Download Beyond medicine and lifestyle: addressing the societal determinants

Beyond medicine and lifestyle: addressing the
societal determinants of cardiovascular disease in
North America
Dennis Raphael
York University, Toronto, Ontario, Canada
E. Sara Farrell
Queens University, Kingston, Ontario, Canada
Keywords
Health care, Lifestyles ,
Cardiovascula r disease
Abstract
Increasin g evidence is
accumulatin g that biomedical and
lifestyl e factors account for rather
small proportions of populatio n
variance in incidenc e of
cardiovascula r disease (CVD). In
North America, however, the
medical and public health
communitie s ± reinforced by
narrow media coverage focused on
biomedica l and lifestyl e issues ±
remain wedded to these models of
cause and prevention . Not
surprisingly , public perception s of
the causes of CVD mirror these
preoccupations . A review
commissione d by a community
heart health network brought
together the evidence of how CVD
results primarily from material
deprivation , excessiv e
psychosocia l stress, and the
adoption of unhealth y coping
behaviors . The review has served
to help shift thinking about CVD
prevention in Canada and the USA.
Leadership in Health Services
15/4 [2002 ] i±v
# MCB UP Limited
[ISSN 1366-0756]
[DOI 10.1108/1366075021045214 3]
Introduction
As with any area of medical or scientific
research, the selection of ``factors’’ to be
studied cannot be immune from prevailing
social values and ideologies . . . It is also
evident that so-called lifestyle or behavioural
factors (such as the holy trinity of risks ± diet,
smoking and exercise) receive a
disproportionate amount of attention. As we
have seen, the identification and
confirmation of risk factors are often subject
to controversy and the evidence about causal
links is not unequivocal (Nettleton, 1997,
p. 319).
In this paper an analysis is made of the
societal determinants of cardiovascular
disease (CVD). Though the emphasis is on
Canada, the results of this analysis of the
causes and means of preventing CVD are
clearly applicable to those working in the
USA and elsewhere. This article is based on
findings contained in two comprehensive
literature reviews of the societal
determinants of CVD (Raphael, 2001a, 2002).
The genesis of these efforts to explore the
societal determinants of CVD was the
recognition by members of the North York
Heart Health Network ± a community-based
heart health coalition ± that lifestyle
programming was clearly an incomplete
means of addressing this important health
issue.
CVD is the leading cause of mortality
among Canadians and US citizens,
responsible for 40,000 Canadian deaths per
year, representing 36 percent of all mortality,
and 959,000 US deaths per year or 41 percent
of all US mortality (Heart and Stroke
Foundation of Canada, 1999; American Heart
Association, 2002). The estimate of the total
annual cost to Canada of CVD is near $20
billion, and to the USA, close to $300 billion
(Heart and Stroke Foundation of Canada,
1999; Fox, 2002). An expanding literature ±
much of it European ± is making clear that
the economic and social conditions under
which people live, rather than biomedical
risk conditions and lifestyle choices, are the
major factors determining whether one
develops CVD (Wilkinson and Marmot, 1999).
The one life condition with the greatest
influence upon the development of CVD is
low income (Raphael, 2001b). This article
provides evidence of the magnitude of
income-related differences in CVD and the
mechanisms by which low income influences
the development of CVD. These effects result
from material deprivation, psychosocial
stress, and the adoption of unhealthy coping
behaviours (Benzeval et al., 1995). The clear
conclusion from this analysis is that new
ways of thinking about CVD are needed.
Some examples of how this paradigm in
thinking about CVD is occurring are
provided.
Income and CVD: the magnitude of
the problem
A series of studies in the UK document how
those living on lower incomes are more likely
to suffer from and die from CVD ± and a
number of other diseases ± at every age
(Black and Smith, 1992; Whiteside, 1992;
[i]
Dennis Raphael and
E. Sara Farrell
Beyond medicine and lifestyle:
addressing the societal
determinants of
cardiovascular disease in
North America
Leadership in Health Services
15/4 [2002] i±v
Acheson, 1998). In the USA, lower-income
Americans have a higher incidence of a
range of diseases. Lower income Americans
are much more likely ± risk ratio of 2.52 ± to
die from CVD than highest income
Americans (US Department of Health and
Human Services, 1998).
In Canada, national examinations of the
relationship between income and mortality
from diseases use census tract of residence to
estimate individuals’ income. Canadians
living within the poorest 20 percent of urban
neighborhoods have much higher mortality
rates for CVD, cancer, diabetes, and
respiratory diseases than other income
groups (Wilkins et al., 1989; Statistics
Canada, 2001).
In 1996, 23 percent of years of life lost from
disease and injuries prior to age 75 in Canada
could be attributed to income differences.
CVD was the disease most responsible for
these differences, accounting for 22 percent of
all of these years lost. In terms of absolute
CVD mortality, income differences accounted
for a 24 percent excess prior to 75 years. Were
all Canadians’ death rates from CVD disease
equal to those in the wealthiest quintile
group, 6,366 fewer deaths each year from
CVD would occur (Statistics Canada, 2001).
What mechanisms mediate the low
income and CVD relationship?
Biomedical and lifestyle factors account for
rather small proportions of variance in CVD
rates among populations (Feldman et al.,
1989; Lantz et al., 1998; Roux et al., 2001).
Typically, studies show that lower income
people are much more likely to develop CVD
and these effects remain strong when
controlling for tobacco use, level of physical
activity, presence of hypertension or
diabetes, level of cholesterol, and body mass
index, and a host of other biomedical and
lifestyle risk factors.
A World Health Organization (1998) study
found CVD changes rates among 21 nations
were unrelated to national changes in a
range of biomedical and lifestyle factors such
as weight, smoking, blood pressure, or
cholesterol levels. Societal unrest, poverty,
and social and economic change were
suggested as potentially the best predictors of
CVD rates.
There is also continuing uncertainty
regarding the processes that contribute to
CVD. Marmot and Mustard (1994, p. 213)
question the importance of cholesterol levels:
[ ii ]
For example, since the main cause of
myocardial ischemia (heart attacks) is a
thromboembolic event, it is difficult to see
how changes in cholesterol levels in adult
males will dramatically change outcomes,
since there is no evidence that cholesterol has
a major clinical effect on the thromboembolic
process. This may be one of the reasons why
risk modifications by trying to lower
cholesterol levels has not had a dramatic
effect on the incidence of heart attacks.
Efforts to reduce CVD mortality through
lifestyle change and cholesterol reduction
have rather limited efficacy (O’Loughlin
et al., 1999; Fitzpatrick, 2001). In contrast,
impressive evidence of the impact of living
on low income continues to accumulate.
There are three main ways in which low
income contributes to CVD. Low income is
associated with material deprivation during
early life and adulthood, excessive
psychosocial stress, and the adoption of
health threatening coping behaviors
(Benzeval et al., 1995). Each of these serves as
a pathway from low income to CVD.
Material deprivation
Material deprivation refers to differences in
exposures to both beneficial and damaging
aspects of the physical world. These
exposures are determined in large part by
income (Lynch et al., 2000). Individuals
experiencing material deprivation have
greater exposures to negative events such as
hunger, and poor quality food, housing,
clothing, and environmental conditions at
home and work (Davey Smith et al., 2002).
These individuals also have fewer exposures
to positive resources such as books,
newspapers, cultural events, quality
education, opportunities for recreation, and
involvement in other stimulating activities
that support health.
Increases in incidence of low income, food
bank use, and homelessness in Canada and
the USA during the past decade contribute
directly to poor population health, including
the incidence of CVD (Raphael, 2001a, b, c).
While each level of the income scale shows
different levels of health ± including CVD ±
the greatest burden is concentrated at the
lower end of the income range (Lynch, 2000).
Low income during childhood and
adulthood makes independent contributions
to the likelihood of developing CVD (Davey
Smith and Gordon, 2000). Low-income
children carry a strong CVD health burden
into adulthood regardless of adult income
status. To illustrate, low birth weight ± itself
related to income status ± is associated with
Dennis Raphael and
E. Sara Farrell
Beyond medicine and lifestyle:
addressing the societal
determinants of
cardiovascular disease in
North America
Leadership in Health Services
15/4 [2002] i±v
greater likelihood of mortality from CVD in
later life (Eriksson et al., 1999, 2001; Forsen et
al., 1999).
Excessive psychosocial stress contributes
to CVD
Living on low income creates uncertainty,
insecurity, and feelings of lack of control
over one’s life: conditions that have powerful
effects on health (Antonovsky, 1987). The
National Population Health Survey found
that, among Canadians in the lower third of
the income distribution, 47 percent reported
seeing the world as not being meaningful,
events as being incomprehensible, and life’s
challenges as being unmanageable (Federal
Provincial and Territorial Advisory
Committee on Population Health, 1999). The
comparable figure for the highest third
income group was 26 percent. Similarly,
people in the lower income group were 2.6
times more likely to have a low sense of
control over their lives than the higher
income third of Canadians (31 percent vs
12 percent).
The means by which continuous stress
leads to CVD disease ± through psychological
and biological pathways ± are becoming
better understood (Stansfeld and Marmot,
2002). Adverse social environments produce
the ``fight or flight’’ reaction, that lead to lipid
abnormalities, high blood pressure, and
clotting disturbances (Bruner and Marmot,
1999).
Animal researchers have identified the
biological and psychological mechanisms by
which chronic stress and hierarchy create
illness and eventually death (Shivey et al.,
1997). These models are consistent with
studies of the experience of living on low
incomes and help explain the low income and
CVD relationship.
Adoption of health threatening behaviors
contributes to CVD
Behavioral risk factors for CVD of tobacco
smoking, diet, and physical inactivity are not
adopted through voluntary lifestyle choices,
but are strongly shaped by the social and
economic environments in which people live.
They ameliorate the stress of daily living for
many low-income people (Jarvis and Wardle,
1999). Lifestyle approaches for avoiding CVD
are inappropriate for numerous reasons.
Behavioral factors account for a small
proportion of the likelihood of developing
CVD compared with income. It blames the
victim whereby those with disadvantage are
blamed for adopting means of coping with
difficult life situations, that is, it fails to
address underlying issues of why
disadvantaged people adopt these behaviors.
Finally, it is rather ineffective as a
population health approach (Jarvis and
Wardle, 1999).
Beyond medicine and lifestyle
CVD, therefore, can be seen as resulting from
processes of material deprivation, excessive
psychosocial stress, and societal features that
lead to unhealthy behaviors. Yet, in spite of
this increasing evidence, the medical and
public health communities persist in
excluding these issues from discussion. The
public shares this perception.
A recent study in the Canadian Journal of
Public Health asked 601 residents of
Hamilton, Ontario to identify ``the major
cause of heart disease’’ (Paisley and Midgett,
2001). Respondents were then provided with
an additional six opportunities to identify
``any other cause of heart disease’’. In
response to these open-ended questions, only
one respondent out of 601 identified poverty
as a cause of heart disease ± out of 4,200
potential responses!
One of the goals of the North York Heart
Health Network in commissioning these
reports was to counter these understandings
and raise awareness of the role societal
factors play in the incidence of CVD. In many
ways this goal has been met. The report
received international attention through
numerous list-serves and bulletin boards. Its
content has been quoted in numerous
submissions to commissions reviewing
health and social policy in Canada. It was
featured in a United Church of Canada video
entitled Keeping the Vision Alive: Saving
Canadian Health Care.
Traditional media coverage has been good
across Canada and it received significant
attention coverage in the alternative
progressive media. Articles have been
published in the Canadian Journal of Public
Health and the Canadian Review of Social
Policy, with additional articles in press in the
Canadian Review of Social Policy, Health
Promotion International, Harvard Health
Policy Review and Health Education.
Additionally, the first author has made
presentations to Ontario medical officers and
health unit board members, and numerous
conferences including a keynote at the Maine
Governor’s Conference Keynote Address.
The CVD area, however, represents a
[ iii ]
Dennis Raphael and
E. Sara Farrell
Beyond medicine and lifestyle:
addressing the societal
determinants of
cardiovascular disease in
North America
Leadership in Health Services
15/4 [2002] i±v
significant challenge to policy-oriented
approach to promoting population health.
Lifestyle messages remain clearly
dominant despite increasing evidence of
their limited role in the incidence of CVD and
the ineffectiveness of behaviorally-oriented
health promotion programs. The North
American medical communities and much of
the public health community in Canada have
actively ignored the work described here.
Despite increasing attention being paid to the
societal determinants of population health in
Canada and the USA, the extent to which the
newly emerging paradigm of the societal
determinants of health can influence
thinking about CVD remains an open
question (Raphael, in press).
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E. Sara Farrell
Beyond medicine and lifestyle:
addressing the societal
determinants of
cardiovascular disease in
North America
Leadership in Health Services
15/4 [2002] i±v
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Hearts: Why Societal Factors ± not Lifestyles ±
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Toronto, available at: www.socialjustice.org
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one Canadian community effort hit ± and
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Further reading
Raphael, D., Brown, I., Bryant T. et al. (2001),
``How government policy decisions affect
seniors’ quality of life: findings from a
participatory policy study carried out in
Toronto, Canada’’, Canadian Journal of
Public Health, Vol. 92, pp. 190-5.
[v]
The social determinants of the incidence and
management of type 2 diabetes mellitus: are we
prepared to rethink our questions and redirect our
research activities?
Dennis Raphael
York University, Toronto, Ontario, Canada
Susan Anstice
Ryerson University, Toronto, Ontario, Canada
Kim Raine
University of Alberta, Edmonton, Alberta, Canada
Kerry R. McGannon
University of Iowa, Iowa City, Iowa, USA
Syed Kamil Rizvi
York University, Toronto, Ontario, Canada
Vanessa Yu
York University, Toronto, Ontario, Canada
An expanding literature is examining the
dimensions of health inequalities in
industrialized nations (Acheson, 1998;
Raphael, 2002a). Specific focus is on
Abstract
This paper discusses the role played dimensions of social exclusion that reflect
by social determinants of health in
increasing income, housing, and food
the incidence and management of
type 2 diabetes mellitus (diabetes) insecurity associated with the weakening of
among vulnerable populations. This the welfare state (Canadian Council on Social
issue is especially important in light
Development, 2001; Health Promotion
of recent data from Statistics
Atlantic, 2001; Raphael, in press). Diabetes
Canada indicating that mortality
mellitus (diabetes) ± like cardiovascular
rates from diabetes have been
increasing among Canadians since
disease ± is an affliction more common
the mid-1980s, with increases
among the poor and excluded (Chaturvedi
being especially great among those
et al., 1998; Hux et al., 2002). A few studies in
living in low-income communities.
Diabetes therefore appears ± like
Canada have included income as a relevant
cardiovascular disease ± to be an
variable in the incidence of diabetes, but
affliction more common among the
these studies lack adequate
poor and excluded. It also appears
to be especially likely to afflict poor conceptualization of the role social
women. Yet we know little about
determinants of health play in diabetes
how these social determinants of
health influence diabetes incidence incidence (Raphael, 2002c). Also, conceptual
and management. What evidence is and empirical analyses have not been carried
available is provided and the case is out in a way that has income as a
made that the crisis in diabetes
determinant of the risk factors usually
requires new ways of thinking about
associated with diabetes morbidity and
this disease, its causes, and its
management.
mortality.
This paper outlines what is known about
the social determinants of type 2 diabetes and
challenges health researchers and workers to
begin asking different questions as to the
causes of its incidence and the factors
affecting its management. It does not include
International Journal of Health examination of the possible role that genes
Care Quality Assurance
play in the incidence of diabetes. McDermott
incorporating Leadership in
Health Services
argues that the evidence for such a role is
Keywords
Diabetes, Health services,
Research work, Social factors
16/3 [2003] x±xx
# MCB UP Limited
[ISSN 1336-0756]
[DOI 10.1108/13660750310486730]
[x]
The Emerald Research Register for this journal is available at
http://www.emeraldinsight.com/researchregister
limited as compared to issues of social and
material deprivation. She also considers how
an emphasis on biological determinism as an
explanation of the late twentieth century
epidemic of diabetes distracts from
consideration of the types of social and
economic issues we raise in this paper
(McDermott, 1998).
Diabetes: definition, incidence,
and management
Diabetes is a common chronic disease that
affects over two million Canadians. All forms
of diabetes are characterized by the presence
of high blood glucose (hyperglycemia) due to
defective insulin secretion, insulin action, or
both. During an acute episode, coma and
even death may result from blood sugar that
is very high or very low, due to medication
overdoses. Chronic hyperglycemia may lead
to serious complications including damage to
the heart, kidneys, eyes, nerves and blood
vessels (Canadian Medical Association and
Canadian Diabetes Association, 1998). The
treatment for diabetes rests on blood glucose
(glycemic) control to be achieved with diet,
exercise and (if necessary) medications ± the
``three pillars'' of the diabetes management
regimen (Canadian Medical Association and
Canadian Diabetes Association, 1998).
Health Canada reports that diabetes is the
seventh leading cause of death in Canada,
claiming 5,000 lives annually (Health Canada,
The current issue and full text archive of this journal is available at
http://www.emeraldinsight.com/1336-0756.htm
1999). It is estimated that by 2010, close to four
million Canadians will have this disease.
Some $9 billion is spent annually on diabetes
care in Canada. Diabetes is a challenge
because it is subject to the ``rule of halves'' ±
only half of all cases of diabetes are
diagnosed, only half of those diagnosed are
treated, and only half of those having
International Journal of Health treatment are managed successfully
Care Quality Assurance
(McKinlay and Marceau, 2000). Little is
incorporating Leadership in
known about the determinants that help put
Health Services
16/3 [2003] x-xx
Canadians into each of these important
halves.
Diabetes is classified into two main types:
1 type 1, gestational diabetes (GDM); and
2 type 2 (Canadian Medical Association and
Canadian Diabetes Association, 1998).
Dennis Raphael,
Susan Anstice, Kim Raine,
Kerry R. McGannon,
Syed Kamil Rizvi and
Vanessa Yu
The social determinants of the
incidence and management of
type 2 diabetes mellitus: are
we prepared to rethink our
questions and redirect our
research activities?
Type 1 diabetes usually develops during
childhood and its onset is generally acute. It
occurs when the pancreas fails to produce
insulin, often as a result of auto-immune
damage and pancreatic beta-cell destruction.
Gestational diabetes is a temporary condition
of glucose intolerance during pregnancy and
is often a precursor to type 2 diabetes later in
life. Type 2 diabetes usually develops during
adulthood, although age of incidence is
decreasing and results from predominant
insulin resistance with relative insulin
deficiency to a predominant secretory defect
with insulin resistance. Onset can be
insidious as insulin secretion may decline
gradually. Type 2 diabetes affects
approximately 90 percent of Canadians
diagnosed with diabetes (Canadian Diabetes
Association, 2000) and is the primary focus of
this paper. In Canada, Type 2 diabetes is
appearing at younger ages (Canadian
Medical Association and Canadian Diabetes
Association, 1998).
Greater burden on vulnerable
populations
An examination of the distribution of
diabetes in the population reveals a
disproportionate burden among low-income ±
including aboriginal ± Canadians. Recent
data from the Institute for Clinical
Evaluation Sciences indicate that in Ontario
the risk of diabetes is four times greater
among low-income women than that seen
among high-income women (Hux et al., 2002).
The rate for low-income males is
40 percent higher, and among lower-middleincome males, 50 percent higher than the
well-off, still very significant figures. CrossCanadian data indicate that the prevalence of
diabetes among Canadians aged 45-64 years
with household incomes of $10,000-29,999 is
twice (6 percent) that of those living in
households with incomes of $60,000 or more
(3 percent) (James et al., 1997). Similar
findings are seen in the UK (Riste et al., 2001).
Wilkins and colleagues provide striking
evidence in the September 2002 issue of
Health Reports of how increases in mortality
rates from diabetes among Canadians since
the mid-1980s have been especially great
among Canadians living in urban low income
communities (Wilkins et al., 2002). These
researchers link the causes of death and
postal code data with census data to provide
profiles of mortality rates in urban Canadian
neighbourhoods classified into income
quintiles. Wilkins et al. (2002, p. 19) describe
the findings regarding mortality associated
with diabetes in urban Canada as follows:
For diabetes among males, mortality rates for
most quintiles decreased from 1971 to 1986,
but then increased from 1986 to 1996. Because
the increases in the latter period were
especially large for the poorest quintiles, the
inter-quintile rate differences widened from
1986 to 1996. For diabetes among females,
mortality rates for all quintiles declined from
1971 to 1986 and then changed little from 1986
to 1996, except for the poorest quintile, in
which rates increased rapidly. Therefore, the
inter-quintile rate difference was
considerably greater in 1996 than it had been
in 1986. The trends with respect to the overall
rates and socio-economic disparities in
diabetes mortality are disquieting and
deserve further study.
Similar findings concerning morbidity and
mortality among low-income communities
are apparent in the USA and UK (Riste et al.,
2001; McKinlay and Marceau, 2000). Diabetes
therefore appears ± like cardiovascular
disease ± to be an affliction more common
among the poor and excluded. Evidence of
increasing income inequality among
Canadians and increasing numbers of low
income families during the past decade
directs special attention to the potential
effects of low income upon the health and
wellbeing of those living with diabetes
(Canadian Institute for Health Information,
2002).
Social determinants of health and
diabetes: potential contributions to
understanding
Virtually nothing is known about the causes
of recent increases in morbidity and
mortality among the Canadian population in
general, and the low-income population in
particular. The presence of the metabolic
[ xi ]
syndrome has been identified as a significant
indicator of a predisposition to diabetes (as
well as cardiovascular disease). Presence of
three or more of the following identify the
syndrome:
1 abdominal obesity: waist circumference
> 88cm in women;
2 hypertriglyceridemia: 150mg/dL
(1.69mmol/L);
International Journal of Health
3 low high-density lipoprotein (HDL)
Care Quality Assurance
incorporating Leadership in
cholesterol: < 40mg/dL (1.04 mmol/L) in
Health Services
men and < 50 mg/dL (1.29 mmol/L) in
16/3 [2003] x-xx
women;
4 high blood pressure: 130/85mm Hg; or
5 high fasting glucose: 110mg/dL
(6.1mmol/L) (Ford et al., 2002).
Dennis Raphael,
Susan Anstice, Kim Raine,
Kerry R. McGannon,
Syed Kamil Rizvi and
Vanessa Yu
The social determinants of the
incidence and management of
type 2 diabetes mellitus: are
we prepared to rethink our
questions and redirect our
research activities?
Conventional thinking among health care,
public health workers, and disease-oriented
associations attributes increases in the
presence of the metabolic syndrome and
increases in morbidity and mortality to
changes in dietary and physical activity
patterns among Canadians (Ford et al., 2002).
This is similar to traditional thinking
concerning cardiovascular-related issues
(Raphael, 2002c). Yet, this dominant ``health
behaviors'' paradigm takes little account of
the increasing literature concerning the
importance of the social determinants of
health in population health in general and
the incidence and management of diseases
such as diabetes in particular. Brunner and
Marmot (1999) point out that 90 percent of the
variance in occurrence of metabolic
syndrome observed in the UK Whitehall
studies cannot be accounted for by
conventional behavioral risk factors. The
literature on societal determinants of health
can contribute to understanding of the causes
of diabetes morbidity and mortality.
The social determinants of health
framework presented by Bruner and Marmot
is helpful for illuminating the potential
contributions of these concepts for
understanding the incidence and
management of type 2 diabetes (Brunner and
Marmot, 1999). The framework also
illuminates the gaps in conceptualizing the
causes of type 2 diabetes and related
management issues. In this model, proximal
causes of morbidity, mortality and wellbeing
are identified such as pathophysiological
changes and organ impairment, and
neuroendocrine and immune responses.
Slightly more distal behavioral
antecedents such as health behaviors (e.g.
diet, physical activity, tobacco use, etc.) are
also identified in this model. Of importance
to the present discussion are the even more
distal antecedents of disease such as
[ xii ]
psychological responses to work and social
environments which themselves result from,
are reproduced as, aspects of social structure.
The model also identifies the direct effects on
mortality, morbidity, and wellbeing of
material factors that accumulate across the
lifespan.
These model components are common to
most conceptualizations related to
population health (Health Canada, 2001;
Marmot and Wilkinson, 2000; Raphael,
2002b). However, in the diabetes area, these
more distal factors ± with very few
exceptions (McKinlay and Marceau, 2000;
Riste et al., 2001) ± are rarely, if ever,
considered by health researchers, public
health workers, and disease-oriented
associations. Virtually all diabetes research
and health discourse is limited to the
proximal issues of health behaviors,
pathophysiological changes and, in some
cases, neuroendocrine and immune
processes. There is a need to address these
other societal determinants of health relative
to diabetes incidence and management.
Drawing on this model, it would appear
that societal determinants of health could
influence diabetes morbidity and mortality
in at least two broad ways. First, these
determinants may influence the incidence ±
and therefore the prevalence ± of the disorder
among the population and its subpopulations. Second, these determinants may
influence the successful management of the
disorder. At the very minimum, societal
determinants of health will influence the
adoption of behaviors that contribute to the
incidence and successful management of
diabetes. But there is also increasing
evidence that societal determinants of health
± especially aspects of material deprivation ±
may directly influence the incidence and
management of this complex disorder
through a variety of biological,
psychological, and social pathways across
the life-span. As argued by Kuh and
Ben-Shlomo (1997, p. 3):
The prevailing aetiological model for adult
disease which emphasizes adult risk factors,
particularly aspects of adult life style, has
been challenged in recent years by research
that has shown that poor growth and
development and adverse early
environmental conditions are associated with
an increased risk of adult chronic disease.
Raphael (2002c) brought together much of
this work on the societal determinants of
cardiovascular disease and during that work
began to locate a similar literature related to
diabetes. But the literature on societal
determinants of diabetes is more dispersed
Dennis Raphael,
Susan Anstice, Kim Raine,
Kerry R. McGannon,
Syed Kamil Rizvi and
Vanessa Yu
The social determinants of the
incidence and management of
type 2 diabetes mellitus: are
we prepared to rethink our
questions and redirect our
research activities?
than that seen for cardiovascular disease.
Also, the diabetes area has not benefited from
having very well known authorities such as
Sir Michael Marmot and George Davey Smith
± both of whom have written extensively on
the life-course approach to the incidence of
cardiovascular disease ± working on these
issues in relation to diabetes.
International Journal of Health
Care Quality Assurance
incorporating Leadership in
Health Services
16/3 [2003] x-xx
The societal determinants of the
incidence of diabetes
Raphael shows that societal determinants of
health are linked with each other and that
income plays an especially important role
(Raphael, 2002c). Income influences the
quality of early life, levels of stress,
availability of food and quality of diet,
physical activity participation, degree of
social exclusion, and so on. Shaw et al. (1999,
p. 65) state that:
Health inequalities are produced by the
clustering of disadvantage ± in opportunity,
material circumstances, and behaviors
related to health ± across people's lives.
Benzeval et al.'s argument that societal
determinants of health such as income
influence health through three main
mechanisms ± material deprivation during
early life and adulthood, excessive
psychosocial stress, and the adoption of
health-threatening behaviors ± proved useful
for considering the social determinants of
cardiovascular disease. These mechanisms
may be useful for identifying how societal
factors influence the incidence and
management of diabetes among vulnerable
populations (Benzeval et al., 1995). McKeigue
(1997) and Lawlor et al. (2002) show how early
material deprivation predicts diabetes in
later life.
Material deprivation and the
incidence of diabetes
Material deprivation refers to the differences
individuals experience in exposures to both
beneficial and damaging aspects of the
physical world (Lynch et al., 2000). These
exposures accumulate over the course of the
lifespan and are determined in large part by
the amount of income people have available
to them (Shaw et al., 1999). Individuals who
suffer from material deprivation have
greater exposures to negative events such as
hunger and lack of quality food, poor quality
housing, inadequate clothing, and poor
environmental conditions at home and work.
In addition, individuals suffering from
material deprivation have less exposure to
positive resources such as education, books,
newspapers, and other stimulating
resources, attendance at cultural events,
opportunities for recreation and other
leisure activities that contribute to human
development over the lifespan. How might
these factors be related to the eventual
incidence of diabetes during adulthood?
Recent studies have shown that
intrauterine-growth retarded and low
birthweight babies are at a higher risk of
developing diabetes in adulthood. And
growth retardation and lower birth weight
are frequently consequences of poor early
nutrition associated with low income
mothers' living in materially-deprived
conditions (Leger et al., 1994; Phipps et al.,
1993). The thrifty phenotype hypothesis
suggests that poor nutrition in early life
leads to poor foetal and infant growth and
produces permanent changes to glucose
metabolism. These changes eventually lead
to development of the metabolic syndrome
and diabetes (Hales et al., 2001).
These changes of reduced insulin secretion
and insulin resistance when combined with
obesity, physical inactivity and advancing
age make individuals highly susceptible to
diabetes. Numerous studies have supported
this hypothesis (McCance et al., 1994; Leger
et al., 1994; Jaquet et al., 2000). Beringue et al.
(2002) provide evidence that the mechanisms
involve insulin resistance rather than
decreased insulin secretion in adults.
Clearly, compromised foetal growth at birth
may be associated with diabetes in
adulthood.
Wimbush found that middle-class mothers
were more likely to participate in social and
recreational activity groups than were
low-income mothers (Wimbush, 1988). More
recently, Brown et al. (2001) found further
support for the notion that mothers of lower
socio-economic status spent less time each
week in active leisure. Brown et al. (2001)
speculated that part of the reason for these
findings related to women of lower socioeconomic status being unemployed or underemployed, the likes of which resulted in
fewer social networks and connections to the
community. Social and community supports
have been found to be extremely important
facilitators for physical activity and leisure
opportunities for mothers of young children
of all socioeconomic backgrounds (Frisby
et al., 1997). Thus, these findings further
reinforce the need to better understand the
role of material and social forces that
underpin constraints to physical activity and
[ xiii ]
leisure participation, particularly for lowincome mothers living in poverty who are at
risk of, or who have, Type 2 diabetes.
Lifespan models of chronic disease risk
that take into account life periods after very
early childhood are being developed for
numerous chronic diseases (Davey Smith
and Hart, 2002; Davey Smith and Gordon,
International Journal of Health 2000; Davey Smith et al., 2001; Kuh and
Care Quality Assurance
Ben-Shilmo, 1997). These conceptualizations
incorporating Leadership in
are much more advanced for the
Health Services
cardiovascular area, but it appears that
16/3 [2003] x-xx
common mechanisms may underlie both
these diseases (Brunner and Marmot, 1999).
One key aspect of life-course models is the
role played by stress. Another is the adoption
of unhealthy behaviors.
Dennis Raphael,
Susan Anstice, Kim Raine,
Kerry R. McGannon,
Syed Kamil Rizvi and
Vanessa Yu
The social determinants of the
incidence and management of
type 2 diabetes mellitus: are
we prepared to rethink our
questions and redirect our
research activities?
Psychosocial stress and the
incidence of type 2 diabetes
Brunner and Marmot (1999) present a model
that provides potential insights into the role
stress plays in the incidence of chronic
disease. They identify potential pathways by
which the stress of living under difficult
living conditions becomes translated into
incidence of both diabetes and
cardiovascular disease. As discussed later, at
the very minimum, exposure to psychosocial
stress influences the adoption of behaviors
such as poor diet and inactivity, all
associated with greater likelihood of type 2
diabetes during adulthood.
But the direct effects that stress has on
metabolic and physiological pathways that
make an individual susceptible to type 2
diabetes may be of more potential value. Two
neuroendocrine pathways that involve the
release of hormones may contribute to the
incidence of this disorder. The sympathetic
adrenal pathway involves the release of
noradrenaline from the sympathetic nerve
endings and adrenaline from the adrenal
medulla into the blood stream. These
hormones affect the target organ of the heart
since it is under the control of both the
autonomic nervous system and adrenaline
levels in the blood. These hormones increase
the heart rate, metabolic rate, blood pressure,
respiration rate, and produce
vasoconstriction, sweating and dryness of
the mouth.
The second pathway comes into play a few
minutes or maybe even a few hours after an
initial stressor stimulus. It causes the release
of hormones from the hypothalamus,
pituitary gland and the adrenal glands and is
known as the hypothalamic pituitary adrenal
axis. The activity of this axis begins in the
[ xiv ]
brain with the release of corticotrophinreleasing factor from the hypothalamus. This
hormone causes the release of the
adrenocorticotropic hormone from the
pituitary gland into the circulation. This
hormone stimulates the release of cortisol
from the adrenal gland. Cortisol is an
antagonist of insulin and increases the levels
of blood glucose and also causes the release of
fatty acids from fat tissues. The role of stress
in the occurrence of the metabolic syndrome
± specifically insulin resistance ± and the
incidence of diabetes has been underresearched (Brunner and Marmot, 1999).
Concerning the relationship between
psychosocial stress and the metabolic
syndrome, Brunner and Marmot (1999, p. 33)
argue that:
. . . this cluster of risk factors may be the
product of altered activity of the HPA
(hypothalamic-pituitary-adrenal) axis in
response to long-term exposure to adverse
psychosocial circumstances.
There is a historical link between lower
socioeconomic status and increased
adrenocortical activity. Destitute people of
nineteenth century England who were
subject to chronic malnutrition were found to
have larger than normal sized adrenal glands
(Sapolsky, 1992). Brunner and Marmot's
(1999) conclusion that the presence of the
metabolic syndrome is strongly predicted by
income and social status would suggest its
presence would also be related to societal
determinants of health associated with
income such as food security, housing
uncertainty and social exclusion, among
other factors.
Adoption of unhealthy behaviors
and the incidence of diabetes
The behavioral risk factors for the incidence
of diabetes are well known: poor nutrition
and sedentary lifestyle are associated with
obesity (Canadian Medical Association and
Canadian Diabetes Association, 1998). There
are also barriers to successful management
of the disorder:
.
poor meal planning/poor diet;
.
tobacco smoking; and
.
physical inactivity (Canadian Medical
Association and Canadian Diabetes
Association, 1998).
All of these behaviors are associated with
lower income and social status. However,
much of the diabetes health literature
assumes that these behavioral patterns are
adopted through voluntary lifestyle choices
(Wilkinson and Marmot, 1999). It is becoming
increasingly clear that patterns of health
behaviors are strongly shaped by the social
and economic environments in which people
live. Stress produces behaviors aimed at
ameliorating tension such as high
carbohydrate and fat diets, and tobacco use
(Wilkinson, 1996). Meal planning (and
International Journal of Health engaging in physical activity) may be
Care Quality Assurance
difficult when concerns about meeting basic
incorporating Leadership in
needs of housing, food, and clothing intrude
Health Services
16/3 [2003] x-xx
on daily activities (Travers, 1996).
It should not be surprising then that
individuals faced with low income or other
stress inducing issues such as
unemployment or underemployment, racism,
insecure or unaffordable housing would have
difficulties maintaining ``healthy lifestyles''.
This would especially be the case for those
managing their diabetes. A sole emphasis by
the diabetes health community on explaining
unhealthy behaviors as a matter of
individual choice may be counter-productive
in the battle against the effects of this
disease. First, these behavioral factors may
not account for the majority of variance
associated with the incidence of diabetes or
its successful management. Second, it leads
towards a ``blaming the victim'' approach
whereby those with disadvantage are blamed
for adopting means ± admittedly unhealthy ±
for coping with their difficult life situations.
Third, an emphasis solely on individual
choice fails to address underlying issues of
why disadvantaged people adopt these
behaviors.
An extensive analysis of the determinants
of adults' health-related behaviors such as
tobacco use, physical activity, and healthy
diets, found these behaviors were predicted
by poor childhood conditions, low levels of
education, and low status employment
(Lynch et al., 1997). The study also found that
poor socioeconomic conditions during early
life make it less likely that people feel they
have control over their lives ± a factor that
can contribute to illness. Identifying some of
the possible pathways to type 2 diabetes such
as material deprivation, excessive
psychosocial stress, and adoption of health
threatening behaviors suggests value in
applying a societal determinants of diabetes
approach. Certainly, such an analysis would
contribute to our understanding of why and
how diabetes is an especially important issue
for low income and other vulnerable
populations. Considering the increasing
numbers of low income families living in
urban Canada, such a focus seems especially
Dennis Raphael,
Susan Anstice, Kim Raine,
Kerry R. McGannon,
Syed Kamil Rizvi and
Vanessa Yu
The social determinants of the
incidence and management of
type 2 diabetes mellitus: are
we prepared to rethink our
questions and redirect our
research activities?
important (Canadian Institute for Health
Information, 2002).
The societal determinants of the
successful management of diabetes
As noted, Wilkins et al. (2002) have
documented the exceptional increases in
diabetes mortality among Canadians living
in low-income communities. The risk of the
disease is especially related to low income
among women. Virtually nothing is known
about the causes of such increases. One
possibility may be that increasing difficulties
in day-to-day living among people living in
disadvantaged circumstances are
contributing to difficulties in disease
management. The diabetes management
regimen is considered ``among the most
demanding regimens of any chronic illness''
(Callaghan and Williams, 1994). The regimen
is associated with a number of lifestyle
changes that people with diabetes often find
difficult to incorporate into their everyday
lives (Maclean and Oram, 1988). Anstice
(2002) argues that there are many reasons to
believe that adherence to the diabetes
management regimen may be especially
challenging for members of low-income
families, and particularly for low-income
mothers who are living with diabetes. Many
are also unable to find time or safe spaces for
exercise or to afford blood sugar testing
equipment to better manage their diabetes.
Studies have found that, for families living
in poverty, meeting food needs is a persistent
problem (Fitchen, 1988; Radimer et al., 1992).
Furthermore, it is commonly reported that
during times of acute food shortage mothers
in low-income families will compromise their
own food intake in order to provide more for
others (Graham, 1993; Hamelin et al., 2002;
Tarasuk et al., 1998). The fact that women
bear children and frequently have
responsibility for caring for the health needs
of their family suggests another mechanism
by which gender may play a role in the
incidence of diabetes. Prospective mothers
may skimp on their own nutritional needs in
order to provide food for the rest of their
family. This may be associated with lower
birthweight and greater likelihood of their
offspring developing diabetes in later life.
Since good nutrition is considered the
cornerstone of good diabetes management, it
may be that mothers with diabetes who live
in low-income families experience
exceptional food problems that challenge the
dietary management of their own diabetes
(Anstice, 2002). A small body of qualitative
[ xv ]
research indicates that the material context
of everyday life helps shape personal
experience of diabetes, and further that acute
financial constraints may present barriers to
successful management. Mason (1985) found
that among people living in socially
disadvantaged areas in Scotland, those faced
with acute financial constraints made
International Journal of Health decisions that did not necessarily prioritize
Care Quality Assurance
their diabetes management. Miewald (1997)
incorporating Leadership in
studied low-income clients at a US clinic and
Health Services
found that both financial constraint and
16/3 [2003] x-xx
shortcomings of low-income neighbourhoods
challenged participants' adherence to a
dietary regimen. She notes that:
social, financial, health and personal
problems that impeded their involvement.
The Canadian literature on the difficulties
of diabetes management faced by vulnerable
populations is small. Anderson and
colleagues examined the diabetes experience
of low-income immigrant women and found
also found that the constraints of low income
helped shape management decisions
(Anderson, 1991, 1998; Anderson et al., 1993,
1995). The researchers contend that an
immigrant woman with diabetes who lacks
access to material resources is in a
paradoxical situation:
Studies have also found low amounts of
leisure-time physical activity to be strongly
associated with low income (Stachenko et al.,
1992; Steenland, 1992), low education
(Sternfeld et al., 1999), and low socioeconomic status (Blanksby et al., 1996;
Mensink et al., 1997). Furthermore, the lowest
participation rates are found among the poor
and women of child-rearing age, many of
whom are the same people (Frisby et al.,
1997). While literature in this area tends not
to explore physical activity participation
from a critical or social determinants of
health perspective, it has been noted that
physical activity is heavily dependent on
financial resources and cultural capital
(Kidd, 1995). In support of this, research links
material and structural circumstances (e.g.
living in disadvantaged neighborhoods with
more crime) to lower levels of physical
activity (Wimbush, 1988; Lindstrom et al.,
2001).
Despite this, the complexity of the
relationship between the foregoing social
determinants and physical activity practices
has not been adequately addressed. Thus, not
surprisingly, little information exists on lowincome families, physical activity, and
diabetes management. However, the results
of a participatory action research study in
Canada ± The Woman's Action Project ±
found that low-income women identified a
lack of access to physical activity in their
community as a major factor inhibiting the
development of healthy lifestyles for
themselves and their families (Frisby et al.,
1997). Focus groups confirmed that although
women in this income bracket desired
benefits from physical activity participation
similar to those of women in higher income
brackets, low-income women experienced
Anderson's research focused on the role of
ethnicity in women's experiences of diabetes;
it is probable that other low-income women
face this self-care paradox.
An investigation by Anstice (2002) provides
further evidence of the importance of this
area of inquiry. In her grounded theory
study, Anstice used multiple, in-depth, oneon-one interviews with three Toronto women
to explore the question: How do sole-support
mothers who live on income support describe
their everyday experiences of diabetes
mellitus? She found that financial
vulnerability, characterized by income
inadequacy and a sense of precariousness,
was manifested in experiences of housing,
food and transportation difficulties. This
everyday context profoundly shaped diabetes
management decisions. For example, food
problems associated with income inadequacy
such as household food shortages were
described as major barriers to implementing
the dietary recommendations of the diabetes
management regimen. Uncertainty
concerning the adequacy of other societal
determinants of health such as housing
certainly plays a role as well in poor dietary
management. These insecurities certainly
create an early childhood environment not
conducive to the healthy development of
children (Hertzman, 1999; Keating and
Hertzman, 1999) ± another area profoundly
under-researched by those concerned with
the health effects of diabetes.
Dennis Raphael,
Susan Anstice, Kim Raine,
Kerry R. McGannon,
Syed Kamil Rizvi and
Vanessa Yu
The social determinants of the
incidence and management of
type 2 diabetes mellitus: are
we prepared to rethink our
questions and redirect our
research activities?
Lack of access to inexpensive grocery stores
and tight food budgets . . . made it difficult for
clients to make changes in their eating habits
(Miewald, 1997, p. 359).
[ xvi ]
On the one hand, she is expected to take
responsibility for carrying out her care. On
the other hand, she does not have access to
the resources that would allow her to do so
(Anderson, 1991, p. 111).
Implications for the further study
of the social determinants of
diabetes
These kinds of hypotheses would suggest that
if the appropriate analyses were completed,
income and social status would have direct
association with the presence of both the
metabolic syndrome and the presence of
diabetes in populations independent of the
health behaviors usually identified as the
primary causes of diabetes. Indeed, there is
evidence that this is the case. Wamala et al.
