Report 3 - Exploring the Link Between Work-Life Conflict and Demands on Canada's Health Care System

Chapter 2 - Background

This chapter of the report puts the research into context. It is divided into three major sections: the first focusing on the health care system, the second outlining models that have been used to formulate health policy and action, and the third discussing workplace health issues. Section 1 presents data on how much it costs to keep Canadians healthy. Included in this section are statistics outlining how much Canada spends to keep its population healthy, how these expenditures have changed over time, and a discussion of who pays for what. Three key models that can be used to frame the analysis-health promotion, population health and the index of social health-are discussed in Section 2. The third section provides information on both sides of the workplace health debate: why companies should invest in workplace health and why they currently are not doing so.

Also included in this chapter are two text boxes that were created to assist the reader. Box 1 provides source information for most of the data used to develop this chapter. Box 2 provides working definitions for key constructs, such as health, well-being, health promotion and population health. Finally, the reader who is interested in how Canadian thinking around health and health care has evolved over time can find a brief summary of this topic in Appendix A.

Box 1 Sources of Data on Canada's Health Care System Data describing Canada's health care system were largely drawn from reports produced by the Canadian Institute for Health Information (CIHI) and Statistics Canada. The CIHI has, in conjunction with Statistics Canada, been providing an annual report on the status of Canada's health care system for the past four years. These reports gather the most recent data about Canada's health care system and, where possible, compare them to those of other countries. They also cover issues of the day, give analyses of topics of ongoing importance, and provide information on various health care indicators. These reports, along with a companion report prepared by Statistics Canada in 1999 entitled Statistical Report on the Health of Canadians and a document written by the Canadian Council on Integrated Health Care (CCIH) in 2002, have provided most of the background information cited in this report.

 

Box 2 Definitions: Health, Well-Being, Health Promotion and Population Health Health: Most governments, including federal and provincial/territorial health departments in Canada, have adopted definitions of health similar to those advanced by the World Health Organization (WHO) which recognizes health "as more than the absence of disease, as a resource for everyday living" (Statistics Canada, 1999, p. 215; WHO as cited in CCIH, 2002). Others define health as: a complete state of physical, mental and social well-being, and not merely the absence of disease (Townson, 1999); and a "resource" to meet the needs of daily life and not the objective of living (CCIH, 2002). Well-being or positive mental health has been defined as: consisting of those physical, mental and social attributes that permit the individual to cope successfully with challenges to health and functioning (Statistics Canada, 1999, p. 220). Health promotion has been defined as: "the process of enabling people to increase control over and to improve their health" (WHO as cited in Townson, 1999); and the science and art of helping people change their lifestyle to move toward a balance of physical, emotional, social, spiritual and intellectual health (CCIH, 2002). Population health has been defined as: an approach that addresses the entire range of factors that determine health and, by so doing, affects the health of the entire population (Townson, 1999, p. iii).

2.1 How Much Does It Cost to Keep Canadians Healthy?

National health expenditures are disbursements for which the primary objective is to improve or prevent the deterioration of health status (Statistics Canada, 1999). They include expenditures in both the public and private sector for personal health care (i.e. health services used by individuals), as well as expenditures made on behalf of society for items such as public health and managing the health care system (Statistics Canada, 1999). Typically, health care expenditures are grouped into seven major categories of use: hospitals, physicians, drugs, other professionals, other institutions, capital and other health spending (Statistics Canada, 1999).

To inform this report, the next section outlines how much we currently spend on health care, how we use that money and how our spending patterns are changing over time. The source of the data included in this section of the report is outlined in Box One.

