused on individuals and the role of medical care in preventing and treating disease and injury . Recent attention to health inequities and social determinants of health has raised the profile of population health and evidence-based strategies for improving the health of whole populations This presentation reviews a historical developments in the fields of risk management and population, health and proposes a joint population health risk management framework that integrates the key elements of both fields

Introduction
Risk science has started at the 1970s, and since that time it has been developed into powerful tool for managing technological change. Modern risk analysis took shape with the application of probabilistic risk assessment methods in the evaluation of reactor safety. As a result of the air pollution in urban areas in Canada associated with motor vehicle and industrial emissions has been linked to adverse health effects, which raised the important of the policy questions about pollution management .We still know little about the potential risks from genetically modified organisms, including foods, therapeutic products, and best control products.

Introduction
The evolution in thinking about how to manage health and environmental risks associated with modern technology and technological change. In 1983, the U.S. National Research Council (NRC) issued a pioneering report on Risk Assessment in the Federal Government: Managing the Process This work proposed a comprehensive framework for assessing and managing health and environmental risks that has influenced the development of risk management policy. This and subsequent frameworks provide guidance both on scientific approaches to characterize risks, and on policy options for managing them.

Introduction
The concept of population health has also emerged over the past 30 years, during which it became accepted that changes in lifestyle or social and physical environments may have a greater impact on population health than the health system.

Although risk management and population health evolved largely independently, both approaches offer firm bases for guiding evidence-based health policy

An Integrated Framework for Risk Management and Population Health (1983)

Figure 1. U.S. National Research Council framework for risk assessment(1983).

EVOLUTION OF RISK MANAGEMENT

The NRC (1983) report, commonly referred to as the Red Book, gave the first structured description of the health risk assessment and management process, and has been widely endorsed throughout the world. The framework consists of three components: Research, Risk assessment, and Risk management (Figure 1). Risk assessment : is defined as characterization of the potential adverse health effects of human exposures to environmental hazards.

Risk assessment involves four steps

1. Hazard identification : is the process of determining whether exposure to an agent can increase the incidence of a health condition 2. Dose-response assessment: is the process of characterizing the relation between the dose of an agent administered or received and the incidence of an adverse health effect in exposed populations; it expresses incidence as a function of exposure to the agent.

Risk assessment involves four steps

3. Exposure assessment : is the process of measuring or estimating the intensity, frequency, and duration of human exposures to an existing agent or of estimating hypothetical exposures that might arise from the release of new chemicals into the environment . Risk characterization: is the process of estimating the incidence of a health effect under the various conditions of human exposure described in the exposure assessment

4.

Risk Management
Risk management: refers to the process of evaluating alternative regulatory options and selecting among them. The results of risk characterization are used to identify potential options that are then evaluated in terms of expected public health, economic, social, and political consequences. The responsible agency then makes a decision and implements the selected option.

Risk Determination Diagram

The limitations of the NRC framework are that it is better suited to dealing with environmental agents than other health hazards; it only considers regulatory options; it contains no provision for monitoring, evaluating, or revising the risk management strategy; nor is stakeholder involvement explicitly addressed . So it was not the best framework .

Health and Welfare Canada 1990 Framework

In 1990, Health Canada developed a risk management framework that defined and described the general process used to assess and deal with health risks, then it was updated at 1993(Health and Welfare Canada 1993).

The Risk Determination Framework consists of two major components: Risk assessment and Risk management .

Health and Welfare Canada 1990-1993 Framework

Figure 2. Health Canada health risk determination framework (1990, 1993).

A- Risk assessment consists of four steps:

1. Hazard Identification: is the process of determining whether exposure to an agent can increase the incidence of a health condition . Risk Estimation :is the process of characterizing the relation between the dose of an agent administered or received and the incidence of an adverse health effect in exposed populations; it expresses incidence as a function of exposure to the agent.

2.

Risk assessment consists of four steps:

3. Exposure Assessment: is the process of measuring or estimating the intensity, frequency, and duration of human exposures to an existing agent or of estimating hypothetical exposures that might arise from the release of new chemicals into the environment Risk Characterization : is the process of estimating the incidence of a health effect under the various conditions of human exposure described in the exposure assessment.

4.

B- Risk management
Risk management : Refers to the process of evaluating alternative regulatory options and selecting among them. The results of risk characterization are used to identify potential options that are then evaluated in terms of expected public health, economic, social, and political consequences. The responsible agency then makes a decision and implements the selected option.

Risk Management consist of four steps

1. 2. 3. 4. Decision: Is the process of choosing between the options . Implementation : Is the process of creating the option that we had choose . Monitoring and Evaluation : Is the process of controlling the option to be sure that we achieved our aim . Review : Is the process of choosing other option in case we

didnt have the best results.

Canadian Public Health Association (CPHA)

In 1989, a National Advisory Panel on the Risk/Benefit Management of Drugs was appointed by the Canadian Public Health Association (CPHA), to review risk/benefit methodology applied to the field of prescription drug use and to develop a framework for use in risk management. The panel built on the 1993 Health Canada Risk Determination Framework as a starting point to develop its Benefit/Risk/Cost Determination Framework (CPHA 1993). This added the assessment and management of benefits and costs within the risk determination paradigm

Canadian Public Health Association (CPHA)

The intent of this expanded framework was to examine benefits, risks, and costs in a formal manner, and to use standard procedures to calculate a net benefit/risk/cost value for the drug under examination. Changes in quality-adjusted life expectancy was proposed as a utility based measure of health benefit associated with therapeutic intervention; however, this refined measure of risk has limited the broader applicability of the framework.