(1999) studied precursors of the metabolic
syndrome among Swedish women. They
International Journal of Health
found that low education (a proxy for lower
Care Quality Assurance
incorporating Leadership in
income) was associated with a 2.3 times
Health Services
greater likelihood of the presence of the
16/3 [2003] x-xx
metabolic syndrome even after accounting
for age, family history, smoking, lack of
exercise, and alcohol consumption. In
Canada, Choi and Shi (2001) found that
income status differences produced a
26 percent greater excess risk of diabetes
among low-income Canadians independent of
other behavioral risk factors. Similar
findings can be inferred, but were not
explicitly presented, in the ICES diabetes
report (Hux et al., 2002).
Clearly, there is a need to analyze
available data within the life-course
frameworks suggested by these models and
empirical findings. These would require
statistical analyses that were firmly
grounded within a life-course perspective.
Much of the available analyses take a less
complex risk-factor approach by which
income is treated as one of many risk
factors to be considered, rather than as a
determinant of the behavioral risk factors
themselves. If data that would allow for
these analyses to be carried out are not
available, mechanisms need to be developed
to gather and analyze such data.
Canada has been a world leader in
conceptualizing the social determinants of
health. Yet recent initiatives in preventing
chronic disease and promoting health appear
to be relegating these concepts to the
sidelines in favor of healthy lifestyle choices.
This appears to be especially the case in the
approaches being taken by the new Chronic
Disease Prevention Alliance of Canada and
the Healthy Living Initiative of the Federal
Government (Chronic Disease Prevention
Alliance of Canada, 2003; Health Canada,
2003). The crisis in diabetes appears to call
for new ways of thinking about and
redirecting our research activities in regards
to this disease. Are health workers and
researchers up to this challenge?
Dennis Raphael,
Susan Anstice, Kim Raine,
Kerry R. McGannon,
Syed Kamil Rizvi and
Vanessa Yu
The social determinants of the
incidence and management of
type 2 diabetes mellitus: are
we prepared to rethink our
questions and redirect our
research activities?
References
Acheson, D. (1998), Independent Inquiry Into
Inequalities in Health, Stationery Office,
available at: www.official-documents.co.uk/
document/doh/ih/contents.htm
Anderson, J., Wiggins, R., Rawjani, R.,
Holbrook, A., Blue, C. and Ng, M. (1995),
``Living with a chronic illness: ChineseCanadian and Euro-Canadian women with
diabetes ± exploring factors that influence
management'', Social Science and Medicine,
Vol. 41 No. 2, pp. 181-95.
Anderson, J.M. (1991), ``Immigrant women speak
of chronic illness: the social construction of
the devalued self'', Journal of Advanced
Nursing, Vol. 16 No. 6, pp. 710-17.
Anderson, J.M. (1998), ``Speaking of illness: issues
of first generation Canadian women ±
implications for patient education and
counseling'', Patient Education and
Counseling, Vol. 33 No. 3, pp. 197-207.
Anderson, J.M., Blue, C., Holbrook, A. and Ng, M.
(1993), ``On chronic illness: immigrant women
in Canada's workforce ± a feminist
perspective'', Canadian Journal of Nursing
Research, Vol. 25 No. 2, pp. 7-22.
Anstice, S. (2002), Diabetes and Disadvantage:
Everyday Experiences of type II Diabetes
Among Sole-support Mothers Living on
Income-support, University of Toronto, Public
Health Sciences, Toronto.
Benzeval, M., Judge, K. and Whitehead, M. (1995),
Tackling Inequalities in Health: An Agenda
for Action, Kings Fund, London.
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Vanessa Yu
The social determinants of the
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International Journal of Child, Youth and Family Studies (2014) 5(2): 220–239
SOCIAL DETERMINANTS OF CHILDREN’S HEALTH IN CANADA:
ANALYSIS AND IMPLICATIONS 1
Dennis Raphael
Abstract: The health of Canada’s children when placed in comparative perspective with
other wealthy developed nations is mediocre at best. Much of this has to do with the
social determinants of children’s health (SDCH) in Canada being of generally lower
quality and more inequitably distributed than is the case in most other wealthy developed
nations. The SDCH are of two kinds: (a) those to which their parents are exposed, and (b)
those specifically related to societal support for early child development. In both cases
Canada’s support of the SDCH through the making of health promoting public policy is
lacking. Much of this has to do with the political ideology of ruling governments
consistent with Canada being identified as a liberal welfare state where intervention in
the unbridled operation of the market system is frowned upon. There are means of
improving the situation. These involve a wide range of activities from more responsive
clinical practice through to advocacy and political action.
Keywords: social determinants, public policy, political economy of health
Dennis Raphael, Ph.D. is Professor of Health Policy and Management at York University,
Room 418, HNES Building, 4700 Keele Street, Toronto, Ontario, Canada, M3J 1P3.
E-mail: [email protected].
1
Material in this paper was presented at the symposium The Coming of Age of Social Paediatrics, a Symposium cosponsored by the Canadian Child and Youth Health Coalition and Paediatric Chairs of Canada, Toronto, October 20,
2013.
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International Journal of Child, Youth and Family Studies (2014) 5(2): 220–239
In this article I consider the current state of the social determinants of children’s health
(SDCH) in Canada. After briefly describing how Canadian children’s physical, mental, and
social health compares to children in other wealthy developed countries (Canada’s performance
is mediocre at best), I explore how children’s health is related to the quality and distribution of a
variety of SDCH in Canada. Here again, Canada’s performance as compared to other wealthy
developed nations is not exemplary.
I then examine the determinants of the SDCH in Canada. This involves an exploration of
how public policy in Canada shapes the quality and distribution of the SDCH to which Canadian
children are exposed. It is suggested that much of what passes for public policy in Canada can be
explained by recourse to Canada being a liberal welfare state in which State intervention in the
operation of the market economy through enactment of employment standards, laws, and the
provision of universal supports and benefits to families with children is minimal. The resurgence
of the ideology of neo-liberalism over the past 25 years has only reinforced these Canadian
public policy trends.
Canada’s modest expenditures on benefits, programs, and services that would improve
the quality and distribution of the SDCH can be explained by politics in that the political
ideology of governing authorities at the federal, provincial, and municipal levels shape these
public policy approaches. These policies continue because the public has not been presented with
an alternative to the neo-liberal welfare state where governments do little to promote children’s
health through action in SDCH-related public policy areas.
Complicating this situation is the existence of a variety of research and professional
discourses by which the SDCH are understood. These range from seeing the SDCH as
identifying those in need of health and social services through to one that identifies those sectors
of society that benefit from children being exposed to health-threatening SDCH. The article
concludes by outlining various means by which the SDCH could be improved. It is argued that
what is really necessary is the strengthening of the environments in which children and their
parents live, work, and play through the creation of healthy public policy that improves the
quality and distribution of the SDCH. Whether this can occur without profound political change
that involves the shifting of power and influence in Canadian society remains an open question.
The State of Children’s Health in Canada
Children’s health is important as it serves as a foundation for health across the lifespan
(Hertzman & Power, 2003; Irwin, Siddiqui, & Hertzman, 2007; Kuh, Ben Shlomo, & Susser,
2004). A number of recent special publications have surveyed the state of children’s health in
Canada and have found Canada’s approach to supporting children’s health generally wanting
(Haddad, 2010, 2011a, 2011b, 2012; Raphael, 2010a, 2010b, 2010c; Raphael, 2010d). Since
there is no central Canadian agency responsible for monitoring the health of Canadians in
general and children’s health in particular, it is left to numerous independent researchers in
universities and research institutes to provide information on the state of children’s health and
the SDCH (Raphael, 2012a). These data are difficult to interpret without benefit of comparative
analysis that takes into account the situation of children in other wealthy developed nations.
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Fortunately, UNICEF’s Innocenti Research Centre in Florence, Italy provides ongoing
comparative analysis of children’s situations across wealthy developed nations that move beyond
simple presentation of comparative data to careful analysis of the public policy antecedents that
shape children’s health in these nations. Much of their data is taken from work done by the
Organisation for Economic Cooperation and Development (Organisation for Economic Cooperation and Development, 2011a, 2011b).
Infant Mortality and Low Birth Weight Rates
Two key indicators of children’s health are infant mortality and low birth weight rates.
Infant mortality rate is seen as an especially sensitive indicator of the overall health of a
population that is shaped by the quality and distribution of the SDCH (Butler-Jones, 2008). The
figures for Canada are rather striking. In addition to Canada having one of the highest infant
mortality rates among wealthy developed nations, of special importance is the shift in relative
ranking of Canada since 1980. In 1980 Canada ranked 10th in infant mortality rates of 24 OECD
nations (Robert Wood Johnson Foundation, 2008). But by 2010 Canada’s ranking had slipped to
27th of 36 nations (Organisation for Economic Co-operation and Development, 2011a).
Canada’s comparative performance for low birth weight rate – a good predictor of health during
childhood and adulthood – is somewhat better. Canada currently ranks 11th of 29 OECD nations
on this indicator (Organisation for Economic Co-operation and Development, 2011a). Earlier
Innocenti reports provide a rather poor portrait of Canada’s standings on other health indicators
such as teen pregnancies, mortality from injuries, and mortality from parental abuse (Innocenti
Research Centre, 2001a, 2001b, 2003).
Canadian Children’s Well-being in International Perspective
The Innocenti Research Centre’s 2013 Report Card examined children’s well-being along
five dimensions: material well-being, health and safety, education, behaviours and risks, and
housing and environment (Innocenti Research Centre, 2013). Canada’s overall rank was 17th of
29 wealthy developed nations. It ranks 15th in material well-being, 27th in health and safety,
14th in education, 16th in behaviours and risks, and 11th in housing and environment.
Table 1 provides the contributors to these different dimensions. It is important to note
that while the nations whose children fare better than Canada unsurprisingly include the Social
Democratic Nordic nations of Norway, Iceland, Finland, Sweden, and Denmark where
commitment to children’s health is expressed through extensive provision to families of
economic and social security, they also include many of the Conservative nations of Continental
Europe: the Netherlands, Germany, Luxembourg, Switzerland, Belgium, and France. These
findings should be of significant concern. Indeed, UNICEF Canada produced a critical
companion report to the Innocenti Report Card on the situation of Canadian children entitled
Stuck in the Middle (UNICEF Canada, 2013).
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Table 1. How Child Well-being is Measured
Dimensions
Components
Dimension 1:
Monetary deprivation
Material well-being
Material deprivation
Dimension 2:
Health and safety
Health at birth
Preventive health services
Overall immunization rate
Childhood mortality
Child death rate, age 1 to 19
Participation
Participation rate: early childhood
education
Participation rate: further education,
age 15–19
NEET rate (% age 15–19 not in
education, employment or training)
Dimension 3:
Education
Achievement
Dimension 4:
Behaviours and risks
Health behaviours
Risk behaviours
Exposure to violence
Dimension 5:
Housing and
environment
Indicators
Relative child poverty rate
Relative child poverty gap
Child deprivation rate
Low family affluence rate
Infant mortality rate
Low birthweight rate
Housing
Environmental safety
Average PISA scores in reading,
maths and science
Being overweight
Eating breakfast
Eating fruit
Taking exercise
Teenage fertility rate
Smoking
Alcohol
Cannabis
Fighting
Being bullied
Rooms per person
Multiple housing problems
Homicide rate
Air pollution
Source: Innocenti Research Centre (2013). Child Well-being in Rich Countries: A Comparative
Overview, Box 1, p. 5. Florence: Innocenti Research Centre.
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International Journal of Child, Youth and Family Studies (2014) 5(2): 220–239
Numerous analyses show these rankings to be strongly determined by national public
policy approaches concerned with families and children (Innocenti Research Centre, 2005, 2007,
2010). The primary dimension which seems beyond dispute is that nations that intervene in the
operation of the market economy to provide families with the means (e.g., employment security
and living wages, family benefits and entitlements, supports during periods of unemployment,
disability, and illness) of living economically and socially secure lives – that is, the SDCH – are
the ones whose children show better health and well-being outcomes (Esping-Andersen, 2002a).
Canada is not one of these nations (Doherty & Friendly, 2004; Friendly, 2009; Hertzman, 2000,
2008; Raphael, 2010c).
The State of the Social Determinants of Canadian Children’s Health
Children’s health is therefore integrally related to the health and well-being of their
families (Engster & Stensota, 2011; Esping-Andersen, 2002a). The most important SDCH
therefore have much to do with their parents’ living and working conditions (Campaign 2000,
2004; Innocenti Research Centre, 2007; Mikkonen & Raphael, 2010). The most important of
these is income which for most parents is a function of their employment and working conditions.
For those parents unable to participate in the labour market, family income is determined by
level of benefits and assistance provided by governmental programs. Important SDCH also
include housing quality and food security which, while closely related to income, are shaped by
specific public policies that address these areas (Bryant, 2009; Tarasuk, 2009). Government
support of early child development through the provision of affordable childcare and early
childhood education is also an important SDCH, as are the health and social services that are
available (Friendly, 2009; McGibbon, 2009).
Finally, in Canada, one’s personal identity or social location (e.g., class, gender, race,
Aboriginal, immigrant, or disability status, etc.) also play an important role in shaping access to
the conditions necessary for health (Anderson, 2011). This has much to do with the unequal
distribution of power and influence that comes to shape the distribution of economic and social
resources – that is, the SDCH – important to health (Grabb, 2007; Raphael, 2011d). The next
section presents what is known about the quality and distribution of four key clusters of SDCH:
income and employment of their parents, food and housing security, early child development,
and children’s specific social locations.
Income and Employment
Income has a direct effect – through parents’ and children’s living and working
conditions – on children’s health (Auger & Alix, 2009; Lightman, Mitchell, & Wilson, 2008;
Raphael, 2010b). The most apparent demonstration of income’s effects on children’s health is
the relationship between poverty and health outcomes (Beiser, Hou, Hyman, & Tousignant,
2002; Engster & Stensota, 2011; Raphael, 2011c; Singer, 2003). Children living in family
poverty – defined as either absolute or relative – are more likely than other children to
experience a whole range of physical, mental, and social health problems (Lightman et al., 2008;
Raphael, 2010a; Raphael, 2011c; Wallis & Kwok, 2008). The Innocenti Research Centre
provides comparative poverty rates – using a relative definition of < 50% of the median family
income – for wealthy developed nations (Innocenti Research Centre, 2013).
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International Journal of Child, Youth and Family Studies (2014) 5(2): 220–239
For the 2009-2010 period the poverty rate for children – representing the poverty rate of
their families – was 14% which gave Canada a ranking of 25th of 35 wealthy developed nations
(Innocenti Research Centre, 2013). On the indicator of child poverty gap – the gap between the
poverty line and the median income of those below the poverty line as a percentage of the
poverty line – Canadian children are 22% below the poverty line. This gives Canada a ranking of
17th of 35 wealthy developed nations. These poverty rates for families with children have for the
most part remained unchanged over the past 20 years. Since 14% of Canadian families with
children live in poverty, large numbers of Canadian children experience various forms of
material and social deprivation that manifests in a variety of adverse health outcomes (Innocenti
Research Centre, 2013).
A nation’s poverty rate is determined in large part by how governments act to regulate
employment and working conditions (Jackson, 2010). In Canada, there is little attempt by the
State to regulate employment and working conditions (Tompa, Polanyi, & Foley, 2009). The
OECD calculates an employment protection index of rules and regulations that protect
employment and provide benefits to temporary workers (Organisation for Economic Cooperation and Development, 2011d). Canada performs very poorly on this index, achieving a
score that was ranked 26th of 28 nations. The OECD also provides data on the percentage of
work identified as being low waged (Organisation for Economic Co-operation and Development,
2013). This index considers earning less than two-thirds of the median income as constituting
low-wage employment. Even without data from the Nordic nations of Norway and Sweden
which historically have levels below 5%, Canada ranks 22nd of 22 OECD nations in having the
highest proportion of men identified as low-wage workers at 21%. Canada’s percentage of lowpaid women workers (22%) give it a ranking of 10th of 22 nations which is a reflection of
nations such as Japan, Australia, Korea, Germany, and Great Britain, among others, having very
high proportions of women working for low pay.
For those parents unable to work, levels of social assistance are the key factors
determining income levels. The supports offered by Canadian governments are well below those
provided by most other wealthy developed nations. The OECD publishes extensive statistics on
social assistance spending amongst its members (Organisation for Economic Co-operation and
Development, 2011b). Canada ranks 22nd of 39 members on social assistance payments, 23rd of
28 for unemployment benefits, 27th of 29 for services for people with disabilities, and 25th of 29
for general supports and benefits to families with children (Organisation for Economic Cooperation and Development, 2009a, 2009b). For those families with children dependent on such
benefits, this places them well below the poverty line, however defined (National Council of
Welfare, 2010; Organisation for Economic Co-operation and Development, 2011b; Organisation
for Economic Co-operation and Development, 2009c; Raphael, 2011a).
Food Security and Housing
The ability to obtain food and housing is closely related to income and the distribution of
income (Bryant, 2009; McIntyre & Rondeau, 2009). Not surprisingly, families living in poverty
are more likely to experience food insecurity and live in problematic housing situations.(Tarasuk,
2009). In addition, the extent of food insecurity and inadequate housing – important SDCH – are
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also impacted by public policy in these specific areas (McIntyre & Rondeau, 2009; Shapcott,
2009). Canada is one of few wealthy developed nations without a national housing strategy
(Shapcott, 2009). It also has no food security strategy of note (McIntyre & Rondeau, 2009).
Figures concerning the amount of food insecurity and inadequate housing in Canada are
alarming. Close to 11% of Canadian families with children experience significant food insecurity
(McIntyre & Rondeau, 2009). The growing numbers of food bank users across Canada – of
which 40% of them are children – is said to underestimate the percentage of families
experiencing food insecurity. Similarly, the percentage of Canadians experiencing inadequate
housing is also striking (Bryant, Raphael, Schrecker, & Labonte, 2011). The Canada Mortgage
and Housing Corporation estimates that 26% percent of urban families with children are in core
housing need, either paying more than 30% of their incomes on housing, living in crowded
housing, or living in substandard housing (Canada Mortgage and Housing Corporation, 2012).
Food insecurity and inadequate housing have been shown to be strongly related to adult health
outcomes (Bryant, 2009; Tarasuk, 2009). There is little reason to doubt that these issues play a
significant role in shaping the health of children as well.
Early Child Development
Canada is one of the lowest spenders on supports and benefits for early child
development (Innocenti Research Centre, 2008; Organisation for Economic Co-operation and
Development, 2011c). There is no national childcare program to speak of and comparative
studies place Canada at the bottom of the heap in its support for families with children (Doherty
& Friendly, 2004). Programs that are available are targeted and there is little evidence of
effectiveness in strengthening the SDCH and making their distribution more equitable (Raphael,
2010c).
In regard to access to regulated childcare – an important contributor to child well-being –
only 17% of Canadian families have access to regulated child care (Friendly & Prentice, 2009).
Even in Quebec where an extensive effort is underway to provide regulated high quality
childcare, only 25% of families have access to it. The OECD published a report that rates Canada
as last among 25 wealthy developed nations in meeting various early childhood development
objectives (Doherty & Friendly, 2004). Canada is also one of the lowest spenders on early
childhood education, ranking 36th of 37 wealthy developed nations (Organisation for Economic
Co-operation and Development, 2011b).
Social Locations
All these SDCH-related issues are closely related to adults’ – and their children’s – social
location in Canadian society. Social location refers to aspects of one’s personal identity such as
class, race, gender, Aboriginal status, immigrant status, disability status, as well as other personal
characteristics (Raphael, 2011d). In Canadian society, these characteristics are indicators of
power and influence and are therefore related to access to economic and social resources that
shape health status (Grabb, 2007). In Canada being of working class origin, a person of colour,
female, Aboriginal, a recent immigrant, and/or having a disability is related to both the quality of
the SDCH one is exposed to, as well as to the adverse health outcomes that result from such
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exposures (Galabuzi, 2009; Jackson, 2010; Rioux, 2010; Smylie, 2009). Canadian children in
these social locations are more likely to experience: (a) a reduced level of health-supporting
SDCH; and (b) adverse physical, mental, and social health outcomes.
It says much about Canadian society that so many social locations come first to be related
to adverse living and working conditions and secondly to unfavourable health outcomes. The
social inequality literature shows that these social locations are associated with differing living
and working conditions as a result of these groups having less influence on the making of public
policy by governmental authorities whose attention is more focused on the needs of the more
powerful and wealthy (Grabb, 2007). These social locations are also important as Canadian
governmental authorities do little to manage the inequality-producing aspects of the dominant
institution in Canadian society – the market economy (Leys, 2001; Macarov, 2003; Saint-Arnaud
& Bernard, 2003). Means of balancing these differences in power and influence through
governmental intervention in and management of the market economy in the areas of
employment security, the setting of wages, and provision of family and child supports should be
an important concern (Esping-Andersen, 2002a, 2002b).
The Determinants of the Determinants
It is becoming more apparent that simple explication of the importance of the SDCH has
done little to improve their quality and make their distribution more equitable in Canada (Bryant
et al., 2011; Collins & Hayes, 2007; Hancock, 2011). Increasingly, attention is being paid to the
importance of public policy in shaping the quality and distribution of the SDCH (Raphael,
2011a). In addition, analysis is focusing on how public policy within a nation is very much a
function of the general organization of governmental decision-making. These differences have
come to be known as a “worlds of welfare” analysis and, not surprisingly, Canada falls within
the cluster which is the least likely to support the strengthening and more equitable distribution
of the SDCH (Esping-Andersen, 1999; Saint-Arnaud & Bernard, 2003). And even more
enlightening has been analysis of how political organization and political values of governing
authorities shape these general forms of the welfare state (Coburn, 2010; Navarro et al., 2004;
Navarro et al., 2006). All of this work suggests that improving the quality and distribution of the
SDCH requires careful political analysis of a range of issues that include public policy, political
ideology, and public understandings of these issues.
Public Policy
Public policy is primarily concerned with whether a problem is recognized as being a
societal rather than an individual problem. If the former, the solution is one that should be
undertaken by society in the form of government activity as opposed to being left to the
individual to solve (Briggs, 1961; Stone, 1988). Despite a long tradition of individualism in
Western societies, it is becoming increasingly apparent that many of the problems that face us in
the 21st century require communal solutions carried out under the authority of governments
(Hofrichter, 2003; Raphael, 2003). With regard to SDCH, there is no shortage of areas that
require such governmental intervention.
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These public policy areas include issues of employment and working conditions,
provision of benefits to families and individuals to provide important necessities such as food
and housing, and support of early child development. If these issues are not considered as public
problems and therefore not amenable to government action, then they are left to the other major
sector of society, the normal operation of the economic system.
This is far from an acceptable solution, since despite what we have been led to believe by
pro-business and conservative institutions and organizations, the economic system as it is
constituted today in Canada and other Western countries is ill-suited to provide families with the
means by which their children can experience high quality SDCH (Coburn, 2004, 2010;
Hertzman & Siddiqi, 2000; Leys, 2001; Macarov, 2003). The economic system itself says little
about the provision of health promoting levels of education, health care, income and employment,
food and housing, and if left to its own devices does little to improve the SDCH.
Differences between nations in providing quality and equitable distribution of SDCH are
due to differences in intervening and managing many aspects of the economic system (Brady,
2009; Pontusson, 2005; Swank, 2005; Teeple, 2000). This is not only the case in the Social
Democratic nations of Scandinavia but also among the Conservative nations of Continental
Europe. This is a reflection of both groups of nations’ long tradition of suspicion about the
ability of the economic system to meet the most important needs of the citizenry (EspingAndersen, 1990). It is only in the Liberal nations such as Canada, the United Kingdom, the
United States, and Australia that the belief is often stated that a well-functioning and profitable
economic system will serve to meet the most important needs of the citizenry. Such a view is
patently untrue. It should not be surprising then that nations that do intervene in the operation of
the economic system are the ones that provide children and their families with the conditions
necessary for health. This raises the issue of the concept of the welfare state and where Canada
fits into its various forms.
Welfare State Approach, Politics, and Political Ideology
Esping-Andersen’s distinction between Social Democratic, Conservative, and Liberal
welfare states has much to do with the SDCH (Esping-Andersen, 1990, 1999). Figure 1 shows
how the basic elements and characteristics of these differing forms of the welfare state have the
potential to affect the SDCH and children’s health itself (Saint-Arnaud & Bernard, 2003). These
differing forms of the welfare state have not come about by accident but have much to do with
the ideology of governing authorities informed by the politics of governing parties.
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Figure 1. Ideological Variations in Forms of the Welfare State
Social Democratic
Ideological
Inspiration
Organizing
Principle
Focus of the
Programmes
Central
Institution
Equality
Reduce:
- Poverty
- Inequality
- Unemployment
Liberal
Liberty
Minimize:
- Government Interventions
- “Disincentives” to Work
Universalism
Social Rights
Residual:
Taking Care of
the Essential
Needs of the Most
Deprived (Meanstested Assistance)
Resources
Needs
State
Conservative
Market
Latin
Solidarity
Maintain:
- Social Stability
- Wage Stability
- Social Integration
Insurance:
Access to
Benefits
Depending on
Past
Contributions
Rudimentary
and
Familialistic
Risks
Family and Occupational
Categories
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, Figure 2,
p. 503.
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The Social Democratic welfare state has been strongly influenced by the Social
Democratic tradition (Esping-Andersen, 1985, 1990; Fosse, 2011, 2012). The Conservative
welfare state is distinguished by governance of Christian Democratic parties that have
traditionally maintained many aspects of social stratification, some degree of commodification of
societal resources, and an important role for the Church (Esping-Andersen, 1990, 1999). Finally
the Liberal welfare state is dominated by its governance by political parties that have been
identified as being pro-business generally with resistance to intervene in the operation of the
economic system (Esping-Andersen, 1990; Myles, 1998; Myles & Quadagno, 2002).
Such an analysis suggests either changing the politics of those parties in power or
electing parties of differing political persuasions that can be depended upon to implement the
kinds of public policies shown to be so effective in improving the quality and distribution of the
SDCH and promoting the health of children themselves. This requires recognition that ultimately
issues related to the SDCH are political issues that require not only careful policy analysis but
also recognition of the important role that politics, ideology, and values play in shaping the
factors important to children’s health (Bryant, 2012; Raphael, 2012b).
Acting to Strengthen the Social Determinants of Children’s Health in Canada
The situation of children in Canada is not helped by the fact that the State provides rather
little in terms of universal entitlements outside of health care, libraries, and education from
kindergarten through Grade 12. This is in marked contrast to many other wealthy developed
nations where parents are routinely provided with State supports for having children through
family allowances and the provision of childcare and housing supports.
Having identified these issues, the task is to identify what means can be implemented to
improve the current situation. A wide variety of actions are possible. The important question is
which approach will ultimately prove to be the most successful in shifting a society’s approach
to the SDCH, thereby promoting children’s health.
Improve Services
No one would dispute the importance of improving children’s health and social services.
Such services need to be responsive, effective, efficient, and geared to the particular needs of
those who require them. Certainly, every attempt should be made to improve their quality
(Haddad, 2011b).
Change Behaviours
There is also ongoing attention to changing the behaviours of children and their parents in
the hope that this will improve health. These usually include issues of tobacco and alcohol use,
diet, physical activity, and weight control. People’s behaviours are strongly embedded however
within those particular environments in which they live and work (Jarvis & Wardle, 2003), and
this is especially the case for children. All too frequently this leads to the simplistic approach by
which people of particular social locations are identified as being particular targets for
interventions to change their behaviour (Raphael, 2011b). Such an approach in itself can be
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stigmatizing, ineffective, and do little to actually improve the living and working conditions that
spawn health and other problems (Labonte & Penfold, 1981).
Strengthen Environments through Community Development Activities
Community development approaches work on the assumption that if individuals and
families come together to effect change they will be able to do so (Heritage & Dooris, 2009; Park,
1993). Such a belief assumes that governing authorities are receptive to the ideas and wishes
identified through such activities. Sadly in Canada, this has not recently been the case and it
appears that governments are becoming more and more resistant to responding to the particular
needs of individuals and communities. This suggests that it may be necessary to organize
communities to not try to persuade governing authorities to effect change, but rather to
undertake actions that will force government authorities – through fear of electoral defeat – to
take actions to improve the SDCH and make their distribution more equitable (Bryant et al.,
2011).
Strengthen Environments by Building Healthy Public Policy
All of the previous activities mentioned are certainly worthwhile. They suffer, however,
from their inadequacy to shape the public policy that determines the living and working
conditions of parents and their children. Moreover, public policy analysis is not part of the
training that health professionals usually receive. It is not just those in the health sciences who
lack public policy analysis skills. Most academic disciplines – psychology, sociology, education,
medicine, nursing, and social work – have little to offer in their curricula regarding public policy
analysis. In fact, it could be argued that the only academic discipline that takes the issue of
public policy seriously is that of political science.
Nevertheless it is becoming increasingly apparent to the health community that public
policy plays a crucial role in shaping not only the health care system but also the SDCH. What
are the specific public policy areas that are of such importance? As mentioned earlier, primary
ones are those concerned with the distribution of income and wealth, provision of supports and
benefits, and generally any public policy that concerns itself with the health and well-being of
children.
Not surprisingly, the Nordic countries have acted upon many public policy areas that in
the end come to strengthen the quality and make more equitable the distribution of the SDCH
(Innocenti Research Centre, 2007, 2008, 2010). A short list would include universal, affordable
childcare, the provision of financial supports to families with children that allow for the
achievement of food and housing security, the provision of employment training and support
prior to training and if employment is lost (Olsen, 2002, 2010). The ability to organize a large
proportion of the population into labour unions is also a powerful driver of SDCH-related public
policy (Raphael, 2012b).
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Conclusions
The literature on the SDCH is providing increasing evidence that the primary means of
improving their quality and making the distribution more equitable is through public policy that
provides parents with the economic and social security necessary for health. These public policy
areas shape all the SDCH of early childhood development, income and wealth distribution,
employment security and working conditions, food and housing security, and the provision of
health and social services. This argument outlines a major role for the State – acting on behalf of
the majority of citizens – in taking an active role in the provision of economic and social security
for citizens. Without such government intervention, the economic system creates the social
inequalities that shape the quality and distribution of the SDCH. In nations such as Canada where
there is growing withdrawal of the State from involvement in these areas, we see evidence of
either stagnating or declining health of children.
While all of us should do what we can to improve the SDCH, it seems to me that the key
issue to be considered is whether those concerned with the health of children will begin the
important debate of the role of the State in providing parents and their children with the
economic and social security necessary for health. Those working in the health field can either
accept or reject this analysis. What they cannot do is ignore it.
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A discourse analysis of the social determinants of health
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Dennis Raphael*
School of Health Policy and Management, York University, Toronto, ON M3J 1P3, Canada
(Received 15 September 2009; final version received 5 April 2010)
The social determinants of health (SDH) concept is common to Canadian
policy documents and reports. Yet, little effort is undertaken to strengthen
their quality and promote their more equitable distribution through public
policy action. Much of this has to do with the SDH concept conflicting
with current governmental approaches of welfare state retrenchment and
deference to the dominant societal institution in Canada, the marketplace.
In addition, many SDH researchers and implementers of SDH-related
concepts are reluctant to identify the public policy implications of the SDH
concept. The result is a variety of SDH discourses that differ greatly in their
explication of the SDH concept and their implications for action. This
article identifies these various SDH discourses with the goal of noting their
contributions and limitations in the service of advancing the SDH agenda
in Canada and elsewhere.
Keywords: public policy; socio-economic; health inequalities
Introduction
Social determinants of health (SDH) refer to the societal factors – and the unequal
distribution of these factors – that contribute to both the overall health of Canadians
and existing inequalities in health (Graham 2004a). With the publication of the
Commission on the Social Determinants of Health’s final report and those of its
knowledge hubs, the SDH concept has achieved a prominence that makes it difficult
for policymakers, health researchers and professionals to ignore (Commission on the
Social Determinants of Health 2008). This has certainly been the case in Canada
where the SDH figure prominently in health policy documents produced by the
Federal government (Public Health Agency of Canada 2007, 2008a), the Chief
Health Officer of Canada (Butler-Jones 2008), the Canadian Senate (Senate
Subcommittee on Population Health 2008), numerous public health and social
development organizations and agencies (United Nations Association of Canada
2006, Canadian Public Health Association 2008, Chronic Disease Alliance of
Ontario 2008) and research funding agencies (Institute of Population and Public
Health 2003, Canadian Institutes of Health Research 2005). Even the businessoriented Conference Board of Canada has established an initiative focused on the
social and economic determinants of health (Conference Board of Canada 2008).
*Email: [email protected]
ISSN 0958–1596 print/ISSN 1469–3682 online
ß 2011 Taylor & Francis
DOI: 10.1080/09581596.2010.485606
http://www.informaworld.com
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D. Raphael
The content of these documents is consistent with the view that (1) SDH are
important influences upon the health of individuals, communities and jurisdictions
as a whole and (2) SDH represent the quantity and quality of a variety of resources a
society makes available to its members. All imply that something should be done to
strengthen them.
It is well documented, however, that actual implementation of these concepts in
Canada lags well behind other jurisdictions (Canadian Population Health Initiative
2002, Lavis 2002, Collins et al. 2007, Raphael et al. 2008). The SDH concept – and its
public policy implications – conflict with current governmental approaches that
reflect welfare state retrenchment and deference to the dominant societal institution
in Canada, the marketplace (Raphael and Bryant 2006, Irwin and Scali 2007). The
result is that while Canada has a reputation as a ‘health promotion and population
health powerhouse’ (Restrepo 1996, Raphael 2008a), the actual reality is that
inequalities in income and wealth have increased at the same time that governments
have weakened their commitments to provide citizens with various benefits and
supports (Organisation for Economic Co-operation and Development 2008, Raphael
2008b, Bryant 2009).
The result of this has been that increasing numbers of Canadians are coming to
experience adverse SDH (e.g. low incomes, food, housing, and employment
insecurity, etc.; Bryant et al. 2009). Since these adverse experiences do not occur
for all Canadians, the argument can also be made that the distribution of the SDH
among Canadians is becoming increasingly unequal (Graham 2004a). There is also
evidence that improvements in key health outcomes such as life expectancy and
premature years of life lost are not keeping pace with improvements seen among
many Organisation for Economic Co-operation and Development nations (OECD
2007). In the case of infant mortality, Canada’s rate may actually be increasing
(Wilkins 2007).
An additional problem is that many SDH researchers and those attempting to
implement SDH-related concepts are reluctant to identify the public policy
implications of the SDH concept (Poland et al. 1998, Robertson 1998, Coburn
2006). This tendency is especially striking among disease-related research publications and policy documents where extensive discussion is provided in early sections
of the importance of the SDH for various afflictions (e.g. cardiovascular disease,
type II diabetes, cancers, respiratory disease, etc.), but recommendations are limited
to the promotion of so-called ‘healthy lifestyle choices’, such as the eating of fruits
and vegetables, increased physical activity, and the avoidance of tobacco and
excessive alcohol use (Basinski 1999, Heart and Stroke Foundation of Canada 1999,
Hux et al. 2002, Health Canada 2003, Canadian Diabetes Association 2008, Public
Health Agency of Canada 2008b).
Even the recent report by the Chief Health Officer of Canada on inequalities in
health and the importance of the SDH demonstrates this reluctance. An analysis of
the report argues that it fails to recognize the role that governments can play in
‘addressing the underlying structural drivers of health inequalities and the treatment
of basic needs’ (Kirkpatrick and McIntyre 2009, p. 94).
There appears to be an even greater reluctance to consider the political and
ideological sources of the inequitable distribution of SDH among Canadians. This
shortcoming is especially apparent among ‘population health researchers’ working
within the Canadian Institute for Advanced Research framework (Poland et al. 1998,
Raphael and Bryant 2002, Coburn et al. 2003).1 The result is the presence of a variety
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of SDH discourses that differ greatly in their explication of the SDH concept and
their implications for action. In this article, I identify these various discourses, and
by noting their contributions and limitations, aim to advance the SDH agenda in
Canada and elsewhere.
SDH discourses
As noted earlier, SDH refer to the societal factors – and the unequal distribution of
these factors – that contribute to both the overall health of Canadians and existing
inequalities in health (Graham 2004a). Since the modern introduction of the term
SDH (Tarlov 1996), a variety of conceptualizations – all clearly referring to the
impact of societal factors upon health – have appeared (Table 1).
The evidence base in support of the importance of the SDH is now extensive
(Davey Smith 2003, Wilkinson and Marmot 2003, Commission on the Social
Determinants of Health 2008). Among those researching and engaged in SDHrelated activities, a consensus exists that non-medical and non-behavioural risk
factors are worthy of attention, but I have observed profound differences in how this
consensus plays out in research and professional activity. To my mind, this variation
is not merely about paradigms that define intellectual world views about how such
phenomena can be understood or investigated (Kuhn 1970, Guba 1990). This
variation rather represents Foucaultian discourses which – since they involve issues
of legitimation, power, and coercion – exert a much more powerful influence upon
research and practice:
Foucault refers to discourses as systems of thoughts composed of ideas, attitudes,
courses of actions, beliefs, and practices that systematically construct the subjects and
the worlds of which they speak. He traces the role of discourses in wider social processes
of legitimating and power, emphasizing the constitution of current truths, how they are
maintained and what power relations they carry with them (Lessa 2006, p. 285).
The reason why I raise the Foucaultian concept of discourse is that these SDH
discourses appear to direct the kinds of research and professional activities that are
deemed acceptable, i.e. fundable in the case of research2 and institutional budgeting,3
and career-enhancing in terms of personal futures.4 The result is that there are just a
handful of Canadian health researchers and workers who write and talk publicly
about the economic and political forces that shape the quality of the SDH.5 In the
following sections, I examine the contribution – and deficiencies – of the various
SDH discourses and how they may play out in SDH research activity and
professional practice (Table 2).
Discourse 1: SDH as identifying those in need of health and social services
In this discourse, individuals and communities who experience an inter-connected set
of adverse SDH (e.g., growing up in a physically poor environment with poor
employment prospects, poor quality education services, etc.) are recognized as
having a greater incidence of a variety of medical and social problems. In response,
the health and social service needs of these individuals are identified and appropriate
services are delivered. Some examples of this include addressing the health care needs
of homeless individuals, effectively managing chronic diseases within vulnerable
communities, and promoting screening and primary health care among immigrant
Agriculture and food
production
Education
Work environment
Unemployment
Water and sanitation
Health care services
Housing
Dahlgren and
Whiteheadb
Income and social status
Social support networks
Education
Employment and working conditions
Physical and social environments
Healthy child development
Health services
Gender
Culture
Health Canadac
Social gradient
Stress
Early life
Social exclusion
Work
Unemployment
Social support
Addiction
Food
Transport
World Health
Organizationd
Socio-economic status
Transportation
Housing
Access to services
Discrimination by social
grouping
Social or environmental
stressors
Centers for Disease
Controle
Aboriginal status
Early life
Education
Employment and working conditions
Food security
Gender
Health care services
Housing
Income and its distribution
Social safety net
Social exclusion
Unemployment and
employment security
Raphael et al.f
Notes: aWorld Health Organization (1986); bDahlgren and Whitehead (1992); cHealth Canada (1998); dWilkinson and Marmot (2003); eCenters for
Disease Control and Prevention (2005); and fRaphael et al. (2004).
Peace
Shelter
Education
Food
Income
Stable ecosystem
Sustainable
resources
Social justice
Equity
Ottawa Chartera
Table 1. Various conceptualizations of the SDH.
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D. Raphael
SDH as identifying those with
modifiable medical and behavioral risk factors
SDH as indicating the material
living conditions that shape
health
SDH as indicating material living
circumstances that differ as a
function of group membership
SDH and their distribution as
results of public policy decisions made by governments and
other societal institutions
SDH and their distribution result
from economic and political
structures and justifying
ideologies
SDH and their distribution result
from the power and influence
of those who create and benefit
from health and social
inequalities
2
3
4
5
6
7
SDH as identifying those in need
of health and social services
1
SDH discourse
Table 2. SDH discourses.
Health and social services should
be responsive to peoples’
material living circumstances
Health behaviors (e.g. alcohol
and tobacco use, physical
activity and diet) are shaped
by living circumstances
Material living conditions operating through various pathways – including biological –
shape health
Material living conditions systematically differ among those
in various social locations
such as class, disability status,
gender, and race
Public policy analysis and
examination of the role of
politics should form the basis
of SDH analysis and advocacy efforts
Public policy that shapes the
SDH reflects the operation of
jurisdictional economic and
political systems
Specific classes and interests
both create and benefit from
the existence of social and
health inequalities
Key concept
Providing evidence of systematic
differences in life experiences
among citizen groups form the
basis for further anti-discrimination efforts
Attention is directed towards
governmental policymaking as
the source of social and health
inequalities and the role of
politics
Political and economic structures
that need to be modified in
support of the SDH are
identified
Identifying the classes and interests who benefit from social
and health inequalities mobilizes efforts towards change
Carry out class-, race-, and
gender-based analysis of differing living conditions and their
health-related effects
Carry out analyses of how public
policy decisions are made and
how these decisions impact
health (i.e. health impact
analysis)
Identify how the political economy of a nation fosters particular approaches to addressing
the SDH
Research and advocacy efforts
should identify how imbalances
in power and influence can be
confronted and defeated
Focus limited to service provision
with assumption that this will
improve health
Focus limited to health behaviors
with assumption that targeting
for behavior change will
improve health
Identifying SDH pathways and
processes reinforce concept and
strengthen evidence base
Practical implications of the
discourse
Develop and evaluate services for
those experiencing adverse
living conditions
Develop and evaluate lifestyle
programming that targets individuals experiencing adverse
living conditions
Identify the processes by which
adverse living conditions come
to determine health
Dominant research and practice
paradigms
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groups among others (Saxena et al. 1999, Hwang and Bugeja 2000, Sword 2000,
Benoit et al. 2003). Public health agencies can provide preventive health services, and
social service agencies can provide supports to these at-risk individuals and
communities.
The provision of responsive health and social services is important, but limiting
research and professional activities to developing and implementing such programs
can neglect the sources of these afflictions – i.e., living under adverse circumstances –
doing little to reduce the need for these services. This discourse can reinforce already
dominant health care and social service emphases, thereby obscuring the importance
to health of the SDH and their inequitable distribution.
Discourse 2: SDH as identifying those with modifiable medical and behavioural
risk profiles
The ‘healthy lifestyles’ SDH discourse recognizes that individuals and communities
who experience an inter-connected set of adverse SDH exhibit an excess of medical
(e.g., high sugar, ‘bad’ cholesterol levels, etc.) and behavioral (e.g., poorly chosen
diet, lack of physical activity, and tobacco and excessive alcohol use) risk factors.
