This may be of interest. It will appear in an upcoming Canadian social policy
journal.
References are available...
Canadian Policy Statements on Income and Health:
Sound and Fury -- Signifying Nothing
Dennis Raphael
School of Health Policy and Management
Atkinson Faculty of Liberal and Professional Studies
York University, 4700 Keele Street, Toronto M3J 1P3
tel: 416-736-2100, ext. 22134, email: [log in to unmask]
Acknowledgment
This article is dedicated to the many employees of federal, provincial, and
municipal health policy departments and public health units who strive under
very difficult conditions to emphasize the social determinants of health. It is
through the efforts of these individuals that Canada's policymakers may yet come
to create the conditions that support Canadians' health rather than the
conditions that threaten it.
Overview
Canada has been rightly seen as a world leader in the development of health
promotion and population health concepts. These concepts expanded the meaning of
health and suggested new ways of thinking about public policy in support of
health. Ideas about reducing health inequalities, empowering individuals and
communities, and building healthy cities and communities were introduced by, or
quickly made their way into Federal and Provincial policy documents. Health
Canada's Population Health website provides key Federal documents within which
the role of income and its distribution is emphasized.
Similarly, the Canadian Public Health Association (CPHA) issued a number of
policy statements on the importance of various societal determinants of health,
including income. Most recently, the CPHA passed an action plan to address the
incidence of poverty and its impacts on health. These developments have
influenced health policy thinking around the world and, most recently, provided
USA health workers with ideas for improving the health of Americans.
Given Canada's acknowledged leadership role in health promotion and
population health, it seems timely to consider two key issues: To what extent
are current governmental decisions related to health determinants such as income
consistent with the ideas contained in government documents? To what extent is
public health practice in Canada dealing with issues such as income that are
highlighted by CPHA statements? Answers to these questions may reveal a stark
contrast between governmental and public health statements about income as a
determinant of health and the actual practice of public policy development and
public health.
Defining Health Promotion and Population Health
Health promotion is the process of enabling people to increase control
over, and to improve their health. Canadian contributions to health promotion
involved moving beyond biomedical and lifestyle approaches of illness prevention
towards analyses of the role played by societal determinants of health. Many of
these concepts made their way into World Health organization (WHO) documents
such as the Ottawa Charter for Health Promotion and provided the basis for the
Healthy Cities Movement.
Canadian concepts also contributed to the axiom that responsibility for
health and its determinants rests not only with the health sector but with a
range of governmental and other public and private institutions. Prerequisites
for health such as peace, shelter, education, food, income, a stable ecosystem,
sustainable resources, social justice and equity are provided through the
building of healthy public policy, creating supportive environments,
strengthening community action, developing personal skills, and reorienting
health services.9
Population Health
Population health aims to improve the health of the entire population and
to reduce health inequities among population groups.3 Canada contributed to this
approach through Canadian Institute for Advanced Research (CIAR) work
identifying cultural, social, and economic aspects of societies as major
determinants of health, and that the healthiest societies are those in which
there is a relatively equitable distribution of wealth. Health Canada enshrined
these beliefs into numerous policy documents. Other key ideas from population
health are that the social environment interacts with individuals' psychological
resources to influence health and that the early developmental environment
strongly influences health.
Population health has identified determinants of health -- and these can be
found in various government policy statements -- of income and social status,
social support networks, education, employment and working conditions, physical
environments, social environments, biology and genetic endowment, personal
health practices and coping skills, healthy child development, and health
services.
The Sound and the Fury: Government and Public Health Statements on Health
Determinants
This brief review considers the content of selected governmental health
documents and CPHA statements with focus on the health determinant of income and
its distribution. Income directly influences health and the presence and
quality of other health determinants. More extensive analyses of the content of
government documents are available.
Canadian Governments' Focus Upon Income and Its Distribution
In 1974 the Canadian government document A New Perspective on the Health of
Canadians saw the incidence of sickness and death in Canada as being determined
by human biology, environment, lifestyle, and health care organization. While
over-emphasizing individual choice upon lifestyle, the document was important in
identifying health determinants other than the health care system.
The 1986 Federal document Achieving Health for All: A Framework for Health
Promotion identified reducing inequities between income groups as a major health
challenge: "The first challenge we face is to find ways of reducing inequities
in the health of low- versus high-income groups in Canada." There was
recognition of greater health problems among low income groups, that "poverty
affects over half of single-parent families", and that "more than one million
children in Canada are poor." One means of improving health was through the
coordination of healthy public policy, and health determinants potentially
related to income differences were explicitly mentioned:"All policies which have
a direct bearing on health need to be coordinated. The list is long and
includes, among others, income security, employment, education, housing,
business, agriculture, transportation, justice and technology."
