Healthy Cities in the SDG Era

2. Good Health and Wellbeing

January 22, 2021 Centre for Global Health, Dalla Lana School of Public Health Season 1 Episode 2
Healthy Cities in the SDG Era
2. Good Health and Wellbeing
Show Notes Transcript

Sustainable Development Goal 3: Good Health and Well-being, holds as its objective, ensuring healthy lives and promoting wellbeing for all at all ages. Its targets encompass a broad range of areas, from improving maternal and child health outcomes, reducing premature death from non-communicable diseases and promoting mental health and well-being, to ensuring universal access to sexual and reproductive health-care services.

SDG 3 is one of the two foundational SDGs of our series, alongside SDG 11: Sustainable Cities and Communities. Throughout the series, we’ll explore the ways that these SDGs intersect with other goals, including gender equality, education, reducing inequalities, zero hunger, and climate action. This episode will feature both global and Canadian perspectives on how we can address SDG3, from community interventions to system-level approaches. 

Sujata Mishra is a PhD candidate in Health Economics, at the Institute of Health Policy Management and Evaluation, University of Toronto. She is a student in the Collaborative Specialization in Global Health at the Dalla Lana School of Public Health, University of Toronto. Her research focuses on community health workers in India called Accredited Social Health Activists or ASHAs in India, and their role in reducing maternal and child mortality and improving their health outcomes.

Dr. Sara Allin is Assistant Professor at the Institute of Health Policy Management and Evaluation at the University of Toronto. She is the Director of Operations at the North American Observatory on Health Systems and Policies. Dr. Allin also works as a Senior Researcher with the Canadian Institute for Health Information. Her research focuses on improving health system performance in Canada and other high-income countries.

CREDITS: This podcast is co-hosted by Dr. Erica Di Ruggiero, Director of the Centre for Global Health, and Ophelia Michaelides, Manager of the Centre for Global Health, at the Dalla Lana School of Public Health, University of Toronto, and produced by Elizabeth Loftus. Audio editing is by Anwaar Baobeid. Music is produced by Julien Fortier and Patrick May. It is made with the support of the School of Cities at the University of Toronto. 

Ophelia Michaelides [00:00:05] Welcome to Healthy Cities in the SDG era, a podcast where we'll talk about the Sustainable Development Goals and how we can achieve them from the perspective of a global health focused center at an academic institution in Canada's most populous city, Toronto. We're recording from Toronto or take Tkaronto on the traditional land of the Mississauga of the new Credit First Nation, Anishinaabe, Wendat Huron and Haudenosaunee Indigenous Peoples. The territory was the subject of the dish with one spoon wampum belt treaty, an agreement between the Iroquois Confederacy and Confederacy of the Ojibwe and allied nations to peaceably share and care for the resources around the Great Lakes. This meeting place continues to be the home to many indigenous peoples from across Turtle Island and we are very grateful to have the opportunity to work on this land. Hi. My name is Ophelia Michaelides, and I'm the manager at the Center for Global Health, a public health professional with experience in global health and health system strengthening, and a track record of building globally influential communities and partnerships. Having worked in the public sector, NGO space and academia, the focus of my work has largely been on program design, implementation, evaluation and collaboration. In this episode will delve into SDG three Good Health and Well-Being, and we will speak with two researchers whose work is centered in this area. We'll discuss what Canada can learn from other countries and how COVID 19 has impacted progress towards good health and well-being. 


Ophelia Michaelides [00:01:42] Sustainable Development Goal number three Good health and wellbeing poses an objective to ensure healthy lives and promote well-being for all at all ages. Its targets encompass a broad range of areas from improving maternal and child health outcomes to reducing premature death from non-communicable diseases and promoting mental health and wellbeing, to ensuring universal access to sexual and reproductive health care services. Perhaps its loftiest target. SDG three also sets out to achieve universal health coverage, including financial risk protection, access to quality, essential health care services, and access to safe, effective quality and affordable essential medicines and vaccines for all. SDG three is one of the two foundational SDGs of our series, alongside with SDG 11 for Sustainable Cities and Communities, which will delve into in another episode. Throughout our podcast series, however, will explore the ways that these SDGs intersect with gender equality, education, reducing inequalities, zero hunger, climate change. And that's only to name a few. Improving the health of individuals and the sustainability of health systems requires research and innovations at both the global and local levels. This episode will feature both global and Canadian perspectives on how we can address SDG three from community interventions to system level approaches. Our first guest will bring forth this global health perspective and speak to the particular challenges that low and middle income countries face in achieving good health and well-being, and the ways in which community based solutions can help. Sujata Mishra is a Ph.D. candidate in health economics at the Institute of Health Policy Management and Evaluation at the University of Toronto. She is also a student in the Collaborative Specialization in Global Health at the Dalla Lana School of Public Health at the University of Toronto. Her research focuses on community health workers in India called accredited social health activists or Asha's, and their role in reducing maternal and child mortality and improving their health outcomes. Welcome, Sujata. 


