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The Political Economy of Health Promotion
Dennis Raphael, PhDSchool of Health Policy and Management, York
University, Toronto, Canada
Presentation at the 20th IUHPE World Conference on Health Promotion. Geneva,
Switzerland, July 13, 2010
Key Health Promotion Concepts• Prerequisites of Health/SDOH
– peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice, and equity.
• Citizen Empowerment– People cannot achieve their fullest health potential
unless they are able to take control of those things which determine their health.
• Important Role for Public Policy– Health promotion policy combines diverse but
complementary approaches including legislation, fiscal measures, taxation and organizational change.
Source: Ottawa Charter for Health Promotion
Dominant Political Ideologies
• “It is profoundly paradoxical that, in a period when the importance of public policy as a determinant of health is routinely acknowledged, there remains a continuing absence of mainstream debate about the ways in which the politics, power and ideology, which underpin it influences people’s health.”
• Bambra, C., Fox, D., & Scott-Samuel, A. (2005). Towards a politics of health. Health Promotion International, 20(2), 187-193.
Health Promotion and Welfare States• Esping-Andersen (1990) identifies three types of welfare state:
Liberal, Conservative and Social Democratic• Liberal -- State provision of welfare is minimal, benefits are
modest and often attract strict entitlement criteria, and recipients are usually means-tested and stigmatized
• Conservative -- Status differentiating welfare programs in which benefits are often earnings related, administered through the employer, and geared towards maintaining existing social patterns. The role of the family is also emphasized and the redistributive impact is minimal.
• Social Democratic -- Welfare provision is characterized by universal and comparatively generous benefits, a commitment to full employment and income protection, and a strongly interventionist state used to promote equality through a redistributive social security system.
• Source: Bambra, C. (2009). Welfare State Regimes and the political Economy of Health. Humanity and Society, 33, (1&2), 99-117, Table 2, p. 105.
What is the central institution in society – in terms of shaping the
distribution of resources?
• The state (government)?
• The family?
• The market?
Source: Saint-Arnaud, S., & Bernard, P. (2003). Convergence or resilience? A hierarchial cluster analysis of the welfare regimes in advanced countries. Current Sociology, 51(5), 499-527.
Union Density, Collective Agreement Coverage and Child Poverty, Early 00's (coverage rates) and Mid 2000s (poverty
rates)
0102030405060708090
100
Un
ion
an
d B
arg
ain
ing
Co
vera
ge
0
5
10
15
20
25
Ch
ild
Po
vert
y R
ate
Union Density Collective Bargaining Coverage Child Poverty Rate
Source: Organization for Economic Cooperation and Development (2006). Trade Union Members and Union Density. Available at http://www.oecd.org/dataoecd/8/24/31781139.xls and Organization for Economic Cooperation and Development (2009). Growing Unequal: Income Distribution and Poverty in OECD Countries Figure 5.a2.1, p.154.
Explicit Health Promotion• Governmental statements about the
importance of providing the prerequisites of health through public policy activity
• Health sector statements about “promoting health” through public policy and community-level activities
• Governmental and health sector statements about “promoting health” through behaviour change related to “healthy living” or “healthy lifestyle choices.”
Statements about Health PromotionFinland, Norway, Sweden (social democratic)
• Finland: The Government Resolution on the Health 2015 Public Health Programme defines reducing health differences between population groups as a central goal.
• Norway: A National Strategy to Reduce Social Differences in Health (2007) provides a ten year perspective for developing policies and strategies to reduce health inequities.
• Sweden: The Public Health Objectives Bill (2003) calls for decisive measures to improve public health through action on social policy, healthcare policy, labour market and working life policy, housing policy, education policy and environmental policy.
• Source: Hogstedt, C. et al (2008). Health for All? A Critical Analysis of Public Health Policies In Eight European Countries. Stockholm: Swedish National Institute of Health.
Statements about Health PromotionFrance, Germany, Netherlands (conservative)
• France: In the end, even if interest in health promotion increased in France over the past 10 years … it remains hindered by a system still very centred on curative care and a lack of political consideration for health determinants (Guillaumie, 2007).
