McMaster University School of Nursing Social Determinants of Health Midterm 1 Notes (Fall 2024) PDF

SOCIAL Inspire. DETERMINANTS of HEALTH Engage. HTH SCI 1RR3 FALL 2024 Lead.  Land Acknowledgement Inspire. McMaster University recognizes and acknowledges that it is located on the traditional ter...

SOCIAL Inspire. DETERMINANTS of HEALTH Engage. HTH SCI 1RR3 FALL 2024 Lead.  Land Acknowledgement Inspire. McMaster University recognizes and acknowledges that it is located on the traditional territories of the Mississauga and Haudenosaunee nations, and within the lands protected by the “Dish with One Spoon” Engage. wampum agreement. That wampum uses the symbolism of a dish to represent the territory, and one spoon to represent that the people are to share the Lead. resources of the land and only take what they need. https://healthsci.mcmaster.ca/docs/librariesprovider59/resources/mcmaster-university-land-acknowledgment-guide.pdf?sfvrsn=7318d517_2  Agenda Inspire. 1. Check ins 2. Course overview 3. Unit 1 Aims Engage. 4. What are the Social Determinants of Health (SDoH)? 5. Why care about the SDoH? 6. Which SDoH will we learn about in 1RR3? 7. Critical Thinking Questions Lead. 8. Plan for next week Lead. Engage. Inspire. 1. CHECK IN  2. COURSE OVERVIEW Inspire. More prep required bc class is 2 hours not 3 hours Purpose: 1. Introduce the Social Determinants of Health Engage. 2. Critically examine health inequities Definition: conditions in which people are born grow live work and age 3. Prepare learners to collaborate with clients, communities, and interprofessional teams in a meaningful way – requires self-reflection and critical Lead. engagement  COURSE LEARNING OUTCOMES Inspire. Upon completion of this course, learners will be able to demonstrate: A broad understanding of the major factors that Engage. determine the health of populations in Canada An awareness of the structure of the Canadian health care system at the federal, provincial, territorial, and municipal levels, including their funding sources, mandates Lead. and regulation. Next week guest lecture about healthcare system  LEARNING OUTCOMES (cont’d) Inspire. An appreciation for the intersectional nature of health inequities (e.g., race, class, and gender). How these things cross paths A beginning understanding of colonialism and the rights and entitlements of Indigenous people. Engage. Foundational understanding for providing culturally safe (respectful engagement; understand power imbalances) and humble (self-reflection; understand personal and systemic biases) care – especially to differently Lead. marginalized/underserved groups E.g. racialized groups and lgbtq  Required Textbook Inspire. Raphael, D., Bryant, T., Mikkonen, J., & Raphael, A. (2020). Social Determinants of Health: The Canadian facts (2nd ed.). Ontario Tech University Faculty of Health Sciences and York University School of Health Policy and Management. The publication is freely available at http://www.thecanadianfacts.org/ Engage. In addition to the weekly readings, be sure to review the required media files in the syllabus Lead.  EVALUATION MEASURES Inspire. Paper based Quiz/Test Scantron QUIZ #1 Lecture and short discussion for QUIZ #2 FINAL EXAM the first hour and then test in Week 6 the second hour For both tests Week 9 During exam period (Dec 6-19) In class Book your own test with SAS In class Units 7,8,9,10,11 Units 1, 2, 3 Units 4, 5, 6 With some questions from Engage. 40 questions With some questions units 4,5,6 Multiple Choice from units 1,2 & 3 90 questions Chap 4,5,6 related to the rest of the chapters intersectionally 50 questions 80 Multiple Choice Multiple Choice + 10 scenario based 30% of course grade Units 1,2,3 are building blocks Might be S/A 40% of course grade 30% of course grade Lead. Quizzes and Final Exam will cover content from lectures, required readings, and required media files. Class discussions not covered bc each class is different We will go through sample questions in lecture  Housekeeping for this class § Student accommodations - ensure that the Inspire. course lead and course instructor is aware – Contact your tutor & the course lead Dr. Robin Enns at [email protected] Tutor / instructor / course lead § How to reach your tutor and office hours Engage. § Check for updates on Avenue to Learn (posted in Announcements) § If sick on a quiz day - follow the policy and guidelines of your site Lead.  3. UNIT 1 AIMS Inspire. At the end of this unit: Learners will have developed their understanding of the course material, learning Engage. format and evaluations of student learning. a beginning understanding of societal forces and factors that contribute to health inequities. Lead. Inspire. 4. WHAT ARE THE SDoH? Engage. Lead.  An Introductory video Inspire. Engage. Lead. A REQUIRED MEDIA FILE: https://www.youtube.com/watch?v=8PH4JYfF4Ns  4. WHAT ARE THE SDoH? Stress Bodies and Illness Geography, Health Services Inspire. Indigenous ancestry Housing, Immigration Disability Income & Income distribution Early Child Development Race Engage. Education Social safety net Employment & working Social exclusion conditions Unemployment & Job Food Insecurity Security Lead. Gender Globalization Overlap Source: Raphael, 2et al 2020  WHAT GOES INTO YOUR HEALTH? When we break these things down they aren’t in our individual control Inspire. Social exclusion Pesticides Microplastics Engage. These things are based off Structural systematic political decisions that take a long time to Lead. change most beyond individual control  IMPROVING LIFE CHANCES Inspire. Fair isn’t always equal Equality = giving people exact same resources Equity = giving people what they need in order to have the same opportunity (individual task) E.g. covid Told to social distance People live in shared homes Engage. 