1

Challenges to Health Promotion in Modern Society

Dennis Raphael, PhD School of Health Policy and Management

York University

Keynote Address at Health Promotion Research: An International Forum

Trondheim, Norway, August 6, 2012

2

Today’s Presentation • Health promotion faces various challenges • These challenges are wrought by globalization

and weakening of concepts of universalism and solidarity

• Effects of these changes are mediated by the form of the welfare state

• Social democratic welfare states can best resist these challenges

• There are means of moving the health promotion agenda forward

3

Key Health Promotion Principles

• Provide prerequisites of health • Build healthy public policy • Create supportive environments • Strengthen community actions • Develop personal skills • Reorient health systems

• Source: WHO (1986). The Ottawa Charter for Health Promotion.

Geneva: WHO

4

Affinities between the Prerequisites and Social Determinants of Health

• Ottawa Charter: peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice, and equity.

• SDOH: The Canadian Facts: income and income distribution, education, unemployment and job security, employment and working conditions, early childhood development, food insecurity, housing, social exclusion, social safety network, health services, Aboriginal status, gender, race, and disability

5

The Nordic Concept of Level of Living I

• “The command over resources in terms of money, possessions, knowledge, psychological and physical energy, social relations, security, and so on by means of which the individual can control and consciously direct her conditions of life.”

• Source: Sten Johansson (1970) cited in J. Kvist et al. (2012). Changing Social Equality: The Nordic Welfare Model in the 21st Century. Bristol UK: The Policy Press.

6

The Nordic Concept of Level of Living II Johansson’s nine components of well-being:

• Health • Employment • Economic

resources • Knowledge and

education • Social integration

• Housing and neighbourhood

• Security of life and property

• Recreation and culture • Political resources

7

HP in Wealthy Developed Nations

• Finland, Norway, and Sweden have emerged as leaders in health promotion

• Australia, Canada, and UK continue to provide conceptual contributions to HP with rather less to show for it in terms of health-promoting public policy

• The Continental nations do a rather good job of supporting health independent of explicit commitments to health promotion

8

The Nordic HP Situation • Finland

– National Action Plan to Reduce Health Inequalities 2008‒2011 (2008)

– Socially Sustainable Finland 2020: Strategy For Social And Health Policy (2011)

• Norway – The Challenge of the Gradient (2005) – National Strategy to Reduce Social Inequalities in

Health (2007) • Sweden

– Objectives for Public Health (2003) – Closing the Gap (2010)

9

The Liberal HP Situation

• Australia – Taking Preventative Action (2010)

• UK – Choosing Health (2004) England – Fair to All, Personal to Each (2004) Scotland

• Canada – Report on the State of Public Health in Canada

2008: Addressing Health Inequalities – A Healthy, Productive Canada: A Determinant of

Health Approach

10

The Continental Situation • France

– Health promotion remains ‘hindered by a system still very centred on curative care and a lack of political consideration for health determinants’

• Germany – The German approach to explicit health promotion

appears to be embedded within a behavioural approach.

• Belgium – Belgium does not have a ‘global comprehensive

policy framework’ to address the social determinants of health.

Source: Raphael, D. (in press). The political economy of health promotion: Part 1, national commitments to the provision of the prerequisites of health. Health Promotion International.

11

The Modern Welfare State I • Welfare state is a nation in which organized

power is used to modify the play of market forces in by narrowing the extent of insecurity by enabling individuals and families to meet certain social contingencies; third, by ensuring that all citizens, regardless of status or class, are offered the best standards available in relation to a certain agreed range of social services.

• Source: Briggs, A. (1961). The Welfare State in Historical Perspective.

12

The Modern Welfare State II • “The welfare state can also be seen as a

capitalist society in which the state has intervened in the form of social policies, programs, standards, and regulations in order to mitigate class conflicts and to provide for, answer, or accommodate certain social needs for which the capitalist mode of production in itself has no solution or makes no provision.”