• Germany: The German approach to health promotion differs from the US approach. Lifestyle issues of health are part of a structural approach which primarily aims at influencing health-related living and working conditions (O’Donnell, 2001)
Statements about Health PromotionFrance, Germany, Netherlands (conservative)
• Netherlands: It can be concluded that in The Netherlands the process of putting equality in health on the political agenda has been successful. There is a broad consensus that such inequalities are unfair, and that avoidable inequalities should be reduced… To what extent has this (political) awareness and concern been followed by initiatives to reduce socioeconomic inequalities in health? … the interventions and policies evaluated.. all had an experimental character. They should, however, be seen within the context of a longer tradition of policies to reduce socioeconomic inequalities generally, and socioeconomic inequalities in health specifically (Stronks, 2003).
• The Dutch Green Paper (2004) ´Living longer in good health´ expressed the Minister’s worries about the unequal distribution of poor health, illness and premature death between population groups…The memorandum, however, strongly emphasises the individual’s responsibility for their own behaviour and health. It states, for example, that ‘Prevention policy will only achieve success if we hold citizens directly accountable for their own behaviour’ (Droomers et al., 2008).
Statements about Health PromotionAustralia, Canada, UK (liberal)
• Australian state governments have provided explicit statements about health equity and addressing health inequalities and developed action plans.
• Canada has long history of providing statements about the determinants of health but has been a clear laggard in acting upon these principles.
• UK: “Clearly, the past 10 years in England have been remarkable for the amount of feverish activity on health inequalities at all levels and the serious political commitment that this demonstrates” (Whitehead and Bird, 2008).
Implicit Health Promotion
• Governmental and institutional activity that manages the extent of income inequality and poverty
• Governmental and institutional activity that promotes employment training and reduces unemployment (active labour policy)
• Governmental and institutional activity that meets the childcare needs of citizens
Total Public Expenditure as Percentage of GDP, Selected OECD Nations, 2005
29.4
29.2
27.2
27.1
26.7
26.4
26.1
25
23.2
23.1
21.6
21.3
21.2
20.9
20.5
20.3
18.5
17.1
16.7
16.5
15.9
0 6 12 18 24 30
SwedenFranceAustria
DenmarkGermanyBelgiumFinland
ItalyLuxembourg
PortugalNorway
UKSpain
NetherlandsGreece
SwitzerlandNew Zealand
AustraliaIreland
CanadaUSA
Nat
ion
Percentage of GDP
Source: OECD Social Expenditure Database (2010).
Red-SD Blue-Con
Orange-Latin Black-Lib
Public Policy towards Key SDOH
• Income inequality, poverty
• Active labour policy
• Early child development
Source: Organisation for Economic Co-operation and Development. (2008). Growing Unequal: Income Distribution and Poverty in OECD Nations. Paris: Organisation for Economic Co-operation and Development.
Income Inequality in Selected OECD Countries, mid-2000s
0.390.38
0.350.340.34
0.330.32
0.320.32
0.300.30
0.280.280.28
0.270.27
0.270.27
0.260.23
0.23
0.20 0.25 0.30 0.35 0.40
PRTUSAITA
NZLGBR
IRLGRCESPCANAUSDEUFRANORCHENLDBELFIN
AUTLUXSW
DNK
Poverty Rates among Families with Children, Selected OECD Nations, Mid 2000s
2117
171616
161515
1312
1212
109
86
54
43
10
0 5 10 15 20
United StatesSpain
PortugalIreland
GermanyItaly
CanadaNew Zealand
GreeceLuxembourg
AustraliaNetherlands
United KingdomBelgium
SwitzerlandFranceAustriaNorwayFinlandSweden
Denmark
Nat
ions
Poverty Rates
Source: Organisation for Economic Co-operation and Development. (2008). Growing Unequal: Income Distribution and Poverty in OECD Nations. Paris: Organisation for Economic Co-operation and Development.