The Framework for Environmental Health Risk Management

The Framework for Environmental Health Risk Management developed by the U.S. Presidential/Congressional Commission on Risk Assessment and Risk Management (1997) is designed to assist risk managers, such as government officials, private sector businesses, and individual members of the public in making good risk management decisions about environmental health risks (Figure 3). The framework is sufficiently general to encompass a wide variety of environmental health risk issues, with the level and effort invested being scaled to the importance of the problem, the potential severity and economic impact of the risk, level of controversy surrounding it,

Figure 3. U.S. Presidential/Congressional Commission Framework for Environmental Health Risk Management (1997).

The Framework for Environmental Health Risk Management

The framework is intended primarily for risk decisions related to setting standards, controlling pollution, protecting health, and cleaning up the environment. The framework consists of Six Steps: Define the problem and put it into context; Analyze the risks associated with the problem in context; Examine options for addressing the risks; Make decisions about which options to implement; Take actions to implement the decisions; and Conduct an evaluation of the results of the action

The Framework for Environmental Health Risk Management

These steps are implemented in collaboration with stakeholders. In this framework, risk management is used both to encompass the process of analyzing, selecting, implementing, and evaluating actions to reduce risk, and to describe the entire process. The framework emphasizes the importance of considering health and environmental problems in a broad context rather than evaluating individual risks associated with single agents in specific environmental media, ensuring stakeholder involvement to the extent appropriate and feasible during all stages of the risk management process, and adopting an iterative approach that affords the flexibility to revisit early stages of the process as new information becomes available.

The Framework for Environmental Health Risk Management

Health Canada has recently revised its approach for dealing with health risks (Risk Management Framework Project Team, Health Protection Branch Transition and Health Canada, 2000). The proposed Decision-Making Framework consists of a series of inter-connected steps that may be grouped into three phases: Issue Identification (identify the issue and put it into context); Risk Assessment (assess potential risks and benefitswhere appropriate); and Risk Management (identify and analyze regulatory and nonregulatory options; select a strategy; implement the strategy; and monitor and evaluate the results).

The Framework for Environmental Health Risk Management

The framework portrays the involvement of interested and affected parties throughout the process, including partners, the public, and other stakeholders. The framework is similar in structure to that developed by the U.S. Presidential/Congressional Commission, although many aspects of the framework have been developed in more detail. The Health Canada framework focuses on examining and integrating other types of information (social, cultural, ethical, and economic factors as well as perceived risk) into the risk assessment process when there is a demonstrated influence on the level of risk for specific populations.

EVOLUTION OF POPULATION HEALTH

Public health addresses environmental conditions that exert widespread effects on the health of populations. The U.S. Institute of Medicine (IOM 1988, p. 7) has defined public health as: fulfilling societys interest in assuring conditions in which people can be healthy. Public health interventions include sanitation, the protection of drinking water; mass immunization against vaccine-preventable diseases and the control of microbiological, radiological, and chemical hazards. The IOM views the application of scientific knowledge to disease prevention and health promotion in an organized community effort as the aim of public health services.

EVOLUTION OF POPULATION HEALTH

Health promotion was defined by the World Health Organization (WHO) as the process of enabling people to increase control over, and to improve their health (WHO 1986, p. 1). Arising out of the health education movement, it focused less on physical factors that cause specific diseases than did public health, and more on changing broad aspects of lifestyles . Population health has been defined as a conceptual framework for thinking about why some populations are healthier than others, as well as the policy development, research agenda, and resource allocation that flow from it (Young 1998,p. 4).

EVOLUTION OF POPULATION HEALTH

The distinction between population and public health continues to be a point of discussion ,Whereas public health focused traditionally on environmental factors that influence disease, including sanitation and infectious disease control, population health takes into account all of the factors affecting the health of populations. The IOM (2002) foresees closer linkages between the fields of public and population health, suggesting that public health can be enriched by the incorporation of population health principles.

EVOLUTION OF POPULATION HEALTH

In an article entitled Achieving Health For All: A Framework for Health Promotion, Epp (1986) proposed a new approach to health that would meet emerging health challenges. The report first emphasized the importance of inequities in health and of reducing inequities in the health of low versus high income groups. Epp cited the disturbing evidence that, despite Canadas equitable health services delivery system, peoples health remained directly related to their economic status. Epps second health promotion challenge was to increase prevention efforts by finding new and more effective ways of preventing injuries, illnesses, chronic conditions, and disabilities .

Figure 5. Federal, Provincial, and Territorial Advisory Committee on Population Health Framework for Population Health (1994).

Conclusion
Although it is now widely recognized that a variety of determinants can influence our health, the conceptualization of health and the determination of how health can be achieved and how health inequalities and inequities can be reduced remains complex. An integrated approach provides a stronger foundation for evidence-based population health risk management decision-making by encouraging a more consistent, systematic and comprehensive evaluation of population health issues.