• Source: Teeple, G. (2000). Globalization and the Decline of Social Reform, p.15

13

The Welfare State is a Choice, not an Economic Imperative

Source: M. O’Brien. The Myth that Entitlements Destroy a Nation’s Growth, Busted in One Chart. The Atlantic, July 11, 2012.

GDP Growth since 2000

S oc i a l

S pe n d i n g

14

Distinctiveness of the Scandinavian Welfare State

• Ideological inspiration: Equality • Dominant institution: The State • Emphasis on full and paid employment • Universalism of supports and programs • Support for gender equity • Greater extent of decommodification • Strong labour activation policies

15

Figure 5. Poverty Rates in Families with Children, Selected OECD Nations by Welfare State Type, 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 Cooperation and Development. (2008). Growing Unequal? Income Distribution and Poverty in OECD Countries. Paris: OECD.

16

Figure 4. Gini Coefficients of Income Inequality, Selected OECD Countries, by Welfare State Type, Mid-2000s

0.2320.234

0.2580.265

0.2690.2710.271

0.2760.276

0.2810.2980.301

0.3170.3190.321

0.3280.3350.335

0.3520.381

0.385

0.0 0.1 0.2 0.3 0.4

DenmarkSweden

LuxembourgAustriaFinland

BelgiumNetherlandsSwitzerland

NorwayFrance

GermanyAustriaCanada

SpainGreeceIreland

New ZealandUK

ItalyUSA

Portugal

Nat

ion

Gini Coefficient of Income Inequality

Source: Organisation for Economic Cooperation and Development. (2008). Growing Unequal? Income Distribution and Poverty in OECD Countries. Paris: OECD.

17

Figure 3. Total Public Expenditures as Percentage of GDP, Selected OECD Nations, 2007

28.4

27.3

26.4

26.3

26.1

25.2

24.9

24.8

23.1

21.6

21.3

20.8

20.6

20.5

20.1

18.5

18.4

16.9

16.3

16.2

16

0 6 12 18 24 30

FranceSwedenAustria

BelgiumDenmarkGermany

ItalyFinland

PortugalSpain

GreeceNorway

LuxembourgUK

NetherlandsSwitzerland

New ZealandCanada

IrelandUSA

Australia

Nat

ion

Source: OECD Social Expenditure Database, http://stats.oecd.org/Index.aspx?datasetcode=SOCX_AGG

18

Figure 7. Public Expenditure on Childcare and Early Education Services as Percentage of GDP, Selected OECD Nations, by Welfare State, 2005

0.1

0.20.2

0.3

0.3

0.4

0.40.4

0.4

0.4

0.4

0.5

0.6

0.7

0.8

0.8

0.91.0

1.0

1.2

0.6

0.0 0.2 0.4 0.6 0.8 1.0 1.2

GreeceCanada

Sw itzerlandAustriaIreland

USAGermanyAustraliaPortugal

LuxembourgSpain

NetherlandsUK

ItalyNew Zealand

Norw ayBelgiumFinland

Sw edenFrance

Denmark

Nat

ions

Percentage of GDP

Source: OECD Family Database (2010). Available at www.oecd.org/dataoecd/45/27/37864512.pdf

19

Decommodification • “Essentially, it is the extent to which

individuals and families can maintain a normal and socially acceptable standard of living regardless of their market performance” (p.4).

• Source: Eikemo, T. A. and Bambra, C. (2008) The welfare state: a glossary for public health. Journal of Epidemiology and Community Health, 62, 3–6.

20

Decommodified Security Ratio • Provision of three types of income:

– (i) replacement income for the risks of old age, unemployment, sickness and disability plus survivors’ pensions;

– (ii) reimbursements and benefits in kind: costs of health care, family allowances, housing benefits; and

– (iii) allowances and benefits in kind paid as part of measures to combat social exclusion (income support, etc.).

– Menahem, G. (2010) How Can The Decommodified Security Ratio Assess Social Protection Systems? LIS Working Paper No. 529. Luxembourg Income Study, Syracuse.

21 Source: Menahem, G. (2010). LIS Working Paper No. 529, How Can the Decommodified Security Ratio Assess Social Protection Systems?

