Health social determinants are defined by the WHO (World Health Organization) (2012) as “the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status.” The WHO definition demonstrates the many layers of complex issues that are involved in determining who has good health and who does not have good health. In other words inequality in the health system is a real problem, a challenging problem and one that must be faced by accepting that change is not easy. Social policy made at the international or national level passes through diverse demographics, economic levels of status and political changes (as well as political controversies and conflict). Perhaps understanding the root cause of why change to health equality could lead to a faster solution to health inequity.
The Ontario Coalition for Social Justice (2008) in an open letter to the people of Ontario lays the cause of the problem solidly at the table of the national government and the government’s Poverty Reduction Strategy policy announced December 4, 2008. Reasonable citizens can understand the relationship between poverty and poor access to good health care but Canada’s Poverty Reduction Strategy directly influenced the amount of social assistance, the disability rates, the and the minimum wage – all were affected negatively because the budget outlays for those three sectors was not increased. The Ontario Child Benefit did receive an increase but as Josephine Grey, co-chair of the OCSJ (2008) explained, “As long as people do not have enough to cover their basic needs, they cannot support their families. A few changes made to the system do little to make up for the increasing hardship.” A basic need of all families everywhere is easy access to high quality health care.
Dennis Raphael, an expert in social determinants of health has cited four factors that determine the occurrence of poverty. Firstly the minimum wage as a percentage of average wage, secondly the level of social assistance as a percentage of average wage, ability of workers to organize for fair labor agreements , and reasonably priced child care. Raphael directly laid the blame on the McGuinty government, “The McGuinty government has actively resisted making it easier for low wage workers to organize, has provided minimum wage and social assistance levels that leave people worse off than they were during the Harris years, and has made little effort to provide affordable childcare for those most in need” (OCSJ, 2008).
John M Bryson and Barbara C. Crosby, professors of Planning and Public Affairs at the University of Minnesota (UM) and Melissa Middleton Stone, Director of Public and Nonprofit Leadership Center, Hubert Humphrey Institute of Public Affairs (UM) compiled a comprehensive literature review to better understand the design and implementation of cross-sector collaborations. The reason they chose this issue is because the need to solve difficult problems like health care inequity requires multiple layers of organizational collaboration “business, nonprofits and philanthropies, the media, the community, and government – must collaborate to deal effectively and humanely with the challenges” (Bryson, Crosby and Stone, 2006, 44). The objective of their study on collaboration was to develop a thorough “propositional inventory” (Bryson, Crosby and Stone, 2006, 44). The researchers considered the progression of collaborations by analyzing the following sections of a collaborative effort; the initial circumstances under which the collaboration is structured, structural mechanisms, governmental factors, “constraints and contingencies, outcomes, and accountability issues” (Bryson, Crosby and Stone, 2006, 44). Their concluding proposition on what to expect “The normal expectation ought to be that success will be very difficult to achieve in cross-sector” does not need to frighten people from trying to solve problems across sectors. Instead the message is that managers and participants must have realistic expectations because the collaboration approach to problem solving and developing cross-sector policies is complex. Open minds and patience would be the best way to handle the collaborative process. Bryson, Crosby and Stone (2006) argued that the main stumbling blocks are the external and internal environmental factors that the manager of a collaboration project has no control over. The authors did point to the essential need for “support from the institutional environment . . . for legitimizing cross-sector collaboration” (Bryson, Crosby and Stone, 2006, 55). Unfortunately institutional support is not under the control of a manager. But a manager can be in charge of internal factors such what governing system to use, inviting participants who are stakeholders, the development of the plan, and what conflict management strategies to use.
An important point was made in a research study from the USA based transforming social work to meet the needs of clients rather than trying to change clients. The researchers pointed out the internal problem of “the status quo of the inertia” within the organization when people are too comfortable carrying out tasks the same way whether the result is effective to reaching the particular goal of the task or not (Evans, Hanlin & Prilleltensky, 2007, 343). The major external problem the researchers expressed was the “strong cultural current working against change” (Evans, Hanlin & Prilleltensky, 2007, 329). The two challenges, organizational inertia and cultural attitudes against change, would be evident in collaborative efforts to move from health inequality to equality regardless of the intentions of the participants in the collaborative effort. And the problem would be exacerbated because of the many layers of cross-sector determinants involved.
Ideology is a big factor in the politics of Ontario’s policy sitting agenda. The open letter to Ontario’s public from the Ontario Coalition of Social Justice demonstrated the conflict between the traditionally conservative attitudes of the government leaders who offered a Poverty Reduction Strategy that offered very little to alleviate the problem of poverty. On the other hand the liberal and progressive reformers and organizations (Raphael and OCSF) argued for policies of equality instead of policies which supported the status quo. An analogy of a lifeboat was used in OCSJ’s open letter that points out the diametrically opposed attitudes that make collaboration particularly difficult. “People adrift in a lifeboat can share what little they have” argued OCSJ while government leaders argued for growing economy before the poor could receive more benefits. Canada is a rich country with abundant resources so if Canada is the lifeboat than change to a more equitable system is realistically possible.
Mikkonen and Raphael (2010) argue that education is critical to creating public awareness and providing opportunities to take action. Canadians do not have to become experts in cross-sector determinants. But they do need to understand how many policy issues such as child care, housing, and minimum wage are all part of the health care equity issues. The stresses that effect health are biological, chemical, physical, social and psychosocial whether the stresses are an impact of access to health care, child care, housing, income, education, job security, social exclusion, food insecurity, aboriginal status, race, gender or disability (Mikkonen and Raphael 2010) The people of Ontario can understand how receiving good health care and enjoying good health should be everyone’s right, not only the right of the rich.
References
Bryson, J. M., Crosby, B. C., & Stone, M. M. (Dec. 2006). The design and implementation of cross-sector collaborations: Propositions from the literature. Public Administration Review, Special Issue: 44-55. Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/jcop.20151/pdf
Evans, S., Hanlin, C. E., & Prillelrensky, I. (2007). Blending ameliorative and transformative approaches in human service organizations: A case study. Journal of Community Psychology, 35(3), 329-346. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/j.1540-6210.2006.00665.x/pdf
Mikkonen, J. & Raphael, D. (2010). Social Determinants of Health: The Canadian Facts. Toronto: York University School of Health Policy and Management. Retrieved from http://www.thecanadianfacts.org/
Mullaly, B. (2007). In Search of a Paradigm. In B. Mullaly (Ed.), The new structural social work: Ideology, theory, and practice (3rd ed.) (pp. 3 – 98). Toronto: Oxford University Press.
NACCHO (National Association of Country and City Health Officials). (24 April 2012). Health in All Policies (HiAP): Frequently Asked Questions. Retrieved from http://www.naccho.org/topics/environmental/HiAP/upload/HiAP-FAQ-Final-12-04-24.pdf
OCSJ (Ontario Coalition for Social Justice). (5 Dec. 2008). An open letter to the People of Ontario in Response to the Poverty Reduction Strategy Announced by the Ontario Government. Retrieved from http://www.ocsj.ca/
Stanford, J. & Biddle, T. (2008). Economics for Everyone: A short guide to the economics of capitalism. Halifax & Winnipeg: Fernwood Publishing and CCPA.
World Health Organization. (14 March 2013). Addressing social determinants of health through intersectoral actions: Five public policy cases from Mexico. Retrieved from http://www.who.int/social_determinants/en/
