CPHA’s new policy process: Truth and Reconciliation, equity and advocacy impact

Part 1:  Looking back to look forward

Canadian news is rife with examples of organizations stumbling in living up to their stated commitments to Truth and Reconciliation with Indigenous Peoples. For both governmental and non-governmental organizations, challenges continually emerge in translating principled commitment into routines of day-to-day practice. 

Stumbles can happen despite sincere intentions, excellent training sessions, and expert advice. This is because training and advice are just the first steps in translating ideals into practice, and are very likely to run up against organizational blind spots. We may not initially grasp that accustomed ways of doing things don’t meet new needs; or there may be tensions among various organizational priorities and practices; or organizational capacity might limit what we can imagine doing differently.

The Canadian Public Health Association (CPHA) formally began its journey towards Truth and Reconciliation at its annual general meeting in May 2015, and in 2019 published a policy on Indigenous Relations and Reconciliation, which laid out high-level principles and commitments. This was followed by the creation of CPHA’s Indigenous Advisory Council, which has the mandate of “support[ing] CPHA in fulfilling its role as a trusted advocate for public health that works towards addressing the historic and contemporary health inequities faced by Indigenous communities by bringing Indigenous perspectives to all aspects of the Association’s policies, practices and programs.”  

Despite those steps, however, we had a notable stumble last year. In June 2022, we released a position statement on a public health approach to alcohol policy in Canada, and soon after retracted it after realizing that it failed to live up to the commitments in our policy on Indigenous Relations and Reconciliation.  

This has led to much learning, reflection and a rethinking of our policy development process. A revised policy development process was approved by CPHA’s Board in November 2022 that aims to produce policy documents that better realize our commitment to Truth and Reconciliation. The reworking of our policy development process was simultaneously intended to advance two additional goals: advancing CPHA’s broader commitments to anti-racism and anti-oppression, and producing policy documents suitable for informing policy advocacy capable of substantial impact in national public policy discussions. 

After CPHA publicized both the retraction of the alcohol position statement and the adoption of a new policy development process last year, a number of public health professionals reached out to ask about these developments and whether we planned to share our learnings. To respond to those requests—and in the hope of generating mutually helpful discussions—I’m offering these reflections on what CPHA has done so far, what we’re learning along the way, and what challenges we see in front of us. 

No other organization’s situation will exactly parallel that of CPHA (particularly given our small size and mandate as a membership-based non-profit). Nonetheless, I hope that these two blogposts might spur supportive conversations on how organizations can do better at manifesting commitments to Truth and Reconciliation, anti-racism, anti-oppression, and social justice in their public policy and advocacy activities.   

June 2022:  Release and retraction of CPHA’s position statement on alcohol use

The position statement on alcohol use in Canada that CPHA released and retracted in June 2022 was developed according to the policy development process then in place. That process relied on staff expertise for initial scoping and conceptualizing of relevant policy issues, and it presumed that CPHA’s commitment to evidence-based policy development meant that policy statements would rest on peer-reviewed and other published evidence. Notwithstanding the commitment in our 2019 policy statement on Indigenous Relations and Reconciliation that pledged for CPHA to work with Indigenous peoples in our activities and to centre Indigenous voices in pursuing health equity, we had not yet adequately modified our policy development process to reflect that commitment. The Indigenous Advisory Council was one of the CPHA committees tasked with reviewing drafts of policy work in progress; but we had not considered whether this measure was adequate to produce drafts that reflected stakeholder perspectives or appropriate kinds of evidence.

As a result of those blind spots, CPHA’s alcohol position statement was produced through a process that did not look beyond mainstream public health sources to define the issues and the evidence. Staff were not sensitive to the depths of impact that alcohol policies and its use have on Indigenous communities; nor did we understand how deeply stereotypes about alcohol use affect daily life for many Indigenous people and shape their interactions with healthcare, policing and justice systems. Approaching the topic wholly from a settler perspective, the statement noted the European introduction of alcohol to Canada as a neutral historical fact, effectively hiding its significance for Indigenous Peoples. Another blind spot emerged in the way the statement surveyed alcohol consumption patterns among various subpopulations in Canada, including a comparison of alcohol consumption rates between Indigenous and non-Indigenous populations. Because we failed to frame that comparison against the context of historical and current realities, it could reasonably be seen to be reinforcing stereotypes about Indigenous alcohol use and to obscure the ongoing impacts of settler colonialism on current substance use patterns. 