Here, the SDH represent a set of living conditions that direct attention to modifying
risk behaviors among those experiencing these adverse SDH (Allison et al. 1999,
Choiniere et al. 2000, Potvin et al. 2000, Choi and Shi 2001).
Unlike Discourse 1 which stresses provision of health and social services to those
experiencing adverse SDH, this discourse and its implementation has significant
negative aspects. First, these risk factors account for relatively little of the variation
in health outcomes as compared to the experience of adverse SDH (Lantz et al. 1998,
Raphael and Farrell 2002, Raphael et al. 2003). Second, it is embedded within a
framework that assumes that individuals are capable of ‘making healthy lifestyle
choices’ such that individuals who fail to do so are held responsible for their own
adverse health outcomes (Labonte and Penfold 1981, Lindbladh et al. 1998, Raphael
2002).
Third, these programs show rather little evidence of effectiveness serving only to
further disenable vulnerable populations and the health workers administering these
programs (O’Loughlin 2001, Raphael 2002). Finally, they have a disturbing tendency
to neglect the sources of the adverse living circumstances to which individuals are
exposed, further obscuring their importance (Raphael 2003).
Discourse 3: SDH as indicating the material living conditions that shape health
Here, we have a clear recognition that experiencing adverse SDH is an important
influence upon health and that various pathways exist by which the experience of the
SDH ‘get under the skin’ to shape health. In one model, interacting material,
psychological, and behavioral pathways are identified that reflect the influence of
societal structures (broadly defined), employment and working conditions, and
neighborhood characteristics (Brunner and Marmot 2006). Other models specify
how the experience of SDH during childhood and adulthood interact to produce
health outcomes across the life span (van de Mheen et al. 1998, Benzeval et al. 2001).
Specifying the physiological processes by which SDH ‘get under the skin’ is also an
area (Sapolsky 1992, Brunner and Marmot 2006, Meany et al. 2007).
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Extensive evidence of the importance for health of the experience of SDH is
available (Gordon et al. 1999, Marmot and Wilkinson 2006, Raphael 2008b). The
clear message of this discourse is that living conditions and their material,
psychological, and behavioral effects – not the adoption of poor ‘lifestyle’ choices
– are the primary determinants of health.
Yet, even this more mature SDH discourse is frequently diluted if the public
policy antecedents of the experience of adverse SDH are not emphasized.
Governments and health and social service organizations and agencies can take
information about the importance of early life, for instance, and translate this into
promoting better parenting or having schools foster exercise among children rather
than improving the provision of financial resources to those in need or providing
affordable housing. Authorities can implement breakfast programs, clothing and
food drives, and coping or anger management classes rather than considering how
public policies create financial insecurity.
Discourse 4: SDH as indicating material living circumstances that differ as a
function of group membership
Much activity identifies how variations in the experience of adverse SDH occur as a
function of class, gender and race (Dunn and Dyck 2000, Ornstein 2000, Galabuzi
2004, Pederson and Raphael 2006, McMullin 2008, Wallis and Kwok 2008). This
work draws upon the extensive social inequalities literature and specifies how
particular groups are exposed to adverse SDH (Graham 2001, 2004b). But like the
previous discourse, this work lends itself open to the possibility – if the public policy
antecedents of the inequitable distribution of SDH are not emphasized – of seeing
the problem as being amenable to program interventions (e.g. literacy and counseling
programs, anti-discrimination training, etc.) directed towards specific individuals or
groups.
Discourse 5: SDH and their distribution result from public policy decisions made by
governments and other societal institutions
As noted, SDH discourses can identify the relationship between the experience of
adverse SDH and subsequent health status. In this discourse, the analysis considers
how exposures to adverse SDH and their inequitable distribution come about as a
result of public policy decisions. There is a clear assumption that the primary means
of improving the quality of SDH and promoting their more equitable distribution is
through public policy activity (Armstrong 1996, Bryant 2006, McIntyre 2008,
Shapcott 2008, Tremblay 2008, Bryant et al. 2009). This discourse is well represented
by the conclusions of the World Health Organization’s Commission on the SDH
(Commission on the Social Determinants of Health 2008).
As an illustration of this discourse, the SDH experienced during early life are
shaped by the availability of material resources that assure adequate educational
opportunities, food and housing, among other SDH (Hertzman 2000). Much of this
has to do with parents’ employment security, wages, the quality of their working
conditions and availability of quality, regulated childcare (Innocenti Research
Centre 2007). All of these experiences of the SDH are shaped by public policy.
228
D. Raphael
In Canada, Kirkpatrick and McIntyre comment on the reluctance to consider
public policy implications of the SDH apparent in the Chief Public Health Officer of
Canada’s (CPHO) report on health inequalities:
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The CPHO report’s failure to emphasize the essential role of government action is
reinforced by the examples used to illustrate ‘successful interventions that . . . may serve
to reduce Canada’s health inequalities and improve quality of life for all Canadians’
(p. 1). In fact, the interventions highlighted tend to be community-based programs that
are unable to address the structural determinants of health inequalities. (Kirkpatrick
and McIntyre 2009, p. 94).
Discourse 6: SDH and their distribution result from jurisdictional economic and
political structures and justifying ideologies
Identifying public policy antecedents of the experiences of the SDH and their
inequitable distribution can promote and support public policy advocacy. But, why
is it that many nations have acted upon SDH-related evidence while others – such as
Canada – are identified as SDH policy laggards (Bryant et al. 2009)? In this
discourse, consideration is given to how a nation’s historical traditions and economic
and political structures support or hinder SDH-strengthening public policies
(Navarro and Shi 2002, Coburn 2004, Bambra et al. 2005, Bambra 2006, Raphael
and Bryant 2006).
Jurisdictional approaches to SDH issues appear to cluster and appear amenable
to a ‘worlds of welfare analysis’ (Bambra 2007, Eikemo and Bambra 2008). In one
prominent model, three distinct types of welfare states are identified: social
democratic (e.g., Sweden, Norway, Denmark, and Finland), liberal (USA, UK,
Canada, and Ireland), and conservative (France, Germany, the Netherlands, and
Belgium, among others; Esping-Andersen 1990, 1999).
Two Canadian sociologists, Saint-Arnaud and Bernard, provide a graphic (that
adds a fourth welfare state type) that suggests how differences in political and
economic structures and processes (political economy) – themselves a result of
historical traditions and governance by specific political parties over time – are
related to the quality and distribution of the SDH (Figure 1; Saint-Arnaud and
Bernard 2003). The social democratic welfare states provide greater exposures to
quality SDH (e.g., more equitable income distribution and lower poverty rates,
family supports including early education and care, higher wages, employment, food
and housing security, extensive health and social services, etc.) than do liberal welfare
states (Navarro and Shi 2002, Conference Board of Canada 2003, 2006, Navarro
et al. 2006, Raphael 2007a, Innocenti Research Centre 2008, Organisation for
Economic Co-operation and Development 2009). It is not surprising that the social
democratic political economies outperform the liberal economies on numerous
health and quality of life indicators (Conference Board of Canada 2003, 2006,
Navarro et al. 2004).
Since the dominant inspiration of liberal political economies is to minimize
governmental intervention in the operation of its central institution – the market – it
should not be surprising that Canada – and its liberal partners – fall well behind
other nations in strengthening and assuring the equitable distribution of the SDH. It
should also not be surprising that Canadian public policy continues to be adverse to
SDH concepts. The discourse broadens analysis beyond simply identifying public
Critical Public Health
Social democratic
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Ideological
inspiration
Equality
Reduce:
• Poverty
• Inequality
• Unemployment
Liberal
Liberty
Minimize:
• Government interventions
• ‘Disincentives’ to work
Universalism
Social rights
Residual:
Taking care of
the essential
needs of the most
deprived (meanstested assistance)
Focus of the
progras
Resources
Needs
Central
institution
State
Market
Organizing
principle
Conservative
229
Latin
Solidarity
Maintain:
• Social stability
• Wage stability
• Social integration
Insurance:
Access to
benefits
depending on
past
contributions
Rudimentary
and
familialistic
Risks
Family and occupational
categories
Figure 1. Ideological variations in forms of the welfare state.
Source: Saint-Arnaud and Bernard (2003, Figure 2, p. 503).
policy implications to one of attempting to influence the political and economic
structures that shape such policy.
Discourse 7: SDH and their distribution result from the influence and power of those
who create and benefit from social and health inequalities
It is not inequalities that kill, but those who benefit from the inequalities that kill
(Navarro 2009, p. 15).
In this final discourse, the individuals and groups who through their undue
influence upon governments create and benefit from social and health inequalities –
and in the process threaten the quality of the SDH to which individuals are exposed
and skew their distribution – are identified (Scambler 2001, Kerstetter 2002, Wright
2003, Yalnizyan 2007, Langille 2008, Chernomas and Hudson 2009, Navarro 2009).
These individuals and groups lobby for – and have been successful in – shifting the
tax structures to favor the corporate sector and the wealthy; reducing public
expenditures; controlling wages and employment benefits; and relaxing labor
standards and protections (Scambler 2001, Kerstetter 2002, Wright 2003,
Yalnizyan 2007, Langille 2008, Chernomas and Hudson 2009, Navarro 2009). In
Canada and elsewhere, these public policy changes have led to increasing income and
wealth inequalities, stagnating worker incomes, and growing incidence of housing
and food insecurity (Jackson 2000, Leys 2001, Kerstetter 2002, Lee 2007).
Who exactly are these villains (or Greedy Bastards, according to Scambler 2001)
and how can their undue influence upon public policy be resisted? Langille (2008)
identifies business associations, conservative think tanks, citizen front institutions,
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D. Raphael
and conservative lobbyists. It is important to recognize that these individuals and
groups are acting in their own interests and in parliamentary democracies they have
every right to do so. In Canada, the problem is that as their power and influence has
increased, there has been declining counterbalances to their influence (McBride and
Shields 1997, Langille 2008).
What form might these counterbalances take? Langille (2008) and others propose
educating the public and using the strength in numbers of the public to promote
public policy that will oppose this agenda. Wright’s (1994, 2003) argument for
organizing to ‘oppose and defeat’ the powerful interests that influence governments
to maintain poverty can be applied to the SDH in general. These defeats can occur in
the workplace through greater union organization and increasing public recognition
of the class-related forces that shape public policy.
Defeats can also occur in the electoral and parliamentary arena by election of
political parties that favor public policy action to strengthen the quality of the SDH
(Esping-Andersen 1985, Brady 2003). Internationally, it is well demonstrated that
social democratic parties are more receptive to – and successful at – implementing
SDH-supportive public policies (Brady 2003, Rainwater and Smeeding 2003,
Navarro 2009). In Canada, the NDP – in contrast to the Liberal and Conservative
Parties – have policy positions more consistent with SDH-enhancing public policies
(Raphael 2007b). It was only upon the election of new Labour in 1997 that health
inequalities began to be addressed in the UK.
Conclusion
Efforts to strengthen the quality of the SDH that are experienced through public
policy activity in Canada lags well behind those seen in other developed nations.
Governmental authorities are resistant to the SDH concept and public lack of
awareness reduces the likelihood that public pressure to address these issues will
appear. Even within the SDH research and professional community there is
reluctance among many to explore the public policy implications of SDH concepts.
Various discourses that consider SDH but ignore their public policy antecedents
allow governmental authorities to neglect the quality of the SDH that are
experienced and their inequitable distribution.
The last discourse proposes addressing these issues through public policy action
in the political realm. To achieve this requires educating the public that deteriorating
quality SDH and inequitable SDH distributions result from the undue influence
upon public policymaking by those creating and profiting from social and health
inequalities. In light of Canada’s current economic and political structures, and the
continuing influence of the corporate and business sector upon public policymaking,
the possibility of achieving significant progress on SDH-related issues by working
within the other discourses appears unlikely.
Notes
1. The critique of population health focuses on the positivist and epidemiological
orientation of the approach, which results in an emphasis on data rather than theory,
the concrete rather than the conceptual, and the avoidance of normative judgments.
2. In my own case, funding for research into a critical analysis of the public policy
antecedents of increasing mortality from type II diabetes among lower income Canadians
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Critical Public Health
231
was denied from traditional health research funding institutes, but received from the
Social Science and Humanities Research Council (SSHRC). The recent termination of
funding for health research by SSHRC is a source of concern to many health researchers
(Social scientists redirected to CIHR for grants, http://www.cmaj.ca/earlyreleases/
12nov09-social-scientists-redirected-to-cihr-for-grants.shtml).
3. An introduction to this phenomenon occurred over 10 years ago when a medical officer of
health of a large Canadian jurisdiction stated that raising issues of public policy and their
contribution to health would result in the agency’s funding being reduced. Similar
sentiments were provided at a recent meeting of public health officials in Ontario.
4. As a consultant to numerous public health and health care agencies and institutions,
I have repeatedly been told that raising public policy issues can be a ‘career threatening
move’. Faculty at health sciences departments frequently tell me of their reluctance to
take a critical approach to health issues until their receipt of academic tenure.
5. Many of these individuals contributed to the 2008 volume Social Determinants of Health:
Canadian Perspectives, Toronto: Canadian Scholars’ Press.
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Critical Public Health, 2013
http://dx.doi.org/10.1080/09581596.2013.820256
Epistemological barriers to addressing the social determinants of
health among public health professionals in Ontario, Canada: a
qualitative inquiry
Julia Brassolottoa*, Dennis Raphaelb and Navindra Baldeoc
a
Graduate Program in Health Policy and Equity, York University, Toronto, Canada; bSchool of
Health Policy and Management, York University, Toronto, Canada; cInstitute of Health Policy,
Management, and Evaluation, University of Toronto, Toronto, Canada
Downloaded by [109.174.179.68] at 09:21 22 July 2013
(Received 14 March 2013; final version received 22 June 2013)
To date, Ontario public health units (PHUs) have generally neglected the
social determinants of health (SDH) concept in favor of risk aversion and
behaviorally oriented health promotion approaches. Addressing SDH and
responding to the presence of health inequities is required under the Ontario
Public Health Standards and is a component of provincial public health
documents and reports. Nevertheless, units vary in their understanding and
application of the SDH concept in their activities. The authors conducted 18
interviews with Medical Officers of Health and lead staff persons from nine
Ontario PHUs, in order to better understand how these differences in
addressing the SDH among health units come about. The findings suggest that
differences in practice largely result from epistemological variations: conceptions of the SDH; the perceived role of public health in addressing them; and
understandings concerning the validity of differing forms of evidence and
expected outcomes. Drawing from Bachelard’s concept of epistemological
barriers and Raphael’s seven discourses on the SDH, we examine the ways in
which the participating units discuss and apply the SDH concepts. We argue
that a substantial barrier to further action on the SDH is the internalization of
discourses and traditions that treat health as individualized and depoliticized.
Keywords: social determinants of health; public health; epistemological
barriers; Canada
Introduction
Despite Canada’s reputation for developing concepts related to the social determinants
of health (SDH), government agencies, professional health organizations, and local
public health units (PHUs) have struggled with how to apply the concept to improve
the health of the Canadian public (Collins and Hayes 2007; Hancock 2011; Low and
Theriault 2008). This is problematic, given that growing income inequality and
deepening poverty in Canada are indicative of a deterioration of a wide range of SDH
(CCPA 2013; OECD 2011).
The French philosopher and historian Gaston Bachelard introduced the concept of
‘epistemological obstacles’ or ‘epistemological barriers’ to explain the intellectual
*Corresponding author. Email: [email protected]
Ó 2013 Taylor & Francis
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2
J. Brassolotto et al.
hurdles that scientists may face when they approach new scientific problems. He
claimed that in order to develop new approaches to a problem, scientists must overcome
the barriers posed by their prior views (Tiles 1984). In other words, past worldviews
and thinking patterns can serve as obstacles to future progress and knowledge production. By this account, scientific progress is not linear; it develops via fractured points of
departure, through epistemological breaks or ruptures. We argue that this concept can
also be applied to research in health policy because progress in this area is similarly
dependent upon critically evaluating or transcending previous ways of thinking in order
to gain a greater understanding of the present-day world. For instance, differing conceptions of health and its determinants have resulted in diverse and divergent treatment and
policy approaches over time and across disciplines.
Raphael (2009) claims that such variation is not simply an issue of Kuhnian
paradigms (Kuhn 1962) that define intellectual worldviews about how such phenomena can be understood or investigated. Rather, he argues that the variation in
approaches and understandings of SDH represents, ‘Foucaultian discourses which –
since they involve issues of legitimating, power, and coercion – exert a much more
powerful influence [than paradigms do] upon research and practice’ (Raphael 2011,
223). The dominant discourse in the health professions is usually biomedical, microlevel, individualized, and depoliticized (Germov and Hornosty 2012). This tradition
treats health as the absence of illness or disease in individuals and seeks to improve
measurable aspects of their lives through the reduction of risk factors using indicators
of morbidity and mortality. Those who have internalized this worldview, ‘[o]ften
(though not always) assume that work against disease is objectively desirable, and so
requires no further justification: the epidemiology (the evidence) frequently thought to
“speak for itself”’ (Seedhouse 2004, 85). The decontexualized and depoliticized view
of health does not question social and political structures; it takes them as given and
deals with issues within these preexisting structures. This approach ignores the presence and intersections of structural phenomena, such as racism, sexism, classism,
homophobia, structural and systemic violence, and other forms of inequity – or treats
them as irrelevant or marginal to health. Public health, however, is usually premised
on the notion of community health and well-being (Baum 2008). Tensions can arise
for public health professionals when they seek to address population health issues but
work within a discourse or framework of individualism (Tesh 1988).
We apply the notion of epistemological barriers in our discussion of Ontario –
Canada’s most populous province – PHUs and their efforts to address the SDH. In this
case, the barriers may stem from particular discourses about health and society and the
appropriate role for the public health community in addressing these issues. To date,
Ontario PHUs have generally neglected the SDH in favor of risk aversion and
behaviorally oriented health promotion approaches (NCCDH 2010). Addressing SDH
and responding to the presence of health inequalities is required under the Ontario
Public Health Standards (2008) and is a component of provincial public health
documents (Ontario Public Health Association 2001) and reports (Ontario Public Health
Association 2005). Nevertheless, units vary in their understanding and application of
the SDH concept in their activities.
We carried out this study to examine our assumption that there might be
epistemological challenges to PHUs applying these concepts. To explore this, we sought
to understand the worldviews of public health officials concerning these issues. We
therefore conducted 18 interviews with Medical Officers of Health (MOH) and lead staff
persons from nine Ontario PHUs with variation in their practices to better understand
Critical Public Health
3
how these differences came about. Our findings suggest that these differences in practice
result largely from varying conceptions of: the nature of SDH, the perceived role of
public health in addressing them, and understandings concerning the validity of differing
forms of evidence and expected outcomes. Based on Raphael’s (2011) model of SDH
discourses and the ways in which the participating units discussed the SDH, we
categorized them into three clusters, those that take functional, analytical, and structural
approaches. These approaches are defined in the results section.
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Background and specific goals of this research
In addition to substantial academic scholarship regarding the SDH (e.g. Armstrong
2001; Bryant 2009; Coburn 2000; Marmot et al. 1991; Navarro 2009; Raphael 2009;
Wilkinson and Pickett 2010), their importance is widely recognized in official
documents and reports. For instance, the WHO (2008) final report from the Commission on SDH emphasized the need to refocus public health activities from ‘lifestyle
choices’ to issues of living conditions and social justice. The Commission presented
substantial evidence that health inequities result from social, economic, and political
environments – and as a result, these inequities are amenable to political intervention
(WHO 2008). Additionally, ‘[t]he report challenged health programmes and policies to
tackle the leading causes of ill-health at their roots, even when these causes lie beyond
the direct control of the health sector’ (WHO 2010). In other words, it was globally
publicized that those doing public health work have some degree of responsibility for
identifying and addressing the structural causes of poor health.
In Canada, Dr Arlene King, in her 2009 Annual Report of the Chief Medical Officer of Health of Ontario to the Legislative Assembly, argued that public health is
‘everyone’s business’ and that prevention is the ‘next evolution of health care’ (King
2009). She drew upon Canadian SDH-focused reports, such as the Lalonde Report
(1974), the Epp Report (1986), and Social Determinants of Health: The Canadian Facts
(2010) to argue that any successful public health strategy requires addressing health
inequalities through a system-wide approach. Indeed, on the first page of the Ontario
Public Health Standards – which dictates required activities of PHUs – it is stated, ‘[a]
ddressing determinants of health and reducing health inequities are fundamental to the
work of public health in Ontario. Effective public health programs and services consider
the impact of the determinants of health on the achievement of intended health outcomes’ (Government of Ontario, 2008, xx).
Regarding the PHUs and their professional association, the Ontario Public Health
Association (OPHA) participates with the Association of Local Public Health Associations (alPHa) in the Joint Working Group on the SDH. Its purpose is to reduce social
inequities using strategic approaches that promote the inclusion of activities to address
the social and economic determinants of health within the mandate of local PHUs in
Ontario, identify, recommend, and support the provincial advocacy efforts of alPHa and
OPHA for improvements in health inequities, and monitor advocacy efforts and policy
changes at the provincial and national levels that impact health inequities (OPHA
2011a). The group’s listed activities and objectives also include monitoring and reporting on poverty reduction strategies and making related recommendations to government.
This further reinforces public health’s role in addressing health inequalities, but retains
language that sees SDH efforts as targeting risk factors rather than as challenging
structural inequalities. For instance, the OPHA’s (2011b) response to Dr King’s Chief
MOH Annual Report on the SDH states,
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J. Brassolotto et al.
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It was encouraging to see our public health challenges framed broadly from a SDH
perspective. In order to be comprehensive, a public health strategy must address all the risk
factors [emphasis added] that impact population health, prioritize interventions based on
the burden of illness and include cross-sectoral and cross-governmental contributors to
public health.
The recommended targeted policies/advocacy efforts were focused on tobacco, food
insecurity, early childhood development, alcohol, and violence prevention (OPHA
2011b). These efforts are certainly important and worthwhile, but they also reveal an
understanding of the SDH that is not necessarily consistent with a broader SDH approach.
Despite – or perhaps because of – the requirements and tentative commitments
noted above, there is an apparent gap between rhetoric and action in addressing the
SDH (Raphael, Brassolotto, and Baldeo 2013). We see little evidence to date that PHUs
have been successful in bridging this gap. This problem is not unique to Ontario, Canada. In the UK, Petticrew et al. (2004) explored how research evidence influences public health policy-making related to reducing health inequities and how it can be
improved. They found in the UK and internationally, a lack of ‘an equity dimension’ in
evaluative research and weak theoretical underpinnings for much public health research
(ibid). Similarly, in the USA, White (2012) found that faculty engaged in public health
education generally lacked a critical perspective and revealed a tension over public
health’s role in politics and policy. Evidently, bridging the gap of SDH evidence to
policy and practice has been a struggle for many.
Perhaps this should not be surprising. For decades, thinkers have commented on
how key concepts of health and the nature of its determinants are contested (Aggleton
1990; Bambra, Fox, and Scott-Samuel 2005; Blaxter 2010; Raphael 2000; Seedhouse
2004; Tesh 1988). The problem is that these issues are rarely made explicit and the
insights of these authors are rarely applied to understanding the gap between rhetoric
and action on SDH issues. This study investigates this problem by examining how
differing understandings of the SDH can serve as epistemological barriers to local PHU
activity on the SDH.
Methods
We present data derived from a series of qualitative interviews with staff members from
nine Ontario PHUs chosen to represent a wide variation in SDH-related activities.
Based on a review of documented activities on their websites, consultation with key
contacts in the public health community and the second author’s extensive involvement
with the public health community, we used purposive sampling and approached 12
PHUs with varying engagement with the SDH in order to secure nine participating
units. Our aim was to include three units that were publicly taking leadership action on
the SDH, three that showed clear signs of SDH activity, and three where there was
lesser action being taken. This was done to obtain maximum variation and illustrate the
range of activities taking place. In the end, two publicly active units, four mid-range
ones, and three seemingly less SDH-active units were included. These represent nine of
36 Ontario PHUs. There were no incentives offered for participation. Ethics approval
was obtained from York University’s Ethics Board.
The authors developed the interview guide using sensitizing concepts based on our
understanding of the related literature. Questions were designed to elicit the
participants’ constructions of the SDH; their personal, professional, and community
experiences/influences that inform these; and their training. We recognize that
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Critical Public Health
5
individuals’ understandings of the SDH will have implications for their actions, so we
wanted to better understand these constructions and their origins (Raphael, Brassolotto,
and Baldeo 2013).
Eighteen interviews were conducted in total, nine with the units’ MOH – and in
some cases, the associate MOH – and nine with lead staff members whose duties
directly address the SDH. In some cases more than two staff members per unit were
interviewed. The participants were both men (n = 5) and women (n = 18) and came from
a mix of urban and rural areas. Their experience in public health ranged from one year
to over 20 years. The participants were sent interview questions in advance.
The authors conducted and recorded open-ended, structured telephone interviews
that were then transcribed. Interviews typically lasted between 60 and 90 minutes. The
findings were coded and critically analyzed using the constant comparison method
(Creswell 2009; Glaser 1965). We used coloured pens and highlighters to identify and
associate repeated ideas. Each of the authors listened to and read over all 18 interviews.
Each author was then responsible for a detailed thematic analysis of a particular cluster
of units. Over several months, we had multiple meetings where we identified key
concepts, and compared, discussed, synthesized, and reached consensus about these
ideas. We then named the themes within which these ideas clustered. We identified the
themes and activities in terms of the type of approach that the units took and the ways
in which they discussed the SDH.
In addition to the interviews, the authors concurrently reviewed the units’ websites,
research reports, public education materials, internal committee documents, position
statements, operational plans, information sheets, logic models, terms of reference, and
other materials. The key concepts from these were analyzed alongside the themes
identified in the interviews. The concepts and themes were consistent across the data
sources.
Once this was complete, we performed member checking by sending all of the
participating units a document that outlined our findings, key themes, and the typology
we created to classify them. All units’ responses indicated that they approved of our
interpretations.
Results
All of the participants expressed an awareness of the SDH and identified the concept as
having some importance. The degree of importance, however, reflected the ways in
which the units engaged in advocacy, public education, and intersectoral coalitions. We
identified three clusters of PHUs that we consider reflective of their approaches to the
SDH at the time of study (Spring-Summer 2011). Of the nine units, three are classified
as Functional, four as Analytical, and two as Structural. Interestingly, the unit clustering
corresponded to the quantity of their SDH activity, but these labels reflect the
qualitative ways in which they actually approach their SDH work.
The clusters are labeled based on the discourses they use to discuss the SDH. These
are not rigid or fixed designations, but they do serve as useful tools in identifying the
points of difference between the PHUs and their approaches. We recognize that unit
activities may well have been modified since the time of this study.
These clusters map nicely onto Raphael’s (2011) SDH typology. Raphael identifies
seven different SDH discourses and provides key concepts for each: dominant research,
practice paradigms, and practical implications (Table 1).
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J. Brassolotto et al.
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Table 1. Raphael’s seven SDH discourses.
SDH discourse
Key concept
1. SDH as
identifying those
in need of health
and social
services.
Health and social
services should be
responsive to
peoples’ material
living
circumstances.
Health behaviors
(e.g. alcohol and
tobacco use,
physical activity,
and diet) are
shaped by living
circumstances.
Material living
conditions
operating through
various pathways –
including biological
– shape health.
Material living
conditions
systematically
differ among those
in various social
locations, such as
class, disability
status, gender, and
race.
Public policy
analysis and
examination of the
role of politics
should form the
basis of SDH
analysis and
advocacy efforts.
Public policy that
shapes the SDH
reflects the
operation of
jurisdictional
economic and
political systems.
Specific classes and
interests both
create and benefit
from the existence
of social and health
inequalities.
2. SDH as
identifying those
with modifiable
medical and
behavioral risk
factors.
3. SDH as
indicating the
material living
conditions that
shape health.
4. SDH as
indicating
material living
circumstances
that differ as a
function of group
membership.
5. SDH and their
distribution as
results of public
policy decisions
made by
governments and
other societal
institutions.
6. SDH and their
distribution result
from economic
and political
structures and
justifying
ideologies.
7. SDH and their
distribution result
from the power
and influence of
those who create
and benefit from
health and social
inequalities.
Dominant research Practical
and practice
implications of the
paradigms
discourse
Approach
in PHU
activity
Functional
Develop and
evaluate services
for those
experiencing
adverse living
conditions.
Develop and
evaluate lifestyle
programming that
targets individuals
experiencing
adverse living
conditions.
Identify the
processes by
which adverse
living conditions
come to determine
health.
Carry out class-,
race-, and genderbased analysis of
differing living
conditions and
their health-related
effects.
Focus limited to
service provision
with assumption
that this will
improve health.
Carry out analyses
of how public
policy decisions
are made and how
these decisions
impact health (i.e.
health impact
analysis).
Identify how the
political economy
of a nation fosters
particular
approaches to
addressing the
SDH.
Research and
advocacy efforts
should identify
how imbalances in
power and
influence can be
confronted and
defeated.
Structural
Attention is
directed towards
governmental
policy-making as
the source of social
and health
inequalities and the
role of politics.
Structural
Political and
economic structures
that need to be
modified in support
of the SDH are
identified.
Functional
Focus limited to
health behaviors
with assumption
that targeting for
behavior change
will improve
health.
Analytical
Identifying SDH
pathways and
processes reinforce
concept and
strengthen evidence
base.
Providing evidence Analytical
of systematic
differences in life
experiences among
citizen groups form
the basis for further
antidiscrimination
efforts.
Identifying the
classes and
interests who
benefit from social
and health
inequalities
mobilizes efforts
towards change.
Structural
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Critical Public Health
7
Discourses 1–3 generally treat the SDH as identifiers of risk factors or undesirable
living conditions. Discourses 4–5 build on these discussions and recognize the importance of group membership, social structures, and political environments. Discourses 6–7
incorporate discussions of the roles played by power and influence within a political
economy framework. In this article, we apply the Functional, Analytical, and Structural
approach framework to reflect how these discourses manifest in PHU activities.
Units using a Functional approach discussed the SDH using discourses 1 and 2
(Raphael 2011). That is, they speak about the SDH as identifying those in need of
health and social services as well as those with modifiable medical and behavioral risk
factors. As a result, their activities are service-delivery and healthy-lifestyle oriented in
a limited behavioral fashion. These PHUs focus on developing and evaluating programs
and services for marginalized or vulnerable populations and reducing barriers to
accessing these resources.
The PHUs that have adopted an Analytical approach utilize SDH discourses 3 and
4. They acknowledge the multiple ways living conditions impact health and see
addressing these issues as within their realm of action. As a result, these units partner
with community organizations that address issues of poverty, food security, housing,
early childhood development, and other SDH. Like the Functional units, these units also
apply SDH thinking in the creation and evaluation of programming in addition to
their strategic partnerships. The SDH serve as an important analytical framework for
them.
Units that have adopted a Structural approach apply SDH discourses 4, 5, and 6. In
addition to the activities of the Functional and Analytic PHUs, they also engage in
public education about the SDH and direct public policy advocacy. These PHUs spoke
about the impacts of race, class, and gender and were also considering using Health
Impact Assessment (HIA) to investigate how policy decisions were affecting their
clients’ health. Discourse 7 includes the notion that, ‘SDH and their distribution result
from the power and influence of those who create and benefit from health and social
inequalities’ (Raphael 2011, 4). While we did not see this discourse explicitly used by
our participants, some of the responses from the Structural units could be interpreted as
implicitly addressing the implications of this perspective. Consistent with our thoughts
about epistemological barriers and their role in varying approaches to addressing the
SDH, we observed systematic variation in how relevant concepts were understood.
SDH as risk factors vs. indicators of structural inequality
The tension between individual risk factors and structural inequalities is prevalent in
health equity scholarship. Others have revealed this by contrasting individualized
approaches with structures associated with differing welfare states (Esping-Anderson
1990, 1999), by examining the role of neoliberal environments (Coburn 2000, 2004;
Wilkinson 2010), and by investigating intersections of marginalization and oppression
(Hankivsky and Christofferson 2008). In our case, tensions surfaced for public health
professionals when they discussed the definition and application of the SDH.
All of the Functional units and some of the Analytical units described the SDH
primarily as risk factors, more or less decontextualized from broader public policy
approaches and structural inequalities. Several participants identified them as
characteristics to be mindful of when providing or targeting services to specific groups
experiencing specific SDH issues. Housing, income, employment, and social issues
were most frequently cited. Those operating within this discourse spoke about health as
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8
J. Brassolotto et al.
a predominantly medical matter, as the absence of disease or illness. Social structures,
public policy, and classifications, such as gender, race, and class were sometimes
recognized as influencing health, but measures taken to address them were seen as
outside the scope of their work. For instance, one participant noted, ‘It all boils down
to behaviours. And so, determinants of health, yes, are talked about in our standards,
but you don’t see, I don’t see them having value in and of themselves except for how
they relate to health behaviours… That’s how I see it framed.’
This view is consistent with the ways these units apply the SDH in their activities.
SDH thinking is discussed by many of them as a ‘lens,’ ‘framework,’ or ‘tool’ to be
used when going about their work. This is why we suggest that these units have
adopted a functional view of SDH. In other words, the concept primarily serves a
functional purpose in the PHU’s programming and activities. At the time of the
interviews, the Functional units reported little systematic staff education or training
about the SDH, had generally not considered taking action towards implementing HIA
protocols or reports and reported minimal engagement in public education about SDH.
One person noted, ‘The SDH is an underlying principle that underlines the standards
and it is, if you will, a concept, a way of thinking about health that should be kept in
mind as you’re implementing programs.’
The application of this thinking can be seen in the PHUs’ decisions on placement
of new SDH nurses. In 2011, the Ontario provincial government allocated two
permanent nursing positions to each public health unit with the understanding that these
positions were to focus specifically on SDH and priority populations (Ontario Ministry
of Health and Long-Term Care 2011). The Functional units and some of the Analytical
units reported that they would use these new staff members to modify or extend existing programs. ‘So it’s not as though I’m going to say, “Your job is to do social determinants.” It’s everybody’s job, right? So it’s two more really to help out with the work
that we’re already doing.’ Members of the Structural units and some Analytical units
said that they would assign these nurses to more general SDH-focused roles that
involve research, coordination, strategic planning, and outreach.
In the Structural units and a couple of Analytical units, SDH were described as
indicators of structural inequalities in society. For instance:
I think about social determinants in terms of all of those factors beyond life style, genetics,
physiology that we know influence health so those range from specific kind of material
influences like access to food or housing, etc., beyond to community structures, to power
differentials within communities, to issues of class, race, and then all of the policy pieces
that govern each of those things.
From this perspective, the SDH extend beyond a person’s living conditions and include
social categories and hierarchies, intersections of marginalization, and the past and present societal structures that create inequities. These units revealed a more contextualized
and structural view of the SDH. From this perspective, the SDH go beyond serving an
operational or analytical function and are seen as inequalities that result from societal
structures, such as codified laws and policies; customs, practices, discourses, and traditions; and social locations, such as race, class, gender, disability, or sexual orientation.
Under this worldview, SDH are about differences in well-being, security, equitable
access, and freedom from oppression.
A participant from a Structural unit claimed that while all levels of government
have a role to play, ‘[t]heir partner and their influencer is public health, because we can
Critical Public Health
9
work with all three levels of government… we also have the ability to identify which
of the issues really belong in the federal ball court and we can challenge and advocate
there.’ Members of these units saw themselves as being in prime positions to witness
and document inequities in their communities and as having the professional
responsibility to act on them via public education and advocacy.
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The role of public health
When discussing public health’s role in addressing the SDH, the Structural units
reported that they should be disseminating information to the public and to politicians,
participating in advocacy, engaging in community partnerships and capacity building,
and assessing the health impacts of various policies and political decisions. Participants
from the Analytical units stated that they can and ought to be: researching, reporting,
collaborating, and resource-sharing with other units. The Functional units reported their
role as primarily applying knowledge of SDH to their programming, using determinantspecific approaches to identify and serve priority populations, gathering data, and
engaging in strategic partnerships. Some especially illuminating quotations from the
Functional units include the following:
We frankly do not see public health as in a position … to fundamentally change every
aspect of our society, particularly our economic structure… It may be emotionally
satisfying to think that we can go out and restructure Canadian society. It’s self-indulgent,
in my opinion, and it’s not the business we’re in.
It’s a means to an end and so you look at your basket of programs and you say to yourself
“how can I influence this basket of programs by applying SDH thinking?”… I think you
need to be realistic.
This perspective is notably different than that of the Structural units who spoke about
economic structure as a significant determinant of health:
I think that we can and should bring the health equities knowledge that we have and the
voice and the credibility that we have back to other tables – so be it education or municipal
councilors, or whomever – to help them think through decisions that they make and
understand the impact that [these decisions] ha[ve] on health and health equity.
We talk about “how are we going to know when we get there?” you know, 10,
20 years from now. We talk about how should our organization look different in
10 years and how should our community look different in 10 years because with our
work in health equities, we have to change what we do etc., but also our community
should look different at the end of all of this. And not only in “do we see a difference
in health status?” but also “what differences do we see in terms of community
ownership of these issues?”
We believe the work done by all nine PHUs is valuable and important. However, when
it comes to effectively and meaningfully addressing the SDH, we are of the view that
the Functional units and Analytical units face epistemological barriers to further action.
We see these barriers as the result of predominantly biomedical discourses and
understandings of the role of PHUs. These discourses emerged when participants
discussed their training and their views on evidence.
10
J. Brassolotto et al.
Evidence as concrete outcomes vs. process indicators of structural change
A notable difference in worldviews and discourses surfaced when participants made
reference to forms of evidence and outcomes of their SDH efforts. All of the Functional
and two of the Analytical PHUs discussed evidence primarily as concrete outcomes.
For instance:
[w]e want to look at and see outcomes and mostly those are defined in terms of
behaviours. So how many people are smoking? How many people are eating their fruits
and vegetables? So if we look at how health is even defined within public health it is
defined in terms of behaviour and absence of disease.
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So we’ve implemented a program called … which is within the mandate of Healthy
Babies, Healthy Children but much more evidence-based, much more resource intensive
and randomized control level evidence showing its effectiveness in improving outcomes for
mothers and children.
A few participants from Functional and Analytical PHUs claimed that there was not, in
their opinions, sufficient evidence supporting the effectiveness of SDH-based interventions and that was why they had not allocated more time and resources to them. These
individuals expressed greater interest in epidemiology and quantitative measurement
techniques. This view can be seen as reflective of a tension between quantitative and
qualitative research methods, a preference for concrete outcomes over process
indicators, or of an internalized biomedical perspective that treats individuals
independent of their living conditions and social context.
The Functional PHUs point to a lack of quantitative local level data as a reason to
be skeptical or apprehensive about adopting more SDH focused approaches. Given that
PHUs have only recently begun to embrace the SDH, comprehensive local data of this
type is yet to come. Evidence in the form of qualitative data or process indicators tends
to be overlooked by the Functional units.
The Analytical units and the other two Structural units spoke about evidence in
similar terms, but also included process or intermediary indicators. In other words, their
evaluation of initiative success or effectiveness could take different forms. The process
outcome-based approach is often used/useful at earlier stages of a program evaluation
process before concrete outcomes are available. However, given the long-term scale that
is required of most SDH projects, we believe that process indicators can be seen as
legitimate forms of evidence at this point in time. For example, one unit noted:
We’ve had definite success in terms of developing new partnerships. The local poverty
reduction network would be a big one that we’ve supported at the Steering Committee
level, the Planning Committee level, and many of the Work Groups. I think internally, the
health unit has shifted a bit in terms of its comfort in using social determinants as a lens
for analysis. We definitely have Board support now, and we have developed a health equity
checklist for the planning of our programs.
Other participants from Structural units reported that some of the outcomes of their
initiatives to date include: increases in services, programs, and resources available for
previously underserved populations; bringing together community agencies; participation in a Homelessness Partnership Strategy; and involvement in a community initiative
to help move people from Ontario Works to Ontario Disability Support Program
(ODSP). Because this group’s understandings of their PHU role include changing and
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Critical Public Health
11
improving the overall well-being of their communities, their process indicators are also
viewed as beneficial outcomes in and of themselves.
The Structural units do not find it necessary to wait for local data supporting the
effectiveness of SDH initiatives. They reference international research that confirms that
improving people’s living situations is good for their health. However, this does not
mean that Municipal and Provincial governments share this perspective; because of tight
budgets for all PHUs, participants from a variety of units reported feeling pressure from
funders to allocate their resources to acute services that provide more tangible and
timely outcomes, rather than to invest long term in the SDH.
Overall, the units’ comments about outcomes and evidence were consistent with
their diversity in applying SDH to unit activities, staff training, public education, and
advocacy. The units that have adopted a Structural discourse reported greater
involvement in these activities than the units operating with a Functional discourse. We
understand the Analytical units as being on a spectrum between the Functional and
Structural groups. Indeed, after member checking, one of the Analytic units contacted
us to let us know about efforts they were undertaking to better address the SDH and
follow the leadership of the Structural units.
In this context, we see a predominantly positivist understanding as to what
constitutes evidence and outcomes that acts – in our opinion – as a barrier to further
action on the SDH. Perhaps it is time for the public health institution to expand its
thinking about legitimate forms of evidence to include methods and measures that
account for social phenomena that are detrimental to human health and flourishing.
Supports and barriers
When asked about barriers to action on the SDH, many units noted barriers that were
mentioned in the 2010 National Collaborating Centre for the Determinants of Health
(NCCDH) Environmental Scan (NCCDH 2010). These include the lack of clarity
regarding what public health should or could do; a ‘limited’ evidence base; preoccupation with behavior and lifestyle approaches; bureaucratic organizational characteristics;
limitations in organizational capacity; the need for leadership; more effective communication; and supportive political environments. In addition, some participants noted
the impact of limited time, funds, and staffing resources; the challenge of maintaining
the institutional momentum required for addressing the SDH over the long-term;
developing an appropriate urban/rural approach; varying degrees of conceptual buy-in
within and between units; leadership on the SDH coming from the periphery of public
health rather than the center; and silo-ed operations between various organizations and
PHUs.
Despite these barriers, the Structural units were still able to create public awareness
campaigns, engage in coalitions, and allocate resources specifically to address the
sources of health inequalities. We recognize that there are different political
environments and demographics for each unit’s catchment area and that these will
produce some unique challenges. However, these differences should account for the
type of SDH action the units take, not the amount they do.
We believe that the discrepancy in action among PHUs has more to do with the
discourses and beliefs of those in leadership roles than with the resource-based barriers
that they face. It does not appear to us that a lack of understanding of the SDH concept
is the barrier to action, though there certainly is confusion about its reach, application,
and legitimacy. All participants offered definitions that implied understanding of the
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J. Brassolotto et al.
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concept. As a result, all PHUs offer services for low-income and ‘at risk’ populations.
