Transcript Social Determinants of Health

The Politics of Population Health
Dennis Raphael, PhD
School of Health Policy and Management
York University, Toronto
Presentation to Nursing 5190.3
Enhancing Nursing Praxis through Public Policy
Week 9: February 27 - March 9, 2006
Overview of Presentation
• To define public policy and its impact on the
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quality of the social determinants of health
To identify the political and economic forces
that influence public policy
To explore specific examples of public policy
and their impacts on health and well-being
To consider the Canadian situation in an
international context
To outline policy directions for Canadian
society
Defining Population
Health and the Social
Determinants of
Population Health
Defining Population Health
• Population health focuses on improving the
health status of the population rather than
individuals. Focusing on the health of
populations also requires reducing health
inequalities between groups.
• One assumption of a population health
approach is that reductions in health inequities
require reductions in material and social
inequities.
• Source: Health Canada. (2004). Population Health
Approach.
What are Social Determinants of Health?
• SDOH are the economic and social conditions that
influence the health of individuals, communities, and
jurisdictions as a whole.
• SDOH determine whether individuals stay healthy or
become ill (a narrow definition of health).
• SDOH also determine the extent to which a person
possesses the physical, social and personal resources
to identify and achieve personal aspirations, satisfy
needs, and cope with the environment (a broader
definition of health).
• SDOH are about the quantity and quality of a variety
of resources that a society makes available to its
members.
A Policy-Oriented Approach to the
Social Determinants of Health
• early life
• housing
• education
• income and
income distribution
working conditions • social exclusion
• food security
• social safety net
• health services
• unemployment
• employment and
Source: Raphael, (2004). Social Determinants of Health:
Canadian Perspectives. Toronto: Canadian Scholars Press.
Defining Public Policy
What is Public Policy?
• Public policy is a course of action or inaction
chosen by public authorities to address a given
problem or interrelated set of problems.
• Policy is a course of action that is anchored in a
set of values regarding appropriate public goals
and a set of beliefs about the best way of
achieving those goals.
• The idea of public policy assumes that an issue is
no longer a private affair.
• Source: Wolf, R. (2005). What is public policy? Available at
http://www.ginsler.com/html/toolbox.htp
SDOH and their Public Policy
Determinants
• early life – income supports, progressive family policy,
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availability of childcare, support services
education – support for literacy, public spending,
tuition policy
employment and working conditions – active labour
policy, support for collective bargaining, increasing
worker control
food security – income and poverty policy, food policy,
housing policy
health services – public spending, access issues,
integration of services
SDOH and their Public Policy
Determinants
• housing – income and housing policy, rent controls
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and supplements, provision of social housing
income and income distribution – taxation policy,
minimum wages, social assistance, social assistance
levels, family supports
social exclusion – anti-discrimination laws and
enforcement, ESL and job training, approving foreign
credentials, support of a variety of other health
determinants
social safety net – spending on a wide range of
welfare state areas
unemployment – active labour policy, replacement
benefits, labour legislation
Why is this Important?
• Greatest challenge to developed nations is sustaining vibrant
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economies to support the quality of life of citizens.
To do so, it is important to apply a life-cycle approach to
sustainability of the welfare state.
Post-industrial society must invest in citizens, especially
children to support the economy and other institutions.
Supporting children will nurture “strong, resource and
productive adults.”
Promote social inclusion: Active versus passive income and
labour policy.
Source: Esping-Andersen, G. (2002). Why We Need a New
Welfare State, 2002. New York: Oxford University Press.
Links to Health Literature
• Shaw et al. emphasize the importance of societal
supports for significant transitions across the life span
such as entering and leaving school, gaining and
possibly losing employment, and entering retirement.
• These supports include provision of income and
employment security, equitable distribution of
resources, and educational and training opportunities
across the life span.
• How can we evaluate whether nations are committed
to such goals?
• Source: Shaw, M. et al., (1999). The Widening Gap.
Bristol: Policy Press.
Spending on Transfers
or
What is the Depth of the
Welfare State?
Public Social Expenditure as Percentage
of GDP, 1980-2001
35
30
25
20
15
10
1980
Canada
1985
1990
United States
1995
2000
United Kingdom
2001
Sweden
Source: OECD (2004). Social Expenditure Database http://www.oecd.org/els/social/expemditure.
Government Spending on Various
Programs as a Function of GDP, 2001
10
9
8
7
6
5
4
3
2
1
0
Old Age
Canada
Survivors
Incapacity
United States
Health
United Kingdom
Family
Sweden
Source: OECD (2004). Social Expenditure Database http://www.oecd.org/els/social/expenditure
And its Effects on
Child Poverty?
