December 14, 2005

Towards a healthier Ontario: Social determinants of health as a framework for creating the provincial budget A pre-budget submission by: Michael Shapcott, Senior Fellow in Residence: Public Policy Telephone – 416-972-1010, x231 Facsimile – 416-921-7228 Cellular – 416-605-8316 E-mail – Michael@wellesleycentral.com www.wellesleycentral.com

Introducing Wellesley Central Wellesley Central Health Corporation is a community-based urban health institute. Our mission is to promote the health of urban communities. We have three active initiatives: community-based research, capacity-building and public policy. The Wellesley Central site initiative is the city’s largest neighbourhood-based development site. On the former lands of the Wellesley Central hospital, we are working with our partners to create market housing, supportive housing and parklands. We are taking our principles of a healthy urban environment and putting them into practice in our development work. Social determinants of health The social determinants of health is an approach to community-building that was pioneered in Toronto during the 1980s, but has since spread around the world through the healthy communities movement. Both the theory and the practice have been widely accepted by the World Health Organization, the Canadian government, public policy experts, academics, elected officials and community-based organizations. The method is simple: • identify those key factors that lead to the healthiest communities possible; • identify the practical solutions that resolve those factors; • implement the effective public policies that include those solutions, and • continually monitor the process and assess results to ensure the most effective results. The key determinants of health Researchers have identified a number of basic determinants of health – the key factors that keep us healthy – and these have been largely accepted by policy experts and others. These include: • safe, secure and affordable housing, • adequate income and income security • nutritious food, • clean and safe environment, • equitable and inclusive communities. It is much healthier (and far less expensive for governments and taxpayers) to house people in good quality, affordable housing than it is to place them in hospitals, jail cells or homeless shelters. Investment in new affordable housing is not only good for the people who will find a home, but it is also a sensible and practical fiscal decision on behalf of government. Cutbacks and cancellations in federal and provincial housing programs in the 1980s and 1990s led to large increases in homelessness throughout the province. Dr. Stephen Hwang, an epidemiologist at the Inner City Health Unit at St. Michael’s Hospital in Toronto, has documented the rapid increase in morbidity (disease) and mortality (death) among the homeless.

1

Others, including the Golden Task Force in 1999, have documented the high cost of “doing nothing”. Homeless people are not only crowding into hospitals because of their poor health, but they represent a disproportionately high share of the prison population. Homeless people with special needs – such as those with HIV / AIDs or with serious mental health issues – face even greater challenges. Barriers to adopting social determinants of health While many municipalities have adopted a healthy community approach, in Ontario and elsewhere, there have been barriers to adopting this at the provincial level. First, the costs of implementing this approach are immediate, while the benefits are sometimes long-term. For instance, tackling child poverty with an investment in good quality housing, income assistance and proper nutrition means increased spending right away for the Ministry of Municipal Affairs and Housing and the Ministry of Community and Social Services, plus likely other government ministries. The benefits, in terms of better health and children who thrive as adults, will be realized over time. Second, the rigid segmentation of government spending means that costs are often borne by one ministry, with benefits realized by another. For instance, funding affordable and supportive housing means spending for the Ministry of Municipal Affairs and Housing. The benefits, in creating a healthier population and preventing hospital costs, are realized by the Ministry of Health and Long-Term Care. Third, the rigid segmentation of responsibilities among many government ministries means that important initiatives are sometimes scattered among various ministries, making effective co-ordination and delivery of the program a challenge. For instance, supportive housing for people living with HIV / AIDs falls under at least two ministries: the brick and mortar is Ministry of Municipal Affairs and Housing, while the support services are at Ministry of Health and Long-Term Care. Many people living with HIV / AIDs also need income assistance, which brings in the Ministry of Community and Social Services. While the Government of Ontario has said that it supports the development of new supportive housing, there is no inter-ministry mechanism to co-ordinate the various elements and make the program happen. All of this means, in practical terms, that it is left to community-based groups – often with limited resources – to navigate a confusing and sometimes conflicting set of rules, regulations and programs in order to put together projects. They can work for months or years to win support from one set of government officials, only to find that another set in another ministry have decided that the wait is unacceptable and withdrawn their support. Recommendation one: Top-down co-ordination required Therefore, our first recommendation to you is that the Government of Ontario should adopt, from top down, a social determinants of health approach to policy and budget-making. The current fractured process leads to a fragmented and sometimes ineffective response.

