Abstract

Canada's healthcare system is approaching structural limits: nearly $400 billion in annual spending, while nearly one in five Canadians is without a regular healthcare provider, emergency departments overflow and health inequities persist that universal coverage alone cannot resolve. This paper argues that social prescribing, a structured referral system connecting people to community resources through trained link workers, offers not merely an additional program but a paradigm shift. By making visible the economic and social value of community-based health work, social prescribing functions as a strategic catalyst for an enabling state model of healthcare: one that redirects public investment toward the community infrastructure where health is actually produced. This paper traces Canada's health system through three historical paradigms: the nation state, the welfare state and the emerging enabling state. It shows how social prescribing bridges the transition, with modelling suggesting a potential return of $4.43 for every dollar invested while building resilience against the compounding disruptions of climate change, trade instability and geopolitical uncertainty. Drawing on Canadian pilots, international evidence and cross-sectoral economic analysis, the paper offers recommendations for community organizations and governments to recognize, resource and protect the resilient future that Canadian communities are already building.

Introduction

Canada is navigating a moment of acute external pressure. Trade disruptions, geopolitical instability and the accelerating impacts of climate change are exposing the fragility of systems built for stable conditions. At this critical moment, we have also reached the limits of what institutionally concentrated, clinically focused healthcare can achieve alone. Canadian healthcare spending has reached almost $400 billion annually (CIHI 2025). Yet 17% of Canadian adults report not having a regular healthcare provider, and 15% of emergency department visits are for conditions that could potentially have been managed in primary care (CIHI 2024). Life expectancy varies by approximately 13 years for females and 14 years for males across municipalities, with estimates positively associated with population size and social determinants such as post-secondary educational attainment (Quick et al. 2025). These are not implementation failures requiring better management but symptoms of the structural exhaustion of inherited institutions.

There is an alternative, and it is in our communities. Nearly 7 million Canadians provide unpaid care, contributing an estimated $97 billion in economic value annually (Fast et al. 2024), while community non-profit institutions contributed $42.3 billion to Canadian gross domestic product (GDP) in 2024 (Statistics Canada 2026). Communities with strong social infrastructure consistently demonstrate better population health outcomes and greater resilience during crises (The British Academy 2021). Yet Canada's care economy remains systematically undervalued, disconnected from formal health systems and chronically underfunded despite overwhelming evidence that social determinants drive most health outcomes (Raphael 2016; Sacks et al. 2019). In 2023, nearly half of community non-profit organizations reported rising demand for their services while fewer than one in four had the capacity to meet it (Statistics Canada 2024).

This paper argues that social prescribing, a supported and structured referral system connecting healthcare with community resources, functions as a strategic catalyst for fundamental health systems transformation (Muhl et al. 2023). By creating measurable pathways between clinical care and community assets, social prescribing makes visible the economic value of the care economy, unlocks potential energy trapped in people and communities and provides the data infrastructure needed to redirect resources upstream (Canadian Institute for Social Prescribing 2025b; Mulligan 2025; Polley et al. 2023). The mechanism is straightforward: healthcare providers refer patients, link workers facilitate connection and outcomes are tracked. But the effect is paradigmatic, shifting how we organize, fund and deliver health and social services away from managing institutional scarcity toward cultivating community capacity (Mulligan and Bloch 2026). What emerges is an enabling state model where strategic public investment builds sustainable, equitable, effective population health through connected and resilient communities.

The Case for Transformation: Structural Exhaustion and Hidden Capacity

Institutional thinking and health system limits

Canada is not alone in confronting the limits of aging healthcare institutions. The Commonwealth Fund's 2024 Mirror, Mirror report ranks Canada's health system last for timely access to primary care and seventh overall among 10 comparable nations (Blumenthal et al. 2024). Reforms across high-income countries concentrate on rearranging institutional elements: hospital governance, physician compensation and health information systems. These changes systematically neglect the community-scale infrastructure where health is actually produced (Lazar et al. 2013). The fact that healthcare systems across wealthy democracies face similar crises despite diverse organizational models suggests that the problem is not primarily a lack of internal reform, but of misdirected focus rooted in long-standing institutional bias.

This bias means our health systems look much as they did at the mid-20th century emergence of medicare. They remain organized, funded and evaluated around hospitals, physicians and prescription drugs (CIHI 2025). When community health work, social supports, Indigenous and traditional practices, women's health knowledge and preventive programs were left outside the fundable core (Armstrong and Deadman 2009; Waring 1988), the result was a set of healthcare systems optimized for acute care but poorly equipped for the chronic disease, mental health challenges and health inequities that now dominate population health needs. The mental, legislative and operational models underpinning Canadian and peer health systems do not constitute a natural or unchangeable order. They are an accumulation of historically specific ideas and paradigms that are politically contingent, demonstrably mutable and open to challenge and change.