22

Figure 9. Infant Mortality Rates, Selected OECD Nations by Welfare State Type, 2007

6.75.0

4.84.8

4.24.1

3.93.9

3.83.8

3.73.7

3.73.6

3.43.13.1

2.72.5

1.8

3.7

0 1 2 3 4 5 6 7

USACanada

New ZealandUK

AustraliaNetherlandsSw itzerland

GermanyFrance

DenmarkSpain

BelgiumAustria

ItalyGreecePortugal

IrelandNorw ayFinland

Sw edenLuxembourg

Nat

ions

Infant Mortality Rates/1000

Source: OECD (2010). Health at a Glance: OECD Indicators. Paris: OECD.

23

Figure 8. Life Expectancy at Birth, among Selected OECD Nations, 2007

78.178.4

79.179.4

79.579.579.5

79.779.8

80.080.1

80.2

80.780.8

81.081.081.0

81.481.4

81.9

80.2

74 75 76 77 78 79 80 81 82

United StatesDenmarkPortugal

LuxembourgUK

GreeceFinlandIreland

BelgiumGermany

AustriaNew ZealandNetherlands

CanadaNorw ay

SpainFrance

Sw edenAustralia

ItalySw itzerland

Nat

ions

Life Expectancy at Birth

Source: (2009c). Life Expectancy. In Health at a Glance 2009: OECD Indicators. Paris: OECD.

24

Changing Welfare States: Retrenchment?

• Most obvious in liberal political economies – England – Canada – USA

• Also apparent in Nordic nations – Norway – Sweden – Finland

25

Increasing Inequality and Poverty?

Source: OECD (2011). Divided We Stand: Why Inequality Keeps Rising. Paris: OECD

26 Source: OECD (2011). Society at a Glance: OECD Social Indicators. Paris: OECD

27

Declining Adequacy of Social Assistance Benefits

Source: Kuivalainen, S. and Nelson, K. (2012). Eroding minimum income protection…

28

Growing Income Inequality

Source: Fritzell, J. et al. (2012). Income inequality and poverty…

29

Growing Relative Poverty

Source: Fritzell, J. et al. (2012). Income inequality and poverty…

30

Challenges Related to Immigration

• Presents employment and integration challenges

• Can leads to split in left party solidarity • Manifests in different nations in different

ways (see next slide) • Requires education efforts but more

important is successful integration and employment strategies

• Source: Finseraas, H. (2012). Anti-immigration attitudes…

31

Growing Strength of Centre-Right and Nationalist Political Parties?

32

Immigration Presents a Threat to Left Solidarity in Nordic Nations

Source: Finseraas, H. (2012). Anti-immigration attitudes, support for redistribution and party choice in Europe. In Changing Social Inequality. Bristol UK: Policy Press.

Percentage of Voters Jointly Supporting Redistribution and Restrictive Immigration Policy,

2008

16

41

22

7

0

10

20

30

40

50

Denmark Finland Norway Sweden

Perc

enta

ge o

f Vot

ers

33

Defining Support for the Welfare State

Source: Jaegar, M. (2012). Do we all (dis)like the same welfare state?

34

Identifying Support for the Welfare State

Source: Jaegar, M. (2012). Do we all (dis)like the same welfare state?

35

Many of these challenges are related to economic changes

wrought by economic globalization and increasing

corporate influence upon public policymaking

36

Globalization and its Discontents?

Source: Labonte, R., & Schrecker, T. (2007). Globalization and social determinants of health: Introduction and methodological background. Part 1 of 3. Globalization and Health, 3(5).

37

The effects of these changes are mediated by the form of

welfare state regime

38

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.

39

Social democratic regimes are best situated to resist these

challenges; Liberal regimes the least able

40 Begg, I. et al. (2008). Is Social Europe fit for globalization? A study of the social impact of globalisation on the European Union. Brussels: European Commission.

