Disparities in health between north and south – we are surprised that any one is surprised

We are happy to see Health Quality Ontario (HQO) embarking on a systematic approach to assessing the quality of Ontario’s diverse health system through their “Common Quality Agenda”. This agenda is an evolving list of indicators that measure the health system along eight domains including health status, public health, primary care, hospital care, home care, long term care, system integration, and health workforce. HQO’s first report on these indicators, “Measuring Up – A yearly report on how Ontario’s health system is performing”, published in 2014, identified disparities across Ontario and namely, how Northern Ontarians face a greater burden of poor health status and health behaviour indicators than Southern Ontarians do, such as lower life expectancy at birth, higher premature avoidable death rates, and higher obesity and smoking rates. This report outlines some of the ways that our health system is not succeeding at producing equitable outcomes across the Province. In other words, it has demonstrated that there is a problem (e.g., the “what”). The approach of this report is not helpful however, for readers who want to further their understanding of determinants that underpin these differences, such as in our current northern Ontario context (e.g., the “why”).

Certain health care service indicators also have poorer outcomes in the north than in the south. We are not commenting on these indicators, as we do not believe that improvements would make an appreciable difference on health status or health behaviours, given the long-standing evidence confirming that access to health care is not a major determinant of population health. Further, health behaviours and lifestyle choices are also not primary predictors of population health status. Rather, our perspective is that the upstream work of the public health sector should be included among the indicators, including the creation of healthy public policy and community-wide programs for preventing disease and promoting health. These approaches aim to reduce the gradient in health status by improving health across the entire population, while at the same time working to reduce socially produced health disparities.

The health system as framed in the HQO report is one that largely addresses sickness and responds to acute illness, rather than a system that influences health and its determinants across the entire population. A comprehensive measure of the quality of the health system should include the social and systemic factors that ultimately shape the health of the population. It should also focus on policies and initiatives at work to address these factors and reduce inequities. It is important to place the role of the health care system in influencing the health of the population into appropriate context. The health care system has a relatively small influence on health outcomes of the Canadian population, especially preventing illness, compared to the fundamental social determinants of health (SDOH) such as income, education, food and housing security. We need an excellent health system; but even more we need to have excellent health. An excellent health system alone cannot facilitate excellent health. As we strive towards improving health outcomes on regional and provincial levels, we need to understand the conditions that make and keep us healthy so that we can modify them with effective policy to ensure optimal opportunities of health for everyone.

The HQO report is missing an important opportunity in their assessment of the quality of Ontario’s health system by leaving out the SDOH. Socioeconomic status (SES) is the strongest predictor of population health outcomes and is therefore a logical starting point in identifying meaningful social indicators to include into the Common Quality Agenda. While SES is a complex multidimensional concept that operates at individual, family or household, and neighbourhood levels, there are existing measures that capture aspects of SES that could be considered in the agenda, such as the Ontario Marginalization Index or the Institut national de santé publique du Quebec’s Deprivation Index. Income data are also available through StatCan’s Taxfiler data series including the Low Income Measure [After Tax] (LIM-AT) indicator that has been included the Ontario Poverty Reduction Strategy since its implementation. The index of Income-Related Household Food Security identified in StatCan’s Canadian Community Health Survey could also be considered as it is anchored around a single issue that is a clear SDOH and it holds promise as a reliable proxy measure of SES and possible predictor of “high-cost users” of health care in Ontario.

Integrating the SDOH with the present indicators of the health system in the HQO report will move beyond simply identifying differential outcomes to a more meaningful explanation of why health status outcomes vary among regions. It will also identify opportunities to improve our health status and inform decision makers, including and especially those outside of the health system, in order to equalize opportunities for health by all. In the North East Local Health Integration Network region where the Sudbury & District Health Unit is located, we have poorer SDOH compared with the Province, including lower median household income, higher rates of long-term and youth unemployment, and lower rates of educational attainment. Our northern context also makes us unique, with an aging population, low population density across large geographic areas and a much higher proportion of Aboriginal groups. The legacy of discrimination and poverty has contributed to considerably poorer outcomes for Aboriginal than for non-Aboriginal groups.

We were not surprised by the findings in the HQO’s report. We live here and understand the broader determinants that impact our health status. But the old adage holds true that you can’t manage what you don’t measure. If we actually want to improve the health status of those living in the north, we need to be measuring the real drivers of northerners’ health status, and that means expanding our measure beyond the health care system.