Building an enabling state on welfare state foundations

Canada's healthcare evolution can be understood through three successive paradigms, each separated by roughly a century. The nation state era, from Confederation in 1867 through the early 20th century, concentrated health intervention in hospitals, asylums and sanatoria under provincial jurisdiction, reflecting beliefs about scientific medicine and professional expertise. Care provided in homes, neighbourhoods and mutual aid networks – primarily by women and Indigenous communities – was largely excluded from public financing (Flood and Thomas 2016). The welfare state era, launched through the Hospital Insurance and Diagnostic Services Act of 1957, extended through the Medical Care Act of 1966 and consolidated in the Canada Health Act of 1984, achieved something genuinely transformative: universal access to medically necessary hospital and physician services, eliminating the financial catastrophe of illness for ordinary Canadians (Martin et al. 2018). But the social contract underlying medicare, negotiated between governments, medical associations and hospital administrators, reproduced the exclusions of what came before. Community-based prevention, social supports and the non-clinical determinants that drive most health outcomes were once again left on the margins.

A third paradigm is on the horizon, and we do not have to wait until 2067 for it (Elvidge 2012). The enabling state strategically invests in community organizations, peer networks and local infrastructure while maintaining robust public funding and accountability, shifting government's role from institutional service provider to strategic enabler. This is not privatization or neoliberal downloading. It builds on universal public services and redistribution by extending public investment and accountability to community infrastructure. The enabling state requires strong public investment redirected to optimize system-wide impact, with integrated budgeting that allows resources to flow wherever they generate the greatest health returns. Crucially, the infrastructure for this third era is already being built: in community health centres, municipal partnerships and social prescribing programs from coast to coast.

Untapped health system capacity

Health-producing work already occurs outside formal systems through the paid and unpaid labour of caregiving, community organizing, peer support and neighbourhood connection. The World Health Organization and UNICEF position such community roles as central to primary healthcare and universal health coverage (Sacks et al. 2019; WHO and UNICEF 2018).

Communities with robust social networks and strong local organizations consistently demonstrate superior resilience during crises, including pandemics, natural disasters and economic shocks (Aldrich and Meyer 2015; The British Academy and Power to Change 2023). The COVID-19 pandemic illustrated this: neighbourhoods with existing community connections organized mutual aid rapidly, while isolated populations experienced disproportionate harm (Bender et al. 2024; Fernandes-Jesus et al. 2021). As geopolitical instability intensifies and climate impacts compound, nations investing in local capacity, civic participation and social cohesion will weather disruption better than those dependent on fragile centralized systems. For health system leaders, this creates real opportunities for cross-ministerial partnerships where community infrastructure investment serves both population health and broader societal resilience simultaneously.

Health systems have long benefited from community infrastructure, but it has been largely unaccounted for because it is distributed across sectors that sit outside formal health budgets. This creates the “wrong-pocket problem” familiar to health system leaders: investments that reduce healthcare costs land in different ministerial budgets, preventing rational resource allocation (McCullough 2019). Medical respite care for people experiencing homelessness illustrates the same wrong-pocket problem: the organizations that fund post-hospital care are not necessarily the institutions that realize the resulting health-system savings, creating barriers to sustained investment (Walton et al. 2024). When community programs address social isolation among older adults, a condition associated with a 57% increased risk of emergency department visits among heart failure patients, emergency departments maintain their budgets while community organizations survive on precarious grants (National Academies of Sciences, Engineering, and Medicine 2020). Siloed budgeting creates perverse incentives to underinvest in precisely the interventions that generate the highest total-system returns (McCullough 2019).

For health system sustainability, mobilizing this existing capacity is imperative. Healthcare spending growth has historically outpaced GDP growth, creating persistent fiscal pressure (CIHI 2025; OECD 2019). Expanding capacity within existing institutions yields diminishing returns at rising cost (OECD 2023). The care economy already exists; what is needed is formal integration, stable funding and accountability mechanisms that value community contributions to population health. Enter social prescribing.