5 or above already at risk LTCH Vaccine distribution Recognizes everyone has different Equality: First come circumstances and need to allocate first serve opportunities differently Equity: seniors in LTCH are more at risk so need it more Healthcare Equality: all have OHIP Does not even cover a lot of things that are medical impairments like vision dental etc Lead. https://publichealthonline.gwu.edu/blog/equity-vs-equality  Can be compared to page 13 of the textbook THE WHO CONCEPTUAL FRAMEWORK Or arc model Inspire. Engage. Lead. Covid immunocompromised individuals Solar, O., & Irwin, A. (2010). A conceptual framework for action on the social determinants of health: Social determinants o f health discussion paper 2. Geneva, Switzerland: World Health Organization Press. Inspire. 5. WHY CARE ABOUT THE SDoH? Engage. Understanding barriers to better support the health of individuals SDoH might affect the care and outcomes of Sustainability of policies Knowing about these SDoH we can be aware of our implicit or explicit biases (culture humility) Causes (up stream thinking) vs downstream which is more reactionary (people coming to hospitals and you treating them) Sometimes known as the causes of the causes Nurses don’t just provide physical care, there’s also emotional care (get to know on a deeper level) Helps us examine trends in marginalized and underserviced populations Lead.  We care about SDoH because - Inspire. “What good does it do to treat people’s illnesses, to then send them back to the conditions that made them sick” Engage. Housing No fixed address e.g. homeless, shelter Monique Bégin (2020) Addictions Food insecurity (living in a food desert) Lives far away from grocery stores e.g. 250km away in Northwest Territories Epidemic of working class who are also food insecure Unsafe appliances Mold Low income No private insurnace for medication cost Lead. Source: Raphael, D., Bryant, T., Mikkonen, J., & Raphael, A. (2020). Social Determinants of Health: The Canadian facts (2nd ed.) pg 8  How do conditions make people sick? The Psychobiological stress response Inspire. Engage. We tend to think about the biomedical model And not address these psychosocial demands, stress tolerance, personality, support system Lead. Research intensive textbook of our course Source: Raphael, D. ( 2016). Social Determinants of Health :Canadian perspectives (3rd Edition) Toronto, ON: Scholars’ Press Inc. pg. 39  T SO WHY STUDY THE SDoH? Answer: to further understand... Inspire. § SOCIETAL FACTORS § SOCIETAL FORCES §..that shape health and §..that shape the quality help explain health and distribution of these Engage. inequities factors §(e.g. income and §(e.g. social and political employment) forces) Who’s in charge of government Decision making and how it affects society Continue working Job laws Go back to school and retrain What info is made available to the public Mandates on covid, travelling, masking, vaccines etc…. Lead. During covid more of these inequities were brought to life  The SDoH: TIPS FOR BETTER HEALTH Inspire. (society-oriented vs. individual-oriented) 1. Don’t be poor. If you can, stop. If you can, try not to be poor for too long. 2. Don’t have poor parents. BUT: These things 3. Own a car. are beyond 4. Don’t work in a stressful, low-paid manual job. individual control 5. Don’t live in damp, low-quality housing. Engage. 6. Be able to afford to go on a foreign holiday and sunbathe. 7. Practice not losing your job and don’t become unemployed. 8. Take up all benefits you are entitle to, if you are unemployed, retired, sick or disabled. 9. Don’t live next to a busy major road or near a polluting factory. 10. Learn how to fill in the complex benefit/asylum application forms before Lead. you become homeless or destitute. Source: Raphael, D. (2016). Social Determinants of Health : Canadian Perspectives (3rd Edition) Toronto, ON: Canadian. Scholars’ Press Inc..pg 19 Inspire. 6. WHICH SDoH WILL WE BE COVERING? Engage. Lead.  Unit 2 - Guest lecture INCOME AND HEALTH - Unit 3 Inspire. o Income inequality is a great difference in income Not just income level It is about income in comparison to those around you distributions within the population which results in a small percentage of the population having a high concentration of income Engage. o Many Canadian studies have linked higher incomes with more favorable health outcomes for people with higher incomes Lead. (Raphael, 2020)  An example of inequalities Communities Inspire. < 1km apart! (10-minute walk) Where you live affects your heath Engage. Lead. Hamilton Spectator. (2019). Code Red: Ten Years Later. Retrieved from https://projects.thespec.io/codered10/  WORK AND HEALTH - Unit 4 Inspire. o Longer hours, high-stress work, o Those with more control over and job insecurity associated their work environment live with poorer health outcomes longer/healthier lives E.g. work from home Engage. Lead. (Source Raphael, 2016)  An example of course materials Inspire. Engage. Lead. Maybe working on contracts Precariat: precarious (insecure) + proletariat (working-class) Not given pension or benefits Compared to full time workers Security = control (Required media file for Unit 4) Systemic and governmental problem  EDUCATION AND HEALTH (Unit 5) Solid Inspire. o Early childhood education and care is linked to better adult health Access to it is expensive