Does Canada’s federal budget address the social determinants of health?
A test for this week’s historic federal budget is whether it recognizes that health and socio-economic circumstances are always interconnected, not just in pandemic circumstances, by planting the seeds for a public-led recovery, including a plan to pay for it in the long term.
When it comes to the social determinants of health, does the 2021 federal budget achieve?
Focusing on the public health arm of the health care system, there are no significant changes in the budget. In fact, the budget largely conflates public health and the broader health care system, which dilutes public health’s unique concerns, such as the health of populations, prevention, and root causes of poor health.
There are no strong signals in this budget of efforts to shift provincial/territorial health spending more towards prevention versus downstream treatment.
In terms of strengthening the social determinants of health, the budget contains some very important new commitments, such as a robust plan for high quality, affordable ($10 a day) child care. This initiative signals a significant commitment to strengthening conditions for health and social equity, especially for women and families.
Transformative change for well-being and health equity, however, demands a comprehensive vision for improving people’s living conditions and tackling inequities in money and power. From that point of view, some important omissions from this historic budget become evident, including deep investment in affordable housing, substantive commitment to decarbonizing the economy via a just transition, and fair taxation beyond the increased tax on luxury items.
COVID-19 caught us unprepared
In a recent article in the Canadian Centre for Policy Alternatives’ The Monitor, Michael Rozworski noted that in April of 2020, Prime Minister Justin Trudeau placed a large order on Amazon for assistance in distributing personal protective equipment to hospitals and health authorities around the country.
That pretty much sums up some of the key lessons of the COVID-19 pandemic.
Despite extensive post-mortem analysis of previous pandemics, such as SARS in 2002-3, we were unprepared for this one—largely due to a significant erosion of the public sector that is supposed to keep people healthy in the first place and protect them, as much as possible, from such a major crisis.
The COVID-19 pandemic has made clear the strong connections between health on the one hand, and broader social and economic circumstances on the other. In doing so, it has exposed longstanding weaknesses in the social determinants of health. It has exposed decades of underspending and privatization in social and economic domains (including but, significantly, not limited to health care) that have led to the massive inequities
Budget 2021 is a historic opportunity to redress this situation, by planting the seeds for a public-led recovery that will support health and wellbeing for all, including a plan to pay for it in the long term.
Does the federal budget deliver? Yes and no.
One useful frame for analyzing Budget 2021 and its potential for transformative change for well-being and health equity is the 2008 final report of the World Health Organization Commission on the Social Determinants of Health.
The commission was a global network of policy makers, researchers, and civil society organizations, who came together to gather and review evidence on what needs to be done to reduce health inequities within and between countries—to “close the gap in a generation.”
The commission came up with three overarching recommendations: first, to improve daily living conditions; second, to tackle the inequitable distribution of power, money, and resources; and thirdly, to measure and understand the problem and assess the impact of action (see Table 1).
Budget 2021 contains some significant movement toward these goals. These include the robust plan for affordable childcare nation-wide, which will contribute importantly to health and social equity; as well as—on the horizon—national standards for long-term care, which could signal a hugely important commitment to the primary role of government (versus the private sector) for providing this essential service.
Pandemic-inspired supports, such as the CERB, made a significant difference in the lives of many, but despite calls for permanent reforms to income supports and insurance, the budget reveals mostly short-term extensions. One important exception is the new, low-entrance requirement for employment insurance, which will continue.
Considering the commission’s goal of tackling the inequitable distribution of power, money, and resources, there remain some gaps in the budget. To do so would require tackling Canada’s dependence on fossil fuel production, including eliminating subsidies to polluting industries; and bold tax reform to support pandemic recovery and beyond.
Both of these are largely absent in Budget 2021. The budget contains no hint of a wealth tax, nor any changes to corporate tax, nor any new top tax brackets; despite the significant revenue-generating and power-dampening potential that such measures could usher in.
No major changes to public health care spending
The budget also does not contain major changes with respect to health care, including to the public health arm of the health care system, which has been leading the pandemic response. Health care spending, which actually means sick care spending, occupies a high and growing proportion of provincial budgets, but that growing spending does not make people healthier—it’s reactive rather than proactive.
If we are serious about wellbeing and health equity, we need to grapple with health care spending.
Make no mistake: health care spending is one dimension of power and resources that works against health and well-being by crowding out spending on the social determinants of health. Re-allocating public funds from overall health care to social determinants of health would be one signal of a truly transformative federal budget, with respect to well-being and health equity.
Investing in child care is a start.
Lindsay McLaren is an associate professor at the Department of Community Health Sciences and the O'Brien Institute for Public Health at the University of Calgary. She is also a research associate with the Canadian Centre for Policy Alternatives.
Overarching recommendations, and examples, from the World Health Organization Commission on Social Determinants of Health, final report, 2008
Improve daily living conditions
Support “equity from the start”, including via high quality early childhood education;
Place health and health equity at the heart of urban governance and planning (for example, affordable housing);
Pursue fair employment and decent work;
Strengthen social protection policies to ensure a level of income that is sufficient for healthy living for all;
Universal health care, built on principles of equity, disease prevention and health promotion;
Expand capabilities of the health workforce to engage with and act on the social determinants of health.
Tackle the inequitable distribution of power, money, and resources
Pursue health equity in all policies, systems, and programs across government sectors;
Strengthen public finance for action on the social determinants of health;
Ensure market responsibility, including by reinforcing the primary role of the state in the provision of basic services essential to health and the regulation of goods and services with a major impact on health;
Achieve gender equity, including by addressing gender biases in the structures of society;
Promote inclusion and voice by empowering all groups in society through fair representation in decision-making.
Monitoring, research, and training
Ensure that routine monitoring systems for health equity and the social determinants of health are in place;
Provide training on the social determinants of health to policy actors, stakeholders, and practitioners and invest in raising public awareness.