Notes from the Guest Editor
I commend Longwoods and Adam Oliver (2012) and the commentators (Culyer 2012; Ellen and Shamian 2012; Forest 2012; Goel 2012; Kennedy 2012; Lawson and Howard 2012; Mitchell and Faulkner 2012; Oliver 2012; Ries 2012; Wharf Higgins et al 2012) for taking on what has become a taboo topic in Canadian health policy discourse, namely personal responsibility for health. They have done a highly readable job of presenting the pros and cons of financial incentives for health. I wish to comment only on why such an examination is important.
Having reviewed the extensive national and international literature on sustainability that has been mounting over the past decade, I have become convinced of two things. The first is that a sustainable publicly financed healthcare system is not achievable unless personal responsibility (i.e., the demand side) is brought into the equation. The second is that we are unlikely to achieve a sustainable system unless and until we introduce some measure of ethos in our system about managing risk as opposed to simply paying the bills. Turning to the first point, Justice Emmett Hall acknowledged this in the landmark 1964 report of the Royal Commission on Health Services. In the first chapter of his report, Hall set out individual responsibility for health as the first basic concept: "The Commission believes that the individual's responsibility for his personal health and that of the members of his or her family is paramount to the extent of the individual's capacities...personal hygiene, cleanliness in the home, balanced diets, precautions against accidents, adequate rest, regular exercise, wise use of time for leisure and recreation; in short, temperate living – all of these are not only of first importance in the maintenance of health but are largely under the control of the individual, and in our opinion, are clearly his responsibility" (Hall 1964: 3).
A decade later, Marc Lalonde introduced the health field concept that firmly established lifestyle as one of four major determinants of health. Lalonde did not mince words. "Personal decisions and habits that are bad, from a health point of view, create self-imposed risks. When these risks result in illness or death, the victim's lifestyle can be said to have contributed to, or caused, his own illness or death" (Lalonde 1981: 32).
The health promotion movement flourished in the 1980s. Indeed, the Study Group on Health and Sports to the Nielsen Task Force went so far as to recommend that the federal government "consider changing its role from a focus on provincial illness-treatment programs to one that emphasizes personal responsibility for one's health through healthier lifestyles, illness and disease prevention and so on" (Nielsen 1986: 82).
After that point, I would argue that attention was diverted from personal responsibility for health. The 1986 Ottawa Charter for Health Promotion focuses more on the enabling conditions for health promotion such as healthy public policy and supportive environments (World Health Organization 1986). The "population health" movement that emerged around 1990 has focused on health inequalities.
I believe another reason is that personal responsibility has been thought of more in terms of potentially punitive disincentives. For example, the 2001 Alberta Mazankowski Report raised the idea of linking healthcare premiums to actions to stay healthy, noting that "others have suggested there should be penalties for people who do not look after their own health" (Premier's Advisory Council on Health 2001: 17). Personal responsibility continues to be linked to user fees for healthcare (Francis 2012, June 7).
Why does personal responsibility matter? While I think there is no doubt/disagreement that lifestyle is influenced by such social factors as income and education, ultimately it is the result of personal choices. Following from that, lifestyle has an impact on health and the healthcare system. Statistics Canada reported for the first time in 1986 that the gap between male and female life expectancy at birth had narrowed by 0.38 years between 1975–1977 and 1983–1985, which is widely attributed to an increase in female smoking behaviour. The gap of 6.9 years seen in 1983–1985 has since been narrowed to 4.5 years, as of 2007–2009 (Statistics Canada 1986, October 27; 2012). Aside from the impact on health and quality of life, lifestyle has an impact on the healthcare system. A recent portrait of obesity in Canada estimated that in 2008 obesity accounted for $1.98 billion in direct costs to the health system (Public Health Agency of Canada and Canadian Institute for Health Information 2011). To underscore this point, according to the Organization for Economic Cooperation and Development (2011), Canada ranked sixth on the rated of adult obesity (24.2%) in 2009.
The second point I raised about risk management would be the subject of a much larger discussion. But, in brief, I am struck by the fact that most of the experimentation with incentives has taken place in the United States, with considerable involvement of employers who are a large sponsor of health insurance. Moreover, broader provision for incentives has been built into the Affordable Health Care Act (Schmidt et al. 2012). I am also fascinated by the uptake of "population health management" in the United States over the past decade – yet another Canadian concept put into practice elsewhere.
In conclusion, as Adam and the commentators clearly set out, incentives for health are no panacea. But I hope these contributions will stimulate much further discussion about personal responsibility in the health field in Canada, as there has been in other public policy areas such as retirement income security and the environment (e.g., recycling, energy use).
Owen Adams, BA, MA
Vice-President, Health Policy and Research
Canadian Medical Association
About the Author
Owen Adams, BA, MA, Vice-President, Health Policy and Research, Canadian Medical Association
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