Public policy as if health matters

Dr. Trevor Hancock

21 February 2023

700 words

In this series of columns I am exploring what a true health system would be like, and what that means for reform of our ‘health care system’. In my last column I stressed the importance of ecological and social factors as determinants of health, noting these conditions also play a big role in shaping our health behaviours.

But ecological and social conditions do not just arise spontaneously, they are the result – intended or not – of societal decisions, often expressed through public policy. Thus to create a Wellbeing society we need to put the wellbeing of people and the planet at the heart of governance.

Back in the early 1980s, building on the work of others, I came up with the concept of  ‘healthy public policy’, which has since been taken up by the World Health Organization and many national and provincial governments; Canada even has a National Collaborating Centre on Healthy Public Policy.

The basic principle is very simple; since most of the major determinants of health come from beyond the illness care system, healthy public policy is concerned with public policy in non-health sectors that affects health. This raises the interesting question as to which policy areas are most important for health.

Let’s start with the most fundamental determinant of human wellbeing, indeed of our very existence: The state of the planet. UN Secretary General Antonio Guterres has been clear in stating we are war with nature and that this is suicidal. So  the most important public policy is to make peace with nature, as he puts it.

The UN identifies a triple crisis of climate change, biodiversity loss and pollution. So we need public policies that stop these things happening. This means an energy policy consistent with net-zero carbon emissions; a halt to activities that further deplete biodiversity (such as deforestation, loss of wetlands, over-fishing and unsustainable forms of agriculture, mining and so on), and a restoration of biodiversity.

In addition, it means stopping all pollution that exceeds the ability of nature to absorb or detoxify it; this particularly applies to the pesticides and various persistent organic pollutants that contaminate entire ecosystems and foodchains and contribute to loss of biodiversity.

Clearly, such policies have enormous implications for our current way of life – but then our current way of life has enormous and potentially existential implications for us and many other species. We have no choice but to develop policies that enable us to live well within the ecological constraints of this one small planet.

A second set of healthy public policies relate to the social factors that determine our health. In a society as wealthy as ours, hunger, homelessness, unhealthy housing and unsafe drinking water are not only morally outrageous, they are a threat to the health of those affected and to the wellbeing of the wider society. Healthy public policies ensure everyone has access to such basic necessities as food, adequate shelter and clean water, as well as a livable income.

A third set of healthy public policies have to do with the interaction between the ecological  and social determinants of health. For example, a low meat diet is not only needed to reduce the impacts of our modern agricultural system on the planet, it is also good for health. And more compact, walkable, mixed use neighbourhoods and active or public transportation systems are likewise good for both our health and the planet.

Fourth, healthy public policy does not allow the private sector to produce or market products or services that harm health. Tobacco is an obvious example, but there are many other examples worthy of attention.

Developing a true health system  will not be easy and it will not be swift.  To create a Wellbeing society and develop healthy public policies, governments must put people and planet at the heart of decision-making. They need to establish Wellbeing Secretariats within their Cabinets Offices, adopt Wellbeing budgets and follow the example of Wales in passing a Wellbeing of Future Generations Act and creating the position of a Wellbeing of Future Generations Commissioner.

The second important way to reduce the burden on the illness care system – a comprehensive self-care strategy – is the topic of my next column.

© Trevor Hancock, 2023

Dr. Trevor Hancock is a retired professor and senior scholar at the

University of Victoria’s School of Public Health and Social Policy


This is what a health system looks like

  • Published as “Human behaviour is affected by factors beyond personal choice”

Many of the conditions we live in and the behaviours we adopt are not freely chosen, no matter how much we may wish to think so

Dr. Trevor Hancock

14 February 2023

699 words

Last week I started to sketch out the elements of a health system – a system designed to keep people healthy so they don’t need to use the illness care system (which we usually call the health care system). The key point is that although illness care is an important part of a health system, most of what keeps us healthy happens beyond ‘health care’, beyond the scope of the Ministry of Health and most health care professionals.

The most fundamental determinants of our health are what I and others call the ecological determinants of health: Air, water, food, fuel, materials, and other ‘ecosystem goods and services’ we derive from nature. A second major set of determinants are the social factors that enable us to meet our basic needs: Healthy food, adequate shelter, clean air and water, sanitation, basic education and health care, an adequate income, social connections and support and other factors.

A vivid illustration of these social determinants came from former Saskatchewan Premier Roy Romanow, who chaired a Federal Commission on the Future of Health Care. In his 2004 address to the inaugural meeting of the Health Council of Canada, he suggested seven things we could do to stay healthy: Number one was “Don’t be poor”.