CPHA’s Indigenous Advisory Council reviewed the first draft (in line with the policy development policy at that time) and recommended adding references to alcohol policy and treatment approaches currently used by Indigenous groups in Canada. However, because our policy process sought their input only once the first draft of the paper was complete, and also because none of the Indigenous Advisory Council members were specialists in public health approaches to substance use, the Council’s input did not fundamentally challenge a settler-oriented framing of the issues. Neither was that framing challenged by the health equity impact assessment (HEIA) that a group of CPHA members carried out on the penultimate draft. 

Within hours of the statement’s publication, an Indigenous public health specialist in substance use notified CPHA that the statement failed to reflect Indigenous realities, perspectives and priorities with respect to alcohol use and policy. In response, CPHA temporarily removed the paper from our website; and after taking a short period to absorb this critique, we concluded that the statement we had released was incompatible with our organizational commitment to Truth and Reconciliation. Following internal consultation within CPHA, we retracted the paper and posted an explanation of what had happened, along with an apology and a commitment to revise our policy development process.

Part 2:  A new policy development process for CPHA

In Summer 2022, it became clear that CPHA needed a better policy development process not only to translate our commitments to Truth and Reconciliation into policy practice, but also to advance other substantive organizational goals. We recognized that the Board of Directors’ commitment that CPHA would become an anti-racist and anti-oppressive organization must also go beyond principled words to shape how we do our policy work. We could no longer ground policy initiatives on assumptions that had previously shaped our efforts: assumptions about which populations and whose perspectives must be considered, which issues were salient, what kinds of evidence would be relevant, and how relevant expertise could be identified. We needed a process capable of exploring these questions from the outset of policy initiatives, looking externally, instead of through the internal review of drafts. 

We also needed changes to the policy development process in order to enable CPHA’s policy work to have greater impact outside the public health community. While our earlier policy and advocacy work resulted in wide-angle accounts of ‘the public health perspective’ on a given topic, accompanied by high-level and wide-ranging recommendations, this approach no longer satisfied our heightened interest in producing effective advocacy. In order to advance advocacy on issues where there was potential for CPHA to have impact as an authoritative stakeholder, we needed a policy development process capable of producing timely, tightly-focused position statements with a small number of salient recommendations.

November 2022:  Launch of a new policy development process

Incorporating advice from CPHA’s Indigenous Advisory Council, Public Policy Committee, and Board of Directors, staff drafted a new process for developing policy statements. It was approved by the Board in November 2022, with explicit recognition that the process would be refined as we learned from experience. 

A key feature of this new process is that each policy initiative begins with an extensive initial scoping process. A preliminary overview is prepared by staff and presented to CPHA members, experts and advisers, who are asked to identify issues that the project should address as well as relevant sources of knowledge on the topic. This front-end-loaded process is intended to ensure that first drafts of policy initiatives will have robust commitments to Truth and Reconciliation, anti-racism and anti-oppression ‘baked in’ from the start in the form of substantive research. In this way, we hope, our policy work will have a relevance and depth of perspective that cannot be gained by applying a late-stage ‘equity lens’ by way of a HEIA analysis.  

The first trials of this new process are currently underway in the form of two major policy initiatives approved by CPHA’s Board: a position statement on a public health approach to sex work decriminalization; and a discussion paper on a public health approach to psychedelics. The former project has a sharply-focussed advocacy goal: to inform public policy debate amid a current court challenge to federal legislation on sex work. The other project aims to shape awareness and engagement of public health professionals in a burgeoning area of research, clinical, commercial and informal activity; it is preliminary work toward potential future advocacy. 

Along with their advocacy purpose, these two projects aim to show concrete evidence of CPHA’s commitment to advancing Truth and Reconciliation, anti-racism and anti-oppression in our policy activities. The initial broad scoping research for both projects has already opened up a much broader range of stakeholders, issues, sources of expertise and kinds of evidence than our previous process would have brought to light. 

Challenging issues remain

We do not anticipate a smoothly unfolding path for these and future policy initiatives.  At least six areas with challenging terrain are already apparent.

