Bryant, T. & Raphael, D. (2020).

The Politics of Health in the Canadian Welfare State

(pp. 133-166). Canadian Scholars' Press, Inc.

CHAPTER 4

Promoting the Health

of Canadians within the
­Liberal Welfare State

Health promotion is the process of enabling people to increase

control over the determinants of health and thereby improve
their health.… Health promotion represents a comprehensive
social and political process, it not only embraces actions dir-
ected at strengthening the skills and capabilities of individuals,
but also action directed towards changing social, environmental,
and economic conditions so as to alleviate their impact on pub-
lic and individual health.
—­Dan Nutbeam, 1998

INTRODUCTION

Ultimately, the purpose of analyzing how the welfare state determines

the organization of the health care system and the distribution of the
social determinants of health is to promote health. There are numer-
ous ways by which governments, agencies, and individual workers work
to promote the health of Canadians (Rootman, Pederson, Frohlich, &
Dupere, 2017). These include improving access to and the quality of
health care, changing health-­ related behaviours, empowering com-
munities, improving the quality and equitable distribution of the social

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 134 THE POLITICS OF HEALTH IN THE CANADIAN WELFARE STATE

determinants of health through public policy action, and changing the

nature of the Canadian welfare state. We believe that even the most
concrete and narrow approaches to promoting health by improving the
health care system and promoting health-­related behaviours must con-
sider how the welfare state shapes the nature of society and the living
and working conditions that are the environments in which health-­
promotion activities take place.

HEALTH PROMOTION

Health promotion is defined by the Ottawa Charter for Health

Promotion as “the process of enabling people to increase control over
and to improve their health” (Nutbeam, 1998). Canada was once a
leader in developing health-­promotion concepts but has lagged in see-
ing these principles put into action (Hancock, 2011; Low & Therault,
2008). Box 4.1 outlines the primary means of promoting health identi-
fied in the Ottawa Charter: reorienting health care services; developing
personal skills; strengthening community action; creating supportive
environments; and building healthy public policy. These areas are sim-
ilar to the actions identified as means of reducing health inequalities
related to one’s social locations in society: strengthening individuals;
fortifying communities; improving living and working conditions; and
promoting healthy macro policies (Whitehead, 2007).

Box 4.1: Five Action Areas for Health Promotion Identified in

the Ottawa Charter for Health Promotion

Reorienting Health Care Services toward Prevention of Illness

and Promotion of Health
The role of the health sector must move increasingly in a health-­promotion
direction, beyond its responsibility for providing clinical and curative ser-
vices. Health services need to embrace an expanded mandate that is sen-
sitive and respects cultural needs.

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 Chapter 4 Promoting the Health of Canadians 135

Developing Personal Skills

Health promotion supports personal and social development through pro-
viding information and education for health, and enhancing life skills. By so
doing, it increases the options available to people to exercise more control
over their own health and over their environments, and to make choices
conducive to health.

Strengthening Community Action

Health promotion works through concrete and effective community action
in setting priorities, making decisions, planning strategies, and imple-
menting them to achieve better health. At the heart of this process is the
empowerment of communities—­their ownership and control of their own
endeavours and destinies.

Creating Supportive Environments

The inextricable links between people and their environment constitutes
the basis for a socioecological approach to health. The overall guiding prin-
ciple for the world, nations, regions, and communities alike is the need to
encourage reciprocal maintenance—­to take care of each other, our com-
munities, and our natural environment.

Building Healthy Public Policy

Health-­promotion policy combines diverse but complementary approaches,
including legislation, fiscal measures, taxation, and organizational change.
It is coordinated action that leads to health, income, and social policies
that foster greater equity. Joint action contributes to ensuring safer and
healthier goods and services, healthier public services, and cleaner, more
enjoyable environments.

Source: World Health Organization. (1996). The Ottawa Charter for Health Promotion.
Geneva: World Health Organization.

These action areas overlap with commonly used approaches to

promoting health in Canada: medical and health care approaches;
behaviour-­focused strategies; community empowerment; and influenc-
ing public policy to improve the quality and equitable distribution of the

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 136 THE POLITICS OF HEALTH IN THE CANADIAN WELFARE STATE

social determinants of health (Rootman et al., 2017). In actual practice,

these approaches frequently fail to achieve the goals envisioned by the
Ottawa Charter—­a result, we argue, of the limitations of the Canadian
welfare state in providing economic and social security to Canadians.

MEDICAL AND HEALTH CARE

SYSTEM APPROACHES

Medical and health care system approaches to promoting health are

the dominant means by which Canadians think about health and ill-
ness (Conference Board of Canada, 2012). This is despite evidence that
medical treatments by themselves have a relatively small influence upon
the overall health of the populations in wealthy nations as compared
to living and working conditions experienced across the life course
(Bezruchka, 2019). Nevertheless, access to quality and responsive health
care is important, and this is especially the case for those in marginal-
ized social locations, whose living and working situations make them
more likely to fall ill (McGibbon, 2016). Canada’s health care system is
related to aspects of its liberal welfare state.
In chapter 3, we noted how Canada’s health care system is similar
in many ways to health care systems in the social democratic, conserva-
tive, and Latin welfare states. It is universal, is funded by general rev-
enues, and covers most “medically necessary” expenses (Bambra, 2013;
Wendt, 2014). Yet there are issues with the system that are related to
Canada’s political economy, and these affect the organization and deliv-
ery of health care and the general living and working conditions that
determine the effectiveness of health care interventions. It is probably
the latter aspect of the welfare state—­its shaping of Canadians’ working
and living conditions—­that is most decisive in determining the effec-
tiveness of the health care system.