However, the Functional units are apprehensive or uncomfortable with the political
nature of the SDH. One participant from an Analytical unit noted, ‘In fact, [the SDH]
are controversial, right? They are inherently political and that makes it challenging for a
public agency like public health to address. We can’t be overtly political … So the fact
that it’s inherently political has been and continues to be a challenge for us.’ Another
participant spoke about the ‘mismatch between the conservative nature of governments
and the controversy of social change movements.’ These views presume that health
itself is not political, only its social determinants. Additionally, it presumes that the
non-SDH work that the units are currently doing is apolitical. This is problematic
because those who regard health in this way neglect the ways in which health is
inherently and unavoidably tied to politics. As Foucault (1963, 38) claims, ‘The first
task of the doctor is therefore political: the struggle against disease must begin with a
war against bad government.’
Discussion
According to Bachelard (Tiles 1984), our beliefs present limitations insofar as they
narrow our foci and establish presuppositions about what is possible. We should
therefore question even the most seemingly obvious of our beliefs – for instance, asking
ourselves how we define health and the means of promoting it. This question is not a
new one. It is well known that conceptions of health vary by location and over time
(Aggleton 1990; Blaxter 2010). What we are concerned with is how pubic health as an
institution understands and acts to further health. Since 1948, the World Health
Organization has defined health as, ‘[a] state of complete physical, mental and social
well being and not merely the absence of disease or infirmity’ (WHO 1948) and yet
many see material, mental, and social well-being as beyond the scope of health work.
The application of an individualized discourse of health to public health work explains
why we see such challenges to effectively addressing health inequalities.
Similar to Bourdieu’s (1992) notion of reflexivity of the researcher, we all must
examine the ways in which our worldviews and actions are the result of our institutional
training, our own social positions and privileges, and the social structures that we have
internalized. Public health professionals are no exception. As Raphael (2000) points out,
Canadian public health professionals are usually trained in clinical areas that work within
a discourse of individualism. As a result, many of them adopt micro-level understandings
of health. The SDH do not easily lend themselves to this way of thinking because they
focus on the macro and meso level contexts in which people become ill. To more
effectively address SDH, public health workers must first acknowledge and grapple with
the barriers that result from the micro-level ways of thinking that dominate medical
discourse and education. This is not to say that the positivist approach is solely to blame
or that this is merely an issue of qualitative vs. quantitative approaches to health research
and practice. Rather, we take issue with approaches to health – and governance – that
focus on ‘objective,’ uncritical, and noncontextualized data. What is included or
excluded from an inquiry and the ways in which data are collected, presented, analyzed,
and applied are indicative of the priorities, concerns, and ideologies of the researchers
(Armstrong 2001). Bachelard argued that in order for science to progress, we must
liberate it from the restrictions imposed by previous ways of thinking (Tiles 1984).
Similarly, the health equity agenda is dependent upon an epistemological and discursive
shift in regards to the politics of public health.
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According to Bambra, Fox, and Scott-Samuel (2005, 187), health is political
because some social groups have more of it than others, because its determinants are
amenable to political interventions, and ‘[b]ecause the right to “a standard of living
adequate for health and well being” is, or should be, an aspect of citizenship and a
human right.’ In light of substantial academic research on the SDH, the plethora of
reports from reputable organizations, and the fact that public health is funded by
municipal and provincial funds and governed by boards of elected officials, there
should be little debate about the political nature of public health work. One can
reasonably argue that remaining inactive on the SDH is equally as political as becoming
vocal about them. As Tesh (1988, 177) so nicely articulates:
[w]e do not have to choose between a desire to find the “real” causes of disease and an
acceptance of the connection between facts and values. Instead, before we ask after the
cause of disease, we must ask what values should guide the search. Values are public
issues … we need public discussion about the values, beliefs, and ideologies with which
scientists and policy makers begin. This is not an unwarranted intrusion of politics into
science. There is no science un-influenced by politics. This is a plea to get the politics out
of hiding.
Conclusion
In sum, we argue that applying the SDH in public health work is not simply a matter
of differing knowledge amongst Medical Officers and staff members. Nor is it simply a
matter of positivist thinking vs. qualitative thinking. Instead, we believe that inaction on
the SDH results from epistemological barriers that result from internalized discourses
and traditions that treat health as divorced from the societal contexts in which it occurs.
We recognize the challenges faced by PHUs and commend them on their efforts to date.
However, we think that there is ample room for improvement. Below are some
suggestions for how public health might go about overcoming these barriers and
developing a new trajectory for SDH work:
(1) Having explicit discussions at the Ministry and PHU levels about the values and
politics that inform decision-making and programming. Such discussions should
also be incorporated into staff [re]training.
(2) Incorporating research tools that address the politics of health in meaningful but
nonpartisan ways. For instance, developing and implementing a sophisticated
form of Health Impact Assessment (Scott-Samuel, Birley, and Ardern 2001).
Examining the health impact of a particular policy requires acknowledging that
health is affected by policy choices and then presenting the evidence to
governments to help them make more informed decisions. Another method is
incorporating an intersectional lens or framework (Hankivsky 2011) in PHU
research in order to better address social location and marginalization.
(3) Centralizing and institutionalizing SDH leadership. While the importance of
addressing the SDH and health inequalities is emphasized in the Public Health
Standards and Joint Working Group, there are no concrete guidelines provided
for doing so. These ideas are recognized in academic literature, but remain to be
institutionalized. The lack of clear guidelines allows for individual MOHs’
personal constructions of the SDH to take over and guide unit activity. Several
participants accounted for the variation in SDH activity between units by
pointing to differences in MOH interests and priorities. This was also noted as a
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barrier to action in the NCCDH Environmental Scan (2010). Shifting the
responsibility for guidelines and planning to the Ministry and OPHA and
aLPHA levels is one way to overcome this barrier. This would also have the
potential to foster greater consistency and collaboration between the units in
their SDH work. Sharing of best practices between units is advisable, as is
sharing best practices internationally with those who have been more successful
in tackling health inequalities.
(4) Given that tackling health inequalities is featured so prominently in the Public
Health Standards, it seems reasonable that units ought to be held accountable for
taking action to do so. This could take the form of: year-end reports on their
SDH activities, standardizing staff training, and retraining on the SDH, requiring
some form of participation in public education, and more support/encouragement
towards advocacy initiatives and policy advising.
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Advocacy
Maintaining population health in a period of welfare state
decline: political economy as the missing dimension
in health promotion theory and practice
Dennis Raphael1 and Toba Bryant1,2
Abstract: There is increasing recognition in the health promotion and population health fields that the primary determinants of health
lay outside the health care and behavioural risk arenas. Many of these factors involve public policy decisions made by governments that influence the distribution of income, degree of social security, and quality and availability of education, food, and housing, among others. These non-medical and non-lifestyle factors have come to be known as the social determinants of health. In many
nations – and this is especially the case in North America — recent policy decisions are undermining these social determinants of
health. A political economy analysis of the forces supporting as well as threatening the welfare state is offered as a means of both
understanding these policy decisions and advancing the health promotion and population health agendas. The building blocks of
social democracies — the political systems that seem most amenable to securing the social determinants of health – are identified as key to promoting health. Health promoters and population health researchers need to “get political” and recognize the importance of political and social action in support of health. (Promotion & Education, 2006, XIII (4): pp 236-242)
Key words: social determinants of health, health promotion, political economy perspective
Résumé en français à la page 257. Resumen en español en la página 261.
There is increasing recognition in the
health promotion and population health
fields that the primary determinants of
health lay outside the health care and
behavioural risk arenas. Decisions made by
governments in sectors such as income distribution, social security, education, and
housing – summed up in the phrase social
determinants of health – are prime contributors to the realization of health. These
decisions – which in their entirety may be
considered as reflecting commitments to
the welfare state — are heavily influenced
by politics. Yet, there has been a neglect of
the politics of health:
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, Fox, & ScottSamuel, 2005)
In Canada, there is little explicit acknowledgment by health promoters and population health researchers of the importance
of the politics of health. We analyse the role
played by politics in determining health by
considering the forces behind recent public policy decisions that impact upon the
social determinants of health. We focus on
Canada – long perceived as a leader in
health promotion – to illustrate how political forces that influence the size and quality of the welfare state need to be incorpo-
rated into ongoing analyses and practice by
health promoters and population health
researchers there and elsewhere.
We first describe the social determinants
of health and their relationship with public
policy. We then provide a description of how
policy decisions in these sectors undermine
various social determinants of health in
Canada. We apply concepts from the field of
political economy to show how analysis of
the supports for, and threats to, the welfare
state offers a way forward for health promoters and population health researchers to gain
insights into means of researching and influencing public policy in support of health. We
show that the building blocks of social
democracies — the political and economic
systems that seem most amenable to securing the social determinants of health – appear
essential to promoting population health. We
identify what these blocks are, show how
they result from strong social movements,
and provide means of nurturing these social
movements in Canada and elsewhere.
KEY POINTS
• The primary determinants of health are
the living conditions to which people
are exposed.
• The quality of these living conditions
are shaped by political and economic
forces.
• The decline of support for the welfare
state threatens these social determinants of health.
• Political action is required to strengthen
the determinants of population health
and to reduce health inequalities.
Reviewing health promotion and
population health
Health promotion as outlined by the
World Health Organization represents a
commitment to improve health and wellbeing through societal change (MacDonald
& Davies, 1998). Health promotion has its
origins in structural analyses of health
issues derived primarily from the social sciences: Health promotion is the process of
enabling people (and communities) to
increase control over (the determinants of
health), and to improve, their health (World
Health Organization, 1986).
The words in parentheses were proposed as part of the Charter but not
included in the 1986 formulation. In line
with its predominantly structural approach
to promoting health, the Charter outlined
the basic prerequisites for health – or social
determinants of health in modern usage —
of peace, shelter, education, food, income,
a stable ecosystem, sustainable resources,
social justice and equity. One of the five pillars of health promotion action is building
healthy public policy.
Each international health promotion
conference to the present has reaffirmed
the importance of the social determinants
of health and public policy that supports
these social determinants (ACT Health Promotion, 2004).
Population health concepts focus upon
the role societal factors play in determining
the health of populations (Evans, Barer, &
Marmor, 1994). We would expect it to
include analyses of how political, economic,
and social forces shape the availability and
1. School of Health Policy and Management, York University, Toronto, Canada. Correspondence to Dr. Dennis Raphael, School of Health Policy and Management,
Faculty of Health, York University, 4700 Keele Street, Toronto, Ontario M3J 1P3 ([email protected])
2. Department of Sociology, University of Toronto, Toronto, Canada
(This manuscript was submitted on October 16, 2005. Following blind peer review it was accepted for publication on November 2, 2006.)
236
IUHPE – PROMOTION & EDUCATION VOL. XIII, NO. 4 2006
Advocacy
distribution of a range of health supporting
resources – income, housing, social and
health services, etc. — among societal members. Such analyses would provide a context
for understanding the quality of various
social determinants of health. In reality,
most population health approaches place
little emphasis upon political and economic
forces in favour of more immediate situational issues such as social and physical
environments (Raphael, 2004a).
There are therefore, two problems with
the state of health promotion and population health research and action in Canada.
The first is a continuing emphasis upon
individualized approaches to illness prevention related to an ongoing neglect of
structural concepts of health promotion
and population health by governments,
public health and health care workers, and
the media (Raphael, 2003a). This emphasis in Canada and the US is well documented (Raphael, 2006a). The second problem – and the focus of this article – is that
even among health promoters and population health researchers that take a structural view towards these issues, there is a
neglect of the political in the analysis of
public policy decisions that influence
health.
To illustrate, it is one thing to say that
insecure employment is a social determinant of health. It is another to analyze how
societal labour policy and density of unionization influence the prevalence of insecure
employment (Jackson, 2004; Tremblay,
2004). The former is an apolitical approach,
the latter less so. The same questions can
be asked about social determinants of
health such as income and income distribution, support for early childhood development, and providing housing for all
(Langille, 2004). The most developed Canadian approach to population health – the
Canadian Institute for Advanced Research
formulation – is an example of an apoliti-
cal approach to population health determinants (Coburn et al., 2003; Labonte, 1997;
Poland, Coburn, Robertson, & Eakin, 1998).
UK population health research is notably
more policy-oriented – see the Inquiry into
Health Inequalities Report (Acheson, 1998)
and the Evidence Presented to the Inquiry
(Gordon, Shaw, Dorling., & Davey Smith,
1999) — but even this work is seen as
neglecting political and economic forces
driving policy approaches (Bambra et al.,
2005).
The social determinants of
health and public policy
Around the world, governments, health
care authorities, and public health officials
profess a commitment to promoting the
health of citizens. This is especially the case
in Canada where health promotion and
population health are seen as primary
means of assuring the sustainability of the
universal public health care system (Kirby,
2002; Romanow, 2002).
The term social determinants of health
grew out the search by researchers to identify the specific exposures by which members of different socio-economic groups
come to experience varying degrees of
health and illness. While it was well documented that individuals in various socioeconomic groups experienced differing
health outcomes, the specific factors and
means by which these factors led to illness
remained to be identified (Townsend,
Davidson, & Whitehead, 1992). Table 1 provides recent formulations of the social
determinants of health. Overviews of the
concept, recent findings, and an analysis
of emerging issues are available (Marmot &
Wilkinson, 2006; Raphael, 2004b; Raphael,
2006b). All these formulations share a concern with factors beyond those of biomedical and behavioural risk. The SDOH
National Conference list is unique in that it
specifically focuses on the public policy
environment (e.g., income and its distribution) rather than characteristics associated
with individuals (e.g. income and social status) (Raphael, 2004a).
Recent work summarizes the status of
these social determinants of health in
Canada and the US and the pathways by
which these come to influence North Americans’ health (Raphael, 2003b; Raphael,
2004b). Most analyses conclude that the
quality of many social determinants of
health are threatened (Raphael, Bryant, &
Curry-Stevens, 2004). And these threats
result from policy decisions being made by
governments at local, provincial/state, and
federal levels.
Public policy is important for health promotion and population health because it
determines the quality of the social determinants of health. In Canada and elsewhere, there is increasing recognition of the
social determinants of health and how the
formulation and implementation of public
policy influences the quality of these determinants (ACT Health Promotion, 2004). In
Canada, Health Canada and Canadian Public Health Association statements and documents argue the best means of promoting
health and maintaining the sustainability of
the public health care system is through
healthy public policy that strengthens the
societal determinants of health (Canadian
Public Health Association, 2001; Health
Canada, 1999). The establishment of the
World Health Organization’s Commission
on the Social Determinants of Health underscores this emerging recognition (World
Health Organization, 2004).
Canadian public policy and the
social determinants of health
What is the nature of policy change in
Canada that threatens the quality of numerous social determinants of health? The
most obvious manifestation of the public
policy environment is government program
Table 1. Various conceptualizations of the social determinants of health
Ottawa Charter1
Health Canada2
World Health Organization3
SDOH National Conference4
peace
income and social status
social gradient
Aboriginal status
shelter social
support networks
stress
early life
education
education
early life
education
employment and working conditions
food
employment and working conditions
social exclusion
income
physical environments
work
food security
stable eco-system
social environments
unemployment
health care services
sustainable resources
healthy child development
social support
housing
social justice
health services
addictions
income and its distribution
equity
culture
food
social safety net
gender
transport
social exclusion
unemployment and employment
security
1. World Health Organization, 1986 – 2. Health Canada, 1998 – 3. Wilkinson & Marmot, 2003 – 4. Raphael et al., 2004
IUHPE – PROMOTION & EDUCATION VOL. XIII, NO. 4 2006
237
Advocacy
spending as a percentage of Gross Domestic Product (GDP). In 1992 the proportion of
Canadian GDP allocated to program spending began to decline such that spending levels are now at late 1940’s levels (Hulchanski, 2002). Canadian governmental program
spending as a proportion of GDP is now
among the lowest of developed nations
(Bryant, 2006).
Government spending is a key aspect of
how societies differ in their commitment
to social infrastructure and support for citizens across the life-span (Shaw, Dorling,
Gordon & Davey Smith, 1999). Such differences in spending – correlated strongly
with a range of other ideological commitments – provide a context for understanding the environments in which health promotion and population health activities are
situated (Navarro & Shi, 2001). The states of
three key social determinants of health
illustrate current policy environments in
Canada: income and its distribution, housing, and early childhood development.
Income and income distribution
2001 Canadian census data show a disturbing picture of incidence of low income
[similar to what is internationally termed
the poverty rate] among Canadians (16.2%
of individuals and 12.6% of families) (Statistics Canada, 2004b). The low income rate
for female-led single families is 56%. The
incidence of low income is especially high
among residents of major Canadian urban
areas where over 20% of Vancouver families
are so identified, 19% of Toronto families,
and 23% of Montreal families. Thirty percent of children aged 17 years and under
live in conditions of low income in Vancouver and Toronto and 34% in Montreal,
an issue with profound importance for
healthy child development. As pointed out
in numerous national and international
reports, these figures are very high in international comparison (Canadian Population
Health Initiative, 2004).
Much of this has to do with the failure
of income transfer programs to distribute
income and wealth more equitably across
the population as is the case in many other
developed nations. Two volumes provide
very recent analyses of where Canada
stands in relation to other industrialized
nations (Innocenti Research Centre, 2005;
Rainwater & Smeeding, 2003).
Housing
Housing is an important social determinant of health. Spending excessive amounts
of income on housing reduces resources
available for other social determinants of
health such as food and recreation (Bryant,
2004a). The proportion of tenants spending
>30% of total income on rent is very high
238
in Canadian cities (43% in Vancouver, 42%
in Toronto, and 36% in Montreal (Statistics
Canada, 2004a). The proportion spending
>50% — putting them at risk of imminent
homelessness is also strikingly high (22% in
Vancouver, 20% in Toronto, and 18% in Montreal). A significant proportion of urban
dwellers (>8%) live in substandard housing.
A recent report documents how rental costs
have far outpaced income increases among
low-income renters in virtually all Canadian
urban areas (for Vancouver the discrepancy is 45%, Toronto 62%, Montreal data is
not available (Federation of Canadian
Municipalities, 2004).
Healthy child development
Healthy childhood development is a
major social determinant of health. Positive
conditions during childhood not only support child health, but have long lasting
effects on health and the development of
disease during adulthood (Friendly, 2004).
Healthy childhood development is influenced itself by other determinants of health
such as adequate income, housing and food
security. Regulated quality childcare is particularly important in early child development. It has an especially positive impact
on children living in the worst socio-economic conditions. Outside of Quebec, the
availability of regulated childcare for Canadian families is 10%-15% (Friendly, 2004).
Recent analyses document how the
amount of money allocated to regulated
childcare in each of the provinces of interest trails well behind allocations made in
Quebec (Campaign 2000, 2003).
How can we understand the forces that
influence these public policy decisions?
Sadly, the health promotion and population
health literatures offer relatively little to
answer these questions (Bambra et al.,
2005; Coburn, 2000, 2004, 2006; Lynch, 2000;
Muntaner, 1999; Navarro, 2004). The political economy literature helps us fill this gap.
The politics of public policy:
insights from political economy
Political economy is about the relationships among the state, economy, and civil
society (Hofrichter, 2003). As an area of
inquiry, it provides insights that link specific
disciplines such as political science, economics, and sociology (Armstrong, Armstrong, & Coburn, 2001). The issues considered within such a perspective are the
production and distribution of wealth, the
relative political power of social classes that
is related to issues of capital accumulation
and the organization of labour, and the
extent to which society relies extensively on
state control of the distribution of resources
versus market control of such activities
(Esping-Andersen, 1985, 1990, 1999, 2002).
Critical health researchers use these
concepts to argue that how a society produces and distributes societal resources
among its population — that is, its political
economy – are important determinants of
population health (Coburn, 2000, 2004,
2006; Navarro, 2002; Navarro & Muntaner,
2004). These links become clearer as evidence accumulates of how income distribution, employment conditions, and availability of social and health services are
important determinants of population
health (Marmot & Wilkinson, 2006;
Raphael, 2004b).
In the following sections we identify
some of this work and outline political
economy concepts that should be considered by health promoters and population
health researchers. The following has particular relevance for developed nations, but
these concepts are relevant for developing
nations as well. The key concepts are the
welfare state, differences among welfare
states, and the forces that either support
or threaten the quality of the welfare state.
Defining the welfare state
The idea of the modern welfare state
encapsulates many political economy concepts. Canadian political economist Gary
Teeple defines the welfare state 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 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,
2000, p.15).
In Globalization and the Decline of
Social Reform, Teeple links decaying policy
environments to increasing economic globalization (Teeple, 2000). He sees increasing
income and wealth inequalities and the
weakening of social infrastructure within
Canada and elsewhere as resulting from
the ascendance of concentrated monopoly
capitalism associated with corporate globalization. Transnational corporations—
many with home bases in the USA—
actively apply their increasing power to
oppose reforms associated with the welfare state to reduce labour costs. Teeple’s
analysis of the effects of economic globalization is consistent with other work on the
evolution of the Canadian welfare state
(Banting, Hoberg, & Simeon, 1997), the US
situation (Hofrichter, 2003; Zweig, 2000)
and UK developments (Farnsworth, 2004;
Leys, 2001).
For Teeple, the forces that led to the
development of the welfare state at the end
IUHPE – PROMOTION & EDUCATION VOL. XIII, NO. 4 2006
Advocacy
of World War II were strong national identities, the need to rebuild Western
economies, the strength of labour unions
within national boundaries, the perceived
threat to business of socialist political alternatives, and a consensus for political compromise to avoid the boom-bust cycles of
the economy. These led to policies that
supported a more equitable distribution of
income and wealth through social, economic, and political reforms such as progressive tax structures and social programs, and governmental structures that
mitigated conflicts between business and
labour, among others.
Since the mid 1970’s, a fundamental
change in the operation of national and
global economics has occurred. The
increasing ability of transnational corporations to easily shift investments across
the globe pressures national governments
to accede to demands to reverse reforms
associated with the welfare state. International trade agreements weaken national
identities and nationally based labour
unions. Trade is now international, but
unions are nationally based. With such a
power shift, business has less need for
political compromises with labour and
even governments. Worker power and the
ability to negotiate better wages and benefits – clear social determinants of health —
are weakened.
Increased concentration of corporate
and media ownership helps assure that justification for these changes — delivered in
the form of neo-liberal ideology — is the
dominant discourse related to political and
economic processes. Neo-liberalism
argues for having the marketplace determine the distribution of resources and
stresses individualism rather than communalism in public policy. Coburn argues
that neo-liberal ideology has negative
effects upon population health and the
organization of health care (Coburn, 2001,
2004, 2006). Teeple pessimistically argues
that in the face of globalization citizens can
do little to resist deteriorating political, economic, social and health conditions. Local
national governments cannot resist the
power of multinational corporations and
become complicit in these processes. Yet,
the effects of economic globalization are
not identical across nations and some
resist forces that heighten economic
inequality and threaten population health
(Coburn, 2001, 2004, 2006; Mishra, 1990).
Esping-Andersen typology of modern
capitalist welfare states
In spite of increasing economic globalization, nations systematically differ in
their commitments to policy environments
that can strengthen the social determinants
of health. A variety of theoretical frameworks identify how public policy components fit together to define a specific type
of welfare state. Esping-Andersen identified
three worlds of welfare capitalism: social
democratic, conservative and liberal (Esping-Andersen, 1990, 1999). There are many
differences in public policy among these
types. The social democratic welfare states
(Finland, Sweden, Denmark, and Norway)
emphasize universal welfare rights and
provide generous benefits and entitlements. The Conservative welfare states
(France, Germany, Spain and Italy) also
offer generous benefits but provide these
based on employment status with emphasis on male primary bread-winners. The
liberal Anglo-Saxon economies (UK, USA,
Canada, and Ireland) provide only modest
benefits and step in only when the market
fails to provide adequate supports. These
liberal states depend on means-tested benefits targeted to only the least well-off. It is
usually assumed that Canada public policy
is very different from the USA, but it is
closer to the USA in its welfare provisions
that to Social democratic (SD) nations and
Conservative (CN) nations (Bernard &
Saint-Arnaud, 2004).
These concepts are very useful for
understanding why nations differ systematically in their commitment to strengthening the social determinants of health.
Tremblay applies the typology to understand current employment policy in
Canada (Tremblay, 2004) while Friendly
does so in relation to Canadian approaches
to early childhood education care
(Friendly, 2004). Jackson considers how
the typology helps explain the state of
employment and working conditions in
Canada (Jackson, 2004).
These differences among nations help
explain variations in population health.
Navarro and Shi show how nations predominantly governed from 1945-1980 by
social democratic political parties show
greater union density, social security
expenditures, and employment levels
(Navarro & Shi, 2001). They had the largest
public expenditure in health care from
1960-1990, and greatest coverage of citizens
by health care. These nations had high
rates of female employment, and lowest
income inequalities and poverty rates. On
a key indicator of population health – infant
mortality – they had the lowest rates from
1960-1996. Recent work extends these findings to life expectancy with similar advantages associated with SD nations (Navarro
et al., 2004).
These findings suggest that health promoters concerned with the social determinants of health and public policies that
strengthen them need to look to the
IUHPE – PROMOTION & EDUCATION VOL. XIII, NO. 4 2006
nations ruled by social democratic parties
for insights and ideas for promoting health.
What are the political and economic forces
that lead to such approaches to health and
well-being?
The building blocks of health
public policy and population
health
The Canadian public policy situation in
relation to the social determinants of
health compares poorly to many other
developed nations and especially to the
social democratic nations of Denmark, Norway, Sweden, and Finland (Navarro & Shi,
2001). What are the building blocks that
make the social democratic nations receptive to such an agenda? Based on an extensive review of the political economy literature, Bryant identifies the following
political and economic forces that support
health-enhancing public policies (Bryant,
2006):
• The ability of “left” parties to influence
government decision-making (Brady,
2003; Navarro et al., 2004; Rainwater &
Smeeding, 2003).
• This ability is strengthened by adoption
of proportional representation in the
electoral process (Alesina & Glaeser,
2004; Esping-Andersen, 1985).
• High union density and the ability of
unions to provide a united front in negotiating wages and employment conditions (Alesina & Glaeser, 2004; Navarro
et al., 2004).
• Proactive governmental action in developing a range of public policies. These
involve commitments to active labour
policy (training, supports, and unemployment benefits), support for women’s
employment, adequate spending to support families, providing assistance to the
unemployed and those with disabilities,
and providing educational and recreational opportunities (Esping-Andersen,
1990, 1999, 2002).
• Commitment to policies that reduce
social exclusion and promote democratic participation (Navarro et al., 2004).
Navarro and colleagues provide compelling evidence that these policies positively influence health in industrialized
nations (Navarro et al., 2004). These policies can be explicitly conceived as health
promotion and population health activities
and goals. For one outstanding example,
see the documents associated with the
Swedish National Public Health Policy
(Swedish Ministry of Health and Social
Affairs, 2001, 2003; Swedish National Institute for Public Health, 2003). The actual
Swedish National Public Health goals are
summarized in Table 2.
239
Advocacy
Table 2. The eleven target areas of the new Swedish Public Health Policy
The Swedish Government has defined 11 target areas for work in the field of public health:
• Involvement in and influence on society
• Economic and social security
• Secure and healthy conditions for growing up
• Better health in working life
• Healthy, safe environments and products
• Health and medical care that more actively promotes good health
• Effective prevention of the spread of infections
• Secure and safe sexuality and good reproductive health
• Increased physical activity
• Good eating habits and safe foodstuffs
• Reduced use of tobacco and alcohol, a drug and doping-free society and a reduction in the harmful
effects of excessive gambling.
Source: Swedish National Institute for Public Health (2004). Sweden’s New Public Health Policy. Stockholm:
Swedish National Institute for Public Health. Available:
http://www.fhi.se/upload/PDF/2004/English/newpublic0401.pdf.
Conclusion: implications
for health promotion
and population health
Recent scholarship is placing differences in the quality of social determinants
of health – and resultant population health
— within these explicitly political perspectives (Coburn, 2000, 2004, 2006; Navarro,
2002; Navarro & Muntaner, 2004). Raphael
and Bryant have compared the determinants of women’s health in Canada with
that seen in the UK, USA, Sweden and Denmark (Raphael & Bryant, 2004). Jackson
(2002) has compared Canada with the USA
and Sweden. These differences in national
indicators have clear ideological and political antecedents (Navarro & Shi, 2001).
Health promotion –and population
health– theory and research identifies the
processes by which societal determinants
influence health and means by which these
determinants can be influenced by citizens.
However, political and economic forces
shape the quality of these societal determinants and state receptivity to these ideas
(Bryant, 2002; Bryant, 2004b, 2006). And it
is clear there are political dimensions that
underlie the conditions that support population health.
While Canada is a liberal welfare state,
members of the liberal welfare state club
are not monolithic in policy approaches.
Canada developed a universal healthcare
system while the USA did not. The UK
embarked upon a systematic policy initiative to reduce child poverty while Canada
has not. Nations systematically shift their
basket of public policies to become outliers
within their welfare state group. This suggests room for policy action in support of
health.
There are two issues to be faced by
health promoters and population health
researchers in Canada and elsewhere. The
first is to confront the continued dominance
240
of lifestyle and behavioural approaches to
health promotion among practitioners and
the understandings held by the media and
public concerning the sources of health
and illness. The second problem is to move
those who are looking at broader issues
such as the social determinants of health to
take an explicitly political approach to
understanding health determinants as
means of moving the health agenda along.
Such a political approach would recognize that the social democratic nations create the conditions necessary for health.
These conditions include equitable distribution of wealth and progressive tax policies that create a large middle class, strong
programs that support children, families,
and women, and economies that support
full employment: For those wishing to optimize the health of populations by reducing
social and income inequalities, it seems
advisable to support political forces such as
the labor movement and social democratic
parties which have traditionally supported
larger, more distributive policies (Navarro &
Shi, 2001).
And while it is clear that Canadian public policy has been moving more and more
towards a neo-liberal US-type model, reversals are possible. Indeed, the UK reversed
twenty years of harsh conservative rule
through election in 1997 of a Labour government that is addressing health inequalities. Similarly, New Zealand took a similar
neo-liberal course during the 1990s, but then
reversed direction. Ideologies are malleable
and national social policies can be changed.
There are various means by which these
shifts can be assisted (Raphael & CurryStevens, 2004). Two primary arenas for
action – among others – for health promoters and population health researchers are
advocacy and community-based action.
Each is considered briefly in turn.
Advocacy
Advocacy is about influencing governments to enact policies in support of health.
This requires that health promoters and
population health researchers be more
explicit concerning their analysis of the role
governments play in influencing the social
determinants of health. It also requires
explicit recognition of the role political and
economic forces play in shaping these policies and the need to confront these sources
of power and influence when they threaten
health and well-being. Once these forces
are acknowledged, health promoters and
population health researchers must go public with these conclusions to influence public policy (Raphael & Bryant, 2006). Numerous Canadian advocacy organizations
working on poverty alleviation, social justice, and fair social assistance rates and
wages already draw upon these findings in
support of their efforts (Campaign 2000,
2004; Curry-Stevens, 2003; National Council
of Welfare, 2004). Closer alliances with
these organizations need to be forged.
Community-based education and research
At the community level citizens can be
involved in these activities through a
process of participatory policy research. In
this approach citizens are asked to consider
decisions that governments and agencies
make that are influencing their health and
well-being. It is similar to conventional participatory research with the exception that
the focus of community members is clearly
directed towards public policy rather than
local community issues. Again, the main
task is to highlight the role that political and
economic forces play in shaping the social
determinants of health and help support
community action in defense of healthy
public policy (Bryant, Raphael, & Travers,
in press). Collaborative efforts between
health promoters and population health
researchers and citizens have taken place
(Bryant et al., 2001; PATH Project, 1997;
Raphael et al., 2001). More needs to be
done.
The best means therefore of promoting
health and improving population health
involves Canadians –and others– being
informed about the political and economic
forces that shape the health of a society.
Once so empowered, they can consider
political and other means of influencing
these forces. Health promoters and population health researchers need to “get political” and recognize the importance of political and social action in support of health.
This seems a rather daunting task, but one
that holds the best hope of promoting the
health of citizens in Canada and elsewhere
(Bryant, Raphael & Rioux, 2006).
IUHPE – PROMOTION & EDUCATION VOL. XIII, NO. 4 2006
Advocacy
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European Office. Viewed n.d.
<http://www.who.int/hpr/NPH/docs/ottawa_chart
er_hp.pdf>
World Health Organization (2004) WHO to
establish commission on social determinants of
health. WHO. Viewed n.d.
<http://www.who.int/social_determinants/en/>
Zweig, M. (2000) The working class majority:
America’s best kept secret. Cornell University
Press, Ithaca.
242
IUHPE – PROMOTION & EDUCATION VOL. XIII, NO. 4 2006
Why are Canadians not being told the truth about disease?
http://www.thespec.com/opinion-story/4405922-why-are-canadians-not-b...
Why are Canadians not being told the truth about disease?
Hamilton Spectator | Mar 11, 2014
It is now widely known, at least among the research and public health
communities, that the primary factors that shape health are not the so-called
"lifestyle" factors of diet, physical activity and tobacco use, but rather the
living conditions — or social determinants of health — individuals experience
throughout their life course (see the Code Red Series in the Spectator).
For example, material and social deprivation — or in common parlance,
poverty — during early childhood are strong predictors of the incidence of
cardiovascular disease, adult-onset diabetes, respiratory disease and some
cancers during adulthood. Even low birth weight — itself related to mothers
living in poverty — is a significant predictor, even better than "lifestyle" factors,
of cardiovascular disease and adult-onset diabetes in later life.
Living conditions sicken and kill us faster than lifestyle choices
But it is not just these major killers that are related to adverse living
conditions. Remarkably, deprivation over the life course is strongly related to
the incidence of such diverse afflictions as Alzheimer's disease, arthritis, emphysema, kidney and lung disease,
osteoporosis, lupus and mental health problems such as depression and suicide. Unemployment and poor working
conditions are important predictors of the incidence of cardiovascular disease. And it is not just the poor — but also the
middle class — who are subject to experiencing health-threatening living conditions and the associated stress that causes
disease.
Yet, if we followed advice from major disease associations such as the Heart and Stroke Foundation, the Canadian Diabetes
Association, the Canadian Cancer Society and others, we would have no sense that these living conditions play any direct
role in the incidence of the major life-ending diseases. Additionally, Canadians are assured that these major diseases and a
host of other afflictions can be averted through the adoption of "healthy lifestyle choices." Even more importantly, Canadians
are assured the solutions to illness will come from medical and behavioural research rather than public policies that improve
the quality of life of Canadians. The table below identifies some of the disease associations that should be concerning
themselves with Canadians' living conditions.
Canadians are rightly confused: Eating fruits and vegetables are sometimes found to be related to cardiovascular disease
but not cancer, sometimes cancer, but not cardiovascular disease, sometimes both, sometimes neither.
Not only does traditional disease association messaging ignore the direct role of adverse social determinants of health, it
usually downplays how social determinants of health even allow such "healthy lifestyle choices" to be made by those most
vulnerable to these diseases. Even more telling is the lack of consistent research evidence that these "healthy lifestyle
choices" are even reliable predictors of the onset of these diseases. Canadians are rightly confused: Eating fruits and
vegetables are sometimes found to be related to cardiovascular disease but not cancer, sometimes cancer, but not
cardiovascular disease, sometimes both, sometimes neither.
Disease association authorities need to be told by the public in general and by their donors in particular to pay attention to
these findings. And even when the social determinants of health are not the primary causes of disease — such as the case
of genetically determined diseases — Huntington's disease or muscular dystrophy are two examples — the quality of the
social determinants of health profoundly shapes the lives of those afflicted and their families.
When experiencing the presence of a life-threatening or disabling disease — regardless of the causes — Canadian
individuals and families are increasingly faced with deteriorating quality health and social services, lack of financial supports
and difficulty achieving secure and well-paying employment, among others. At the very minimum, disease associations
should recognize that deteriorating social determinants of health are not good for families facing the presence of the
illnesses with which these organizations are concerned. Ideally, they would call upon policy-makers to improve the quality of
life of the most vulnerable Canadians. Until they do so, donors should carefully consider where their money can best be
used.
Dennis Raphael, PhD, is a professor of health policy and management at York University in Toronto. He is author of Social
Determinants of Health: The Canadian Facts, which can be downloaded at no cost from http://thecanadianfacts.org.
Major disease associations that must be encouraged to adopt a broader social determinants of health perspective
Alzheimer Society of Canada*
1 of 2
12/8/2014 9:40 AM
Why are Canadians not being told the truth about disease?
http://www.thespec.com/opinion-story/4405922-why-are-canadians-not-b...
Amyotrophic Lateral Sclerosis Society of Canada
The Arthritis Society*
The Brain Injury Association of Canada*
Canadian Breast Cancer Foundation
Canadian Cancer Society*
Canadian Cystic Fibrosis Foundation
Canadian Diabetes Association*
Canadian Foundation for AIDS Research*
Canadian Hospice Palliative Care Association
Canadian Liver Foundation*
Canadian Lung Association*
Canadian Mental Health Association*
Canadian Orthopedic Foundation
Crohn's and Colitis Foundation of Canada
Easter Seals Canada
The Foundation Fighting Blindness — Canada
Heart and Stroke Foundation of Canada*
Huntington Society of Canada
Kidney Cancer Canada
Lupus Canada*
The Kidney Foundation of Canada*
The Mood Disorders Society of Canada*
Muscular Dystrophy Canada
Multiple Sclerosis Society of Canada
Osteoporosis Canada*
Ovarian Cancer Canada
Parkinson Society Canada
SMARTRISK (Injury Prevention)*
Spina Bifida and Hydrocephalus Association of Canada
•Illnesses strongly associated with adverse living conditions
2 of 2
12/8/2014 9:40 AM
Dealing with symptoms, not disease
http://www.thespec.com/opinion-story/4612455-dealing-with-symptoms-n...
Dealing with symptoms, not disease
Hamilton Spectator | Jul 04, 2014
I recently wrote a piece in The Hamilton Spectator chastising the major
disease associations for neglecting research findings that adverse living and working conditions are the primary causes of
chronic disease during adulthood (Why are Canadians not being told the truth about disease?, March 11, 2014). I pointed
out that decades of research indicated adverse living conditions — especially during childhood — are much better predictors
of chronic diseases such as heart disease and stroke and adult-onset diabetes than the behavioural risk factors we hear so
much about.
In response to that piece I was invited to meet with staff from the Heart and Stroke Foundation in Toronto. Reviewing their
recent materials, I pointed out that the Foundation continues to neglect the direct effects upon health of adverse living
conditions — especially poverty — and maintain the mantra of how eating fruits and vegetables, exercising and giving up
tobacco would guarantee a heart disease-free future. They do so in spite of the evidence these behaviours play far less of a
role in the onset of heart disease and stroke than adverse living conditions.
I was assured the Foundation is working hard to integrate findings concerning the importance of living conditions into its
future campaigns. I pointed out that I received similar assurance 12 years ago when I had a similar meeting at the
Foundation. I left the meeting puzzled as to why it was so difficult for this organization — and other disease organizations —
to take seriously the issues I and others have been raising for the past 20 years. I began to gain insight into why this might
be the case by taking a look at its current board of directors (www.heartandstroke.com/site/c.ikIQLcMWJtE/b.7501641
/k.745D/Our_Board_of_Directors.htm ).
Before continuing, I would point out that my own and others' research has identified how growing corporate influence and
power in Canada had skewed public policy-making away from the provision of the conditions necessary for health over the
past three decades. These developments have also changed how health promotion and disease prevention campaigns are
developed and implemented.
Until recently, Canada had a well-earned reputation for considering health promotion and disease prevention as involving a
wide range of activities that provide the conditions for health through the making of healthy public policy, enabling citizens to
take control over the determinants of health, and strengthening communities in addition to the promotion of healthy
behaviours. It also stressed how the provision of adequate income, housing and good employment and working conditions
were absolutely essential for health. My work and others document how increasing corporate influence and power has
shifted public policy away from providing Canadians with the prerequisites of health and skewed health promotion and
disease prevention toward a sole emphasis on promoting healthy behaviours while ignoring broader issues of social and
economic security.
Back to the issue at hand, I was disturbed to see that the overwhelming proportion of board members of the Heart and
Stroke Foundation come from highly successful corporate careers in finance and investment and corporate management.
Given that the corporate and financial sectors have lobbied hard during the past three decades to shift Canadian public
policy away from providing Canadians with economic and social security, it becomes clear why the Heart and Stroke
Foundation would hesitate to raise issues of how growing income and wealth inequality, shifting of tax burdens from the
wealthy and corporate sector to the middle class and poor, and the shrinking of the social safety net increases Canadians'
risk of experiencing heart disease and stroke.
Given the composition of the board of directors can we expect that such directed institutions will lend their voice to the call
for public policy that will reduce the economic and social insecurity that causes so many Canadians to develop heart
disease and stroke? I think not. Maybe it is time to have a broader range of Canadians appointed to the boards of disease
associations. Considering these chronic diseases — and this is especially the case for heart disease and stroke —
disproportionately afflict the poor and insecure, maybe members of the board of directors should also include these
Canadians in addition to the wealthy and secure? Is that too much to ask?
Dennis Raphael, PhD, is a professor of health policy and management at York University in Toronto. He is author of Social
Determinants of Health: The Canadian Facts, which can be downloaded at no cost from thecanadianfacts.org.
1 of 1
12/8/2014 9:42 AM
THE PARAMETERS OF CHILDREN’S HEALTH:
KEY CONCEPTS FROM THE POLITICAL ECONOMY OF HEALTH LITERATURE
Dennis Raphael
Abstract: In this article key aspects of a political economy approach to addressing
children’s health are identified. These aspects include a concern with how power and
influence of various societal sectors come to shape the social determinants of children’s
health through the creation of specific forms of public policy. These public policies affect
children’s health through two primary pathways: shaping the social determinants of
parents’ health and shaping specific social determinants of children’s health. These
approaches cluster such that a worlds of welfare states approach can illuminate specific
aspects of Canada’s approach to creating public policies that shape children’s health.
Implications for promoting children’s health that derive from a political economy
approach are presented.
Keywords: social determinants of health, children’s health, political economy, public
policy
Dennis Raphael, Ph.D. is a Professor of Health Policy and Management at the School of Health
Policy and Management at York University, 4700 Keele Street, Toronto, Ontario, Canada, M3J
1P3. Telephone: (416) 736-2100, extension 22134. E-mail: [email protected]
1
Political economy models of society are concerned with how political ideology and
power and influence operate through economic and political systems to create public policy that
distributes material and social resources (Bryant, 2009). Central to this perspective is the idea
that politics and economics are intrinsically related and this dynamic shapes public policy
development. As applied to understanding health and the determinants of health, a political
economy approach draws a direct link between these societal structures and processes, the
making of public policy that shapes the social determinants of health, and the health of the
overall population and specific groups classified according to social class, gender, age, and race
among other characteristics (Coburn, 2010).
