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Healthy public policy requires working within and beyond the health care system

Population health metrics are about more than just health care—they're about the society we live in.

Medical health officers in B.C. are mandated by the B.C. Public Health Act to monitor the health of the population and provide advice to governments, health boards, and the public on public health matters.

This requires looking outward, to acknowledge the needs of the diverse populations within the region, and upstream, to the modifiable factors that influence the conditions in which people live and that ultimately shape their health.

Underpinning this approach is the understanding that socioeconomic factors—such as income and employment status and the strength of social supports, along with access to education, safe housing, greenspace, and affordable early learning and care—have the greatest influence on a population’s health.

Many of these factors lie beyond the control of the health care system, yet they create pressing health issues that the system is tasked with addressing. Solutions involve institutions within and beyond the health care sector.

That’s where the Vancouver Coastal Health (VCH) comes in. The Office of the Chief Medical Health Officer established the Healthy Public Policy Unit (HPPU) in 2022 to promote health through a comprehensive, healthy public policy approach. The HPPU collaborates with other VCH public health teams to advocate for policies that could improve the social and economic influences on health.

Policies that influence the population’s health fall within the mandates of multiple government ministries. Healthy public policy requires collaborative action on issues outside of traditional areas of involvement, which is challenging, given different priorities, constraints, and discrete budgets. In addition, publicly funded organizations face budget and accountability challenges if they are not able to attribute outcomes to a specific policy change.

Such silos are difficult to break, and cross-sector alliances require significant investments of time, resources, and expertise. The HPPU responds to these challenges by working alongside public health colleagues in a three-pronged approach to advance healthy public policies in, and well beyond, the health care system. Because the HPPU is not a policy-making entity, it must facilitate, rather than implement, policy change.

The team focuses first on building and fostering relationships within the health care system, and with governments, organizations and leaders to identify common goals and community priorities, mobilize knowledge, and focus on collaborative efforts.

Second, the HPPU draws on VCH’s public health expertise to contextualize local population data, highlight inequities, and identify trends. The team identifies windows in which to advocate for policy change or contribute to the development of evidence-informed policy options.

Thirdly, since the HPPU approach recognizes that policy change involves many parties, the team works with public health colleagues to track the contributions of different players, monitor incremental changes over time, and identify links between population health outcomes and policy changes. This involves sharing information between sectors, which further contributes to shared advocacy and public health goals.

Poverty is one of the most important factors driving poor health outcomes and health inequities in the VCH region and elsewhere in B.C. For example, 2022 data from the Office of the Provincial Health Officer show that life expectancy in the VCH region ranges from 70.5 years for populations in the lowest income quintile to 88.8 years for those in the highest income quintile.

Social indicator data from Statistics Canada in 2021 also point to avoidable differences between populations by income quintile, in educational attainment, income, unemployment rates, and proportion of household income spent on shelter in the region.

Poverty impacts health by affecting people’s access to housing, quality child care, educational opportunities, and their capacity to adapt to a changing climate. Experiences of poverty also increase people's risk of chronic disease, stress, and mental health issues, but investing in the health care system alone will not address the underlying factors that are causing these problems.

As B.C. faces deepening societal challenges related to housing, increasing income inequality, and more frequent climate events, poverty and other root causes of ill health must be addressed.

Progress on these systemic issues requires support for policies that effectively reduce poverty as well as increase social sector funding (i.e., child care, housing, education) by all levels of government.

There are strong justifications for people within the health care system to get involved in creating public policies that foster health-promoting environments for everyone—even when the policy levers exist outside of the health care system.

For example, the HPPU supports strategic investments in early childhood environments, acknowledging their significant influence on future health. Approximately one-third of B.C. kindergarten children are considered developmentally vulnerable and those who experience poverty are more likely to be vulnerable.

Poverty influences children’s environments, experiences, and social support networks, but quality, affordable child care can reduce and mitigate poverty and its health impacts. The health care system already supports mothers and children with prevention and support programs. The HPPU encourages further investments in a universal child care system that promotes inclusive and flexible care models, equitable compensation for early childhood educators, and more quality child care spaces.

The HPPU also focuses on equitable and climate-resilient communities that better protect people during extreme heat events.

Poverty presents a greater risk of heat-related illness or death than any chronic health condition. Low-income populations were more impacted during the 2021 B.C. heat dome because of substandard housing, lack of social supports, and fewer resources.

Public health programs support heat-susceptible individuals and municipalities to prepare for heat events and help community organizations to respond. Healthy public policy approaches support the development and adoption of public policies that protect people from extreme heat in residential buildings—especially in affordable rental buildings—in ways that do not increase their risk for housing insecurity.

These examples illustrate potential pathways for health care sector engagement in public policy and highlight the importance of working beyond the walls of the traditional health care system. They also emphasize the importance of re-defining health as much more than what can be addressed by health care services alone by placing equal value on the factors that influence health.

The continued expansion of a healthy public policy approach by institutions situated both within and beyond the health care system is critical, as are the collaborative relationships that underpin its success.

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