Sujata Mishra [00:03:56] Thank you very much, Ophelia, for the introduction and for inviting me to be a part of this amazing series on messages. 


Ophelia Michaelides [00:04:04] Thank you so much for being with us today, Sujata. I am super curious to know more about your research and how your work contributes to achieving these global goals that we've set out for ourselves through the SDGs. 


Sujata Mishra [00:04:18] Great. Thank you so much. 


Ophelia Michaelides [00:04:21] Fantastic. So let's get right into it. I would love to hear more about what your research is about and how they are aligned with achieving our SDGs. 


Sujata Mishra [00:04:32] So before I start to speak about maybe I'd like to take a minute to just give a background, some context. Globally, low and middle income countries that are disproportionately high burden of maternal and child mortality. For example, despite making substantial economic progress, about 15% of all global maternal mortality and about 25% of all in child mortality occurs in India alone. And not surprisingly, this mortality burden is much greater among marginalized communities like the ones with low socioeconomic status. And among scheduled castes, tribes in India and among people who actually reside enslavers. A sizable proportion of these deaths are preventable and treatable. So infants access to care, early detection of pregnancy complications, dying units, specialized healthcare centers, and promoting institution based on evidence based research has shown that community health workers who are aware of the social and traditional contexts of communities and form an integral part of the local primary. Health care centers can also be very effective in improving health outcomes for women and children. Also in 2005, to expedite the attainment 12 Millennium Development Goals of the MDGs, particularly MDG four and five that relate to a substantial reduction in child mortality and maternal mortality. The Government of India actually introduced a special gathering of Community Health workers, called the accredited social health activists or ASHAs that incidentally actually means hope in Hindi under the new National Rural Health Mission. So the idea was that women between ages 25 to 45 and who have had like basic high school education and reside within a village and were also familiar with the traditional and cultural practices of the community, if are given basic healthcare training, they can become agents of change for their communities. So these actions were expected to use this social and artistic capital to act as a bridge between the local village communities, the healthcare needs and the health systems or the primary healthcare sectors, which was supposed to be the first point of funding. Again, ASHAs are responsible mainly for registering people are registering new pregnancies in her village, following pregnant women to their pregnancy, motivating them to again activities get sessions. And they also are supposed to stress on an institutional base so that the childbirth process is a much safer one. Further, they basically advise on nutrition, breastfeeding practices and also conduct immunization drives in the village, since ASHAs are women volunteers, in fact, there are about a million of them now in the field. The government, I think, considers this to be a very low cost, high impact intervention. So obviously it's not going to punch a hole in the national exchequer, but interestingly to incentivize ASHAs to perform their duties better, there is a performance based payment system in place which is tied to then achieving specific goals or targets. So my research basically focuses on examining these existing incentive systems, how they have evolved over time and how different they are between the different states in India. Because again, the outcomes, the health outcomes, particularly for maternal and child, have been very different between the states. And again, the role that this plays in improving outcomes and mortality in general. To answer the second part of your question. I think my research is quite organically aligned to the SDGs on sustainable development goals, particularly as 3.1 or 2.2 and 3.7. That aims at substantial reduction in maternal and child mortality, as well as ensures access to sexual and reproductive health services like family planning. I believe that the actions of pharmaceuticals part in making sure that women, particularly the ones who are at higher risk of having pregnancy related complications and hence having a heavy mortality and morbidity associated with it, have access to a continuum of care towards their pregenancy and in their close proximity, and are also supported adequately by the system to prevent any adverse outcomes. Again, in the past we've seen that ASHAs play a very significant role in motivating women to attend their anti-natal care session. We are supposed to accompany women to a healthcare facility to have a safe delivery and on many occasions they also arrange for transportation for the women to actually get to the healthcare facility, which is very, very important. So I think that such practices potentially contributing to India's progress towards achieving these two goals. 


