Jacob Cramer is a Researcher and Planning Assistant with BC Healthy Communities.
In order for public policies to be healthy, they must be equitable. Why? Let me explain.
Equity is the fair distribution of opportunities, power and resources to meet the needs to all people, regardless of age, ability, gender, income, education level, culture or background. When a policy is equitable, it seeks to address power imbalances, both in the process of its creation and in its impacts.
In the words of Nancy Milio, one of the originators of the concept of healthy public policy, healthy public policies are policies designed to “improve the conditions under which people live: secure, safe, adequate and sustainable livelihoods, lifestyles, and environments, including housing, education, nutrition, information exchange, child care, transportation, and necessary community and personal social and health services.”1 Rather than directly addressing health, healthy public policies make changes to living conditions that impact health. These policies look toward root causes of ill health and try to improve the environments—social, built, economic—that cause that ill health in the first place.
This definition helps us to understand where healthy public policies operate and what they seek to influence. It’s also critical to understand the impact of a policy or set of policies in order to gauge their effectiveness, or be able to correct course. In the stages model of policy development, this process is known as the policy evaluation stage—implementing and readjusting policies to more effectively resolve an identified issue—and it forms a key component in the iterative (and nonlinear) process of developing policy.2
Milio goes on to explain that “policy adequacy may be measured by its impact on population health.” Population health itself, “aims to improve the health of the entire population and to reduce health inequities among population groups.”3 The two pieces of the population health definition are separate but tethered; each imperative to the fulfillment of the other. Just as we can’t ignore power while striving toward equity, we can’t disregard that the reduction of health inequities is core to the population, public and community health approaches. In trying to increase the capacity of all community members to be able to pursue the life they want, we must also be working to reconcile the differences varying community members currently face in doing so.
If the goal of healthy public policy is to create improved conditions which in turn improve population and community health, then as a whole, healthy public policies must also be equitable and serve to reverse health inequities. This doesn’t mean that every public policy needs to target every group, and some policies may even target groups that are more well off. What’s important is that the sum of these public policies must be equitable if we are to improve the health of our populations and communities. A singular policy can have a positive impact toward mitigating inequity, but as a standalone, it can’t be effective in improving population health. Healthy public policy can only be an effective tool if it operates within a broad and equitable social contract, implemented and enforced by policies that serve to collectively increase the well-being of the population as whole by reducing inequities.
At BCHC, our focus on equity stems from the understanding that the only way to improve a community’s health is by allocating more resources to those who are experiencing poorer health outcomes, so that everyone is better off together. This is sometimes referred to as proportionate universalism (see the graphic below). The fundamental principles underlying proportionate universalism—that a health and social gradient exists, and that the best way to improve health at a population level is by providing support proportionate to the level of need within that gradient—are well-established within the public health field.4 In planning and governance, however, we have seen slower adoption and on the whole, we aren’t making the strategic investments and interventions needed to reduce inequities.
In the figure to the left, we see a visual representation of proportionate universalism. By applying more support at the lower end of the graph, we are able to reduce the individual disparity between health outcomes across a population and improve the overall health and well-being of the entire community.
Housing & Equity
We need look no further than our suite of housing policies to see how ignoring equity considerations can affect the ability of our housing system to provide greater health and well-being for all. A lack of stable housing can impact so many other aspects of an individual’s life, from their ability to work or go to school, to their ability to consistently access nutritious food or to create the conditions for healthy development of their children. It’s clear from these few examples alone the degree to which housing issues contribute to health inequities in our populations. Policies that primarily benefit those already in high quality, stable housing may be favourably received by those who will see an immediate benefit, but in the long run, they are less effective in raising the overall health of our communities. It is being argued by many, from academics to government-backed researchers and experts, that we need a stronger focus on equity in our housing policies if we want to make a dent in our housing system’s current inability to provide equal health and well-being.
The impacts of an inequitable system have consequences for us all; even those who have access to safe, secure housing. We see these in other areas of our societal systems, where a lack of affordable, appropriate and stable housing can contribute to issues such as labour shortages, reduced civic engagement and social isolation. These challenges, in turn, hamper the health and well-being of all community members, not just those directly dealing with housing issues. A lack of staff at a childcare facility because there is no affordable housing in the community, for example, can translate into the inability of a parent to work or attend school. An older adult on a fixed income, forced to frequently move neighbourhoods in a search for stable housing within their budget, will not be able to build long term ties with their neighbours, creating the conditions for social isolation.
Continuing to develop and fund healthy public policies which disproportionately support those who have less need in the name of health improvement for all is a recipe for failure.
The ability to live better, fuller and more prosperous lives together is possible. But it is only possible if we commit to an equitable approach—supporting everyone in our communities through healthy public policies that tailor their benefits according to community members varying level of need.
Interested in learning more about implementing Healthy Public Policy at the local government level? Join us for our Creating Healthy Public Policy Speaker Series, with events happening across 2021.
- Milio, N. (2001). ‘Glossary: healthy public policy’. Journal of Epidemiology and Community Health 55:622–623. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1731988/pdf/v055p00622.pdf
- Benoit, F. (2013). Public Policy Models and Their Usefulness in Public Health: The Stages Model. Montréal, Québec: National Collaborating Centre for Healthy Public Policy. http://www.ncchpp.ca/docs/modeleetapespolpubliques_en.pdf
- Government of Canada. (2012). Determinants of Health: What is the Population Health Approach?. Public Health Agency of Canada. https://www.canada.ca/en/public-health/services/health-promotion/population-health/population-health-approach.html#What
- Carey, G., Crammond, B. & De Leeuw, E. (2015). Towards health equity: a framework for the application of proportionate universalism. International Journal for Equity in Health 14, 81. https://doi.org/10.1186/s12939-015-0207-6