Canada spends over $100 billion per year providing health services to Canadians

Health care is a large, resource-intensive industry. More than 1.5 million Canadians worked in health care and social services in 2000 (CIHI, 2002). The following statistics provide us with an idea of the economic burden associated with keeping Canadians healthy:

• Researchers estimated that the total economic burden of illness in Canada in 1998 was $159.4 billion. Direct costs were $83.9 billion; indirect costs were $75.5 billion (CIHI, 2003). Four diseases (cardiovascular, musculoskeletal, cancer and injury) accounted for 39% of these costs (CIHI, 2003).
• The average health care spending per household in Canada in 2000 was $1,357-up from $1,009 in 1996 (Statistics Canada, 1999).
• In 1996, Canadians spent 3% of their after-tax earnings on health care (up from 2.3% in 1978). The majority of these expenditures went to pay for
  insurance premiums, medicinal and pharmaceutical products and dental services (Statistics Canada, 1999).
• In 2001, Canada spent an average of $3,300 per person ($102.5 billion per year) providing health services to Canadians (CIHI, 2002).
• In 2002, Canada spent an estimated $122 billion (an average of $3,572 per person) on health care. Hospitals, retail drug sales and payments to
  doctors accounted for over 60% of total spending (CIHI, 2003).

Spending on health care has increased over time

Annual increases in health care costs are the norm in Canada. With the exception of the mid-1990s, there has been steady growth in health care expenditures over the past several decades. Between 1997 and 2002, total health spending in Canada grew by almost $34 billion (an unprecedented rate of increase) and is at an all-time high, even after taking into account inflation and population growth (CIHI, 2003). The following statistics give the reader a clearer picture of the extent to which health care costs have increased over time:

• Health care spending accounted for 32% of total government expenditures, including debt charges in 2000-up from 27% in 1975 (CIHI, 2002).
• Adjusted for inflation and population growth, health care spending rose 4.3% in 2001 compared to 2000. This increase in health care spending occurred every year for the previous four years (CIHI, 2002).
• When population growth and inflation are taken into consideration, spending on health care in 2001 was 80% higher than in 1975 (CIHI, 2002).
• In Canada, spending on health care has increased at a faster rate than overall economic growth. In 2001, Canada spent about 9.4% of its gross domestic product (GDP) on health care. This is higher than observed in 2000 when Canada spent 9.1% of the GDP on health care (CIHI, 2002).
• Canada's combined public and private health care bill rose by over 43% between 1997 and 2002. Inflation accounted for only one quarter of this increase. Population growth accounted for a further 11%. Rising levels of public (a 49% increase) and private (a 16% increase) spending per person accounted for the rest of the upswing (CIHI, 2003).

Per capita expenditure is the average value of health expenditures at the personal level and for each category of spending. Per capita information allows comparisons over time by removing the effect of population growth (Statistics Canada, 1999). Per capita expenditure data can also be used to illustrate the extent to which health care expenditures have increased over time. Consider the following data:

• Health care spending per person rose faster from 1998 to 2002 than in any period since Medicare was introduced (CIHI, 2002).
• In 2003, total public and private spending on health care per person (adjusted for inflation) rose for the sixth straight year in Canada (CIHI, 2003).
• Between 1975 and 2001, Canada's total health expenditures had increased at an average annual rate of 9.8% per capita (CIHI, 2002).

Why the larger increase in health care costs between 1997 and 2003? CIHI (2003) provides the following answer to this question:

• population growth accounts for $3.7 billion of this total,
• inflation accounts for $8.3 billion of this total,
• increases in public spending on health per person account for $16.3 billion of this total, and
• increases in private spending on health per person account for $5.2 billion of this total.

On the one hand, most of the increase in public spending on health can be attributed to changes in spending on hospitals (29% of the growth), drugs (15%) and capital investment (14%). Most of the increase in private spending on health, on the other hand, is associated with drugs (46%) and payments to other health care professionals such as dentists and optometrists (33%) (CIHI, 2003).

