Equity in Times of Austerity: Ontario’s Revenue Crisis in Historical Perspective

Concerns for health equity have found entry into social policy discussions in Canada at both the national and provincial levels of government. However, in the aftermath of the global financial crisis social programs improving the distribution of social determinants of health (SDHs), such as adequate housing and income, secure employment opportunities, affordable education and health care are increasingly under attack. In light of persistent deficits, historically high debt, and the precarious state of the global economy, there is a need to re-examine various revenue tools as, to date, there has been little historical analysis of the structural changes made to revenue sources or acknowledgment of the need to re-examine the revenue side of government activity in addressing fiscal imbalances. The article interrogates changes to the Ontario taxation system, especially during the deepening of neoliberal policies in the province (post 1990), to provide historical context to the current state of the provincial treasury. It focuses particularly on income, sales, and corporate income tax, which comprise the majority of revenue generated through taxation. The decline in government revenue is then linked to three key pathways affecting the distribution of social determinants of health: social assistance, labour market policy, and housing. The article finally probes the plausibility of alternative tax structure scenarios and their potential for financing social programs that address health equity.  Résumé Une préoccupation pour l’équité en matière de santé a été incorporée aux discussions de politiques sociales, tant au niveau provinciale que  fédérale. Cependant, suivant la crise financière globale, l’amélioration d’une distribution plus équitable des déterminants sociaux de la santé par des programmes d’aide sociale, comme un logement et un revenu approprié, la sécurité d’emploi, une éducation et des soins de santé accessibles, sont chaque jours plus menacés. Considérant les déficits constants, un historique de dette élevée, ainsi que l’état précaire de l’économie globale, il existe un réel besoin de réexaminer différents outils du revenu. À date, il n’y a eu que très peu d’analyses historiques des changements structuraux qui ont été apportés aux sources de revenus, et même, de la nécessité de réexaminer le côté revenu de l’activité gouvernementale lorsqu’ on aborde le déséquilibre budgétaire. Cet article interroge les changements apportés au système de taxation de l’Ontario, surtout lors de l’approfondissement des politiques néolibérales (après 1990), afin d’offrir une analyse historique de l’état actuel de la trésorerie provinciale. L’article examine plus particulièrement les taxes sur le revenu, les ventes, et sur la fiscalité des sociétés, ce qui comprend la vaste majorité des revenus obtenus à travers la taxation. La baisse de revenus gouvernementaux est reliée  avec trois voies majeures affectant la distribution des déterminants sociaux de la santé: l’assistance sociale, la politique du marché du travail, et le logement.  Finalement, des structures de taxes alternatives sont examinées, ainsi que leur plausibilité et leur potentiel pour financer des programmes d’assistance sociale qui traitera de l’équité en matière de santé.Mots-clefs: équité en matière de santé; austérit

Globalization and the health of Canadians: ‘Having a job is the most important thing’

Background Globalization describes processes of greater integration of the world economy through increased flows goods, services, capital and people. Globalization has undergone significant transformation since the 1970s, entrenching neoliberal economics as the dominant model of global market integration. Although this transformation has generated some health gains, since the 1990s it has also increased health disparities. Methods As part of a larger project examining how contemporary globalization was affecting the health of Canadians, we undertook semi-structured interviews with 147 families living in low-income neighbourhoods in Canada’s three largest cities (Montreal, Toronto and Vancouver). Many of the families were recent immigrants, which was another focus of the study. Drawing on research syntheses undertaken by the Globalization Knowledge Network of the World Health Organization’s Commission on Social Determinants of Health, we examined respondents’ experiences of three globalization-related pathways known to influence health: labour markets (and the rise of precarious employment), housing markets (speculative investments and affordability) and social protection measures (changes in scope and redistributive aspects of social spending and taxation). Interviews took place between April 2009 and November 2011. Results Families experienced an erosion of labour markets (employment) attributed to outsourcing, discrimination in employment experienced by new immigrants, increased precarious employment, and high levels of stress and poor mental health; costly and poor quality housing, especially for new immigrants; and, despite evidence of declining social protection spending, appreciation for state-provided benefits, notably for new immigrants arriving as refugees. Job insecurity was the greatest worry for respondents and their families. Questions concerning the impact of these experiences on health and living standards produced mixed results, with a majority expressing greater difficulty ‘making ends meet,’ some experiencing deterioration in health and yet many also reporting improved living standards. We speculate on reasons for these counter-intuitive results. Conclusions Current trends in the three globalization-related pathways in Canada are likely to worsen the health of families similar to those who participated in our study

The TPP Is Dead, Long Live the TPP? A Response to Recent Commentaries

One of President Trump’s first actions on assuming office was to formally withdraw the United States from the Trans-Pacific Partnership (TPP), ironically an agreement driven more by American business interests than by those of the other 11 signatory countries. But the issues raised in our health impact assessment (HIA) of the TPP, and the insightful commentaries it generated, have not died alongside the agreement. Regardless of the unpredictability of global politics during the Trump presidency, especially in terms of global trade relationships, the importance of ongoing analyses of the health impacts of trade has not abated. If anything, as several commentators note, it requires expansion, not diminishment

The Trans-Pacific Partnership: Is It Everything We Feared for Health?

