Interpreting forty-three-year trends of expenditures on public health in Canada: Long-run trends, temporal periods, and data differences

Do expenditures on public health reduce preventable mortality in the long run? Evidence from the Canadian provinces

BACKGROUND

Investments in public health - prevention of illnesses, and promotion, surveillance, and protection of population health - may improve population health, however, effects may only be observed over a long period of time.

OBJECTIVE

To investigate the potential long-run relationship between expenditures on public health and avoidable mortality from preventable causes.

METHODS

We focused on the country spending the most on public health in the OECD, Canada. We constructed a longitudinal dataset on mortality, health care expenditures and socio-demographic information covering years 1979-2017 for the ten Canadian provinces. We estimated error correction models for panel data to disentangle short-from long-run relationships between expenditures on public health and avoidable mortality from preventable causes. We further explored some specific causes of mortality to understand potential drivers. For comparison, we also estimated the short-run relationship between curative expenditures and avoidable mortality from treatable causes.

RESULTS

We find evidence of a long-run relationship between expenditures on public health and preventable mortality, and no consistent short-run associations between these two variables. Findings suggest that a 1% increase in expenditures on public health could lead to 0.22% decrease in preventable mortality. Reductions in preventable mortality are greater for males (-0.29%) compared to females (-0.09%). These results are robust to different specifications. Reductions in some cancer and cardiovascular deaths are among the probable drivers of this overall decrease. By contrast, we do not find evidence of a consistent short-run relationship between curative expenditures and treatable mortality, except for males.

CONCLUSION

This study supports the argument that expenditures on public health reap health benefits primarily in the long run, which, in this case, represents a reduction in avoidable mortality from preventable causes. Reducing public health expenditures on the premise that they have no immediate measurable benefits might thus harm population health outcomes in the long run.

The political and fiscal determinants of public health and curative care expenditures: evidence from the Canadian provinces, 1980-2018

OBJECTIVES

Public health systems have been centre stage during the COVID-19 pandemic, but governments invest relatively little in public health as compared to curative care. Previous research has shown that public health expenditures are under pressure during recessions and could be politically determined, but very few studies analyze quantitatively their determinants. This study investigates the political and fiscal determinants of public health and curative care expenditures.

METHODS

After constructing a dataset building on disaggregated health expenditures in the Canadian provinces from 1975 to 2018, we use error correction models to study the short-run and long-run influence of fiscal and political determinants on public health expenditures and on curative expenditures. Fiscal determinants include measures of public debt charges and federal transfers. Political determinants include government partisanship and election cycles. We also explore whether curative expenditures crowd out public health expenditures.

RESULTS

We find no difference between left and right governments in curative care expenditures but show that left governments spend more on public health if we control for past spending decisions in favour of curative care. Fiscal austerity reduces both public health and curative expenditures, and provincial governments use additional intergovernmental transfers to increase their curative care budgets. A growth in the proportion of curative care relative to total health budgets is associated with a decline in public health expenditures.

CONCLUSION

Even though they have low political salience, public health expenditures remain driven by partisanship and electoral concerns. Despite their widely acknowledged importance, public health programs develop in the shadow of curative care priorities.

Prioritization of public health financing, organization, and workforce transformation: a Delphi study in Canada

BACKGROUND

The increased scrutiny on public health brought upon by the ongoing COVID-19 pandemic provides a strong impetus for a renewal of public health systems. This paper seeks to understand priorities of public health decision-makers for reforms to public health financing, organization, interventions, and workforce.

METHODS

We used an online 3-round real-time Delphi method of reaching consensus on priorities for public health systems reform. Participants were recruited among individuals holding senior roles in Canadian public health institutions, ministries of health and regional health authorities. In Round 1, participants were asked to rate 9 propositions related to public health financing, organization, workforce, and interventions. Participants were also asked to contribute up to three further ideas in relation to these topics in open-ended format. In Rounds 2 and 3, participants re-appraised their ratings in the view of the group's ratings in the previous round.

RESULTS

Eighty-six public health senior decision-makers from various public health organizations across Canada were invited to participate. Of these, 25/86 completed Round 1 (29% response rate), 19/25 completed Round 2 (76% retention rate) and 18/19 completed Round 3 (95% retention rate). Consensus (defined as more than 70% of importance rating) was achieved for 6 out of 9 propositions at the end of the third round. In only one case, the consensus was that the proposition was not important. Proposition rated consensually important relate to targeted public health budget, time frame for spending this budget, and the specialization of public health structures. Both interventions related and not related to the COVID-19 pandemic were judged important. Open-ended comments further highlighted priorities for renewal in public health governance and public health information management systems.

CONCLUSION

Consensus emerged rapidly among Canadian public health decision-makers on prioritizing public health budget and time frame for spending. Ensuring that public health services beyond COVID-19 and communicable disease are maintained and enhanced is also of central importance. Future research shall explore potential trade-offs between these priorities.

The politics of public health investments

Public health investments help to prevent mortality and reduce health care costs. Yet very few studies have examined the determinants of preventive care investments across countries and over time. We develop a theory of health spending priorities contrasting preventive and curative care. Preventive care is particularly unlikely to be prioritized by governments since it is a public good that requires the allocation of scarce resources in the present to generate diffuse benefits that unfold only in the long-term. As such, public health is a "quiet" policy that is not supported by interest groups or public opinion. These characteristics have two implications: like other long-term investments, public health programs are particularly vulnerable to fiscal austerity, and prevention expenditures are not influenced by government partisanship since parties cannot attract votes with such low visibility, long term investments. We use a dataset covering 25 OECD countries from 1970 to 2018 to demonstrate that fiscal consolidations are negatively associated with the absolute level of preventive care and with its proportion relative to curative care. We also confirm that left-wing governments are not more likely to invest in public health than right-wing governments. Finally, contributing to the literature on comparative health care systems, we show that National Health Services systems maintain higher preventive care investments than Social Health Insurance systems.