B.C.’s auditor general noted last week that “despite the fact that promoting healthy well-being and preventing disease has been a major theme in every throne speech since 2008,” the B.C. government and its health authorities spend little on prevention. He might also have pointed out that the Liberal-dominated Select Standing Committee on Health recommended in 2004 that “funding for public-health activities should gradually increase from about three per cent of total health expenditure per annum to at least six per cent per annum.” Currently, as he noted, it is at 4.25 per cent.
It is not just a matter of funding, however, important though that is. What has been missing is a full commitment to a comprehensive approach to health promotion and disease prevention, which involves much more than providing information and education. Prevention is one of the keys to creating a fiscally sustainable health-care system, because it can reduce the burden of disease the system has to manage. A serious commitment to a comprehensive approach would involve the following four elements.
First, recognizing that many of the most important determinants of health lie beyond health care, in other ministries and sectors of society. This calls for a “whole of government” approach such as was called for in a 2009 report from the Senate’s subcommittee on population health. The report called on the federal and provincial governments to establish a population health policy and a population health committee of cabinet chaired by the premier. Not one government has done so; B.C. could provide leadership.
Of critical importance here, and largely ignored by this government, is the need to address poverty. Quite aside from issues of fundamental justice and fairness and the loss of human potential, poverty adds an additional burden of disease that the health-care system then has to deal with. Our experience with homelessness has shown that it is cheaper to house people and provide supportive services than to leave them homeless and pick up the pieces. More broadly, poverty may now be so expensive, in human, social and economic terms, that we can no longer afford it. B.C. needs to join several other provinces in developing a poverty-reduction strategy.
In the second area — strengthening and renewing public-health services — B.C. has shown national leadership in developing a set of evidence-informed core public-health programs and a quality-improvement system. Despite the best efforts of former health minister Kevin Falcon to undermine this approach, it remains largely in place. What is needed now is an increase in funding (largely by re-allocation over time) to meet the standing committee’s target of six per cent of funding going to public health. This will provide the human and other resources needed, and must be accompanied by more direction to the health authorities to make this a priority.
The third strategic area is the clinical prevention services that people receive mainly through primary care. Here, too, B.C. has shown national leadership, identifying a set of priority preventive services and instituting a prevention fee for physicians. But here, too, the commitment is only partial, with some of the key recommendations in the report ignored. Missing is funding of a strategy to educate and train primary-care teams in enhancing prevention, integrating automated physician reminders and patient recalls into electronic medical records, and establishing the small office needed to maintain and improve these important preventive services.
The final strategic area is self-care. Self-care is often seen as involving the self-management of minor ailments and injuries, as well as chronic diseases. This is true, but it also involves keeping oneself and one’s family healthy and safe, and helping to create a healthier community. No province in Canada has developed a comprehensive self-care strategy, so this is another area where B.C. could show national leadership. To do so, it will also have to develop a health literacy strategy, since 60 per cent of Canadian adults have only level 1 or 2 health literacy, too low to make informed health choices and decisions.
It is perhaps too late for this government to adopt such a comprehensive approach to prevention, having already squandered many opportunities to do so, but let us hope the next B.C. government will take prevention seriously and make it a priority.
Dr. Trevor Hancock is professor and senior scholar in the School of Public Health and Social Policy at the University of Victoria.