In 1974, the Lalonde Report titled “A New Perspective on the Health of Canadians” argued that we needed to look beyond traditional health care focused on medicine. If we wished to improve the health of the public, a broad determinants of health approach focused on things like lifestyle choice and behaviour needed to be pursued.
Nearly forty years later, does the evidence show a major swing towards public health as a priority in government health expenditure? Health expenditure data from CIHI shows that real per capita spending on the public health component of public sector health spending was indeed flat in the decade after the Lalonde Report but starting in the early 1990s, it appears to have taken off and indeed now represents one of the fastest growing categories of provincial government health spending (See Figure 1). Between 1975 and 1990, the average real per capita amount across Canada’s provinces only grew from 48 to 63 dollars while by 2009 it tripled to reach 183 dollars. The SARS crisis appears to have particularly sparked a jump in Ontario spending after 2002.
Figure 1
However, the slow growth prior to 1990 compared to the other categories of health spending in the long term has meant that spending on public health has not come to occupy that much larger a share of provincial government health spending. In 1975, about 4 percent of government health spending was on public health programs and stayed at this level until the early 1990s. It then began to grow as an expenditure share and at present is about nine percent. However, there is a lot of variation across the provinces (See Figure 2). Ontario, Saskatchewan and Alberta are now spending between 10 and 12 percent of government health funds on public health programs while New Brunswick, Nova Scotia and Newfoundland & Labrador are below 4 percent. Prince Edward Island and Quebec are only slightly higher. There is a definite divide between Ontario and the West and Quebec and the Atlantic provinces when it comes to spending on public health programs.
In 1974, Canada was at the forefront of the public health approach with the Lalonde Report so it is surprising that after forty years there is such variance across its provinces.The question is whether this is a function of resource constraints or does it reflect regional preferences when it comes to the composition of health care programs? The east is generally lower income than the West. Are scarce resources are targetted first at traditional medicine given the less immediate return to public health spending? Or, perhaps Quebecers and Newfoundlanders do not enjoy being lectured on what or how to eat while British Columbians and Ontarians are more into the nanny state? Are these differences in expenditures reflected in health indicators? For example, self-reported obesity rates are highest in the Atlantic provinces and Saskatchewan and lowest in British Columbia and Quebec. Yet, Quebec is among the low public health spenders while Saskatchewan is among the high spenders when it comes to government budget share. Food for thought?
Figure 2
Livio, interesting post. A further complication is the amount of public health spending by the federal government, primarily through PHAC and its subsidiaries (about $590 million, roughly an extra 10% over provincial spending, or an extra $18 per head). And there are some variations in what falls under public health, but that is minor.
There are a few questions that need to be examined first in regards to your reference to Lalonde and the later data on public health spending:
1. Was Lalonde (and many others besides) correct in asserting that health determinants could be influenced positively by policy?
2. Was it also correct that "prevention" would increase health and be more cost-effective?
3. How exactly are the provinces spending their money?
On the first two questions, I think the answer is a resounding no. In a rich country with an open economy and good institutions, achieving big upstream gains in public health through health spending is very difficult. Vaccination is the one--and highly successful--outlier. When it comes to population health, education, good food, and economic growth will kick dust in the face of health policy every time. If the government wants to do something to really influence public health and in particular future health, I suggest Leona Aglukkaq could publicly cane Andrew Wakefield and subsidize more childhood vaccines.
Consider the decline in smoking since the 70s: how did that happen? Some would claim it is due to government demarketing such as warning labels and taxes, but alcohol use also declined without being vilified. Furthermore, both smoking and heavy alcohol use (which creates a major burden in child welfare expenditures, a very serious public health cost) have hit a hard floor in lower SES groups, despite high taxes and grisly advertising. The argument for policy effectiveness is weak; changing social mores and greater wealth may be better explanations.
How the provinces spend their money is an issue too. Some put public health dollars into a lot of high-end direct care services, like public nurse home visits, while others spend more on education campaigns. Some provinces invest more in disaster management programs like H1N1 and avian flu preparation.
I think we have hit a ceiling in regards to support for public health expenses: it's always there, but it's not what you think of when you get sick. As the population ages, I think the next fool's gold will be some variation on home health care for the elderly. Evidence there is not good.
Posted by: Shangwen | May 31, 2011 at 12:58 PM
Shangwen: Another point that comes to mind is that many of the public health gains particularly with respect to mortality declines occurred prior to 1950 with the spread of immunization as well as clean water technologies. Cutler & Miller have an article in Demography (2005) "The role of Public Health Improvements in Health Advances: The Twentieth Century United States"in which they argue that half of total mortality decline in a number of major U.S. cities was the result of the adoption of chlorination and filtration. They estimate a social rate of return of 23 to 1 for these technologies. Would be interesting to see current social rates of return to the public health components of public health spending.
Posted by: Livio Di Matteo | May 31, 2011 at 01:20 PM
A large share of health care spending goes to salaries. I would look at how various governments have negotiated contracts with health care workers. In BC many doctors are earning the same as their American counterparts with favourable tax "treatments" to boot.