The increased incidence of stress over the decade (see Duxbury and Higgins, 2001, 2003) has likely also contributed to increased health care costs. Both chronic stress and life events have been found to have, at the very least, a strong indirect impact on physical and mental health by affecting the physiology and morphology of the circulatory system and an effect on the development of cancer by psychoneuroimmunological mechanisms (Statistics Canada, 1999). With the exception of pregnancy and related conditions, the major causes of hospitalization and death in Canada are stress related (Statistics Canada, 1999). Since work is such an important facet of daily life for so many Canadians, the stress they experience at work is a key determinant of overall mental health (Statistics Canada, 1999).

How we spend our health care dollars has also changed over time-less money is spent on hospitals

The way Canadians spend their health care dollars has changed significantly over the past several decades. In 1975, almost half (45%) of health care spending in Canada went to hospitals. While hospitals were still the largest single recipients of health care spending in 2002, their share of total health spending had dropped to 31% (CIHI, 2003). The pattern of spending within hospitals has also shifted, and the proportion of funding spent on salaries has declined while the percentage of the budget devoted to benefits, drugs and medical supplies has increased (CIHI, 2003).

Twenty-five years ago, physician services were the second largest recipient of health care spending, followed by other health institutions, other health care professionals and then drugs. Today, this ordering has changed; spending on drugs (16%) has overtaken physician services (14%) as the second largest cost driver (CIHI, 2003).

More money is spent on prescription and non-prescription drugs and home care

The fastest growing component of health care expenditures, drug costs, have grown at an average rate of more than 11% over the past five years (Duffy, 2002). Retail sales of drugs (both prescribed and non-prescribed) has become the second largest category of health spending, accounting for 16% of all expenditures ($18 billion in 2002). Approximately two thirds (65%) of these expenditures were assumed by private insurance companies and individual Canadians (CIHI, 2003).

The other fast-growing sector of health spending is home care services. In 1980-81, Canadian governments spent $205 million on home care. This had increased to $2.5 billion in 2000-01. A similar trend can be observed with respect to private spending on home care. CIHI (2003) attributes this increase to the following factors: changing demand for home care (e.g. Canadians are living longer), more reliance on home care as an alternative to hospital care, changes in the availability of informal care, and more emphasis on self-managed care.

2.1.1 Who pays for health care?

In Canada, many groups share the costs of health care. In 2001, about three quarters (73%) of total expenditures (i.e. approximately $2,400 per person) was provided by public sector sources (i.e. federal, provincial/territorial and municipal governments). The rest came from private sector sources (e.g. insurance) and individuals (e.g. out-of-pocket expenses) (CIHI, 2002).

Seven out of every ten health care dollars come from the public purse

In 2002, seven out of every ten dollars spent on health care came from the public purse (CIHI, 2003). Government and social security programs spent just over $70 billion on health care. The rest (a total of $32.9 billion in 2002) comes from private sources, such as insurance plans or out-of-pocket payments. It should be noted, however, that governments also share these costs through foregone tax revenues as firms can deduct insurance premiums from their taxable income while employees do not pay taxes on these benefits (CIHI, 2003).

Health care spending varies widely by province and territory. This variation can be attributed to factors such as health needs, how health care is organized and delivered, the salaries paid to medical service professionals, and demographic differences in provincial/territorial populations (e.g. average spending is linked to both gender and age) (CIHI, 2002).

While overall government spending on health care has increased significantly over the past several years, the number of supported services has dropped. For example, some jurisdictions have de-listed needed services such as optometry and physiotherapy, and continue to underfund key areas such as mental health and home and community-based services (CCIH, 2002).

In Canada, both public and private sectors pay part of the drug bill. Public sector payments come from governments, Workers' Compensation Boards and social security systems. Individual Canadians pay some of the drug costs out of their own pockets, while private insurance (often provided through the employer) is the other major source of funds (CIHI, 2002).