Social Prescribing as Strategic Catalyst

The Trojan horse effect: operational change enabling system transformation

Social prescribing connects people with non-medical community resources to address the social determinants of health (Muhl et al. 2023). In the most common model, a link worker – a non-clinical professional – co-develops a personalized plan with the patient or participant and supports connections to community assets such as arts programs, green spaces, peer support groups or social services (Morse et al. 2022; Mulholland et al. 2025). On the surface, implementation appears more tractable than sweeping legislative reform: it works within existing systems and operates through training and referral pathway development rather than structural reorganization. But this accessibility conceals deeper transformative potential. Social prescribing functions as “a Trojan horse for a health-creating community” (Dixon 2016): an intervention that shifts the paradigm of care through incremental, everyday practice.

The transformation occurs through several interconnected mechanisms. Formal integration pathways between traditionally siloed sectors establish precedents for cross-sectoral collaboration and shared accountability (Morse et al. 2022; National Academy for Social Prescribing 2024). These pathways generate data on the relationships between community services and health outcomes, building an evidence base that can translate the value of social infrastructure into clinically and financially relevant evidence (Lin et al. 2024; Wobi et al. 2025). They also enable subtle but significant shifts in power: toward patients and caregivers, whose self-determination is centred; toward communities and non-health organizations, whose services can be more consistently matched to local need; and toward providers, who report reclaiming purpose by gaining concrete tools to address their patients' social needs (Bhatti et al. 2021; Kung et al. 2019).

Social prescribing's four-step process: operationalizing health system integration

Social prescribing's operational elegance lies in its structured simplicity (Muhl et al. 2023):

Identification and referral

Using clinical judgement, structured screening tools or patient self-referral, healthcare providers or other referrers identify individuals with health-related social needs, such as loneliness, housing instability or financial strain, and make a referral to a link worker.

Connection and co-production

The link worker meets with the patient for holistic assessment using strengths-based, person-centred approaches. Together they co-create a personalized plan connecting the patient to relevant community resources. This shifts the conversation from “what's the matter with you?” to “what matters to you?”

Activation and support

The individual actively participates in non-clinical activities. The link worker provides follow-up support, addressing barriers such as transportation or access, ensuring successful integration and building social capital, purpose and self-efficacy.

Learning and improvement

Outcomes, experiences and service use are systematically tracked using shared metrics integrated into electronic health records and community data systems, enabling continuous quality improvement and informing resource allocation decisions.

The fourth step, embedding social prescribing within a Learning Health Policy System (Oh et al. 2021), distinguishes social prescribing from one-off integration efforts. With systematic evaluation and feedback loops engaging decision makers, implementers, participants and communities, social prescribing becomes a mechanism for evidence-based resource reallocation across sectors.

Returns on investment

Social prescribing achieves its strategic aims by demonstrating value rather than requiring ideological conversion. Decision makers can start with modest pilots: for approximately $100 million annually, roughly 0.03% of Canada's current healthcare spending, the federal government could fund one link worker for every 40,000 to 50,000 patients nationwide, broadly consistent with England's initial policy of funding one link worker per primary care network serving approximately 30,000 to 50,000 people (Mulligan 2025; Sandhu et al. 2022). Each successful implementation strengthens the case for budget reallocation, supported by economic modelling showing a $4.43 return on every dollar invested in Canadian social prescribing programs (Canadian Institute for Social Prescribing 2024).

These returns derive from several sources. Local UK evaluations report reductions of up to 42% in primary care visits and up to 23% in emergency department attendances, with consistent directional findings in Canadian pilots (Mulligan et al. 2023; National Academy for Social Prescribing 2024). Potential economic gains include reduced absenteeism and improved workforce participation. Social prescribing can also build social capital: in Ontario's Rx:Community pilot, 71 participants became volunteer Health Champions who co-created programs for others (Bhatti et al. 2021). For targeted populations, modelled impacts are pronounced: social prescribing for older adults is projected to generate approximately $268 million annually in healthcare cost savings, while social prescribing for youth could generate an additional $59 million annually in employment income through improved mental health and educational attainment (Canadian Institute for Social Prescribing 2024). These estimates are conservative and do not capture the full value of strengthened social cohesion, community resilience or environmental co-benefits. Canada's healthcare system accounted for approximately 4.6% of national greenhouse gas emissions between 2009 and 2015, suggesting that reductions in unnecessary prescribing and clinical procedures may also contribute to health-system decarbonization (Eckelman et al. 2018).

Made in Canada approaches

Social prescribing is expanding rapidly across Canada, with programs from coast to coast demonstrating feasibility, acceptability and effectiveness (Canadian Institute for Social Prescribing 2025b). At the national level, social prescribing is included in the draft CAN/HSO 34015:2026 Primary Health Care Services National Standard (Health Standards Organization 2026). British Columbia is expanding its social prescribing program for older adults from 19 to approximately 90 Community Connector positions across the province, while Manitoba has made social prescribing available in all five regional health authorities (British Columbia Ministry of Health 2024; Province of Manitoba 2026).

