Health Promotion International, Vol. 19, No. 2, 269-273, June 2004
HEALTH PROMOTION INTERNATIONAL Vol. 19. No. 2 © Oxford University Press 2004. All rights reserved
Toronto charter outlines future health policy directions for Canada and elsewhere
1School of Health Policy and Management and 2York Centre for Health Studies, York University, Toronto, Canada M3J 1P3 and 3Department of Adult Education, Ontario Institute for Studies in Education, University of Toronto, Toronto, Canada M5S 1V6
From 29 November to 1 December 2002, a conference of more than 400 Canadian social and health policy experts, community representatives and health researchers met at York University in Toronto, Canada, to consider the state of 10 key social or societal determinants of health across Canada, to explore the implications of these conditions for the health of Canadians and to outline policy directions to improve the health of Canadians by influencing the quality of these determinants of health. The conference took place at a time when Canadian social and health policies were undergoing profound changes related to shifting political, economic and social conditions (Bryant, 2002
).
The conference was funded by the Policy Research Program of Health Canada, with support from the Canadian Institutes for Health Research, in the tradition of Canadian government action on the determinants of health. It brought together representatives from a wide range of sectors: labour, childcare, food security, social development, anti-poverty, housing, education, and many others. Ten social determinants of health—early life, education, employment and working conditions, food security, health services, housing, income and income distribution, social exclusion, the social safety net, and unemployment and job insecurity—were examined. These were chosen on the basis of their prominence in Health Canada and World Health Organization (WHO) policy statements and documents (WHO, 1986; Health Canada, 1998; Wilkinson and Marmot, 2003), and because social and economic restructuring has profoundly affected the quality of these determinants of health in Canada (Raphael, 2003).
The conference was also a response to accumulating evidence that growing social and economic inequalities among Canadians are contributing to higher health care costs and other social burdens. Indeed, the recent Canadian Senate Report on the Federal Role in Health Care points out that 75% of Canadians' health is determined by physical, social and economic environments (Kirby, 2002). Evidence was also accumulating that a high level of poverty—an outcome of the growing gap between rich and poor—has profound societal effects as poor children are at higher risk for health and learning problems in childhood, adolescence and later life, and are less likely to achieve their full potential as contributors to Canadian society (Raphael, 2003).
As a result of the conference, the Toronto Charter on the Social Determinants of Health was developed. It drew upon initial feedback by conference participants and was then ratified by conference participants. The Peterborough and Toronto Boards of Health and Ottawa Toronto City Council have since endorsed the Charter and it is going before additional municipal councils across Canada for endorsement. Conference presentations (Centre for Social Justice, 2003) and electronic versions of the Charter are available in English, French and Spanish (Raphael and Curry-Stevens, 2003). Health Canada has prepared summaries and policy implications of the presentations, four articles based on the Conference appeared in the prestigious Canadian journal Policy Options (Institute for Research in Public Policy, 2003), and a volume of conference papers is in preparation (Raphael, 2004). The conference served to reintroduce the concept of the social determinants of health to Canadians at a time of increasing influence of neo-liberal ideology in Canada and the weakening of the welfare state (Coburn, 2001).
Additional efforts are being made to bring this issue to public attention and to influence the policy community. A public relations campaign on the social determinants of health is being offered (Centre for Social Justice, 2003). There is also a concerted policy effort on the part of Health Canada and various civil society actors to raise and address a variety of important social determinants of health. The cooperation of the labour movement and other progressive societal sectors with university researchers is a particularly promising development.
This Charter itself has and will continue to be a tool for promoting health and social justice, both within and outside of Canada. It can provide a powerful impetus for social change, notably by municipal council endorsement followed by political action. The contents of the Charter should be especially relevant for health promoters in jurisdictions where the social determinants of health are being weakened by short-sighted governmental policymaking.
Appendix
Strengthening the Social Determinants of Health: The Toronto Charter for a Healthy Canada
From November 29 to December 1, 2002 a conference of over 400 Canadian social and health policy experts, community representatives, and health researchers met at York University in Toronto, Canada to: a) consider the state of ten key social or societal determinants of health across Canada; b) explore the implications of these conditions for the health of Canadians; and c) outline policy directions to improve the health of Canadians by influencing the quality of these determinants of health. The conference took place at a time when Canadian social and health policies were undergoing profound changes related to shifting political, economic, and social conditions.
Ten social determinants of health—early life, education, employment and working conditions, food security, health services, housing, income and income distribution, social exclusion, the social safety net, and unemployment and job insecurity were chosen on the basis of their prominence in Health Canada and World Health Organization policy statements and documents.
The conference was a response to accumulating evidence that growing social and economic inequalities among Canadians are contributing to higher health care costs and other social burdens. Indeed, the Kirby Report on the Federal Role in Health Care points out that 75% of our health is determined by physical, social, and economic environments. Evidence was also accumulating that a high level of poverty—an outcome of the growing gap between rich and poor—has profound societal effects as poor children are at higher risk for health and learning problems in childhood, adolescence, and later life, and are less likely to achieve their full potential as contributors to Canadian society.