There are a variety of political economy models and in this paper I consider the insights
that a critical materialist approach offers (Coburn, 2010). Such an approach sees public policies
that shape health policies as resulting from the organization of society which is itself shaped by
the relative balance of power and influence among competing societal sectors. As a result,
improving health involves acting upon these societal dynamics (Raphael, 2014a). Children’s
health is directly influenced by the public policies that result from these structures and processes
in two ways. The first pathway is through public policy that shapes the living and working
conditions of their parents. The second pathway is through public policies that directly affect
children and their development. Since jurisdictions differ in how their economic and political
systems operate, it is not surprising there are differences in the overall health of children from
different jurisdictions (Innocenti Research Centre, 2013).
Figure 1 provides a model of the structures and processes that shape children’s health
identified by a critical materialist political economy approach. In the following sections, I
describe each of the model’s components and their importance for children’s health. For ease of
presentation, I begin with the most concrete aspects of the model, children’s health, and then
work my way up to the more abstract concepts of the political economy approach. The purpose is
to provide means of making sense of the material contained in this special issue on the political
economy of children’s health.
2
Children’s Health
Children’s health is usually considered in terms of physical, mental, and social well-being.
Physical health includes measures of mortality such as infant mortality and mortality prior to age
18, and measures of morbidity such as the presence of various diseases or the occurrence of
injury. It can also include functional health or health-related behaviours such as diet or physical
activity. Mental health includes measures of childhood psychological functioning and coping
mechanisms as well as the presence of disorders. Social health includes measures of school
performance and academic achievement, quality of peer relationships, as well as delinquency.
3
Another set of indicators concerns the extent of inequalities among children in a jurisdiction on
these and similar measures.
The Innocenti Research Centre provides indicators of health and well-being for wealthy
developed nations that include many of these and additional indicators that capture the broad
dimensions of children’s health and well-being. Table 1 provides some of these that were
provided in a recent report (Innocenti Research Centre, 2013). Analyses are also available for
extent of injuries (Innocenti Research Centre, 2001a), teenage births (Innocenti Research Centre,
2001b), mortality by abuse and neglect (Innocenti Research Centre, 2003) and extent of
inequalities among children in health and well-being (Innocenti Research Centre, 2010).
Table 1
How Child Well-being is Measured
Dimensions
Components
Dimension 1:
Monetary deprivation
Material well-being
Material deprivation
Dimension 2:
Health and safety
Health at birth
Indicators
Relative child poverty rate
Relative child poverty gap
Child deprivation rate
Low family affluence rate
Infant mortality rate
Low birthweight rate
Preventive health services
Overall immunization rate
Childhood mortality
Child death rate, age 1 to 19
Participation
Participation rate: early childhood
education
Participation rate: further education,
age 15 to 19
NEET rate (% age 15 to 19 not in
education, employment or training)
Dimension 3:
Education
Average PISA scores in reading,
maths and science
Being overweight
Eating breakfast
Eating fruit
Taking exercise
Achievement
Dimension 4:
Behaviours and risks
Health behaviours
Risk behaviours
Exposure to violence
4
Teenage fertility rate
Smoking
Alcohol
Cannabis
Fighting
Being bullied
Dimension 5:
Housing and
environment
Housing
Environmental safety
Rooms per person
Multiple housing problems
Homicide rate
Air pollution
Source: Innocenti Research Centre (2013). Child Well-being in Rich Countries: A Comparative
Overview, Box 1, p. 5. Florence: Innocenti Research Centre.
The Centre’s 2013 Report Card examined children’s well-being along five dimensions
(Innocenti Research Centre, 2013). Canada’s overall rank was 17th of 29 wealthy developed
nations. It ranks 15th in material well-being, 27th in health and safety, 14th in education, 16th in
behaviours and risks, and 11th in housing and environment. Numerous analyses show these
health and wellness rankings to be strongly determined by children and their families’ living and
working conditions. These factors have come to be called the social determinants of health
(Mikkonen & Raphael, 2010). The next section explores how these social determinants manifest
within the family context.
Familial Health Determinants
Families’ living and working conditions differ within and across jurisdictions. Overall
conditions are more favourable in some nations than others (e.g., poverty rates) and variation is
greater in some nations than others (e.g., extent of income inequality) (Innocenti Research Centre,
2012). Both sets of measures are related to children’s health outcomes. The most obvious
manifestations of these differences – important because they predict children’s health outcomes –
are familial material circumstances, psychosocial factors including stress experienced by families
and coping mechanisms, and health-related behaviours (Benzeval, Judge, & Whitehead, 1995).
Material circumstances refer to the concrete exposures to health strengthening and health
threatening conditions that are associated with income and wealth. Income and wealth are
important as these provide access to a wide range of material goods such as housing, food, and
learning and recreational opportunities, among others. In addition, since income and wealth are
associated with spatial segregation, differences manifest in quality of neighbourhoods and the
opportunities for education and recreation associated with these neighbourhoods. The amount of
crime and threat are also associated with material circumstances (Raphael, 2011).
These material exposures can have both immediate and long-lasting effects upon
children’s health. The latter have been termed latency effects and can result from biological
processes during pregnancy and early childhood associated with poor maternal diet and
experience of stress (Hertzman & Frank, 2006). Early childhood experiences, such as the
experience of numerous infections or exposures to adverse housing conditions, also appear to
have immediate and later health effects regardless of later life circumstances. As one example,
adverse childhood living circumstances are excellent predictors of cardiovascular disease and
adult-onset diabetes during later adulthood (Raphael et al., 2003; Raphael & Farrell, 2002).
In response to these material circumstances, families experience differences in a number
of psychosocial variables such as stress, sense of efficacy and control, and self-identity. These
5
come to shape parents’ and children’s health in both the present and future (Lynch, Kaplan, &
Salonen, 1997). Psychological health-related effects may also result from early experience. A
general non-adaptive reaction to stress may be established during early childhood as well as a
general sense of hopelessness and lack of control, both of which are important determinants of
health (Irwin, Siddiqui, & Hertzman, 2007).
The third familial determinant of health is how experience of varying circumstances and
the levels of stress associated with these circumstances lead to the adoption of health-supporting
or health-threatening behaviours. In the latter case, these behaviours can be seen as coping
responses to adverse life circumstances. Numerous Canadian studies show that children raised in
familial conditions of low income, unemployment or precarious employment, poor quality
housing, and food insecurity are more likely to take up risk-related behaviours such as smoking,
excessive alcohol consumption, and lack of physical activity (Health Canada, 1999). Similarly,
adoption of carbohydrate-dense diets and weight gain are also seen as means of coping with
difficult circumstances (Wilkinson, 1996). The troika of material circumstances, psychosocial
processes, and behavioural responses are shaped by what are called the social determinants of
health.
Social Determinants of Health
Social determinants of health are the specific economic and social conditions that shape
the health of individuals, communities, and jurisdictions as a whole (Mikkonen & Raphael,
2010). Canadian researchers have outlined 14 of these: Aboriginal status, disability status, early
life, education, employment and working conditions, food security, gender, health services,
housing, income and income distribution, race, social exclusion, social safety net, and
unemployment and employment insecurity (Raphael, 2009). Social determinants such as
Aboriginal status, disability status, gender, and race can be thought of as social locations that do
not, by themselves, lead to differing health outcomes, but interact with societal conditions to
create particular health outcomes.
An emphasis upon societal conditions as determinants of health contrasts with the
traditional health sciences and public health focus upon biomedical and behavioural risk factors.
Since a social determinants of health approach sees the mainsprings of health as being how a
society organizes and distributes economic and social resources, it directs attention to economic
and social policies as means of improving it. It also requires consideration of the political,
economic, and social forces that shape their distribution amongst the population.
Distribution of the Social Determinants of Health
Much social determinants of health research simply focuses on determining the
relationship between a social determinant of health and health status, so a researcher may
document, for example, that lower income is associated with adverse health outcomes among
parents and their children. Or a researcher may demonstrate that food insecurity is related to poor
health status among parents and children, as is living in crowded housing, and so on. This
approach says little about how these poor-quality social determinants of health come about
(Raphael & Bryant, 2002).
6
Social determinants of health do not exist in a vacuum. Their quality and availability to
the population are usually a result of public policy decisions made by governing authorities
(Graham, 2004). As one example, consider the social determinant of health of early life. Early
life is shaped by availability of sufficient material resources that assure adequate educational
opportunities, food, and housing among others (Raphael, 2014b). Much of this has to do with the
employment security of parents and the quality of their working conditions and wages. The
availability of quality, regulated child care is an especially important policy option in support of
early life (Esping-Andersen, 2002). These are not issues that usually come under individual
control. A policy-oriented approach places such findings within a broader policy context. The
next section considers the public policies that shape the quality and distribution of the social
determinants of children’s health.
Public Policy
The term social policy is usually used to refer to issues that have direct relevance to
social welfare, such as social assistance, child and family policy, and housing policy, but the
factors that shape the health of children are affected by a wide range of other public policies that
include labour and employment, revenue, and tax policies, among others. These public policy
activities are courses of action or inaction taken by public authorities – usually governments – to
address a given problem or set of problems (Briggs, 1961). Governments constantly make
decisions about a wide range of issues, such as national defence and the organization and
delivery of health, social, and other services. The decisions that are the special concern here
determine how economic and social resources are distributed among the population.
Governments influence this distribution by establishing taxation levels, the nature and
quality of benefits – whether these benefits are universal or targeted – and how employment
agreements are negotiated. Governments are also responsible for establishing housing policies,
maintaining transportation systems, enacting labour regulations and laws, and providing training
related to employment and education.
Table 2 shows the interconnections between public policy issues and the social
determinants of health in general and children’s health in particular. These public policy
decisions that provide equitable or inequitable distribution of the social determinants of health do
not exist in a vacuum. They reflect the operation of three primary societal systems: the economic,
political, and ideological.
7
Table 2
Social Determinants of Children’s Health and their Public Policy Antecedents
_____________________________________________________________________________
Early life
Wages that provide adequate income inside the workforce, or assistance
that does so for those unable to work, affordable quality child care and
early education, affordable housing options, and responsive social and
health services
Education
Support for adult literacy initiatives, adequate public education spending,
tuition policy that improves access to post-secondary education
Employment and
working conditions
Training and retraining programs (active labour policy), support for
collective bargaining, enforcing labour legislation and workplace
regulations, increasing worker input into workplace environments
Food security
Developing adequate income and poverty-reduction policies, promoting
healthy food policy, providing affordable housing and affordable child
care
Health services
Managing resources more effectively, providing integrated,
comprehensive, accessible, responsive and timely care
Housing
Providing adequate income and affordable housing, reasonable rental
controls and housing supplements, providing social housing for those in
need
Income and its
distribution
Fair taxation policy, adequate minimum wages and social assistance
levels that support health, facilitating collective bargaining
Social exclusion
Developing and enforcing anti-discrimination laws, providing ESL and
job training, approving foreign credentials, supporting a variety of other
health determinants for newcomers to Canada
Social safety net
Providing economic and program supports to families and citizens
comparable with those provided in other wealthy developed nations
Unemployment and
job insecurity
Strengthening active labour policy, providing adequate replacement
benefits, provisions for part-time benefits and advancement into secure
employment
_____________________________________________________________________________
8
Economic, Political, and Ideological Systems
Economic system
The economic system both creates and distributes economic resources amongst the
population. Since all economic systems in wealthy developed nations are capitalist, market
principles – of which profit-making is paramount – have the potential to drive their operations
(Coburn, 2010). Some of the main features associated with the market process that impact the
health of children are wage structures their parents experience, benefits available through work,
working conditions, and vacation time of their parents, among others (Jackson, 2009).
It has long been recognized, however, that without State intervention in the operation of
the market economy, the distribution of economic resources becomes skewed in favour of the
wealthy and powerful (Macarov, 2003). In addition, some structures and processes necessary for
societal functioning may not be made available at all by the economic system. The welfare state
arose because the economic system itself is not capable of dealing with provision of basic
societal resources such as education, health care, housing, and other programs and services that
provide citizens with resources necessary for well-being (Teeple, 2000).
What are some of the influences upon how the market economy operates and distributes
economic resources amongst the population? Political economists speak of the power and
influence of societal groups such as the business and corporate sectors, the organized labour
sector, and civil society (Coburn, 2010). These sectors influence the political system that can
manage the economic system through public policy-making (see below). The business and
corporate sector has power and influence over the economic and political systems through its
control of many economic levers such as its ability to move and invest capital (Brooks & Miljan,
2003).
The organized labour sector usually supports greater redistribution of economic resources
through higher taxation on the business and corporate sector, stronger government management
of aspects of the workplace such as wages and benefits, and greater provision of supports and
benefits through government programs funded by taxes (Navarro et al., 2004). The civil society
sector gains power and influence to influence the economic system from its ability to influence
public opinion and shape public policy through networks of agencies, organizations, and other
non-governmental institutions (Brady, 2009).
Political system
The political system consists of the organization of the State and its collection of laws
and regulations. The political structure can intervene in the operation of the economic system by
enacting laws and regulations that affect employment practices and by having governments
provide supports and services to the citizenry through programs and benefits. These supports,
benefits, and services come from the enactment of corporate and personal taxes, which are
usually progressive in that greater proportions of taxes accrue from those with higher incomes.
9
There are many specific areas where State activity impacts upon the social determinants
of the health of children. Working through the making of public policy, these areas include
income and income distribution, employment and job insecurity, working conditions, housing
and food security, and the availability of health and social services, among others (Mikkonen &
Raphael, 2010). These social determinants of health indirectly affect the living conditions – and
health – of children by shaping the living conditions of their parents; in other cases the effect is
more direct. One example of a direct effect would be in the provision of differing forms of child
care to families (Friendly & Prentice, 2009). Child care can be provided as a universal right or as
a commodity that must be purchased. Another instance would be whether college and university
education is provided to all or must be bought.
Ideological system
Finally, the means by which economic and political systems distribute resources are
usually justified by dominant discourses on the nature of society and the different roles that the
State, Economic Marketplace, and Family should play in providing economic and social security.
These different discourses usually involve dichotomies such as socialism versus liberalism,
social justice versus economic justice, and communal versus individual responsibility for wellbeing.
The socialism versus liberalism dichotomy is well described by Wiktorowicz (2010). She
points out that liberalism emphasizes personal freedom whereby individuals can pursue their
own interests free of coercion by government. Governments should intervene only to assure the
free market distributes basic resources. In contrast, socialism distrusts the results provided by the
market economy and emphasizes that assets should be collectively owned with the benefits of the
economic system distributed equitably across the population. In essence, liberalism is concerned
with equality of opportunity, while socialism is concerned with equality of result. Anglo-Saxon
nations tend towards liberalism, European nations towards socialism.
The social justice versus economic justice dichotomy is concerned with whether there is
an inherent right for everyone to receive the benefits available in a society or whether individuals
are entitled to only those earned through their participation in the market economy (Hofrichter,
2003). Not surprisingly, this dichotomy is related to the liberalism versus socialism dichotomy.
The business sector usually espouses the economic justice view while the labour sector and
frequently the civil society sector favour the social justice view. Again, Anglo-Saxon nations
tend towards the economic justice approach while European nations lean towards the social
justice view.
Related to both of these dichotomies is the issue of broad concepts of society and how
these lead to action and change in a society. Stone (2002) contrasts individualized (market)
versus communal (polis) approaches. In the market conception of society, the emphasis is on the
individual and the primary motivation for action is self-interest. Society is inherently competitive
and the source of change is the exchange of material goods through the market economy.
By contrast, in the polis view of society the focus is on the community and there is a
strong role for public interest in addition to self-interest. While there is competition among
10
individuals there is also cooperation in the pursuit of common goals. The building blocks of
social action are groups and organizations. The building blocks of change are ideas and alliances
rather than material exchanges among individuals. Finally the polis model sees the pursuit of the
public interest as a source of change.
More recently, analysis had been made of the impact of neo-liberalism as a societal
doctrine that shapes the distribution of resources. Neo-liberalism is an ideology that believes that
governments should withdraw from managing the economy thereby ceding more power and
influence to the business and corporate sector (Coburn, 2010). This has been seen as leading to
the skewing of the distribution of the social determinants of health and threatening the health of
citizens in general and children in particular.
The ideological system is especially important because it shapes the means by which the
population comes to understand these issues. If the general public is convinced of the validity of
neo-liberal arguments about the primacy of the marketplace over the State, then little can be
expected to come from public policies that will manage the economy in the service of children’s
health. Ideological beliefs of the public are important determinants of whether a jurisdiction
comes to address the social determinants of health through public policy action. These ways of
thinking about society and the responsibilities for providing citizens with economic and social
security come together with the operation of the political and economic systems to shape what
has been called the differing worlds of welfare states.
Form of the Welfare State
These three aspects – the economic, political, and ideological – come together to create
distinctive forms of governance that have come to be called the worlds of welfare approach. In
The Three Worlds of Welfare Capitalism, Esping-Andersen (1990) identified three welfare state
regimes: the Social Democratic, Conservative, and Liberal. As a political economy model, it
conceives ideas and institutions – and the public policy that flows from these – as evolving from
societal arrangements influenced by historical traditions. The central features of welfare regimes
are their extent of social stratification, decommodification, and the relative role of the State,
Market, and Family in providing economic and social security to the population. Importantly, the
State’s role is influenced by class mobilization, in that the loyalties of the working and middle
classes determine the forms by which these systems operate. These differing patterns of loyalties
have contributed to the formation and maintenance of these welfare state regimes.
The Social Democratic welfare state (e.g., Denmark, Finland, Norway, and Sweden) has
been strongly influenced by social democratic ideology and politics. Its concern with Equality
outlines a key role for the State in addressing inequality and providing the population with
various forms of economic and social security (Saint-Arnaud & Bernard, 2003). Its provision of
programs and supports on a universal basis is consistent with its goal of reducing social
stratification and decommodifying the necessities of life. In essence, the Social Democratic
welfare state strives to provide the means by which one can live a decent life independent of
employment market involvement.
11
The Conservative welfare state (e.g., Belgium, France, Germany, and the Netherlands) is
distinguished by its concern with maintaining Stability (Saint-Arnaud & Bernard, 2003).
Historically, governance is by Christian Democratic parties that maintain many aspects of social
stratification, a moderate degree of decommodification of societal resources, and an important
role for the Family in providing economic and social support. The Church played a significant
role in its development. An underdeveloped form of the Conservative welfare state – the Latin
(e.g., Greece, Italy, Portugal, and Spain) – has been added to Esping-Anderson’s three regimes
by Saint-Arnaud and Bernard (2003).
Finally, the emphasis of the Liberal welfare state (e.g., Australia, Canada, the United
Kingdom, and the United States) is on Liberty and is dominated by the Market and ruled by
generally pro-business political parties (Saint-Arnaud & Bernard, 2003). Little attempt is made
to reduce social stratification and its degree of decommodification is the lowest. There is little
State intervention in the operation of the economic system.
Esping-Andersen’s distinction between Social Democratic, Conservative, including Latin,
and Liberal welfare states has much to do with the making of public policy that addresses the
social determinants of health. Figure 2 shows the basic elements and characteristics of these
differing forms of welfare states and their alignment with social determinants of health-related
public policy is apparent (Raphael, 2013a, 2013b). These differing forms of the welfare state
have not come about by accident but are shaped and maintained by ideologies of governing
authorities informed by the politics of political parties.
Figure 2. Ideological Variations in Forms of the Welfare State
Social Democratic
Ideological
Inspiration
Organizing
Principle
Equality
Reduce:
- Poverty
- Inequality
- Unemployment
Universalism
Social Rights
Focus of the
Programmes
Resources
Central
Institution
State
Liberal
Conservative
Liberty
Minimize:
- Government Interventions
- “Disincentives” to Work
Residual:
Taking Care of
the Essential
Needs of the Most
Deprived (Meanstested Assistance)
Needs
Market
Latin
Solidarity
Maintain:
- Social Stability
- Wage Stability
- Social Integration
Insurance:
Access to
Benefits
Depending on
Past
Contributions
Rudimentary
and
Familialistic
Risks
Family and Occupational
Categories
12
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, Figure 2, p. 503.
This approach is important as it considers how the ideological views of governments
shape receptivity to the timing and content of public policies. This model suggests that
addressing the social determinants of children’s health through public policy action in Liberal
welfare states such as Canada will require no less than shifting the role of the State. This shift
will occur as a result of addressing imbalances in power and influence that at present favour the
business and corporate sector. Public health activities designed to address the social determinants
of health may help facilitate such a shift (Brassolotto, Raphael, & Baldeo, 2014).
Power and Influence of Societal Sectors
At the top of Figure 1 are the three key sectors that influence the entire public policy
process. The Business and Corporate Sector is centrally placed as it has the greatest potential in
capitalist societies – and all wealthy developed nations are capitalist – to shape aspects of
economic and political systems, public policy-making, and the quality and distribution of the
social determinants of health. It also has the ability to shape the attitudes and values of the public
through its creation of ideological discourse – the ways society members come to think about
these issues (Grabb, 2007). The business sector usually favours less provision of social and
economic security and advocates for weakened government management of employment
practices, coupled with fewer support programs and benefits, all of which results in less
redistribution of income and wealth (Langille, 2009; Leys, 2001; Macarov, 2003). Its call for
lower taxes – especially for the corporate sector and the wealthy – weakens governmental ability
to provide benefits and supports that provide economic and social security to the population
(Menahem, 2010).
The organized labour sector usually supports greater redistribution through higher
taxation on the business and corporate sector and the wealthy, stronger government management
of the workplace, and greater provision of supports and benefits (Navarro et al., 2004). It gains
power and influence through the percentage of the population that belong to trade unions and its
alliance with governing parties of the left (Brady, 2009; Bryant, 2009; Navarro & Shi, 2001).
The civil society sector gains power and influence from its ability to influence public opinion
and shape public policy through networks of agencies, organizations, and other nongovernmental institutions (Brady, 2009). And, of course, the citizenry itself has influence
through its ability to elect representatives to governments.
The balance of power among sectors differs among nations with resulting impacts on the
distribution of the social determinants of health (Raphael, 2013b). It has long been noted that
public policy approaches of the social democratic nations of Denmark, Finland, Norway, and
Sweden act such that the distribution of the social determinants of health is more equitable than
in the Liberal nations of Australia, Canada, New Zealand, the U.K., and the U.S.A. (Health
Council of Canada, 2010; Innocenti Research Centre, 2005; Navarro & Shi, 2002). Denmark
provides a conundrum for a welfare state analysis in that its life expectancy is very low in
comparison to other wealthy developed nations. Its infant mortality rate, however, is very
favourable and there is evidence that it has begun to explicitly address issues of health equity in
its public policy (Povlsen, Karlsson, Regber, Sandstig, & Fosse, 2014).
13
The Conservative nations such as Belgium, France, Germany, and the Netherlands fall
midway between the Social Democratic and Liberal nations, with the Latin states closer to the
Liberal states. In both the Social Democratic and Conservative nations, consultation and
communication among these sectors is common, sometimes institutionalized and sometimes
informal (Swank, 2002). This is usually not the case in the Liberal nations, a situation that is
sometimes called “disorganized capitalism” (Offe, 1985).
Implications
Attempts to improve children’s health can benefit from the insights provided by a
political economy approach. The approach specifies that children’s health is shaped by a range of
societal structures and processes that act to distribute the social determinants of both children’s
and their parents’ health. These structures and processes create specific forms of public policy
that provide parents and their children with the economic and social conditions necessary for
health. These public policy areas include income and wealth distribution, employment security
and working conditions, features supporting early child development, food and housing security,
and the provision of health and social services.
Each jurisdiction will see a differing balance of power and influence among the business,
labour, and civil society sectors. These differences in power and influence have a profound
influence upon the direction that public policy will take. Ultimately, these differences in power –
and the resultant distribution of the social determinants of children’s health – are shaped by the
politics of a nation. As well intentioned as efforts will be to work directly to influence public
policy and strengthen specific social determinants of children’s health through community action
and direct service delivery, these efforts may have limited effects.
Instead, the political economy approach argues that the key goal should be to shape the
politics of a nation in the direction of supporting children’s health. This will require controlling
the influence of the business sector and strengthening the organized labour and civil society
sectors. It will also involve support of, and election of, political parties whose positions are
consistent with such an approach. Ultimately, the promotion of children’s health requires
engagement in the political process with the goal of reordering a society’s economic and political
systems such that they provide the conditions necessary for children’s health.
14
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18
Advancing knowledge
Identifying and strengthening the structural roots of urban
health in Canada: participatory policy research and the urban
health agenda
Toba Bryant1,2, Dennis Raphael2 and Robb Travers3
Abstract: An urban health research agenda for health promoters is presented. In Canada, urban issues are emerging as a
major concern of policy makers. The voices raising these issues are from the non-health sectors, but many of these issues
such as increasing income inequality and poverty, homelessness and housing insecurity, and social exclusion of youth, immigrants, and ethno-racial minorities have strong health implications as they are important social determinants of health. Emphasis on these and other social determinants of health and the policy decisions that strengthen or weaken them is timely as the
quality of Canadian urban environments has become especially problematic. We argue for a participatory urban health research
and action agenda with four components: a) an emphasis on health promotion and the social determinants of health; b) community-based participatory research; and c) drawing on the lived experience of people to influence d) policy analysis and policy change. Urban health researchers and promoters are urged to draw upon new developments in population health and
community-based health promotion theory and research to identify and strengthen the roots of urban health through citizen action
on public policy. (Promotion & Education, 2007, XIV (1): pp 6-11)
Key words: urban health, social determinants of health, participatory research, health policy
Résumé en français à la page 48. Resumen en español en la página 55.
Health promotion has a long tradition of
emphasizing community action to influence the determinants of health. One of
health promotion’s achievements was the
Healthy Cities Movement which emphasized
community participation and intersectoral
action in support of healthy public policy
(Ashton, 1992). The recent Belfast Declaration on Healthy Cities reflects a commitment
by European municipal leaders to apply
these principles to reduce health inequalities and poverty, promote citizen influence,
and address social exclusion (World Health
Organization, 2003).
Despite the notable successes of
Healthy Cities in Europe, there is reason to
be concerned about the current state of
urban health research and policymaking in
Canada. While Canada was the birthplace
of Healthy Cities, the movement there is
now moribund (Raphael, 2001b). Policymakers take little notice of its principles and
show little awareness of how emerging
urban issues influence health (Raphael,
2001a). Urban health researchers generally
pursue medically-oriented agendas concerned with access to health care rather
than ensuring citizen control over the determinants of health. Indeed, “health promotion” in Canada has largely deteriorated
into an emphasis on “choosing healthy
lifestyles” to the exclusion of structural
analysis of the mainsprings of health
(Raphael, 2003a). This has occurred as
urban environments in Canada have deteriorated.
KEY POINTS
• Emerging urban health issues are centred on the social determinants of
health.
• These social determinants of health
are shaped by public policy decisions.
• Urban health promotion research and
action must be concerned with public
policy issues and how these decisions
influence health.
• Health promotion theory and practice
must draw upon community members’
understandings of these issues in
order to develop an agenda for promoting health in urban communities.
Urban issues and urban health
in Canada
Urban issues are a major concern of
Canadian municipal, provincial, and federal
policy makers (Government of Canada,
2004c). Increasing income inequality and
poverty, homelessness and housing insecurity, and social exclusion of racial minorities, new immigrants, and the economically
disadvantaged are profoundly important to
health (Auger, Raynault, Lessard, &
Choinière, 2004; Galabuzi, 2005). Yet concern about these urban health issues is
being raised not by the health sector but by
a variety of municipal, charitable, and advocacy organizations. The relative silence
from the health sector is puzzling as these
issues are clearly related to health as out-
lined by Health Canada, the Canadian Public Health Association, and the World
Health Organization in numerous documents (Canadian Public Health Association, 2001; Health Canada, 1998; Wilkinson
& Marmot, 2003). The association between
these urban issues and urban health comes
about through the concept of the social
determinants of health (Marmot & Wilkinson, 2006; Raphael, 2004b).
Social determinants of health are the
political, economic, and social forces that
influence health at the individual, group,
community and population levels (Raphael,
2004a). These factors have as much, if not
more, impact on health as do traditional
medical and behavioural risk factors
(Davey Smith, 2003). This has been known
since the early Whitehall studies but is frequently ignored in favor of individual riskfactor approaches to health (Nettleton,
1997). Evidence indicates that the incidence of a variety of health issues including chronic diseases such as Type II diabetes and cardiovascular disease is caused
largely by factors related to poverty and
material deprivation across the life-span
and not by diet, activity, and tobacco use as
traditionally espoused (Raphael, Anstice, &
Raine, 2003; Raphael & Farrell, 2002). While
Canada has been a world leader in conceptualizing social determinants of health
through work in health promotion and population health (Restrepo, 1996), its leadership in these areas has slipped (Canadian
Population Health Initiative, 2002).
1. Department of Sociology, University of Toronto, Toronto, Canada. Correspondence to: Dr. Toba Bryant, 62 First Avenue, Toronto, Ontario M4M 1W8
([email protected])
2. School of Health Policy and Management, York University, Toronto, Canada.
3. Ontario HIV Treatment Network, Toronto, Canada.
(This manuscript was submitted on October 4, 2005. Following blind peer review it was accepted for publication on November 2, 2006.)
6
IUHPE – PROMOTION & EDUCATION VOL. XIV, NO. 1 2007
Advancing knowledge
A focus on urban health with a renewed
emphasis on the social determinants of
health therefore appears timely. Many political, economic and social challenges – all of
which influence people’s health – are based
in urban communities (Government of
Canada, 2004c). We outline an urban health
research and action agenda of four components: a) an emphasis on health promotion
and the social determinants of health; b)
carried out through community-based participatory research; c) that explores the
lived experience of people; d) to effect policy analysis and change.
We first identify some emerging Canadian trends in urban and urban health
issues and then explore the four components of our urban health research model.
These trends should be recognizable to
urban health promoters in many nations.
We link the model to the emerging emphasis on participatory democracy and how
civil society can influence public policy,
thereby promoting health. We also consider supports and barriers to implementing our approach and consider its relation
to the goals outlined in the Belfast Declaration on Healthy Cities.
Renewed emphasis on urban
environments in Canada
There has been a flurry of recent federal/provincial activities related to the
social determinants of health of income distribution and poverty, homelessness and
housing insecurity, and social exclusion of
racial minorities, new immigrants, and economically disadvantaged youth (Canadian
Mortgage and Housing Corporation, 2002;
Government of Canada, 2004b). Urban
issues are the focus of organizations such as
the Federation of Canadian Municipalities
(Federation of Canadian Municipalities,
2003), the Conference Board of Canada
(Conference Board of Canada, 2003), and
the National Council on Welfare (National
Council of Welfare, 2002a, 2002b, 2004),
among others. Many city-based organizations such as United Ways (Capital Region
United Way, 2003; United Way of Ottawa,
2003; United Way of Winnipeg, 2003) are documenting deteriorating social and economic
conditions. To illustrate, the United Way has
reported on declining median incomes of
families and individuals, increasing poverty
among children and youth, and spatial concentration of economic disadvantage during
the 1990’s in Toronto, Canada’s largest city
(United Way of Greater Toronto, 2004;
United Way of Greater Toronto & Canadian
Council on Social Development, 2002). The
Centre for Social Justice in Toronto has provided leadership in raising issues of increasing wealth and income inequalities (CurryStevens, 2003; Yalnizyan, 1998, 2000).
These findings suggest profound shifts
in the lived experience of urban residents
with strong implications for health and wellbeing (Galabuzi, 2001, 2004, 2005). Yet little
research is being done by urban health
researchers into income, housing, and
exclusion issues and how these influence
health (Bryant, 2004). Even fewer studies
recommend policy directions. Indeed, the
urban health field is dominated by
researchers whose work is illness-based
and dominated by epidemiological methods.i Their research focuses on disease
incidence and access to health care and
services in urban centres. The 3rd International Conference program was more
accepting of alternative approaches to
healthii and the 4th Conference emphasizes
innovative approaches to promoting urban
health.iii
Nevertheless, at the 3rd International
Conference on Urban Health, noted scholar
Meredith Minkler discussed how epidemiology and medical journal guidelines
explicitly discourage policy-oriented discussions (Minkler, 2004b). Our model calls
for an urban health approach that focuses
on the social, political and economic factors
that influence health. Figure 1 illustrates
these components.
Component 1: Health promotion and the
social determinants of health
Health promotion is the process of
enabling people (and communities) to
increase control over (the determinants of
health), and to improve, their health (World
Health Organization, 1986).
Health promotion is based on a commitment to improve health and well-being
by developing healthy public policy (World
Health Organization, 1986). Health promotion has its origins in structural analyses of
health issues based on the application of
social science methods to health problems
(MacDonald & Davies, 1998). The most succinct statement of the principles and values
of health promotion are in the Ottawa Charter for Health Promotion (World Health
Organization, 1986).
In line with its predominantly structural
approach to promoting health, the Charter
identifies the prerequisites for health of
peace, shelter, education, food, income, a
stable ecosystem, sustainable resources,
social justice and equity. A structural
approach is one that is primarily concerned
with how a society distributes economic
and social resources among the population
(Labonte, 1997). It has roots in the field of
political economy and considers public policy as resulting from the influence of political and economic forces (Coburn, 2006).
Five action areas are outlined: building
healthy public policy; creating supportive
environments; strengthening community
action; developing personal skills; and
reorienting health services. Two of these
areas are especially relevant to our model:
strengthening community action and building healthy public policy. The prerequisites
of health are now spoken of as social determinants of health.
The mantle of urban health leadership
in Canada is now held by Montreal. The
Montreal Region health unit outlines four
key dimensions of urban health: the natural and built environment, the political and
social environment, health infrastructure,
and social and community infrastructure
(Lessard, Roy, Choinière, Lévesque, & Perron, 2002). Montreal is notable as one of
only a handful of Canadian health units
embracing a broader determinants agenda
(Raphael, 2003a).
Component 2: Community based participatory research (CBPR)
CBPR holds immense potential for
addressing challenging health and social
problems, while helping bring about conditions in which communities can recognize
and build on their strengths and become full
partners in gaining and creating knowledge
Figure 1. Components of the Urban Health Research and Action Agenda.
IUHPE – PROMOTION & EDUCATION VOL. XIV, NO. 1 2007
Policy Analysis and Policy Change
In Support of Urban Health
H
P
S
D
O
H
Lived Experience of Community Members
Community-Based Participatory Research
7
Advancing knowledge
and mobilizing for change (Minkler, Wallerstein, & Hall, 2002, p. 20).
CBPR in urban health is superior for
many reasons to mainstream research
approaches (Minkler, 2004b; Minkler et al.,
2002). It provides capacity-building opportunities for community members. It ensures
research is community-relevant by focusing
on community members’ lived experiences. CBPR also has the potential to effect
changes in public policy.
CBPR is research that engages community members as research partners to collaboratively tackle community-relevant
issues. Studies take place in the community
rather than research labs and offer capacity-building opportunities so skills remain
in the community once a study is complete
(Parker, Margolis, Eng & Henriquez-Roldan,
2003). CBPR moves from a model of academic ownership to one of joint ownership
with communities (Manson, Garoutte, &
Turner Goins, 2004). CBPR also requires an
intellectual commitment to look at the dayto-day lived experiences and understandings held by community members (O’Brien
Teengs & Travers, 2006.)
The benefits of CBPR are apparent in the
context of traditional approaches to health
science research. Such research has typically not been particularly focused on
improving the health and well-being of community members. And such research is
rarely concerned with identifying and challenging existing power structures that may
oppress, marginalize, or threaten the health
of individuals (Minkler, 2004a).
The five key contributions that CBPR
offers to understand and promote community-based health are to:
• provide voice (e.g. power, capacity, control) to communities and their members;
• increase theoretical and practical knowledge about community health;
• improve health through community
action;
• identify community issues requiring
action; and
• effect political and social change.
Further details concerning each of these
contributions of CBPR are available elsewhere (Park, 1993).
lived experience approach. A criticism of
traditional approaches to understanding
community health is their inability to focus
upon the lived experience of people (Bryman, 1988). Lincoln has argued that the
most effective way of understanding healthrelated issues is by discerning individuals’
perceptions and constructions of events
(Lincoln, 1994). Exploration of the meaning
of health and staying healthy among community members provides rich insights
that cannot be assessed by traditional
approaches (Blaxter, 1990; Popay &
Williams, 1994). The increasing popularity
of qualitative methods is a result of the failure of traditional methods to provide
insights into the determinants – both structural and personal – of health.
This missing piece in health research
has been termed interactive knowledge
(Park, 1993). It is derived from lived experience and is also known as constructivist,
naturalistic, ethnographic, or qualitative
knowledge. Its focus is the meanings and
interpretations individuals place on events.
Its theoretical bases are phenomenology,
symbolic interactionism, and grounded theory (Lincoln & Guba, 1985).
A related form of understanding is critical or reflective knowledge, examples of
which draw upon insights and approaches
suggested by materialist or structural, and
feminist theory (Fay, 1987). Critical knowledge is derived from reflection and action
on what is right and just. It considers how
societal structures and power relations promote inequalities and disenable people.
The goal of research is to illuminate these
health-harming societal structures and to
raise consciousness about the causes of
problems and deriving means of alleviating
them.
Lived experience and critical approaches
are important for engaging communities in
research activity and assuring their voices
are heard by policymakers. Such activities
help counteract the drive towards weakened
democratic structures increasingly common
in urban areas. This trends calls for active
community involvement in addressing policy issues that influence the social determinants of health.
Component 3: Lived experience of people
If public health research is to develop
more robust and holistic explanations for
patterns of health and illness in contemporary society, and contribute to more appropriate and effective preventive policies, then
the key is to utilize and build on lay knowledge – the knowledge that lay people have
about illness, health, risk, disability and
death (Williams & Popay, 1997, p. 267).
There are especially compelling theoretical and practical reasons for favoring a
Component 4: Policy analysis and
change emphasis
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 (Canadian Public
Health Association, 1996, p. 1).
Thinking about health and its determinants increasingly focuses on the distribution of resources within societies and how
8
these influence health (Raphael, 2003b).
Also important are government decisions
that determine how resources are distributed (Raphael & Curry-Stevens, 2004).
These issues are illuminated by analyses of
how governments systematically differ in
how issues of income, housing, employment, healthy child development and others are managed (Langille, 2004). Shifting
government policies in Canada have contributed to deteriorating urban environments. To counter these health-threatening
policies and promote health-supporting
ones, it is vital to understand how policy is
made at every level of government (Bryant,
2002, 2003).
Theories of policy change help us
understand the policy change process.
Recent developments – termed learning
approaches to policy change – consider the
role of knowledge and ideas in the policy
change process. These models help make
explicit core epistemological beliefs (i.e.,
ways of knowing and understanding problems) of political actors as they create and
select knowledge to bring about particular
policy outcomes. An understanding of the
motivations of people and groups responsible for policy change can help bring about
policy outcomes.
For example, social spending – which
results in either strong or weak programs in
support of health – is shaped by the political ideology of the government of the day,
public perceptions towards those in need,
and the dominance of particular
approaches to evidence deemed legitimate
to inform these issues (Bryant, 2006).
Swedish national and local governments
– supported by public opinion – have an
ethos of supporting vulnerable populations
illustrated by their spending at 31% of its
GDP on social spending. In contrast,
Canada (18% of GDP), the US (14.6% GDP),
and UK (20% of GDP) spend rather less and
show corresponding weakness in social
programs and population health (Organization for Economic Cooperation and
Development, 2003).
These latter three countries have been
governed by parties whose neo-liberal ideology prefers seeing the market as determining resource distribution and a reduced
state role in these matters (Bernard & SaintArnaud, 2004). This ideology predisposes
governments to favor the evidence that justifies these tenets (Teeple, 2000). These ideologies about the nature of the state’s role
in supporting citizens influence policymaking at every level of government
(Coburn, 2001; Coburn, 2004; Coburn,
2006). These policies – while shaped by
prevailing ideologies – can be influenced
by citizen action (Esping-Andersen, 1985;
Langille, 2004).
IUHPE – PROMOTION & EDUCATION VOL. XIV, NO. 1 2007
Advancing knowledge
Combining democratic process
with the social determinants of
health
There is a need then, for models that
incorporate an understanding of how citizens can use diverse types of knowledge
to influence the policy change process. Fischer proposes a model for democratizing
policy analysis through a collaborative
process (Fischer, 1993). He links scientific
knowledge with the practical knowledge
held by citizens to address important
macro-policy issues. This collaborative
inquiry makes the knowledge created by
social scientists accessible to citizens to
“systematize their own local knowledge”.
CBPR creates cooperative relationships
between scientists and citizens with the aim
of meeting citizens’ basic social needs and
welfare (Merrifield, 1989).
CBPR can support democratic empowerment (Gaventa, 1980, 1988). The expert
scientist can work with citizens to assess
their own interests and make decisions on
how to see these interest put into action
(Hirschhorn, 1979). To do so requires institutional and intellectual contexts in support
of these aims. One example is the Dutch Science Shops where citizens are invited to
put forth issues and concerns for scientists
to research and to give back solutions to citizens. This process can lead to the formation of an alliance between practitioners
and clients to address a social issue. Fischer’s approach requires investigation relevant to specific “real-life contexts and to
the formation of goals and purposes” (Stull
& Schensul, 1987).
Fischer’s collaborative research model
addresses two methodological problems in
policy science: the relationships between
theory and practice, and empirical and normative inquiry. It links theory with practice
and demonstrates how empirical inquiry
should involve assumptions about what the
world should be like. In the present case,
it identifies the need to be explicit about the
goals of urban health research and demonstrate a commitment to seeing that such
ends are met.
Discussion
The four-component research and
action agenda reflects many principles of
the Healthy City approach and the Belfast
Declaration such as policy development
and citizen participation in decision-making to improve urban population health
(World Health Organization, 2003). The
Belfast Declaration emphasizes collaborative efforts at all levels and urban governance to meet the needs of citizens, tackle
the wider determinants of health, and create effective policies, strategies and tools for
action. Specific areas of action are reducing
inequalities and addressing poverty, city
health planning, good governance and creating inclusive and safe cities; promoting
health impact assessment and shaping and
implementing strategies for health.
Our four components provide the analytic tools for working towards these goals.
They specify the pathways for citizen participation – community-based research and
lived experience – in the development and
design of healthy cities through healthy
public policy development and change.
These components give citizens a voice in
project and program development and
political decisions. These pathways provide opportunities for capacity-building
among citizens to develop academic and
community research partnerships to
address community issues.