1. In moving from principled commitment to Truth and Reconciliation toward organizational practice, what will it mean to seek relevant input from Indigenous stakeholders into the issue-framing and evidence-gathering stages of our projects? CPHA is a national organization with a very small policy department; this means that we cannot realistically develop and sustain active relationships with the spectrum of Indigenous organizations across Canada. Nor do we have the staff or financial resources to engage Indigenous stakeholders in specific policy initiatives on a scale commensurate with expectations for government-run consultations. Furthermore, many Indigenous organizations are under-resourced and over-burdened with requests for engagement; how can we seek Indigenous expertise in a timely way without adding to these organizations’ burdens? And when we are trusted with sensitive information and perspectives shared by Indigenous experts, will we know enough to make responsible use of this in our work?
2. The two new policy projects in progress have each launched into a wide-ranging scoping process aiming to address the problem of ‘you don’t know what you don’t know’. But now we have another methodological problem: when do we know enough to stop the scoping and move onto the research-gathering and analysis stage? At present our approach is ‘talk to many people and read many things, and consider moving on once you’re hearing the same things repeatedly’. This doesn’t look like a formal methodology quite yet. We’re considering adapting an evidence-to-decision framework in order to help formalize what evidence we’re looking to gather as a basis for policy recommendations, and we expect that more methodological clarity will emerge as we gain experience.
3. Extensive scoping of issues and sources is leading us to discover new kinds of evidence and expertise coming from communities and stakeholders. Sometimes they represent perspectives that don’t readily align with Western scientific research, and sometimes they’re produced through partnerships and engagements that diverge from gold-standard conventional research methodology. How will we synthesize these emerging kinds of evidence with peer-reviewed and grey-literature publications in our first draft, and how will this synthesis of sources and methods be received by CPHA’s governance bodies and members as they review draft materials? Furthermore, how will we marshal diverse kinds of research findings to maximize advocacy impact? New sources of input will likely challenge expectations among wider public policy audiences about what top-quality evidence-based research and advocacy looks like.
4. Our new policy development process will inevitably encounter tensions around policy scope and timeliness, and we will have to find satisfactory ways of negotiating these tensions. With respect to scope, the new process commits us to begin policy projects expansively by following insights, topics and sources of knowledge; yet it also aims to produce well-focussed policy interventions suited for advocacy impact. After the expansive scoping and research stages, each policy project will have to narrow down which terrain of issues the final analysis and recommendations will cover, and this terrain will necessarily be narrower than the wealth of material identified and researched. Perhaps some kind of appendix document will serve to capture the insights left out of a position statement’s final analysis and recommendations. As for the timeliness problem, our scoping process demands that we take the time needed to explore new terrain and to contact very busy or hard-to-reach sources. However, there will be projects requiring compressed timelines in order to achieve the intended advocacy intervention. We may have to experiment with condensed research and review processes on rare occasions when CPHA policy advocacy might make a significant impact in an externally time-constrained policy context.
5. Another potential issue is how our shift toward more advocacy-relevant policy development will be received by CPHA members and other public health stakeholders who have told us that they still value our former style of policy statements for their high-level topic overviews and wide-ranging, aspirational policy recommendations. How CPHA can (or whether it should) pursue both kinds of policy development work, and how we define and prioritize topics and modes of policy work to undertake, will be an ongoing issue for the Board to consider. 
6. CPHA’s new policy development process reflects the best efforts of our Board, advisory committees, members and staff—but none of these groups include specialists with deep professional expertise in translating principled equity or Truth and Reconciliation commitments into organizational processes. For that reason, CPHA has recently been and will be engaging with expert consultants who support organizational change toward Truth and Reconciliation as well as diversity, equity and inclusion. Their advice will undoubtedly lead us to reassess whether our policy development processes are adequate to produce the quality of engagement we are seeking with Indigenous Peoples and other equity-deserving stakeholders. It may be that new kinds of relationship-building and perspective-enlarging work will be required, and that this will lead to substantial revisions to our policy development process in the months and years ahead.

Concluding questions

Are other organizations in the health sector or wider public policy fields wrestling with similar challenges in their policy development work? Are there related challenges to be addressed that CPHA isn’t yet grappling with?

Are some of these issues particularly salient for small-sized organizations that aim to produce high-impact and evidence-informed policy work capable of advancing principled commitments to Reconciliation and social equity? What are best approaches for combining high ambitions with modest resources?

Would an informal community of practice for policy professionals grappling with these issues be useful? 

Please share your thoughts with me! 

Natalie Brender
Director of Policy
CPHA