The Social Determinants of Health Across the Life-Span Conference coincided with the release of the Romanow Report on the Future of Health Care in Canada that called for strengthening the Canadian health care system by expanding its coverage, resisting privatization, and increasing financial investment. The report also discusses the importance of economic and social determinants of health. The evidence heard at the conference reinforced the view that immediate and long-term improvements in the health of Canadians depend upon investments that address the sources of health and disease.
The participants at the Social Determinants of Health Across the Life-Span Conference therefore resolve:
Whereas the evidence is overwhelming that the health of Canadians is profoundly affected by the social and economic determinants of health, including—but not restricted to—early life, education, employment and working conditions, food security, health care services, housing, income and its distribution, social exclusion, the social safety net, and unemployment and employment security; and
Whereas the evidence presented at the conference clearly indicates that the state and quality of these key determinants of health are linked to Canada's political, economic and social environments and that many governments across Canada have not responded adequately to the growing threats to the health of Canadians in general, and the most vulnerable in particular; and
Whereas these social determinants of health are also human rights as defined in the Universal Declaration of Human Rights and the International Covenant on Economic, Social and Cultural Rights, which Canada is obliged to protect and promote; and
Whereas the evidence presented indicates that investments in the basic social determinants of health will profoundly improve the health of Canadians most exposed to health threatening conditions—the poor, the marginalized, and those Canadians excluded from participation in aspects of Canadian society by virtue of their living conditions—therefore providing health benefits for all Canadians; and
Whereas the evidence presented to us has indicated the following to be the case:
- Early childhood development is threatened by the lack of affordable licensed childcare and continuing high levels of family poverty. It has been demonstrated that licensed quality childcare improves developmental and health outcomes of Canadian children in general, and children-at-risk in particular. Yet, while a national childcare program has been promised, 90% of Canadian families with children lack access to such care.
- Education as delivered through public education systems has helped to make Canada a world leader in educational outcomes but our education systems are now at risk due to funding instability and poorly developed curriculum in many provinces. These conditions may weaken the trend toward greater number of students graduating despite evidence that those who do so show significantly better health and family functioning than non-graduates.
- Employment and working conditions are deteriorating for some groups—especially young families—with potential attendant health risks. One in three adult jobs are now either peripheral or precarious as a result of increasing contracting out of core jobs and privatization of public employment. These jobs are often temporary, with low pay and high stress. Precarious working situations are directly related to the weakening of labour legislation in many jurisdictions. These changes threaten the gains made by workers in the past, jeopardizing their health and well-being.
- Food security among Canadians and their families is declining as a result of policies that reduce income and other resources available to low-income Canadians. In Canada, food insecurity exists among 10.2% of Canadian households representing 3 million people. Monthly food bank use is 747,665 or 2.4% of the total Canadian population, which is double the 1989 figure; 41% of the food bank users or 305,000 are children under the age of 18.
- Health care services can become a social determinant of health by being reorganized to support health. Many examples of effective—but all-too-rarely implemented—means of preventing deterioration among the ill through chronic disease management and rehabilitation are available. Screening that has been carefully assessed for its effectiveness can support health. Preventing disease in the first place by promoting the social and living conditions that support healthy lifestyles has also been neglected. While the Romanow Report reaffirmed the principles of the Canada Health Act, missing were strong statements about the important roles public health, health promotion, and long-term care play in supporting health.
- Housing shortages are creating a crisis of homelessness and housing insecurity in Canada. Lack of affordable housing is weakening other social determinants of health as many Canadians are spending more of their income on shelter. More than 18% of Canadians live in unacceptable housing situations and one in every five renter households spent 50% or more of their income on housing in 1996, an increase of 43% since 1991.
- Income and its equitable distribution have deteriorated during the past decade. Despite a 7-year stretch of unprecedented economic growth, almost half of Canadian families have seen little benefit as their wages have stagnated. Governments at all levels have let the after-tax-and-transfer income gap between rich and poor grow from 4.8:1 in 1989 to 5.3:1 in 2000. The growing vulnerability of lower-income Canadians threatens early childhood, education, food security, housing, social inclusion, and ultimately, health. Low-income Canadians are twice as likely to report poor health as compared to high-income Canadians.
- Social exclusion is becoming increasingly common among many Canadians. Social exclusion is the process by which Canadians are denied opportunities to participate in many aspects of cultural, economic, social, and political life. It is especially prevalent among those who are poor, Aboriginal people, New Canadians, and members of racialized—or non-white—groups. As our racialized composition grows, it is unacceptable that these groups earn 30% less than whites and are twice as likely to be poor. These trends contribute to social and political instability in our society.