Ophelia Michaelides [00:10:08] Thanks, Sujata. That's that's fascinating. And if I may, I actually absolutely love that Asha's means hope in India. I think that is very, very clever. But, yes, absolutely. And I think I mean, undoubtedly, I think it's them, the Asha's that work in India and an important exemplar of how primary health care is grounded in community in India and all over the world. But I'm encouraged to hear that the role of Asha's as that bridge between community and the health system is continuing to make a difference in the types of health outcomes for women and children that we're seeking improvement on. However, I can't help but think, as with most things in this world, health interventions such as this one don't exist in a vacuum and are undoubtedly being impacted by the COVID 19 pandemic that we are living through around the world. And I do imagine India to be no exception to this. I was wondering if you could tell us a little bit more about COVID, about how COVID 19 has impacted progress towards achieving the SDG three targets related to maternal and neonatal health? 


Sujata Mishra [00:11:26] Absolutely. I think that's a great question and very pertinent part of the science. Well, I think the ongoing pandemic has shifted the priority settings for health systems, which are already struggling to maintain even routine services, and more so for resource constraints, low and middle income countries. This has also led to a lot of disruptions in access to health services, as well as has had huge impact in access to, I guess, basic services like food and water, medical supplies, medications and things like that. So in the past six months or so, countries have witnessed large reductions in access and utilization of health services, which are even more heightened for women and children, given that countries have increased restrictions, including India, on movement as well as have declared portions of the closures and lockdowns to prevent the spread of this virus. I think women in general and obviously in India are finding it difficult to seek guarantees during the pregnancy and after childbirth. This translates to more women not being able to attend, for example, their activities or sessions. Are women learning to have delivery at home instead of going to a hospital or even children getting their immunization doses? Not do on time. But there is a delay in that sense. So. That is actually a very interesting modeling study done by Timothy Hutton and things in The Lancet that models 118 countries and suggests that even the very least in the least severe case study coverage of maternal and child interventions have reduced by 10% or 20%. The world will witness about 250,000 more additional child deaths and about 10,000 more maternal deaths over a six month period. So that's a huge impact. So in the Indian context, I think, in fact, in the last 15 years, since the introduction of the National Health Commission and the ASHA program, India has seen huge reductions in modern child mortality. In fact, other related indicators like institutional deliveries and immunization rates, have also gone up drastically over that time period. Unfortunately or fortunately, I don't know, but we'll have to decide. But due to the ongoing pandemic, options now have to have additional responsibilities like surveillance of the village communities, local faces, mobilizing the village community to create awareness about the spread of COVID, as well as to talk about prevention strategies, screening and monitoring of migrant workers who have lost their jobs and are now back at home due to COVID and also been of contact tracing in case of potential exposure. So while these are essential services, I think, to prevent the spread of the pandemic this obviously means that ASHAs now have less or absolutely no time to find out routine women and child related activities. Again, like you mentioned, India, I don't think it's a one-off case and globally many countries are faced with similar problems. So yeah, I think it would definitely be challenging for a country like India to achieve their goals by 2020, with the ongoing pandemic evolving so dramatically each day and might slow down the process to a large extent. However, I think having said this, I think the pandemic has also exposed issues with the existing health care system, and this means that there's a renewed consensus in public funding for health and to bring discussions around universal healthcare to the forefront. So I think that this is perhaps a very good opportunity for countries like India to reevaluate their existing healthcare financing models, experiment with enhancing the scope of existing health systems to include all and also to put potential healthcare services like or services for maternal and child health at a high value. 


Ophelia Michaelides [00:15:49] Thanks. Sujata That's truly sobering to hear, not only about the expanded role of ASHA's now given the COVID 19 pandemic, but also to hear about the current and potentially future devastating impacts of of COVID 19 on the progress that we've made towards achieving improved health for women and children and, of course, communities at large. And I do love how you brought to the forefront the the interconnectedness of of our systems and our world and how really COVID 19 is kind of that inflection point. And it really brings to bear some of the existing cracks in our system. Perhaps we can call it and using that as an opportunity to for change in the future. I think that's incredibly important. And I think, you know, an important message of hope, you know, but a very sober one at that. And one thing that I've really appreciated throughout, you know, listening to you is throughout this conversation, I think you've really allowed us to look through a window that looks onto the Indian landscape and the role of ASHA's and India in their primary health care system, which to me begs the question, why is this important for the Canadian community? And and how can Canada and engage around discussions and contribute to discussions around maternal and child health outcomes around the world? 