Employers contribute a substantive amount to the costs of health care in Canada

In the past several years, provincial/territorial governments across Canada have responded to federal fiscal tightening by reducing their own role in financing health care. Government cutbacks have increased the need for the private sector to assume many of these costs through benefits programs. One of the main consequences of this set of strategies has been the growth of private health care expenditures, from 25.5% of all health care funding in 1991 to 29.8% of spending in 1997. This growth has occurred because private plan sponsors (e.g. companies) and individuals have no choice but to pay for these services if they want to facilitate an early return to good health (and hence to work). In fact, the role of the private sector in health care funding has become so critical that "private health plans can no longer be considered 'fringe benefits' to employers or to Canada in general" (CCIH, 2002, p. 27).

Drugs and payment for the services of other health care professionals (e.g. chiropractors, dentists, physiotherapists, optometrists), dental and vision care account for most private spending. The private share of spending varies by the type of service.

The private sector's share of health costs has increased in the past decade

A 1996 Conference Board study found that the costs of providing a supplemental health plan increased by an average of 26% between 1990 and 1994. Between 1980 and 2000, the percentage of total health care expenditures paid for by the private sector grew from 24% to 29% (Bachmann, 2002) while the share of prescribed drugs financed by private insurers increased from 30.5% in 1985 to 33.5% in 1999 (Bachmann, 2002). The major factors contributing to these increases were rising drug costs, the rising cost of dental services, greater utilization of these plans by employees, inflation and cost shifting of services from provincial/territorial plans (Bachmann, 2002). The current situation is not expected to improve in the next several years as recent forecasts have predicted an increase in drug claims of up to 20% (Bachmann, 2002). These data support our contention that employers should place a high priority on workplace health programs that reduce health costs to their bottom line.

Individual employees also have substantive "out-of-pocket" health care expenditures

Individual Canadians pay for health care both directly (health insurance premiums and out-of-pocket health care expenses) and indirectly (the taxes Canadians pay contribute to public spending on health care) (CIHI, 2002). Just under 15% of health care spending is in the form of "out-of-pocket" expenses assumed by the employee/patient (CIHI, 2003).

2.1.2 How much does Canada spend on health care compared to other countries?

Canada spends more on health care than most countries, but does not enjoy better health

Canada spends more on health care in relation to the size of its economy than every country in the world except the United States (13% of GDP), Germany (10.6% of GDP) and France (9.5%) (Duffy, 2002; CIHI, 2003). The magnitude of the differences are illustrated by the following statistics:

• After adjusting for differences in exchange rates and cost of living, Canada spent more per person than 25 of the 29 Organisation for Economic Co-operation and Development (OECD) countries in 1998 (CIHI, 2002).
• In 1997, Canada ranked fourth among the Group of 7 (G-7) industrialized countries in total health expenditure as a percentage of GDP (Statistics Canada, 1999).
• In 2001, 9.3% of Canada's GDP (a measure of economic output) went to health care, up from 7.3% in 1981 (CIHI, 2003).

The research that is available indicates that those countries that spend more on health do not report higher life expectancy (CIHI, 2003). Starfield and Shi (2002), for example, have done research that suggests that countries with stronger primary health care systems spend less on health care. They based their conclusions on per capita health care expenditures in 1997 and countries' scores on 15 health system and practice characteristics deemed to facilitate primary care (CIHI, 2003). Using Starfield and Shi's criteria (see the graph on p. 36 of CIHI, 2003), Canada achieves a "middle of the pack" score of 17.5-better than the United States' score of 6.0 and Germany's 5.5 but significantly lower than the United Kingdom (29) and Denmark (26).

2.2 Models That Can Be Used to Frame the Discussion

During the 1990s, two different models were used to formulate health policy and action: health promotion and population health. Somewhat simplistically, the basic difference between the two models is that population health is concerned with the social determinants of health, while health promotion focuses on the individual (Townson, 1999). Details on each model and its association with workplace health are given below. Information on a third model that has relevance to this issue, the Index of Social Health, is also included in this section of the report.