Current federal statements recognize the effects of income inequality upon
health. Population Health Promotion: An Integrated Model of Population Health
and Health Promotion states: "It is not the amount of wealth but its relative
distribution which is the key factor that determines health status." Concern
with income and social status as a determinant of health is also found in the
document: Taking Action on Population Health: A Position Paper For Health
Promotion and Programs Branch Staff.15
The most recent government statement on health, Towards a Healthy Future:
Second Report on the Health of Canadians was commissioned by the Federal,
Provincial and Territorial Advisory Committee on Population Health to provide a
comprehensive and detailed overview of the health status of Canadians and the
major determinants of that status. In a chapter on Income and Health, much of
the data on economic inequality, family income, and poverty levels initially
publicized by social development organizations is presented. The emphasis upon
income is also found in provincial documents. In Saskatchewan, the document A
Population Health Framework for Saskatchewan Health Districts contains the
statement:
While the list of these determinants of health is long and potentially
overwhelming, consensus is growing that one general factor may be particularly
important, and that is economic inequality. What this means is that the
healthiest societies are those in which there is a relatively small gap between
the best-off and the worst-off members., p. 5
In Prince Edward Island, the Health Promotion Framework asks the questions:
"What makes and keeps us healthy?" Among its 11 determinants of health, the
first listed is Income and Social Status:
People are healthiest when they live in a society that can afford to meet
everybody's basic needs. Once basic needs are met, people's health is also
affected by how big a difference there is between the richest and poorest
members of the society. When there are big differences in income in a society,
there are also big differences in social status. This affects health because
people with lower status have less control over their lives and fewer choices
for themselves., p. 2
In the Ontario report Wealth and Health, Health and Wealth,reanalysis of
data from two studies obtained strong relationships between income adequacy --
from the very poor to the wealthy -- with self-rated health, health problems,
and health service utilization. It states:
We conclude that efforts to create health in Ontario will not come from a
narrow focus; both social and behavioural determinants must be addressed. Two
sets of responses are required: policies that reduce poverty and policies that
reduce the effects of poverty., p. 1
Canadian Public Health Association Documents
The Action Statement for Health Promotion in Canada identifies advocating
for healthy public policies as the single best strategy to affect the
determinants of health. Priority areas include reducing inequalities in income
and wealth, strengthening communities through local alliances to change
unhealthy living conditions, supporting environments that promote healthy
lifestyles, and developing a settings approach to practice.
More recently, Health Impacts of Social and Economic Conditions:
Implications for Social Policy, brought together the most recent developments in
population health and health promotion and articulated a clear, comprehensive
statement of what is known about the role of the social determinants of health,
including income inequality, upon health.
Signifying Nothing: Governmental Policy Decisions and Public Health Actions
Yet, with very few exceptions, the directions of governments and the
actions of public health units show little relationship to these pronouncements.
The full extent of government policy decisions upon income inequality, the
incidence of poverty, and the weakening of social infrastructure is described
elsewhere. By 1996, the incidence of low income among Canadians had risen to 18%
and the rate for children reached a 17-year peak of 21%. Ontario experienced
an increase in low income from 11% in 1989 to 20.3% in 1996. In Toronto it is
estimated that 38% of children are now living on low incomes. Also during this
period, the average depth of poverty -- the gap between the low income cut-offs
and the levels of income received by low income people -- increased 11%, social
assistance benefits for parents with children declined 19%, and the number of
rental housing starts were reduced by 92%. Similar data is available for Canada
as a whole.
Additionally, increasing incidence of low income has occurred in
conjunction with and is exacerbated by the reduction of social safety nets. In
Canada, government policies of reducing eligibility for employment insurance and
other benefits, weakening services and supports, and reducing the absolute level
of these benefits have served to both increase the incidence of Canadians living
on low income and remove the means by which those living on low incomes can
sustain themselves. Documentation detailing how these changes have increased the
number of low income families is available.
Government responses have been pitiful. One example will illustrate. The
National Council of Welfare documents how much if not all of the Federal
government's National Tax Benefit
? specifically designed to assist children and
families living on low incomes ? has been clawed back by many provinces. In
Ontario for instance, families on social assistance now receive less money than
they did prior to the Benefit, but the Federal government now pays a greater
portion of it. Such policies do nothing to raise the incomes of those living on
low incomes. Raphael recently reviewed current public health practice in
relation to income issues.16 Sutcliffe, Deber, and Pasut found "Many provinces
had no evidence of mandated programs that were explicitly health focussed, that
addressed broader determinants of health, or used multiple strategies.", p. 247
Reasons given by informants for this lack of focus included a lack of political
commitment and the failure to allocate resources to population health issues.
Williamson surveyed 199 federal, provincial/territorial ministries of
health, and health regions' initiatives that address poverty. Responses were
received from 98 health regions (71% response rate). Fifty of these responding
regions (51%) indicated they did not have any initiatives addressing poverty
issues. Among those that did, virtually all were concerned with dealing with the
consequences of poverty rather than addressing its causes.
"The vast majority of these initiatives focus on the consequences that
poverty has for individuals and their families...The findings from this study
suggest that health sector initiatives that address and attempt to change the
social, economic, and economic conditions within which poverty is rooted are
very rare.,p.182"
Conclusion
Few readers will be surprised that current governmental and public health
practice activities ignore issues of increasing incidence of both low income and
unequal income distribution. There should be surprise however, over the stark
contrast between practice and the printed policy statements concerning health
promotion and population health that emanate from our governments and public
health officials. Perhaps it is time that these officials were reminded of
these statements and called to task for ignoring their own prescriptions for
improving the health of Canadians.
References
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