1. Linking Health and Social Policy:
Addressing the Impact of Low Income on Health
Public Health in Canada: Strengthening Connections
Winnipeg Convention Centre, Winnipeg
June 8, 2009

2. Introduction
“Inequality kills.” This is the conclusion of the WHO Commission on the Social Determinants of Health – published last fall.
The Commission argues that closing the health gap is possible – but it will take urgent and sustained action, globally, nationally and locally.
This panel takes up the question of what is needed to close the gap – here in Canada.
My job today is to provide an overview of where we stand in Canada – with regard to income inequality and the challenge of low income in our communities.

3. Poverty Trends
Looking at Canada, recent analyses have brought this message home:
There has been little change in the aggregate low income rate over past 25 years (measured at business cycle peaks), falling only recently after 2004.
Generally, we see cyclical stability for children and working-age adults and significant decline among seniors.

4. Poverty Trends
Seniors
Children
Adults
The most recent data show that the poverty rate (as measured by the after-tax Low Income Cut-off) fell again in There were 400,000 fewer Canadians living in poverty – a rate of 9.2%, the lowest in 30 years.
The rate of poverty among children was 9.5% in 2007 (26.6% among children living in female lone-parent families and 6.5% among children living in two-parent families).
The rate of seniors has continued to fall – to roughly 5%. It was 14% however among unattached seniors (still lower than the one-third of non-seniors living alone).

5. Poverty Dynamics
Looking at income dynamics, one in five of Canadians experienced low-income for at least one year between 2002 and 2007.
Of those experiencing low income, most lived in this situation for one or two years (40% and 21% respectively). One in ten (11%) lived in low income throughout this entire six year period.
Entry and exit to low-income was largely associated with change in employment earnings or other income sources, but changing family formation was also important – accounting for ¼ to ⅓ of exits from low-income.

6. Concentration of Poverty
We also know that persistent poverty in concentrated in certain groups:
Lone parents – improvement since the mid-1990s
Aboriginal peoples (off reserve) – remains high, some improvement
Unattached – flat, essentially unchanged
Work limiting disabilities – flat, essentially unchanged
Recent immigrants – deterioration, considerable concentration of poverty
Persistent low-income rates ranged from 15% to 30% for these groups but only 3% to 4% among the remainder of population.

7. Income Inequality
While overall poverty rates have fallen, the same cannot be said for income inequality.
There has been income growth among families at the bottom of the income ladder since 2002, after years of stagnation. But at the same time, growth at the top has been significantly higher.
Looking at the 1989 to 2007 period, the adult equivalent adjusted after-tax income rose by 7.6% among the 20% of persons with the lowest adjusted after tax income, but by 30% among the top 20%.
The gap in incomes that opened up through the 1990s has not been reduced.

8. Income Inequality
A recent OECD study notes that the rich in Canada are particularly rich compared to their counterparts in other OECD countries – the average income of the richest 10% in Canada is $71,000 (USD) in purchasing power parities, which is one-third above the OECD average of $54,000 (USD).
The poor and middle classes are also richer in Canada than the OECD average, but by less – their average incomes are only 18% above that of their counterparts in a typical OECD country.
Only Germany saw a similar rate of increase in income inequality during the period.
Source: OECD, Growing Unequal?, 2008.

9. “Running Hard to Stand Still”
One important reason for growth in inequality has been the erosion of key income supports for working-age Canadians.
In Canada, the direct effect of tax/transfer system on rates of low income is about same now as it was in In comparison to other countries, Canada spends less on cash benefits such as employment insurance and family benefits.
Furthermore, more households in Canada struggle to purchase basic goods and decent housing.
Canada’s welfare state has not been able to keep up with the growth in income inequality generated by the market. “We are running hard to stand still.”

10. Impact of Low Income on Health
What does it matter?
There is a clear and persistent relationship between health and low income over a range of measures, at various levels of geography. Years of research has confirmed that health status improves in a stepwise fashion for each increment of income.
 Russell Wilkins, for example, has shown that both individual income and education are strongly predictive of life expectancy and mortality – two key measures.
It has been estimated that if all Canadians had the same rate of premature death as the most affluent one-fifth of Canadians, there would be a 20% reduction in premature mortality across the population.

11. Impact of Low Income on Health
That said, the social gradient in health does vary according to what is being measured (i.e., causes of premature mortality; chronic disease, self-reported health) and by population group.
New research suggests, for example, that health related disparities seem to be most acute for mid-life Canadians.
As well, the poor bear the greatest burden of poor health – compared to those in higher income brackets.

12. Impact of Low Income on Health
There is also a robust international literature that links income inequality and health outcomes, again at different levels of geography.
Place matters. Income inequality – at the community and national levels – has been shown to have an impact on mortality, even after controlling for individual level indicators such as age, income and education.
Current research is trying to better understand these patterns:
Some evidence suggests that some causes of mortality are more sensitive to income inequality than others – those traditionally associated with social hierarchy such as heart disease.
And the impact of inequality appears, again, to be stronger among low income individuals, and among men.

13. Impact of Low Income on Health
These findings are not new for this audience. We can also look back on almost forty years of public health efforts to mitigate the impact of low income on health.
Even as Canadians marked significant progress on a range of population health measures – these gains were greatest among those that were already healthy. There is still a long way to go including closing the gap.
But where to target our efforts?
Improve the health of the poorest?
Reduce the gap between the richest and the poorest?
Lower the gradient?

