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This resource replaces an earlier version (2014) of Let’s Talk: Moving upstream. Click here to access the 2014 version.
Stream analogy
A stream analogy is often used by public health to show how responding to health emergencies and immediate health needs is equivalent to rescuing people downstream, while addressing structural and social determinants of health shifts the focus upstream to prevent people from falling in to begin with.
This resource uses the stream analogy to highlight different levels of intervention and action for public health to advance health equity by addressing the structural and social determinants of health.
What is upstream?
In this Let’s Talk, upstream is applied as:
- a concept to describe relative points of intervention to address root causes of poor health
- a rationale for focusing public health work on the systems and structures that influence health equity
- an approach to guide thinking and working
The resource lists defining attributes of working upstream and highlights upstream interventions that target structural and social roots of health outcomes.
Moving upstream
This resource further describes downstream, midstream and upstream approaches and encourages reflection on where current practices and policies are located along the stream. It also provides examples of actions to guide public health to shift upstream and consider the broader systems and driving forces that contribute to poor health outcomes and inequities. Finally, it includes discussion questions to guide individual and organizational reflection on where current work is positioned, and to prompt more upstream action.
Use this resource to:
- Deepen understanding of what is means to work upstream
- Guide action to address the structural and social determinants of health and advance health equity
- Shift the perspectives, values and practices that can reinforce downstream approaches and limit movement upstream
Related resources
Let’s Talk: Determinants of health
Let’s Talk: Language of health equity
Glossary of essential health equity terms
See other resources in the Let’s Talk series.
Reference
National Collaborating Centre for Determinants of Health. (2025). Let’s Talk: Moving upstream (2nd ed.). Antigonish, NS: NCCDH, St. Francis Xavier University.