Sujata Mishra [00:17:23] I think that's a great question, and I think you've already touched upon the fact that with this current pandemic, I don't think countries can no longer function in isolation or work in isolation. And there is a greater need for global partnerships to build capacity to tackle health problems and find common solutions to these problems. So I think for Canada, even despite the fact that Canada has a much higher standard of living and a much more robust health care system as compared to other countries in the global south, many Canadians still struggle to access basic health care services, this leading to large health inequalities and obviously consequential adverse health outcomes. Again, I think the burden of mortality and morbidity is disproportionately high, especially among the marginalized communities like the indigenous population who are women and new immigrants. So these are also the population groups that perhaps are more likely to face issues of poverty, discrimination and social exclusion. I think that's making them more susceptible in some sense for early onset of diseases and having lower access to health care and keeping all of this in mind. Canada has a publicly funded health care system. So just to give an example, infant mortality rates are more than twice as much in the Indigenous communities as compared to non-Indigenous population, and an Indigenous woman is less likely to have completed her recommended prenatal or antenatal care sessions. So I guess like pretty much similar to how it is in the low and middle income countries, these communities face issues like access to healthcare, utilization of healthcare, and also there is a dearth of healthcare professionals like nurses and physicians and limited medical supplies. So I think there's an urgent need to look for low cost, innovative solutions to make sure that these issues that are addressed and addressed, quite soon right? And also, I think it is well acknowledged that Canada is a country that welcomes a lot of newcomers and refugees. And so research has that language, culture, traditional values give you a significant role in determining how health seeking behaviors are done, are expected, are particularly for women. And this is done is associated with health outcomes, particularly in the prenatal and also need to be. So I think it's it's in the interest of Canada to delve deeper into these aspects and look around around as to what other countries have done and how I'd be addressing these issues. So I think that engaging in these discussions, especially around within an objective globally, will allow for opportunities to do some sort of competitive health systems analysis and also allow for opportunities for mutual learning and knowledge sharing, which will strengthen innovative multi-stakeholder partnerships and also encourage collaborative action to see and examine which interventions work and for which population and how. And to answer the second part of your question about how Canada can engage better to contribute to this discussion. I think Canada is committed to achieving its own SDGs goals. So in some way engaging in conversations around women and child health will bring about a change to help positively shape health care for future generations, not only for Canadians, but globally. I think that I think Canada needs to step up its efforts in terms of greater representation and leadership in organizations like the UN World or the World Health Organization to actively engage and participate in discussions on Public Health England and with interventions in particular, or also I guess increase investments in research, specialized training, capacity building for global health related issues at schools, colleges and universities is very important to things like innovation and new evidence and to provide opportunities for learning day by day in bridging the evidence gap that exists currently in global health in general and what you're trying to do. 


Ophelia Michaelides [00:22:12] Thank you, Sujata. I want to thank you for that very insightful commentary around, I mean, the important threads that that weave us and connect us together around the world, as well as the importance of contextualizing. Although we may have, you know, common challenges or even common opportunities, I think it's important to to see how those are fit in a particular setting around the world, whether be in Canada or in India, and, of course, how we can work together to the towards these common goals at these, you know, multilateral forum that fora that we are a part of. I certainly want to thank you for your time today. It was certainly a very eye opening conversation. I felt like I walked away from this conversation knowing more about the primary health care system in India, particularly the incredible role of these women, these ASHAs in India who do so much to keep their communities healthy. So on behalf of the Center for Global Health, I want to thank you for being on our podcast today. 


Sujata Mishra [00:23:21] Thank you so much for having me. It was a pleasure. 


Ophelia Michaelides [00:23:25] Likewise. 