2.2.1 Workplace health promotion

Workplace health promotion is defined as the "art and science of helping individuals change their lifestyle more toward a state of optimal health" (Bachmann, 2002, p. 3). Optimal health, in turn, is defined "as a balance of emotional, physical, social, spiritual and intellectual health" (Bachmann, 2002, p. 3). Primary health promotion activities (e.g. education, immunization, general health promotion campaigns) focus on eliminating health risk factors and preventing disease before it develops (CIHI, 2003). Secondary health promotion activities (e.g. screening programs) are concerned with early detection and treatment of disease in people who do not show symptoms (CIHI, 2003). At this point in time, we do not know how much is spent in Canada per year on workplace health promotion and disease prevention activities and programs (CIHI, 2003). Nor do we know how much is spent on complementary and alternative therapies.

Traditionally, workplace health has focused primarily on occupational health and safety

Traditionally, when employers and governments have focused on workplace health, they did so primarily on occupational health and safety (OH&S) issues related to the physical work environment (e.g. hygiene, safety, physical health, hazards), which is monitored through OH&S legislation (Bachmann, 2002; CCIH, 2002). The impact of monitoring legislation seems quite clear. Between 1970 and 1997, the incidence of workplace injuries in Canada fell from 11.3 to 6.4 per 1000 workers while the incidence of time-loss injuries decreased from 4.3 to 3.2 per 100 workers (Bachmann, 2002).¹³

The OH&S approach to workplace health is necessary, but not sufficient, to address the needs of today's workforce. Companies today need to take an expanded view of workplace health and focus on the issues that are impairing the physical and mental health of their employees-issues such as work-life conflict, heavy workloads, etc. The movement to extend the focus of workplace health beyond health and safety is occurring worldwide (CCIH, 2002). In 2001, Smallman (as cited in CCIH, 2002) published a comprehensive review of 55 peer-reviewed empirical studies in the area of health and safety. This review covered research done in the United States, United Kingdom, Canada, Norway, Sweden, Germany, Hong Kong, India and Taiwan. From this research, he concluded that:

"The health and safety system needs to do more than just prevent work-related harm. It must promote better working environments characterized by motivated workers and competent managers." (Smallman, 2001, p. 401)

CCIH (2002) notes that over the past several decades there has been a shift in our understanding of workplace health. As such, the focus on OH&S has been supplemented by a call for workplaces to adopt health policies, procedures and practices that go beyond compliance with legislation and focus instead on work environment issues. In other words, the approach to workplace health is becoming more consistent with the population health model.

Why do we need a new vision of workplace health promotion?

Several arguments can be made for expanding workplace health promotion offerings beyond simple OH&S efforts. The first argument revolves around the idea that people may, for one reason or another, fail to follow personal health practices. Researchers have compiled a long list of reasons, including lack of time, lack of knowledge about fitness/nutrition, lack of access to facilities, fatigue, boredom, lack of incentives, psychological barriers, delayed gratification (benefits are felt in the future but the effort must be made now) and socio-economic status (Bachmann, 2002). No matter what the cause, however, organizations that rely on their human capital need to reduce the probability that their employees will engage in unhealthy practices by designing appropriate health promotion programs. The second argument revolves around the business case for introducing such programs. Bachmann (2002, p. 1) does an excellent job of making this case:

"Whether health promotion programs are a frivolous cost or a sound investment is not the correct topic of debate. Rather the discussion should be at a more strategic level because there is mounting evidence that workplace health promotion, when included in a broader, more integrated approach to employee health, can result in cost savings, higher levels of productivity and enhanced worker engagement and retention."