Posted by: jesse | May 31, 2011 at 01:24 PM
to echo Jesse's point, the way physician fees are negotiated in BC is absurd - the BCMA basically fights the government for a pot of money, then the physicians split into specialist and GP factions, hire consultants and fight each other for a while. When that is over the specialists split into factions, hire consultants and fight within themselves. By the time the specialists are done with their civil war, its time for the BCMA to ask for more money.
Missing from the negotiations is any sense of policy direction from the Government. It comes down to who can hire the best consultants to craft the most convincing argument. (though it usually goes to arbitration where a mediator inevitably ignores all arguments and splits the money in half).
Posted by: brendon | May 31, 2011 at 01:33 PM
Livio: thanks for the reference. I suspect that returns diminish as GDP advances over the generations. The places where you would expect to replicate huge returns like that would be in Africa and other developing nations, where there are big gains to be made in water, infectious diseases, health behavior, and child health. I don't know what current ROI for projects in OECD countries would be, but there aren't quite as many big projects to do either. But I think the main issue is that bike helmets in Toronto can't hold a candle to chlorine tablets in Zambia, when it comes to the size of impact.
Obesity is a real conundrum, since the term covers a wide range and the health impact still seems to be mediated heavily by education and income. Yet its prevalence is a function of an overall increase in wealth. Would it be better for us to see our ability to purchase excess calories erode through economic decline, making us thinner but poorer overall? I suspect not, but I think this is also why public health spending on obesity is often misguided. I work with a number of analysts in public health, and they do not seem to get the concept of trade-offs. Public health advocates are very open to rhetoric of perpetual improvement.
Jesse and Brendon: wage expenditures in public health are generally lower, and go towards much less expensive professionals. There's no eye surgery in public health. The cost-effectiveness problem is what proportion of resources will go into the costlier last-mile services like home visits from public health nurses (PHN). PHN services for moms with newborns are very popular, but because they are optional they are used overwhelmingly by the middle class. Yet the return from that kind of utilization is very low.
Posted by: Shangwen | May 31, 2011 at 02:50 PM
Fair point Shangwen. I was simply ranting about health expenditures. Interesting point too about the PHN newborn services. I didn't realize the uptake on that service was so poor in low-income households. (actually, I have three kids and I didn't even realize it was optional).
Posted by: brendon | May 31, 2011 at 03:10 PM
Here's a news article on fitness and income in the US that says a lot about the sources of increased health in a rich country.
"There are considerable correlations between fitness and several measures of economic development including average wages (.56) average income (.47) and economic output (gross metro product) per capita."
Posted by: Shangwen | May 31, 2011 at 03:14 PM
Shangwen's point is intuitive. Once the big, one-time gains are made in water purification, waste collection and sewerage, hygiene diseases go away statistically. It's a hurdle, not a line. Add in vaccination and you can see why we are at the same point in terms of public health we were in the late 1950's.
Knowing a bit about how our great-grandparents ate, diets back in the 1920's had a very high proportion of fat and sugar in what was served. Food intake was limited by income. It was fried, sauced, gravied and fruit was often packed in syrup.
Now we are in a situation where housing has overtaken food as the largest household expense and food is not income-limited to such an extent. But we still hang on to our fat-filled ways. Here I believe much change could come through tradeoffs into less fatty, salty food and generally fresher food. Less fat, more bread, etc.
Posted by: Determinant | May 31, 2011 at 03:34 PM
The problem with the government trying to "encourage" a healthier population is that it usually results in a greater incursion into personal freedoms and ever more commercial regulations. There are some cities where one is not allowed to smoke in public places, even outside.
Posted by: rabbit | May 31, 2011 at 04:10 PM
And the problem is? Seriously, I don't smoke, I don't like walking through someone else's smoke cloud, which I often have to do since smokers congregate outside the entrances to public buildings. Tobacco bothers my allergies and causes me to get nasal congestion. I appreciate not having as much smoke around.
Rabbit's experience is the logical outcome of what I call the McDonald's Effect. In the 1980's most McDonald's franchises in suburban settings were built to a standard pattern: Kitchen occupying the top left third of the rectangle, smokers out front with the nice windows in front of the tills, non-smokers in the alleyway going back to the washrooms. Then McDonald's reversed it's corporate policies and I got to sit out front where I always wanted to. Then the city passed a no smoking bylaw and smoking in restaurants was outlawed. It made fast food joints smell much better.
Rabbit's complaint is the end result of that trend. Besides, who is going to defend the Noxious Weed? :devilish grin:
Posted by: Determinant | May 31, 2011 at 05:01 PM
Determinant:
Smoking outside does not represent a threat to anyone's health except the smokers, who tend to keep a some distance between themselves and the front entrance (often regulated).
The readiness to limit other people's freedoms using the slightest pretense is a plague of modern society.
Posted by: rabbit | May 31, 2011 at 05:47 PM