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

draphael@yorku.ca