Social prescribing is emerging rapidly at local and regional levels, spanning diverse settings, professions, populations and sectors. Alberta supports link workers across urban and rural communities (Mansell et al. 2024), and Ontario's Health Teams are embedding social prescribing into care coordination (Mulligan et al. 2023). In primary care, link workers are being integrated into family health teams and community health centres, while Youth Wellness Hubs Ontario is adapting social prescribing for youth and equity-deserving populations (Turpin et al. 2024). Hospital-based programs at Unity Health, Fraser Health, Hamilton Health Sciences and other large health centres connect patients with complex social needs to community organizations at the point of care (Lin et al. 2024; Unity Health Toronto 2024). Healthcare Excellence Canada is supporting 36 paramedic service and related teams across Canada to implement and systematize social prescribing within their services (Healthcare Excellence Canada 2025a, 2025b). Dedicated programs serve older adults, Black communities through Afrocentric models, Indigenous peoples through culturally grounded approaches, newcomers, caregivers, post-secondary students, Francophones and rural and remote populations (Kadowaki et al. 2024; Ramirez et al. 2024; Vaillancourt et al. 2024; Yu et al. 2024). Food prescription, arts prescription and nature prescription programs operate in multiple provinces (Canada Council for the Arts 2026; Little et al. 2024; Vaillancourt et al. 2024).

What Next? Building on What's Strong

Social prescribing in Canada is not a future aspiration; it is a present reality. The question for governments, health systems and funders is not whether to begin, but how to recognize, resource and protect what communities are already building and how to remove the structural barriers that limit its reach.

Community organizations, non-health sectors and municipal governments: essential partners

Community organizations are the primary originators of social prescribing in Canada. What is often missing is recognition, stable resourcing and formal integration into health pathways (Mulligan 2025). These organizations, formal and informal, can build and share community asset maps to make visible the community strengths that health systems have historically overlooked (Canadian Institute for Social Prescribing 2025a). They can also address barriers to participation – including transportation costs, language barriers, lack of culturally appropriate services or accompaniment, and program fees – that disproportionately exclude equity-deserving populations (Chater 2024). They can also build community-defined evaluation capacity, contributing community-prioritized evidence to shared learning alongside clinical metrics (Saluja and Dahrouge 2024).

Municipalities are essential partners. Because they are responsible for libraries, recreation centres and parks, they are natural social prescribing hubs even where they lack direct authority over healthcare. Towns and cities can dedicate facility space for community health workers, support community organizations through below-market rent and administrative support and integrate social infrastructure requirements into official plans, ensuring that development contributes to community capacity, consistent with the Ottawa Charter (WHO 1986). Municipalities can also leverage their unique position as cross-sector convenors to establish local social prescribing collaboratives (Canadian Institute for Social Prescribing 2025b).

Provincial and territorial governments and regional health authorities: operational leadership and system integration

Provinces and territories hold direct operational authority over health and social systems, and their health and non-health ministries are equally essential: ministries responsible for housing, social services, education and justice share responsibility for the social determinants that social prescribing addresses. Regional health authorities can translate provincial and territorial commitments into practice. They can make social prescribing a standard component of primary care networks and community health centres, prioritize referrals for frequent emergency department and primary care users and populations facing health inequities and formalize partnership agreements with community organizations through joint governance and shared accountability (Alliance for Healthier Communities 2020; Kadowaki et al. 2024; Mulligan et al. 2023).

The most consequential near-term action is workforce investment. The $100 million annually cited earlier could fund a meaningful network of community health workers, combining standardized core competencies with flexibility for local adaptation (Mulligan 2025). Existing health human resources could also be redeployed to support further growth and systematization. This link-worker workforce should be supported by clear compensation, benefits and advancement pathways rather than precarious contracts, while retaining the flexibility to value lived experience and local trust over extraneous credentials (Mulligan et al. 2023). Provincial funding to community organizations should transition from short-term project grants to multi-year core agreements (Alliance for Healthier Communities 2020). Integrated data infrastructure that supports coordination across health, housing and social services is essential for equity-centred accountability. It must be designed according to Indigenous data-sovereignty principles and corresponding frameworks developed by other equity-deserving communities, including Black communities (Black Health Equity Working Group 2021; First Nations Information Governance Centre 2014). Pooled cross-sector budgets, supported by joint governance, transparent public dashboards and authority to reallocate resources based on impact data, can drive continuous improvement.