41

. Figure 9.4 Factors Contributing to the Extent of Health Inequalities and Willingness to Tackle Them

Source: Raphael, D. (2012). Tackling Health Inequalities. Toronto: CSPI.

42

Electoral Behaviour – 1946-1990s

43

Growing Strength of Centre-Right and Nationalist Political Parties?

• Finland: Centre-Left Coalition • Norway: Red-Green Coalition • Denmark: Centre-Left Coalition • Sweden: Centre-Right Coalition

• Numerous authors, however complain of

weakening of social democratic resolve and this is especially the case in liberal nations

44

Figure 2. Union Density among, Selected OECD Nations, 2008

7.711.9

14.318.318.618.919.1

20.420.8

24.027.127.1

33.437.4

51.953.3

67.567.6

68.3

28.9

0 10 20 30 40 50 60 70

FranceUSA

SpainSwitzerland

AustraliaNetherlands

GermanyPortugal

New ZealandGreece

United KingdomCanadaAustria

ItalyLuxembourg

BelgiumNorwayFinland

DenmarkSweden

Na

tion

s

Percentage of Workforce that are Members of Unions

Data Source: Organization for Economic Cooperation and Development (2010). Trade Union Density. Available at http://stats.oecd.org/Index.aspx?DataSetCode=UN_DEN

Trade Union Strength

45

Figure 1. Collective Agreements Coverage among,Selected OECD Nations, 2008

13.030.0

32.035.0

48.060.060.0

62.063.0

72.080.080.0

82.085.0

90.092.0

95.096.0

99.0

82.0

0 10 20 30 40 50 60 70 80 90 100

USANewZealand

CanadaUK

SwitzerlandAustralia

LuxembourgPortugalGermany

NorwaySpain

ItalyNetherlands

DenmarkGreeceFinland

SwedenFrance

BelgiumAustria

Nat

ions

Percentage of Workforce Covered by Collective Agreements

Source: Venn, D. (2009). Legislation, Collective Bargaining and Enforcement: Updating the OECD Employment Protection Indicators, OECD Social Employment and Migration Working Papers, No. 89, Paris: OECD

Figures for Ireland are from Ireland: Industrial Relations Profile, EIRO, 2009, available at http://www.eurofound.europa.eu/eiro/country/ireland.pdf.

Collective Agreement Coverage

46

Civil Society Coalitions I

Percentage of Non-profit Work that is Unpaid Voluntary Activity, mid 1990s

76

6150 49

3932

01020304050607080

Sweden Norway UK Finland USA Australia

Per

cent

age

of A

ctiv

ity

Wijkström, F. (2004). The Role of Civil Society. The Case of Sweden in International Comparison. Stockholm: The Stockholm School of Economics.

47

Civil Society Coalitions II Voice versus Service Focus in Non-profit Sector Work,

mid 1990s

107

61 58

3021

11

0

20

40

60

80

100

120

Sweden Norway UK Finland Australia USA

Rat

io o

f Voi

ce v

s. S

ervi

ce

Act

ivity

Wijkström, F. (2004). The Role of Civil Society. The Case of Sweden in International Comparison. Stockholm: The Stockholm School of Economics.

48

Social Democratic Welfare States: Finland

• Finland has been a success story of how an agrarian society was transformed in the course of half a century into a well-developed welfare state with an educated population and high-tech industries.

• Future challenges of the Finnish welfare state are similar to those of other European nations, an aging population, economic instability, increased inequality, globalization, and migration.

• Sustaining the Finnish welfare state is chiefly a matter of commitment and determination.

• Source: Mikonnen, J. (2012). Finnish Experiences. In D. Raphael Tackling Health Inequalities: Lessons from International Experiences. Toronto: CSPI.

49

Social Democratic Welfare States: Norway • Norwegian public health policy approach is radical in

its emphasis on upstream measures and intersectoral collaboration.

• These principles represent a revitalization of universal and structural measures in line with the social democratic welfare state model.

• Universal welfare measures are seen as more important than contributions from the health sector in reducing social inequalities in health.

• It is born from a conviction that the social democratic welfare state project should be sustained.