Gaps in Canada’s Health Care System

Canada’s health care system covers only 70 percent of health care costs.
It does not cover prescribed drugs, aspects of home and long-­term care,

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 Chapter 4 Promoting the Health of Canadians 137

vision and dental care, and some rehabilitation services (Armstrong &
Armstrong, 2016). It has been identified in numerous studies as not
providing integrated care and being resistant to reform (Lazar, Forest,
Lavis, & Church, 2013; Mackenzie & Rachlis, 2011). This is due to
entrenched interests within the health care system, fiscal crises asso-
ciated with the acceptance of neoliberal ideas, and competing notions
about society and the nature of health care (Lazar et al., 2013). Canada’s
liberal welfare state’s aversion to government intervention is related to
both the development of Canada’s health care system and recent devel-
opments that threaten its vitality (Armstrong & Armstrong, 2010). The
most obvious aspect is the aforementioned exclusion of numerous health
care services (prescriptions, home care, and so on) from its universal
medicare system, which exists as a patchwork across Canada. There
have been no new national programs since medicare was implemented
federally (Armstrong & Armstrong, 2016).
In addition, successive Conservative and Liberal federal governments
have limited increases in health transfers to provincial and territorial gov-
ernments yet continue to specify what the provinces and territories can
and cannot do. These funding actions opened the door to increasing pri-
vatization in health care by provincial and territorial governments, lead-
ing to the threats of increasing out-­of-­pocket payments for care, private
ownership, for-­profit methods, privatized care work, private responsibil-
ity, and private decision-­making regarding the organization and delivery
of health care (Armstrong & Armstrong, 2016). All of these develop-
ments toward privatized, for-­profit control of health care have significant
risks to health (Canadian Doctors for Medicare, 2015).
The development of public-­private partnerships (PPPs) as a means
of organizing and delivering health care is another problematic develop-
ment in the Canadian health care system (Whiteside, 2015). Seen as a
means by cash-­strapped provinces and territories to fund health pro-
jects, they allow private, for-­profit corporations to assume control over
project design, construction, financing, and operations that used to
be provided by governments. These arrangements, however, are more
costly than having these projects funded and managed by governments.
For 74 privatized P3 projects in Ontario, the total difference in cost was

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 138 THE POLITICS OF HEALTH IN THE CANADIAN WELFARE STATE

estimated at $8 billion (Ontario Health Coalition, 2015). The adverse

impacts upon health care have been summarized as follows (Whiteside,
2015, p. 168):

Private financing is more expensive, social costs are greater, and the
loss of public control, oversight, and accountability is anti-­democratic.
The implications of P3s’ institutionalization will reverberate for de-
cades to come. Passing on higher cost, lower quality, riskier and less
innovative infrastructure and service forms to future generations is
no solution to meeting the needs of today.

Canadian federalism also plays a role in health care and health care
reform, as discussed in chapter 2. Banting and Corbett (2002) note that
federal institutions interact with other political and economic factors to
fundamentally shape the balance between the public and private sectors
in health care provision. They argue that federalism as a political insti-
tution breeds distrust of government, constraining the extent of state
involvement in the health sector in the 20th century.

Remediating the Gaps in Canada’s Health Care System

There is no shortage of recommendations for remediating gaps in
health care. Armstrong and Armstrong (2016) called for an expan-
sion of the national medicare plan to include home care, long-­term
care, dental and eye care, and pharmacare throughout the country.
This expansion would not only improve the health care system and
the health of Canadians, but in many cases, especially that of phar-
macare, it would lead to significant health care savings (Macdonald &
Sanger, 2018). McKenzie and Rachlis (2011) likewise provide numer-
ous examples by which to improve access to care and the integration
of services.
Resisting privatization and for-­profit ideas about health care, along
with returning control of the health care system to the public sector, is
another means of improving the quality and organization of the health
care system and to prevent its wasting away (Armstrong & Armstrong,

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 Chapter 4 Promoting the Health of Canadians 139

2010, 2016; Whiteside, 2015). There are many lessons available for
Canadian health care from other nations concerning the integration of
services to cover a wider range of health issues and to manage costs
(Mossialos, Wenzl, Osborn, & Sarnak, 2016; Schneider, Sarnak,
Squires, & Shah, 2017). Of course, within Canada’s liberal welfare
state, with its declining role for state action across areas, adopting these
measures without reforming the welfare state will be difficult.
Liberal welfare states tend to have limited health care systems (e.g.,
in Canada and the United States); these systems are most likely to be
two-­tiered and subject to greater privatization (e.g., in Australia and the
United Kingdom). There are some significant developments in Canada’s
health care system that show some relationships to its evolving political
economy (see box 4.2), generally resulting from the reduced role for
government in public policy, especially social and health policy. Since
the mid-­1980s through the 1990s, both Liberal and Conservative fed-
eral governments have adopted a neoliberal approach to health care and
social policies (Armstrong & Armstrong, 2016). It reflects an increas-
ing reliance on the market and also reinforces blaming-­the-­v ictim pol-
itics, which attributes blame for poor health to individuals and their
behavioural choices.

Box 4.2: Recent Threats to Canadian Health Care

Canadian medicare is also undergoing changes that threaten equitable ac-

cess to health care, a cornerstone of the system. During the 2015 federal
general election campaign, the Liberal Party promised to renegotiate the
2004 Health Accord, the 10-­year plan to strengthen the health care sys-
tem. Since its election (and subsequent re-­election), however, the Liberal
government has not renegotiated the 2004 accord.
Instead, the federal government negotiated bilateral agreements with
all of the provinces except Manitoba. These agreements lock in the Harper
cutbacks of increases at 3 percent per year, with some additional funds for
home care and mental health of approximately $11 billion over a 10-­year

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 140 THE POLITICS OF HEALTH IN THE CANADIAN WELFARE STATE

period. Advocacy groups have raised concerns about the implications for
health care service provision, particularly the impact of under-­resourcing.
The bilateral agreements do not include investment for the enforcement
of the Canada Health Act. This raises fears about a potential shift toward
further privatization, extra-­billing by physicians, and two-­tiered health care
that will lead to inequitable access to these critical services.
A considerable body of evidence from countries that have adopted a
two-­tiered system suggests that those waiting for care in the public system
cannot afford private care; that a parallel private health care system would
draw resources, particularly human health resources, away from the public
system; and that the private sector can provide powerful incentives for phy-
sicians and allied health professions to leave the public system. There are
no assurances that equity, access, or quality would increase were Canada
to replace its historical tradition of “private practice, public payment” with
a system in which private payment played a greater part.