Subsidized childcare A lot of provinces don’t have this o Education provides a sense of control over life circumstances Better education = better income Passed down generations Engage. Lead. Raphael, 2020, Chapters 4 and 7)  Another model for understanding SDoH: BARTLEY TYPOLOGY Inspire. MATERIAL PSYCHOSOCIAL POLITICAL ECONOMY access to food, stress, sense of control, family distribution of power housing, education and environment, social affect on distribution of recreation support economic resources Engage. Interplay CULTURAL/ LIFECOURSE BEHAVIOURAL events/processes before beliefs, norms, birth and during childhood values (health and social Lead. circumstances) Income is an excellent marker for a cluster of other life circumstances; https://www.cdc.gov/violenceprevention/acestudy/index.html mediated by education  INDIGENOUS COMMUNITIES & HEALTH – Unit 6 Inspire. Indigenous peoples subjected to SDoH inequities experience poorer health outcomes Engage. o Also results in difficulty accessing appropriate health-related services Lead. Inspire. Note price of water vs. pop Engage. They had to boil their water to make it safe to drink Price of water is more expensive Basic human right = access to water Many communities in canada live without safe drinking water Lead. https://thenarwhal.ca/this-ontario-first-nations-boil-water- advisory-has-been-in-effect-for-25-years/  GENDER AND HEALTH (Unit 7) Inspire. We will distinguish between sex and gender o Gender inequality vs inequity (unfair) Engage. o Gender overlaps with all the SDoH What stories have you seen in media recently that might be examples of gender Lead. bias/discrimination ?  Examples of unit resources Inspire. Engage. Urgency of intersectionality Often times these problems are layered resulting in worsening of health Unit 7. Gender and health - preparatory Media File: Kimberle Crenshaw. (2016). The Urgency of Intersectionality. Ted Talk. (16 minutes) *see course manual Example of a ted talk as a required resource Lead.  RACIALIZED COMMUNITIES AND HEALTH – Unit 8 Inspire. o Racialized groups are more likely to live in poverty (economic exclusion) Limited research data linking Engage. o health and race o Some studies emerged as a result of the inequities that were highlighted during the first two years of the pandemic. Lead. Not enough data linking health and race More work to do on this Raphael, 2020  Ethno-Racial Differences with Covid -19 in Toronto 2020 Inspire. Disproportionate Shows that some racial groups had a higher proportion of COVID-19 cases compared to their population size in Toronto Green = % of population Highlights disparities among these ethnic groups Engage. Lead. https://www.toronto.ca/home/covid-19/covid-19-latest-city-of-toronto-news/covid-19-status-of-cases-in-toronto/  Ethno-Racial Differences with Covid -19 in Toronto 2021 Inspire. Engage. Lead.  FOOD HOUSING & HEALTH (Unit 9) Inspire. 6.9 Million people (18.4%) are food insecure in Canada (2021 census) Food bank clients doubled in Toronto in 1 year (2022-2023) Engage. Hamilton numbers increased by 40% (2022-2023) In 2021, 1 in 10 households were in core housing need (10%) Why are food insecurity and housing insecurity linked? Lead. Sources: Proof 2022 & Raphael 2020 Statistics Canada - https://www150.statcan.gc.ca/n1/pub/11-627-m/11-627-m2022056-eng.htm  PHYSICAL ENVIRONMENT & HEALTH – Unit 10 Inspire. Climate change impacts our physical environment Engage. Some environmental factors may seem unrelated to health but play significant roles in our health (e.g., agricultural practices) Lead.  A few impacts of climate change Inspire. Engage. E,g, forest fires Nov 2019: “Between 200 million and 300 million people could be forced to migrate due to the effects of climate change by the end of the century, as long as we’re not able to keep the temperature rise below 2 degrees Celsius as set out by the Paris Agreement.” Lead. Every year since 2008, 21.5 million people are displaced by extreme weather events https://global.ilmanifesto.it/climate-refugees-could-reach-300-million-a-population-without-rights/  REMINDER: WHY ARE WE STUDYING THE SDoH? Inspire. To better understand: 1) SOCIETAL FACTORS o (e.g., income and employment) that shape health and help Engage. explain health inequities 2) SOCIETAL FORCES o (e.g., social and political) that shape the quality and distribution of these Lead. factors  How can we act on our knowledge Inspire. of SDoH? Action arenas- Consider: Engage. ○ As a student ○ As a nurse ○ As a citizen Lead.  POLICY AND SDoH Inspire. Engage. Lead. Bottom line: Policies impact health equity and well-being Solar, O., & Irwin, A. (2010). A conceptual framework for action on the social determinants of health: Social determinants of health discussion paper 2. p7&8 p Geneva, Switzerland: World Health Organization Press. Retrieved from https://www.who.int/sdhconference/resources/ConceptualframeworkforactiononSDH_eng.pdf  Why do nurses need to know about Inspire. SDoH? As you learn about interviewing patients, families Engage. and communities think about what you need to consider to ensure people will enjoy the best health they can in their homes and communities. Lead. Inspire. References used in this Engage. presentation are cited on the slides Lead.  7. UNIT 1 CRITICAL THINKING QUESTIONS Inspire. 