2

In practical terms, this means that when a policy initiative spans more than one government ministry – such as supportive housing – then it has to be effectively managed to co-ordinate the work of the various ministries, agencies and departments. The current government was elected on a promise to work with Ontarians to create “strong communities”. Wellesley Central shares that goal. A strong economy is essential for strong communities, but so is a strong social infrastructure. An important, and troubling, trend that has been emerging throughout Ontario has been more intense poverty and homelessness in both urban and rural areas, plus a general decline in moderate and middle-incomes as the economy continues its shift from a manufacturing base to service industries. New economic growth requires a strong foundation, and that foundation is built on an effective social infrastructure. In addition to this important overall observation, we want to underline two financial priorities: More funding for affordable housing supply, and more funding for income assistance. Recommendation two: More affordable housing urgently needed Therefore, our second recommendation is that the Government of Ontario move more quickly to implement the promises that were made in the last provincial election for new affordable housing. Housing is a fundamental determinant of health and good quality, affordable housing is in desperately-short supply across Ontario. The current government promised in 2003 to re-build Ontario’s public services, including: • “almost 20,000 new housing units for needy families”, • “a housing allowance for low-income families [to] provide direct, immediate housing relief

for 35,000 families”, • “a provincial rent bank to help tenants with short-term arrears so that they can keep their

homes”, • a “priority to the development of affordable housing on Ontario government-owned lands”, • the creation of a new “Ontario Mortgage and Housing Partnership to provide competitive

financing rates for non-profit, co-operative and commercial developers who want to build rental housing in Ontario”, and,

• a “significant increase [to] supportive housing options for those suffering from mental illness”, approximately 6,600 units over four years.

The latest federal-Ontario housing agreement calls for only 5,000 of the 35,000 housing allowances, and about half the 27,000 new affordable and supportive homes. Clearly, the Ontario government needs to ramp up its housing supply programs. Recommendation three: Adequate nutrition for those on income assistance Recently, the Ontario government has started to take steps, through the Ministry of Community and Social Services, to impose harsh new restrictions on the special diet allowance that is

3

available to recipients based on a simple declaration from a health care provider. Many thousands of Ontarians receive this important nutrition supplement, yet it is threatened by a change in regulations at the official level. Dr. Valerie Tarasuk, who is recognized as one of the leading authorities in Canada on nutrition, has studied the nutrition needs of low-income people and published in respected, peer-reviewed journals on this topic. Dr. Tarasuk has concluded, along with other health experts, that it is not possible for a person receiving income assistance to be adequately nourished. The relatively low level of assistance combined with the high cost of housing and other costs, means that there little money left to purchase nutritious foods. Making sure that children and families living on income assistance are adequately nourished makes sense not only from health policy, but also fiscal policy. It’s a wise investment in better health outcomes, better education outcomes and better economic opportunities in the future. Therefore, our third and final recommendation for today is that the Ministry of Community and Social Services set income assistance levels to properly reflect the real cost of living, including shelter, food and energy costs. This is a recommendation that has been made by expert panels going back to the Social Assistance Review Committee appointed by the Peterson government in the 1980s. The implementation is long overdue. In the meantime, the government should remove the restrictions on the use of the special diet allowance based on the declaration of a health care provider. Thank you for the opportunity to make these initial submissions. Sincerely,

Senior Fellow in Residence: Public Policy Wellesley Central Health Corporation

4