A comparison of health equity policy in Alberta and British Columbia

Today’s blog post is a collaborative piece written by Lisa and Danielle. You can find the article on Lisa’s and Danielle’s blogs.

“Health equity exists when all people can reach their full health potential and are not disadvantaged from attaining it because of their race, ethnicity, religion, gender, age, social class, socioeconomic status, sexual orientation or other socially determined circumstance” (BC Centre for Disease Control, 2019). Since the release of the Lalonde Report in 1974 and the Ottawa Charter for Health Promotion in 1986, Canada is seen as a global leader in health equity policy development (Lucyk & McLaren, 2017). The delivery of Canadian health equity programs may be funded nationally, but the work is mostly driven by provincial policy and guiding documents. In today’s post we compare the health equity policies of Alberta and British Columbia, noting their similarities, differences and unique features.

Alberta’s Priority Health Determinants

Alberta has the notorious reputation of having the highest income inequality in all of Canada, and has had this reputation for decades (McRae, 2017). Most notably, the top 1% of earners in Calgary earn 62x more than the poorest 10% in the city. In 2005, Calgary Region’s Medical Officer of Health sounded the alarm in a precedent-setting report showing a distinct gradient of health, with health improving as income increased for Albertans (National Collaborating Centre for Determinants of Health, 2013). When Alberta Health Services (AHS) came into existence in 2008, the Promoting Health Equity Team was established. AHS has since made health equity one of the organization’s strategic priorities, specifically addressing the social and economic determinants of health.

Guiding Documents in Alberta

With a focus on the social and economic determinants of health, particularly income, education, and occupation, AHS released the Promoting Health Equity Framework in 2013. This framework is a long-term action plan for the organization, with a goal to “reduce inequalities in population level health outcomes” (AHS, 2013).  The foundational concepts used to inform the framework are as follows: health is a resource for everyday living, social justice, nothing about us without us, accountability, social gradient in health, universal and targeted approaches. The framework makes clear that multisectoral work is necessary to address the social and economic determinants of health and that AHS has a leadership role in this collaborative process (AHS, 2013). The framework specifies that AHS work with media, the volunteer sector, communities, and all levels of government to tackle health inequities in Alberta.

The AHS Senior Leadership Team are champions of this goal, encouraging all levels of the AHS team to address program planning and policy development through the lens of health equity. To support this mission, the Healthy Public Policy Unit released a health equity impact assessment process in early 2019, including a step-by-step workbook and guide to conduct such assessments by AHS staff. Although the workbook and guide are not publicly released, the unit describes health equity impact assessments in their publicly-released situational analysis (AHS, 2017).

The Alberta Social Policy Framework is another long-term action-plan for use by Albertans (Government of Alberta, 2013). This framework is broader in scope, addressing six distinct outcomes: health, safety, lifelong learning, security and resiliency, inclusiveness, and engagement. In terms of health, the goal is for all Albertans to achieve the highest attainable standards of health and well-being by reducing inequality, protecting vulnerable people, creating a person-centered system, and enabling collaboration and partnerships. This framework goes so far as to suggest the roles and responsibilities of all stakeholders and the strategic directions these stakeholders should follow over the next 10-15 years.

Together, these frameworks have been used to generate unique, upstream approaches to address the social and economic determinants of health in Alberta. The latest example is the Healthy Communities Approach, a pilot initiative lead by Alberta Health Services with national and provincial partners. Part of the initiative is the 2019 release of the online Healthy Communities Hub, a resource that communities can use to find relevant data, learning material, and specific strategies for building healthier neighbourhoods. With so much action within the last year (AHS health equity impact assessment tools, Healthy Communities Hub), Alberta is honouring their commitment to addressing the population-level determinants of health.

British Columbia’s Priority Health Determinants

The health that British Columbians experience is amongst the best in the world and part of this is due to the excellent health care system that exists. However, not all British Columbians have a high level of health, therefore differences can be seen in various groups of people. It is alarming to know that if you live in certain parts of British Columbia (BC) that you can expect to live 10 years less (BC Center for Disease Control, 2019). When the new NDP government came into power in July 2017 there was a promise of working towards fixing the health services that British Columbians rely on. The importance of such a platform was crucial in helping areas that had historically seen a lack of investment in healthcare. However, in order for this to be achieved the government would have to balance all of the health determinants, as it would be somewhat pointless to improve one health determinant at the cost of another health determinant falling by the wayside (Longhurst, 2017). The health services of BC are delivered by five regional health authorities and a sixth health authority that is responsible for delivering province wide programs and/or services (Auditor General of British Columbia, 2019).