1. Reflect on the degree of familiarity you had with the idea of living and working conditions as primary determinants of health prior to today. When you thought of health and its determinants what did you Engage. People might think genetics is the main factor think of?Consider war, displacement, stress Health insurance beyond OHIP card People of colour facing systemic barriers (various political movements may have opened our eyes to this) 2. Can you think of examples from the news in which the social determinants has affected somebody’s health (or the health of a population)? Lead. 3. What are some of the things/actions you do for health (as a student, citizen, or nurse)?  8. PLAN FOR NEXT WEEK Inspire. Review key concepts and key terms for Units 1 and 2 Complete required readings for Unit 1 (4) and Unit 2 (6) Engage. Watch/Listen to required media files for Unit 1 (2 videos) and Unit 2 (1 video) Lead.  WHO FRAMEWORK Inspire. THANK YOU FOR PARTICIPATING! Engage. SEE YOU NEXT WEEK! Lead.  McMaster Health Forum Products Related to Nursing https://www.mcmasterforum.org/about-us/products?keyword=nurs Canadian Health Care System Related to social services and sustainable development goals https://www.mcmasterforum.org/about-us/products?projecttopics=a6233582-6168-616d-a574- ff000044313a%7C26d203ef-e250-44f3-993e-5f0e97dd20ca Fall 2024 R. James McKinlay FORUM: Senior Lead, Programs Evidence performed policy roles McMaster Health Forum McMaster University People come for help making policy decisions based on [email protected] the evidence mcmasterforum.org 2 mcmasterforum.org 1 2 Health Care in Canada Federal Responsibility Canada has a predominately publicly financed, privately delivered health care system setting and administering national principles or standards for the system it provides access to universal, comprehensive coverage for medically necessary hospital, in-patient, and assisting in the financing of provincial health care services through fiscal transfer out-patient physician services delivering direct health services to specific groups doctors are not employed by the government fulfilling other health-related functions most are private practitioners who work in independent or group practices, enjoy a high degree of autonomy, and are generally paid on a fee-for-service basis Establish rules of delivered healthcare (mom and dad of Our healthcare system is all about these points the house) Doctors work for themselves, contractors Provide funds to help support Universal, comprehensive, medically necessary = pay attention to them How they are used and defined are very important They are there for a reason and a backbone of everything mcmasterforum.org mcmasterforum.org we do in Canada 3 4 3 4  Before 1947 = mostly private Tax funded First step to what we have today Provincial/Territorial Responsibility History (universal healthcare) managing and delivering health services 1947 Saskatchewan – first province to establish public, universal hospital insurance  Tommy Douglas planning, financing, and evaluating the provisions of hospital care, physician, and allied health care services 1957 – Federal government passed legislation to allow the fed to share in the cost of provincial hospital managing some aspects of prescription care and public health insurance plans Gave them money by 1961 – all 10 provinces and two territories had public insurance plans that provided comprehensive Delivers the healthcare (kids) coverage for in-hospital care Followed Saskatchewan As a reward they get money for doing this work 1962 Saskatchewan – provided insurance for physicians’ services outside hospitals Covered services anywhere Main job is to take rules that feds lay down and as long as doctor is providing the care 1966 – Federal government enacted medical care legislation deliver healthcare by 1972 – all provincial/territorial plans had been extended to include doctors’ services Are we getting what we are paying for? 5 mcmasterforum.org 6 mcmasterforum.org 5 6 Any care in hospital was covered by this insurnace plan Determinants of Health Determinants of Health (2) 1974 Lalonde Report – “The White Paper” Why produce this report? Marc Lalonde - Minister of National Health and Welfare Government was spending enormous sums of money on health care expenditures A New Perspective on the Health of Canadians: A Questioning of the Efficacy of Medical Interventions However, it was becoming increasingly evident that the overall health of the population was, at best, improving only marginally (e.g. mortality and morbidity) How many is being spent in healthcare system in canada and are we getting what we are spending? 7 mcmasterforum.org 8 mcmasterforum.org 7 8  Determinants of Health (3) Determinants of Health (4) Report found that health care, in fact, has very little to do with “health” Major Contention of the Report: More accurate description of the primary activities of the health care sector was “sick care” Need to focus on these factors Sick care is very expensive (rapid increases during the 1960's and 1970's after the institution of universal Determinants of Health health care) Biological Factors RESULT - financial strains on Government Lifestyle Environment Spending a lot of money, not getting huge positive health Health Care returns We aren’t spending on health We are waiting for people to get sick and trying to get them better again Much cheaper and better for society to spend money on encouraging healthy behaviours from preventing them to get9 mcmasterforum.org 10 mcmasterforum.org 9sick in the first place 10 Spending on sick care and not healthcare Determinants of Health (5) Determinants of Health (6) Importance of the Report: Specific Findings: One of the 1st formal statements by any western government concerning the broader array of changes in lifestyles or social and physical environments would