Ophelia Michaelides [00:23:31] Our second guest will speak to the Canadian perspective, including the areas in which the Canadian health care system must improve in order to achieve good health and well-being for all. And what we can learn from other countries and how COVID 19 has changed priorities within health systems and policymaking spheres here in Canada. Dr. Sarah Allen is assistant professor at the Institute of Health Policy Management and Evaluation at the University of Toronto. She is also the Director of operations at the North American Observatory on Health Systems and Policies. Dr. Allan also works as a senior researcher with the Canadian Institute for Health Information. Her research focuses on improving health system performance in Canada and other high income countries. Welcome to our podcast, Sara. 


Sarah Allen [00:24:18] Thank you so much for that kind introduction. It's great to be here. 


Ophelia Michaelides [00:24:23] Thank you for joining us. We are really looking forward to learning more about the type of work that you do. But firstly, I was wondering if you could perhaps tell us a little bit more about what is the North American Observatory on Health Systems and policies and how its work is contributing to achieving SDG three. 


Sarah Allen [00:24:44] Great question. So we like to call it the NAO for short. It's much easier to say so much to us now. The NAO is a research center based at the Institute for Health Policy Management and Evaluation at the Dalla Lana School of Public Health and the University of Toronto. It was actually founded by Greg Marshallden in 2017 as a sort of sister organization to the European Observatory on Health Systems and Policies. Similar named different region. And I've been fortunate to have the position as director of operations for just over two years. It's not actually a center as much as it is a partnership of interested researchers who collaborate across North America and beyond who contribute to comparative research. And this includes rapid reviews at the request of decision makers. And we aim to contribute to evidence informed decision making broadly to strengthen health systems. And we're interested in both international and subnational comparative research. And while we've focused our first few years of developing this center on the Canadian arm of the observatory, there are also hubs in the United States with the academic director based out of UCLA and in Mexico based at the National Institute for Public Health. But I believe you asked me two questions. One was who we are and the other is how our work is contributing to SDG three Good Health and Well-Being. And so part of the work we do at the NAO is directly supporting decision makers in their efforts to make improvements to the health systems that they manage. And as I mentioned, this takes the form of rapid reviews that respond to questions that decision makers face. They are pressing policy challenges that they're looking for advice on. And so we would consolidate evidence with rapid literature reviews. We also conduct environmental scans and conduct expert interviews to compare across jurisdictions how similar challenges are being addressed elsewhere. So let me give you a very recent example of a rapid review we conducted for Toronto Public Health to help them to improve their system for managing COVID 19 cases and contacts. It's been a major challenge in Canada in the current pandemic, so they asked us to conduct a comparative case studies of a selection of countries that had some initial evidence of effective, robust case and contact management. And these included South Korea, Iceland, Singapore, Taiwan and Germany. And we were hoping to just gain some insight into what some of those promising practices were through some of the common themes that emerged from these comparative case studies. And so we conducted a review of literature. We spoke to people in each of these countries and tried to gain some of these lessons or ideas in terms of how they used digital tools and big data effectively and and how they were setting up really innovative kind of rapid testing to facilitate the kind of case and contact management that goes hand-in-hand with testing. And so this type of international policy learning is one of the ways that we aim to contribute to improved health and well-being in Canada. And that's just one example. It was one month. It was a really quick review. We've covered many other topics that that's just an example. 


Ophelia Michaelides [00:28:37] Thank you, Sarah. Besides sounding like a lot of work in this partnership, the NAO sounds like it fulfills a very important and necessary role in the interface between evidence and practice or, as you mentioned, that decision making body. And so it sounds like the the work that you're doing is not only very real, but has very relevant application, as you mentioned. And in in your in your just most recent work with Toronto Public Health, which is is fascinating in and of itself. I'm wondering, you know, in in the types of studies and comparative work that is done at the NAO, if you've already started to glean some lessons or even some thoughts around how Canada is faring in comparison to other high income countries when it comes to achieving universal health coverage or UHC. 


