Health Policy in Canada:

Perspectives on health politics and policy

Exclusive MapleLine Magazine: February 3, 2010

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by Rebecca Brooke, B.Sc.

Politics and public policy play a strong role in influencing the health of individual Canadians. This is a very broad topic, so instead of going into details here are some perspectives that will help readers to see the role of politics in personal health.

Medical care
When we think of “health policy”, the first thing many people think of is the finance and delivery of medical care. While I cannot stress enough that this is not the only type of health policy, and not even the most influential type, it serves as a good starting point for this discussion.

The Canada Health Act sets out the rules that provinces must follow if they want to receive money from the federal government in the form of the Canada Health Transfer. One of the five pillars of the Canada Health Act is that no one can privately purchase “medically necessary” services or purchase insurance for these services. Canada is the only country in the world to actually make private health care illegal. However, by changing the list of which services are “medically necessary” provinces can make small changes to this rule. Also, provinces could evade the Canada Health Act altogether if they chose to go without federal money. Overall, federalism is a major political factor in the area of medical care.

It is public opinion among Canadians that really keeps our system public. Most Canadians overwhelmingly support the ideal of universal medical coverage, and this makes medical care a sacred cow that most politicians won’t touch. Other big players are the vested interests like doctors, nurses, hospital staff, pharmaceutical companies, and insurance companies. Non-profit groups representing patients, often patients with particular diseases, are also involved in the politics of medical care.

Basically, one perspective on health policy is to look at who the players are in medical care and on what kind of playing field they meet.

Prevention
We usually need medical care when we get sick, but politics and public policy affect our health before we even get sick. In order to prevent some illnesses, we might make sure that sick people don’t get sicker and that we do a lot of testing to catch disease as soon as possible. However, the provincial government makes decisions about which of these services is going to be covered. There is a lot of politics involved in trying to get the government to pay for preventive services.

Prevention is not only about accessing medical services. Living a healthy lifestyle goes a long way towards preventing diseases like heart disease, type 2 diabetes, and cancer. Governments engage in what we call “health promotion”, which is basically advertisement giving people the information they need to live a healthy lifestyle. While these programs have the best of intentions, they tend to be unsuccessful.

What many health experts now believe is that lifestyles are a symptom of the society we live in. How can we eat in a healthy way when junk food is everywhere and it’s comparatively cheap? How can we exercise enough when we drive to work where we sit in cubicles? On top of that many Canadians are working more and more overtime, which reduces opportunities for sleep and exercise. Prevention goes really deep into the mechanics of modern societies.

All of these disease-causing social conditions are upheld by government policy or lack thereof. For example, food prices are determined in part by subsidies on certain foods. There are small taxes on some junk food. On the whole, food policy needs a major overhaul so that people can buy healthy food at good prices.
Our labour policies are much more complicated. While working lots of hours is bad for our health, it is good for employers who don’t have to hire another employee and sometimes don’t even pay for those overtime hours. Happy businesses are important in a functioning economy, but aren’t happy workers important too?

What I’m meaning to say is that prevention policy that targets these sorts of social influences gets us into some very sticky politics.

Social determinants of health
Delving further into how the structure of society impacts our health, health experts have defined twelve major “social determinants of health”. They are: income and its distribution, education, food security, health care services, housing, social safety net, social exclusion, unemployment and employment security, employment and working conditions, Aboriginal status, early life, and gender. Each of these twelve items has an undeniable statistical correlation with our health status.

Of the twelve, income and education have the greatest impact on health status – greater than access to medical care. It is a fact that people with low socioeconomic status will be sick more often and live shorter lives. This is the reality of the Canada we live in, and it’s 2010. How is it still true that the affordable and sanitary housing impacts our health so greatly? This type of social inequality is making Canadians unhealthy. The politics of tackling the inequality is heated to say the least, but this provides us with an additional perspective on how politics shapes our health.

Culture and health
Gender is one of the twelve social determinants of health. This means that what it means to be a man or a woman in Canada affects our health. For example, the way culture makes women conscious of their bodies can change eating habits. While this leads to eating disorders, it may be more difficult to see the less obvious effects of eating habits. Women may be malnourished due to social pressures on eating, and there is a big correlation with poor diet and osteoporosis in women. This is all because of culture and how many women are pressured to behave.

I’ll give an example about men. Men are less likely than women to ask for help. For many men, part of being a man is being independent and not asking for help. However, this impacts the health of men. There is hard evidence that men are less likely to seek medical attention than women, even when they need it just as much. Again, culture affects our behaviour in a way that impacts our health.

Alcohol use is also influenced by culture. Tobacco use is sometimes the result of peer pressure, but the social norms regarding smoking are changing and even improve the health status of some people. Culture in the workplace may pressure us to skip lunch.

What is not always obvious is that politics and culture are interconnected. Behavioural expectations are hugely political. People expect others to act in certain ways, but who decides how certain groups are required to act? Who decides what constitutes “cool” behaviour? It’s an informal politics, but it’s politics indeed.

Age and lifecycle
One issue that no one likes to talk about is at what point in our lifecycle we spend the most on health. About 80% of health care funds are spent on people in their last year of life. It is a difficult issue because it is very difficult to deny care to someone in need. Near the end of life, people are often in poor health and require care. It presents an immediate need for medical attention.

However, this immediate need often detracts our focus from where we might otherwise spend money on health. Early life is one of the social determinants of health. The healthier a child is early in life (including prenatally), the healthier that child will be throughout his or her whole life. Investing in the health of infants and young children makes a huge impact on health status. Canada fairs quite poorly in international comparisons when it comes to early life investment. Eventually this lack of attention to the health of our children will catch up with us as a society. Looking long-term gives us another perspective on health.

Individuals are the ones who get sick, but our social context will contribute to whether or not we will get sick is not only up to us. The health status of individuals is determined in part by the society that we live in, whether it be through access to medical care or the cultural norms surrounding eating. I have shown that politics impacts our health in a number of ways. I hope that I have helped readers to see past the politics of medical care, to acknowledge the myriad of other ways in which politics influences our health. MM

Rebecca Brooke, B.Sc. (Microbiology) is now taking her Masters in Political Science at UBC.

See healthy policy analysis of the handling of H1N1.

See definition of immunocomprised, from the Vancouver Island Health Authority website.

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