This was followed by “Pick your parents well; Graduate from high school and then go on to college or university; Don’t work in a stressful, low-paid, manual job in which you have little decision-making authority or control; Don’t lose your job and become unemployed; Be sure to live in a community where you trust your neighbours and feel that you belong, and finally, live in quality housing, but not next to a busy street, in an urban ghetto or near a polluted river.”

Clearly, these are not really conditions we can freely choose, influenced as they are by the socio-economic, Indigenous or ethnic status of the families and communities into which we are born. Which is why the third major set of determinants – human behaviour, can be problematic.

Because while there is of course an element of personal choice, our behaviour is very much shaped by our culture, our society, our community, our family and our peers, as well as – these days – a multi-billion dollar industry that markets unhealthy products and behaviours. Roy Romanow’s tongue-in-cheek advice reminds us that many of the conditions we live in and the behaviours we adopt are not freely chosen, no matter how much we may wish to think so, for a wide variety of reasons.

A final major category, of course, is human biology, but much of that – our genetic inheritance – cannot be changed easily, if at all. Of course, when our body or mind does not work well, or is damaged, we try to fix it, or help people to adapt to live with the damage; that is what the illness care system is mainly focused on.

This broad understanding of what keeps people healthy is hardly new; it is as old as humanity, as well as being a modern insight. One of the things that inspired me to work in public health was the 1974 federal government ‘Lalonde Report’ on the health of Canadians. Among other things, it stated: “there is little doubt that future improvements in the level of health of Canadians lie mainly in improving the environment, moderating self-imposed risks and adding to our knowledge of human biology.” But unfortuantely we have largely ignored that important insight ever since.

Which brings us to the latest attempt to drag our focus back to creating health. As I laid out in a series of columns in January and February this year, the World Health Organization has started calling for the creation of Wellbeing societies. These are societies that will “provide the foundations for all members of current and future generations to thrive on a healthy planet.”

Of the five key action areas proposed, I have previously dealt with the first two – valuing and respecting the earth and its ecosystems, and creating a wellbeing economy. Over the next two weeks I will look at the third – develop healthy public policy for the common good – and the fourth, achieve universal health coverage.

© Trevor Hancock, 2023

Dr. Trevor Hancock is a retired professor and senior scholar at the

University of Victoria’s School of Public Health and Social Policy

Time for a radical re-think of health care

If you had to remake the health system from scratch, what would you do? Turn the system on its head, making the hospital the place of last resort and beginning with what keeps people healthy.

Dr. Trevor Hancock

7 February 2023

699 words

Last week I suggested we need to radically re-think Canada’s  ‘health care system’ – actually, thirteen separate, mainly publicly-funded, often privately operated non-systems for illness care, with federal cost-sharing.

Having worked as a family physician in primary care; as a public health physician in health planning and as a Medical Health Officer; as an advisor and consultant on health promotion to the World Health Organization – mainly in Europe; as a medical consultant in population and public health at B.C.’s Ministry of Health, and as a health futurist, I have had lots of time to observe and think about Canada’s ‘health care system’.

Back in the 1990s and into the 2000s I sometimes led workshops on health care reform which, over time, I came to call ‘Blow it up and start again!’. Now obviously we can’t blow up the system, so I did a thought-experiment, inspired by Albert Einstein’s approach to physics: What if the health care system disappeared overnight and we had to rebuild it from scratch? What would we build, knowing what we know today?

Well, we would not start with the hospital, which is what happened in Canada. If you look at the history of health care, the federal government first got involved by supporting the building of hospitals in the late 1940s, then supported public insurance for hospital care in the late 1950s, and then brought in public insurance for physician care outside hospitals in the late 1960s.

Unfortunately, we got it backwards. For the most part, ever since, we have been running around trying to plug holes in the system, without stepping back and seeing if perhaps we need an entirely different system.

What I propose instead is a true health system, one that is designed to first create good health. So the first thing to do is keep people healthy, because clearly, the best way to deal with an over-burdened illness care system is to stop over-burdening it. The second important way to reduce the burden is to increase people’s capacity for appropriate self-care, so they don’t seek medical care when they don’t really need it.

We need to begin, then, with a clear vision of what a true health system would look like, including what an illness care system within such a system would look like. Then every decision we make should be one that takes us closer to that vision.