Pratt's (2001) work on the healthy scorecard can be used to make the third argument for expanded workplace health promotion programs. Pratt (2001) points out that most companies today pursue costs containment as their number one reason for health promotion, health benefits, etc. She feels that this perspective is misguided and recommends instead that organizations introduce health promotion programs that reduce the event rate for stress, illness and injury (i.e. the incidence of the event and the severity of the event). Her rationale for this argument is that the costs incurred by an organization to reduce the occurrence of an event are typically much less than the cost of curing the employee once the person is sick. Bachmann (2002, p. 1) concurs with this view and notes that many leading organizations are moving away from a narrow focus on return on investment (ROI) measures and are aligning workplace health programs with human capital management, "employer of choice" or triple bottom line reporting strategies."¹⁴

The evidence supporting workplace health programs is still subject to debate

The value of workplace health programs continues to be debated based on their return on investment for the organization (Bachmann, 2002). Research methodologies in particular are open to criticisms, including self-selection, short duration of evaluation, subjectivity of measures, diffusion of information, and intervening and confounding factors (Bachmann, 2002). That being said, Bachmann (2002) does offer a number of examples of how health promotion programs can save organizations money:

• University of Michigan reported that for every $1 (U.S.) spent on workplace health programs, the organization saved U.S.$1.50 to $2.50 (U.S.) on health care costs and absenteeism.
• Steelcase observed a decline in average health care costs over a three-year period from $1,122 to $993 (U.S.) among employees who shifted their health behaviours from high risk to low risk.
• B.C. Hydro's 1996 internal cost benefit analysis of the organization's wellness program estimated that the company saved $3 for every $1 (Cdn) spent on the program.

She also notes, that to achieve benefits from health promotion, an organization needs to do two things: (1) adopt a broad set of programs, and (2) take a holistic approach rather than focus on a single program (Bachmann, 2002). Furthermore, she points out that research has shown that health promotion programs that include counselling, offer the employee a choice of interventions and take into account the culture of the organization were more successful in reducing risk factors than programs which featured a more restricted choice of interventions (Bachmann, 2002).

But not everyone feels positively about the health promotion approach

Not everyone feels positively about the health promotion approach to workplace health. Critics of the health promotion approach, such as Townson (1999), note that such a strategy individualizes both the root of the problem and many of the remedies. It also means that companies and governments do not need to tackle issues like work environment, income distribution, control over the environment or the medical establishment. Townson (1999, p. 6) summarizes this point of view when she says that the health promotion approach "Exhorts individuals to live better and implicitly blames them for their own illnesses."

2.2.2 The Population Health Model

The competing model to health promotion is the population health approach put forward by Dr. Fraser Mustard. Population health is defined as the "label used to describe the analysis of major social, physical, behaviour and biological influence upon overall levels of health status within and between identifiable population groups" (Townson, 1999, p. 6). "The goal of a population health approach is to ward off potential health problems before they require treatment within the health care system" (Senator Kirby as quoted in Bachmann, 2002, p. 16). The population health approach is based on the idea that health problems can be prevented by modifying the impact of cultural, economic and social factors on the health of populations.

The population health model assumes that health is influenced by many factors other than health care

According to the population health model, health services are not the only (or perhaps even the most important) influence on health (Townson, 1999). Instead, this model suggests that policies to improve population health need to address the following: living and working conditions, physical work environment, personal health practices (e.g. lifestyles) and health services (Townson, 1999).

A workplace health model that takes a population health-based perspective addresses issues from three perspectives:

• the physical work environment (e.g. occupational health and safety issues);
• the psychosocial work environment (e.g. management practices and strategies); and
• individual health practices (e.g. lifestyle choices and health habits) (Bachmann, 2002).

The psychosocial work environment has been defined as a set of organizational job factors that deal with the interaction between people, their work and the organization (Bachmann, 2002, p. 10).

Health policy in Canada has largely focused on the health care system itself

At this point in time, factors identified by the population health model as affecting health (e.g. work environment, ability to balance work and life) remain largely outside the scope of national health policy. Townson (1999) points to a large gap between what the government identifies as causes of concern (e.g. socio-economic factors) and what is actually being done in the area of population health. She notes that social and economic policies which address these key socio-economic factors "have not yet been incorporated into strategies to improve the health of Canadians" (p. 8).

