The politics of public health: A rapid review of the impact of public health reform on population health outcomes




health equity, population health outcomes, public health reform, public health nursing


Canada’s public health (PH) systems are vulnerable to constant system and structural changes, influenced by political and economic factors. This rapid review examines how PH system restructuring impacts population health outcomes, with special consideration of health equity. Due to a lack of Canadian evidence, international research was examined to produce recommendations for Canadian nurses, researchers, and decision-makers. Evidence indicates that PH spending and PH system organization have important impacts on population health outcomes and suggests PH reform has a negative impact on health equity. Opportunities for advocacy, activism, lobbying and capacity building to achieve health equity are discussed. Nurses, in a unique position between public policy and the lives of those they care for, are presented with the opportunity to effect social change through political action and to work across disciplines to address inequities. We encourage researchers and decision-makers to prioritize looking more deeply at the impact of PH reform.


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Author Biographies

Charlotte Riordon, St. Francis Xavier University

Charlotte Riordon, RN, BA, BScN is a Registered Nurse in Fredericton, New Brunswick. She earned her Bachelor of Science in Nursing from St. Francis Xavier University and worked with Sionnach Lukeman and Christine Johnson to conduct this research for her thesis. Through her studies, Charlotte became passionate about public health, health equity and all aspects of nursing. 

Sionnach Hendra, St. FX

Sionnach Hendra, MScN, RN, is a PhD student in Nursing at the University of Victoria. She is also an Assistant Professor at St. Francis Xavier University’s Rankin School of Nursing. Her practice background before academia was public health leadership and content expertise in healthy development. Her research program involves:  Public health services and systems, political economy of health, and the integration of social justice in nursing education curriculum.

Christine Johnson, St. FX

Christine Johnson is an Adjunct Professor in the Department of Human Nutrition at St. Francis Xavier University and currently works as Health Equity Lead with Public Health with the Nova Scotia Health Authority.  As a Professional Dietitian, Christine’s work has long focused on the intersection of social justice, equity and food and works in community, research and professional capacities to advance health equity for all.


Andruszkiewicz, N., Ogunniyi, C., Carfagnini, C., Branston, A. & Hirji, M. M. (2019). Utilizing public health core competencies to share data effectively with community organizations to promote health equity. Canadian Journal of Public Health, 110, 303-313. DOI:

Bambra, C., Garthwaite, K. & Hunter, D. (2014). All things being equal: Does it matter for equity how you organize and pay for health care? A review of the international evidence. International Journal of Health Services, 44(3), 457-77. DOI:

Buck-McFadyen, E. & MacDonnell, J. (2017). Contested practice: Political activism in nursing and implications for nursing education. International Journal of Nursing Education Scholarship, 14(1), 1-13. DOI:

Canadian Network of Public Health Associations (CNPHA). (2019). A collective voice for advancing public health: why public health associations matter today. Canadian Journal of Public Health, 110, 335-339. DOI:

Canadian Public Health Association (CPHA). Public Health in the Context of Health System Renewal in Canada: Position Statement. May 2019. Available at

Canadian Public Health Association (CPHA). (2017). Public health: A conceptual framework. Retrieved from:

Critical Appraisal Skills Programme (CASP). (2018a). CASP case control study checklist. Retrieved from: Accessed on 2018 April 27.

Critical Appraisal Skills Programme (CASP). (2018b). CASP cohort study checklist. Retrieved from: -Checklist.pdf. Accessed on 2018 April 27.

Demaio, A. & Marshall, R. (2018). Social lobbying: a call to arms for public health. Lancet, 391(10130), 1558-1559. DOI:

Dobbins, M. (2017). Rapid review guidebook: Steps for conducting a rapid review. Version 1.2.Hamilton, ON: National Collaborating Centre for Methods and Tools. Accessed on 2018, April 23. Retrieved from

Dutton, D. J., Forest, P. G., Kneebone, R. D., & Zwicker, J. D. (2018). Effect of provincial spending on social services and health care on health outcomes in Canada: An observational longitudinal study. CMAJ, 190, E66-71. DOI:

Erwin, P. C., Greene, S. B., Mays, G. P., Ricketts, T. C., & Davis, M. V. (2011). The association of changes in local health department resources with changes in state-level health outcomes. American Journal of Public Health, 101(4), 609-615. DOI:

Erwin, P. C., Mays, G. P. & Riley, W. J. (2012). Resources that may matter: The impact of local health department expenditures on health status. Public Health Reports, 127, 89-95. DOI:

Fafard, P. (2018). Contested roles of Canada’s Chief Medical Officers of Health. Canadian Journal of Public Health, 109, 585-589. DOI:

Fafard, P. & Hoffman, S. J. (2018). Rethinking knowledge translation for public health policy. Evidence & Policy, 1-11.

Fierlbeck K. 2019. Amalgamating Provincial Health Authorities: Assessing the Experience of Nova Scotia. Health Reform Observer - Observatoire des Réformes de Santé 7 (3): Article 3. DOI:

Finney, J. W., Humphreys, K., Kivlahan, D. R. & Harris, A. H. S. (2011). Why health care process performance measures can have different relationships to outcomes for patients and hospitals: Understanding ecological fallacy. American Journal of Public Health, 101(9), 1635-42. DOI:

Guyon, A., Hancock, T., Kirk, M., MacDonald, M., Neudorf, C., Sutcliffe, P., et al. (2017). The

weakening of public health: a threat to population health and health care system sustainability [Editorial]. Canadian Journal of Public Health, 108(1), e1-e6. DOI:

Guyon, A. & Perreault, R. (2016). Public health systems under attack in Canada: Evidence on public health system performance challenges arbitrary reform. Canadian Journal of Public Health, 107(3), e326-e329. DOI:

Health Evidence. (2016). Quality assessment tool – Review articles. Retrieved from: Accessed on 2018 June 15.

