COVID-19 Pandemic
Public health funding, vulnerable groups, and COVID-19 hospitalizations and deaths: a time-to-event analysis in Ontario, Canada Samantha Forbes* Samantha Forbes Naomi Schwartz Stephen Hunter Roman Pabayo Brendan Smith
Background: The COVID-19 pandemic disproportionately impacted health across sociodemographic groups. Areas with higher pre-pandemic public health funding may have better protected population and vulnerable group health. The objective was to estimate the association between public health unit (PHU) funding and COVID-19 hospitalization or death, and whether it differs among vulnerable groups in Ontario, Canada.
Methods: A population-based cohort study was conducted using linked health administrative data from all Ontario residents covered by government health insurance (March 1, 2020-December 31, 2022). PHU funding per capita in 2019, a measure of pre-pandemic preparedness, was linked from the Ontario Public Health Information Database (OPHID). The association between PHU funding per capita and COVID-19 hospitalization or death was estimated using Fine and Gray subdistribution hazard models, with non-COVID-19 death as a competing risk. Interactions between PHU funding per capita and neighborhood socioeconomic status (SES) quintile, neighbourhood racialized population quintile, and individual immigrant status on COVID-19 hospitalization or death were estimated. Quintile 1 (Q1) was the referent and represented the highest SES/lowest racialized population neighborhoods. Models were adjusted for individual- and area-level covariates and included robust sandwich co-estimators by PHU.
Results: A $10 increase of PHU funding per capita was associated with a 5% decreased risk of COVID-19 hospitalization or death (HR=0.95, 95%CI:0.90-0.99). The protective effect of increased PHU funding on COVID-19 hospitalization or death was stronger in neighborhoods with lower SES (Q5 vs, Q1: HR=0.94, 95%CI:0.90-0.99) and higher racialized populations (Q4 vs. Q1: HR=0.92, 95%CI:0.87-0.97), and among immigrants (recent immigrant [≤5 years] vs. Canadian born: HR=0.92, 95%CI:0.84-1.01).
Conclusion: Public health funding plays an important role in mitigating harm and reducing health inequities.