The Healthy City model focuses on local
decision-making towards achieving healthy
public policy and assumes that governments will be responsive to citizen concerns. The policy analysis and change component in our model assumes the contrary:
Governments may not be predisposed to
listen to citizens who challenge government
policy. Indeed, our model sees citizen
engagement as potentially forming the basis
for development of social movements to
challenge government decision-making.
It is also important to note that our
fourth component, Policy Analysis and
Change, is not limited to municipal policymaking and emphasizes decision-making at
senior – provincial, state, or regional as well
as federal levels – of government. This component reflects lessons we have learned
from the Federation of Canadian Municipalities (FCM) Quality of Life Indicator Project and the Canadian Policy Research Networks (CPRN) Quality of Life Project
Approach (Federation of Canadian Municipalities, 2004a; Michalski, 2001). Both FCM
and CPRN identify how urban issues are
influenced by policy decisions made by
senior levels of government.
The FCM tracks indicators in 10
domains: 1) affordable, appropriate housing; 2) civic engagement; 3) community and
social infrastructure; 4) education; 5)
employment; 6) local economy; 7) natural
environment; 8) personal & community
health; 9) personal financial security; and
10) personal safety (Federation of Canadian
Municipalities, 2001). The FCM notes that
many of these domains are affected by federal and provincial policy changes (Federation of Canadian Municipalities, 2004b,
2004c).
The CPRN identified political rights and
general values, health, including health
care, education, environment, social programs, personal well-being, community,
economy and employment, and govern-
IUHPE – PROMOTION & EDUCATION VOL. XIV, NO. 1 2007
ment as key aspects of quality of life
(Michalski, 2001). These are all domains
within the purview of federal and provincial governments in Canada. The FCM and
CPRN projects show how important policy
analysis at all levels of government is in an
urban health research agenda.
Conclusions
Our urban health agenda encourages
community-driven research where locally
produced knowledge – the lived experience of people – is at the forefront. This
agenda ensures that research studies focus
on deepening understanding of how political, economic, and social environments
influence health. Our urban health agenda
emphasizes social change as an endpoint.
Local consumption of knowledge will occur
through community-relevant research studies that offer clear social change endpoints.
As in the WHO Healthy City program,
the explicit orientation is action oriented,
community-based, and policy-oriented.
The approach moves beyond understanding urban health and its determinants to
action to promoting urban health. While
such an agenda will provide insights into
the processes that shape urban health and
how public policy is developed, the primary goal of citizen participation in
research and the policy process is the promotion of health for those living in cities.
Supports and barriers
Supports for this agenda exist. There is
increasing emphasis on the social determinants of health in Canada (Government of
Canada, 2004a). The WHO’s Commission
on the Social Determinants of Health
should elevate their prominence in public
and urban health discourse (World Health
Organization, 2004). There is increased
focus on urban policy by a variety of Canadian institutions and agencies such as the
United Ways across Canada. The obvious
deterioration in urban conditions and associated quality of life apparent in Canadian
urban areas should promote receptivity to
this new approach.
As one example, Wellesley Central
Health Corporation in Toronto has declared
itself as an urban health organization in support of research activities that deepen our
understanding of the relationship between
health status and income and its distribution, housing and homelessness, and social
exclusion.iv In just one year, the organization has shown leadership by promoting
capacity-building toward community-unii http://www.who.int/social_determinants/en/
ii http://www.iuhr.neu.edu/conference/detailed_
conference_guide.html
iii http://www.crich.ca/isuhconference2005/call.asp
iv http://www.wellesleycentral.com/wellesley/
9
Advancing knowledge
versity research collaborations and has
funded numerous innovative research initiatives.
Nevertheless, active debate persists in
Canada concerning definitions of health
and its determinants among the professional community and general public. Medical and lifestyle approaches dominate professional and public modes of
understanding health (Canadian Population Health Initiative, 2004). Pointing to and
drawing upon WHO and Health Canada
documents and recent research should
help communicate the approach. Another
issue is the perception that the approach
could be seen as “political.” This could be
countered by drawing attention to the
research literature on the social determinants of health and the importance of democratic participation.
Also, the dominant class of urban health
researchers is atheoretical medically-oriented, and not particularly action oriented.
Some believe there are too few researchers
able to meet the criteria of understanding
policy analysis and the policy change
process. We do not believe this to be the
case. Instead we would argue that there are
opportunities for collaborations among traditional urban health researchers and
social science-oriented policy analysts to
conduct innovative, effective research into
urban health, its determinants, and means
of improving it.
Towards the future
The model provides the tools to achieve
healthy communities and build on the
insights of the Belfast Declaration. It emphasizes democratizing and building on existing community traditions and knowledge,
and community capacity-building through
community-based research and the emphasis on the lived experience of community
members. These mechanisms bridge different forms of knowledge to provide critical insights into how structural arrangements foster inequalities in health and
social exclusion within urban populations.
These insights can lead to policy solutions.
Community-based participatory policy
research can democratize the public policy
change process and enable citizens to contribute directly to influence the social determinants of their health.
Acknowledgement
Support for the production of this document was
received from the Wellesley Central Health Corporation of Toronto, Ontario. The views
expressed are not necessarily those of the
Wellesley Central Health Corporation.
10
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Health Policy 101 (2011) 44–58
Contents lists available at ScienceDirect
Health Policy
journal homepage: www.elsevier.com/locate/healthpol
Canada: A land of missed opportunity for addressing the social
determinants of health
Toba Bryant a,∗ , Dennis Raphael b , Ted Schrecker c , Ronald Labonte d
a
b
c
d
Health Studies, Department of Social Sciences, University of Toronto Scarborough, Canada
School of Health Policy and Management, York University, Toronto, Canada
Department of Epidemiology and Community Medicine, University of Ottawa, Canada
Globalization/Health Equity, Professor Faculty of Medicine, Institute of Population Health, University of Ottawa, Canada
a r t i c l e
i n f o
Keywords:
Social determinants of health
Public policy
Canada
a b s t r a c t
The first 25 years of universal public health insurance in Canada saw major reductions in
income-related health inequalities related to conditions most amenable to medical treatment. While equity issues related to health care coverage and access remain important,
the social determinants of health (SDH) represent the next frontier for reducing health
inequalities, a point reinforced by the work of the World Health Organization’s Commission on Social Determinants of Health. In this regard, Canada’s recent performance suggests
a bleak prognosis. Canada’s track record since the 1980s in five respects related to social
determinants of health: (a) the overall redistributive impact of tax and transfer policies;
(b) reduction of family and child poverty; (c) housing policy; (d) early childhood education and care; and (e) urban/metropolitan health policy have reduced Canada’s capacity to
reduce existing health inequalities. Reasons for this are explored and means of advancing
this agenda are outlined.
© 2010 Elsevier Ireland Ltd. All rights reserved.
The poor health of the poor, the social gradient in
health within countries, and the marked health inequities
between countries are caused by the unequal distribution
of power, income, goods, and services, globally and nationally, the consequent unfairness in the immediate, visible
circumstances of people’s lives – their access to health
care, schools, and education, their conditions of work and
leisure, their homes, communities, towns, or cities – and
their chances of leading a flourishing life [1], p. 1.
1. Introduction
The first 25 years of universal public health insurance
in Canada saw major reductions in income-related health
∗ Corresponding author at: University of Toronto, Scarborough, Department of Social Sciences, 1265 Military Trail, Toronto ON M1C 1A4 Canada.
Tel.: +1 416 465 7455; fax: +1 416 465 7455.
E-mail address: [email protected] (T. Bryant).
0168-8510/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.healthpol.2010.08.022
inequalities related to conditions most amenable to medical treatment such as appendicitis and asthma, although
“there was little change in income-related inequalities in
mortality from causes amenable to public health interventions” such as lung cancer and motor vehicle accidents [2].
Assuming Canada’s public health care insurance system
survives attempts to increase its privatization, addressing the social determinants of health (SDH) and their
unequal distribution among the population represent the
next frontier for reducing health inequalities, a point
long recognized in Canadian governmental and public
health institutional documents [3]. It is also an emphasis
reinforced by the conclusions of the World Health Organization’s Commission on Social Determinants of Health
[1].
Although the role public policy plays in reducing (or failing to reduce) inequalities in health has been demonstrated
at both the macro- and micro-levels, Canada’s recent performance in numerous key policy areas suggests a bleak
prognosis [4,5]. Like other liberal welfare states, Canada
T. Bryant et al. / Health Policy 101 (2011) 44–58
has been especially susceptible to the influence of the neoliberal resurgence of the last three decades resulting in
the creation of a public policy environment adverse to:
(a) strengthening the general quality of the SDH and (b)
making their distribution among the population more equitable [6,7]. The first goal manifests in analyses that call
for improving the general quality of living conditions of
a population. The second is about “leveling-up” the health
of disadvantaged populations by making the distribution
of the social determinants of health more equitable [8].
In reality, the two usually go hand-in-hand but lead to
differing emphases with the former assuming awareness
and knowledge will lead to more progressive public policy,
while the latter is focused on how differences in power and
influence among groups lead to skewed distribution of the
social determinants of health across the population [9].
After reviewing relevant SDH literature, we detail the
extent of SDH-related inequalities as situated in income
inequality and poverty in Canada with specific emphasis
on housing affordability issues. We then locate Canada’s
approach to supporting citizen security across the life-span
in comparison with six other wealthy developed nations.
Canada’s public policy track record since 1985 in five social
determinants-related respects is examined: (a) the overall
redistributive impact of tax and transfer policies; (b) reduction of child poverty and the associated long-term effects
on health inequalities; (c) housing policy, in a context of
declining housing affordability, (d) early childhood education and care; and (e) determinants of urban/metropolitan
health. This last area assumes special importance in a
highly urban nation where accumulating evidence of deepening spatial segregation along socioeconomic lines is
consistent with evidence of how neighbourhood-scale
socioeconomic variables affect health.
We suggest the past three decades have seen a weakening of Canada’s capacity to address health inequalities
by way of reducing the inequitable distribution of the
social determinants of health. We identify two stylized explanations of how these policy directions came
about: (a) inadequate or ineffective knowledge generation, dissemination, and translation, and (b) changes in
Canada’s political and economic economy, partly related to
increased integration into the world economy, and associated with shifting political allegiances and values. Decisive
political and professional leadership may be necessary conditions for action on the social determinants of health but if
the second explanation is even partly valid; such leadership
may still be insufficient.
2. Health care, SDH, and health inequalities in
Canada
Canada introduced universal public health insurance in
1971 [10]. Since its introduction, this popular social program contributed to a significant decline in income-related
health inequalities, particularly for conditions treatable
by medical interventions [2]. The development of universal health care in Canada probably contributed to
differences in life expectancy between Canadians and
Americans since its introduction in the 1970s [11], although
these US–Canada differences may also be due to national
45
differences in commitments to the provision of social
infrastructure that emerged during this same time period
[12]; it is difficult to disentangle the relative contribution
of the two sets of variables.
Nevertheless, significant health care-related equity
issues remain [13]. The proportion of health care costs covered by the public system in Canada (∼70%) is among the
lowest of member nations of the Organisation for Economic
Cooperation and Development [14]. Lower-income Canadians are more likely to experience difficulty seeing a medical
specialist as needed or to wait 5 days or more to see a physician, and are less likely to have prescriptions filled or to
receive supplementary health services due to cost, compared to other Canadians [15]. A recent study described a
clear socioeconomic gradient in cancer survival rates, and
demonstrated that at best only a small part of this gradient was due to delays in diagnosis [16]. In other words,
efforts to explain the gradient need to focus not only on
events in the health care system, but also on conditions in
the broader society post-diagnosis.
In general terms, the conditions of life and work (the
SDH) to which individuals are exposed are of greater
importance as influences both on overall population health
and on health disparities within populations [17,18], Here,
Canada falls well behind other nations in: (a) the objective
quality and the distribution of these SDH as compared to
other wealthy nations of the OECD [19], and (b) its apparent
willingness to address the SDH through public policy action
[3]. This is the case even though Canada’s economy experienced one of the greatest increases in growth among OECD
member nations since the mid-1980s [20]. The problem
does not appear to be one of lack of awareness on the part
of government officials and policymakers as institutional
documents are replete with concepts and data showing the
importance of these issues. Rather, the problem seems to
be shifts in the political economy of the nation that has
led to welfare state retrenchment and governmental withdrawal from assuring an equitable distribution of the social
determinants of health across the population. Canada has
missed a clear opportunity for reducing health inequalities
and promoting the health of its population.
3. A brief review of the SDH concept in Canada
The term social determinants of health has come to stand
for the societal factors that shape the health of individuals and populations. Recently, a distinction has been made
between social determinants of health and the distribution
of the social determinants of health. In the former case,
focus is on how these factors shape health outcomes in
general. In the latter case, focus is on how the inequitable
distribution of these determinants comes to cause health
inequalities.
This distinction is important. In Canada, analysis has
focused on social determinants of health without explicitly
considering how their distribution comes to cause health
inequalities [21]. In the UK, in contrast, there has been
greater concern with how reducing the inequitable distribution of these determinants can be applied towards
the goal of reducing health inequalities. A focus on social
determinants has the potential to ignore how public
46
T. Bryant et al. / Health Policy 101 (2011) 44–58
Table 1
Various conceptualizations of the social determinants of health.
Ottawa Chartera
Dahlgren and
Whiteheadb
Health Canadac
World Health
Organizationd
Centers for disease
controle
Raphael et al.f
Peace
Socioeconomic status
Aboriginal status
Stress
Transportation
Early life
Education
Food
Work environment
Unemployment
Early life
Social exclusion
Housing
Access to services
Income
Water and sanitation
Work
Health care services
Discrimination by
social grouping
Social or
environmental
stressors
Education
Employment and
working conditions
Food security
Stable ecosystem
Income and social
status
Social support
networks
Education
Employment and
working conditions,
Physical and social
environments
Healthy child
development
Social gradient
Shelter
Agriculture and food
production
Education
Sustainable resources
Social justice
Equity
Housing
Health services
Gender
Culture
Unemployment
Social support
Addiction
Food
Transport
a
b
c
d
e
f
Gender
Health care services
Housing
Income and its
distribution
Social safety net
Social exclusion
Unemployment and
employment security
[150].
[151].
[30].
[17]. Available from: http://www.euro.who.int/document/e81384.pdf.
[152].
[153].
policy shapes the quality of these factors; whereas a focus
on public policy is more likely to concern the distribution
of these determinants [9,22]. Since the modern introduction of the term [23], a variety of approaches – with many
clear similarities – has appeared (Table 1).
Canadians contributed to these emerging understandings. The Canadian government’s A New Perspective on the
Health of Canadians specified the environment as playing
a role in shaping health [24] and its Achieving Health for
All: A Framework for Health Promotion argued that reducing
health inequities could be accomplished through strengthening income security, employment, education, housing,
business, agriculture, transportation, justice, and technology policies, among others [25]. The Population Health
Working Group of the Canadian Institute for Advanced
Research specified the mechanisms by which SDH come to
shape health and produce health inequalities [26,27]. More
recently, Canadian researchers were actively involved with
several of the knowledge networks that supported the
Commission on Social Determinants of Health, three of
which were funded by Canadian government agencies.
Furthermore, since the mid-1970s Canadian governmental
and public health agencies have produced numerous policy documents consistent with the SDH discourse [28–33].
Clearly, lack of awareness and knowledge of the social
determinants of health are not the culprits for the situation
described below.
In contrast to the situation in many European nations
[34] there has been little application of these concepts in
the making of Canadian public policy [35–37]. In actual fact,
governments, disease associations, and the media have
focused – with some notable though scattered exceptions –
on the importance of influencing biomedical risk factors
and Canadians’ “lifestyle choices” [3,35,38,39]. Why SDH-
related public policy activity lags far behind many other
OECD nations appears to be related to shifts in the operation of Canada’s economic and political system or its
political economy.
4. An overview of the Canadian population health
scene
Canada’s relative ranking as compared to the member
nations of the Organization for Economic Cooperation and
Development (OECD) on a number of population health
indicators is presented in Table 2.
Except for life expectancy – and even here, Canada’s
ranking has been slipping in recent years – Canada’s
health indicators are far from superlative. Insight into the
changing Canadian health scene is provided by its infant
mortality rate which is often identified as a sensitive indicator of overall population health [40]. In 1980, Canada’s
rate was 10/1000 which gave it a relative ranking of 10th
of 30 OECD nations [41]. Canada’s decline to 5.3/1000 in
2005 is a significant achievement, but the decline has failed
to match that seen in many other OECD nations [20] such
that Canada’s ranking over this period has fallen from 10th
to 24th of 30 OECD nations [41].
Most nations doing better than Canada in both infant
mortality and low birthweight rates are not as wealthy as
Canada in terms of Gross Domestic Product (GDP) [20]. For
example, the average Swede is $3000 less wealthy than
the average Canadian in terms of national per capita GDP
in comparable dollars, yet Sweden’s life expectancy, infant
mortality and low birthweight rate indicators are far superior to Canada’s [14,40].
Health inequalities in Canada are widespread and
manifest in numerous indicators of health such as life
T. Bryant et al. / Health Policy 101 (2011) 44–58
47
Table 2
Canada’s relative rankings among OECD nations on a number of health indicators.
Indicator
Rate
Relative rank (1 is best)
Life expectancy at birth (2005)a
Premature years of life lost prior to age 70 (2005)a
Infant mortality rate (2005)a
Low birthweight rate (2005)a
Child mortality by injury rate (1991–1995)b
Teenage birth rate (1998)c
80.7 years
3365/100,000
5.3/1000
5.9/100
9.7/10,000
20.2/1000
6th of 28 nations
17th of 28 nations
24th of 30 nations
9th of 30 nations
19th of 26 nations
21st of 28 nations
expectancy, infant mortality, disease incidence and mortality, and injuries at every stage of the life course [42].
The primary category used to demonstrate the existence
of these health inequalities is family or individual income.
Unlike other nations, Canada does not routinely collect
information on the social class or occupational status of
citizens that would allow these to be used as health equality indicators [43]. In addition, Canada is only beginning
to establish databases that allow for the examination of
the effects of income differences upon health over time.
Raphael provides an extensive review of the extent of
health inequalities in Canada [44]. Wilkins provides evidence of increasing inequalities related to income for infant
mortality rate and mortality from diabetes and suicide [45].
5. An overview of the Canadian SDH scene
Our analysis of three key SDH-related issues, income
inequality, incidence of poverty and the extent of housing affordability, provides a snapshot of the Canadian SDH
scene. Income has been identified by various sources as
a key determinant of health. For some, its distribution –
primarily its skewed distribution – is the direct cause of
health-related inequalities. For others, it is the material and
social deprivation associated with lack of income that has
health consequences. Housing is of special importance in
Canada as a social determinant of health as Canada has
undergone significant policy shifts in this area that have
led to both a “housing crisis” and a “homelessness disaster”
[46] (p. 221). We then provide support for our argument
that these shifts have come about by changes in Canada’s
political economy by comparing Canada’s public spending
on health and social programs – well established policy precursors of better quality and more equitably distributed
social determinants of health – with that of six selected
OECD nations.
6. Income inequality and poverty in Canada
Fig. 1 shows that income inequality in Canada has
increased since 1980 with the increase being especially
great for market income [47]. The reduction in the Gini
coefficient seen by including the effects of other income
and the distributional aspects of the tax system, while significant, falls well behind the effects seen in most other
OECD nations [48,49].
Fig. 2 shows the percentage of Canadians living on
low-income from 1980 to 2007 using Statistics Canada’s
Gini Coefficient
c
[75].
[154].
[155].
0.55
0.5
0.45
0.4
0.35
0.3
1980
1985
1990
1995
2000
2005
2007
Year
Market Income
Total Income
After-tax Income
Fig. 1. Gini coefficient for various types of income, Canada 1980–2007.
Source: Statistics Canada (2009). CANSIM Table 2020705 – Gini coefficients of market, total and after-tax income, by economic family type.
Ottawa: Statistics Canada.
before-tax low-income cut-offs (this indicator identifies
Canadians spending significantly more resources on necessities, such as housing, than the average and provides rates
comparable to internationally used indicators of relative
poverty) [50]. Little change is apparent over this period
and it should be noted that Canada is one of the few
nations where child poverty rates were higher than overall
poverty rates over the past two decades [51]. Fig. 3 provides
these data for Canadian families of various compositions
during the same period. For the most part, overall rates
remain unchanged, although some reduction is apparent
for single-parent families with children [52]. It should be
noted that this improvement predated the economic crisis
that began in 2008.
6.1. Housing affordability
A significant aspect of income inequality and poverty
in developed nations is its relation to housing affordability. Spending large amounts of income on housing reduces
25
Percentage
a
b
20
15
10
5
0
1980
1985
1990
1995
2000
2005
2007
Year
All Persons
Children
Fig. 2. Percentage of Canadians living on low incomes, 1980–2007.
Source: Statistics Canada (2009). CANSIM Table 2020802 – Individuals in
low income, by economic family type, 2007 constant dollars, annually.
Ottawa: Statistics Canada
48
T. Bryant et al. / Health Policy 101 (2011) 44–58
that ensured an affordable private rental market were
seen as artificial impediments to the proper functioning
of the private market [59]. These changes have coincided with retrenchment in other social policy areas in
Canada.
Percentage
60
50
40
30
20
10
0
1980
1985
1990
1995
2000
2005
2007
7. Canadian public policy in broader perspective
Year
All Family Units
One Parent Families with Children
Two Parent Families with Children
Fig. 3. Percentage of various types of Canadian families living on low
incomes, 1980–2007.
Source: Statistics Canada (2009). CANSIM Table 2020804 – Families in low
income, by economic family type, 2007 constant dollars, annually. Ottawa:
Statistics Canada
resources available for other SDH such as food and recreation [53]. Housing is not a discretionary need and housing
affordability in Canada has been a policy focus. According
to the Canada Mortgage and Housing Corporation: “Affordable housing costs less than 30% of before-tax household
income. Shelter costs include the following: (a) for renters,
rent and any payments for electricity, fuel, water and other
municipal services; and (b) for owners, mortgage payments
(principal and interest), property taxes, and any condominium fees, along with payments for electricity, fuel,
water and other municipal services” [54].
A significant proportion of Canadian households experience housing affordability issues and this proportion
increased between 1991 and 2006 (Fig. 4). This situation
is particularly acute for Canadian renters, a situation associated with especially low levels of income and wealth
[55,56]. Indeed, the proportion of tenants spending >30%
of total income on rent is higher in Canadian cities than
the Canadian average (43% in Vancouver, 42% in Toronto,
and 36% in Montreal) [57]. The proportion spending >50%
– putting them at risk of imminent homelessness – is also
strikingly high (22% in Vancouver, 20% in Toronto, and
18% in Montreal). Rental costs have far outpaced income
increases among low-income renters in virtually all Canadian urban areas [58].
An explained later in the article, this situation developed as the federal and some provincial governments
withdrew from social housing provision during the 1990s.
In addition, some provincial governments have abolished
rent control which has reduced affordability in the private rental market, as rent control and other measures
Percentage
40
30
20
15
10
0
1991
1996
Year
Total Households
2001
Owners
2006
Renters
Fig. 4. Percentage of Canadian households Spending >30% of income on
shelter costs, 1991–2006.
Source: Canada Mortgage and Housing Corporation (2009). Housing in
Canada Online. Available online at http://data.beyond2020.com/CMHC/.
Ottawa: Canada Mortgage and Housing Corporation.
Since we argue that these developments are not due to
lack of awareness or knowledge on the part of governments
or policymakers but rather in the operation of Canada’s
political economy, we place Canada’s standing on these
indicators within a broader context of provision of citizen
security and supports over the life-span frequently termed
as the “worlds of welfare” [60–62]. Esping-Andersen outlines three distinct types of welfare capitalism (liberal,
conservative, social democratic) [63,64]; Saint-Arnaud and
Bernard outline a four-type approach (adding a Latin type)
[65]. Pontusson makes the distinction between liberal market economies and social market economies [66]. Other,
similar typologies with clear relation to understanding policy approaches to health determinants exist [67,68]. Of
particular note is that while no less than 12 welfare state
typologies are described by Bambra [60], in six of the seven
typologies that include Canada it is found in the group
similar to the so-called liberal welfare state: liberal, basic
security, or liberal Anglo-Saxon, the exception being for the
provision of health care in which Canada is grouped within
the conservative cluster.
7.1. Three (or four or two) forms of the welfare state
Esping-Andersen’s three-type approach has illuminated understandings of how nations approach health
determinant-related issues. The basic conclusion is that liberal political economies are distinguished – in comparison
to conservative and social democratic regimes – by less
attention to citizen security and provision which translates into lower quality and greater commodification of
resources associated with the SDH [69]. The key difference
between conservative and social democratic regimes lies in
their approach to gender equity issues, and tax-supported
(social democratic) versus contributory, social insurancebased (conservative) programs [70–72].
Canada’s extent of income inequality, poverty and
housing affordability over time can be viewed against
a consideration of governmental allocation of national
wealth in the service of citizen provision. In the following section, Canada is compared to two other liberal
(UK and USA), two social democratic (Sweden and Norway), and two conservative (France and Germany) political
economies.
7.2. Total public expenditures
What is notable about welfare state analyses of health
is the clear relationship between public policy choices and
the SDH. Research shows that increased public spending on
citizens through social and health programs is beneficial to
the health and well-being of populations [68,73,74]. Public
expenditure is a key indicator of jurisdictional commit-
49
5
30
20
10
1980
1985
1990
1995
2000
2005
Year
Canada
France
Germany
Norway
Sweden
UK
USA
OECD Total
Percentage of GDP
Percentage of GDP
T. Bryant et al. / Health Policy 101 (2011) 44–58
4
3
2
1
0
1980
1985
Canada
Sweden
Fig. 5. Total public social expenditure, selected OECD nations, 1980–2005.
Source: Organisation for Economic Cooperation and Development. Total
Public Social Expenditures. Available online at http://stats.oecd.org/
Index.aspx?datasetcode=SOCX AGG. Paris: OECD.
ment to provision of citizen security: the extent to which
a nation collects revenues and transfers them to citizens
in the form of various benefits, programs and services.
Such allocations include spending on education, employment training, social assistance, family supports, pensions,
health and social services, and free or subsidized housing.
Fig. 5 shows overall public social expenditures as a percentage of GDP for the seven nations in our comparison
from 1980 to 2005. Canada (similar to the USA) is distinguished by its relatively low spending, which is well
below the OECD average. In contrast, Sweden, France and
Germany are distinguished by high levels of public social
expenditure.
7.3. Public spending on health care
This indicator has been shown to be related to longer
life expectancy and lower infant mortality rate [4].
Canada’s public spending on health care is higher than the
OECD average and indistinguishable from the comparison
nations except Norway (Fig. 6). Canada and USA spending
can be seen as excessively high as public coverage of health
care costs is only 70% and that for the USA is 45% [75]. It is in
public spending in support of non-health care-related areas
that Canada clearly lags. We focus on support to families
and spending on old age as Esping-Andersen among others
identifies these as being key components of the modern
1990
France
UK
Year
1995
Germany
USA
2000
2005
Norway
OECD Total
Fig. 7. Public spending on families, selected OECD nations, 1980–2005.
Source: Organisation for Economic Cooperation and Development. Public Expenditures on Families. Available online at http://stats.oecd.org/
Index.aspx?datasetcode=SOCX AGG. Paris: OECD.
welfare state and areas in which modern welfare states
differ most widely (Figs. 7 and 8) [76,77].
7.4. Public spending on families and old age
Canadian spending on families and old age is notable
in two aspects: it is unchanged from 1980 to 2005, and it
is very low in comparison to the OECD average and the
six selected nations. Much of this has to do with Canadian policymakers’ resistance to universal programs as is
the case in other nations [78]. In addition, since the 1980s,
there has been a scaling back of family-related benefits programs such that family benefits were first reduced and then
eliminated [78].
7.5. Income inequality and poverty in comparative
perspective
The OECD provides comparative data from the mid1980 to mid-2000 on indicators of income inequality and
poverty. Fig. 9 shows that among the comparison nations,
Canada, the USA, Germany, and the UK are distinguished
by their relatively high poverty rates; regardless of threshold level applied. For Canada and Germany, current high
rates reflect, in part, significant increases from the mid1990s to the present (Fig. 10). For the UK and the US, high
Percentage of GDP
8.5
7.5
6.5
5.5
4.5
3.5
1980
1985
Canada
Sweden
1990
France
UK
Year
1995
Germany
USA
2000
2005
Norway
OECD Total
Fig. 6. Public spending on health, selected OECD nations, 1980–2005.
Source: Organisation for Economic Cooperation and Development. Public Expenditures on Health. Available online at http://stats.oecd.org/
Index.aspx?datasetcode=SOCX AGG. Paris: OECD.
Fig. 8. Public spending on old age, selected OECD nations, 1980–2005.
Source: Organisation for Economic Cooperation and Development. Public Expenditures on Old Age. Available online at http://stats.oecd.org/
Index.aspx?datasetcode=SOCX AGG. Paris: OECD.
50
T. Bryant et al. / Health Policy 101 (2011) 44–58
Fig. 9. Relative poverty rates for different income thresholds, mid-2000. Relative poverty rates at 40, 50 and 60% of median income thresholds.
Source: Organisation for Economic Cooperation and Development. (2008). Growing Unequal: Income Distribution and Poverty in OECD Nations. Available
online at http://dx.doi.org/10.1787/422066332325. Paris: OECD.
rates represent very high poverty rates existing since the
mid-1980s.
Fig. 11 provides evidence of increasing inequality
among all the selected nations with the exception of France
from the mid-1970s to the present. The Canadian increase
in income inequality (and poverty) has been especially
great over the last 10 years – a point emphasized by
the OECD [79]. What have been the specific public policy actions taken by Canadian jurisdictions that account for
these findings?
[51,82,83] and have been shown to be clear precursors of
SDH-supporting public policy by such diverse agencies as
UNICEF [40], the SDH Commission [1], the OECD [20,84],
and researchers concerned with the political economy of
health [48,65,68,85,86].
Canada was never a welfare state to the extent of many
European nations and this continues to be the case [87].
There has been, however, a profound shift in the federal
influence on public policy which has led to a deterioration
in the quality of the SDH for many Canadians [88,89].
8. Canadian public policy and the SDH
8.1. Income and income distribution
Public policy is an important influence upon population
health outcomes among other developing and developed
nations [1]. Researchers have come to focus on public policy decisions related to the provision of citizen security and
supports in navigating the life course [9,22,80,81]. These
public policy approaches are clear reflections of national
differences in governmental willingness to intervene in
the operation of the economic system or marketplace
As presented earlier, Canadians experience a disturbingly high incidence of poverty and the OECD notes
striking increases in income inequality and poverty rates
since the mid-1990s. Lee argues that much of this has come
about through changes in the tax structures that redistribute wealth [90].
To illustrate, in 1990 the total tax burden of the bottom
10% of income earners was 25.5% of broad income, that is
Fig. 10. Changes in relative poverty rates at 50% threshold, selected countries, mid-1980 to mid-2000.
Source: Organisation for Economic Cooperation and Development. (2008). Growing Unequal: Income Distribution and Poverty in OECD Nations. Available
online at http://dx.doi.org/10.1787/422076001267. Paris: OECD.
T. Bryant et al. / Health Policy 101 (2011) 44–58
51
Fig. 11. Gini coefficient for income, selected OECD nations, mid-1970 to mid-2000.
Source: Organisation for Economic Cooperation and Development. (2008). Growing Unequal: Income Distribution and Poverty in OECD Nations. Available
online at http://dx.doi.org/10.1787/420558357243. Paris: OECD.
including market, investments, and benefits, a figure that
increased to 30.7% in 2005. In contrast, the top 1% of earners saw their total taxes being reduced from 34.2% to 30.5%
over this period; the next highest 4% saw a reduction from
36.5% to 33.8%; and the next five percent (those constituting the 90–95 percentiles of earners saw reductions from
38.6% to 36.9%. These patterns represent changes in federal and provincial personal income tax rates, federal and
provincial commodity taxes, and property taxes [90].
Additionally, the Canadian National Council of Welfare
– a policy advisory group to the national government details how during the 1980s, social assistance rates began
to fall well below 1970s levels in real dollar terms [91].
Much of this can be traced to changes in how the federal
government transfers resources to the provinces. During
the 1980s the federal government began to limit its costsharing of social and health programs with the provinces,
forcing retrenchment in many social programs [92]. The
striking decline in federal budgetary expenditures over
time in spite of increasing GDP is apparent in Fig. 12.
Then in 1996, as part of a major deficit reduction effort,
the Canada Assistance Program (CAP) which saw the federal government providing separate funding envelopes to
the provinces for social services, post-secondary education,
and health care, on the basis of specified performance and
cost-sharing criteria – was replaced by a largely uncon-
Fig. 12. Federal budgetary expenses and GDP, Canada, 1961–2006.
Source: Canada, Department of Finance (2003). Fiscal Reference Tables, October 2003. Ottawa: Centre for the Study of Living Standards.
52
T. Bryant et al. / Health Policy 101 (2011) 44–58
ditional single funding envelope under the Canada Health
and Social Transfer (CHST). The result was that provinces
began to transfer resources from the social services envelope, not a program with wide popular support, to the other
two more popular policy areas (health and post-secondary
education).
The effects of these activities are clear. A recent Statistics Canada study notes a marked change in the overall
redistributive effect of taxes and transfers since 1979.
“[R]edistribution grew enough in the 1980s to offset 130%
of the growth in family market-income inequality – more
than enough to keep after-tax income inequality stable.
However, in the 1990-to-2004 period, redistribution did
not grow at the same pace as market-income inequality
and offset only 19% of the increase in family market-income
inequality” [93] p. 8.
Minimum wages (which are set provincially) also began
to fall well-behind inflation and increases in living costs in
the late 1980s [91,94]. Much of this had to do with Canada’s
adopting what Cerny has termed “the competition state” in
which governments must appear to be business-friendly
[95]. The weakening of labour union influence associated
with the adoption of welfare retrenchment policies and
declines in union membership from 38% in 1981 to 31%
in 2004 likely also contributed to the erosion in minimum wages [96]. In Ontario, Canada’s largest and most
industrialized province, unionization was made significantly more difficult as a result of public policy changes
associated with the election of a Conservative, explicitly
business-friendly provincial government in 1995 [97]. The
subsequent Liberal government has refused to change most
of the anti-union elements of the policy (although it has
reversed the legalization of the 60-h work week), despite
having campaigned on a platform of doing so. Similar
changes in labour relations policy were made in British
Columbia after the election of a comparably right-wing
government.
8.2. Reduction of family and child poverty
In 1989 the House of Commons (the lower house of
Canada’s bicameral national Parliament) resolved to end
child (family) poverty by the year 2000 [98]. As detailed
above, the mix of public policies related to income and
social assistance levels and the housing issues described in
the next section have done little to reduce Canada’s relatively high child and family poverty rates. The reasons
for this are clearly detailed in numerous reports, research
studies, and institutional analyses: like other liberal political economies Canada’s economic and political structures
do little to intervene in the operation of the marketplace
[19,48,49,99,100].
Several anti-poverty initiatives have also been
announced by provincial governments but combined
with an unwillingness to deal with issues of unequal
power, increasingly unfair tax structures, and weakened
ability of labour to influence public policy making, these
efforts have come to little. The increased incidence of
low-income has become especially problematic in major
Canadian urban areas. Poverty is now heavily concentrated in the large urban areas of Vancouver, Toronto,
and Montreal [101]. As noted, a significant proportion of
lone-parent families, 90% of which are led by women, live
in poverty.
8.3. Housing
Profound shifts have occurred in housing policy in
Canada since the mid-1980s [102]. The end of World War
II until 1993 saw the federal government (with some costsharing from the provinces) funding about 650,000 housing
units for low-income Canadians. Like many provinces,
Ontario funded a social housing program from the mid1980 to 1995.
Upon the election of a Conservative government in
1984, the federal government began to withdraw its commitment to housing provision. Within 10 years, almost $2
billion from housing programs was withdrawn and all new
social housing cancelled. The election of a Liberal government in 1993 saw a 1996 announcement of plans to end all
federal government involvement in the provision of affordable housing. More recently, the pronounced increase in
homelessness in Canada that resulted from these shifts
led to growing pressures on the federal government to
respond [102]. In December 1999, a national homelessness
strategy was implemented. A key component of this initiative was the Supporting Community Partnerships Initiative
(SCPI). SCPI funding of $753 million over 3 years created innovative transitional housing and services in several
cities.
In November 2001, the federal government signed the
Affordable Housing Framework Agreement with every
province and territory. The federal government agreed to
provide $1 billion over 5 years. Provinces and territories
agreed to match the federal dollars. However, Shapcott
points out [102]:
• Most provinces are not paying their matching share. The
definition of “affordable” has been changed to “average
market rents,” so the new housing will be rented at existing market rents. However, as many as two-thirds of
renters cannot afford average rents, which puts the housing out of the reach of those who need it the most.
• Even if the framework agreement was fully funded, the
total number of units would be well short of the amount
required to meet the massive and growing need for
affordable rental housing (p. 231).
• Researchers have noted that it is well within the reach
of Canadian governments to end the homelessness crisis by increasing their budgetary allocation for housing
by 1% of overall government spending [103]. Canadian
governments are unwilling to make such a commitment.
8.4. Early child development
Early childhood development is a major social determinant of health and as noted earlier, Canada allocates rather
few national resources towards families. Positive conditions during childhood not only support child health, but
have long lasting effects on health and the development of
disease during adulthood [104]. Early childhood development is influenced itself by other determinants of health
T. Bryant et al. / Health Policy 101 (2011) 44–58
such as adequate income, housing and food security. Regulated quality childcare is particularly important in early
child development. It has an especially positive impact
on children living in the worst socioeconomic conditions
[105]. Outside the province of Québec, which offers universal access to subsidized child care (albeit with long waiting
lists), the availability of regulated childcare for Canadian
families is 10–15% [104].
Recent reports on OECD nations’ spending on childcare and pre-primary spending placed Canada 36th of 37
nations and in the case of paid maternity leave (in weeks)
multiplied by percent of usual salary paid, gave Canada a
ranking of 13th of 25 nations [106,107]. A national program
of childcare was promised in the Liberal Party of Canada’s
1993 election platform but was not implemented until a
minority government situation forced a start to implementation of this in 2005. Even this initial commitment was
derailed by the subsequent election of a Conservative Party
government in 2006.
8.5. Urban/metropolitan areas as settings for the social
determinants of health
This last area acquires special importance in a highly
urban country given the growing evidence of deepening
spatial segregation along social class and racial lines, of
how a range of neighbourhood-scale social and economic
variables influence health. Increasing economic segregation on spatial lines is an important feature of Canadian
metropolitan life [108,109]. Notably, in the Toronto Census
Metropolitan Area, 2001 census data showed that:
“[T]he rising income gap between high and low-income
families was mirrored by a rising gap between high
and low-income neighbourhoods. In Toronto, median
family before-tax income in the poorest 10% of neighbourhoods rose 0.2% from 1980. In the richest 10%, it
was up 23.3%. This increasing difference was observed
in all larger CMAs. This steady rise in the income of
high-income neighbourhoods suggests a widening gap
between the rich and poor that is not only seen in
income polarization but also in terms of spatial polarization” [110] p. 12.
Two noted Canadian urbanists conclude that US-style
urban ghettos are not (yet) a feature of Canadian urban
life, but concede in the case of Toronto that certain
high-poverty areas are characterized by concentrations of
low-rent apartment housing and of recent low-income
immigrants [111]. The growth of concentrated poverty has
been especially great in Toronto, Canada’s largest city [112]
but is apparent across all major metropolitan areas [113].
The growth of poverty and substandard housing for lowincome households shows that urban areas have developed
into platforms for the unequal distribution of risk within a
population [114]. Households experiencing material deprivation often live in conditions that can be dangerous with
implications for their long-term health. The situation is
exacerbated when supports for housing such as rent control and subsidized housing are not available. Low-income
households are forced to become consumers in the private
market.
53
It is not as if these issues have been unexamined or
unpublicized. The Federation of Canadian Municipalities
has issued numerous reports pointing out growing inequality in cities [108,115,116], the growing housing crisis [117],
a failure to meet the needs of recent immigrants in cities
[118], and a general decline in urban quality of life.
9. Discussion: welfare state development and
retrenchment
From the data presented in this paper Canada (and the
USA, and the UK to some extent) is clearly distinguished
from both the social democratic and conservative welfare state exemplars. Among some conservative nations
the welfare state emerged as early as the last 19th century. For others, particularly the liberal nations, it marked
a significant development in most developed economies
following the end of the Second World War. National governments intervened in social provision, including housing,
social services such as social assistance, unemployment
insurance, and health care to ensure all citizens had access
to these goods [119,120]. These reforms continue to be
important as the research literature has shown them to
be good predictors of the overall health of a population
[4,40,49]. There is a clear relationship between public
policy choices and the SDH. Public policies can promote
income redistribution and can directly influence the quality of other important social determinants such as housing,
food security and employment security and working conditions through legislation.
Nations had diverse reasons for developing their welfare states. In most countries, the welfare state provided
some security for family and individual households against
the adverse effects of the market. The welfare state also
helped rebuild war-damaged economies of Europe following the Second World War [119]. It redistributes income
and other economic resources from high-income groups
to low-income earners in a population. For example, the
health care system in Canada is financed from general
revenues received through taxation [18,121,122], fulfilling
one of the principles of health system efficiency: crosssubsidization from rich to poor, and from healthy to ill
[123].
All developed economies have limited increases, and
in some cases, reduced public spending in response to
global economic pressures [119]. The proffered justification for reduced public expenditures is that it enhances
a nation’s competitiveness in the global economy. These
changes have been especially apparent in the liberal political economies and we have illustrated their effects in
Canada. The general result was significant deregulation of
market forces and reduced public expenditures such as the
welfare state. The United Kingdom has been an excellent
example – to which Canada can now be added – as illustrations of such policy changes. In 1979, Margaret Thatcher
launched the first assault on the welfare state in conjunction with a radical shift from Keynesianism to monetarism
[124]. Canada began to adopt these approaches in the late
1980s and in earnest during the early 1990s [59,125].
Labour market restructuring in Canada resulted in
increasing precarious employment, low-paying jobs, and
54
T. Bryant et al. / Health Policy 101 (2011) 44–58
growing income and wealth inequality in Canada [126].
Among OECD countries, Canada is now among nations with
the highest percentage of low-paying jobs at 25% [127]. The
incidence of low-paying jobs is one of the best predictors
of higher child and family poverty [49]. Not surprisingly,
income, housing, and food security have become strikingly
apparent across Canada [102,128,129].
The value of the SDH concept is that it directs attention
to public policy domains that can be the focus of advocacy efforts. Public policy decisions made over the past two
decades have reduced Canada’s capacity to address health
inequalities by way of their underlying social determinants.
