Transcript Economic Inequality and Health: Policy Implications

Social Policy and
Population Health
The Importance of Policy
• Policies shape how money, power and material
resources flow through society and therefore affect
the determinants of health. Advocating healthy
public policies is the most important strategy we
can use to act on the determinants of health.
Current policies that emphasize deficit reduction
and private sector economic growth can be
unhealthy for people. These policies may increase
economic inequalities, environmental degradation,
social intolerance and violence.
• CPHA Action Statement on Health Promotion, 1996
Human and Income Poverty in Canada and
Four Comparison Nations, 2000
UK
USA
1
Ranking
0
2
4
6
8
10
12
14
16
18
Canada Denmark Sweden
5
11
15
17
Source: United Nations Human Development, Report, 2002
Percentage
People Lacking Functional Literacy Skills in
Canada and Four Comparison Nations, 1998
25
20
15
10
5
0
21.8
20.7
UK
USA
16.6
9.6
7.5
Canada
Denmark Sweden
Source: United Nations Human Development Report, 2002
Population Below Income Poverty Line of 50% of
Median Income in Canada and Four Comparison
Percentage
Nations, 1998
18
16
14
12
10
8
6
4
2
0
16.9
13.4
12.8
9.2
6.6
Canada
Denmark Sweden
UK
USA
Source: United Nations Human Development Report, 2002
Inequality in Consumption or Income in Canada and Four
Comparison Nations, 2000: Share Held by Richest and
Percentage Held
Poorest 10% of the Population
35
30
25
20
15
10
5
0
23.8
2.8
27.7
20.5
30.5
20.1
3.6
3.7
Canada Denmark Sweden
2.2
UK
1.8
USA
Source: United Nations Human Development Report, 2002
Richest 10%
Poorest 10%
Poverty Rate (%)
Child Poverty in Lone-Parent and Other Families
in Canada and Four Comparison States, 2000
60
55.5
51.6
45.6
50
40
30
15.8
13.8
20 10.4
13.3
6.7
3.6
10
1.5
0
Canada Denmark Sweden
UK
USA
Source: Innocenti Report Card on Child Poverty in
Rich Nations, June 2002
Other Families
Lone-Parent
Poverty Rate (%)
Percentage of Persons Living in Poverty in LoneParent Working and Non-Working Families in
Canada and Four Comparison States, 1994
73.0
80 72.0
65.0
70
60
50
40
30
20
10
0
26
24.0
10
Canada
39
34.0
Denmark
23
4
Sweden
UK
Source: Society at a Glance, OECD, 2001
Non-Working Single
Working Single
USA
Percentage of GDP Spent
Priorities in Public Spending: Public Expenditure on
Education and Health as a Percentage of GDP in
Canada and Four Comparison Nations, 1995-1998
10
8
6.96.6
8.1
6.9
8.3
6.6
5.3
6
5.8
5.4 5.7
4
2
0
Canada Denmark Sweden
UK
USA
Source: United Nations Human Development Report, 2002
Education
Health
Percentage of GDP Spent
Canada Denmark Sweden UK
Cash Benefits
Services
USA
Total Spending
35
30
25
20
15
10
5
0
of GDP
18.2
20
33.3
16.8
18
30.5
15.1
16
13.6
13.7
14
21.6
12 10.2
1.5
9.0 16
10
8.0
7.0
8
6.7
6
4
2
0
Total Spending as Percentage
Public Social Expenditure by Broad Social Policy Areas
as Percentage of GDP in Canada and Four Comparison
Nations, 1997. Source: Society at a Glance, OECD, 2001
Net Replacement Rates at the Earnings Levels of 2/3 of an Average
Production Worker In the First Month of Benefit Receipt and For
Long-Term Benefit Recipients, in Canada and Four
Comparison Nations, 1999
Canada Denmark Sweden UK
USA
Single
Short-term
62%
Long-term
35%
Married Couple
Short-term
65%
Long-term
57%
Couple - 2 children
Short-term
69%
Long-term
77%
Lone Parent - 2 children
Short-term
67%
Long-term
77%
89%
67%
77%
84%
73%
73%
59%
10%
94%
94%
77%
100%
88%
88%
59%
18%
95%
92%
90%
100%
83%
95%
51%
61%
89%
82%
96%
100%
69%
81%
51%
51%
____________________________________________________________________________
Source: SGR Report (OECD, 2001).
3.0
2.7
2.5
2.2
2.0
3
2.7
2
1.0 1.3
1.0 0.8 1.5
0.5
0.0
0.3
2.5
2.2
1.5
0.0
Public Spending
0.3
0.0
Canada Denmark Sweden
Total Spending as Percentage
of GDP
Percentage of GDP Spent
Long-Term Care Spending as a Percentage of GDP in
Canada and Four Comparison Nations, 1995.
Source: International Reform Monitors Newsletters, 2002
1.3
0.7
0.6
1.5
1
0.5
0
UK
Private Spending
USA
Total Spending
Social Policy, Health
Determinants and Health in
the USA and Canada Today
Policy Decisions Create Poverty
and Economic Inequality
• Changing tax structures in the USA and
Canada
• Does globalization make this inevitable?
• How does economic inequality come
about?
