Reducing Health Disparities - Roles of the Health Sector: Recommended Policy Directions and Activities

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Overview Of Health Disparities In Canada

Definition and Description

Health disparities are differences in health status that occur among population groups defined by specific characteristics. They mostly result from inequalities in the distribution of the underlying determinants of health across populations. Socio-economic status (SES), Aboriginal identity, gender and geographic location are the important factors associated with health disparities in Canada. These factors are interdependent.

• Men in the lowest income quintile live an average of five years less than men in the highest; the gap among women is two years.

• Canadians in the bottom SES quintile are five times more likely to rate their health as fair or poor as people in the highest.

• Personal health practices, such as smoking, diet and physical activity, vary with educational and income level.

• All men in Canada (as a whole) live 7 years longer than First Nations men; for women the gap is 5 years.

• Aboriginal peoples are twice as likely to report fair or poor health status than non-Aboriginal people with the same income levels.

• Injuries, including suicides, are the largest cause of potential years of life lost for First Nations on reserve - four times the rate for all of Canada.

• Women live 6 years longer than men but are more likely to experience long-term activity limitations and chronic conditions.

• People living in Canada's northern remote communities have the lowest disability-free life expectancy (DFLE) and lowest life expectancy in the country. Rates of smoking, obesity and heavy drinking are above Canadian averages.

Community characteristics, like governance and cultural continuity, are associated with health disparities. For example, suicide rates in Aboriginal communities are lower in those communities that have taken active steps to preserve and strengthen their own cultures. The distribution, accessibility, and quality of health services are also associated with health disparities. Financing of insured health services in Canada is intended to ensure that there is access to services for lower SES groups and others in order to reduce health disparities, but these goals have not yet been fully or consistently achieved.

Consequences

Disparities affect all Canadians

The consequences of health disparities are most pronounced in the lowest 20% of the SES scale and for Aboriginal peoples, but health disparities affect everyone, not just the most severely disadvantaged populations. At every step in the SES gradient there are differences in risk factors and risk conditions, health status, incidence of disease and mortality across a wide range of physical and mental disorders. Moreover, the overall health of communities is affected by disparities.

Socio-economic status includes income, employment and education. Poor health is not only due to a lack of financial resources, although for some living in poverty this may be sufficient explanation for poor health outcomes. For others, low SES is often associated with low self-esteem, the absence of life skills essential to making healthy choices, an unhealthy physical environment, etc. Those who experience ill-health may become trapped in a vicious cycle of illness, poverty, marginalization and isolation that can persist through several generations.

Disparities are health system cost drivers

Because they are more often and more severely sick or injured, people in the lowest quintile of income groups use approximately twice as much in the way of health care services as those in the highest quintile. On the basis of an estimation of health care resources used by Canadian households, approximately 20% of total health care spending may be attributable to income disparities. Despite this higher overall use of health services, health disparities persist among lower SES groups.

In summary

All of society feels the impact of health disparities - directly and indirectly. Health disparities are inconsistent with Canadian values. In addition to the excess burden of illness on those who are already disadvantaged, health disparities threaten the cohesiveness of community and society, challenge the sustainability of the health system and have an impact on the economy. These consequences are avoidable and can be successfully addressed.

Reducing Health Disparities

Where Canada Stands

Countries such as Sweden and the United Kingdom (UK) have developed comprehensive, integrated strategies for health disparities reduction and are formulating goals and targets to achieve them. In the UK, this has been elevated to a government-wide agenda. A commitment to documenting the extent of disparities, developing evidence-based policies and evaluating interventions has been an essential building block of the most comprehensive European strategies.

In Canada, there is a need for more comprehensive, integrated efforts to address known health disparities, and the factors and conditions that lead to them. Although health ministries in all jurisdictions, often in collaboration with other sectors, have launched a variety of initiatives to improve health and reduce health disparities, these efforts could benefit from a more coherent, system-wide approach. Some major gaps still exist. For example, more indicators of health disparities are needed than are currently in the frameworks developed by CIHI (Canadian Institute for Health Information) and Statistics Canada. At this time, only one of the indicators developed by the Performance Indicators Review Committee (PIRC) has been required to be reported by SES or other characteristics; all others have been reported as averages for the whole population. Indicators that measure disparities could be used by all jurisdictions in the measurement of health status and evaluation of health programs and services.

