Chapter 5: The Chief Public Health Officer's report on the state of public health in Canada 2008 – Addressing inequalities
Addressing Inequalities –
Where are we in Canada
Canadians take pride in the fact that they live in a healthy and egalitarian society. However, the evidence in the previous chapters should serve as notice that this is not a state of affairs shared across the population. The situation is not irreversible, as shown by the interventions highlighted in this report. These demonstrate examples of effective actions that can be undertaken to address inequalities and improve people’s health status.
This chapter provides an accounting of where Canada is in terms of addressing health inequalities and identifies areas that require priority consideration in order to achieve further change. Chapter 6 provides more specific direction on how Canada, as a country, can move forward in three key areas.
Of course, solutions are not always easy or straightforward. What works for one individual or community may not work for another. Understanding the reasons for this, and identifying what does and does not work, is key. Part of the challenge is that many of Canada’s social investments do not have the explicit goal of reducing health inequalities, and so their impact is never measured in those terms. In fact, Canada does not have a strong record on measuring the outcomes of many of its investments, not just those involving public health.2, 7, 82, 92, 406 Impact measurement is an area where better investment would be warranted.
While there is work to do in terms of measuring the impact of Canada’s policies and programs, some things are already very clear. The first is that it is not enough to focus solely on individual health choices and behaviours, as peoples’ actions are very much shaped by the social and environmental conditions in which they live and work. A balanced mix of targeted interventions for some and universal programs for all is more likely to work in a country as vast and complex as Canada.2, 7 This kind of balance ensures that, regardless of personal circumstances, Canadians experience those conditions necessary for better health and for making healthy choices easier choices.
A number of reports are expected in 2008 that will contribute greatly to a better understanding of promising approaches to addressing health inequalities and determinants of health. Among them are reports from:
WHO Commission on Social Determinants of Health - Canada is a significant contributor to the Commission, which was established to reduce health inequalities within and between countries through policy and action. The Commission will release several reports of interest, including its final report and recommendations, reports of country partners' experiences in addressing health inequalities and research synthesis reports from the Commission's Knowledge Networks.
Senate Sub-Committee on Population Health - Established in 2006, this sub-committee is mandated to examine the multiple determinants of health and make recommendations to Parliament regarding how to more effectively address them through action across government departments.
Finally – and most importantly – waiting until all the evidence is in before taking action is not an option. Some health inequalities are widening, necessitating that Canada move further and faster to alleviate the conditions that contribute to their existence in the first place.144 Failing to do so will impact all Canadians.
Priority areas for action
Evidence indicates that the following priority areas can make a difference in reducing health inequalities:
- social investment;
- community capacity;
- inter-sectoral action;
- knowledge infrastructure; and
- leadership.2, 407
Canada has strong social policy foundations that have helped to make it both healthier and more egalitarian. Programs like the Canada and Quebec Pension Plans, Old Age Security, Employment Insurance, publicly funded health care and universal primary and secondary education have all helped to establish a minimum standard of living. This minimum standard is a critical factor in the health of Canadians.
However, Canada may not be keeping pace with the progress being made in other countries, especially (as noted) in areas like child poverty.307, 408 If this continues, increasing numbers of Canadians may not achieve their health potential and increased inequalities will follow, impacting the nation’s collective economic and social well-being.
Working to strengthen communities is a critical component of any comprehensive plan to address health inequalities and is an area of strength in Canada.
Programs and initiatives that rely on input and participation at the community level – like the Community Action Program for Children and Aboriginal Head Start − enable communities to be directly involved in identifying their needs and tailoring appropriate solutions. In addition to building capacity within communities, investments in such initiatives are often managed by coalitions of local stakeholders, ensuring more comprehensive, cross-sectoral approaches. Much has been learned about how to reach people and influence behaviours and health outcomes as a result of these partnerships.
