The state's role in promoting population health: Public health concerns in Canada, USA, UK, and Sweden
Introduction
Public health is ultimately a question of what kind of society we wish to live in. There is a close connection between democracy, participation, equality and social security on the one hand and good public health on the other [1, p. 24].
Promoting and maintaining the public's health is an ongoing preoccupation of national, regional and municipal governments around the globe. Promoting health comprises three distinct, though potentially related sets of activities: (a) traditional public health activities of environmental protection, infection control, and modifying risk behaviours; (b) advocating for and contributing to developing health supporting public policy; and (c) delivering health care services [2]. The first two sets of activities – our concern in this article – are primarily concerned with promoting the health of the population while health care services focus on treating individuals who are ill.
In Canada, these components for the most part operate independently of each other. With few exceptions, public health agencies and units carry out traditional public health activities, policymakers design public policy in their spheres of influence, and health care professionals deliver health services through the universally accessible health care system. In the UK and Sweden however, efforts have been made to integrate traditional public health activities with the development of health supporting public policy. In the USA however, public health authorities are frequently involved in delivering health care services to indigent populations.
Despite the expanding literature on the importance of public policy for influencing the public's health, profound differences exist among jurisdictions in the attention placed upon such activities by State institutions such as public health authorities and agencies. Whether public health agencies and authorities concern themselves with public policy depends upon the particular model of health adhered to within the jurisdiction. If the dominant health model is highly individualized and focused on biological dispositions and the effects of risk behaviours, public health will direct efforts to managing risk factors such as hypertension, cholesterol levels, weight, tobacco use, and diet. They will downplay or even deny the role public policy issues of income, employment, housing, and service provision – the social determinants of health – play in health.
In contrast, a model of health that sees health as influenced by structural factors such as the organization of society and how society distributes resources will be associated with a public health focus on health-supportive public policy. The emerging literature on the broader determinants of health will be seen as a source of concepts and findings to inform the development of public policy. The selection of a dominant model by which the origins of health are understood is itself influenced by the political, economic, and social environments within which public policy and public health activities operate.
Canada has been seen as a leader in health promotion and population health concepts congruent with developing health supportive public policy. Despite this history, it has been argued that Canada has been surpassed by other nations such as the UK and Sweden in applying these concepts to policy development and implementation. In this article we compare – and examine the influences upon – Canadian, USA, UK, and Swedish approaches to public health and public policy in the service of health. Our focus on Canada is set against the USA and UK scenes, since evidence indicates these latter English-speaking nations are placed upon diverging paths to promoting the public's health. Sweden is examined as an exemplary example of how governments and public health authorities can draw upon the literature on health determinants to develop public policy. Sweden is also of relevance as Canada may be moving to model its new Public Health Agency along the lines of the Swedish public health model.
In this paper we are concerned with answering these questions:
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What principles and concepts direct public health activities in each nation?
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What do local public health units do to promote health?
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To what extent are these activities integrated with the development of health-related public policy?
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What are the ideological components and antecedents of public health approaches?
To answer these questions, we examine governmental statements about health and means of promoting it, the structure and activities of public health agencies, and the relationship of public health to other arms of government policy activity. We consider the political, economic, and social forces that influence the selection of one health model over another. We argue that public health models both influence – and result from – the general public's perceptions of health and its determinants. The roles of governments and the media in advancing models of public health are also considered.
Section snippets
Canada
Canada has led the world in understanding health promotion and population health…. However in recent years, as the costs and delivery of health care has dominated the public dialogue, there has been inadequate policy development reflecting these understandings. In fact, Canada has fallen behind countries such as the United Kingdom and Sweden and even some jurisdictions in the United States in applying the population health knowledge base that has been largely developed in Canada [3, p. 1].
This
United States of America
The current infant mortality rate of seven infant deaths per 1000 live births is moving in the wrong direction…. This ranks the United States 28th internationally. Clearly, we still have more work to do for our communities, our families, and our children [32, p. 4].
The USA has one of the worst health profiles of modern industrialized nations. It is one of the least developed welfare states, spending less than most industrialized nations on public infrastructure to support citizens. It is the
United Kingdom
A new minister for public health will attack the root causes of ill health, and so improve lives and save the NHS money. Labour will set new goals for improving the overall health of the nation, which recognise the impact that poverty, poor housing, unemployment and a polluted environment have on health [46].
The UK has a longstanding intellectual and academic concern with inequalities in health. In 1980 the Black Report revealed that despite a generation of accessible health care, class-related
Sweden
Sweden and Finland are world leaders in public health. As Canada works to develop a pan-Canadian public health strategy, I look forward to learning more about public health systems around the world. Canadian Minister of State for Public Health, Carolyn Bennett [65].
The 2001 Swedish Ministry of Health and Social Affairs document Towards Public Health on Equal Terms illustrates government understandings of the nature of health:
The health of the population is affected by a range of what are known
Understanding variations in public health approaches
A background paper prepared for a Canada-wide consultation on developing public health objectives devoted extensive attention to the Swedish health objectives. The paper notes that these objectives are consistent with Canadian theorizations concerning both health promotion and population health. The extent to which these objectives will find support in the current public health context remains an open question. This is so since acceptance and action on a broad-based model of public health is
Conclusion
In the UK and Sweden ideological commitments to health equity provide a fertile soil in which policy can be developed from empirical findings concerning broader determinants of health. The USA is an example where the policy environment is resistant to a broad-based determinants of health approach. Canada presents an example where the public health community can profoundly influence the public policy environment.
There are many supports for a progressive public health agenda in Canada. These
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