- Social safety nets are changing in character as a result of shifting federal and provincial priorities. The 1990s have seen a weakening of these nets that constitute threats to both the health and well-being of the vulnerable. The social economy may provide opportunities for community organizations to provide services in more democratic, transparent and community-sensitive ways. It may be, however, unable to meet emerging needs without further burdening caregivers in the community, many of whom are women, or inadequately compensating them.
- Unemployment continues at high levels and employment security is weakening due to the growth of precarious, unstable, and non-advancing jobs. Higher stress, increasing hours of work, and increasing numbers of low-income jobs are the mechanisms that link employment insecurity and unemployment to poor health outcomes. Unionized jobs are the most likely to help avoid these health-threatening conditions.
- Canadian women, Aboriginal people, Canadians of colour, and New Canadians are especially vulnerable to the health-threatening effects of these deteriorating conditions. This is most clear regarding income and its distribution, employment and working conditions, housing affordability, and the state of the social safety net.
It is therefore resolved that:
Governments at all levels should review their current economic, social, and service policies to consider the impacts of their policies upon these social determinants of health. Areas of special importance are the provision of adequate income and social assistance levels, provision of affordable housing, development of quality childcare arrangements, and enforcement of anti-discrimination laws and human rights codes. It is also important to increase support for the social infrastructure including public education, social and health services, and improvement of job security and working conditions;
Public health and health care associations and agencies should educate their members and staff about the impacts of governmental decisions upon the social determinants of health and advocate for the creation of positive health promoting conditions. Particularly important is these associations and agencies joining current debates about Canadian health and social policy decisions and their impacts upon population health;
The media should begin to seriously cover the rapidly expanding findings concerning the importance of the social determinants of health and their impacts upon the health of Canadians. This would strike a balance between the predominant coverage of health from a biomedical and lifestyle perspective. It would also help educate the Canadian public about the potential health impacts of various governmental decisions and improve the potential for public involvement in public policymaking; and that
Immediate Action
As a means of moving this agenda forward, the conference recommends that Canada's federal and provincial/territorial governments immediately address the sources of health and the root causes of illness by matching the $1.5 billion targeted for diagnostic services in the Romanow Report on the Future of Health Care in Canada and allocating this amount towards two essential determinants of health for children and families: 1) affordable, safe housing; and 2) a universal system of high quality educational childcare; and
Long-Term Action
Similar to governmental actions in response to the Acheson Inquiry into Health Inequalities in the United Kingdom, the federal government should establish a Social Determinants of Health Task Force to consider these findings and work to address the issues raised at this conference. The Task Force would operate to identify and advocate for policies by all levels of government to support population health. The federal and provincial governments would respond to these recommendations in a formal manner through annual reports on the status of these social determinants of health.
So Resolved, this December 1, 2002, in Toronto, Canada, and Ratified, February 10, 2003.
REFERENCES
Bryant, T. (2002) The role of knowledge in public health and health promotion policy change. Health Promotion International, 17, 89–98.
Centre for Social Justice (2003) Social Determinants of Health Across the Life-Span. Centre for Social Justice, Toronto (available online at http://www.socialjustice.org).
Coburn, D. (2001) Health, health care, and neo-liberalism. In Armstrong, H. Armstrong. P. and Coburn, D. (eds) Unhealthy Times: The Political Economy of Health and Care in Canada. Oxford University Press, Toronto, pp. 45–65.
Health Canada (1998) Taking Action on Population Health: A Position Paper for Health Promotion and Programs Branch Staff. Health Canada, Ottawa (available online at http://www.hc-sc.gc.ca/hppb/phdd/pdf/tad_e.pdf).
Institute for Research in Public Policy (2003) Policy Options. Dossier, March 2003 (available online at http://www.irpp.org/po/index.htm).
Kirby, M. J. (2002) The Health of Canadians: The Federal Role. Standing Senate Committee on Social Affairs, Science and Technology, Ottawa (available online at http://www.parl.gc.ca/37/2/parlbus/commbus/senate/Com-e/SOCI-E/rep-e/repoct02vol6-e.htm).
Raphael, D. (2003) When social policy is health policy: why increasing poverty and low income threatens Canadians’ health and health care system. Canadian Review of Social Policy, 51, 9–28.
Raphael, D. (ed.) (2004) Social Determinants of Health: Canadian Perspectives. Canadian Scholars Press, Toronto.
Raphael, D. and Curry-Stevens, A. (2003) The Toronto Charter for a Healthy Canada. York University School of Health Policy and Management and the Centre for Social Justice, Toronto (available online at http://quartz.atkinson.yorku.ca/draphael).
Wilkinson, R. and Marmot, M. (2003) Social Determinants of Health: The Solid Facts. WHO European Office, Copenhagen (available online at http://www.who.dk/document/e81384).
WHO (1986) Ottawa Charter for Health Promotion. WHO, Geneva (available online at http://hc-sc.gc.ca/hppb/phdd/docs/charter/).
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