The influence of community-level initiatives is limited by the communities’ inability to address or override the broader societal factors affecting the health of their inhabitants.409 At times, social programs and policies operating in an uncoordinated way may negate the good work of community-level initiatives and consequently discourage the pursuit of financial independence for individuals. For example, if social assistance recipients lose money or benefits as the result of increasing their income or gaining employment, they are essentially discouraged from becoming independent and leaving social assistance. In these cases, government benefits programs work contrary to their purpose.410 Complementary and coherent action is therefore needed over broader social policy and investments.
Greater support for the various efforts being made in community health can also make a difference. This requires considering and more strongly defining the roles that can be taken by governments, non-governmental organizations and the private sector.
Finally, it is essential to measure longer-term progress being made in communities so that programs can be supported consistently based on their impact and effectiveness.
Throughout this report it has been demonstrated that factors such as adequate income, education and housing are critical to maintaining good health. Most interventions in these areas fall outside of the mandate of the formal health sector. Therefore, to effectively prevent and improve health inequalities, all levels of government, the private and non-governmental sectors, and international organizations must work together towards integrated, coherent policies and actions.
Canada has experience working across sectors. These efforts generally fall into four categories:
- supporting communities to solve complex issues (e.g. the Vancouver Agreement);
- population-specific approaches to address multiple determinants of health (e.g. Healthy Child Manitoba);
- issues-based collaboration (e.g. ActNow BC, Joint Consortium on School Health); and
- providing tools for cross-departmental policy review (e.g. Quebec Public Health Act – see text box).
Canada can build on these efforts, especially where mutual benefits across sectors (health, social and economic) hold the greatest promise.
There is good and improving knowledge of what is required to address the social determinants of health that lead to inequalities in this country. The roles that the public (individuals and communities), civic leaders and decision-makers (government, not-for-profit and private sectors) can play in addressing these inequalities are also well understood.409 This provides a good foundation from which to build:
- better information about specific sub-populations and regions of this country that consistently demonstrate poorer health outcomes;
- further research to more clearly understand how determinants interact to create health inequalities; and
- stronger insight into how to apply practices that have proven effective in other jurisdictions domestically and internationally.411
Most important, however, is the need to determine whether current and future efforts in addressing health inequalities are working. This can only be achieved by monitoring results over time. This, in turn, depends on the use of better reporting systems and tools, increasing the availability of data, and better co-ordination and co-operation across sectors and jurisdictions. Some work is underway to address these requirements but support for further efforts is critical.
Bringing about action requires more than good ideas or honourable ideals. The many examples outlined in this report have underscored that, ultimately, high-level leadership in all sectors – health and otherwise – is crucial to reducing health inequalities.
While socio-economic conditions and specific health problems vary globally, all countries have portions of their population at higher risk of health challenges.7, 10, 122, 412, 413, 414, 418 Some, however, have moved from concern to concerted action by establishing a commitment to reducing health inequalities. In particular, the Nordic countries and the United Kingdom (U.K.) have identified health inequalities as a priority and conducted audits of the roles that government departments can and do play in reducing social and health inequalities.412, 414 The U.K. has set specific goals, objectives and targets to reduce inequalities, with implications across a number of sectors, and they have committed to measuring impact and reporting on progress.
Domestically, Quebec is at the forefront of efforts to reduce health inequalities through new approaches to leadership and healthy public policy. Considering the approaches taken by various governments can help Canada’s efforts to evolve and improve as new information and best practices emerge (see text box).