lead to more improvements in health than determinants that define the “health” of a population would be achieved by spending more money on existing health care delivery systems Broadened “health care” to the “health care field” Preventing illness is better than treating illness Novel idea Back then this was all brand new Impact: gave rise to a number of successful proactive health promotion programs which increased awareness of the health risks associated with certain personal behaviours and lifestyles They leave it up to each province and territory to come up with their own way of doing it Direct response in Ontario - Participaction Response to the law report (find ways to encourage health) healthy behaviour type programs 11 mcmasterforum.org 12 mcmasterforum.org 11 12  Takes us 5 years to get a federal document CHA to prevent that Report on money side of things But we still have this sick care system Extra billing concerns, they are charging more by the We need to better understand what things encourage health. end of the 70s How do people stay healthy? How do we integrate that into our Not only do we have a sick care system not designed system? Instead of waiting for people to get sick? to keep people healthy History (2) Two-tiered system - more money = better services Determinants of Health (7) 1979 – health services review by Emmett Hall Health Promotion Framework (Epp, 1986) o health care in Canada ranked among best in the world “health is a resource for living influenced by our beliefs, culture, social economic and physical o warned that extra-billing by doctors and user fees levied by hospitals were creating a two-tiered system environments” that threatened the accessibility of care Achieving Health for All: A Framework For Health Promotion o "self-care“ 1984 – fed passes the Canada Health Act to discourage hospital user charges and extra-billing by physicians o "mutual aid” o “healthy environments" Whole perspective of health as o the Act provides for an automatic dollar-for-dollar penalty if any province permits such charges for insured health services Ottawa Charter for Health Promotion part of our culture is coming back to the forefront Need to make sure that this doesn’t happen Equality and equity Canada Health ACT Rules by which healthcare in this country must be served in terms of the population 13 mcmasterforum.org 14 mcmasterforum.org 13 The whole purpose is to prevent a two—tiered system 14 That would create a financial gap in terms of their access to healthcare services Determinants of Health (8) Determinants of Health (9) 1986: The Charter and the Framework 1989: Canadian Institute of Advanced Research offered a “strategy” for change that embraced the criticisms put forward since the Lalonde report Individual determinants do not act in isolation expanded the White Paper by focusing on the broader social, economic, and environmental factors that It is the complex interaction among determinants that can have a far more significant effect on health effect health Leads to why some groups are healthier than others these determinants include income, education, physical environment Health Promotion becomes “mainstream” “outsiders now become insiders” Evolution, novel idea, Canada is forefront of this thinking We are looking at these determinants individually WRONG Need to focus on income, education, environment, When in reality these are interactive with each other economical situations Understanding their interaction, how one influences the other This is a blueprint of how we can integrate them into etc.. our system then we can create a system that encourages a health system 15 mcmasterforum.org 16 mcmasterforum.org 15 16  Determinants of Health (10) Canada Health Act 1994: Strategies for Population Health: Investing in the Health of Canadians a Federal document Population health approach officially endorsed by the federal, provincial and territorial Ministers of Health ensures that all residents have access to medically necessary hospital and physician services Health Canada has now made promoting the population health approach one of its four business lines based on need, not on ability to pay sets the criteria and conditions that provinces/territories must satisfy to qualify for their full cash transfers 20 years later they added it into paper under the Canada Health Transfer (CHT) Health Canada only had 3 business lines and then added These are the rules by which healthcare in this country this fourth one in 1994 should be delivered Population health was being recognized by the federal Direct response passed, prevent this from happening government as an important part of the system (two-tiered) 17 mcmasterforum.org 18 mcmasterforum.org 17 18 Canada Health Act (2) Public Administration Based on five criteria: The administration of the health care insurance plan of a province/territory must be carried out on a non- 1) public administration profit basis by a public authority accountable to the provincial government 2) comprehensiveness 3) universality 4) portability Least interested in 5) accessibility High level administrative role Provincial and territorial health funded program (tax dollar) Insurnace program Car private insurnace, main responsibility to chair holder = to make a profit CNA says that any publicly financed healthcare system must be 19 mcmasterforum.org administered for non-profit (break even at the end of the day) 20 mcmasterforum.org 19 20  Comprehensiveness Universality All medically necessary services provided by hospitals, medical practitioners, and dentists working within