Sarah Allen [00:29:34] It's a really interesting question. The this notion of achieving UHC is really interesting, as if it's some end point, as if it's something that's done and then we move on. But really we know it's a process and in Canada it's a process that we're working on as well. Compared to other high income countries, the Canadian system has many strengths. This idea of universal access to medically necessary care on uniform terms and conditions is kind of unique internationally. So as per the Canada Health Act that sort of sets these criteria for health coverage systems that the provinces manage, there are no co-payments for these medically necessary care. We don't have to pay up front in that get reimbursed. We don't have user fees. This kind of financial barriers to access and this concept of uniformity, there's no alternate way of getting access through a private sector alternative, for instance. But the universal health system in Canada, the what we call Medicare, is very narrow in scope. It's only covering the hospital physician diagnostics and surgical dental care that's detailed in the Health Act. And even though the coverage is deep in terms of no user fees, there's this huge gaps in our coverage program. So if we're to look at the SDG goal, Canada does not yet have access to affordable, essential medicines for everyone. So there are uninsured and underinsured people in Canada. That's a notable gap. There are others mental health services in the community, long term care services for which people do have to pay quite a lot to cover home and institutional care, rehab and of course dental care to name a few. So there are these big gaps. There's hasn't been any major change to our universal coverage system in Canada since the Canada Health Act of 1984. So we're sort of frozen in time, but there have been some marginal changes on the edges and there is still a lot of progress that we can make. 


Ophelia Michaelides [00:31:46] I think. Sarah I think it's so important that you bring up these elements of our if this was a video, people would see me putting out my finger is almost in quotation marks universal health system in Canada. I think as Canadians we often associate universality of our health care system as part of our national identity. However, I think it is very important to note that there is still a lot of work to be done and the type of work that your you and the team are doing. With that in mind, I'm wondering if and what we can learn from other health systems in other countries. I mean, knowing again that NAO is all about comparative health system research. You know, can you give us a few examples, one to around what other health systems are doing and what lessons can be gleaned for the Canadian context? 


Sarah Allen [00:32:40] That's a great question. We can learn so much from other health systems. It's really hard to pick one or two examples, but I can give you an example of one of the big gaps in coverage that I mentioned around dental care. So arguably, basic preventive dental care would be considered essential to ensuring good health and well-being. We know that oral diseases are interconnected with chronic health conditions and can exacerbate them. It's strongly correlated with well-being, healthy aging. Yet in Canada, aside from very few programs supporting low income children, mostly dental care is left to the private market. I recently worked on a study with colleagues in seven other countries to compare how dental care is covered in their systems. In their. Publicly funded systems. And so we looked at the United States, Australia, Italy, England, Sweden, France and Germany, and we were looking at the older adult population for this study because it's a group that doesn't receive as much attention in this area, yet it's more likely to face increased needs as well as major costs associated with these oral health needs. They're also less likely to have private insurance coverage that comes from a job as they are more likely to be retired. So the study was really interesting because I got to work with people in these countries and learn about this aspect of health care that doesn't receive a lot of attention. One of the surprising things for me was that when we were looking for Canadian cases to include in the study, there are so few public programs of any kind for dental care for seniors, and Alberta has one that's been in place the longest, and Ontario has one as of last year in 2019 for low income seniors, that seems very similar, almost modeled after the Alberta program. And when we compare the Alberta program to other countries, it has the most limited coverage in terms of how much of the seniors population is covered. Only the lowest income get full public coverage in Alberta, but there's limits in terms of costs that can be incurred over a five year period, and it's also more limited in terms of which services are covered. It doesn't include really low cost preventive services like fluoride, for example, or some of the major services to treat gum disease. And I learned a lot about dental care and this project is really interesting. But what was fascinating is that even in other countries with also low levels of public spending in dental care like Italy and Australia, they do have more generous coverage for seniors oral health care. So there's a lot to be learned in terms of how those countries have been able to kind of move more of those dental care services within their universal health coverage programs. And the most generous by far was Germany, which was really interesting. And part of the reason for that is that the dental profession itself sits on the decision making body of the health system in Germany. So they're part of the structure that governs the health system in terms of making decisions on what is covered. So it'd be really hard to remove dental care from their insurance program in Germany given that fact. And it's likely to be pretty resistant to the it's unlikely to to see any changes to that. But in fact, in Germany and France, there's moves toward expanding coverage of dental care in their universal programs, whereas in Canada, there's been just pretty little movement on this front. But so much to learn. 


Ophelia Michaelides [00:36:36] Absolutely. And thank you for highlighting that highlighting that particular example around dental care. It's obvious there's so much to learn across systems. And and I think also understanding how these learnings when taking into account the needs of our own populations can have an impact on the type of health systems that we design in our own backyard, so to speak. And also, I thought it was particularly interesting to hear, you know, the study is around the provision of dental health care. However, the factors that contribute to that, such as governance and agenda setting, are so important as more upstream factors. And what actually ends up on the, I guess, on the output side of a health care system? With that in mind, I am also very aware that we are all living through a pandemic right now, which has undoubtedly put an incredible amount of stress on our health system, which we know is beyond just the provision of health care. And, I mean, it would be my hope that we'd be able to use this moment as a launchpad for change. But keeping that in mind and my question to you is how has the COVID 19 pandemic impacted Canada's progress towards UHC and the types of elements that you had previously alluded to? I'd be interested to know. 