As noted earlier, there are two stylized explanations of
how these policy directions came about: (a) inadequate
or ineffective knowledge translation, and (b) changes in
Canada’s economic and political structure, partly related
to increased integration into the world economy, and the
associated impact on political allegiances and values.
The first explanation of inadequate knowledge translation is consistent with what political scientists term the
pluralist approach to public policy making. In this model,
policy development is driven primarily by the quality of
ideas in the public policy arena such that those judged as
beneficial and useful will be translated into policies by governing authorities [130]. More research and publications
such as this one can be brought to the attention of policy
makers who will evaluate their potential contribution and
then act on it.
The pluralist approach suggests the need for further research, knowledge dissemination, and public policy
advocacy with the aim of convincing policymakers to
enact health-supporting public policies [130,131]. And the
implementation of this analysis can be seen in increasing Canadian funding of health inequality-related research,
prolific governmental and institutional reporting of the
importance of health inequalities research, and Canadian
involvement with a variety of inequality related organizations and institutions such as the SDH Commission and its
knowledge networks. The problem is that in Canada all of
these activities have so far had little impact in terms of
policy action to address the SDH.
In contrast, the alternative explanation of changes in
Canada’s economic and political structures, partly related
to increased integration into the world economy, and the
associated impact on political allegiances and values as
shaping public policy action in support of the SDH is consistent with what political scientists term the materialist
analysis of public policy making [130]. In this model, policy
development is driven primarily by powerful interests who
assure their concerns receive rather more attention than
those not so situated. In Canada, it would be argued that
these powerful interests are usually based on the private
sector and have powerful partners in the political arena.
The materialist model suggests the need for developing
strong social and political movements with the aim of forcing policymakers to enact health-supporting public policy.
In Canada, governing authorities have been resistant to
actions that would strengthen the SDH. The “hard right
turn” in Canadian public policy that became apparent in
the last 1980s through the early 1990s [89] was clearly
correlated with increasing acceptance of liberalization in
global trade, increased deregulation, and creating more
business-friendly labour markets [88,132,133]. Associated
with these shifts has been the rise of US and UK-influenced
neo-liberal policy orientations that have both the Conservative and Liberal parties shifting sharply to the right.
The strongest retrenchment actually came about during
an era of Liberal Party rule, The Liberal Federal Budget of
1995 introduced measures that reduced social and health
spending, specifically with the Canada Health and Social
Transfer [88,134]. This transfer effectively replaced costsharing with block funding for social and health programs
in Canada, enabling the federal government to reduce
the federal deficit and accumulate a surplus. The reduced
federal contribution has imposed more responsibility on
the provincial governments to finance social programs. In
their quest to raise these funds, provinces have increasingly turned to privatization as means of financing health
care, municipal services, and other governmental programs
through public–private partnership and outright contracting out to private firms. The result has been downward
pressures on wages and the inability of governments to
influence the provision and quality of these services.
10. Conclusion
The changes in SDH that we have described are related
to changes in the operations of Canada’s economic and
political system. Much of this involves shifts in governance
where authorities relegate important decisions on resource
allocation and distribution to the marketplace. This has
increasingly led to a “privatization of security” whereby
security is (financially) guaranteed for the wealthy and
rather less so for the poor and disadvantaged [135]. Frequently, the argument justifying this is that economic
globalization leaves us no alternative [136–138].
However, these changes are most apparent in liberal
political economies where government intervention in
the marketplace has always been difficult to attain. For
Europeans living under social democratic and continental
conservative political economies, the importance of governmental intervention in the marketplace is usually taken
as a given [139]. Governmental ideological commitments
to reducing inequality common among social democratic
regimes and/or building cohesion and solidarity common
among conservative regimes assist the uptake of evidence
and information in the service of reducing social and health
inequalities [65]. In liberal political economies this is less
so and is especially the case for nations with weak social
democratic parties of the left such as Canada and the USA.
For Canadians (and others) living under liberal political
economies, social movements aimed at shifting dominant
approaches to governance seem necessary [140]. Shifting
economic, political and ideological structures is no easy
task [141].
Recent UK policies under New Labour gave some
cause for optimism, including the commissioning of a
national follow-up study to the WHO Commission on
Social Determinants of Health which contained detailed
policy analyses and advice [142]. The election of a coalition
Conservative/Liberal Democratic government in 2010,
however, corresponded with a deep public deficit, partly a
T. Bryant et al. / Health Policy 101 (2011) 44–58
consequence of the global financial crisis and subsequent
banking bailouts and counter-cyclical stimulus spending.
This has been seized upon by the new government as a
basis for advising cuts in most departments of between 25%
and 40% [143] and increased marketization of its National
Health System [143,144], the financial and health burdens
of which will be borne disproportionately by women [145].
Although decisive political and professional leadership
may be necessary conditions for strengthening the SDH and
reducing health inequalities, the ideological bent of such
leadership can (rather rapidly) push public policy in an
opposite direction. At base, the challenge facing Canada,
all other liberal political economies and, increasingly, even
those with social democratic legacies, have been shifts in
the nature of global capitalism, in which capital accumulation is increasingly facilitated through financial markets
(and not through the ‘real’ economy of production and consumption) and the ability of investors to reap windfall gains
through speculation, land acquisitions and other forms of
‘dispossession’ of peoples’ livelihoods [146]. Not only must
social movements engage with national policy shifts; they
must also confront the global shifts in capitalism, yet such
shifts have occurred in the past [146–149]. Decisive political and professional leadership are necessary conditions for
strengthening the SDH and reducing health inequalities are
urgently needed. At the same time, since Canadian public
policy appears to be a result of shifting economic and political structures, these activities may not be sufficient but will
require the building of social and political movements that
will force the modification of the economic and political
structures that shape public policy.
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Critical Public Health
Vol. 18, No. 4, December 2008, 483–495
Grasping at straws: a recent history of health promotion in Canada
Dennis Raphael*
York University, Toronto, Canada
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(Received 16 April 2008; final version received 1 September 2008)
Despite Canada’s reputation as a leader in the development of health promotion
concepts, implementation of these concepts in the service of health has always
been far from stellar. Much of this has to do with Canada’s liberal political
economy and the recent further ascendance of neo-liberal approaches to public
policymaking. These developments have combined with longstanding biomedical
and epidemiological traditions in health policy to inhibit health promotion
approaches that incorporate the principles and themes of the Ottawa Charter.
Additionally, the emergence in Canada of population health as a competing – and
displacing – discourse to health policy has further eroded health promotion’s
profile and presence. There is increasing interest in the social determinants of
health concept, yet government spending, media attention, and health sector
activities lavished on ‘lifestyle’ approaches to health promotion and the
emergence of the ‘obesity epidemic’ as a focus of public, media, and health
sector attention serves to further reinforce this dreary picture.
Keywords: public policy; population health; health promotion
Grasping at straws
(1) trying to find reasons to feel hopeful about a bad situation.
(2) trying to find some way to succeed when nothing you choose is likely to work.
Cambridge Dictionary of American Idioms, Cambridge University Press, 2003.
Introduction
Arguably, the most important contribution of health promotion has been the
identification of the roles that societal structures and public policy play in shaping the
health of populations in general and the most vulnerable in particular (Kickbusch 2003).
Intertwined with this is a belief that individuals and communities can undertake
activities that can increase their control over the determinants of health (Nutbeam
1998). Ultimately, these thrusts should combine to create healthy public policy that is
responsive to the needs of the citizenry. The best illustrations of the health promotion
approach are the declarations delivered by the series of international conferences on health
promotion (ACT Health Promotion 2004).
*Email: [email protected]
ISSN 0958–1596 print/ISSN 1469–3682 online
ß 2008 Taylor & Francis
DOI: 10.1080/09581590802443604
http://www.informaworld.com
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D. Raphael
There are numerous outstanding examples of these concepts being put into practice
in the service of health. The ones that come most easily to mind are those of the
WHO-Europe Healthy Cities Office, public policies in the service of health in the Nordic
nations, and ongoing efforts in the UK (Kautto et al. 2001, Benzeval, 2002, Burstrom et al.
2002, Einhorn and Logue 2003, World Health Organization Regional Office for Europe
2003, Raphael and Bryant 2006b). Yet, examples of such activities being implemented in
Canada are few and far between, a conclusion come to by any number of authorities in the
health promotion and health policy fields (Legowski and McKay 2000, Canadian
Population Health Initiative 2002, Lavis 2002, Collins and Hayes 2007, O’Neill et al. 2007).
This is surprising to many, as most analyses of the history of health promotion
pay homage to Canadian contributions to the field (Restrepo 2000, O’Neill et al.
2007). In particular, these analyses typically laud the impact of the 1974 Canadian Lalonde
Report (Lalonde 1974), A new perspective on the health of Canadians, as signalling the
beginning of the modern health promotion era. Add to this the 1986 Canadian Epp Report,
Achieving health for all: a framework for health promotion (Epp 1986), which was released
simultaneously with the Ottawa Charter, the 1984 birth of the Healthy cities movement in
Toronto (Hancock and Duhl 1986), the important contributions from the likes of Ronald
Labonte and Trevor Hancock among others, the Canadian Institute for Advanced Research
discourse of population health (Evans et al. 1994) and ongoing creative work by Health
Canada (2001). All of this provides the makings – it would appear – of a health promotion
powerhouse. Well, not exactly.
In reality, health promotion in Canada – and its ambitious agenda for community
action and public policy in the service of health – has always served as a marginal discourse
in the Canadian health policy arena (Labonte 1994, Legowski and McKay 2000, Lavis
2002). It is increasingly being recognized (Raphael and Bryant 2006a, Collins and Hayes
2007) that the primary reason for this has been the public policy realities associated with
Canada’s being a clear representative of what has been identified as a liberal political
economy (Esping-Andersen 1999, Bernard and Saint-Arnaud 2004). Such a system
places the market-place, rather than the State, as the primary institution and arbiter of
resource distribution – political, economic, and social – within a society (Saint-Arnaud
and Bernard 2003).
Within such a scenario, strong public policy – supported by community action – in the
service of health promotion is difficult to implement (Raphael and Bryant 2006a, Collins
and Hayes 2007). Interestingly, in Canada the presence of a market-dominated approach
to public policy did not prevent the development of health promotion and population
health concepts and some impressive activities in the service of health. Much of this has to
do with the space provided for Health Canada civil servants at the federal level and some
rather remarkable Canadian thinkers to develop important concepts and applications.
Yet in practice, these concepts and activities have always been marginal and their
implementation falls far short of what would have been expected from the birthplace of so
many health promotion concepts.
This review provides a brief overview of the history of health promotion in Canada and
an analysis of recent developments on the Canadian health promotion scene. My analyses
suggest that these developments in the Canadian public policy realm offer little sustenance
to health promotion concepts and activities consistent with the vision of the Ottawa
Charter (Raphael and Bryant 2006b). However, increasing Canadian interest in the social
determinants of health may help spark a renewal of interest in public policy approaches to
health promotion.
Critical Public Health
485
Table 1. Key developments in health promotion/population health in
Canada.
1974
1980
1984
1986
1986
1994
1994
2000
2002
Lalonde report
Shifting medical paradigm conference
Beyond health care conference
The Ottawa charter
The Epp report
Federal/provincial/territorial report on population health
Publication of Why are some people healthy and others not?
Health Canada population health template
Social determinants of health across the life-span conference
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Note: Expanded from Labonte (1994). See Labonte (1994), Legowski and
McKay (2000), O’Neill et al. (2007a) and Raphael (2004a) for further
details.
Background
The role Canada has played in the development and application of health promotion
is well documented in Health promotion: an anthology (Restrepo 2000), the 1994 volume
Health promotion in Canada (Pederson et al. 1994) and the 2007 volume Health
promotion in Canada: critical perspectives (O’Neill et al. 2007). Table 1 provides some key
events.
The Lalonde Report
Despite the lauding of A new perspective on the health of Canadians – the Lalonde Report –
(Lalonde 1974) for raising environmental issues as important to health in addition to
lifestyle, health care and biology, there were always two problems associated with the
report’s reception and implementation. The first was the excessive focus on lifestyle issues,
a point commented on as early as 1981 (Labonte and Penfold 1981). The second was
a governmental decision to focus on health issues seen as providing the most immediate
payoff for health authorities. The priority issues selected for action were automobile
accidents, occupational health, and alcoholism and ‘For all three, lifestyle was identified as
the underlying cause’ (Legowski and McKay 2000, p. 7). Public programmes implemented
in the wake of the Lalonde report in 1976 were ‘Dialogue on drinking’ and ‘Operation
lifestyle’. A range of similar activities organized along the lines of lifestyle programming
emerged in the lead-up to the Epp report (Legowski and McKay 2000).
The Epp Report
Two developments contributed to a broader Canadian approach to health promotion
enshrined in Achieving health for all (Legowski and McKay 2000). One was Health and
Welfare Canada’s work with the WHO European Office in 1984. Much of these activities
were consistent with the materialist/structuralist conclusions concerning the determinants
of health provided by the UK’s Black Report (Black and Smith 1992). The second was the
1984 Beyond Health Care international conference held in Toronto which spawned two
new ideas: healthy public policy and healthy cities. Compared to European developments,
it was apparent that Canada was falling behind in considering the broader determinants
of health.
486
D. Raphael
Aim
Achieving health for all
Health challenges
Reducing inequities
Increasing prevention
Enhancing coping
Health promotion
mechanisms
Self-care
Mutual aid
Healthy environments
Fostering public
participation
Strengthening
community health
Coordinating healthy
public policy
Implementation
strategies
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Figure 1. A framework for health promotion.
Source: National Health and Welfare, Achieving health for all: a framework for health promotion,
Ottawa, 1986.
Integrating many of these ideas and coincident with the release of the Ottawa Charter,
Achieving Health for All is now seen as the high water point of health promotion in
Canada (Frisby et al. 1999). The document took a strong structural approach to health
promotion with the key aspects presented in Figure 1.
Legowski and McKay (2000) therefore suggest that contrary to conventional wisdom,
Canada’s health promotion approach was a response – rather than a stimulus – to
European developments. Despite the extensive distribution of the new document, policy
development for the most part continued within the lifestyle vein. While some
demonstration projects associated with the healthy communities approach shared this
broader perspective, the lion’s share of funding and activity continued to be allocated to
the marketing of lifestyle messaging to the Canadian public.
It is clear that these two competing aspects of health promotion – the ‘lifestyle’ and
‘broader’ – discourses competed for funding from the Lalonde report right through to the
development, release and follow-up to the Epp report. At virtually every period, the
lifestyle approach trumped the broader approach. Certainly, important ‘broader’ ideas
were developed and some related initiatives were implemented. But these health promotion
concepts and approaches seem to exist in parallel to public policy attitudes of the 1970s
and 1980s and had rather little input into the adoption of public policies that addressed
even then broader determinants of health such as housing, income security, and
employment training.
One exception that comes to mind is the Community Health Centre concept that saw
its implementation primarily in Ontario and Quebec. In these cases there has been
and continues to be clear implementation of health promotion concepts into real and
meaningful action. The appendix provides details concerning the Ontario manifestation of
the Community Health Centre concept.
Enter the 1990s
As noted, despite Canada’s reputation as a leader in the development of such health
promotion concepts, the implementation of these concepts in the service of health
was always been far from stellar and lagged behind developments in most other
developed nations (Canadian Population Health Initiative 2002). Unfortunately, health
promotion – always at odds with dominant lifestyle approaches to health – then ran smack
into the neo-liberal public policy resurgence of the early 1990s (McBride and Shields 1997,
Critical Public Health
487
Teeple 2000, Scarth 2004). In a time of welfare state retrenchment, there was even less
policy space for an activist health promotion, especially one that seemed to contradict the
basic tenets of neo-liberalism: government withdrawal from citizen support; increased role
for the market, privatization of public goods, and treatment of the individual as a
consumer rather than a citizen, among others (Coburn, 2001, 2004).
In the 1994 volume Health promotion in Canada: provincial, national, and international
perspectives, some of the foremost health promotion leaders recognized these storm clouds
but yet saw promise in the future (Pederson et al. 1994). Since then, the threat to health
promotion of neo-liberalism has materialized. Living conditions have deteriorated for the
most vulnerable, governments has abdicated much of their responsibilities for assuring
citizen health, and the concept that citizens and communities should be assisted in gaining
control over the determinants of health has dissolved (Raphael 2001, 2004b).
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Squeezed by population health
The 1990s also saw the emergence of population health as a competing health policy
discourse. Population health grew out of efforts by the Canadian Institute for Advanced
Research to identify what they termed the determinants of health (Evans et al. 1994,
Stoddart 1995). The population health discourse displaced health promotion with
remarkable speed – at least in terms of government departments, health policy rhetoric,
and distribution of research funding. Some have attributed this to its being consistent with
a neo-liberal approach to governmental governance (Poland et al. 1998, Robertson 1998),
dissatisfaction with the lack of success of health promotion (Legowski and McKay 2000),
and government willingness to turn over policy development to an outside institute
manned by impressive health researchers in the face of funding reductions within Health
Canada and a resurgent neo-liberal political discourse (Labonte 1997, Legowski and
McKay 2000).
There are no shortages of critiques of the population health discourse by health
promotion workers (Labonte 1997, Raphael and Bryant 2002, Labonte et al. 2005).
While certainly an advance over lifestyle approaches, the population health approach has
been criticized as being an epidemiologically oriented approach that de-politicizes
health issues, leaves little room for alternative views of knowledge to the traditional
positivist model, and has little to say about community involvement or participation
(Raphael and Bryant 2002). Nevertheless, Health Canada has tried to integrate the
most progressive elements from each approach and the potential of such integration
continues to be explored (Hamilton and Bhatti 1996, Health Canada 2001, Labonte
et al. 2005).
Despite the absence of any apparent effects of the population health discourse upon
health policy (Lavis 1998, 2002, Collins and Hayes 2007), the effect of the rise of
population health has been to shift much of the remaining enthusiasm for health
promotion principles in universities and community organization into a discourse that
celebrates epidemiological approaches to understanding health determinants, a withdrawal
from advocacy into carrying out research activities, and a weakening of the value of
alternative views concerning the nature of knowledge and the means of promoting health
(Robertson 1998, Raphael and Bryant 2002). These effects have been particularly
prominent among the public health community where population health rhetoric fits in
better with the prevailing reluctance to engage in community development and public
policy discussions and activities (Raphael 2003).
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D. Raphael
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Squeezed by healthy lifestyles
At the same time health promotion concepts and activities bled towards the population
health school, healthy lifestyles rhetoric by governments, the health care and public
health sectors, and the media continued at an accelerating pace fuelled by the ‘obesity
epidemic’.
The first Canadian critique of lifestyle approaches to health promotion emerged in
1981 (Labonte and Penfold 1981). These critiques should be well-known to readers and
I will not reiterate them here. Let me summarize the Canadian scene succinctly: Canadians
are being bombarded on a daily basis by government agencies, public health agencies,
disease associations and the media by lifestyle messaging that promotes healthy diets,
physical activity, and reducing tobacco use. Perusal of any public health document or
disease agency publication gives lip service to the broader determinants of health but
quickly succumbs to exhortations about making healthy choices in the service of health.
Even critical health promoters feel obliged to incorporate a healthy lifestyle discourse into
their work (Frohlich and Poland 2007).
And the media obliges by headlining each and every obesity study taking place
anywhere and everywhere (Gasher et al. 2007, Hayes et al. 2007). All of this takes place as
the public policy scene deteriorates. Wages for the majority of Canadians stagnate,
poverty rates remain unchanged, and the gap between rich and poor continues to grow
(Curry-Stevens 2003, 2004). Food bank use and homelessness may be increasing across
Canada and employment and working conditions may be deteriorating, but every
Canadian believes that the primary determinants of health are diet and physical activity
(Canadian Population Health Initiative 2004). The result of all of this is that health
promotion – never a dominant force – is barely visible.
Whither health promotion?
It is a testament to the de-politicization of health promotion in Canada that I was
working – researching, teaching, and writing – in the field for close to 10 years before I
came across Esping-Andersen’s work on the political economy of differing welfare states
(Esping-Andersen 1990, 1999). This came about as numerous contributors to my edited
volume – Social determinants of health: Canadian perspectives – called upon his welfare
state typology to provide a means of understanding why Canada’s approach to numerous
prerequisites of health such as employment and working conditions, early childhood, and
income and housing security were so undeveloped as compared to numerous European
nations (Friendly 2004, Jackson 2004, Tremblay 2004). The contrast was especially great
between nations with liberal political economies such as Canada, UK, USA, and Ireland
and those with social democratic political economies such as Denmark, Finland, Norway,
and Sweden.
Bolstered by the work of David Coburn (2001, 2004, 2006) on the impact of
neo-liberalism on health and well-being and Vincent Navarro’s ongoing analyses of the
political economy of health (Navarro 2002, Navarro et al. 2004, Navarro and Muntaner
2004), it became increasingly clear that the extent to which health promotion was nurtured
as a means of both understanding and creating the conditions necessary for health was
determined in large part by the dominant ideological discourse concerning the organization
and distribution of resources within a society (Raphael and Bryant 2006b). Indeed, the
relevance of the political economy literature for understanding the implementation of health
promotion concepts is strikingly apparent when public health goals are compared among
nations that differ in their orientation to the welfare state.
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Critical Public Health
489
The most interesting examples of this are the public health goals of Sweden and
Finland where these goals appear to be direct descendents of the Ottawa Charter with
the addition that these apply a critical perspective to understanding the role of the
State in reaching these objectives. In contrast, emerging goals in the Canada and the
USA are narrow, behavioural and say nothing about broader determinants of
health nor empowering citizens and communities (Raphael and Bryant 2006a,
Raphael 2008).
Health promotion as outlined in the Ottawa Charter took as a given that societies
would strive to support the prerequisites of health and provide the means by which
individuals and communities would gain control over the determinants of health
(World Health Organization 1986). This may have been the case in Canada during the
1970s and 1980s. And indeed, there is much evidence that during this ‘Golden Age’ of the
welfare state in Canada, there was greater public policy commitment to both meeting
citizens’ basic needs and promoting community development in support of health.
But as noted, the emerging health promotion discourse had little to do with these policy
emphases.
It may very well be that the enlightened policy environment simply allowed
Health Canada and university researchers to develop and export these concepts to
more receptive jurisdictions. The Healthy Cities and other important health
promotion concepts were created by Canadians and then exported to the world. But
these concepts always remained in the shadow of the healthy lifestyle discourses
in Canada.
More evidence for this neglect of Ottawa Charter concepts comes from surveys of
Canadian public health units, approaches towards establishing health goals, their
responses to poverty, and analyses of public health priorities and activities (Sutcliffe
et al. 1997, Williamson 2001, Williamson et al. 2003). While health promotion concepts
were usually found in abstract mission statements and health goals objectives, their
translation into action were few and far between.
[Collins and Hayes (2007) develop the argument that the ongoing Canadian
preoccupation with health care has also served to inhibit adoption of a health promotion
or population health perspective to health policy. Yet, health care is a preoccupation
within all developed nations. To suggest that Canadian concern with health care
provides an explanation for Canada’s backward approach to health policy is not
persuasive.]
Prospects for a re-emergence of health promotion
Health promotion
There are continuing efforts by a handful of visionary Canadian health promotion
advocates to implement the vision of health promotion outlined in the Ottawa Charter and
subsequent WHO health promotion declarations and charters (O’Neill et al. 2007).
The Canadian Consortium for Health Promotion Research stubbornly clings to the health
promotion title rather than the population health identifier. Graduate programmes in
health promotion continue to produce a handful of graduates who are exposed to the
history and theory of health promotion. Community health centres across Canada
maintain a commitment to the principles of Alma Mata, Ottawa, and other declarations.
In addition, recent work in the social determinants of health area offers some hope in the
public policy arena.
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D. Raphael
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Social determinants of health
There have been some notable developments in the social determinants of health field in
Canada. The 2002 Social Determinants of Health Across the Life Span Conference
brought together 400 researchers and community workers to consider the public policy
and action implications of the deteriorating state of numerous social determinants of
health (Raphael 2004a). Building upon conference presentations Social Determinants of
Health: Canadian Perspectives was published and reached a rather wide audience
(Raphael 2004b).
Since then, the establishment by the World Health Organization of an International
Commission on the Social Determinants of Health – of which two of the knowledge
networks (Globalization and Health and Early Childhood Development) are centred in
Canada while another (Workplace Health) has significant Canadian representation – has
stimulated discussion (World Health Organization 2004). The Canadian Senate’s
Subcommittee on Population Health has undertaken a review of the social determinants
of health (Canadian Senate 2007). The successor to Health Canada – the Public Health
Agency – has established a National Coordinating Centre for the Determinants of Health
at St. Francis Xavier University in Nova Scotia. The federal government has organized a
federal/territorial/provincial task force on health disparities headed up by Trevor
Hancock, and there are ongoing provincial initiatives to address poverty in Quebec and
Newfoundland. These governmental activities have resulted in large part from devoted and
committed civil servants who have not retreated from advancing and implementing a
progressive vision of public health and health promotion.
In addition, a few Canadian health units have distinguished themselves by their work
in raising the importance of the social determinants of health (Raphael 2007). And there is
clear evidence that those working in specific social determinants of health concept areas
such as employment security and working conditions, early childhood education and care,
housing, income, and food security, health and social services and poverty reduction are
more aware of how their issues impact health (Conference Board of Canada 2003, 2006,
O’Hara 2006, United Nations Association of Canada 2006). Non-governmental agencies
such as United Ways across Canada and the United Nations Association of Canada have
drawn upon the social determinants of health concept to advance their work (United Way
of Greater Toronto and Canadian Council on Social Development 2002, United Way of
Ottawa 2003, United Way of Winnipeg 2003).
Conclusion
These scattered efforts, however, count for little in the face of massive amounts of
government spending, media attention, and health sector activities being lavished on
‘lifestyle’ approaches to health promotion (Hayes, 2002). The emergence of the ‘obesity
epidemic’ as a focus of public, media, and health sector attention has only served to
reinforce this orientation. This focus on lifestyle concerns escalates in spite of emerging
evidence that these factors count for little against the important of developing health
promoting public policy and strengthening the ability of the citizenry to influence the
determinants of health.
In a recent thoughtful review of health promotion in Canada, Poland identified the
following successes of Canadian health promotion: (a) supporting municipal leadership
in promoting healthly public policy through healthy community initiatives; (b) uptake
of health promotion concepts outside health sector institutions such as schools
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Critical Public Health
491
and workplaces; (c) acknowledgment of the need for environmental supports for
behaviour change; (d) recognition of need for training in culturally sensitive service
provision; and (e) greater integration of health promotion into the healthcare system
(Poland 2007).
I am not as upbeat as Poland. Rather, I am drawn to what he identifies as failures
and shortcomings of health promotion: (a) a growing gap between rich and poor;
(b) continuing high poverty rates in Canada; (c) dreadful living conditions on Aboriginal
reserves; (d) growing numbers of homeless and under-housed Canadians; (e) an epidemic
of obesity and early-onset diabetes; (f) a steady erosion of the social safety net; (g) no
national public health goals of any significance; (h) diminishing federal leadership in
health promotion; (i) little public participation in decision-making; (j) an overwhelming
emphasis on modifying individual risk behaviours; (k) little evidence of intersectoral
action; (l) few forums for health promotion discussion; and (m) little development of social
analysis into the determinants of health (Poland 2007).
The primary lesson from this brief overview of the history and recent developments in
health promotion in Canada is that health promotion is an explicitly political activity
concerned with improving living conditions and empowering communities to gain control
over the determinants of health. When the public policy environment is supportive of such
concepts health promotion has the opportunity to move forward in building support for
these activities and having governments respond positively to these efforts.
The 1970s and 1980s in Canada could have been such a period. Health promotion was
at its conceptual highpoint, but the extent to which it could have influenced public policy
was restrained by the reticence of federal authorities to make it a major theme in health
activities. This reticence was probably influenced by Canada’s dominant public policy
approaches that were themselves influenced by its liberal political economy.
Nevertheless, there was a relaxation of liberal orthodoxy during this time (Myles 1998).
It may be that during the period of relaxation of dominant liberal approaches to
political and economic organization, health promotion concepts were able to simply
co-exist in parallel. Since the 1990s, this policy environment has shifted. Even this
space has narrowed. Health promotion concepts, however, are certainly not in the
political air.
In addition, the advent of population health has provide a cover for governments,
public health agencies, and health researchers to ignore the key issues that shape the health
of Canadians: the provision of the prerequisites of health for all, applications of values of
social justice and equity, and strengthening means by which individuals and communities
can attempt to shape the determinants of their health.
What we are left with is a duo of de-politicized streams supposedly in the service of
health. The first is population health with its emphasis on further research and the
application of epidemiological concepts to social issues. The second is the lifestyle
discourse of healthy lifestyle choices. Both do little to implement the principles and themes
of the Ottawa Charter. The social determinants of health perspective is gaining some
currency within health policy circles, at least among civil servants who appear to be
operating below the political radar. These activities have occurred previously, however
with rather little to show for their efforts.
In any event, health promotion may be alive and well elsewhere in the world.
In Canada it is hanging on by its fingernails. While an infrastructure and institutional
memory of the meaning and promise of health promotion remains, with every passing year
it grows weaker and weaker.
492
D. Raphael
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Appendix. Community health centres in Ontario
Community health centres are non-profit, community-governed organizations that provide primary
health care, health promotion and community development services, using multi-disciplinary teams
of health providers. These teams often include physicians, nurse practitioners, dieticians, health
promoters, counsellors and others who are paid by salary, rather than through a fee-for-service
system. Community health centres (CHCs) are sponsored and managed by incorporated non-profit
community boards made up of members of the community and others who provide health and social
services.
Services are designed to meet the specific needs of a defined community. In addition, CHCs
provide a variety of health promotion and illness prevention services which focus on addressing and
raising awareness of the broader determinants of health such as employment, education,
environment, isolation and poverty. CHCs have been in existence in Canada since the 1920s;
today, there are over 300 CHCs across Canada. There are 55 CHCs in Ontario.
In many communities, CHCs provide their programs and services for those people who have
difficulties accessing a full range of appropriate primary health-care services. Some examples of
priority groups are members of linguistic or cultural groups, individuals who live in remote under
serviced communities, individuals with low incomes, individuals who are homeless, and the elderly.
Our approach to community health encompasses the broad factors that determine health such as
education, employment, income, social support, environment and housing. Health centres provide
accessible primary health care services in northern and rural communities, in communities where
many people have a high risk of ill health or to individuals and families with significant access issues,
such as their race, ethnicity, or mother tongue. Health centres serve all people within their catchment
area and have particular expertise in serving people who have difficulty accessing other health
services. Health centres are an integral part of the provincial health services system. Individual health
centres have a significant role in providing essential services in many communities. They are often
the main delivery mechanism for core community-based health services offering a continuum of
services that promote individual and community ownership over health.
Source: Association of Ontario Health Centres (2008). What are CHCs? Available at http://
www.aohc.org/aohc/index.aspx?CategoryID¼10&lang¼en-CA
Health Promotion International, Vol. 28 No. 1
doi:10.1093/heapro/dar084
Advance Access published 3 November, 2011
# The Author (2011). Published by Oxford University Press. All rights reserved.
For Permissions, please email: [email protected]
DEBATES
The political economy of health promotion: part 1,
national commitments to provision of the prerequisites
of health†
Health Policy and Management, York University, Toronto, ON, Canada
*Corresponding author. E-mail: [email protected]
†
Material in this article was presented at the 20th IUHPE World Conference on Health Promotion
in Geneva, Switzerland, 13 July 2010.
SUMMARY
Canada is a leader in developing health promotion concepts of providing the prerequisites of health through
health-promoting public policy. But Canada is clearly a
laggard in implementing these concepts. In contrast,
France is seen as a nation in which health promotion concepts have failed to gain much traction yet evidence exists
that France does far better than Canada in providing
these health prerequisites. Such findings suggest that it is
the political economy—or form of the welfare state—of a
nation rather than its explicit commitments to health promotion concepts—that shape provision of the prerequisites of health. Part 1 of this article examines how health
promotion rhetoric specifically concerned with provision
of the prerequisites of health differs among nations
identified as being either liberal, social democratic, conservative or Latin welfare states. Governing authorities of
nations that are liberal or social democratic welfare states
are more likely to make explicit rhetorical commitments
to provision of the prerequisites of health, the conservative
and Latin states less so. Part 2 of this article provides evidence however, that despite their rhetorical commitments
to provision of the prerequisites of health, liberal welfare
state nations fall well behind not only the social democratic nations, but also the conservative welfare states in
implementing public policies that provide the prerequisites
of health. The Latin welfare states express little commitment to provision of the prerequisites of health and rather
limited public policy activity towards meeting this aim.
Key words: government programmes; health policy; public health
INTRODUCTION
Canada has come to be seen as a leader in developing health promotion concepts that emphasize
the importance of providing the prerequisites
of health (i.e. peace, shelter, education, food,
income, a stable eco-system, sustainable
resources, social justice and equity) through
health-promoting public policy (i.e. complementary approaches including legislation, fiscal measures, taxation and organizational change)
(World Health Organisation, 1986). Yet,
Canadian governmental authorities have been
repeatedly identified as laggards in implementing these concepts through public policy activity
(Raphael, 2008a; Senate Subcommittee on
Population Health, 2009; Health Council of
Canada, 2010; Bryant et al., 2011).
Along similar lines, Australian and English
governing authorities are also seen as providing
leadership in health promotion (Health Council
of Canada, 2010), yet evidence indicates they do
far worse in providing the prerequisites of
health than nations such as France, Belgium
and Germany where governmental health
promotion commitments are less apparent
95
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DENNIS RAPHAEL*
96
D. Raphael
social democratic welfare state nations doing
rather well, the liberal welfare states less so
(Navarro and Shi, 2002; Navarro et al., 2004).
The strength of these rhetorical health promotion
commitments among governing authorities—and
their policy activities—in nations identified
as conservative (e.g. Belgium, France and
Germany) and Latin (e.g. Greece, Italy and
Spain) welfare regimes have been less examined.
In this two-part article, I explore these issues
by examining the intersections among the presence or absence of explicit governmental commitments to provision of the prerequisites of
health through health promotion activities, the
public policy activities that support such provision, and a nation’s welfare state type. I coin
the phrase ‘explicit health promotion commitments’ to refer to rhetorical commitments of
governing authorities that endorse—within a
health promotion framework—provision of the
prerequisites of health. These explicit health
promotion commitments should also endorse
the importance of developing health-promoting
public policy that provides the prerequisites of
health. Ideally, these explicit commitments
should be followed by ‘explicit health promotion policy activities’ that address these issues.
I also coin the phrase ‘implicit health promotion activity’ to refer to public policy efforts that
provide the prerequisites of health but do so in
the absence of explicit commitments made
within a health promotion framework. In the implicit health promotion activity case, health promotion statements are less salient—or even
absent—but existing public policy approaches
are consistent with the health promotion principle of providing the prerequisites of health. An
examination of these public policy activities constitutes the main content of Part 2 of this article.
These distinctions between explicit commitments and implicit activities are important
because those concerned with health promotion
will be more likely to be involved in activities
that have been clearly identified as falling
within their domain of expertise. If public
policy activities that address provision of the
prerequisites of health are clearly situated
within a health promotion framework then the
expertise and involvement of health promoters
should be seen by governing authorities and the
public as necessary to these efforts. In contrast,
if health prerequisite strengthening activities are
not explicitly identified as health promotion activities, health promoters’ involvement may not
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(Organisation for Economic Co-operation and
Development, 2011). As one example, France is
a nation where health promotion concepts have
failed to gain traction among governmental authorities (Lang et al., 2003; Guillaumie, 2007),
yet France does far better than Canada—and
perhaps Australia and England—in providing
its citizens with these prerequisites of health
(Organisation for Economic Co-operation and
Development, 2011).
Such contrasts between rhetoric and action has
led to my thinking that it is the political economy
of a nation—the general organization of its economic and political systems—rather than governmental authorities’ explicit commitments to the
provision of the prerequisites of health through
health promotion activities that determines
whether citizens are provided with these prerequisites (Raphael and Bryant, 2006). What are
some of the features of these differing political
economies that would support such a hypothesis?
The political economies—or form of the
welfare state—of wealthy Western nations
cluster into four general welfare regimes: the
social democratic, conservative, Latin and liberal
(Esping-Andersen, 1990; Esping-Andersen,
1999; Saint-Arnaud and Bernard, 2003). The
social democratic welfare states are distinguished
by their strong commitments to State provision
of citizen economic and social security—a
concept that appears closely related to provision
of the prerequisites of health—while the liberal
welfare states generally rely upon the economic
marketplace to distribute economic and social
resources. The conservative and the less extensively developed Latin welfare states are distinguished by their emphasis upon social insurance
programs that reduce economic and social risks
among wage earners. Evidence suggests a continuum of State support of citizens from stronger
to weaker as follows: social democratic—
conservative—Latin—liberal (Esping-Andersen,
1999; Saint-Arnaud and Bernard, 2003; Eikemo
and Bambra, 2008).
Interestingly, the nations that fall at the opposite ends on this citizen support dimension, the
liberal (e.g. Canada, Australia and England) and
social democratic welfare states (e.g. Norway,
Sweden and Finland) are those whose explicit
governmental commitments to the prerequisites
of health through health promotion activities are
strongest (Raphael and Bryant, 2010). But at the
same time, the implementation of these concepts
in public policy appears to differ widely with the
The political economy of health promotion
97
Table 1: Proposed intersections of commitments and policies towards provision of the prerequisites of health
with nations’ form of the welfare state
Explicit commitment to provision of the prerequisites of health within a health promotion frameworka
Yes
No
Public policy efforts towards provision of the prerequisites of health
Extensive
Undeveloped
Extensive
Undeveloped
Social democraticb Welfare states
Liberal Welfare states
Conservative Welfare states
Latin Welfare states
a
Judgements of explicit and implicit commitments and policies based on published reviews of national profiles.
Welfare state designation based on Saint-Arnaud and Bernard (2003).
b
† What are the implications of a nation’s placement in the welfare state regime typology for
health promoters concerned with provision of
the prerequisites of health through public
policy activities?
† What are the implications for health promoters’ efforts of the presence or absence of
explicit health promotion commitments to
provision of the prerequisites of health by
governmental authorities through public
policy activities?
HEALTH PROMOTION AND THE
PREREQUISITES OF HEALTH
In this article, the focus is on ‘health promotion’
as defined by the World Health Organisation
(WHO) (World Health Organisation, 1986) as distinguished from traditional public health concerns
of health protection (Nutbeam, 1998). Health promotion as outlined by the WHO represents a
commitment to improve health and wellbeing
through societal change This concept of health
promotion—not to be confused with its narrow incarnation focused on behavioural change—has its
origins in structural analyses of health issues
derived primarily from the social sciences
(MacDonald and Davies, 1998; Bunton and
MacDonald, 2002). Three key principles of health
promotion that can be abstracted from the Ottawa
Charter for Health Promotion are as follows:
(i) political and economic structures that provide
the prerequisites of health should be strengthened;
(ii) individuals and communities can undertake
activities to increase their control over the determinants of health and (iii) these thrusts should
combine to create healthy public policy that is
responsive to the needs of the citizenry.
In line with its predominantly structural
approach to promoting health, the Ottawa
Charter outlines prerequisites of health of
peace, shelter, education, food, income, a stable
ecosystem, sustainable resources, social justice
and equity (World Health Organisation, 1986).
Each international health promotion conference
to the present has reaffirmed the importance of
the prerequisites of health—now frequently
spoken of as the social determinants of health—
and the public policy that provides these prerequisites (World Health Organisation, 2009).
Health-promoting public policy that provides
these prerequisites of health includes legislation, fiscal measures, taxation and organizational change (World Health Organisation, 1986).
The importance of public policy is also a
key component of the work done by the
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be seen as relevant by governing authorities and
the public and therefore will be neither solicited
nor encouraged.
I expect that the governing authorities of
nations identified as social democratic and liberal
welfare states will be more likely to express explicit commitments to provision of the prerequisites
of health within a health promotion framework.
I also expect that nations identified as social
democratic and conservative welfare states—
based on their commitments to the provision of
citizen economic and social security—will devote
rather more policy attention to provision of the
prerequisites of health than nations identified as
liberal and Latin welfare states. Table 1 outlines
the proposed intersections of health promotion
approach, extent of public policy activities
towards the prerequisites of health and a nation’s
form of the welfare state.
If these intersections are found to be accurate,
two important questions arise for health promoters:
98
D. Raphael
Table 2: Public policies that influence three key
prerequisites of health
Prerequisite
Public policy influences
Early life
Policies that assure provision of
adequate income to families
either through universal
benefits, sufficient wages for
those inside the work force or
assistance levels for those
outside the work force.
Policies that provide affordable,
high-quality childcare and early
education and benefits to
families with children.
Policies that enable collective
bargaining and agreements
(e.g. regulations that facilitate
trade union activity, presence
of intersectoral bargaining and
agreement coordination).
Policies that require provision of
benefits to part-time and
temporary workers
commensurate to that provided
to full-time employees.
Policies that provide training and
retraining programs (active
labour policy).
Policies as described above with
additional policies that create
more progressive taxation
policy that narrows the gap
between the top and bottom.
Policies that prove greater
decommodification of supports
and services such as pensions,
employment and sickness
benefits and resources such as
education, recreation, housing
and other necessities.
Employment and
working conditions
Income and income
distribution
In wealthy developed capitalist nations, the State, in the
form of governmental public policy-making can intervene
to influence how the marketplace distributes economic
resources amongst the population. Frequently, these
decisions to manage the economy and its effects are the
result of particular political forces that are accompanied by
dominant ideological discourses. In social democratic and
conservative nations, these interventions in the operation
of the economy are common. In liberal and Latin welfare
states, such interventions are less common. Examples of
some of these prerequisites of health-related areas that
indicate State intervention in the operation of the market
economy are presented in the table.
Sources: Irwin et al., 2007; Wilkinson and Pickett, 2009;
Benach et al., 2010.
These contrasts among English-speaking,
Scandinavian and Continental nations in health
promotion activity and outcomes appear to represent differences in their political economies—
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Commission on Social Determinants of Health
(World Health Organisation, 2008). In Canada,
the Canadian Public Health Association sees
public policy that strengthens the determinants
of health as the best means of promoting health
(Canadian Public Health Association, 1996).
What are some examples of public policy that
support the prerequisites of health? Extensive
overviews of the public policy antecedents of all
the prerequisites of health are available (World
Health Organisation, 2008; Raphael, 2009), but
Table 2 provides a flavour of these policies
through a sampling of the relationships between
public policy and three important prerequisites
of health that have been the primary focus of
both prerequisites and social determinants of
health activity: early child development, employment and income (Irwin et al., 2007; Wilkinson
and Pickett, 2009; Benach et al., 2010).