Source: Innocenti
Research Centre.
(2005). Child poverty
in rich countries, 2005,
Innocenti report card
No.6. Florence:
Innocenti Research
Centre.
Figures are for the
years around 19982001.
Pre-Transfer and Post-Transfer Poverty Rates in
Canada and other Nations, 1990’s
30
28.8
25
28.3
23
21
20
18.6
16.4
15
11.4
10
5
3.3
0
Canada
USA
Pre-Transfer
UK
Sweden
Post-Transfer
Source: Nelson, K. (2004). Mechanisms of poverty alleviation: Anti-poverty effects of non-means
and means-tested benefits in five welfare states. Journal of European Public Policy, 14, 371-390.
Political and Economic
Forces that Influence
Public Policy
Gosta EspingAndersen:
The Modern Welfare
State
Esping-Andersen Typology of
Welfare States I
• Social Democratic (e.g., Sweden, Norway, Denmark,
Finland), Liberal (UK, USA, Canada, Australia), and
Conservative (Germany, France, Italy, Portugal)
welfare states form a continuum of government
support to citizens.
• These supports range from high government
intervention welfare systems in the Social Democratic
countries to residual welfare systems as seen in
Liberal political economies.
• Conservative nations (e.g., Germany, France, Italy fall
midway in their provisions.
• Source: Esping-Andersen, G. (1999). Social Foundations of
Post-Industrial Economies. New York: Oxford University Press.
Esping-Andersen Typology of
Welfare States II
• The Liberal welfare state sees means-tested
assistance, modest universal transfers, and modest
social-insurance plans.
• Means-testing refers to benefits in the Liberal welfare
state being primarily geared to low-income groups.
• Social assistance is limited by traditional, liberal workethic attitudes that stigmatize the needy and attribute
failure to individual, rather than, societal failures.
• Liberal nations limit welfare benefits since it is
believed generous benefits lead to a preference for
welfare dependency rather than gainful employment.
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Source: Esping-Andersen, G. (1999). Social Foundations of PostIndustrial Economies. New York: Oxford University Press.
Social Democratic Regimes
• SD regimes present higher levels of union density.
• SD regimes have > levels of social security and public
employment expenditures, > public health care
expenditures, and > extensive health care coverage.
• SD nations implemented full employment strategies,
attained high rates of female employment, and the
lowest levels of income inequality and poverty.
• SD nations had the lowest % of income derived from
capital investment and the largest from wages.
• On a key indicator of population health – infant
mortality – SD countries had the lowest rates from
1960 to 1996.
•
Source: Navarro, V., & Shi, L. (2002). The Political Context of Social Inequalities and Health. In
V. Navarro (Ed.), The Political Economy of Social Inequalities: Consequences for Health and
Quality of Life. Amityville, NY: Baywood.
Anglo-Saxon Liberal Regimes
• Anglo-Saxon liberal political economies had the
lowest health care expenditures and the lowest
coverage by public medical care.
• Had greater incidence of low wage earnings,
higher income inequalities, and the highest poverty
rates.
• These economies derived the greatest proportion
of income from capital investment rather than
wages.
• These economies had the lowest improvement
rates in infant mortality rates from 1960 to1996.
•
Source: Navarro, V., & Shi, L. (2002). The Political Context of Social Inequalities and
Health. In V. Navarro (Ed.), The Political Economy of Social Inequalities: Consequences
for Health and Quality of Life. Amityville, NY: Baywood
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.
Power Relations and the Welfare State
• Power relations -- electoral behaviour and
trade union solidarity -- interact with civic
behaviour -- trust in government, corruption
and cynicism – to produce labour market and
welfare state policies.
• When these policies ameliorate social and
economic inequalities, population health as
measured by infant mortality, cause-specific
mortality, and life expectancy should improve.
Predictors of Declines in Infant Mortality and
Increases in Life Expectancy in OECD Nations
• Increasing support for social democratic
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parties
Increases in the proportion of citizens voting
Increases in public health care coverage
Increases in the proportion citizens employed
Increases in female labour force participation
Increasing income equality
Increases in national wealth
Source:Navarro, V., et al.(2004). The importance of the political and the social
in explaining mortality differentials among the countries of the OECD,
1950-1998. In V. Navarro (Ed.), The Political and Social Contexts of
Health. Amityville NY: Baywood Press.
Source: Rainwater,
L., & Smeeding, T.