• Source: Fosse, E. (2012). Norwegian Experiences. In D. Raphael Tackling Health Inequalities: Lessons from International Experiences. Toronto: CSPI.

50

Social Democratic Welfare States: Sweden • Changes observed in public policy approaches have

been inspired by neo-liberal ideas on the role of government, acceptance of growing income inequalities, retrenchment of the welfare state, and an emphasis on the importance of individual choice.

• Health equity should be a goal across the left-right spectrum in a country with a strong egalitarian legacy.

• Since the political majority will not change soon, public health advocates need new strategies to bring politicians on board.

• Source: Backhuns, M. and (2012). Swedish Experiences. In D. Raphael Tackling Health Inequalities: Lessons from International Experiences. Toronto: CSPI.

51

Liberal Welfare States: Australia • Economic inequities in Australia have increased

with worrying signs of a growing divide between haves and have-nots in Australian society.

• Concerted policy action is required to use progressive taxation and other revenue-raising methods to ensure funding for redistributive policies.

• Leadership is required to create the political will to institute a systematic approach to reducing inequities.

• Source: Baum, F. et al. (2012). Australian Experiences. In D. Raphael Tackling Health Inequalities: Lessons from International Experiences. Toronto: CSPI

52

Liberal Welfare States: UK • Despite a raft of policy measures designed to reduce

health inequalities, health inequalities remain high on policy agendas throughout the UK.

• By the time Labour left office in 2010, health inequalities continued to widen triggering some despair within the health inequalities community.

• Scholars have called for stronger links between academics and policy-makers to co-produce research; engage in public health advocacy and work with communities; and promote awareness of the actors and forces influencing policies.

• Source: Smith, K. and Bambra, C. (2012). British and N. Irish Experiences. In D. Raphael Tackling Health Inequalities: Lessons from International Experiences. Toronto: CSPI.

53

Liberal Welfare States: Canada • Health inequalities are being driven by the country’s

expending fewer resources toward citizen support than most other OECD nations.

• Continuing evidence of a decline in relative population health and stagnating or increasing health inequalities can be expected.

• Canada’s unwillingness to promote citizen economic and social security are troubling with little sign this situation will improve in the near future.

• Source: Raphael, D. (2012). Canadian Experiences. In D. Raphael Tackling Health Inequalities: Lessons from International Experiences. Toronto: CSPI.

54

Resiliency Factors • SD Welfare state: Path dependency • Central governance • Proportional representation • Union strength • Strength of civil society • Nordic values of equality • Buy-in of the middle class

55

Nordic Nations: Immediate Challenges

• Integrating immigrants • Counterbalancing corporate influence • Resisting lure of right-wing parties • Responding to welfare state fatigue? • ???

56

What about the Conservative and Latin welfare regimes?

57

Implications for Health Promotion • Need for continued education and public

awareness as to the importance of health promoting public policy (hear Toba Bryant on Thursday)

• Need for a political economy lens that considers how issues of power, influence, and economics shape the making of health promoting public policy

• Identifying of barriers to the making of health promoting public policy provide means means of overcoming these barriers (hear me tomorrow)

58

Implications for Health Promotion Research

• Need to systematically research the political economy of health promotion

• Study citizen attitudes and values towards redistribution, health, and health promotion

• Examine the forces that oppose health promotion and the public policies that support it

• Evaluate the impacts of governments’ policies on the health and well-being of citizens and the extent of health inequalities

• Put special focus on the situation of immigrants

59

Conclusions and Take Away Messages • Nordic welfare state appears to be the best

means of promoting health and quality of life • Challenges to promoting the health and well-

being of citizens can be addressed but only if they are accurately identified.

• “Don't it always seem to go That you don't know what you've got 'Til it's gone They paved paradise And put up a parking lot -- Joni Mitchell, Big Yellow Taxi, 1970

60

Dennis Raphael

draphael@yorku.ca

This presentation and other presentations and related papers are available at:

http://www.atkinson.yorku.ca/draphael

[go to the library there]