0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4
Greece
Canada
Switzerland
Ireland
Austria
US
Germany
Australia
Luxembourg
Portugal
Spain
Netherlands
UK
Italy
New Zealand
Norway
Belgium
Finland
Sweden
France
Denmark
% GDP
Public Expenditure On Childcare And Early Education Services, Per Cent Of GDP, Selected OECD Nations, 2005
Public Spending on Active Labour Policy as Percentage of GDP, Selected OECD Nations, 2003
1.6
1.3
1.2
1.1
1.1
1.1
0.9
0.8
0.7
0.7
0.7
0.7
0.7
0.6
0.5
0.4
0.4
0.4
0.3
0.2
0.1
0.00 0.25 0.50 0.75 1.00 1.25 1.50 1.75
DenmarkSw edenBelgiumFrance
NetherlandsGermany
Finland
Norw aySpain
IrelandPortugal
ItalySw itzerland
Austria
UKNZ
AustraliaCanada
LuxembourgGreece
USA
Source: Social Expenditure Database, OECD 2008. Paris: OECD.
Health Indicators
• Life expectancy
• Infant mortality
• Suicides
• Homicides
Life Expectancy at Birth, Selected OECD Nations, 2007
78.178.4
79.179.479.579.579.5
79.779.8
80.080.180.2
80.780.8
81.081.081.0
81.481.4
81.9
80.2
70 72 74 76 78 80 82
United StatesDenmarkPortugal
LuxembourgUK
GreeceFinlandIreland
BelgiumGermanyAustria
New ZealandNetherlands
CanadaNorway
SpainFrance
SwedenAustralia
ItalySwitzerland
Nat
ions
Life Expectancy at Birth
Source: OECD (2009). Health at a Glance, Table 1.1.1, p. 17. Paris: OECD.
Infant Mortality Rates, Selected OECD Nations, 2006
6.95.4
5.25.0
4.74.44.4
3.83.83.83.8
3.7
3.73.6
3.33.2
3.02.82.8
2.5
3.7
0 1 2 3 4 5 6 7
United StatesCanada
New ZealandUK
AustraliaNetherlandsSwitzerland
SpainGermany
FranceDenmark
IrelandGreece
BelgiumAustria
PortugalNorway
ItalyFinlandSweden
Luxembourg
Nat
ions
Infant Mortality Rates/1000
Source: OECD (2009). OECD Family Database, Table CO1.1, p. 3. Paris: OECD.
Suicide Rates, Selected OECD Nations, 2006
18.014.2
14.012.8
12.211.3
10.810.8
10.210.1
9.99.8
8.98.7
8.16.3
6.14.8
2.9
9.1
0 2 4 6 8 10 12 14 16 18 20
FinlandFrance
SwitzerlandAustria
New ZealandSweden
LuxembourgNorwayCanada
USADenmarkAustraliaGermany
IrelandPortugal
NetherlandsSpain
UKItaly
Greece
Natio
ns
Suicide Rates/100,000
Source: OECD (2009). Health at a Glance, Table 1.7.1, p. 29. Paris: OECD.
Homicide Rates, Selected OECD Nations, 2005
5.6
2.2
2.1
1.7
1.6
1.6
1.5
1.5
1.5
1.3
1.3
1.2
1.1
1.1
1.0
1.0
0.9
0.9
0.7
0.7
1.2
0 1 2 3 4 5 6
USAFinlandCanada
BelgiumFrance
IrelandNew Zealand
Australia
UKDenmark
P ortugalNetherlands
Spain
ItalyGreece
Switzerland
GermanySweden
LuxembourgAustriaNorway
Nat
ions
Homicide Rates/100,000
Source: OECD (2009). OECD Regions at a Glance, Table 28.1, p. 150. Paris: OECD.
In Canada – and other liberal nations, analysis has suggested…
Business Sector Influence
Civil Society Including Labour Influence
The State – Government Policies
that Provide Citizen Security
Balance: The Post-World War II Consensus 1945-1975
Business
Sector
InfluenceC
ivil Society
Including Labour
Influence
The State – Governm
ent Polices
that Provide Citizen Security
Imbalance:
The Post-1975 Scene
Implications • Attention must be paid to both explicit and implicit
aspects of health promotion• Both health and quality of life considerations should
enter into public policymaking• Links between health indicators and form of the
welfare state are not always obvious• Liberal welfare states arguably show the worse
indicators of health and quality of life• Politics plays a key role in shaping the quality and
distribution of the social determinants of health• How do I get an EU Passport?
Dennis Raphael