Source: Feldberg, G., Vipond, R., & Bryant, T. (2019). Cracks in the foundation: The
origins and development of the Canadian and American health care systems. In
T. Bryant, D. Raphael, & M. Rioux (Eds.), Staying Alive: Critical Perspectives on Health
Illness and Health Care. Toronto: Canadian Scholars’ Press.

The Interaction of Health Care with Living

and Working Conditions
Literature now shows how living and working conditions affect the
efficiency and effectiveness of the health care system across all stages
of the health care continuum (Bachrach, Pfister, Wallis, & Lipson,
2014; Guillemin, Carruthers, & Li, 2014; Rasanathan, Montesinos,
Matheson, Etienne, & Evans, 2011; Sayani, 2017). We cannot assume
that a health care system will adequately respond to health care needs
without also taking account of the broader living and working condi-
tions under which people interact with the system.
There are numerous ways in which living and working conditions
affect health care outcomes. These include issues of preventing disease

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 Chapter 4 Promoting the Health of Canadians 141

and taking up prevention opportunities, being diagnosed and conform-

ing with treatment regimens, the effectiveness of treatments, and even-
tual outcomes. In the following sections, we provide an overview of
these issues, with particular reference to chronic disease (e.g., cardiovas-
cular disease, type 2 diabetes, cancer, and respiratory disease) preven-
tion, treatment, and outcomes, although these issues apply to just about
every disease and illness.

Prevention
Canadians occupying marginalized social locations are more likely to
experience health-­threatening living and working conditions; in turn,
they are more likely to develop numerous diseases that can be life threat-
ening. Cardiovascular disease, type 2 diabetes, respiratory disease, and
cancer are especially associated with material deprivation across the
life course (Auger & Alix, 2016; Davey Smith & Hart, 2002; Franco,
Bilal, & Diez-­Roux, 2015; Williams & Buttfield, 2016). Stress asso-
ciated with these adverse conditions is implicated, too, as it adversely
impacts the immune system (Kelly & Ismail, 2015; Stansfeld & Marmot,
2002). In addition, marginalized Canadians are more likely to take up
health-­threatening behaviours, such as tobacco use, excessive alcohol
consumption, and unhealthy diets, as means of coping with their situ-
ations (Frohlich & Poland, 2007; Jarvis & Wardle, 2006; Katikireddi,
Higgins, Smith, & Williams, 2013). Marginalized individuals are
also less likely to take up screening procedures that can detect disease
(Logan & McIlfatrick, 2011; Sayani, 2017; Steele et al., 2010). All of
these issues require efforts to improve the problematic living and work-
ing conditions associated with the adverse quality and inequitable dis-
tribution of the social determinants of health.

Diagnosis and Conforming with Treatment Regimens

Marginalized Canadians are more likely to be diagnosed with illness
later than other Canadians (Booth, Li, Zhang-Salomons, & Mackillop,
2010; Ricci-Cabello, Ruiz-Perez, De Labry-Lima, & Marquez-
Calderon, 2010; Sayani, 2017), and they also experience greater diffi-
culties accessing prescribed medicines (Blendon et al., 2002; Schneider

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 142 THE POLITICS OF HEALTH IN THE CANADIAN WELFARE STATE

et al., 2017). The difficulties associated with experiencing material and

social deprivation, as well as the stress associated with these situations,
make conforming to complicated treatment regimens for chronic dis-
eases like cardiovascular disease, type 2 diabetes, respiratory disease,
and cancers more difficult (Billimek & Sorkin, 2012; Clark, 2013;
Sayani, 2017).

Effectiveness of Treatment
For reasons not well understood, disease treatments are less effective for
marginalized Canadians (Canadian Partnership Against Cancer, 2016;
Sayani, 2017; Schmitz et al., 2009). This may be due to compromised
immune systems associated with material and social deprivation as well
as experience with stress across the life course (Fioranelli et al., 2018;
Marques, Bjørke-­Monsen, Teixeira, & Silverman, 2015; Morris, Berk,
Maes, Carvalho, & Puri, 2019). Again, these findings highlight the
necessity of reducing the material deprivation of those occupying mar-
ginalized social locations through higher quality and more equitable
distribution of the social determinants of health.

Health Outcomes
For all of the reasons provided above, health outcomes are worse for
marginalized Canadians even when such afflictions should be amenable
to treatment (Tjepkema, Wilkins, & Long, 2013). This is especially
the case for cardiovascular disease, type 2 diabetes, respiratory disease,
and cancer, among others (Auger & Alix, 2016; Tjepkema et al., 2013).
Again, the broader context of people’s lives must be considered when
attempting to improve the effectiveness of the health care system.

BEHAVIOURAL APPROACHES

Behavioural approaches to promoting health are concerned with chang-

ing health-­related behaviours like tobacco use, excessive alcohol con-
sumption, unhealthy diets, and lack of physical activity. There is active
debate about the relative importance of behaviours versus living and

