BCHLA Submission to the 2008 Senate Subcommittee on Population Health

BACKGROUND

The BC Healthy Living Alliance is pleased to submit the following paper to the Senate Subcommittee on Population Health regarding the Social Determinants of Health. We congratulate the Subcommittee on the work they have done to date in identifying the key issues and options which must be addressed to improve the health of all Canadians.
 
The BC Healthy Living Alliance is a provincial coalition of organizations working together to improve the health of British Columbians. BCHLA is committed to advocating for and supporting health promoting policies, environments, programs and services; enhancing collaboration among government, non-government and private sector organizations; increasing capacity of communities to create and sustain health promoting policies, environments, programs and services.

The BC Healthy Living Alliance has recognized that we have a shared responsibility - in addition to providing excellent services and programs to support individuals, families and communities to live healthy lives - to raise the level of public understanding and discussion around these issues and to encourage governments to work with other sectors to address the underlying social determinants which have a significant impact on health.

The BC Healthy Living Alliance has recently prepared a position paper for the BC Government on the issues surrounding the social determinants and “health inequities” and is pleased to share some of our findings and perspectives with the Senate Subcommittee for your examination of these issues. The Alliance is planning further work on these issues over the fall and will bring together a wide range of stakeholders, providing a forum for dialogue and feedback on the issues and priorities.

While the focus of the work of the BC Healthy Living Alliance relates to the situation in British Columbia, we believe many of the issues and options we are presenting have wider applicability for the country as a whole.
 

IDENTIFYING THE PROBLEM IN BRITISH COLUMBIA

British Columbians are among the healthiest people in Canada and the world. And yet, despite our excellent average, there is still a large gap between the healthiest British Columbians and those who suffer from ill health.

Disadvantaged British Columbians have increased susceptibility to numerous chronic conditions and are more likely to live with chronic illness. The BC Healthy Living Alliance (BCHLA) in partnership with ActNow BC have recognized the importance of healthy living and established concrete targets and mobilized an action plan to address the common risk factors of chronic disease: tobacco use, physical inactivity and unhealthy eating. These efforts need to be accompanied by actions to address health inequities.

Access to income, affordable housing, healthy food, education, early childhood development, and recreational opportunities influence our ability to make healthy lifestyle choices and ultimately the state of our physical and mental health as well as life expectancy.

BCHLA has reviewed the literature and sought expert opinion on what actions can be taken to address these health inequities we can ensure healthy living is achievable for all citizens.

KEY FINDINGS

1. Some Canadians are much healthier than others. Poor health outcomes are more likely among: children and families living in poverty; the working poor; the unemployed/under-employed; those with limited education and/or low literacy; Aboriginal and remote populations; newcomers; persons suffering from social exclusion; the homeless; and those who have difficulty securing affordable housing ^{1, 2, 3, 4}   

Based on current Canadian data, it is well documented that:

• Infant mortality rates remain two-thirds higher in the poorest neighbourhoods than in the richest.⁵
  
• Men in the highest income quintile live five years longer than men in the lowest; for women the gap is two years.⁶
  
• Aboriginal men die, on average, seven years earlier than other men; for women the gap is five years.³
• Disadvantaged Canadians have increased susceptibility to a broad range of chronic conditions and are more likely to be living with chronic illness.⁷

-  For example, the rate of diabetes among those with low incomes is double that of those with high incomes.  
-  Similarly, the rate of heart disease among those with low incomes is almost double that of wealthier citizens.

2. Persistence of these health inequities continues to be a major driver of healthcare costs. 

• The poorest fifth of the population use approximately twice as much in the way of healthcare services as do the wealthiest fifth because they are more often and more severely sick or injured. 

