Addressing the Social Determinants of Health – Modernizing Primary Health and Care

This is the third story in our series Modernizing Primary Health and Care where we share the recommendations we provided to Alberta Health’s Modernizing Alberta’s Primary Health Care System (MAPS) initiative.

Our health is shaped by a complex set of factors, including genetics, lifestyle choices, environment, and social determinants of health. Social determinants of health refer to a wide range of social, economic, and environmental factors that affect our health, such as income, housing, education, and discrimination.

More than 75% of our health is influenced by social, environmental and other factors and not by healthcare. However, investments in addressing social determinants of health are still modest compared to investments in the traditional healthcare system.

In Canada, there has been a gap in implementing coordinated policies and programs that address social determinants of health, reduce health inequalities, and improve the overall health of the population. The social determinants of health are often seen as too complicated to deal with, and politicians prefer to focus on issues that fit neatly into a four-year political cycle. However, there are models that other jurisdictions have implemented that have been successful in addressing social determinants of health and health inequalities.

One such model is the Nuka model offered by the South Central Foundation in Alaska, which takes a population health approach, is focused on social determinants of health, and has moved from a transactional “fee for service” model of care to one built on relationships and factors driving individuals’ overall health and well-being. In this model, physicians are not the only providers in the system, and individuals enter the system through different pathways. Physicians who do not delegate to other providers working at full scopes of practice are not retained by the Foundation. Nuka has significantly lower costs of care than other established primary health system models, even as it serves a relatively high health and social needs population.

The Taber Integrated Primary Healthcare Project in Alberta is another example of a successful primary healthcare renewal initiative that involved rural physicians and the Chinook Health Region. The goal of the project was to improve healthcare services delivery through the integration of the services provided by the physician group and the health region, focused on the needs of the population in one rural community. Community health workers became an example of customizing team supports and community engagement to the needs of the population, including new immigrants from the Mexican Mennonite Community. An HQCA study examining the Taber and Calgary Crowfoot initiative found that investing in strong, team-based primary care focused on the needs of the population resulted in better patient outcomes and lower overall health system costs.

In addition to the above models, there is also evidence that addressing social determinants of health such as income and housing can significantly improve health outcomes. The MINCOME field experiment in Dauphin, Manitoba, between 1974 and 1979 looked at the implications of a guaranteed annual income. Analysis of Manitoba health administration data documented an 8.5 percent reduction in the hospitalization rate for participants relative to those who did not participate. Participant contacts with physicians declined, especially for mental health. These results suggest that a more holistic model of primary care, one that includes service providers who can address the broader needs of individuals and families, is more desirable than a narrow, physician-oriented primary care model.

Similarly, the At Home/Chez Soi project in Canada aimed to generate knowledge about effective approaches for people experiencing serious mental illness and homelessness. The project evaluation results showed that about 80% of participants remained housed after two years’ follow up – very high for a highly vulnerable and transient population – and led to a significant reduction in service use and costs, including a reduction in nights slept in shelters and fewer emergency department visits.

ICN recommended to the MAPS initiative that a leadership group spanning multiple sectors be established to increase our understanding of the factors that contribute to health. Building understanding among Albertans about the contribution of factors to health other than healthcare and hospitals is an important part of ‘changing the story’. We hope to embed this perspective into the range of potential topics we explore in our future citizen engagement work. 

April 2023