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 Chapter 4 Promoting the Health of Canadians 143

working conditions such that questions have been raised about the value
of the behavioural approach (Scott-­Samuel & Smith, 2015).
First, evidence indicates that these behaviours play a rather small
role in predicting health as compared to broader indicators of living and
working conditions (Dinca-­Panaitescua et al., 2011; Dinca-­Panaitescua
et al., 2012; Lemstra, Rogers, & Moraros, 2015). Second, the empha-
sis on behaviours fails to address the underlying issues of why people,
especially the disadvantaged, adopt these behaviours in the first place
(Jarvis & Wardle, 2006). Third, these approaches are generally unsuc-
cessful in changing behaviours among the most disadvantaged groups
(Carey, Malbon, Crammond, Pescud, & Baker, 2017). Fourth, and per-
haps most important, an emphasis on behaviours diverts attention from
adverse living and working conditions and how these larger factors shape
health, as well as from the need for societal action to improve these con-
ditions (Kirkland & Raphael, 2018; Scott-­Samuel & Smith, 2015).
Nonetheless, health-­related behaviours do contribute to health out-
comes, and working to change health behaviours, especially tobacco
and excessive alcohol use, will continue to be an important focus of
health-­promotion activities. The forms these activities take are varied,
and, like the medical approach, their effectiveness is shaped by the
nature of Canada’s welfare state, which determines living and working
conditions.
Despite health promotion’s recognition of how context helps to
“make the healthy choice the easy choice,” behavioural health pro-
motion usually involves exhorting people—­by detailing the adverse
health effects of these behaviours—­to quit smoking, control their alco-
hol consumption, choose healthier diets, and become physically act-
ive (Lyons & Chamberlain, 2017). This approach strays little from the
traditional health education approach, which works on the assumption
that simply knowing something will lead to behavioural changes.
Not only is it well documented that those in marginalized social
locations will be the ones most likely to take up these risk behaviours
as a means for coping with their circumstances (Shelley & Cupples,
2015; Shortt et al., 2015); it is also well documented that these indi-
viduals are the least likely to modify these behaviours (Alvaro et al.,

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 144 THE POLITICS OF HEALTH IN THE CANADIAN WELFARE STATE

2010). It follows, then, that highly stratified societies will therefore see
these health-­threatening behaviours especially concentrated in the dis-
advantaged and excluded. Since liberal welfare states are the ones most
likely to exhibit these characteristics, the likelihood of success of these
approaches is less than in societies where greater economic and social
security are provided (de Leeuw, 2013; Labonté & Stuckler, 2016;
Schrecker & Bambra, 2015).

Supports for Behavioural Choices

Much has been written about how societies can “make the healthy
choice the easy choice.” Numerous recommendations for doing so have
been advanced, with some of them implemented through public policy
(Jackson et al., 2006; Laverack & Labonté, 2000). These include ban-
ning tobacco use from restaurants and other public spaces and regulat-
ing alcohol use by having the provinces manage liquor and beer sales.
Bringing in bicycle paths may also be helpful. There has also been an
increase in food labelling, with the assumption that this would lead to
behavioural change. These are all positive developments, although pol-
itical commitments to these approaches are inconsistent (see box 4.3).

Box 4.3: Ontario Has an Alcohol Crisis—­and the Government

Is Making It Worse

If you were asked to find a topic that Kathleen Wynne and Doug Ford would
agree upon, increasing access to cheap alcohol probably wouldn’t be your
first guess. Yet dismantling decades-­old policies used to protect Ontarians
from alcohol harms—­everything from alcohol-­related car crashes to liver
disease—­seems to be one of the few bipartisan issues left in Ontario.
In 2015, the Wynne government relaxed alcohol sales regulations by
allowing grocery stores in Ontario to begin selling beer, wine, and cider, a
policy that has resulted in a 25 percent increase in the number of stores
where alcohol can be purchased. And what the Liberals started on this file,
the Ford government seems determined to finish: it committed to allowing
alcohol sales in corner stores, introduced “buck-­a -­beer” to decrease the

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 Chapter 4 Promoting the Health of Canadians 145

minimum price of beer by 25 percent, cancelled a planned 4-­percent in-

crease in beer prices in October, and increased the weekly legal limit on
the hours of alcohol sales from stores like the LCBO and Beer Store by
8 percent in December. “It is time to acknowledge that Ontario is mature
enough for this change and ready to join other jurisdictions in making life a
little more convenient,” Mr. Ford said on the campaign trail.
His government’s budget delivered on that promise and more. There
has been a significant expansion in the number and type of alcohol stores
across Ontario, with a focus on privatization. The government has also
allowed alcohol consumption in parks, tailgating at sporting events, earlier
opening hours for bars, and more relaxed alcohol-­advertising rules—­all
described as “early wins for the people.”
Maybe Premier Ford is right. Perhaps, as a society, we can handle a bit
more choice in a responsible manner. These are popular decisions, too, of
course: who can argue against increased consumer choice and cheaper …
well, anything? And at first glance, it can be hard to imagine why having
your nearest grocery store or corner store sell beer would result in harms
from alcohol.
But a large body of Canadian and international evidence has shown
that one of the best ways to prevent alcohol harms is to set limits on how
cheaply and widely it can be sold. That also includes research that my
colleagues and I conducted on the Ontario Liberal government’s decision
to allow beer and wine sales in grocery stores. When we compared the
two years before and two years after the policy took effect, we found a
17.8 percent increase in the number of emergency-­room visits due to alco-
hol, compared to the 6.2 percent growth of all types of ER visits. Areas of
the province that had grocery stores selling alcohol had a 6 percent greater
increase in the rate of ER visits due to alcohol than areas that did not. And
this was not a simple correlation; we accounted for differences in age, sex,
income, and the possibility that grocery stores that started selling alcohol
were located in areas that had more ER visits due to alcohol at baseline.
Ontarians’ relationship with alcohol is already spinning out of control.
The most recent available data, from 2014, estimates that alcohol was
directly responsible for 5,147 deaths in Ontario, or just over 5 percent of