Thus in my thought experiment I turned the system on its head, making the hospital the place of last resort and beginning with what keeps people healthy.  After all, various estimates suggest that medical care is responsible for around 10 – 20 percent of avoidable premature mortality. The other 80 – 90 percent is attributable to human biology, personal behaviours, social  and economic factors that shape our behaviours and our communities, and the quality of our built and natural environments. So that is where we need to start.

The model I created – first published in 1993 – is an upside down triangle, with each layer in the model involving fewer people needing services. The better the layers higher up in the model do their work, the fewer people the lower levels need to care for.

Thus the first couple of layers of the model, which affect the whole population, are about creating a Wellbeing society, something the World Health Organization has been calling for recently. Such a society puts the wellbeing of people and the planet at the centre of all decision-making, testing all policies, especially economic policy, against their ability to either improve or harm wellbeing.  It also ensures that people are protected from harmful activities by the private or public sectors.

Then come layers that are about people learning to look after themselves, both to keep healthy and to manage their minor ailments and injuries, activities the health system must support. The first real contact with the health care system involves receiving preventive services and quality primary care, then – if needed – specialty ambulatory care and home care. Only if all that is insufficient do people actually need to be admitted to a community facility or hospital.

In the next couple of columns I will describe this in more detail.

© Trevor Hancock, 2023

Dr. Trevor Hancock is a retired professor and senior scholar at the

University of Victoria’s School of Public Health and Social Policy

Canada does not have a health care system

(Published as “If doctors operate as a business, what’s wrong with surgery through private clinics?”)

Dr. Trevor Hancock

1 February 2023

700 words

There is much wringing of hands these days about the state of the Canadian health care system, as well there should be. But in fact there is no such thing as a Canadian health care system, although there is a Canadian way of funding health services. In the 1990s, when I helped organise study tours for Swedish health system managers to visit Canada, I used to describe the ‘Canadian health care system’ to them as ten publicly-funded private non-systems.

Let me pick that apart. First, there is no Canadian health system, because when Canada was formed in 1867, the federal government got what was then important in politics – foreign affairs, defence, international trade etc., while the provinces got the less important stuff; health, education, social support etc. So constitutionally, health is a provincial, not a federal responsibility.

That is why we have 10 health ministries and ministers, 10 sets of licensing and regulatory Colleges for physicians, nurses and so on; 13 if you include the territories. Each province licences its professionals – which is why it is hard to transfer from province to province, even though – in my experience – the human body and its diseases, and the treatment of those diseases, is the same across the country. Hardly a system, certainly not an efficient one.

As a result we have ten different provincial systems, each of which has its own policies and programs, negotiates its own fee schedule and salaries with staff, its own approved drug lists and so on. The only thing that really unites them are the five principles enshrined in the Canada Health Act; if the province is to receive federal funding the provincial system must be comprehensive, universal, accessible, portable and publicly administered.

Importantly, the principles only apply to physician and hospital services (and selected dental surgical services), which is why almost all dental care, as well as home care, pharmacy, physio, psychological counselling and similar services  are either not covered or only partly covered. This lack of coverage is why one quarter of all health expenditure in Canada is funded though the private sector – mainly out of your own pocket or through private insurance as part of a benefits package, unless your income is low enough that you qualify for public assistance.

An important area of confusion is that health services only have to be publicly administered, not provided by public authorities. So insured services can and are provided by the private sector. In fact a large part of the publicly funded system is privately owned and operated, starting with your doctor.

A 2016 brief from the Canadian Medical Association reported “the vast majority of physicians are self-employed professionals operating medical practices as small business owners”. Similarly, if you have had lab or X-ray work, chances are it was a privately operated lab or X-ray. But because they are providing an insured service and billing the single public payer, this is fine.  

Which is why the recent furore over providing surgery through private clinics is a bit puzzling. Now don’t get me wrong, I am opposed to a two-tier system in which the wealthy can jump the queue and get better services. Apart from anything else, that may draw staff and resources away from the public sector, leading to its deterioration.

But if you can go to a family doctor and then a surgeon who are private business people, and get your lab and X-ray work-up done by private businesses, then what is wrong with having your surgery done in a privately owned and operated clinic, as long as it is a procedure that the public system insures (if it isn’t, you would have to pay privately anyway), is as safe as and has outcomes at least as good as in the public system, is no more expensive than the public system, and bills only the public system, not the patient.

Finally, a system? Really? Well, if so, it is a badly-designed system, because, as the Institute for Healthcare Improvement likes to say, “every system is perfectly designed to achieve the results it gets”, and this ‘system’ is not delivering what we need. Time for a radical re-think, a topic I will return to soon.