3. Early markers of vulnerability such as low birth weight are related to socio-economic status. The social gradient impacts school readiness, cognitive performance and behavioural problems in primary school; dropout rates in secondary school and participation in post-secondary education. Thereafter, the consequences pervade nearly every aspect of adult life: employment; income levels; parenting skills and health status.
4. In part, health inequities arise as the result of a concentration of risk factors within disadvantaged populations. However, the risk factors are only part of the equation; there is an active gradient at work: as socio-economic status improves so too do health outcomes. ,  , 
5. Some of the main challenges confronting Canada include: family and child poverty (including the “working poor”); unemployment; housing/homelessness; education/literacy; and food insecurity.

POLICY DIRECTIONS ON THE SOCIAL DETERMINANTS OF HEALTH

The findings in British Columbia and Canada are consistent with studies from around the globe. The World Health Organization Commission on the Social Determinants of Health has released an interim statement which indicates that this is an international problem and will be releasing its final report and recommendations in September 2008.

There has been much discussion of policy interventions that are promising for alleviating health inequities. There is, however, very little research measuring the efficacy of policies on long-term health outcomes of those populations that are negatively affected by the social determinants of health. Much of the literature on policy options focuses on those that have been proven in other jurisdictions or appear to be effective at mitigating the negative effect of specific determinants, such as early childhood development, affordable housing, income security, food security and improved education outcomes.

No single policy will be effective in itself. What is required is an integrated and intersectoral approach that will address the complex problem of health inequity from various angles.

BCHLA recognizes that some provinces – e.g. Quebec and Newfoundland have already engaged on ambitious poverty reduction strategies which will impact on health inequities in their provinces while others including Nova Scotia and Ontario are also in the process of developing strategies to deal with such inequities. Some provinces have developed concerted and coordinated strategies around a particular issue – e.g. Manitoba’s integrated strategy for early childhood development and childcare, while British Columbia, under the leadership of ActNow BC, is engaged in a “whole of government” approach to improving the health of the people of BC. These efforts could be strengthened by a strong Federal commitment to reduce health inequities among Canadians.

The Senate Subcommittee has raised a number of important issues and options to address the Social Determinants of Health. The BC Healthy Living Alliance supports the options put forward and would ask the Subcommittee to consider the following policies and actions that have the potential to address the social determinants of health and begin the process of redressing health inequities.

POLICY GOAL: Health outcomes for Canadians of lower socio-economic status are at the same rate as those of higher socio-economic status and health outcomes for Aboriginal peoples are the same as for others in Canadian society. 

Planning and Accountability

Targets: Establish coordinated national targets to reduce health inequities

• All levels of government should renew their commitment to reducing health inequities with the establishment of targets for improving health outcomes for all Canadians of lower socio-economic status. While some provinces have established targets relating to health status or poverty reduction, there should be coordinated national targets to which all jurisdictions can commit. A good start would be:
• By 2017 a 50% reduction in the number of children and their families living in poverty.
• By 2017, an improvement of 20% in the health status of children in Canada (0 – 16 years) as measured by infant mortality, morbidity, premature mortality, and healthy weights, as well as a reduction in risk factors which contribute to childhood disease, ill health and injuries.

Planning: Strengthen the intergovernmental and inter-ministerial structures for population health.

• While there are a number of intergovernmental committees which focus on population health, many of which also include research organizations to these mechanisms should be strengthened. An inter-ministerial committee whose mandate would be to reduce health inequities within federal jurisdiction should be matched by continued support for a Federal/Provincial/Territorial mechanism responsible for ensuring coordinated action to reach the targets and a “whole of government” approach

Measurement: Establish an appropriate surveillance mechanism for measuring and reporting progress to the public on meeting the targets.

• The responsibility for data gathering could lie with the Canadian Institute for Health Information with the Health Council of Canada playing a lead role in evaluation and dissemination of findings to all players and the public.