Support for Townson's (1999) point of view comes from work done by the National Forum on Health in the mid-1990s. This group undertook two years of consultation and research on the topic of population health and drew the following conclusion in a report released in late 1996:

"Despite what is known about the determinants of health, the general public continues to be mainly concerned about healthcare, especially when services are seen to be threatened. As well, governments and public administrators have not demonstrated in their decisions any appreciation of the impact of social and economic determinants and their impact on the health of individuals and communities" (cited in Townson, 1999, p. vii).

In Canada, as in many industrialized countries, health policy has focused on the health care system itself (Townson, 1999). The debate with respect to health policy generally focuses on the legitimacy of the financial claims on the health care system made by various health care professionals (doctors, hospitals, nurses) and beneficiaries (Townson, 1999). As Townson (1999, p. 19) notes, there is little attention to perhaps the most important question of all: "What reforms would help improve the health of the population?"

2.2.3 The Index of Social Health

The standard of living of societies has traditionally been measured by their GDP per capita (Townson, 1999). Within the past decade, however, there has been a movement to augment this indicator by including social indicators and indicators of well-being. Statistics Canada (1999), for example, argues that because economic indicators such as the GDP fail to take into account non-economic activities or the negative impacts of economic activity it means that they are not good indicators of social health. Construction of a comprehensive indicator of social health that provides an accurate picture of the relationship between social health, well-being and overall health is, however, a non-trivial issue given the large number of potentially important social indicators. To overcome this issue, a composite measure (the Index of Social Health or the ISH) was developed in 1997 by Brink and Zeesman of Human Resources Development Canada (HRDC). This index is made up of 15 social indicators which have been found to have an impact on overall population health as it is commonly defined (e.g. infant mortality, unemployment, homicides, gap between rich and poor, number of beneficiaries of Canada Assistance Plan). Statistics Canada (1999) reports that the ISH gives a more comprehensive view of the health of society than traditional measures of progress such as GDP or the Human Development Index (the United Nations' measure of quality of life).

The ISH provides two pieces of information that are important to this study: (1) a summary of the health of Canadian society that incorporates the ideas of social health and societal well-being, and (2) information on how this social health has changed in Canada since 1970 (Statistics Canada, 1999).

According to Statistics Canada (1999), the ISH increased impressively in Canada from 1970 to 1980. The peak values were, however, reached in 1980. Since this time, there has been a slow and steady decline.¹⁵ In 1995, the index stood at 50, which means that the indicators were at only half the maximum levels they had reached during the 25-year period. In sharp contrast, Canada's GDP continued to increase markedly from 1970 to 1995 (Statistics Canada, 1999).

This index suggests that the quality of life and the social health of Canada has declined since the early 1980s, even as economic output has grown. Since this negative association followed several years when social health and economic output were very highly correlated, these data suggest that policy choices starting over a decade ago have led to a divergence of the two trends. This suggests that a different course in economic and social policy could restore the positive trend in social health (Statistics Canada, 1999).

2.3 Workplace Health

This section begins with a summary of evidence from the literature supporting an investment in workplace health. It concludes with an objective discussion of why such investments in this area are the exception to the rule rather than the norm.

2.3.1 Why invest in workplace health?

If people really are Canadian organizations' most valuable resources, why aren't more organizations creating work environments that contribute to the health and well-being of their workers? Why are governments and organizations still debating this issue when there is a large body of compelling evidence that links supportive work environments and organizational success (Bachmann, 2002)?

