Determinants of Health: a socio-politico-economic context

Contemporaneous theories on population health have evolved to acknowledge that health is not merely the absence of disease and recognize that health must be considered within in a socio-politico-economic context. The World Health Organization (WHO) defines social determinants of health as “conditions or circumstances in which people are born, grow, live, work and age” – all of which are conditions shaped by political, social, and economic factors.

The Government of Canada draws distinction between determinants of health and social determinants of health. Determinants of health are the broad range of personal, economic, and environmental factors that determine individual and population health identified in the pictogram below: (Source: ARCHIVED - Health and the Environment: Critical Pathways - Canada.ca https://images.app.goo.gl/uBABYmFnC7LpfawV7)

Social determinants of health are characterized as a specific group of social and economic factors within the broader determinants of health that relate to an individual’s place in society such as income, education or employment which also serve to recognize that experiences of discrimination, racism, and historical trauma are important determinants of health. Differences in health status between individuals and groups are called health inequalities.

The public health system in Canada is made up of government/non-government and community agencies that operate at local, provincial, and federal levels. As previously discussed, Canadian health care policy is federally administered through the authority of the Canada Health Act (CHA), where each of the provinces and territories receive conditional funding from the federal government through the Canada Health Transfer to manage and administer health services to their residents in accordance with the provisions of the CHA.

In Ontario, the Ministry of Health and Long-Term Care (MOHLTC) has downloaded this responsibility to its 34 Public Health Units (PHU’s). Each PHU is accountable for protecting and promoting the Health of Ontarians in accordance with the Ontario Health Standards: Requirements for Programs, Services, and Accountability. PHU’s are governed by a medical officer of health who reports to the local board of health.

The local board of health is an official health agency established by urban and rural municipalities and is considered an “autonomous” corporation legislated under the Health Protection and Promotion Act. The local board of health is comprised of elected representatives from municipal councils. The funding and expenses for PHU’s are covered under a cost sharing arrangement between the provincial MOHLTC and municipalities. This funding arrangement is important when considering the true “autonomy” – especially when considering the implications of a board whose membership is comprised of publicly elected officials.

Elections at the local, provincial and federal levels each occur every four (4) years in Canada. Publicly elected officials seeking re-election need the public – their constituents – to vote for them. To achieve this, elected officials need to focus on and demonstrate RESULTS. The caveat is two-fold. Firstly, sustainable health policy and population health interventions require long-term commitment (> 4 years) for proper assessment, implementation, and evaluation. Secondly, this survivalist hyper focus on short-term results that can be publicly reported to boost political popularity often favors superficial short term “band-aid” population health initiatives and a “downstream” approach to health care which addresses immediate health needs (which are often the most politically sensitive), achieving little progress towards midstream (addressing material issues such as housing and employment), or upstream health which advocates for broad policy changes to promote greater equity in power structures and income.

In a 2019 article titled Social Determinants of Health and Related Inequalities: Confusion and Implications, the author, M. Mofizul Islam argues that social services - also known as social determinants of health- are shaped by public policies. To this point he argues that “…public policy is a more fundamental determinant that the often-discussed social determinants of health.” Islam also illustrates the inherent risk of politicizing health services by stipulating that “a toxic combination of poor policies and programs, unfair economic arrangements and bad governance may lead to unfavourable conditions”. (Islam, 2019)

The following YouTube video illustrates a well-known public health parable in which rescuers are situated downstream in a raging river exhaustively saving drowning person after drowning person passing by them in the river. This downstream approach to the rescue is not sustainable and lives inevitably will be lost. A midstream thinking rescuer gathers supplies and decides to throw all the drowning people life preservers so that they can hopefully save themselves. Finally, someone takes the time to look upstream to determine why people are falling into the river in the first place and fixes the broken bridge to stop people from falling into the river in the first place.

https://www.youtube.com/watch?v=qarQXqKbmLg