Determinants of Health
Jacob Schor ND
May 12, 2009

Reading the morning newspapers these last few days about President Obama’s breakthrough meeting with representatives from the healthcare industries has got me thinking. Not that this is wonderful turning point for the future of health care but about how our focus on healthcare access is misplaced.

Many researchers and organizations over the years have studied and attempted to formulate an understanding of what makes people healthy. This research yields carefully calculated and thought out lists of the ‘determinants of health.’ When these lists are examined, we consistently find that ‘access to health care’ invariably falls near the bottom of the list; other factors have far greater effect on health. Health care plays a relatively small influence on how healthy a population is.

The World Health Organization (WHO) has studied this issue at great depth. Here is the WHO list of the determinants of health in order of importance:

1. Income and social status - higher income and social status are linked to better health. The greater the gap between the richest and poorest people, the greater the differences in health.
2. Education – low education levels are linked with poor health, more stress and lower self-confidence.
3. Physical environment – safe water and clean air, healthy workplaces, safe houses, communities and roads all contribute to good health. Employment and working conditions – people in employment are healthier, particularly those who have more control over their working conditions
4. Social support networks – greater support from families, friends and communities is linked to better health. Culture - customs and traditions, and the beliefs of the family and community all affect health.
5. Genetics - inheritance plays a part in determining lifespan, healthiness and the likelihood of developing certain illnesses. Personal behaviour and coping skills – balanced eating, keeping active, smoking, drinking, and how we deal with life’s stresses and challenges all affect health.
6. Health services - access and use of services that prevent and treat disease influences health
7. Gender - Men and women suffer from different types of diseases at different ages.

Thus for the WHO, access and use of Health Services is number 6 on a list of 7 factors.[1]

Health Canada’s website provides a slightly longer take on this list of determinants; they list a full dozen factors that determine a person’s health. Health Canada puts health services at number 10 out of 12:

1. Income and Social Status
2. Social Support Networks
3. Education and Literacy
4. Employment/Working Conditions
5. Social Environments
6. Physical Environments
7. Personal Health Practices and Coping Skills
8. Healthy Child Development
9. Biology and Genetic Endowment
10. Health Services
11. Gender
12. Culture

Health Canada’s website goes into each of these factors and the research data behind their opinions. If you are interested in this business, this is your best source for reading. [2]

The take home message is that health services and access to health services has a relatively small effect on health. Other factors make a bigger difference.

This information perhaps helps explain our current situation in the United States. When comparing life expectancy in the US to other nations, we rank number 19 for females, and 26 for males. We are far back in the ranks. Yet the US spends more on health care than any other nation.

“The United States spends more money on health care than any other country in
the Organization for Economic Cooperation and Development (OECD). The OECD
consists of 30 democracies, most of which are considered the most economically
advanced countries in the world. According to OECD data, the United States spent
$6,102 per capita on health care in 2004 — more than double the OECD average and
19.9% more than Luxembourg, the second-highest spending country. In 2004, 15.3%
of the U.S. economy was devoted to health care, compared with 8.9% in the average
OECD country and 11.6% in second-placed Switzerland.”

Congressional Research Service [3]

Bottom line is we spend a lot more on health services and get less in return. This is kind of old news.

Look back at those lists of determinants.

It is an easy guess that if we compare the performance of our nation in addressing these determinants that we fall behind or below those other nations that appear to have healthier populations. Perhaps our focus on more and cheaper health care services is misdirected.

Addressing these other determinants may provide more benefit if our end goal is really promoting health. Reducing income disparity and the social status associated with low income, increasing social networking and improving education, the top three determinants on all lists, may do more for our nation’s health than providing insurance to everyone.

Just a thought…..

References and Links:

[1] WHO Determinants of Health:
[2] Health Canada Determinants of Health:
[3] U.S. Health Care Spending: Comparison with Other OECD Countries. September 17, 2007. Chris L. Peterson and Rachel Burton

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