14. Where to Next?
The most appropriate and effective way to improve overall population health status is by improving the health of those at the bottom of the income scale and other disadvantaged populations – pushing the bottom up where opportunity for gains are greatest.
The approach needs to be comprehensive – including both targeted measures while promoting improvements in the conditions underlying health disparities.
To this end, partnership and inter-sectoral policy / program development are essential.

15. Poverty Reduction in Canada and Abroad
Several jurisdictions have adopted “whole-of-government” approaches to poverty reduction and have had some success in reducing poverty and social exclusion.
Ireland and the United Kingdom are two examples of countries that have implemented comprehensive anti-poverty strategies which include explicit targets and timelines.
Three jurisdictions in Canada – Québec, Newfoundland and Labrador and Ontario – have multi-year anti-poverty strategies. Nova Scotia and Manitoba have released “smaller” poverty reduction plans. And New Brunswick – and possibly Prince Edward Island – is exploring the options for developing its own strategy.

16. Poverty Reduction in Canada and Abroad
To date, calls for a poverty reduction strategy have not been taken up by the federal government
However, the Senate Subcommittee on Population Health (chaired by Senator Keon) has just released its final report calling for a pan-Canadian population health strategy and the Senate Subcommittee on Cities (chaired by Senator Eggleton) will be publishing its final report shortly.
This spring, the House of Commons Standing Committee on Human Resources (HUMA) reconvened and is holding public hearings into the desirability of developing a poverty reduction strategy for Canada.

17. Health Sector: In Action on Poverty
Poverty reduction work has not been confined to the social development community.
The UK stands out as having adopted a government-wide program to reduce health disparities as a part of an overall Poverty Reduction Strategy. Specific national targets have been set and national indicators developed to report on progress.
The UK Treasury tracks public expenditures and advises departments as to how best to target expenditures to reduce disparities. Moreover, departments and health institutions are required to conduct and report on Equalities Impact Assessments (EIAs).
The strength of the UK approach is that its population health objectives are explicitly linked to other policy fields related to poverty such as unemployment, housing, social justice, and homelessness.

18. Health Sector: In Action on Poverty
In Canada, there has certainly been important investment in research on health disparities:
at the national level (i.e., Canadian Institutes of Health Research, and the National Collaborating Centres on Public Health and Aboriginal Health);
at the provincial level (i.e., Manitoba Centre for Health Policy; Institut de la santé publique du Québec).
But federal and provincial efforts to introduce and implement a “whole-of-government” approach to the determinants of health – and reducing health disparities in particular – have fallen short (i.e., via vehicles such as National Health Goals, a Population Health Strategy or FPT Framework).

19. Health Sector: In Action on Poverty
This is not to say that the health sector hasn’t had any success in moving individual poverty reduction initiatives forward – activity at the local level provides ample evidence of this.
At the program level, there is growing awareness of the critical need to take the specific needs of disadvantaged populations and communities into account, to ensure that these groups are able to benefit to the maximum extent possible from universal and population-specific programs.
Efforts to reduce health disparities and tackle the roots of poverty, however, have tended to proceed via single issues or determinants such as early child development, Aboriginal health, or healthy living strategies.

20. Health Sector: In Action on Poverty
Poverty reduction efforts on the part of the health sector have been hamstrung by:
perennial problems related to political jurisdiction;
lack of political will;
entrenched institutional barriers between government departments, between institutional and community-based service providers, between professional groups;
lack of vehicles (and will) to engage community / public; and
the reality that many of the tools that are needed to effect change lie outside of the health sector.
Poverty truly is a challenge that demands an integrated approach across levels of government, across departments, bringing together the public, private and community actors.

21. Making Partnership Work
The WHO and PHAC have completed an analysis of 18 country case studies, looking at the pursuit of health equity through inter-sectoral action. Several of their findings are useful to consider here:
Community engagement is critical. “Whole of government” approaches that originate at the national level can be limited in their capacity to influence the determinants of health if such initiatives are not supported by comprehensive, ground-up work at the local level.
Building a strong case for intersectoral action is vital to getting activities off of the ground (i.e., building on public concern for a particular group; using political champions; building on concerns to use scarce resources more effectively);
Establishing clear roles and responsibilities is essential as well as a decision-making process suitable to the task at hand (inter-sectoral action will look different at different levels of decision-making).
Securing resourcing for the long term is key as inter-sectoral action tends to cost more and take longer to achieve results than other approaches.

22. Making Partnership Work
The authors make the point that effective action to reduce health disparities is not always organized around this explicit goal.
How the issue is framed is very important. Framing complex health issues broadly (not necessarily as health equity) allows people from all sectors to more easily define their roles and engage in working towards solutions, employing a range of strategies.
To this end, the role of the health sector needs to be flexible depending on the issues and tasks at hand. The sector has extraordinary resources to bring to bear as leader, partner and supporter.

23. Looking Forward
Today, there is an opportunity for health practitioners and advocates to find common cause with anti-poverty advocates and community coalitions.
There exists an opportunity to leverage and align existing efforts, for example, with advocacy coalitions such as the “25 in 5” in Ontario or initiatives such as the Vivre Saint-Michel en Santé in Montréal or the Calgary Committee to End Homelessness.
This is not a question of bringing other sectors around the health disparities table – but of creating a common table around preventing, reducing and eliminating poverty – and its devastating impact on the health and wellbeing of Canadians.

24. Contact Information
For additional information, contact:
Katherine Scott
Canadian Council on Social Development
(613)