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 146 THE POLITICS OF HEALTH IN THE CANADIAN WELFARE STATE

all deaths that year. In the same year, there were 32,897 hospitalizations
due to alcohol across Ontario—­representing a big obstacle to ending hall-
way medicine, as the government has promised to do. Alcohol use has a
high cost: Researchers estimate that in 2014, Ontario spent $5.34 billion,
or $391 per person, covering the health, lost productivity, and legal costs
from alcohol—­and that’s a lot more than the $2.12 billion that the Ontario
government received from the LCBO in 2018.
Nearly every Canadian knows someone who suffers or has suffered
from an alcohol-­use disorder. Now imagine that person having to struggle
with the decision of whether or not to buy alcohol every time they go shop-
ping or take a walk though their neighbourhood. Add on everyone making
more impulsive decisions to buy alcohol, or making it easier to grab a last-­
minute six-­pack or bottle of wine, and it starts making sense that when
alcohol is more available, people will drink more—­and potentially end up
in the ER.
So, yes, while this pattern of change unfortunately predates the cur-
rent government, we can likely expect consequences from Premier Ford’s
changes around Ontario’s alcohol policy, which essentially encourage
higher-­volume and heavier drinking. At this point, we can only hope that
sometime in the near future, we sober up, reverse course, and double-­
down on measures that we know will reduce alcohol harms. Critics will be
all too eager to paint such policies as paternalistic—­the last gasps of a
nanny state—­but maybe adopting healthy and responsible public policy,
rather than increasing ease of access to alcohol, would actually be the
truest sign of a mature Ontario.

Source: Myran, D. (2019). Ontario has an alcohol crisis—­and the government is

making it worse. Globe and Mail, April 12. Used by permission of the author.

The problem with tackling this issue behaviourally is that evidence

exists that those least at risk are most likely to respond to these initia-
tives (Kelly et al., 2016). As a result, these efforts may serve to increase
health inequities rather than reduce them, as those who are influenced
by these efforts are the ones that are least disadvantaged to begin with

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 Chapter 4 Promoting the Health of Canadians 147

(Kirkland & Raphael, 2018; Scott-­Samuel & Smith, 2015). Therefore,

the best way to improve the effectiveness of behavioural approaches to
health promotion would be to increase the economic and social security
that Canadians experience. Unfortunately, trends in Canada’s liberal
welfare state have increased economic insecurity, precarious employ-
ment, and housing and food insecurity. Without improving these con-
ditions, the efficacy of behavioural approaches to promoting health will
be limited.

COMMUNITY-­BASED APPROACHES

These approaches to health promotion involve building networks and

connections among community members that allow individuals to gain
control over their social determinants of health and becoming empow-
ered to improve their health (Bracht, 1999; Eldredge et al., 2016;
Rootman et al., 2017). These approaches may involve local governments
as well as local agencies and institutions. Bracht and colleagues suggest
a continuum of stages, beginning with personal development, extending
to mutual support groups, issue identification, and campaigns, involving
community organizations, organizational coalition building and advo-
cacy, and collective political and social action (Bracht, Kingsbury, &
Rissel, 1999). There should then be success in gaining control over
economic and social resources, resulting in healthy social change. The
commonality among all community-­based approaches is the notion of
community empowerment. This is consistent with the WHO definition
of health promotion as “the process of enabling people to increase con-
trol over and improve their health” (World Health Organization, 1986).
One of the most comprehensive approaches to community-­based
health promotion was developed in Canada and goes by the name of the
Healthy Cities Movement (Hancock & Duhl, 1986). While the move-
ment began in the city of Toronto, it has seen its greatest implementa-
tion in Europe (de Leeuw, 2017; World Health Organization: European
Regional Office, 2019). The key tenets of the Healthy Cities Movement
are provided in box 4.4; the approach sees a strong role for local governing

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 148 THE POLITICS OF HEALTH IN THE CANADIAN WELFARE STATE

authorities, a tendency that goes against the liberal welfare state’s seeking
to shrink the state’s role in governance (Raphael & Sayani, 2019). This
may be one of the reasons why the Healthy Cities Movement has not
taken root in Canada. Instead, a variation, the Healthy Communities
Movement, aims to promote community empowerment for the most
part without governing authorities’ involvement (Ontario Healthy
Communities Coalition, 2019). The success of these endeavours without
fundamental shifts at the provincial and federal public policy level, how-
ever, is questionable (Raphael & Sayani, 2019).

Box 4.4: The Healthy Cities Vision

Healthy cities are places that deliver for people and the planet. They engage
the whole of society, encouraging the participation of all communities in
the pursuit of peace and prosperity. Healthy cities lead by example in order
to achieve change for the better, tackling inequalities and promoting good
governance and leadership for health and well-­being. Innovation, knowledge-­
sharing and health diplomacy are valued and nurtured in healthy cities.

People
A healthy city takes a human approach to development, prioritizing invest-
ment in people and ensuring access for all to common goods and services.
This includes:

• investment in human and social capital as a strategic approach

for urban development
• promoting inclusion, integration and non-­discrimination
• building trust, resilience, and a focus on ethics and values

Participation
A healthy city leads by example, ensuring community participation in de-
cisions that affect where and how people live, their common goods and
services. This includes:

• improved city spaces and services, based on the needs and as-
sets in communities

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 Chapter 4 Promoting the Health of Canadians 149

• stronger accountability and governance for health and well-­being

• empowered and resilient populations
• increased ownership over individual health and well-­being

Prosperity
A healthy city strives for enhanced community prosperity and strengthened
assets through values-­based governance of common goods and services.
This includes:

• progressive measures of social progress

• investment in the circular economy
• universal minimum social protection

Planet
A healthy city ensures that the health and well-­being of both the people and
the planet are at the heart of all of the city’s internal and external policies.
This includes:

• a whole-­of-­city approach to health and well-­being

• coherence across levels of governance in the approach to health
and well-­being
• strengthened city health diplomacy

Place
A healthy city creates an accessible social, physical, and cultural en-
vironment that facilitates the pursuit of health and well-­
b eing. This
includes:

• shifting from a needs-­based to an assets-­based approach

• human-­centred urban development and planning
• integrating health equity and sustainability into urban develop-
ment and planning
• enhanced inclusiveness in the use and governance of common
spaces

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 150 THE POLITICS OF HEALTH IN THE CANADIAN WELFARE STATE

Peace
A healthy city leads by example by promoting and keeping peace in all its
actions, policies, and systems. This includes:

• institutions, governance systems and architecture that prioritize

social justice and inclusive participation
• the promotion of cultural norms of inclusion and equity, a non-­
exploitative egalitarian approach
• formal governance and societal norms that tackle corruption, dis-
crimination, and all forms of violence

Source: World Health Organization: European Regional Office. (2019). Healthy Cities
Vision. Retrieved from http://www.euro.who.int/en/health-topics/­environment-­​and-
health/urban-health/who-european-healthy-cities-network/healthy-cities-vision

In contrast to a depoliticized approach that ignores the role of govern-

ing authorities, a strong manifestation of the community-­based approach
can be seen in the Norwegian health equity initiative (CHRODIS, 2018).
The initiative calls for coordinating health equity both horizontally, across
various sectors, and vertically, between different levels of government at
local, regional, and national levels (Bekken, Dahl, & Van Der Wel, 2017;
Hagen, Torp, Helgesen, & Fosse, 2016). Each of the 428 municipalities
in Norway was provided with a mandate by the national government and
tools for promoting health equity among residents.
Each municipality was provided with (a) a health profile of the
jurisdiction by the Norwegian Public Health Institute, (b) regulations
and guidelines from the Ministry of Health and Care, and (c) guide-
lines from the Norwegian Directorate of Health (Hagen et al., 2016).
They are required to hire a public health coordinator whose role it is to
coordinate activities across the various components of municipal gov-
ernance in collaboration with other local groups.
The coordinator works with these sectors and groups to produce an
overview of health, including the positive and negative factors shaping
health across the overall population and subpopulations (Hagen, Øvergård,

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 Chapter 4 Promoting the Health of Canadians 151

Helgesen, Fosse, & Torp, 2018). Some of the areas that have been focused
upon include (a) green and recreational areas, (b) universal design, (c) hous-
ing, (d) physical activity, and (e) kindergartens (Fosse & Helgesen, 2015).
Municipalities report that these supports have strengthened their
abilities to promote health and have increased collaboration with vol-
untary organizations and with actors external to municipal government
(Hagen et al., 2016), including cross-­sectorial strategic working groups.
These activities are unique among developed nations, but they are con-
sistent with the social democratic welfare state’s commitment to equal-
ity (Fosse, 2009). The likelihood of such systematic institution of this
initiative in Canada’s liberal welfare state is slim.

Supports for Community Health

The effectiveness of such a community-­based approach requires a strong
commitment to promoting health equity on the part of local governing
authorities. This is clearly present in the case of Norway and many other
jurisdictions, especially in Europe (Fosse, 2009, 2011), but it is rather less
the case in Canada—­promoting health equity is not on the agenda of most
cities and communities here. This has much to do with the prevailing ide-
ology toward public policy in general and promoting health in particular.
As noted, the prevailing ideological inspiration in the liberal wel-
fare state is that of liberty rather than equality, as in the case of the
social democratic welfare states, or solidarity, in the case of conservative
welfare states. There have been scattered instances of local authorities
taking up the task of promoting health through concerted community
action in Canada, but these are rare (National Collaborating Centre
for Determinants of Health, 2012; Sudbury and District Health Unit,
2012; Vancouver Coastal Health, 2020).

Living and Working Conditions and Community

Health Promotion
In addition to the general lack of governing authorities’ commitment to
community-­ based health-­ promotion activities, the difficult situations
many Canadians face make such participation unlikely even when such

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 152 THE POLITICS OF HEALTH IN THE CANADIAN WELFARE STATE

opportunities are available. Those most in need of community-­based

approaches are the same people whose excessive hours working, difficulty
meeting economic and financial obligations, and alienation from soci-
ety in general make participation, and potential empowerment, difficult
(Gatewood et al., 2008; Merzel & D’Afflitti, 2003; Rongen et al., 2014).
These circumstances are most associated with the liberal welfare state.

PUBLIC POLICY APPROACHES

Public policy approaches and health promotion take on the task of explic-
itly prompting governments to create the conditions necessary for health
through legislation and regulations (Mantoura & Morrison, 2016). There
is a rich tradition in the health-­promotion literature of the importance of
promoting healthy public policy to meet these aims. However, in prac-
tice, most health promoters do rather little work in this sphere (Raphael,
2006); when policy work is done, it is usually limited to eliciting legislation
concerning behavioural risk factors, such as tobacco use, excessive alcohol
use, physical activity, and diet (Bryant, Raphael, & Travers, 2007).
Health promoters sometimes advocate for higher taxes on tobacco
and alcohol, the creation of bicycle paths to promote physical activity,
and nutrition labelling, all in the service of promoting health-­related
behaviours. There is generally less direct effort in advocacy for higher
wages and better benefits in the workplace or the implementation of
universal programs such as pharmacare and childcare. There is certainly
little calling for the equalizing of power relations between the business
and corporate sector and organized labour and civil society.
This is not to say that there aren’t such organized efforts to create
legislation to improve the quality and distribution of the social determi-
nants of health. Rather, this is usually undertaken by those who do not
consider themselves to be health promoters. For example, food security
advocates will argue for higher wages and benefits to improve access to
affordable housing in order to reduce food insecurity (PROOF, 2016),
housing advocates argue for more nonprofit affordable housing to reduce
homelessness and housing insecurity (Homeless Hub, 2019), and the