Federal government: enabling frameworks and strategic investment

The federal role is strategic: providing policy frameworks, research infrastructure and catalytic funding that incentivizes provincial action while respecting jurisdictional boundaries. Canada's 2025 budget frames nation-building as a project of strengthening sovereignty and resilience and introduces the Build Communities Strong Fund as a major infrastructure investment. The fund supports health, community and local infrastructure through separate funding streams (Government of Canada 2025). Expanding support to include community-organization operating spaces, infrastructure for link workers and social prescribing programming would align Canada's physical nation-building investments with the social infrastructure that makes communities resilient.

Veterans Affairs Canada has already committed to introducing and expanding a Social Prescribing Model (Veterans Affairs Canada 2024, 2025), and other federal departments with operational healthcare responsibilities, such as Indigenous Services Canada and Correctional Service Canada, could develop comparable interventions. The Canadian Institutes for Health Research should establish dedicated multi-year funding for social prescribing implementation science, and the Canadian Institute for Health Information could act as a convening body for a national data strategy that is standardized, interoperable and governed according to community data sovereignty principles. Making community health infrastructure more explicit within Canada's Quality of Life Framework – which comprises 91 indicators across prosperity, health, society, environment and good governance – would make social infrastructure more legible in federal decision making (Government of Canada 2021; Statistics Canada 2025). Federal-provincial health accord negotiations should incorporate community health infrastructure metrics alongside traditional hospital and physician metrics, and a cross-ministry, Deputy Minister-level Social Infrastructure Committee should be tasked with eliminating the “wrong-pocket” barriers that prevent savings in emergency care from being reinvested in the community infrastructure that generates them.

Governing for scale: technology, data and risk

Social prescribing's expansion includes risks that governance and technology infrastructure must address proactively. The most significant are structural. If healthcare systems capture savings generated by community investment without reinvesting them, social prescribing becomes extractive rather than reciprocal. If governments use social prescribing to justify cutting essential clinical services, the model is being misread: an enabling state invests more in community infrastructure, not less in everything else (Mulligan 2026). And if programs systematically reach easier-to-access populations while bypassing those with the greatest need, or sacrifice co-production for scaling at speed, we risk encoding inequity into the infrastructure (Alliance for Healthier Communities 2020). These risks are manageable through formal reinvestment agreements, well-being budgeting that makes cross-sectoral returns visible, explicit equity and co-production expectations and disaggregated reporting.

Effective technology infrastructure requires referral-management platforms that integrate with electronic medical records while remaining accessible to community organizations. It also requires asset directories containing information on costs, languages and cultural appropriateness; outcome-tracking tools; and analytics dashboards accessible across levels of the system (Rafiei et al. 2025; Saluja and Dahrouge 2024; Wobi et al. 2025). Artificial intelligence applications can reduce administrative burden but should neither replace human judgement in referral decisions nor displace the vital human role of the link worker (Kubota 2026). Community data governance is a precondition for the trust that social prescribing depends on. The governance frameworks developed by First Nations communities and Black health equity researchers provide models for equitable implementation across all populations (Black Health Equity Working Group 2021; First Nations Information Governance Centre 2014).

Conclusion

Toward a community and human-scale health system

Canada's health system was built in broad chapters, each responding to the failures of what came before. The nation state concentrated care in institutions, rendering invisible the community work that actually sustained people. Through the profound achievement of medicare, the welfare state addressed the catastrophe of unaffordable illness. Yet it reproduced earlier exclusions by leaving community infrastructure, social determinants and the care economy outside the funded core. We are now at the limits of that second chapter: spending more, producing less and facing compounding disruptions for which institutional concentration is actively the wrong response.

The stakes of this transition are not merely administrative. The fracturing of the 20th-century global order is exposing something that health systems were never designed to address: the need for communities that can sustain themselves under pressure, that hold people when institutions cannot reach them, that distribute care through relationships as much as through appointments. This is what neighbourhoods with strong social infrastructure did during COVID. It is what resilient communities do in every crisis. It is, in a very old sense, what health has always required.

Social prescribing shows that we need not wait until 2067 to write our third chapter and build the enabling state. This new model is already taking shape in the spaces between our institutions, making community health visible, valued, operational and scalable. Our communities are ready. It is time to join these efforts and ensure that every Canadian and every community can participate fully in building this next chapter.

About the Author

Kate Mulligan, Phd, Founder, The Department of Neighbouring, Founding Scientific Director (2021–2026), Canadian Institute for Social Prescribing, Associate Professor (status-only), Dalla Lana School of Public Health, University of Toronto, Toronto, ON

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