Background: Negotiations surrounding the Trans-Pacific Partnership (TPP) trade and investment agreement have recently concluded. Although trade and investment agreements, part of a broader shift to global economic integration, have been argued to be vital to improved economic growth, health, and general welfare, these agreements have increasingly come under scrutiny for their direct and indirect health impacts. Methods: We conducted a prospective health impact analysis to identify and assess a selected array of potential health risks of the TPP. We adapted the standard protocol for Health impact assessments (HIAs) (screening, scoping, and appraisal) to our aim of assessing potential health risks of trade and investment policy, and selected a health impact review methodology. This methodology is used to create a summary estimation of the most significant impacts on health of a broad policy or cluster of policies, such as a comprehensive trade and investment agreement. Results: Our analysis shows that there are a number of potentially serious health risks associated with the TPP, and details a range of policy implications for the health sector. Of particular focus are the potential implications of changes to intellectual property rights (IPRs), sanitary and phytosanitary measures (SPS), technical barriers to trade (TBT), investor-state dispute settlement (ISDS), and regulatory coherence provisions on a range of issues, including access to medicines and health services, tobacco and alcohol control, diet-related health, and domestic health policymaking. Conclusion: We provide a list of policy recommendations to mitigate potential health risks associated with the TPP, and suggest that broad public consultations, including on the health risks of trade and investment agreements, should be part of all trade negotiations

Monitoring Frameworks for Universal Health Coverage: What About High-Income Countries?

Implementing universal health coverage (UHC) is widely perceived to be central to achieving the Sustainable Development Goals (SDGs), and is a work program priority of the World Health Organization (WHO). Much has already been written about how low- and middle-income countries (LMICs) can monitor progress towards UHC, with various UHC monitoring frameworks available in the literature. However, we suggest that these frameworks are largely irrelevant in high-income contexts and that the international community still needs to develop UHC monitoring framework meaningful for high-income countries (HICs). As a first step, this short communication presents preliminary findings from a literature review and document analysis on how various countries monitor their own progress towards achieving UHC. It furthermore offers considerations to guide meaningful UHC monitoring and reflects on pertinent challenges and tensions to inform future research on UHC implementation in HIC settings

Characterizing 'health equity' as a national health sector priority for maternal, newborn, and child health in Ethiopia

The study findings point to global pressures in terms of maximizing health investments, and questions how social, political, and economic determinants of health are addressed through broader development agendas. The article characterizes how health (in)equity is represented as a policy issue. Implications for the framing, incentivization, and implementation of health policies follow representations (and misrepresentations). Health inequity is regarded as actionable (can be altered) but not fully resolvable (can never be fully achieved). Operationally, health equity is viewed as a technocratic matter, reflected in the widespread use of metrics to motivate and measure progress.Global Affairs Canada (GAC)Canadian Institutes of Health Research (CIHR

Integrated surveillance systems for antibiotic resistance in a One Health context: a scoping review

Antibiotic resistance (ABR) has emerged as a major threat to health. Properly informed decisions to mitigate this threat require surveillance systems that integrate information on resistant bacteria and antibiotic use in humans, animals, and the environment, in line with the One Health concept. Despite a strong call for the implementation of such integrated surveillance systems, we still lack a comprehensive overview of existing organizational models for integrated surveillance of ABR. To address this gap, we conducted a scoping review to characterize existing integrated surveillance systems for ABR.The literature review was conducted using the PRISMA guidelines. The selected integrated surveillance systems were assessed according to 39 variables related to their organization and functioning, the socio-economic and political characteristics of their implementation context, and the levels of integration reached, together with their related outcomes. We conducted two distinct, complementary analyses on the data extracted: a descriptive analysis to summarize the characteristics of the integrated surveillance systems, and a multiple-correspondence analysis (MCA) followed by a hierarchical cluster analysis (HCA) to identify potential typology for surveillance systems.The literature search identified a total of 1330 records. After the screening phase, 59 references were kept from which 14 integrated surveillance systems were identified. They all operate in high-income countries and vary in terms of integration, both at informational and structural levels. The different systems combine information from a wide range of populations and commodities -in the human, animal and environmental domains, collection points, drug-bacterium pairs, and rely on various diagnostic and surveillance strategies. A variable level of collaboration was found for the governance and/or operation of the surveillance activities. The outcomes of integration are poorly described and evidenced. The 14 surveillance systems can be grouped into four distinct clusters, characterized by integration level in the two dimensions. The level of resources and regulatory framework in place appeared to play a major role in the establishment and organization of integrated surveillance.This study suggests that operationalization of integrated surveillance for ABR is still not well established at a global scale, especially in low and middle-income countries and that the surveillance scope is not broad enough to obtain a comprehensive understanding of the complex dynamics of ABR to appropriately inform mitigation measures. Further studies are needed to better characterize the various integration models for surveillance with regard to their implementation context and evaluate the outcome of these models