AFB 2024: Health equity

Introduction

Health equity means that all people have fair access to, and can act on, opportunities to reach their full health potential. Health, from this perspective, is about collective physical, mental, and social well-being and not just sickness or its absence in individuals. Health equity means that people are not disadvantaged by social, economic, political, and environmental conditions, including how those conditions intersect with social identities based on factors such as ability, age, gender, race, sexuality, and social status.¹

Equitable access to high-quality, publicly funded and delivered, universal medical care is an essential component of health equity. Yet, it is insufficient. Who gets sick in the first place is strongly shaped by the conditions in which we are born, grow, live, work, and age; including the integrity of our natural environment. These social and ecological determinants of health are not distributed nor experienced equally, reflecting the inequitable distribution of power and resources that are built into our capitalist economic system.² In short, equity and health equity are one and the same.

Health equity demands a bold, coherent, public-driven vision that extends beyond medical and health care, transcends government silos, and maintains a critical stance that views health inequities as ethically indefensible and that speaks truth to the power structures that perpetuate them.³ Here we focus on the role of the federal government in that vision.

Overview

The COVID-19 pandemic made very clear the imperative of the social determinants of health.⁴ Yet, while “health” appears over 180 times in the 2023 federal budget, it overwhelmingly refers to the health care system and it disproportionately pertains to physical aspects of health, which is incomplete. The single reference to “health equity” is in the context of an Indigenous-specific funding stream to enhance equitable access to quality and culturally safe health care services.⁵ While this is an important investment, it is incremental with respect to the health equity implications of ongoing colonial structures and other intersecting systems of oppression, such as classism, racism, and sexism.

The past year has seen massive federal investments in health care. In February 2023, an additional 10-year, $46.2 billion funding deal between the federal and provincial/territorial governments was announced. This is intended to relieve strain on emergency rooms, paediatric hospitals, surgical wait times, and health care workers.⁶ Yet the federal government only attached funding conditions to 58 per cent of the new money, raising questions about the extent to which it will be directed to a public-driven vision of improving medical care quality and equitable access for all Canadians.⁷

Stemming from the 2022 supply and confidence agreement between the federal Liberal and New Democratic parties, budget 2023 included a large investment in dental care ($13 billion over five years, starting in 2023-24, plus $4.4 billion ongoing). This historic funding is described as allowing millions of Canadians to access dental care who previously could not and it helps to redress the omission of dental care from our public health care system.⁸ However, and although the new program is still evolving, it appears that it will be a publicly funded initiative, with delivery remaining mostly in the private sector. It is based on a means tested rather than universal model. To the extent that the new plan does not restructure the private, for-profit elements of dental care, we must remain concerned about ongoing inequities.

Weak investment in social and ecological determinants of health perpetuates a downstream orientation

Recent federal budgets have included investments in social determinants of health, such as the Canada-wide early learning and child care system. This initiative signifies an important commitment to early child development, gender equity, and a robust care economy—all of which significantly contribute to population well-being and health equity.⁹

But this investment, and indeed investment in social determinants of health in general, continues to be dwarfed by health care spending, which is inconsistent with the significance of social determinants for population health and health equity.¹⁰ A mechanism is needed to rebalance budgets so that they align with what is known about the social and ecological determinants of population well-being and health equity, which largely lie outside of the health care system.

Budget 2023 was weak with respect to social and ecological determinants of well-being and health equity.¹¹ For example, it was remarkably silent on affordable housing, where it continued to focus on tax-free savings mechanisms for home buyers with no substantive attention to regulations to protect tenant families nor to address the problem of financialization and profiteering, which drive growing housing insecurity. As well, while budget 2023 included a large investment ($80 billion) in a transition to a lower-carbon economy, much of those funds take the form of a tax break to incentivize private investment. What is needed, in line with a mission-oriented approach,¹² is a bold, public led vision to protect and respect our natural environment in a way that promotes environmental justice¹³ and ensures that no one is left behind in terms of the social foundations that people need to be well.¹⁴

A bold, cross-cutting vision for population well-being and health equity

The weaknesses of budget 2023 in addressing upstream causes of health inequities reflect the lack of a bold, coherent, cross-cutting vision to guide budgeting and policy so that (health) equity is at the centre. A potential such vision exists, in the form of Canada’s Quality of Life framework.

First announced in budget 2021, the framework explicitly recognizes the significant drawbacks of relying on blunt economic measures of societal success such as Gross Domestic Product (GDP). Those drawbacks include widening inequities and ecological destruction (i.e., social and ecological determinants of health). The Quality of Life framework includes five domains deemed important to quality of life—prosperity, health, environment, society, and good governance—with cross-cutting lenses: fairness and inclusion, and sustainability.¹⁵

While the framework has been applied to three federal budgets (2021, 2022, 2023) in the form of an impact statement, and investments have been made to support data and measurement, so far it is not guiding budgeting and policy in a way that meaningfully addresses (health) inequity and its root causes in structures of capitalism, colonialism, white supremacy, and patriarchy.

