Introduction
Structure of health care delivery and operations: challenges for food
How can food have a positive impact on health care?
Strategies for integration
Efficiency
Substitution
Redesign
Financing the transition
Introduction
Food companies provide food with little regard for health. Health practitioners provide health care with little regard for food. (quote inspired by Wendell Berry, 1983)
Canada has not organized its health care system, in particular primary care, to reflect the evidence connecting diet and health. Many chronic diseases and conditions, including cardiovascular disease, hypertension and stress, cancer, diabetes, low birth weight infants (and associated problems), anaemia, and some infections in children are strongly related to nutrition. Other diseases may have a significant food system- related dimension, but the evidence is less definitive:
- Stress and compromised immune system
- Hormone disruption
- Creation or acceleration of cancers
- Inadequate micronutrient intakes and associated diseases
- Inactivity (related to food access and urban design)
- Anti-biotic resistant bacteria and difficult to treat human disease
- Allergies
- New bacterial disease organisms
We’re all paying for the consequences of each other’s food choices because we pay through taxes and charges for publicly-funded health insurance. That reality provides governments with a rationale for significant interventions in the food and health systems.
The absence of health care design features linking diet, health, and primary care is compounded by Canada’s deficient primary care performance relative to many other industrial nations (Glazier, 2012). The costs of primary care are high relative to the quality of delivery and healthcare outcomes, with other parts of the healthcare system stretched because of primary care deficiencies (e.g., Emergency Departments of hospitals). “Healthcare costs are rising so fast in advanced economies that they will become unaffordable by mid-century without reforms” (OECD, 2015). Efforts to integrate health promotion and disease prevention in primary care, rather than just curative treatment, have not historically been very successful, and consequently, using food as a health promotion strategy is similarly compromised (Nutting, 1986).
The dominant approach is deeply cultural and legislative. Health promotion is not valued by the dominant health system. The federal government never implemented phase II of the Douglas proposals to design a community-based health promotion system to complement publicly–funded health insurance. The supply of services, primarily those of doctors and hospitals, drives demand for health care. Consequently, when people are healthier, the perverse incentives of the system cause service providers to look for new patients. Physicians are the primary gatekeepers of patient care. The state negotiates with doctor associations to govern the system. A significant inequality exists between rural and urban services. Physicians do not behave as if food access has a significant impact on health.
Yet, primary care still represents an opportune place for food as health promotion. Providing a foothold for augmenting the role, primary care has traditionally focused on some of the more limited dimensions of disease prevention and health promotion: immunization, screening, basic risk assessments, one-on-one health behaviour education, and counseling. In contrast, the hospital sector is more designed for acute care, and long-term and palliative care are not, by definition, about prevention.
Considering new approaches is timely because a primary care reform agenda is being implemented in many provinces. The traditional physician fee-for-service model is less popular and new approaches that blend capitation, fee-for-service and salary are being explored. Increasingly, physicians are organized in teams and groups, with new types of incentives, and patients enrolled specifically with that team. Some groups involve a range of health care professionals, many of whom have stronger training in health promotion than doctors. Within an efficiency and substitution transition approach, are there significant opportunities to advance food as health promotion within primary care?
Structure of health care delivery and operations: challenges for food
The Canada Health Act is the overarching federal legislation [1]. But health has been seen for some time as a federal provincial/territorial partnership, with some aspects delivered by the municipalities, particularly public health.
".... at the time of Confederation, however, health care was not considered a matter of national importance but was seen primarily as an issue of private or local interest. In the event of illness, most people were dependent on their families and neighbours for care within the home. What little institutionalized health care did exist in 1867 was organized and delivered largely by local charities and religious groups rather than by the state..... As a consequence, the Constitution Act, 1867 does not include “health” as a specific head of federal or provincial legislative responsibility" (Jackman, 2000).
Municipalities, thus, where there was any state intervention, were seen to be the responsible jurisdiction until the 20th century. Such authorities have been morphed, in the current period, to be responsible for community health delivery and local health planning. Federal jurisdiction in health then flows from its spending and criminal law power. The Canada Health Act essentially forces provinces to participate in cost-shared arrangements to fund health care. It works with the Federal Provincial Fiscal Arrangements Act, and the Canadian Health Transfer (CHT), to force provinces to meet certain conditions in order to receive money. It is defended legally as the setting of national standards, a constitutional authority of the federal government.