It's all about the bottom line

The data that are available provide convincing proof that dealing with issues around workplace health and work-life conflict can have a significant, positive impact on Canadian society, the health care system and our ability to compete globally (see Schmidt, 1999; Chen et al., 2000; Bachmann, 2002; Duxbury and Higgins, 2003 for examples). A sampling of these data-all examples and references cited in CCIH (2002)-are provided below:

• Members of the Canadian Life and Health Insurance Association (CLHIA) made health benefit payments in Canada of $12.5 billion in 2000. These health benefits included drugs, other medical/hospital, disability, dental, and accidental death and disability. In 1990, the CLHIA paid $5.9 billion in costs.
• In 2002, Statistics Canada noted that absenteeism in Canada had increased to 8.5 days per year for each full-time worker in 2001 from 7.4 days per year in 1996. Canada lost 85.2 million workdays for personal reasons in 2001 versus 65.5 million days in 1996. (Note: these totals do not include vacation and maternity leave.) Approximately 75% of time lost for personal reasons could be attributed to illness or disability. This absenteeism was estimated to cost Canadian businesses about $8.5 billion per year.
• A 2000 survey of 41 major Canadian employers, done by Mercer Consulting, indicated that these organizations spent between 2% and 8% of their payroll on absenteeism. These are estimates for direct costs only and do not include the costs associated with replacement workers and casual absence.
• Watson Wyatt's 2000-01 "Staying@Work" survey of 281 Canadian employers determined that the direct costs of absenteeism and disability were 7.1% of payroll. When they included the indirect costs for overtime and replacement workers (6.2%) and lost productivity (4%) in this total, they arrived at a cost estimate of 17% of payroll.
• The Association of Workers' Compensation Boards of Canada noted that in 2000 there were 392,502 new lost time claims. This was estimated to cost just over $4 billion.
• A 2001 Health Canada study done by Stephens and Joubert stated that mental illness was a $14-billion health issue in Canada.
• The CLHIA estimates that depression costs $300 million per year in long-term disability payments. The World Health Organization predicts that depression will become the second leading cause of disability (heart disease is predicted to remain number one) by 2020.
• BCE Emergis noted that 8.7% of its paid claims (or $8.7 million) were for prescriptions used to treat depression. This was the largest drug category in its 2001 listing of the 20 "most expensive disease states."
• In 2001, approximately half of short-term and long-term disability claims were for mental and nervous disorders-an increase from 30% of disability claims in 1990 and 15% in 1980.

Cost data from our own research (see Section 1.2) can also be used to establish the link between work-life conflict and the bottom line.

Why do companies not invest in workplace health programs? The research available indicates that most Canadian companies do not make a strategic decision to support workplace health programs. Nor do they link support of workplace health to business viability or the bottom line. Rather, many view health benefits as a tax-effective form of total compensation (CCIH, 2002).

2.3.2 Why are organizations and governments not addressing workplace health issues?

Senior management has a critical role to play in creating a healthy work environment as they make most of the decisions about how, when, where and under what conditions work gets done (Bachmann, 2002). Why, given the evidence presented above, do senior managers not embrace the concept of workplace health?

Lack of leadership and a focus on the short term

Problems that researchers have encountered with respect to building the business case for workplace health include the following (see Bachmann, 2002 for a more complete discussion):

• the costs of improving health of workers are incurred in the present, while the desired benefits and savings are often not realized for many years;
• in some cases, prevention programs result in higher health costs for organizations as they may uncover medical conditions in their employees that require an ongoing course of treatment;
• unions fear that shifting the focus away from occupational health and safety to the broader concept of employee well-being may water down efforts to eliminate physical hazards in the workplace;
• an integrated approach to workplace health requires a level of cooperation and coordination between employees, employers and unions that is simply not present in many firms; and
• many of the groups interested in employee health (e.g. human resources, wellness practitioners, operational management, OH&S specialists) work in professional silos. As such, there is a high potential for duplication of effort which may diminish the positive outcomes experienced from the programs. There is also little synergy between the various groups.

CIHI (2002) adds the following barriers to the list:

• Canadian governments provide little incentive (except for legislated requirements concerning occupational health and safety) for employers or other health care benefit providers to focus on the workplace;
• the research available has not yet established to what extent workplace health initiatives lead to positive performance or productivity-related outcomes; and
• there is relatively little government leadership or assistance offered in relation to the promotion of health in the workplace.

It is hoped that this research study will spur both governments and organizations to action.

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