BC’s Guiding Framework for Public Health

BC public health is built on a foundation comprising of the Public Health Act and strategies targeted to specific areas. The Guiding Framework for Public Health in BC is built upon the goals of the Ministry of Health. This Framework has the vision of  “vibrant communities in which all people achieve their best health and well-being where they live, work, learn and play,” (BC Ministry of Health, 2017, p. 7), while their mission is to “promote, improve and protect the health and well-being of British Columbians through leadership, partnership, innovation and action” (BC Ministry of Health, 2017, p. 7). Looking further into the BC framework we learn that the goals are: “1) creating a long-term vision for the public health system, which incorporates all pre-existing major public health strategies 2) formalizing a collaborative process to identify future public health priorities 3) reinforcing core public health functions as the foundation for public health services 4) supporting a population health approach and the public health role in health equity 5) connecting to and supporting self care, primary care, and clinical prevention” (BC Ministry of Health, 2017, p. 4).

There are three types of public health functions within this framework: core programs, public health strategies and provincial-level functions and infrastructure. In order for these functions to be achieved, partnerships with all levels of government and non-governmental organizations are imperative for implementing programs. Delving deeper into the BC framework we see that there are seven visionary goals: “1) healthy living and healthy communities 2) maternal, child and family health 3) positive mental health and prevention of substance harms 4) communicable disease prevention 5) injury prevention 6) environmental health 7) public health emergency management” (BC Ministry of Health, 2017, p.17). In order for these visionary goals to be improved upon the monitoring of trends and emerging themes through health surveillance is vital. Similarly, performance measures are in place to help determine if goals are being met. Perhaps of the utmost importance is that future public health priorities are identified in order to help move the health of BC residents forward, and this framework allows for this to occur.

BC Healthy Living Alliance

This alliance is a collection of organizations that work together to promote and further develop the health of British Columbians. More specifically they work on promoting health policies, programs and the development of environments that foster the well-being of individuals. Their main goals are to continue to build the relationships among alliance members and to work on chronic disease prevention and healthy living (BC Alliance for Healthy Living, 2019). In a document published in 2009 aimed at outlining recommendations to improve the health of British Columbians, they state that the health determinants of BC are defined as “access to income, affordable housing, healthy food, education, early childhood development, and recreational opportunities influence our ability to make healthy choices and ultimately the state of our physical and mental health as well as life expectancy.” (BC Healthy Living Alliance, 2009, p. 2). They noted that “British Columbia is a Canadian leader in health promotion and disease prevention and has the lowest rates of smoking and obesity and the highest rates of physical activity of any Canadian province.” (BC Healthy Living Alliance, 2009, p. 1). While this is a positive for the province of BC, it is important to note that there are still areas the require improvement. Certain populations or groups of people within BC seem to have poorer outcomes compared to others, for example Aboriginal people, those in lower income brackets and individuals that live in rural areas. The document goes on to further stratify these disadvantages and states that “there is significant evidence confirming that health inequities in BC are most pronounced among children and families living in poverty, the working poor, the unemployed/underemployed; those with limited education and/or low literacy, Aboriginal Peoples, new immigrants, persons suffering from social exclusion, the homeless and people with addictions and/or mental illness” (BC Healthy Living Alliance, 2009, p.4). It is these types of disadvantages that the alliance tries to help develop policy for so that all British Columbians have an equal opportunity and chance to be as healthy as possible.

Areas of Environmental Public Health Impacted by the Social Determinants of Health

To examine health determinants in BC from a different perspective, the Environmental Health Services BC Centre for Disease Control published a document looking at how environmental public health is impacted by the health determinants of BC. One of the health determinants for BC is healthy food, when we look at this from an environmental standpoint many barriers can be identified. For example, Rideout (2015) states that if a food related business has a cash flow issue then they are less likely to repair machines or provide appropriate food safety training to staff. Similarly, if there is a repair required in a remote area this may take longer to be remedied than in an urban area and remote areas may live mainly off of locally sourced food or it may be difficult to have food transported to certain areas. Taken together all of these things impact the ability for someone in BC to obtain healthy food, it is not as simple as driving/walking to your local grocery store to pick up a bag of apples in all of BC, therefore it is important to remember there are many items that must be properly managed in order for one health determinant to be met.

Similarities Between Alberta and British Columbia

When comparing the health determinants between Alberta and British Columbia it is easy to draw similarities between the two neighboring provinces. First, both provinces rely on frameworks in order to guide them and improve health determinants of its citizens. The goals and targets of these frameworks are both acted upon by secondary groups - in Alberta it is AHS and in BC it is the BC Healthy Living Alliance. In both provinces one of the main aims is to reduce inequalities in health throughout the population. It is believed that all levels of government must be involved in order for inequalities to be reduced and that this can be achieved through program planning and policy development. Therefore, it can be seen that both provinces have a similar approach in dealing with and aiming to improve the health determinants of residents in their respective provinces. To further cement this similarity, it is interesting to note that the goal in Alberta is to achieve the “highest attainable standards of health and well-being” (Government of Alberta, 2013), while in British Columbia the goal is to “achieve their best health and well-being” (BC Ministry of Health, 2017, p. 7). From these goals it is easy to see that both provinces are working towards the same ultimate goal - the best possible health for each and every individual.

