The Government of Canada (2018) defines the determinants of health as the broad range of personal, social, economic and environmental factors that determine individual and population health. The government identifies eleven (11) main determinants of health including 1) income and social status , 2) Employment/working conditions, 3) Education and literacy, 4) Childhood experiences, 5) Physical environments, 6) Social supports and coping skills, 7) Healthy behaviours , 8) Access to health services, 9) Biology and genetic endowment , 10) Gender and 11) Culture.
A number of others sources have similar definitions and at times, there are additional social determinants listed. For example Mikkonen & Raphael (2010) list fourteen social determinants of health. The additional three appear to be aboriginal status, disability and unemployment and job security as a separate area from employment.
However, no matter the description used or the number listed the overall key message remained consistent. There are many factors that come together to impact a person’s health (WHO, 2018) and these social determinants of health affect people in different ways and are intricately woven together (Lovell & Bibby, 2018).
When reading the Canadian Facts, it was interesting to note that Mikkonen and Raphael (2010) were very definitive with an assertion that income was one of the most impactful social determinants. Mikkonen and Raphael (2010) stated “Income is perhaps the most important social determinant of health. Level of income shapes overall living conditions, affects psychological functioning, and influences health-related behaviours such as quality of diet, extent of physical activity, tobacco use, and excessive alcohol use. In Canada, income determines the quality of other social determinants of health such as food security, housing, and other basic prerequisites of health (p13).”
As I reflected on my personal experience in health care, I could easily think of examples where income was impacting health and on the ability to access care. There are broad implications; however, I will focus my remaining comments on the impacts on accessing health care.
Mikkonen & Raphael (2010) remind us that the Canadian Health Act requires provinces to provide all “medically necessary” services at a universal level (p. 39), which mainly applies to hospital and physician services. However, many of us know that how health care is enacted by the provinces is variable (Mikkonen & Raphael, 2010, p.39). Despite the fact that we have publicly funded health care, there are private pay options and/or requirements for some services and/or supports. Some of these costs are covered in the form of private insurance and some are direct costs and/or user fees or co-payments covered by the individual. Williamson et al (2006) highlights that provincial health care plans have limited or variable coverage of services (p108). These unfunded costs can then present a barrier to accessing health services. This presents a challenge for the health system and for health care providers to offer equitable access to care.
Canadian Medical Association (2013) reports that low income Canadians are 10 times more likely to report unmet needs of health care (p 5). The main reason for the unmet needs relates to the inability to pay for services not covered by provincial health plans (CMA, 2013, p.5).
With the increased understanding of the social determinants of health, there has been an intentional focus over the past number of years to ensure health care providers consider these determinants when planning and delivering services. In Ontario, with the introduction of the Excellent Care for All Act in 2010, there were clear requirements to strengthen the focus and accountability for delivering high quality patient care (MOHLTC, 2016). This legislation introduced Health Quality Ontario in the role as provincial advisor on the quality of health care. On an annual basis, health care providers are required to submit Quality Improvements Plans that respond to six dimensions of quality: safe, effective, patient-centered, timely, efficient and equitable (HQO, 2018). Health providers are required to provide a specific response related to the population and health care equity.
To support the understanding and implementation of equity the province of Ontario, introduced the Health Equity Impact Assessment (HEIA) tool for use when planning programs and services (MOHLTC, 2013). HEIA is a decision support tool which leads users through the steps of identifying how a program, policy or similar initiative will impact population groups in different ways (MOHLTC, 2013).
All of these actions are steps in the right direction. However, there will need to be a continued and expanded effort. We need to continue to increase our understanding of the determinants of health, the impacts on population health and implications for the health care system. In addition this is not just a focus for the health care system. There is work to be done across programs, sectors and ministries to develop a comprehensive plan that will improve the socio-economic determinants of health (Williamson et al, 2006, p 119). A comprehensive approach would provide hope for a future of improved population health among Canadians.
References
Canadian Medical Association (2013) Ensuring Equitable Access for Care. Retrieved from: https://www.cma.ca/Assets/assets-library/document/en/advocacy/PD14-04-e.pdf
Government of Canada. (2018, May 22). Social determinants of health and health inequalities. Retrieved May 31, 2018, from https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health.html
HQO (2018) Health Quality Ontario’s Health Equity Plan Retrieved from: http://www.hqontario.ca/Portals/0/documents/health-quality/Health_Equity_Plan_Report_En.pdf
Lovell, N., & Bibby, J. (2018) What makes us healthy: An Introduction to social determinants of health. London, UK: The Health Foundation Retrieved from https://www.health.org.uk/sites/health/files/What-makes-us-healthy-quick-guide.pdf
Mikkonen, J., & Raphael, D. (2010). Social Determinants of Health: The Canadian Facts. Toronto: York University School of Health Policy and Management. The publication is available at http://www.thecanadianfacts.org/
Ontario MOHLTC (2016) Excellent Care for All: Legislation, Regulations and Policy Retrieved from: http://www.health.gov.on.ca/en/pro/programs/ecfa/legislation/
Ontario MOHLTC (2013) Health Equity Impact Assessment Retrieved from: http://www.health.gov.on.ca/en/pro/programs/heia/
Williamson, D. , Stewart, M. , Hayward, K., Letourneau, N. , Makwarimba, E. , Masudab, J., Raine, K., Reutter, L., Rootmang, I., & Wilson, D. (2005) Low-income Canadians’ experiences with health-related services: Implications for health care reform Health Policy , Volume 76 , Issue 1 , 106 – 121 Retrieved from: http://homelesshub.ca/sites/default/files/LOW-IN~1.pdf
World Health Organization (2018) Health Impact Assessment: The determinants of health Retrieved from: http://www.who.int/hia/evidence/doh/en/