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 Chapter 4 Promoting the Health of Canadians 153

organized labour sector certainly advocates for improved working and

living conditions for employees (Canadian Labour Congress, 2011).
Nonetheless, there is some evidence that health promoters, usually
those employed in public health units across Canada, have begun to take
up the task of advocating public policies that promote the quality and
equitable distribution of the social determinants of health (Raphael &
Sayani, 2019). The Hamilton Spectator contributed to this through their
groundbreaking “Code Red” series of articles, followed up by separate
“Code Red: Born” and “Code Red: Cancer” investigations, which high-
light inequalities in health in Hamilton and elsewhere, as well as the
sources of these inequalities (Hamilton Spectator, 2010, 2011, 2013).
Similarly, the National Collaborating Centre for Determinants of
Health (NCCDH) in Antigonish, Nova Scotia, has worked hard to raise
the issues of the social determinants of health and produced a wealth of
materials for use by public health workers (NCCDH, 2015). The Health
Council of Canada and the Canadian Medical Association undertook
cross-­Canada consultation on the factors that make Canadians sick,
and their final reports—­and similar reports from other organizations—­
received some media coverage (Canadian Medical Association, 2013;
Health Council of Canada, 2010).
Local public health authorities across Canada are engaging in
public policy advocacy and public education activities concerning the
social determinants of health (Brassolotto, Raphael, & Baldeo, 2014;
Raphael & Brassolotto, 2015). Importantly, one local public health unit
in Ontario created a video animation entitled “Let’s Start a Conversation
about Health . . . and Not Talk about Health Care at All” (Sudbury and
District Health Unit, 2017), which has been adapted for use by no less
than 20 other public health units in Ontario (out of the total of 36) and
numerous others across Canada (Raphael and Sayani, 2019). Two more
Ontario developments worth noting are the introduction of the Ontario
Public Health Standards (OPHS) Foundational Standard (in effect
since January 1, 2009), which mandates equity and social determinants
of health–focused monitoring and planning requirements, as well as the
introduction of 100-­percent provincially funded social determinants of
health nurse positions (two per health unit, three in Toronto) since 2011.

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 154 THE POLITICS OF HEALTH IN THE CANADIAN WELFARE STATE

Finally, Mikkonen and Raphael’s (2010) public primer on the social

determinants of health, Social Determinants of Health: The Canadian Facts,
has been downloaded almost one million times since April 2010, with 85
percent of these downloads made by Canadians. And a Canadian organi-
zation, Upstream, aims to produce a movement to create a healthy soci-
ety through dissemination to the public—­as well as policy-­makers—­of
evidence-­based, people-­centred ideas (Upstream, 2019).

Relation to Canada’s Liberal Welfare State

Yet, despite these activities, rather little has been accomplished in creat-
ing health-­promoting public policy (Hancock, 2011; Raphael & Curry-­
Stevens, 2016). Analyses of barriers to having the social determinants of
health concept taken up by policy-­makers have linked these problems to
Canada’s liberal welfare state (Bryant, 2016; Raphael, 2015). As noted
earlier, in the liberal welfare state, the business and corporate sector’s
excessive influence shapes the state’s role in providing economic and
social security to Canadians. As a result, Canada lags far behind many
other wealthy nations in public spending, which makes improving the
quality and equitable distribution of the social determinants of health
an uphill battle.
It has also been suggested that the liberal welfare state’s problem-
atic social determinants of health profile is actually profitable for cor-
porate and business owners, as it increases their revenues at the expense
of workers, who must contend with low wages, lack of benefits, and pre-
carious work situations (Raphael, 2015; Scambler, 2009). Furthermore,
the corporate and business sector’s control of the ideas around the deter-
minants of health, as another feature of Canada’s liberal welfare state,
makes achieving higher quality and equitable distribution of the social
determinants of health through public policy action particularly difficult.
Research has shown the dominance and influence of the corporate and
business sector within the boards of directors of organizations such as the
Heart and Stroke Foundation and Diabetes Canada, such that they are
unlikely to raise issues of public policy that they perceive as threatening
to their financial interests (Chaufan & Saliba, 2019; Raphael et al., 2019).

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 Chapter 4 Promoting the Health of Canadians 155

We return to these barriers and means of overcoming them in the final

chapter of this volume.

POLITICAL ECONOMY APPROACHES

Political economy approaches to promoting health recognize that it is

Canada’s political and economic systems that determine the quality and
distribution of the social determinants of health. Therefore, promoting
health requires changing these political and economic systems. This can
be accomplished by shifting power and influence held by different soci-
etal sectors. Currently, it is the corporate and business sector that dom-
inates over the organized labour and civil society sectors. Rebalancing
power would enhance health-­promotion efforts that involve all of the
approaches described: medical and health care systems, behavioural,
community, and public policy. How this can be accomplished is consid-
ered in this book’s final chapter.

DIVERSITY: A BARRIER TO EQUITY

AND WELL-­BEING?

It has been suggested that the diversity of Canada’s population makes

a strong welfare state unlikely due to the inherent tensions in such an
arrangement. This is addressed in Fighting Poverty in the US and Europe:
A World of Difference (Alesina & Glaeser, 2004), which contains a graph
illustrating that welfare states are further developed in more homoge-
neous countries. However, through a historical analysis of trends in the
United States, Alesina and Glaeser argue that every nation has com-
peting left, centre, and right interests, who use whatever methods they
can to enact their agenda. In heterogeneous societies such as Canada
or the United States, the right or more conservative—­whether it is the
business and corporate sector, the for-­profit sector, or simply reactionary
Canadians—­have historically used racism as a means of advancing their
political agenda. Such efforts are easier when a society is diverse and

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 156 THE POLITICS OF HEALTH IN THE CANADIAN WELFARE STATE

people can be pitted against each other. Therefore, while it may be more
difficult to achieve shared consensus in more heterogeneous societies, it
is not an inevitable feature of a society—­it is simply that, historically,
diversity has been used as a weapon to divide people and make it more
difficult to reach a more developed welfare state.
Similarly, Kymlicka and Banting’s (2006) Canadian volume exam-
ines the extent to which multiculturalism is incompatible with a well-­
developed welfare state. The editors conclude that such a welfare state is
not incompatible with multiculturalism. But for the same reasons pro-
vided by Alesina and Glaeser, regressive forces in Canada, like those in
the United States, can use diversity as a political weapon to split people,
making such welfare state development more difficult to attain.