Rising Together and Drifting Apart - USA
Changes in Family Income 1947-79 and 1979-1998
1947-79
1979-98
120%
100%
80%
60%
40%
20%
0%
-20%
Bo
20%
m
tto
Se
20%
d
n
o
c
M
%
e 20
l
d
d
i
%
h 20
t
r
u
Fo
20%
p
o
T
5%
p
o
T
The Wealth Gap in the USA
Distribution of Net Worth, 1997
4.4%
0.5%
10.7%
Top 1%
40.0%
11.4%
Next 4%
Next 5%
Next 10%
Next 20%
11.2%
Middle 20%
Bottom 40%
21.9%
Economic Inequality and Health:
Policy Implications
• Poverty and economic inequality is on the
rise in the USA and Canada
• Poverty is bad for health
• Economic inequality is dangerous for the
health of all of us
• Policy decisions create poverty and
economic inequality
• Citizens can influence policy decisions to
improve health
45
40
35
Low Income
%
Q1-Richest
Q2
Q3
Q4
Q5-Poorest
30
25
20
15
10
5
0
1971
1986
1991
1996
Source: Wilkins et al., 2002
Policy Directions and Population Health
• The policies that Canada has developed to improve
population health reflects its more egalitarian
structure. Examples include various tax and
economic transfer policies that help to limit income
differences across the country, as well as provision of
important social services... If a healthy population is
the goal, we must enter the political arena and fight
to maintain the social contract that has sustained
Canada as one of the world leaders in health.
• Stephen Bezruchka, CMAJ, 2001
Canadian Policy Directions
It has become obvious that people on the low end of
the income scale are cut off from the ongoing
economic growth that most Canadians are enjoying.
It is also obvious that in these times of economic
prosperity and government surpluses that most
governments are not yet prepared to address these
problems seriously, nor are they prepared to ensure
a reasonable level of support for low-income people
either inside or outside of the paid labour force.
-- Poverty Profile, 1998. Ottawa: National Council of Welfare
Reports, Autumn, 2000.
Implications of Increasing Family Poverty
Given the disturbing increases in income inequality
in the United States, Great Britain, and other
industrial countries, it is vital to consider the impact
of placing ever larger numbers of families with
children into lower SES groups. In addition to
placing children into conditions which are
detrimental to their immediate health status, there
may well be a negative behavioural and psychosocial
health dividend to be reaped in the future.
Why Do Poor People Behave Poorly? Variation in Adult Health
Behaviours and Psychosocial Characteristics by Stages of the Socioeconomic
Life Course, J.W. Lynch, G.A. Kaplan, & J.T. Salonen. Social Science and
Medicine, 1997, 44, 809-819.
--
Policy Trends Responsible for Shift Towards
Home Rather than Hospital Care for Canadians
•
•
•
•
debt/deficit pressures,
a recognition of the limits to health care,
increasing technology and associated costs,
and the increasing perception of health as a
business leading to:
• increased privatization with negative effects upon
women as a) care recipients; b) health care
workers and c) informal caregivers within the
home (Armstrong, 2002).
US/Canada Disparities in Infant Mortality
Mortality rate ratios (Canada=1.0)
1.5
1.4
1.3
US/Can
1.2
1.1
1
1970
1975
1980
1985
Source: Wilkins et al., 2002
1990
1996
US-Canada Life Expectancy Trends
Years (at birth), total both sexes
79
78
77
76
75
Canada
USA
74
73
72
71
70
1971
1976
1981
1986
Source: Wilkins et al., 2002
1991
1996
Source: Dunn, 2002
Components of the Index of Social Health
Children
infant mortality
child abuse
children in poverty
Youth
teen suicide
drug abuse
HS drop-outs
Elderly
Adults
unemployment
weekly earnings
health insurance
coverage
All Ages
- Poverty among those
65 and over
- Out-of-pocket health
cost for those 65 and over
-homicides
-alcohol-related traffic fatalities
- social assistance rates
-access to affordable housing
- gap between rich and poor
Source:Brink & Zeesman, HDRC, 1997
Reducing Health Inequalities
We consider that without a shift of
resources to the less well off, both in and
out of work, little will be accomplished
in terms of a reduction of health
inequalities by interventions addressing
particular downstream’ influences.
-- Report of the Acheson Independent Inquiry
into Inequalities in Health, 1998, p. 33.
Social Policy, Health, and
the Welfare State
The Role of Values and Principles in
Public Health and Health Promotion
The public ideas – and the language associated
with them – which currently envelop us are those
of the market, corporatism, fiscal restraint, and
globalization, ideas which are driving the near
universal dismantling of the welfare state, and
eroding any notion we might have of the common
good. Health promotion represents one
possibility for countervailing ideas: ideas about
equity, social justice, interdependence, the
common good.
-- Robertson, 1999, p. 130
Key Tenets of Neo-liberalism
• markets are the most efficient allocators
• of resources in production and distribution;
• societies are composed of autonomous
individuals (producers and consumers)
motivated chiefly by material or economic
considerations;
• competition is the major market vehicle for
innovations
• - Coburn, 2000.
Defining the Welfare State
• The welfare state is a capitalist society in
which the state has intervened in the form
of social policies, programs, standards, and
regulations in order to mitigate class
conflict 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.
• - Teeple, G. (2000). Globalization and the decline
of social reform.
Forces that Led to the Development of
the Welfare State
• Strong national identities at end of WWII
• Need to rebuild Western economies after WW II
• Strength of labour unions within national labour
boundaries
• Perceived threat of “socialist” alternatives
• Political compromise to avoid boom-bust cycles of
the economy
• - - Teeple, G. (2000). Globalization and the decline of
social reform.
Forces Leading to the Decline
of the Welfare State
• Weakened national identities as a result of trade
agreements
• Internationalization of investment thereby
weakening nationally-based labour unions
• Political compromises between business, labour and
governments becoming unnecessary
• Perceived threat of “socialist” alternatives removed
• Slowing of economies and concentration of corporate
and media ownership
• - - Teeple, G. (2000). Globalization and the decline of
social reform.