a All insured persons in the province/territory must be entitled to public health insurance coverage on hospital setting must be insured uniform terms and conditions Insured hospital services include: in-patient care at the ward level, all necessary drugs, supplies, and In other words: everyone is treated the same diagnostic tests, and a broad range of out-patient services Chronic care services are also insured (minus accommodation) What services are “medically necessary”? Those medically necessary things are true for all people Answers the question: “What is covered?” Universal, everyone has access to the same stuff in the Medically necessary = no one knows what it means same way Provinces/territories have flexibility Up to them to define what is medically necessary Required under CNA to cover it as apart of OHIP As soon as they remove it they are no longer required to cover it 21 mcmasterforum.org 22 mcmasterforum.org Ambulance trip in ON = trying to save cost, made them 21 22 not covered by OHIP Tweaked to define what is medically necessary How much money ON payed for other places to cover medical service for Ontario Portability Ontario example of portability citizens Coverage for insured services must be maintained when an insured person moves or travels within Canada or travels outside the country Answers the question: “Where am I covered?” You pay into a provincial health insurnace plan In ON its OHIP You pay for it through your taxes (supposed to be able to access it everywhere) Why would anyone get travel insurance then? DINGO BITE IN AUSTRALIA Pay out of pocket then fill out all insurnace forms in ON to be reimbursed for all medical expenses 23 mcmasterforum.org When people were stuck in other countries 24 mcmasterforum.org If it is covered in ON then you will be reimbursed 23 If not then it is important to get travel insurnace 24 due to COVID-19 The care they are receiving is under OHIP If you have claustrophobia there is an Open MRI machine - requisition sent to Buffalo since they have one  Accessibility In summary (putting it all together) Reasonable access by insured persons to medically necessary hospital and physician services must be healthcare is administered not-for-profit unimpeded by financial or other barriers each province/territory determines what is “medically necessary” within that province/territory In other words: everyone has the same ‘level’ of access every citizen in the province/territory can use those medically necessary procedures under the same terms and conditions, with the same reasonable access, and be covered for them no matter where they are in What is reasonable to one person is not reasonable to the world another Open to debate Unique in each province/territory PEI - small, one MRI machine in entire province ON - many MRI machines but such a large population No matter what province you’re in it is challenging 25 mcmasterforum.org 26 mcmasterforum.org 25 26 Provisions Where Does The Money Come From? no extra-billing by medical practitioners or dentists for insured health services under the terms of the Citizens health care insurance plan of the province/territory o Federal and provincial taxes no user charges for insured health services by hospitals or other providers under the terms of the health o Direct purchase of private insurance care insurance plan of the province/territory o Direct purchase of medical and non-medical services 3 places the money comes from It all comes from US Healthcare in Canada is not free We pay for every single cent of it It is free at point of purchase (don’t have to use credit card) 27 mcmasterforum.org 28 mcmasterforum.org 27 28  Where Does The Money Come From? (2) Where Does The Money Come From? (3) Federal Government Provinces/Territories o Canada Health Transfer o Program and service payments to providers, institutions and health authorities for “medically o Equalization support to less wealthy provinces necessary” doctor and hospital services under the CHA o Programs for medical and non-medical research and public health o Supplementary programs not covered by the CHA (eg. Home care, long-term care, drug coverage) o Direct health services for selected Aboriginal populations, veterans, military personnel, Federal o Programs for medical and non-medical research and public health inmates, “foreign” visitors, RCMP Take our tax dollars Taxes takes chunk of our money and sent to federal Allocate resources for various programs which government include payment to HCPs for medically necessary Federal government sends it out to the province/ services and services not covered by CHA territory 29 mcmasterforum.org 30 mcmasterforum.org 29 30 Funding Canada Health Transfer Financed primarily through taxation Largest federal transfer to provinces/territories Some provinces use ancillary funding methods Provides cash payments and tax transfers in support of health care Alberta and B.C. utilize health care premiums Gives provinces/territories the flexibility to allocate payments according to their priorities, while upholding Today, the fed’s contribution to provincial health programs is done in a single block transfer (CHT) the principles of the CHA Provincial health insurance plans must adhere to the principles of the CHA in order to be eligible for the full federal transfer payments Healthcare premium - residents pay for additional services, helps cover cost that goes beyond medically necessary services but can also create barriers for lower income individuals who struggle to pay for these fees Federal gov takes tax dollar, creates a budget