Beyond health care: the other determinants of health
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* Trevor Hancock

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/189/50/E1571/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/189/50/E1571/F1)

The perception that health comes from the health care system is widespread. Yet the health care system accounts only for a small — albeit important — part of the overall health of the population, mainly through treatment. It’s really an illness care system. Most major determinants of health lie outside the health system, something that, to its credit, the Canadian Medical Association highlighted in its 2013 report *Health Care in Canada: What Makes Us Sick?*.

A 2014 policy brief found the health care system to be responsible for just 10%–20% of broadly defined health outcomes. Behaviour accounted for 30%–50%, social circumstances (which, along with physical environments, largely shape behaviour) accounted for 15%–40%, and genetic factors and the physical environment accounted for 20%–30% and 3%–20%, respectively. The recent report of *The Lancet* Commission on Pollution and Health held pollution alone responsible for 16% of all deaths globally.

This is hardly a new understanding. The Canadian government’s 1974 landmark Lalonde Report suggested four health fields: human biology, lifestyle, environment and health care. It famously stated, “there is little doubt that future improvements in the level of health of Canadians lie mainly in improving the environment, moderating self-imposed risks and adding to our knowledge of human biology.”

Two other key Canadian initiatives — the 1986 Ottawa Charter for Health Promotion, and the concept of population health championed by Dr. Fraser Mustard through the Canadian Institute for Advanced Research — expanded the list of determinants of health from the four health fields of the Lalonde Report to a dozen or more. Among the main determinants of health today in Canada are the “prerequisites for health” identified in the Ottawa charter: peace, shelter, education, food, income, a stable ecosystem, sustainable resources, and social justice and equity.

This is why much of the work of public health is conducted outside the health sector, working to change the environmental, social and economic conditions we have created to make them more health-enhancing. Any attempt to reduce the overall burden of disease, including the excess burden rooted in health inequalities, must address factors that lie upstream of the health care system. In addition to those listed in the Ottawa charter, these include ensuring clean water and air, clean and reliable energy, quality early child development experiences and — since we are 80% urbanized and spend most of our time indoors — healthy built environments.

Clearly most of these factors do not lie within the jurisdiction of the Minister of Health or the health authorities. Thus governing sectors most responsible for the health of the population are beyond health care. In fact, almost every governmental minister is in some sense a Minister of Health, and almost every municipal department is a local health department. We need to broaden our concept of health policy and ask ourselves, in what way is current food, housing, transport, or economic policy bad for health, and, conversely, what would a healthy housing and transport policy look like? We have to ask, what business is government in — and society as a whole, for that matter? Is it simply to grow the economy — which is what federal and provincial governments seem to think — or to maximize human health, well-being, quality of life and development?

Improving population health must become the responsibility of the whole government — and of society as a whole. We need to create the conditions for good health through healthy public policies at all levels, complemented by health-promoting private sector policies.

And there is no need to reinvent the wheel. In 2009, a Senate Subcommittee on Population Health released a report that has been completely ignored. It called for a “whole of government” approach to population health, with a Cabinet Committee on Population Health chaired by the premier or prime minister and charged with developing a population health improvement plan. Such a reorientation of government towards health and human development is what I call “reform for health.” It is perhaps the most important health innovation we need in the 21st century.

*Dr. Trevor Hancock is an internationally recognized public health physician. He was one of the creators of the global Healthy Cities and Communities movement, and he cofounded both the Canadian Association of Physicians for the Environment and the Canadian Coalition for Green Health Care. He’s a senior editor for the* Canadian Journal of Public Health*, on the editorial board of* Cities & Health *and a columnist for a daily newspaper in Victoria, BC. The Canadian Public Health Association recently recognized his outstanding contributions in the broad field of public health with the R.D. Defries Award.*