The criminal law power of the federal government is used, for example, to regulate the safety of products under the Food and Drugs Act, as part of ensuring the physical health and safety of the public. There are, however, legal debates about the degree to which criminal law powers can be invoked when intervening in health, which raises questions about a truly substantial federal intervention in health promotion beyond traditional health and safety issues. Sounding a more interventionist note, regulatory, rather than just prohibitive, initiatives have been supported recently by the courts as legitimate under traditional spending authority. The courts appear to have extended the federal role in environmental health as well. There have also recently been decisions that support the view that the federal government has the right to intervene when situations are clearly national in scope, beyond individual provinces, under the peace, order, and good government provisions of the Constitution.
From the constitution, the provinces have exclusive authority over the establishment, maintenance, and management of hospitals. With jurisdiction over property and civil rights as well, which supports provincial regulation of relations between individuals, the provinces have primary responsibility for health care delivery. Most provinces have public health acts granting authority to a medical officer of health and the power to regulate health professions and practices. Health insurance is also under provincial jurisdiction.
The federal government, thus, has an indirect ability to shape health care compared to the provinces, but a sense of partnership was somewhat formalized in the first Health Accord of 2004. The Accord identified the need for public health and health promotion coordinated and planned interventions, though there hasn’t been much success in executing this part of the agreement. But the Harper federal government unilaterally decided not to renew the Accord and set the financial transfer schedule without consulting the provinces, essentially saying health care is a provincial jurisdiction and the federal government would provide some money, with transfers progressively restricted. In this 2014 Accord, only the principles of the Canada Health Act applied. The federal government was effectively abandoning a quality oversight role. However, the Trudeau government appears to be taking a different, possibly hybrid approach, negotiating a new Accord that somewhat adapts the funding arrangements of the 2014 Accord in the hope of obtaining approval from the provinces for new programming in the areas of home care and mental health. They are also in the process of introducing a National Dental Program.
The jurisdictional and financial quagmires of health care create multiple sites for decision making. In areas of health promotion, the provincial role is paramount, with municipalities substantially involved in delivery. Still, this area is poorly funded relative to acute care and receives limited attention from medical associations, hospitals, and provincial ministries of health. Much of health care policy is negotiated, given constitutional traditions, between the government, the hospital sector, and the provincial medical associations, a limited negotiated governance model. The pharmaceutical industry is the most influential private sector actor, although since doctors in private practice are essentially small businesses, they too can be viewed as significant private sector players. NGOs are active in some subsectors, not so much in others. Food NGOs have had very modest influence, and where it has occurred has often been associated with some programme successes.
Food as a health promotion strategy receives even scanter resources and is a significant discussion in only a limited number of sites, most typically municipal public health units. By some estimates, less than 5% of total health care spending is devoted to health promotion (Picard, 2018) and likely 1/100th of that to food as a health promotion strategy (TFPC, 1997). This reality reflects the dominant norms and assumptions that health care and health care professionals create health, as opposed to social determinants. There is significant international evidence that social inequalities lead to ill health (Raphael, 2016) and that spending on social welfare is more important to improving population health than a narrow focus on health care reform (Dutton et al., 2018). Dutton et al's study of provincial spending is aligned with the international results, finding that a " 1-cent increase in social spending per dollar spent on health was associated with a 0.1% ..... decrease in potentially avoidable mortality and a 0.01% .... increase in life expectancy". Recently, health care spending/capita has exceeded social welfare spending by 3x, with healthcare spending rising much more rapidly. All this suggests that it is more appropriate, in a fiscally restrained environment, to shift health care dollars to social welfare spending. Food access, as a recognized social determinant, would contribute to these positive outcomes were investments in food as health promotion to be increased.
Endnotes:
[1] Note that this Act is not really about ensuring the optimal health of Canadians despite some of the language of the Act. Its primary purpose is to govern the conditions of money transfers to the provinces.