Early Childhood Development

• Extend parental leave benefits to cover the period of birth to 18 months to enable families to be with infants during their earliest period of development and encourage employers to provide top ups to the current benefits available under Employment Insurance (Federal)
• Provide comprehensive, quality and affordable early childhood development and parenting services and programs ensuring that priority is given to those neighbourhoods and communities with the highest numbers of vulnerable children. (All levels of government)
• Reinvest in a Child Care Subsidy Program to provide incentives for the creation and maintenance of quality and affordable childcare spaces for working families, while continuing to provide financial assistance to parents who stay at home with their children.( Federal/provincial)

Housing

• Provide the mechanisms by which non-profit organizations, the private sector and all levels of government work together and coordinate their efforts and investments to ensure the availability of a full spectrum of housing for those in need, including affordable housing, supportive housing, social housing, emergency and transition housing. (All levels of government and agencies involved)
• Develop a national housing strategy and allocate an additional 1% of Federal spending for affordable housing. (Federal)

Income

• Structure marginal tax rates and benefits so that low wage earners are not penalized for working rather than relying on income assistance. ( Federal/Provincial)
• Increase the National Child Tax Benefit and Supplement provided by the Federal Government to $5100 per child. Ensure that this benefit is delivered in addition to income assistance and that for low income families, other benefits are not reduced to off-set this increase. (Federal/Provincial)

Food

• Develop a healthy eating and food security strategy which integrates and coordinates policies and actions among Federal, Provincial, Aboriginal and Municipal governments. (All levels of government )

Supportive Environment

• Continue to support collaboration with local governments to provide resources to develop healthy communities through an integrated approach to social, physical, environmental and economic planning and development. (All levels of government)
• Define and remove barriers to health, social services and healthy living programs for new Canadians, low income families and Aboriginal people. (Federal, provincial, local)

CONCLUSION

The BC Healthy Living Alliance is looking forward to continuing its discussions with interested partners including governments, NGOs and other sectors to advance an agenda for the reduction of health inequities among Canadians. This will require committed leadership and vision from all sectors to make the investments and changes if Canada is to stand out as the country with the healthiest population in the world.

We will be pleased to provide any further information which may be requested by the Senate Subcommittee on Population Health and look forward to your findings.

___________________  

REFERENCES

 ¹  Federal Provincial Territorial Advisory Committee on Population Health and Health Security. Reducing Health Disparities – Roles of the Health Sector: Recommended Policy Directions and Activities. Public Health Agency of Canada. ISBN: 0-662-69312-4., 2005.

²    Frohlich K. Theoretical pathways to health disparities in Canada. Appendix 1. Report prepared for the FPT Advisory Committee on Population Health, 2003.

³   Federal Provincial Territorial Advisory Committee on Population Health. Second Report on the Health of Canadians. Health Canada: 1999.

⁴    Canadian Institute for Health Information (CIHI), Improving the Health of Canadians, 2004. www.cihi.ca

⁵ .  Goulet, K. “Reducing Health Disparities: Cross-cutter Initiative”. Reducing Health Disparities and Promoting Equity for Vulnerable Populations: Synthesis Papers. CIHR, 2006. Accessed at: www.igh.ulberta.ca

⁶ .  Canadian Institute for Health Information (CIHI), Improving the Health of Canadians. 2004. Accessed at: <www.cihi.ca>.

⁷ .  Adapted from ACPH. Reducing Health Disparities. 2007.

⁸ .  James, R., et al. “The Health of Canadians with Diabetes”. Health Reports, 9(3), 1997.

⁹ .  Johansen, H. “Living with Heart Disease”. Health Reports, 1999; and Wilkins, R. “Trends in Mortality by Neighbourhood Income”. Health Reports, 2006.

¹⁰    Roos, N. Variation in health and health care use by socio-economic status in Winnipeg. Milbank Quarterly, 1997.

¹¹    Banting, K. The Social Condition in British Columbia. BC Progress Board, December 2006

¹²    World Health Organization. Achieving Health Equity: From Root Causes to Fair Outcomes. 2007. W.H.O. Commission on the Social Determinants of Health.

¹³   Public Health Agency of Canada. Addressing Health Disparities in Canada Through Intersectoral Action on the Determinants of Health. 2006.

¹⁴   Kerstetter, S. & Goldberg, M. A Review of Policy Options for Increasing Food Security and Income Security in British Columbia. Draft paper prepared for PHSA, Vancouver, March, 2008