Government Approaches to Tackling Health Inequalities and the Social Determinants of Health
The U.K. approach
In 1998, the U.K. government undertook a study of health inequalities, examining the social, economic and environmental factors affecting peoples' health. A subsequent report provided 40 recommendations to tackle the underlying issues at the root of health disparities. It also emphasized that addressing the short-term consequences of ill health is not enough and that efforts must be made in partnership with the voluntary, community and business sectors, as well as individual citizens to prevent ill health and promote healthy living.415
The following year, "The National Health Services (NHS) Plan: A Plan for Investment, A Plan for Reform" committed government to local targets to reduce health inequalities with reinforcement from proposed national health inequalities targets.416 A cross-cutting federal review followed in 2002 that examined how government spending could be applied to greatest effect on health inequalities.417
Based on this research and advice, the National Public Service Agreement (PSA) committed government to, by 2010, reducing inequalities in health outcomes by 10% as measured by infant mortality and life expectancy at birth. A high-level, government-wide strategy called "A Programme for Action" was then developed. The first principle of the strategy was to stop the U.K.'s health gap from widening further, before trying to narrow it.412
Status reports on the progress made since the initiation of the program have shown an improvement in two of the indicators associated with health inequality: child poverty and housing. There is also evidence of a narrowing of the gap in heart disease mortality, cancer, influenza vaccinations and educational attainment. Life expectancies were found to be higher overall since 1997-1999 and the life expectancy gap seemed to be narrowing in three fifths of the 70 local authority areas with the worst health and deprivation indicators. The one exception was infant mortality rates where the gap widened since the baseline period.413
A plan to target health inequalities in Norway
The general health of the population of Norway is considered quite good by international standards. Like other nations, however, not everyone in the population enjoys the same level of health – in order to have an average you must have people whose health is either better than average or worse. On June 6, 2007 the Norwegian parliament (Storting) adopted a 10-year "National Strategy to Reduce Social Inequalities in Health" which identifies key actions to be taken in four priority areas:
- reduction of social inequalities that contribute to health inequalities;
- reduction of social inequalities in health-related behaviour and use of health services;
- use of targeted initiatives to promote social inclusion; and
- development of knowledge and cross-sectoral tools.
The strategy is based on the premise that health inequalities should be tackled through a process called 'levelling up' where those who enjoy the best health should strive to maintain it while national efforts focus on helping the rest of the population to bring their health up to that same level.414
Quebec's Public Health Act (Article 54)
A unique approach to public health in the province of Quebec has other provinces and, indeed, other countries, taking notice.419 By requiring other government departments to consult with the Minister of Health and Social Services in regard to decisions or actions that could impact public health – a broader, more comprehensive and inclusive approach to public health strategies and interventions has been taken.420 The consulting component of this 'whole of government' approach came into law with the adoption of Article 54 in Quebec's Public Health Act in 2001. It states that new measures provided for in an Act or regulation in all provincial ministries be assessed to determine significant impacts of proposed actions on the health of populations. A health impact assessment (HIA) process is currently used to carry out these determinations, an approach that is fairly new to Canada outside of Quebec but more common in some European countries.420 At the national level, Canada's National Collaborating Centre for Healthy Public Policy is currently studying HIA in relation to Article 54 and public policy, and will disseminate its findings to the public health community.421
Potential for progress
With the creation of the position of Chief Public Health Officer, as well as the establishment of the Public Health Agency of Canada, there is strengthened national public health leadership in Canada. When the Agency was formed, its legislation provided the authority to communicate with other sectors regarding public health issues in order to foster collaboration towards better health for all Canadians. It also mandated the Chief Public Health Officer to report on the state of public health and identify the issues which impact the health of Canadians. This report has been submitted to the Minister of Health and Parliament as part of that mandate.
Along with the creation of the Agency came the development of the Pan-Canadian Public Health Network.422 The network is comprised of federal, provincial and territorial representatives, and is a forum for discussion across Canada on public health issues. As well, the National Collaborating Centres for Public Health were created to translate existing and new research evidence into public policy. The six centres are located in different regions across the country and each one specializes in a priority area (see Appendix B).
These are new tools and resources that, when combined with efforts like those highlighted throughout this report by the health sector and other sectors (e.g. education and social services), provide Canada with an unprecedented opportunity to effect positive change in public health. The question is: are Canadians up to the challenge?
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