Joanna Briggs Institute (JBI). (2017). Critical appraisal checklist for text and opinion papers. Retrieved from: Accessed on 2018 June 15.

Jobse, B. N., Adams, O. & Levy, I. (2014). Population health management: A Canadian perspective on the future of health systems. The Canadian Society of Physician Leaders, 4(1), 8-15.

Kershaw, P. (2018). The need for health in all policies in Canada. CMAJ 190(3), E64-E65 DOI:

Mays, G. P., Halverson, P. K. & Scutchfield, F. D. (2003). Behind the curve? What we need to know from public health systems research. Journal of Public Health Management and Practice, 9(3), 179-82. DOI:

Mays, G., Smith, S.A., Ingram, R.C., Racster, L.J., Lamberth, C.D., Lovely, ES (2009). Public health delivery systems: evidence, uncertainty, and emerging research needs. Am J Prev Med, 42, p. 214-220 DOI:

Mays, G. P. & Smith, S. A. (2011). Evidence links increases in public health spending to declines in preventable deaths. Health Affairs, 30(8), 1-9. DOI:

McCartney, G., Hearty, W., Arnot, J., Popham, F., CUmbers, A. & McMaster, R. (2019). Impact of political economy on population health: A systematic review of reviews. AJPH, 109(6), e1-e12 DOI:

McGibbon, E. & Lukeman, S. (2019). Critical social justice: The moral imperative for critical perspectives in nursing. Witness: The Canadian Journal of Critical Nursing Discourse, 1(1), 3-12. DOI:

McLaren, L., Braitstein, P., Buckeridge, D., Contandriopoulos, D., Creatore, M. I., Faulkner, G., & Smylie, J. (2019). Why public health matters today and tomorrow: the role of applied public health research. Canadian Journal of Public Health, 110, 317-322. DOI:

Ministers of Health and Health Promotion/Healthy Living (2010). Creating a healthier Canada: Making prevention a priority - a declaration on prevention and promotion from Canada’s Ministers of Health and Health Promotion/Healthy Living. Ottawa: PHAC Available at: Accessed August 1, 2019.

National Collaborating Centre for Determinants of Health (NCCDH). (2013). Let’s talk: Health equity. Antigonish, NS: National Collaborating Centre for Determinants of Health, St. Francis Xavier University.

National Collaborating Centre for Determinants of Health (NCCDH). (2018). Building a culture of equity in Canadian public health: An environmental scan. Antigonish, NS: National Collaborating Centre for Determinants of Health, St. Francis Xavier University.

Pinto, A. D., Manson, H., Pauly, B., Thanos, J., Parks, A. & Cox, A. (2012). Equity in public health standards: A qualitative document analysis of policies from two Canadian provinces. International Journal for Equity in Health, 11(28), 1-10. DOI:

Potvin, L. (2014). Canadian public health under siege [Editorial]. Canadian Journal of Public Health, 105(6), e401-403. DOI:

Public Health Agency of Canada (PHAC). (2008). Core Competencies for Public Health in Canada. Retrieved from: eng090407.pdf

Raphael, D. (2012). Latest OECD figures confirm Canada as a public health laggard. Canadian Journal of Public Health, 103(6), 425-27. DOI:

Raphael, D. (2015). Beyond policy analysis: The raw politics behind opposition to healthy public policy. Health Promotion International, 30, 380-396. DOI:

Raphael, D. (2017). Implications of inequities in health for health promotion practice. In I. Rootman, A. Pederson, K. L. Frohlich, & S. Dupéré (Eds.), Health promotion in Canada: New perspectives on theory, practice, policy, and research (4th ed.). (pp.146-166). Toronto: Canadian Scholars.

Schick-Makaroff, K., MacDonald, M., Plummer, M., Burgess, J. & Neander, W. (2016). Whatsynthesis methodology should I use? A review and analysis of approaches to research synthesis. AIMS Public Health, 3(1), 172-215. DOI:

Scutchfield, F.D., Ingram, R.C., (2013). Public health systems and services research: building the evidence base to improve public health practice. Public Health Review, 35(1). DOI:

Singh, S. R. (2014). Public health spending and population health: A systematic review. American Journal of Preventive Medicine, 45(5), 634-640. DOI:

Smith, M. J., Thompson, A. & Upshur, R. E. G. (2018). Is ‘health equity’ bad for our health? A qualitative empirical ethics study of public health policy-makers’ perspectives. Canadian Journal of Public Health, 109, 633-642. DOI:

Strosher, W., MacDonald, M. & Hancock, T. (2012). Advancing public health systems and services research in Canada: Developing a pan-Canadian agenda. Proceedings from: Canadian Public Health Systems and Services Research Think Tank. Montreal, Quebec. 2011 May 26-27. Retrieved from

Thomson, D. R., Amoroso, C., Atwood, S., Bonds, M. H., Rwabukwisi, F. C., Drobac, P., & Binaqwaho, A. (2017). Impact of a health system strengthening intervention on maternal and child health outputs and outcomes in rural Rwanda 2005-2010. BMJ Global Health, 3, 1-11. DOI:




How to Cite

Riordon, C., Hendra, S., & Johnson, C. (2021). The politics of public health: A rapid review of the impact of public health reform on population health outcomes. Witness: The Canadian Journal of Critical Nursing Discourse, 3(1), 98–115.