Where Has the Canadian Public Health Sector Gone?: The Optimal Mix of Patient and Community Oriented Health Programs and Policies

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In health terms, the post-war period in Canada has been noteworthy mainly for the introduction and maintenance of national health insurance (NHI); but the period has also been one of significant paradigm changes concerning public health. Before the introduction of NHI (roughly 1945-1970), public health was eclipsed by curative health objectives; with the objective of introducing medicare dominating all policy options designed to prevent diseases and injuries from occurring, or to promote healthy lifestyles and living environments. The decade following the introduction of medicare (the 1970s) was one of policy concern about health costs in the context of rapidly increasing prices. During this period, interest was rekindled in public health, not as a mechanism for promoting better health but as a mechanism for constraining curative health expenditures. By the beginning of the 1980s, this interest declined, and two new paradigms emerged. One was the paradigm of population health maximization via evidence based medicine - a paradigm in which containment of health sector expenditures remained the main objective of policy but reliance on public health ceased to be a primary cost containment tool. The other paradigm was health promotion, in which the idea of health policy was replaced by that of healthy public policy. Integral to both 1980s paradigms was recognition that public health was no longer appropriately defined as a sectoral concept, and no longer pertinent to health sector policies concerned mainly with the funding of curative services. Policy-makers and health analysts are currently struggling to find the best ways to define public health policy in a world where health and non-health goals are becoming increasingly comparable, and where non-health policies are as important as health ones in defining the standard of a health.