Drawing from budget 2023, one good illustration is the grocery rebate intended as a form of “targeted inflation relief.” An alternative, which would be more consistent with the vision offered by the Quality of Life framework, would be to make permanent the important income supports from the COVID-19 pandemic, which were shown to reduce poverty rates and empower communities,¹⁶ coupled with stronger regulation of large grocery chains that set food prices in the first place and are profiting from inflation.¹⁷

Actions

Underpinned by a health equity perspective, including its social justice values, critical orientation, and scholarly evidence base, the AFB will implement the following actions:

The AFB will advance progressive, publicly led, equity-oriented policy in all domains of social and ecological determinants of health (see Affordable housing and homelessness; Agriculture; Arts and culture; Child care; Decent work; Employment Insurance; Environment and climate change; Fair and equitable transition; First Nations; Food security; Gender equality; Health care; Health equity; Immigration; Income and poverty; Infrastructure, cities and transit; International development; International trade and investment; Post-secondary education; Prisons; Public services; Racial equality; Regulation; Seniors’ care; and Taxation chapters).

The AFB will work to strengthen the visibility and impact of the federal Quality of Life initiative and framework as follows: The AFB will commit $3 million per year to support independent, advocacy-oriented NGOs to play a watchdog role with respect to tracking the Quality of Life initiative and reinforcing accountability to its stated commitment to fairness and sustainability.

The AFB will commit $3 million per year to CIHR and SSHRC to fund joint, critically oriented, interdisciplinary, and academic-community partnered research to support the evaluation and implementation of the Quality of Life framework; and to consider legislative mechanisms, including those from other jurisdictions (e.g., the Sustainability of Future Generations legislation and corresponding Commissioner in Wales, UK).

The AFB will commit $3 million per year to place academic researchers with expertise in health equity and the political economy of health, coupled with members of communities most negatively affected by our current extractive and exploitative systems, within the federal government to study and make recommendations concerning interdepartmental mechanisms, processes, and activities through the lenses of policy incoherence and failure-demand (i.e., our tendency to direct public spending towards reacting to immediate, avoidable problems, rather than promoting the well-being of all people and the planet).¹⁸

The AFB will commit $2 million per year to create and sustain a citizens’ assembly focused on narrative change—shifting the dominant narrative around the role of government away from incrementalism and risk management. Instead, it will look towards strong government leadership with a bold, publicly led and equity-centred vision for an economy and a society that works for everyone (i.e., a “third way,” which moves beyond the false dichotomy of capitalism or socialism).

The AFB will commit $1.5 million to create a cross-ministerial committee in the federal government that is tasked with narrative change within government, to work with the citizens’ assembly noted above.

Towards advancing a much more holistic, upstream, and collective version of health, the AFB will work to strengthen and re-orient key federal legislative and funding mechanisms as follows:

The AFB will commit $5 million in 2024, plus $10 million annually starting in 2025, to fund an independent, high-profile commission with a strong public mandate to review and substantially revise the Canada Health Transfer so that it strongly and explicitly steps outside of the health care system to embrace social and ecological determinants of health and align with the social justice values and critical upstream orientation of a health equity stance. Some key considerations include:

• Leadership by communities most negatively affected by our current extractive and exploitative systems, whose work must be resourced in an ongoing manner at a level that is adequate to the task.
• Anchor the process in a holistic and collective vision of health that is based on an ethic of care and reciprocity and that goes far beyond the (misnamed) “health” sector, with legislation and budgeting to match.
• For example, affordable housing and protected ecosystems would be recognized as imperative to population well-being and health equity and would be legislated and resourced accordingly within the new “health” transfer.
• Carve out health (medical) care as one part of the new “health” transfer, and identify mechanisms to prevent ‘failure demand’ where spending on health care overwhelms spending on other policy domains that are more important to keeping all people healthy in the first place.
• One example is the ratio of social and education spending relative to medical spending (the SE/M ratio), which provides a way to track progress in annual budgets towards spending on the building blocks for a healthy society, such as decent earnings, homes, child care, and a healthy environment (see also Health Care chapter).
• Another example is mandating a “health equity analysis”¹⁹ for Memoranda to Cabinet, with explicit attention to identifying horizontal policy initiatives (where two or more departments work together to achieve objectives) and a corresponding accountability framework, built in.
• Revive the universalism of the post-WWII Keynesian period, which has been significantly eroded, and the strong but neglected principles (rights-based, public, comprehensive) that underpin the current Canada Health Act but do so in a way that meaningfully integrates the significant and more recent knowledge of equity (as distinct from equality) and its roots in intersecting structures of capitalism, colonialism, white supremacy, and patriarchy.
• Contend with the complexities of Canadian federalism and the imperative of equal and meaningful relations with Indigenous forms of governance.
• Connect with, and draw inspiration from the growing momentum around a well-being economy and its heterodox or progressive economics underpinnings, both internationally²⁰ and in Canada.²¹
• Engage the broader public and all progressive political parties (not just the sitting government) in a large-scale decoupling of health from medical care, which is required to support a bold, coherent, upstream, and public vision of well-being for all people and our planet.