M. (2003). Poor Kids
in a Rich Country:
America's Children in
Comparative
Perspective. New
York: Russell Sage
Foundation.
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
• “There is no such thing as society.”
• Source: Coburn, D. (2000). Income inequality, social
cohesion and the health status of populations: The role of
neo-liberalism. Social Science & Medicine, 51(1), 135-146.
Neo-Liberalism
• Considering that Canada and the UK are already
identified as a liberal political economy within
Esping-Andersen’s typology, they may be especially
susceptible to neo-liberal ideology (see
Vandenbroucke (2002) for a discussion of European
Union resistance to neo-liberal influences.
• And, indeed many have argued that this has been
the case in Canada. The growth of the welfare state
in Canada leveled off in the early 1980’s, and since
1990 there has been a drastic decline in public
expenditures in support of a variety of welfare state
policies.
Hulchanski, D. (2002). Can Canada Afford to Help Cities, Provide Social
Housing, and End Homelessness? Why Are Provincial Governments Doing So
Little? Toronto: Centre for Urban and Community Studies.
Hulchanski, D. (2002). Can Canada Afford to Help Cities, Provide Social
Housing, and End Homelessness? Why Are Provincial Governments Doing So
Little? Toronto: Centre for Urban and Community Studies.
Canada
in Comparative
Perspective
Poverty Rate (%)
Child Poverty in Lone-Parent and Other Families
in Canada and Three Comparison States, 2000
60
50
40
30
20
10
0
55.5
51.6
45.6
10.4
1.5
Canada
6.7
Sweden
13.3
UK
15.8
USA
Source: Innocenti Report Card on Child Poverty in
Rich Nations, June 2002
Other Families
Lone-Parent
Public Social Expenditure by Broad Social
Policy Areas as Percentage of GDP in Canada
and Four Comparison Nations, 1997.
18
13.6
14
10
8
30
15.1
16
12
35
18.2 33.3
10.2
25
21.6
16.9
8.0
20
9.0
6.7
16
7.0
6
15
10
4
5
2
0
0
Canada
Sweden
Cash Benefits
UK
Services
USA
Total Spending
Source: Society at a Glance, OECD, 2001
Total Spending as
Percentage of GDP
Percentage of GDP Spent
20
Income Inequality – Gini Coefficient
Canada, USA, UK, and Sweden,
Mid 80’s, mid 90’s 2000
40
35.7
35
30
32.6
30.1
24.3
25
20
15
10
5
0
Canada
USA
Mid 1980's
UK
Mid 1990's
Sweden
2000
Source: OCED (2005). Society at a Glance 2005. Paris: OECD.
Social expenditures and child poverty—the U.S. is a noticeable outlier,
Economic Policy Institute, July 23, 2004
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.
Source: Poverty Profile, 1998. Ottawa: National Council
of Welfare Reports, Autumn, 2000.
Resistance: The Future
of the Welfare State
Society and Health:
Where are We Now?
Social Determinants of Health
“Individual Lifestyle Choices”
Individual Health and Illness
Society and Health:
How Far Upstream Should We Go?
Welfare State
Social Determinants of Health
Population Health
Union Density Rate
Canada, USA, UK, and Sweden, 2000
79
80
70
60
50
40
38
29
30
20
13
10
0
Canada
USA
UK
Sweden
Source: Navarro, V. et al. (2004). The importance of the political and the social in explaining mortality
differentials among the countries of the OECD, 1950-1998. In V. Navarro (Ed.), The Political and Social Contexts
of Health. Amityville NY: Baywood Press.
Self-Positioning on “Left” of Political Scale,
Canada, USA, UK, and Sweden, 1990, 2000
35
34
30
25
24
21
20
15
26
28
16
17 18
10
5
0
Canada
USA
1990
UK
Sweden
2000
Source: Inglehart, R. et al. Human Beliefs and Values: A Cross-cultural sourcebook based on the
1999-2002 values survey. Delegacion Coyoacan: Siglo XXI Editores.
Alesina, A., &
Glaeser, E. L.
(2004).
Fighting
poverty in the
US and
Europe: A
world of
difference.
Toronto:
Oxford
University
Press.
% of GDP in
Transfers
Degree of Proportional Representation
Source: Alesina, A. & Glaeser, E. L. (2004). Fighting Poverty in the US and Europe: A World
of Difference. Toronto: Oxford University Press
Dennis Raphael
[email protected]
This presentation and other presentations
and related papers are available at:
http://www.atkinson.yorku.ca/draphael