CTH - single block transfer, sent the sum of money all at once for provinces to allocate 31 mcmasterforum.org 32 mcmasterforum.org 31 32  How much? How much? (2) ON gets the most money bc 18,000,000,000 more populous province As soon as 16,000,000,000 On a per capita basis money is 14,000,000,000 labeled for 12,000,000,000 10,000,000,000 health it can 8,000,000,000 only be 6,000,000,000 4,000,000,000 used/spent 2,000,000,000 for health - NL PEI NS NB QC ON MB SK AB BC (Apart of $52.1 billion for 39.7 million Canadians $1,310.46 per person CHA) Note: in Ontario the annual cost per person is $8,563 33 mcmasterforum.org On average 34 mcmasterforum.org 33 34 Huge 7k short fall for each person It all comes from us just from different buckets Comes out every single year Summary of healthcare in this But What If….. Annual Report country Remember, in order to get their Federal money, the provinces/territories must adhere to the Canada Canada Health Act Annual Report Health Act Produced by the federal Minister of Health, Health Canada, and the Department of Justice What if they don’t? Full examination of each province/territory and their compliance to the CHA Simple, they don’t get all their money Typically, when a province/territory is penalized, it is either because of extra-billing issues or queue How does the Federal Government know? jumping https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/canada-health- How do they know who’s following the rules act-annual-reports.html There is a report on that Investigate crimes against CHA Charges being made RCMP sees what has been done in violation to CHA Oshawa doctor VIP services - Illegal 35 mcmasterforum.org 36 mcmasterforum.org 35 36 How much money was penalized in each province/territory Violated the CHA Will take money away from them Alberta and BC charge HC premiums, so as soon as it is marked for health it can only be spent for health, but they use it on other things Quebec - 2016 first provinces to merge social and health (test case) Transportation to get people from point A to point B Food security - health implications Health Spending Health care spending accounts for one-third of provincial program expenditures 2/3 is everything else 37 mcmasterforum.org 38 mcmasterforum.org 37 38 Half of the money goes to these 3 resources Other half is spent on the people Health stats Out of pocket Private insurnace To support hospital s Tax dollars 39 mcmasterforum.org 40 mcmasterforum.org 39 Student will pay student health insurance 40 Used to be physicians Can opt out before tied with drugs  Are we getting what we payed for? Above line & outside grey area - Benefits of the system statistically higher Weaknesses of the System Medical Dominance Home Care Health Maintenance/Promotion For females Heavily physician-centric, prioritizing medical services over broader health and social care Home care focuses on maintenance and prevention remains underdeveloped compared to other services 41 mcmasterforum.org 42 mcmasterforum.org Below 41 average country of the world for these two health indicators 42 Male numbers is always higher Genders aren’t equalizing No one perceives their health better than Canadians for some reason though Home Care Home Care (2) Home Care focus: There has been a general policy shift away from discussions of the health care system to a focus on the o Maintenance/prevention health system o Long term care substitution Health is more than health care o Acute care substitution “all provinces and territories provide a range of health services that go beyond the requirements of the CHA” o These include programs such as pharmacare, home care, ambulance services, and aids to independent living 43 mcmasterforum.org 44 mcmasterforum.org 43 44  Maintenance/Promotion Onward and Upward The Canadian Health Care System is not designed to prevent illness Now what? Who is responsible for preventing us from getting sick? Both the Federal and Provincial governments have started to shift the emphasis of the health care system away from institutionally-based delivery models to integrated community-based models which place increased emphasis on health promotion and prevention 45 mcmasterforum.org 46 mcmasterforum.org 45 46 2nd most important report on HC in this Romanow Report country Health Care Reform in Canada 2002: Royal Commission on the Future of Health Care in Canada 2004: First Minister's Meeting on the Future of Health Care: 10-year plan to strengthen health care o Focus on the Determinants of Health o Reducing Wait Times and Improving Access o Home Care o Strategic Health Human Resource (HHR) Action Plans o Palliative Care o Home Care o Regional and Community Delivery of Health Services o Primary Care Reform List of things we need to do o Primary Health Care Reform o Access to Care in the North o National Pharmaceuticals Strategy to improve HC based on RR Looking at improving health o Prevention, Promotion and Public Health o Health Innovation Encourage healthy behaviours o Accountability and Reporting to Citizens Taking our work, based HC systems on it and have o Dispute Avoidance and Resolution developed better healthcare systems, health metrics better than ours Canada wants to do better 47 mcmasterforum.org 48 mcmasterforum.org 47 48  LHIN system Health Care Reform in Ontario People living in diff areas Health Care Reform in Ontario (2) have diff needs Local Health Integration Networks (2007) E.g. compare sauga to up https://www.ontario.ca/page/ontario-health-teams Patients First: Action Plan to Health Care (2016) Bundled Care Teams north o the Hamilton