© Trevor Hancock, 2023

Dr. Trevor Hancock is a retired professor and senior scholar at the

University of Victoria’s School of Public Health and Social Policy

Morgan’s columns should come with a health warning

Fossil-fuel advocate Gwyn Morgan’s columns are an example of ‘discourses of delay,’ which argue that we need oil and gas to fuel our society and change is impossible — thus delaying action on climate change.

Dr. Trevor Hancock

24 January 2023

702 words

Fossil fuel advocate Gwyn Morgan recently provided yet another nonsensical defence of his industry (“Net-zero fantasy has empowered dictators”, 11 Jan 2023). But as Professor Roland Clift – a past member of the UN Intergovernmental Panel on Climate Change and the U.K. Royal Commission on Environmental Pollution – wrote in response, it is Morgan who is the fantasist: “It is people like me who live in the real world; the fantasists are those who think we can continue to dig up and burn fossil carbon.”

Of course, Morgan completely ignored the environmental, health and economic costs of the fossil fuels he touted, as several letter writers pointed out. “Unfortunately, he either ignores or unfairly dismisses environmental concerns about fossil-fuel production”, wrote Steve Housser of Shawnigan Lake.

Short of outright denial of climate change, ignoring the problem is the next best thing, perhaps best understood as the ostrich strategy: Just close your eyes, stick your head in the sand and hope the problem will go away.

Unfortunately for Morgan, his timing was off. He wrote: “As 2022 made painfully clear, however, there’s nothing at all funny about the enormous damage currently being inflicted by pursuit of this technically impossible goal” of net-zero. But this appeared opposite an article titled “U.S. climate disasters racked up $165 billion in damage in 2022” and another titled “Landslides, sinkholes, floodwaters plague California”.

His main point – that a reliance on renewable energy had made Germany vulnerable to Russia’s weaponizing of oil and gas – was ably refuted by Thomas Pedersen of Saanichton: “Morgan’s views are exactly backward”, he wrote, arguing that in promoting “untrammelled consumption of oil and natural gas and [decrying] adoption of renewables”, Morgan “has contributed to keeping demand for fossil fuels high, thereby enriching coffers in Russia and other autocracies like Saudi Arabia.”

Another criticism of Morgan’s article came from Ed Wojczynski, former chief energy planner for Manitoba Hydro, who wrote that Morgan’s “learning from the European crisis is to expand oil and gas while Europe’s learning instead is to increase renewables and nuclear to enhance self-reliance and minimize gas requirements.”

Full marks to Mr. Morgan, however, for his persistence in trying to obfuscate the science of  climate change and clean energy; he never gives up peddling the distortions, half-truths and downright lies of the fossil fuel industry that he represents. His column is an example of what one group of researchers have called ‘discourses of delay’.

In an article in the journal Global Sustainability in 2020, a team of researchers  explained that these ‘discourses of delay’, which “pervade current debates on climate action  . . . accept the existence of climate change, but justify inaction or inadequate efforts.”

The team identified four categories of climate delay discourses. First are proposals to redirect responsibility: Examples include arguing that we are small and should wait for others to act, or that if we act, others won’t, so it’s better we do nothing.

The second category, which Morgan’s column is full of, is pushing non-transformative solutions: Rather than expand alternative energy to reduce our dependence on fossil fuels – be they from Russia or elsewhere – we should ramp up production. No mention, of course, of the enormous health, environmental, social and economic costs that will ensue.

The third category – emphasize the downsides of climate policies – is in many ways the opposite of the second: Morgan argues that controls on fossil fuels make us vulnerable, while again ignoring the downsides of fossil fuel use and the benefits of alternatives.

Finally, is the category of surrender to climate change, which is inherent in all he writes: We need oil and gas to fuel our society, change is impossible, the alternatives are unfeasible – none of which is true, by the way – so just carry on as we are.

I realise that the media feel they need to provide ‘balance’, but the fossil fuel industry continually tries to mislead us. Given his persistent ignoring of the ‘inconvenient truth’ of climate change and its health, environmental, social and economic costs, I think Gwyn Morgan’s columns should come with a health warning: “This article may contain unfounded, biased and distorted information that may harm your health or that of your descendants. Read with care.”

© Trevor Hancock, 2023

Dr. Trevor Hancock is a retired professor and senior scholar at the

University of Victoria’s School of Public Health and Social Policy