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Trevor Hancock: What happened to an ounce of prevention?

The notion that an ounce of prevention is worth a pound of cure is an old adage. It is also a strategy proposed by the B.C.’s select standing committee on health a decade ago.

The notion that an ounce of prevention is worth a pound of cure is an old adage. It is also a strategy proposed by the B.C.’s select standing committee on health a decade ago.

The committee’s 2004 report noted that “one ounce is one-16th of a pound — or about six per cent [but] for decades we have been routinely investing in about half an ounce of prevention.”

The committee then recommended: “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.”

In 2006, the committee reaffirmed its earlier recommendation, noted that planned increases were “limited investments compared to the total health budget” and stated: “Additional resources must be provided to public health to ensure it plays a greater role in the prevention of disease and illness.” The current provincial government has signally failed to do, ignoring the advice of its own Liberal-dominated committee.

In a 2013 report, Health Funding Explained, the auditor general found that in 2011/12, B.C.’s health authorities received and spent $12.6 billion. Of that, a mere 4.2 per cent ($536 million) went to population health and wellness (PHW is the usual name for public health services these days), even though, as the auditor noted: “Prevention has been a major theme in recent throne speeches.”

Moreover, the proportion spent on PHW ranged from three per cent for Island Health, Fraser Health and Interior Health to four per cent in Vancouver Coastal and five per cent in Northern Health. Even more telling is the trend in expenditures.

The auditor general’s report revealed that the proportion of the budget allocated to population health and wellness actually declined in three of the five health authorities (Island Health, Interior Health and Northern Health) between 2008/09 and 2011/12.

Meanwhile, funding to acute care — where almost 60 per cent of health-authority funding goes — increased in all five regions, by as much as 21 per cent in Fraser Health (where PHW funding increased only four per cent). In Interior Health, while PHW funding declined as much as nine per cent, acute-care funding increased 15 per cent; in Island Health, it was a four per cent decline in population health and wellness and a 19 per cent increase in acute care. Only in Vancouver Coastal Health did they both increase equally.

No doubt the health authorities — especially those demonstrably giving low priority to prevention — will argue that public-health funding is difficult to track because staff have been re-assigned to new roles and new parts of the organization, and that they really spend more than three per cent.

But if that is the case, it represents another assault on public health. To separate public health nurses, community nutritionists, environmental health officers and other public-health staff from each other and from medical health officers is to undermine public health as a discipline and as a cohesive force for prevention and health improvement, and to make it less effective.

Regrettably, the Health Ministery’s attitude has been hands-off when it comes to the funding and integrity of public health, which is at odds with its professed commitment to prevention. It has not insisted — as it could and should — that the integrity of public health be maintained and that funding should not only be protected, but should increase at least at the same rate as acute care, and indeed more so, if prevention truly is a priority.

So what is to be done? I suggest that the government — both this one and the next one — commit to increase the share of funding to public health to at least six per cent. It could do so by increasing the health-care budget by 0.2 per cent annually for five years and requiring the health authorities to find an equivalent amount in savings and re-allocation.

It also needs to ensure that public health, far from being disassembled, be re-united and strengthened, where necessary.

We will never reduce the mounting costs of acute care without reducing the burden of disease, which is the work of public health (and many others beyond the health-care system). By allowing public health in the health authorities to be weakened, the government has sabotaged its supposed commitment to improving health and reducing costs, and failed in its duty to the people of B.C.

Dr. Trevor Hancock is a professor and senior scholar at the University of Victoria’s school of public health and social policy.