Niagara Haldimand Brant LHIN has now been divided into (at least) four OHTs:  Brantford Brant Norfolk OHT - https://bbnoht.ca/ Connecting Care Act (2019)  Burlington OHT - https://www.burlingtonoht.ca/en/index.aspx o Dissolution of LHINs  Greater Hamilton Health Network OHT - https://greaterhamiltonhealthnetwork.ca/ o Creation of ‘super agency’ called Ontario Health  Niagara OHT - https://www.niagarahealth.on.ca/site/ontario-health-team o Creation of Ontario Health Teams (OHTs) https://www.ontariohealth.ca/system-planning/ontario-health-teams We now need to consider the impact of COVID-19 on the system both at the provincial/territorial and https://www.mcmasterforum.org/rise national levels After abolishment of LHINs Give LHINs flexibility to make decisions, regional authority That one LHIN has become 4 Ontario health teams 14 of them Regional and community delivery of health services Must put PT needs first e.g. how does cancelling ambulance 49 mcmasterforum.org 50 mcmasterforum.org fee create difference? 49 Bundled care team - everything pt needs, so they don’t get 50 bounced around to different specialities Allows linkage to different HC teams Went out the window after gov changes Liberal government: creating connecting care act OHTs Income and Health Unit #3 HTHSCI 1RR3  Land Acknowledgment 1. Only take what you need 2. Leave something in the dish for other people 3. Keep the dish clean Source https://www.whose.land/en/treaty/dish-with-one-spoon AGENDA Quiz 1 OCT 7 Know sequence of things Don’t need to know specific dates or stats Know larger trends Defining poverty Practice Questions Income as a SDOH According to WHO conceptual framework what is considered a structural determinant of health? Social gradient Social policies What was significant about 1974 lalonde report? It emphasized the export ace of lifestyle and environment on health Improving quality of health The psychobiological stress response is a combination of stressors and resistance factors: True (no true and false on the quiz) In terms of Canadian healthcare system what is a federal responsibility? Delivering direct health services to specific groups (refugees, rcmp, military) Mickey Mouse gets stung by a wasp you check if the care is medially necessary and covered by OHIP what CHA criteria? Comprehensiveness (what is medically necessary and what is not) Which CHA criteria refers to everyone being covered under the same terms? Universality Difference between equity and equality Equity means fairness and justice at the forefront Poverty is “…the condition of a person who is deprived of the resources, means, choices and power necessary to acquire and maintain a basic level of living standards and to facilitate integration and participation in society.” We think of poverty from a financial standpoint (Government of Canada, 2018) But also involves: Social connectedness Basic human needs (a lot are tied to money but not all of them) Power Ways to Measure Poverty Survival is threatened Ex. Someone in a rural village in poor country Absolute poverty Having less than an absolute minimum income level (fixed poverty line), based on the cost of basic needs (deprivation of basic needs; things that threaten survival, eg, shelter, food, etc); SURVIVAL Disadvantages of the absolute poverty measure: 1. Difficult to select a minimum set of necessities 2. The cut-off of what is considered the minimum income level, changes over time Depends on country Rural, urban setting Relative poverty Having less than the AVERAGE standard in a society; EXCLUSION Linked to social inequality Someone who has a job but can’t afford eating out or a new phone (unable to keep up with that standard living)  Poverty rate in Canada In 2020, 6.4% of Canadians lived in poverty, down from 10.3% in 2019 Poverty rate gone up and down from 2012 to 2020 8 year period Highest in 2012 COVID-19 CERB (Giving 2k to people) Mitigating pandemics impact What are some potential Retrieved from https://www.statcan.gc.ca/en/topics-start/poverty reasons for the decrease in 2020? Conceptual framework for action on the SDOH CONSIDER: The alignment of income and poverty within the framework Downstream vs upstream interventions The meaning of downstream Treating heart attack pts Downstream: during covid managing cases showing The meaning of Prevention up in emerg Upstream: introducing upstream PA vaccine, social distancing, Weight management Monitoring for co-morbid Solar, O., & Irwin, A. (2010). and masking measures conditions Nutrition Mean vs Median Income Mean Income: average income (sum of a set of numbers, divided by the count of numbers in the data set) Better representation Median Income: the midpoint level of income whereby half of the population has a higher income, and the other half has a lower income Mean calculation becomes less useful Scews distribution Misrepresentation of actual population Your Town Your Town with Bill Gates Mean income: $50,000 Mean income: $51,000,000 Median income: $50,000 Median income: $50,000  What would happen if we remove the fence? Let’s say it represents structural Equality vs Equity determinants of health = liberation Inequality and Inequity Inequality = uneven distribution of resources, opportunities, Inequality or outcomes among different groups The condition of being unequal (may or may not be fair) Inequity Inequity = unfairness or injustice in these differences Unfairness or bias Often occurs when differences relate to factors such as race, gender, sexuality, or intersectionality of factors (Raphael, 2020) Income Inequity in Canada ** Note age of report