Sarah Allen [00:38:00] Yeah. I'll tell you about this sort of movement toward more true expansions of universal health coverage. In the context of the study I was working on as a one of the flagship products of the European Observatory on Health Systems and Policies, a series of country health system studies called Hits. And the NRO has partnered with the European Observatory to produce these hits for Canada, the United States and Mexico. Mexican Hit was launched published last month. The Canadian hit will be out in a couple of weeks and us at the end of this year. And so I was working on the third edition of the Candida hit with Greg Marshallden then and one of the chapters is on recent reforms where things are going. So we'd written the chapter we've been describing what we were seeing as building momentum toward introducing a more universal program of prescription drug coverage, which we call pharmacare. In the last five years or so, the federal government has taken an increased interest and publicly stated their intention to move in this direction. There were various committees that people were probably familiar with that have that were arguing for recommending a kind of universal pharmacare program modeled after Medicare. And so we were writing this chapter and, you know, predicting the future of this would be the next biggest change to universal health coverage in Canada. Then we were wrapping up the editing of the book and we were entering the pandemic. And so we we had to rethink a lot of what we were writing in this. And we didn't do major overhaul of the book. That was, you know, it's been a year and a half or two years in the making. So what we did, though, was rethink some of those speculations. And, you know, we we have we had seen this window of opportunity to expand coverage to pharmacare. But our prediction that was more optimistic at the time, I think, is is less. So the window may have closed because the pandemic has really drawn to the fore many other pressing health challenges. There is a crisis in long term care, with over 80% of COVID related deaths occurring in long term care. And Canada was an outlier in this regard. High. That percentage was higher in Canada than all of our usual comparator countries. So that fact, as well as major challenges and an urgency to address racism and cultural safety in health care, have also emerged as other priorities and have been expressed by the federal government as priorities. So the pandemic, the the huge amount of spending and the deficit that will ensue and as well as all these other competing health priorities really may have, you know, put at least a temporary halt on major universal health coverage changes that hopefully there will be some positive change as a result. And tackling any of these major challenges would be a huge benefit to Canadians, to their health and well-being. So whether it's pharmacare or anti racism or long term care reform, it's just not as clear that the the agenda will be on universal health coverage in the near future. 


Ophelia Michaelides [00:41:49] Makes absolute sense, Sarah, and certainly speaks to that fine balance between addressing both pressing and immediate needs of our communities while continuing to work towards longer term goals such as universal health coverage. So I do want to thank you very much for joining our podcast series. 


Sara Allen [00:42:08] Thanks for having me. 


Ophelia Michaelides [00:42:16] The work of our guest highlights the complexity and diversity of approaches being developed around the world to achieve SDG three. Both Sara and Sujata certainly outlined the very significant challenges posed by the COVID 19 pandemic in achieving many of the targets set forth by SDG three. However, both reaffirming the need to sustain our efforts towards these in our current context. And I think another important takeaway that both Sara and Sujata brought forth was the the varied dimensions and the diverse dimensions that come along with health and well-being, whether it be its intersection with gender, with issues of social justice, of governance, all very important aspects and dimensions in achieving health and certainly foundational to the rest of our discussions in this series, highlighting the interdependence and interconnection of the SDGs. In order to achieve one, we must achieve them all. Thank you very much to Sara and Sujata for being with us today and having these very important and timely conversations with us. 


Ophelia Michaelides [00:43:35] Healthy cities in the SDG era is made with the support of the School of Cities at the University of Toronto, whose mission is to bring urban focused researchers, educators, students, practitioners and the public together to explore and address complex urban challenges. You can find healthy cities in the SDG era on Spotify, Apple Podcasts, SoundCloud and the Dalla Lana School of Public Health YouTube page. Join us for a next episode where we'll be discussing what it takes to make cities and communities healthy and sustainable for all. Thank you for tuning in and we look forward to speaking soon. Stay well.