Given the magnitude of the issue and the great potential for health gains, greater focus and investment should be given to health disparities. At this juncture, 30 years of policy development culminating in the 2003 Accord has positioned Canada's health sector to play a leadership role in developing and implementing strategies for reducing health disparities and promoting this agenda within all governments. Some promising initiatives, ranging from research, to targeted community programming, to issue-based intersectoral collaboration, are already in place. The framework for the development of the Integrated Pan-Canadian Healthy Living Strategy, which includes the reduction of disparities as one of its two goals, provides one key opportunity to advance the health disparities reduction agenda. Research and non-government partners are also engaging in this issue in a variety of ways, including highlighting the extent of disparities, analyzing and developing policy options, and delivering innovative, on-the-ground programs. The conditions exist now to galvanize these efforts and accelerate progress.

Where and How to Focus Change

Research has consistently shown that a limited number of non-medical determinants underlie the greatest health disparities. The most appropriate and effective way to improve overall population health status is by improving the health conditions and health services for those in lower SES groups and other disadvantaged populations.

• Health Services policies can either reduce or increase health disparities depending on how they are implemented and/or taken up by the population. Primary health care innovations and other reforms to increase comprehensiveness and accessibility have great potential to benefit lower SES groups and other disadvantaged populations.

• Universal health promotion strategies, e.g. general lifestyle education, tend to be more effective in higher SES groups, which are more likely to have the motivation, resources, social support and environment to adhere to them. Supporting health promotion and preventive programs with partnerships that address the economic, community and environmental characteristics that affect uptake will enhance program effectiveness.

• Building a disparities perspective and focus into performance indicator frameworks and public reporting requirements will strengthen accountability, advance understanding of what works best and galvanize support for disparities reduction.

Taking a systemic, integrated approach to disadvantaged populations is proposed. As part of a comprehensive disparities reduction strategy, this approach places emphasis on building leadership and processes to address health disparities generally, and the interrelated determinants of health that are associated with them. It also recognizes that a balance of universal and targeted interventions is needed to create environments supportive of change for all populations, including Aboriginal peoples and lower SES groups.

Moving Forward

The following outlines a Canadian approach for reducing health disparities. It briefly considers the current health sector landscape and identifies key success factors for a coherent strategy. Four recommended policy directions to carry out health sector roles for addressing health disparities are described. Proposed activities have been identified for each policy direction and are positioned as a guide for comprehensive action on health disparities.

The current environment of change in the health sector includes the transition to new organizations such as the Health Council, the Public Health Agency of Canada, the Pan-Canadian Public Health Network, and the National Collaborating Centre for Determinants of Health. This creates an opportunity to incorporate a health disparities focus into these new entities as an essential element of their work.

Canada already has in place a foundation on which to build, over time, a coherent strategy for addressing health disparities. Coordinated and sustained action on several fronts has the greatest potential to increase the overall quality of life of Canadians and pay major dividends for the health system and the economy. The health sector needs to strengthen its commitment to making health disparities reduction a priority for action and put in place the mechanisms that will facilitate building this perspective into relevant aspects of its work. This foundation, commitment and infrastructure are key elements of an effective strategy to reduce health disparities. Other key success factors noted from analyses of international and Canadian experiences include the following:

• identifying indicators, setting goals and, where appropriate, agreeing on targets and objectives that are measured, monitored and reported on;
  • sustaining focus over time to achieve results;
  • involving a wide range of organizations in an investment of effort and resources;
  • combining universal and targeted (to disadvantaged groups) interventions, based on evidence of effectiveness;
  • informing and engaging the public;
  • increasing intersectoral and international collaboration;
  • supporting community capacity development.

Within this context, four health sector roles for addressing health disparities are described. These roles fall within the health sector mandate and direct span of control, including roles in partnering with other sectors to achieve health gains and in shaping broader policy agendas at Cabinet tables or in communities. A set of recommended policy directions has been identified related to each role of the health sector. These are intended as a blueprint to inform and guide activities that FPT jurisdictions and stakeholders may undertake.

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