CONCLUSION

In this chapter, we have outlined various approaches to promoting health

and showed how even narrow approaches to health promotion must be
placed within the context of Canada’s liberal welfare state, which shapes
not only the nature of Canada’s health care system but also the living
and working conditions that influence the effectiveness of various health-­
promotion approaches. Promoting healthy behaviours and enhancing
community empowerment will be much easier in a society in which
people are not haunted by the spectres of economic and social insecurity.
Building health-­promoting public policy that enhances the quality and
equitable distribution of the social determinants of health will also be
easier once Canada’s welfare state is made more responsive to these issues.

FURTHER READINGS

Armstrong, P., & Armstrong, H. (2010). Wasting Away: The Undermining of Canadian
Health Care. Toronto: Oxford University Press.
Wasting Away examines and assesses the Canadian health care system, exploring
its development and breaking its analysis down into accessible units: who

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 Chapter 4 Promoting the Health of Canadians 157

provides (the institutions and the people); who pays (funding sources); and who
decides (public, private, and patients). It traces recent developments that are
threatening the health care system in Canada and sums up the winners and
losers in this system.

Chaufan, C., & Saliba, D. (2019). The global diabetes epidemic and the nonprofit
state corporate complex: Equity implications of discourses, research agendas,
and policy recommendations of diabetes nonprofit organizations. Social
Science & Medicine, 223, 77–­88.
This paper assesses publicly available information on educational and policy
prescriptions, funding sources, corporate affiliations, funded research, and social
media presence pertaining to one Canadian, one United States–based, and
one international nonprofit organization concerned with diabetes. Rather than
helping to reduce the incidence of this condition, corporate dominance of these
organizations may instead be contributing to the global unequal distribution of
diabetes.

Hagen, S., Øvergård, K. I., Helgesen, M., Fosse, E., & Torp, S. (2018). Health
promotion at the local level in Norway: The use of public health coordinators
and health overviews to promote fair distribution among social groups.
International Journal of Health Policy and Mangement, 7, 807–­817.
The Norwegian Public Health Act (PHA) of 2012 aimed to further health
equity by having municipalities identify and target underserved groups and
adopt means to promote their health. This study investigates the implementation
and municipal prioritization of the fair distribution of social and economic
resources among social groups.

Mantoura, P., & Morrison, V. (2016). Policy Approaches to Reducing Health Inequalities.
Montreal: National Collaborating Centre for Healthy Public Policy. Retrieved
from http://www.ncchpp.ca/docs/2016_Ineg_Ineq_ApprochesPPInegalites_​
En.pdf
This document enables public health actors to more easily distinguish between
the most widespread policy approaches that have been proposed to reduce health
inequalities. The approaches identified and discussed are: political economy;
macro social policies; intersectionality; the life course approach; the settings
approach; approaches that address living conditions; approaches that target
communities; and approaches aimed at individuals.

Raphael, D. (2015). Beyond policy analysis: The raw politics behind opposition to
healthy public policy. Health Promotion International, 30(2), 380–­396.
This article shows how the imbalance of power in Canada between the corporate
and business sector and other sectors, such as organized labour and civil society,

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 158 THE POLITICS OF HEALTH IN THE CANADIAN WELFARE STATE

makes it difficult to attain the implementation of public policy that supports

health. It suggests means of transcending these difficulties through political and
social action.

Rootman, I., Pederson, A., Frohlich, K., & Dupere, S. (Eds.). (2017). Health
Promotion in Canada: New Perspectives on Theory, Practice, Policy, and Research
(4th ed.). Toronto: Canadian Scholars’ Press.
This volume offers an in-­depth analysis of the past, present, and future of health
promotion. It covers a broad range of key concepts and issues related to health-­
promotion practice within cities, communities, education, and clinical care
settings. This new edition also features updated content on health-­promotion
ethics, social theory, health inequities, global ecological change, intervention
entry points, and the role of the reflexive practitioner.

WEBSITES OF INTEREST

Health Promotion Canada (HPC)—­https://www.healthpromotioncanada.ca/

HPC aims to be nationally and internationally recognized as the main source
for supportive resources, to create a community of health promoters from every
province and territory, and to share tools, resources, and effective strategies for
ethical and comprehensive progressive health-­promotion practice.

National Collaborating Centre for Healthy Public Policy—­http://www.ncchpp.ca/en/

The National Collaborating Centre for Healthy Public Policy (NCCHPP)
focuses on healthy public policy: policy that potentially enhances populations’
health by having a positive impact on the social, economic, and environmental
determinants of health. The NCCHPP has several streams of work related to
determinants and health inequalities.

Nordic Health Promotion Research Network—­https://nhprn.com/

This network consists of about 50 researchers from the five Nordic countries:
Denmark, Finland, Iceland, Norway, and Sweden. The network aims to
(1) develop the theoretical understanding of health promotion; (2) develop
Nordic research co-­operation in health promotion from a Nordic perspective;
and (3) work together with the Nordic Conference on Health Promotion, held
every third year. It focuses on empowerment, equity in health, healthy aging,
health literacy, theory in health promotion, and work-­related health.

Politics of Health Group—­http://www.pohg.org.uk/

The Politics of Health Group (PoHG) consists of people who believe that power
exercised through politics and its impact on public policy is of fundamental

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 Chapter 4 Promoting the Health of Canadians 159

importance for health. PoHG is a United Kingdom–based group but with a

clear international perspective and members throughout the world.

World Health Organization: Health Promotion—­https://www.who.int/

healthpromotion/en/
This website provides definitions and a history of health promotion, as well as
numerous resources that illustrate means of promoting health.

World Health Organization, European Office: WHO European Healthy Cities

Network—­http://www.euro.who.int/en/health-topics/environment-and-health/
urban-health/who-european-healthy-cities-network
WHO Healthy Cities is a global movement working to put health high on
the social, economic, and political agenda of city governments. For 30 years,
the WHO European Healthy Cities Network has brought together some 100
flagship cities and approximately 30 national networks that cover some 1,400
municipalities. Their shared goal is to engage local governments in health-­
focused political commitments, institutional changes, capacity building,
partnership-­based planning, and innovation.

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