Differences Between Alberta and British Columbia

In both Alberta and British Columbia, health equity policy includes a large list of determinants of health. However, the priority determinants of each province are understandably different. With the highest income inequality in Canada, Alberta has recognized the social and economic determinants of health as needing the most action at this time. Low-income families are the target population of many health equity initiatives across the province. In British Columbia, people living in rural and remote locations are seen to be the most vulnerable to poor health outcomes such as shorter life expectancy. The environmental determinants of health, in particular the effects of rural and remote living, are considered priority health determinants for many health inequity initiatives in BC.  A second difference between the two provinces is how health equity programs are implemented. Alberta has created a single health authority, known as Alberta Health Services, to organize the delivery of health services. AHS is responsible for both the development of provincial policy and the delivery of health equity programs throughout the province. In British Columbia there are 5 regional health authorities responsible for delivering health services to residents within their region. The BC Healthy Living Alliance is therefore a necessary organization to develop and promote health policy on a provincial scale.

Summary

Health inequity is a challenge facing all Canadian provinces. How health equity is addressed in each province depends largely on which determinants of health are seen as the most in need of addressing. In Alberta, AHS has focused its efforts on addressing the social and economic determinants of health, most notably education, employment, and income. In British Columbia, much work is being done to support residents living in rural and remote locations of the province. It is important to note that the determinants of health do not operate in isolation. Rather, complex interactions between the various determinants of health impact the health status of an individual. For example, a family living in a remote location may also be experiencing poverty, underemployment, and lack of local health services. While identifying priority health determinants is important for shaping health equity policy, the interactions of all health determinants must be considered and addressed to maximize impact.

References

Alberta Health Services. (2013).  Promoting health equity framework. Calgary, AB: Alberta Health Services.

Alberta Health Services. (2017). Health Equity Impact Assessment Situational and Resource Analysis. Retrieved from https://www.albertahealthservices.ca/assets/healthinfo/poph/hi-poph-surv-shsa-heia-situational-analysis.pdf

Alberta Healthy Communities Hub. (2019). Building healthy communities together. Retreived from https://albertahealthycommunities.healthiertogether.ca/

Auditor General of British Columbia. (2019). Health Authority: Overview. Retrieved from: https://www.bcauditor.com/online/pubs/775/782

BC Center for Disease Control. (2019). Health Equity. Retrieved from http://www.bccdc.ca/health-info/prevention-public-health/health-equity

BC Healthy Living Alliance (September, 2019). Healthy Futures for BC Families Policy Recommendations for Improving the Health of British Columbians. Retrieved from https://www.bchealthyliving.ca/wp-content/uploads/2014/07/BCHLA_Healthy_Futures_Final_Web.pdf

BC Healthy Living Alliance. (2019). Working Together, What we do. Retrieved from https://www.bchealthyliving.ca/healthy-living/health-inequities/

BC Ministry of Health. (2017). BC’s Guiding Framework for Public Health. Retrieved from https://www.health.gov.bc.ca/library/publications/year/2017/BC-guiding-framework-for-public-health-2017-update.pdf

Government of Alberta. (2013). Alberta’s social policy framework. Retrieved from https://open.alberta.ca/publications/6214203#summary

Longhurst, A. (2017). Three Healthcare Priorities for a New Government. Retrieved fromhttps://www.policynote.ca/three-health-care-priorities-for-a-new-government/

Lucyk, K., &  McLaren, L., (2017). Taking stock of the social determinants of health: A scoping review. PLoS ONE, 12(5). https://doi.org/10.1371/journal.pone.0177306

McRae, R.G. (2017, September 21). A rising tide doesn’t lift all boats: What Census 2016 reveals about income inequality in Alberta [Web log post]. Retrieved from https://www.parklandinstitute.ca/a_rising_tide_doesnt_lift_all_boats

National Collaborating Centre for Determinants of Health. (2013). Leadership for health equity: Alberta Health Services - Establishing a province-wide social determinants of health and health equity approach. Retrieved from http://nccdh.ca/images/uploads/Alberta_Health_Services_Case_Study_Final_En.pdf

Rideout, K. (2015) Areas of EPH Practice Impacted by the Social Determinants of Health. Retrieved from http://www.bccdc.ca/resource-gallery/Documents/Educational%20Materials/EH/BCCDC_primer_2.pdf