In practice, however, there is wide disparity in
the take-up and application of these principles
across national jurisdictions (Raphael and Bryant,
2010). Health promotion activities in the wealthy
developed English-speaking jurisdictions, while
working with policy statements and documents
that recognize the importance of public policy
that provides the prerequisites of health, have
emphasized modifying health-related risk behaviours (Raphael, 2008a; Wills et al., 2008; Wise,
2008). This has especially been the case in North
America (Hofrichter, 2003; Raphael, 2008b).
In Europe there has been greater focus on the
development and implementation of public
policy that provides the prerequisites of health
(Mackenbach and Bakker, 2003; Hogstedt et al.,
2008). The Scandinavian nations have been identified as both adopting the rhetoric of health promotion and implementing its key principles in
public policy activities, the Continental nations
less so. But this latter conclusion may be deceiving. While explicit health promotion rhetoric
may be less apparent in Continental nations’
policy statements and documents than in the
Scandinavian nations, in many respects public
policy appears to be aligned with the important
health promotion principle of providing the prerequisites of health (Olsen, 2002; Pontusson,
2005). The real distinction may be between the
English-speaking nations and European nations.
There is evidence that these differences in providing the prerequisites of health are associated
with variations in important health outcomes
(Navarro and Shi, 2002; Navarro et al., 2004;
Bambra, 2006).
The political economy of health promotion
that is the interplay between the economics and
politics of a nation—and how these economies
provide various forms of citizen economic and
social security (Raphael and Bryant, 2006). If
this is the case, two key questions arise: How do
these differences in political economies lead to
the adoption of differing approaches to health
promotion? What are the implications for
health promoters who wish to strengthen the
prerequisites of health through public policy
activity?
Recent literature has considered different political economies within a ‘worlds of welfare’
framework that distinguishes between differing
forms of the welfare state (Bambra, 2007;
Eikemo and Bambra, 2008). In this framework,
varied public policy components fit together to
define a specific welfare state regime.
Esping-Andersen identifies three regimes of
welfare capitalism: social democratic, conservative and liberal to which Saint-Arnaud and
Bernard add a fourth Latin type (EspingAndersen, 1990, 1999; Saint-Arnaud and
Bernard, 2003). Bambra (2007) identifies no less
than 12 different welfare state typologies but virtually all make a distinction between liberal or
residual and social democratic or encompassing
types with a mid-level type that usually corresponds to the conservative form. The
Scandinavian, Continental—including Latin—
and English-speaking nations mentioned above
appear to correspond to social democratic, conservative and liberal political economies, respectively. Esping-Anderson sees these differing
regimes as resulting from distinctive political
and social histories (Esping-Andersen, 1990).
The social democratic welfare states (e.g.
Finland, Sweden, Denmark and Norway) emphasize universal welfare rights and provide
generous benefits and entitlements. Their
political and social history is one of political
dominance by social democratic parties of the
left, a result of political organization of initially
industrial workers and farmers, and later the
middle class. Through universal provision of a
range of benefits, these regimes have been able
to secure the loyalties of a significant proportion
of the population (Esping-Andersen, 1990,
1999).
Conservative welfare states (e.g. Belgium,
France, Germany and Netherlands) also offer
generous benefits but provide these based on
social insurance plans associated with employment status with emphasis on primary male
wage earners. Their political and social history is
one of political dominance by Christian
Democratic parties where traditional Church
concerns with supporting citizens merges with
traditional approaches towards maintaining
status differences and adherence to authority
(Esping-Andersen, 1990, 1999). These tendencies sometimes manifest in corporatist
approaches (e.g. Germany) where business interests are major influences or in Statist approaches
(e.g. France) where the State plays a key role in
provision of citizen security (Pontusson, 2005).
Liberal welfare states (e.g. Australia, Canada,
UK and USA) provide modest benefits and the
State usually steps in with assistance only when
the market fails to meet citizens’ most basic
needs. Their political and social history is one of
dominance by business interests that has led the
population to give its loyalty to the economic
system rather than the State as a means of providing economic and social security (EspingAndersen, 1990, 1999). These liberal welfare
states are the least developed in terms of provision of citizen economic and social security. A
key feature is their use of means-tested benefits
that are targeted only to the least well-off.
Latin welfare states (e.g. Greece, Italy, Spain
and Portugal) are identified by Saint-Arnaud
and Bernard (2005) as less developed familyoriented versions of the conservative welfare
regime. While there has been extensive debate
about the value of the worlds of welfare typology
(Bambra, 2007), recent analyses provide strong
evidence of their validity (Saint-Arnaud and
Bernard, 2003). Figure 1 identifies key elements
of each of these four forms of the welfare state
(it should be noted that some nations are more
centralized in their health policy-making such as
Sweden and England, while others are decentralized such as Germany, Italy and Canada. These
differences do not appear to have a determining
influence upon the primary issues of the provision of the prerequisites of health through
health-promoting public policy).
There are clear affinities between the health
promotion principle of providing the prerequisites of health as defined by the WHO (i.e.
peace, shelter, education, food, income, a stable
eco-system, sustainable resources, social justice
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THE POLITICAL ECONOMY
OF THE WELFARE STATE
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D. Raphael
and equity) and aspects of these differing forms
of the welfare state. The liberal welfare state
with its emphasis on minimizing State intervention in the operation of the marketplace and
provision of minimal benefits appears to be the
least likely to produce public policy that provides the prerequisites of health. The social
democratic and conservative welfare states—
with their emphasis on promoting equality in
the former case and solidarity in the latter—
should be more likely to implement public policies that provide the prerequisites of health.
Little has been written about how the Latin
welfare states may provide the prerequisites of
health except to point out their relatively undeveloped nature and their emphasis upon the
family as providing the primary means of
support (Navarro and Shi, 2001; Saint-Arnaud
and Bernard, 2003). Therefore, they may be
expected to provide to a lesser extent the prerequisites of health than the social democratic
and conservative welfare states.
Evidence exists that this is the case. State
provision to citizens of economic and social
supports appears to lag among liberal welfare
states with the greatest differences seen
between the social democratic and liberal
welfare states (Navarro and Shi, 2002, Navarro
et al., 2004, Bambra, 2006). In this article, these
findings are updated, and additional indicators
are compared. The situation in the Latin
welfare states is carefully examined. Most importantly, all of this is done in conjunction with
analysis of the health promotion scenes in
selected exemplars of these differing welfare
states. By situating health promotion activities
within the context of the political economy of
the welfare state, the implications for health
promoters of differing forms of the welfare state
and the presence or absence of explicit health
promotion commitments can be identified.
METHODOLOGY
This examination of the intersection of health
promotion activities with political economies
focuses on the forms health promotion has taken
in the liberal welfare states of Australia, Canada
and England (the USA is not examined since it
is such a negative outlier in its health promotion
and public policy approaches to the provision of
the prerequisites of health, Raphael (2008b));
the social democratic welfare states of Finland,
Norway and Sweden (Denmark provides an
interesting case where a well-developed welfare
state that appears to be committed to the prerequisites of health, yet lacks a rhetorical health
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Fig. 1: Ideological variations in forms of the welfare state. Source: Saint-Arnaud and Bernard, 2003, Figure 2,
p. 503.
The political economy of health promotion
Search of the literature
This article relies on literature that is available
in English. It is important to note that the
liberal and social democratic welfare state
nations’ documents and statements about
provision of the prerequisites of health are
widely available in English, the conservative
and Latin welfare state nations rather less so.
More specifically, the preparation of this article
involved a systematic search of all articles published in the last 10 years in Health Promotion
International, Promotion and Education (now
Global Health Promotion), Critical Public
Health and Social Science and Medicine as well
as through Google Scholar identified by the
keyword ‘health promotion’ and the national
identifier of the specific nation. This search
showed a preponderance of articles in the
English-language literature by authors from
Australia, Canada and the UK. There were virtually no articles available in English that explicitly spoke about the conservative or Latin
welfare state approach towards provision of the
prerequisites of health within a health promotion framework.
Literature searches using these keywords,
however, identified some key texts which contained national case studies in English concerned with either health promotion or health
inequalities. Three key sources are the volume
Reducing Inequalities in Health: A European
Perspective (Mackenbach and Bakker, 2002),
Health for All? A Critical Analysis of Public
Health Policies in Eight European Countries
(Hogstedt et al., 2008), and the national case
reports provided by the European Portal for
Action on Health Equity. The Portal is part of
the European Union Consortium for Action on
Socio-economic Determinants of Health which
is concerned with reducing health inequalities
through action on the social determinants of
health (DETERMINE, 2010a). When national
reports and documents were available in
English, these were reviewed.
Identification of explicit or implicit approaches
The finding of explicit health promotion commitments can be seen when some or all of the
following governmental or health sector rhetoric is present: (i) statements about the importance of providing the prerequisites of health
through public policy activity; (ii) statements
about promoting health through communitylevel activities or (iii) statements about promoting health through individual behaviour change
related to ‘healthy living’ or healthy lifestyle
choices. These levels represent macro-, meso- or
micro-level approaches to health promotion and
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promotion commitment to these concepts and
shows rather poor health outcomes); the conservative welfare states of Belgium, France and
Germany (The Netherlands is not included in
this study since its efforts in reducing health inequalities has been extensively reported with
rather less attention given to the three nations
chosen), and the Latin welfare states of Italy,
Greece and Spain (Portugal is not included primarily because of a lack of literature concerning
their health promotion efforts). These nations
are all clearly situated within their respective
welfare state groupings according to a detailed
empirical analysis of the range of their public
policies in a variety of prerequisite-related areas
(e.g. overall public transfers to citizens, laws
related to financial and social support to citizens
and expenditures on social infrastructure such as
education and health care) (Saint-Arnaud and
Bernard, 2003).
Australia, Canada and England were chosen
since their contributions to the health promotion literature are apparent yet they are clear
examples of liberal welfare states that limit their
support for the prerequisites of health through
public policy activity (Esping-Andersen, 1999;
Saint-Arnaud and Bernard, 2003; Eikemo and
Bambra, 2008). Finland, Norway and Sweden
are clear leaders in both expressing ideological
commitments to the provision of the prerequisites of health and in developing public policy
in support of these aims.
Belgium, France and Germany are excellent
examples of conservative welfare states whose
explicit health promotion commitments are less
apparent yet evidence suggests provide prerequisites of health supportive public policy.
Greece, Italy and Spain are examples of the
Latin welfare state, which lacks a health promotion emphasis and manifests as an undeveloped
form of the conservative welfare state.
Characteristics of not-selected members of
these welfare state regimes—the USA and New
Zealand (liberal), Denmark (social democratic),
Netherlands and Switzerland (conservative) and
Portugal (Latin)—can be seen in the broader
analysis reported in Part 2 of this article.
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D. Raphael
POLICY STATEMENTS AND ACTIVITIES
CONCERNED WITH HEALTH
PROMOTION
This overview, based on previously published
documents, has the modest aim of providing an
evaluation of how governmental commitments
to the prerequisites of health and related public
policy activity intersect with form of the welfare
state. The 12 brief overviews of national explicit
health promotion commitments that follow identify the extent to which there are governmental
commitments to provision of the prerequisites
of health within a health promotion framework.
There will be some reference to public policy
activity that is related to provision of the prerequisites of health but the bulk of the analysis of
these activities occurs in Part 2 of this article.
Focus is therefore on the extent to which national policy statements on provision of the prerequisites of health are placed within a health
promotion framework. This would include the
situation where prerequisites of health issues
are embedded within a concern with ‘reducing
health inequalities’ (DETERMINE, 2010a).
These overviews are for the most part based
on national situations prior to the onset of the
2008 global recession. And the most recent data
related to the public policy indicators presented
in Part 2 of this article are from 2007 to 2008.
There is no doubt that public policy since then
has been influenced by this as well as changes
in electoral outcomes in many nations. But
these overall effects are probably minor in
terms of the profiles presented here and findings
presented in Part 2 of this article since research
has found that:
[W]elfare states are highly resistant to pressures attendant to international and domestic structural
socio-economic change (e.g. internationalisation,
deindustrialisation, and ageing). Incumbent governments find it very difficult to reduce concentrated
benefits to well-defined, mobilised constituencies in
return for future, diffuse benefits. Generally, welfare
states are path dependent in that the cognitive and
political consequences of past policy choices constrain
and otherwise shape efforts at programmatic and
systemic welfare retrenchment (Swank, 2005, p. 187).
Australia
Australia has produced numerous policy documents that address the issues of health inequalities and the social determinants of health
(Health Council of Canada, 2010). It has done
so by emphasizing the importance of promoting
health equity—reducing inequalities in health
that are unfair and avoidable—and strengthening the social determinants of health. Until
2006, these activities were focused in Australian
state governments with rather little activity by
the federal government (Newman et al., 2006),
but the election of a federal labour government
in 2007 has seen the development of a Social
Inclusion Initiative that shares some affinities
with this state-level work (Macdonald, 2010).
With regard to state-level activity, the documents and policy statements from New South
Wales, Victoria, South Australia and Tasmania
are especially impressive (see Health Council of
Canada, 2010 for a recent review). As an
example, The New South Wales Department of
Health document, In all Fairness (Department
of Health—New South Wales, 2004b), contains
a health and equity statement that provides direction for planning, a resource distribution and
funding formula that provide guidance on how
to allocate resources on eight health areas on
the basis of population numbers and extent of
deprivation or disadvantage, as well as research
to create new knowledge on the causes and
means of addressing health inequalities. A New
South Wales Public Health Bulletin expanded
upon that document to identify the need to
‘work with the community, non-government
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may or may not be accompanied by actual activities that implement these goals. In this article,
the focus is on health promotion rhetoric at the
macro-level ‘a’.
Implicit health promotion activity is seen
where governmental policies serve to provide
the prerequisites of health but these are not
explicitly identified as health-promoting public
policy and is the focus of Part 2 of this article.
These policies include: (i) processes that enable
the negotiation of collective employment agreements that provide a modicum of employee
rights and benefits; (ii) governmental and institutional activity that manages the extent of
income inequality and poverty within a jurisdiction; (iii) governmental and institutional activity
that promotes employment training and reduces
unemployment (active labour policy) and (iv)
governmental and institutional activity that
meets early child development needs of citizens,
among others.
The political economy of health promotion
Canada
For decades, Canadian governmental and professional associations have argued the importance of the determinants of health and healthy
public policy (Legowski and McKay, 2000;
Collins and Hayes, 2007; Low and Theriault,
2008). The federal government’s A New Vision
of Health for Canadians identified four fields
that determined health: human biology, lifestyles, environment and health care (Lalonde,
1974). The identification of the environment
field has been seen as signalling the beginning
of a broader health promotion era which saw its
realization in the Ottawa Charter’s definition of
health promotion.
Similarly, the federal government’s 1986
document Achieving Health for All: A
Framework for Health Promotion identified the
importance of providing the prerequisites of
health through the coordination of healthy
public policy (Epp, 1986). It declared: ‘All policies which have a direct bearing on health need
to be co-ordinated The list is long and includes,
among others, income security, employment,
education, housing, business, agriculture, transportation, justice and technology’ ( pp. 4,10).
More recently, the prerequisites of health
concept figures prominently in Canadian health
policy documents produced by the Federal
government, numerous public health and social
development organizations and agencies, and
research funding agencies (Canadian Institute
for Health Information, 2002; Institute of
Population and Public Health, 2003; Health
Council of Canada, 2010). Even the businessoriented Conference Board of Canada established an initiative focused on the social and
economic determinants of health (Conference
Board of Canada, 2008).
It has been suggested that there has been little
application, however, of these concepts at either
the federal or provincial levels such that Canada
is now seen as being well behind other nations in
applying its own concepts to promoting health
(Bryant et al., 2011). The Canadian Population
Health Initiative—a federal government-funded
research institute—noted (Canadian Population
Health Initiative, 2002): ‘Canada has fallen
behind countries such as the UK and Sweden
and even some jurisdictions in the USA in applying the population health knowledge base that
has been largely developed in Canada’ ( p. 1).
Similarly, the Canadian Senate Subcommittee
on Population Health carried out an extensive
review of how Canada has been approaching the
issues of inequalities in health and concluded in
its Press Release: (Senate Subcommittee on
Population Health, 2009): The subcommittee
found that Canada is seriously falling behind
countries such as the UK and Sweden ( p. 1).
England
England has a long-standing intellectual and
academic concern with inequalities in health.
The election of a Labour government in 1997—
which campaigned on a platform of reducing
health inequalities—saw the ongoing academic
and policy concern with health inequalities
translated into a government-wide effort to
address health inequalities through the development of public policy.
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organizations and other government departments, to influence those things we know affect
health—a good education, secure employment,
safe communities and access to affordable accommodation, food and transport’ (Department
of Health—New South Wales, 2004a, p. iii).
MacDonald (2010) argues that the 2008
Social Inclusion Initiative of the federal government—which appears to be similar to the UK
social exclusion initiative—while not using the
expression social determinants provides recognition that political, social, economic and cultural
contextual factors influence health. Specifically,
the federal government adopted a set of principles—developed by the Australian Social
Inclusion Board—to guide the Social Inclusion
Agenda. The aspirations of the Initiative are to
‘reduce disadvantage, increasing social, civic
and economic participation and develop a
greater voice, combined with greater responsibility’. Some of the health-related activities to
accomplish this are building partnerships with
key stakeholders; giving high priority to early
intervention and prevention; building joined-up
services and whole of government (Keskimäki
et al., 1997) solutions and using evidence and
integrated data to inform policy (Government
of Australia, 2011). MacDonald (2010) believes
this represents ‘the need to adopt policies to
tackle health inequalities through the social
determinants of health’ ( p. 37). Other health
researchers take a similar view with regard to a
related initiative by the South Australia state
government (Baum et al., 2010).
103
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D. Raphael
The focus here is on England although developments in Wales and Scotland parallel these.
Among the initial major policy initiatives was
the document Reducing Health Inequalities: An
Action Report (Department of Health, 1999).
The government organized a strategy based on
nine themes that included the following:
Goals were set for the elimination of health
inequalities. The 2002 Spending Review Public
Service Agreement—a kind of business plan—
for the Department of Health contained the
goal of ‘By 2010 to reduce inequalities in health
outcomes by 10% as measured by infant
mortality and life expectancy at birth’ (UK
Government, 2002). These initiatives focused
on: (i) tackling poverty and low income;
(ii) improving educational and employment
opportunities; (iii) rebuilding local communities
and (iv) supporting vulnerable individuals and
families (Oliver and Nutbeam, 2003). To facilitate action, the government set up ‘cross-cutting
spending reviews’ focused on health inequalities
to be used by a number of departments to
inform spending plans for 2003–2006.
The most striking aspect of these developments in England—and those that followed was
the placing on the public policy agenda of a
wide range of issues related to a structural
approach to health promotion. Whitehead and
Bird (2008, p. 117) comment:
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 . . . England now
More recently, the government—since defeated
in a national election—commissioned a report
to propose an evidence-based strategy for reducing health inequalities from 2010 on (Marmot
et al., 2010). The strategy includes policies and
interventions that address the social determinants of health inequalities and lays out a plan
for the next 10 years.
In all three liberal nations then, there are clear
policy statements about promoting health
through public policy that addresses either the
prerequisites or social determinants of health. In
the case of Australia and England, these statements have been paralleled by public policy
activity designed to achieve these objectives.
While how these nations fare in provision of these
prerequisites of health is considered in Part 2 of
this article, evidence suggests that in England,
these efforts have born some fruit in that reductions in child and pensioner poverty occurred up
until 2004/2005, and there has been a marked
decline in persistent poverty and deprivation
among families with children (Hills et al., 2009).
SOCIAL DEMOCRATIC WELFARE
STATES
The social democratic welfare states are distinguished by policy statements that stress the
important role public policy plays in promoting
health through action on the prerequisites of
health and their concerted public policy action
that addresses these issues.
Finland
Finnish health policy has been concerned with
reducing inequalities in health since the 1960s
(Palosuo et al., 2008). Finland became one of
the first nations to apply the WHO Health for
All by the Year 2000 program to its national
scene. As early as 1986, the four general targets
under the Health for All program included
reducing health disparities between population
groups, producing smaller health differences
between genders, socio-economic categories
and people living in different regions.
The Government Resolution on the Health
2015 Public Health Programme (2001) defined
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Raising living standards and tackling low income
by introducing a minimum wage and a range
of tax credits and increasing benefit levels.
Improving education and early years by introducing policies to improve educational standards, creating ‘Sure Start’ preschool services
in disadvantaged areas free to those on low
incomes.
Increasing employment by creating a range of
welfare-to-work schemes for different priority
groups.
Building healthy communities by investing in a
range of regeneration initiatives in disadvantaged areas, including Health Action Zones.
Improving housing by changing capital financial
rules to promote investment in social housing
and introducing special initiatives to tackle
homelessness.
has a semblance of a co-ordinated strategy to tackle
inequalities in health, which may not be perfect, but
which is a vast improvement on previous efforts.
The political economy of health promotion
The goal of reducing health inequalities is explicitly
mentioned in both the 2003 and 2007 Finnish
Government Programmes. The 2006 Social and
Health Report to the Parliament also identified the
reduction of health inequalities and the prevention of
marginalisation as key challenges for the future. In its
strategy document for social and health policies
(Strategies for Social Protection 2015), the Ministry
of Social Affairs and Health identifies the reduction
of health inequalities as a major target in the promotion of the population’s health and functional
capacity (Palosuo et al., 2009, p. 5).
Palosuo et al. (Palosuo et al., 2008) point out
that a quantitative target of reducing health
inequalities—defined as differences in death
rates among genders, those of differing educational levels and of differing occupation
status—of 20% by the year 2015 has been set.
Norway
Norway has a history of emphasizing a structural approach to promoting population health
and reducing health inequalities (Fosse, 2008).
In 1984, a Norwegian Government White Paper
adopted the World Health Organisation’s
Health for All 2000 Strategy and provided a specific commitment to reduce social inequalities
with a strong emphasis upon health-in-all public
policy areas. Since then a series of documents
further developed Norway’s approach. The 2003
Government White Paper entitled Prescriptions
for a Healthier Norway, called for (i) interventions to influence lifestyles will be assessed in
terms of their consequences for social inequalities in health; (ii) new actions aimed at vulnerable groups or geographic areas will be assessed
in terms of the target of reducing social inequalities in health; (iii) addressing social inequalities
in health through health impact assessment and
(iv) developing a plan of action to combat
social inequalities in health (Fosse, 2008, p. 51).
The Challenge of the Gradient concerns itself
with health inequalities right across the entire
population (Norwegian Directorate of Health
and Social Affairs, 2005) and the 2007 National
Strategy to Reduce Social Inequalities in Health
comes down squarely on the side of a structural
analysis of health determinants (Ministry of
Health and Care Services, 2007). It explicitly
states the case that governments have a role to
play in promoting health through public policy
action. Four sets of public health objectives aim
to Reduce social inequalities in health by levelling up. The four priority areas for achieving
this are as follows:
† Reduce social inequalities that contribute to
inequalities in health.
† Reduce social inequalities in health behaviour
and use of the health services.
† Targeted initiatives to promote social
inclusion.
† Develop knowledge and cross-sectoral tools—
to ensure that the measures we implement
increasingly achieve their intended purposes.
The report provides detailed schemes for
achieving these sets of objectives. For example,
in relation to income: ‘As long as systematic
inequalities in health are due to inequalities in
the way society distributes resources, then it is
the community’s responsibility to take steps to
make distribution fairer’ ( p. 33).
Sweden
Health promotion activities in Sweden focus on
strengthening democratic participation, promoting security and well-being of families, and
reducing health inequalities. Sweden also provides an example of a governmental approach
that strives to promote population health and
reduce health inequalities by addressing the
prerequisites of health.
The 2001 Swedish Ministry of Health and Social
Affairs document Towards Public Health on
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reducing health differences between population
groups as a central goal (Finnish Ministry of
Social Affairs and Health, 2001). Similarly, in
Strategies for Social Protection 2010 (2001), the
Finnish Ministry of Social Affairs and Health
outlined preventive social policy that (i) supports growth and development of children and
young people, (ii) prevents exclusion, (iii) supports personal initiative and involvement
among the unemployed and (iv) promotes basic
security in housing. Promoting lifelong learning,
wellbeing at work, increasing gender equality
and social protection, and giving priority to preventive policy, early intervention and actions to
interrupt long-term unemployment and providing adequate income security were key processes to accomplish this.
The Finnish Government Resolution on the
Health 2015 Public Health Programme (2001)
concluded that progress had been made on
these health goals. More recently, the Minister
of Health Paula Risikko has commented:
105
106
D. Raphael
THE CONSERVATIVE WELFARE STATES
As noted, primary policy documents and statements related to these issues are generally not
available in English. The following is primarily
drawn from the case studies in volumes that are
available in English. Especially useful is work
prepared for the European Portal on Health
Inequalities and the Commission on the Social
Determinants of Health (Mackenbach and
Bakker, 2002; Commission on the Social
Determinants of Health, 2008; Hogstedt et al.,
2008; DETERMINE, 2010a).
Belgium
De Maeseneer et al. prepared an overview of
‘intersectoral action for health in Belgium’ for a
WHO/Health Canada publication related to the
work of the Commission on Social Determinants
of Health (De Maeseneer et al., 2007). They
note that Belgium does not have a ‘global comprehensive policy framework’ to address the
social determinants of health. They do note that
this lack of a comprehensive health-related
social determinants agenda does not dilute the
Bismarkian-type insured health-care system that
provides 100% health-care coverage.
More importantly, governmental action—in
response to the increasing popularity of extreme
right wing parties in the 1990s—has focused on
improving housing and living conditions, and
improving educational opportunities. These activities, however, were not carried out within a
‘health promotion’ framework.
Consistent with these activities, there now
exists an Interministerial Conference for Social
Integration which can take action on poverty,
health and welfare policies. Maeseneer et al. also
describe a variety of local activities that apply
intersectoral approaches to issues of poverty and
children’s health, but these are not framed by
an overall national policy. They conclude:
‘Although there is no formal policy addressing
health inequalities, there are a lot of actions at
different levels that contribute incrementally to
health for the poor and the underserved’ ( p. 11).
France
Guillaumie (2007) provides an overview of the
health promotion situation in France and concludes that it remains ‘hindered by a system still
very centred on curative care and a lack of political consideration for health determinants’
(Guillaumie, 2007, p. 267). While there has been
effort to establish a network through the
National Institute for Health Promotion and
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Equal Terms proposes an explicit role for health
promotion policy in reducing health inequalities
between various groups in society (Swedish
Ministry of Health and Social Affairs, 2001).
Policy areas identified include employment, education, agriculture, culture, transport and housing.
A 2003 report emphasized promoting health by
closing the major health gaps in society and the
2002/2003 Public Health Objectives provided
plans to achieve this (Swedish Ministry of Health
and Social Affairs, 2003). Prerequisite-related
areas were as follows: involvement in and influence on society; economic and social security;
secure and healthy conditions for growing up;
better health in working life; healthy, safe environments and products; health and medical care
that more actively promotes good health; effective
prevention of the spread of infections; and secure
and safe sexuality and good reproductive health.
Municipalities and county councils were
required to draw up and evaluate targets, and
then report on these activities. The 2005 Public
Health Policy Report provided a set of indicators
for implementation of the public health policy at
the national, regional and local levels during
phase 1 (2003–2005) (Swedish National Institute
for Public Health, 2005). As a result of extensive
consultations, 42 priority proposals were presented. Twenty-nine deal with issues of how inequitable living conditions contribute to mental
health, working life, air pollution and accidents,
communicable diseases, overweight and physical
inactivity, tobacco, alcohol, violence against
women and inequalities in health. Thirteen proposals deal with policy and include increasing
capacity for public health promotion involving
more active engagement, coordinated regional
public health promotion and support for more
competence in public health matters among municipalities (Swedish National Institute for Public
Health, 2005).
The social democratic nations are distinguished both by their explicit commitments and
their longstanding commitments to implementing public policy that provides the prerequisites
of health. They have also taken great efforts to
make their policy documents and statements
available in English-language versions.
The political economy of health promotion
Germany
The German approach to explicit health promotion appears to be embedded within a behavioural approach. The DETERMINE case study
points out that the Federal Ministry of Health
created a set of initiatives that added disease
and addiction prevention to the three existing
pillars of therapy, rehabilitation and care
(DETERMINE, 2010b). These initiatives,
however, focused on:
† growing up healthy: nutrition, exercise,
coping with stress;
† strengthening
health
competencies
of
patients;
† behaviour-related targets (e.g. reducing
tobacco consumption);
† disease-related targets including depression,
diabetes, breast cancer (screening programmes) and
† framing the establishment of disease management
programmes.
(http://www.gesund
heitsziele.de/).
However, a recent report by the Federal Centre
for Health Education and the Robert Koch
Institute on the health of children and adolescents in Germany identified the importance of
† a comprehensive implementation of highvalue concepts of health promotion in
day-care centres and schools,
† family-support measures and
† development of quality in these resources.
However, like the other conservative welfare
states, activities related to the prerequisites of
health appear to be taken under auspices of
other ministries than health. The Federal
Ministry of Labour and Social Affairs:
[D]eals with three branches of social security: pensions, unemployment benefit and industrial accident
insurance. The tasks include the maintenance of
social systems, social integration and the framework
for more jobs. Units within the purview of the ministry with responsibility for issues related to health inequalities are the following: with issues of social
security ( pensions, unemployment benefit and industrial accident insurance (DETERMINE, 2010b).
In Germany then—like the other conservative
nations described—explicit health promotion
concerned with the ‘prerequisites of health’
seems rather undeveloped, yet the conservative
approach to promoting solidarity seems to indicate commitments to provision of the prerequisites of health in numerous areas.
THE LATIN WELFARE STATES
Analyses of the health promotion scene related
to provision of the prerequisites of health in
these three Latin welfare states is fairly straightforward: there is little explicit attention paid to
reducing health inequalities through provision
of the prerequisites of health: ‘In most Latin
countries, social inequalities in health have
received little attention in research, and even
less in public health policy’ (Costa et al., 2008,
p. 161). As is the case for the conservative
welfare states, this does not necessarily mean
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Education, lack of funding has not allowed
for the established of ‘professional excellence’ in
the health promotion field. Guillaumie (2007)
commented that universities in Canada,
‘[R]ecognized as a world leader in health promotion’, have influenced the development of health
promotion in French through training and interaction with French students and academics. But
results to date have been disappointing.’
An analysis by Lang et al (Lang et al., 2003)
reaches similar conclusions concerning the
health promotion scene in France. They argue
that until the mid-1990s there was little if any
policy interest in health in equalities related to
socioeconomic issues. Conferences of health
professionals and policy-makers raised these
issues but they were not given priority in deliberations or reports.
But in a telling statement they point out that
‘some aspects of the French health system have
implicitly addressed the problem. The national
health insurance and occupational medicine
system are two examples of this’ ( p. 218). In the
former case, France’s health-care system provides universal care to any legal resident. In the
latter case, France’s occupational health system
‘takes a global approach to health in the workplace, including interventions on working conditions’ ( p. 220). The authors conclude that
numerous policies related to welfare payments,
housing and occupational health may have
worked to promote health. ‘However, these were
not designed with health in mind, and their
effects on health inequalities have not been
assessed’ ( p. 221).
107
108
D. Raphael
that there is no public policy activity related to
these issues, but it does provide evidence that
there has been little explicit penetration of
health promotion concepts related to the prerequisites of health into the making of public
policy.
Recent policy and legislative articles on social justice/
social inclusion to tackle macro environmental factors
include general references to health inequalities. The
current Public Health Policy (officially implemented
by the Greek Ministry of Health, Welfare and Social
Solidarity) does express the aim of integrating specific
vulnerable groups of the population, but lacks specific
objectives, quantitative targets and timeframes
(DETERMINE, 2010c).
Ballas and Tsoukas (Ballas and Tsoukas, 2004)
place this reluctance to specify and measure
objectives as endemic to the entire Greek
health-care system, but in terms of the present
analysis, the lack of specific concern with
reducing health inequalities is of primary
importance.
Italy
Until the mid-1990s health policy was focused
solely on health care (Costa et al., 2008). The
1998–2000 National Health Plan had as one of
its many objectives reducing social inequalities
in health, but these objectives—according to the
authors—were not put into practice nor were
any objectives or targets identified. A 2003 –
2005 plan did target those living in poverty,
Spain
Spain provides a similar portrait as that seen in
Greece and Italy. Health policy is decided upon
by the National Ministry of Health and the
departments of what are called the Autonomous
Communities (Ramos-Diaz and Castedo, 2008).
These plans do not contain any references to
issues of inequalities in health and only one
region mentions socioeconomic inequalities.
Ramos-Diaz and Castedo (2008) argue that
Spain’s health and social welfare systems are
underdeveloped in relation to other European
nations. Much of this has to do with the late
arrival of democracy in Spain, a result of the
long-standing Franco dictatorship. In 1996,
however, a report by Navarro, Benach and
others outlined the extent of health inequalities
and their socioeconomic roots. This came to be
known as the ‘Spanish Black Report’. But the
newly elected conservative government in 1997
ignored its findings and its recommendations
were rejected. Ramos-Diaz and Castedo (2008)
argue that these issues continue to be absent
from political discourse and do not appear to
be at all on the Spanish political agenda.
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Greece
There is little explicit concern with health
inequalities and the prerequisites of health in
Greece government policy documents (Tountas
et al., 2003). Nevertheless, there is government
activity in many prerequisites of health-related
areas but these are not explicitly identified as
being concerned with promoting health.
These areas are concerned with poverty
reduction, improving housing quality, reducing
unemployment and improving access to health
care. The authors comment: ‘Although these
policies have a considerable effect in alleviating
health inequalities, they have not been planned
as such, as in Greece socio-economic inequalities in health have not been recognized as a
priority in public policy ( p. 227)’. The
DETERMINE Greece case study concludes:
persons with mental illness and specific immigrant groups, however, for policy action.
But the lack of any central organization to
address broader issues is apparent: ‘There is no
institution or agency explicitly committed to
linking health goals to non-health policies’
( p. 185). Not surprisingly, the issue of health
determinants is not seen as being high on the
public agenda nor has it aroused much interest
among the Italian public. But again, this does
not suggest that there has not been public
policy activity that is concerned with the prerequisites of health.
The social assistance program involved a
variety of schemes yet are seen as being undeveloped as compared with other nations relying
much on volunteer agencies. Pension plans have
been revised and updated, workplace improvements have been legislated, and educational
opportunities enlarged. But such activities are
consistent with an observation made by Costa
et al.’s in an earlier publication: ‘Some general
policies, such as those on employment or income
support, or specific ones such as those on
housing, education and the environment, may be
beneficial but are not designed to have an impact
on health’ (Costa et al., 2003, p. 236).
The political economy of health promotion
Despite this lack of explicit attention to issues
of health inequalities and their sources, there
is still policy attention to prerequisite-related
issues: ‘When policies are designed with the intention of affecting key social dimensions such
as the labour market or social protection, these
are not understood as social determinants of
health’ (Ramos-Diaz and Castedo, 2008, p. 285).
SUMMARY
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theory and practice. Promotion and Education, 13, 12–18.
Raphael, D. and Bryant, T. (2010) The political economy
of public health: public health concerns in Canada, the
U.S., U.K., Norway, and Sweden. In Bryant, T.,
Raphael, D. and Rioux, M. (eds), Staying Alive: Critical
Perspectives on Health, Illness, and Health Care.
Canadian Scholars’ Press, Toronto.
Saint-Arnaud, S. and Bernard, P. (2003) Convergence or resilience? A hierarchial cluster analysis of the welfare regimes in
advanced countries. Current Sociology, 51, 499–527.
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Healthy Productive Canada: A Determinant of Health
Approach. Senate of Canada, Ottawa.
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Health Promotion International, Vol. 28 No. 1
doi:10.1093/heapro/dar058
Advance Access published 3 November, 2011
# The Author (2011). Published by Oxford University Press. All rights reserved.
For Permissions, please email: [email protected]
The political economy of health promotion: part 2,
national provision of the prerequisites of health†
Health Policy and Management, York University, Toronto, ON, Canada
*Corresponding author. E-mail: [email protected]
†
Material in this article was presented at the 20th IUHPE World Conference on Health Promotion in
Geneva, Switzerland, 13 July 2010
SUMMARY
Governmental authorities of wealthy developed nations
differ in their professed commitments and activity related
to the provision of the prerequisites of health through
public policy action. Part 1 of this article showed how
nations identified as social democratic or liberal welfare
states were those where such commitments are present.
Nations identified as conservative or Latin welfare states
were less likely to express such commitments. However, the
political economy literature suggests that despite their
expressed commitments to provision of the prerequisites of
health, liberal welfare states fare rather poorly in implementing these commitments. The opposite is seen for conservative welfare states. Social democratic welfare states
show both commitments and public policy consistent with
this objective. Part 2 of this article documents the extent to
which public policy activity that provides the prerequisites
of health through public policy action differs among
varying welfare state regimes. Despite extensive rhetoric
concerning the prerequisites of health, nations identified as
liberal welfare states do a rather poor job of meeting these
goals and show evidence of adverse health outcomes. In
contrast, social democratic welfare states fare better in providing such prerequisites—consistent with their rhetorical
statements—with better health outcomes. Interestingly, conservative—and to a lesser extent Latin—nations fare well in
providing the prerequisites of health despite their lack of
explicit commitment to such concepts. Findings suggest that
health promoters have to concern themselves with the
broad strokes of public policymaking whether or not these
policy activities are identified as health promotion activities.
Key words: government programmes; health policy; public health
INTRODUCTION
Part 1 of this article reported how wealthy
developed nations differ in their expressed commitments to provision of the prerequisites of
health (i.e. peace, shelter, education, food,
income, a stable ecosystem, sustainable
resources, social justice and equity) (Raphael,
2013). The term ‘explicit health promotion commitments’ was used to refer to rhetorical commitments found in policy documents and
statements of governing authorities that endorse
provision of the prerequisites of health through
the implementation of healthy public policy (i.e.
complementary approaches including legislation, fiscal measures, taxation and organisational change) (World Health Organisation,
1986). Canada was identified as a nation where
such explicit commitments are provided within
a health promotion framework, while France
was identified as a nation where these commitments are lacking. It was also noted that despite
its commitments, Canada does a poor job of
providing the prerequisites of health, while
France, though lacking these commitments,
fares rather better. It was suggested that the
political economy—or the form of a nation’s
welfare state—was related not only to the
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DENNIS RAPHAEL *
The political economy of health promotion
provision of the prerequisites of health, extent
of public policy action that provides these prerequisites and the form of a nation’s welfare state.
Part 2 of this article examines the extent to
which the rhetorical commitments of social
democratic and liberal welfare states are translated into public policy activity. At the same
time, it examines the activities of the conservative and Latin welfare states, which lack these
rhetorical commitments. The nations included
in this analysis expands beyond the 12 exemplar
nations to include the 21 Western members of
the Organisation for Economic Co-operation
and Development (OECD) that have been
reliably identified as fitting into the four welfare
regimes—social democratic, conservative, Latin
and liberal—by Saint-Arnaud and Bernard
(Saint-Arnaud and Bernard, 2003). The data
are taken from OECD databases and reports.
The OECD prepares these indicators in close
consultation with member nation authorities
(Organisation for Economic Co-operation and
Development,
2008a;
Organisation
for
Economic Co-operation and Development,
2009a). In situations where the data collection
and computation processes may not be strictly
comparable, the OECD undertakes its own computations. For example with regard to the calculation of life expectancy, the OECD (OECD,
2009a) comments:
Each country calculates its life expectancy according
to methodologies that can vary somewhat. These
differences in methodology can affect the comparability of reported life expectancy estimates, as different
methods can change a country’s life expectancy estimates by a fraction of a year. Life expectancy at birth
for the total population is calculated by the OECD
Secretariat for all countries, using the unweighted
average of life expectancy of men and women ( p. 16).
Therefore, any inaccuracies in comparable data
reporting will probably be minor and since the
Table 1: Proposed intersections of commitments and policies towards provision of the prerequisites of health
with nations’ form of the welfare state
Explicit commitment to provision of the prerequisites of health within a health promotion frameworka
Yes
No
Public policy efforts towards provision of the prerequisites of health
Extensive
Undeveloped
Extensive
Undeveloped
Social democraticb welfare states
Liberal welfare states
Conservative welfare states
Latin welfare states
a
Judgments of explicit and implicit commitments and policies based on published reviews of national profiles.
Welfare state designation based on Saint-Arnaud and Bernard (Saint-Arnaud and Bernard, 2003).
b
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presence or absence of such commitments, but
also to their implementation in public policy.
Three national examples of each of the four
forms of the welfare state were identified and
evidence presented as to whether their governing
authorities express commitments to provide the
prerequisites of health within a health promotion
framework (Saint-Arnaud and Bernard, 2003).
Nations identified as social democratic welfare
states (e.g. Finland, Sweden and Norway) that
emphasize universal welfare rights and provide
generous benefits and entitlements were found to
express such commitments. Liberal welfare states
(e.g. Australia, Canada and England), which
provide modest benefits and assist citizens only
when the market fails to meet their most basic
needs were also found to express these commitments. Interestingly, conservative welfare states
(e.g. Belgium, France and Germany), which also
offer generous benefits through social insurance
plans, were not found to make such commitments. This was also the case for the Latin
welfare states (e.g. Greece, Italy and Spain)
which are seen as less supportive family-oriented
versions of the conservative welfare regime.
It was suggested that it may be the form of
the welfare state and not the professed commitments of governing authorities to provision of
the prerequisites of health that is the primary
determinant of whether public policy activity
provides the prerequisites of health. The term
‘implicit health promotion activity’ was used to
refer to public policy efforts that provide the
prerequisites of health but do so in the absence
of explicit commitments. In the implicit health
promotion activity case, health promotion statements are less salient—or even absent—but
public policy frameworks are consistent with
the health promotion principle of providing the
prerequisites of health. Table 1 outlines the proposed intersections of commitments to
113
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D. Raphael
(i) What are the implications of a nation’s
placement in the welfare state regime
typology for health promoters concerned
with provision of the prerequisites of health
through public policy action?
(ii) What are the implications for health promoters’ efforts of the presence or absence
of explicit health promotion commitments
to provision of the prerequisites of health
by governmental authorities through public
policy action?
PUBLIC POLICY AND THE PROVISION
OF THE PREREQUISITES OF HEALTH
Public policies that provide the prerequisites of
health take various forms. The focus in this
article is on broad macro-level public policy
approaches that involve the distribution of
economic and social resources rather than
specific programmes directed at those perceived
as being in need. One public policy area that
has been somewhat neglected by the health promotion literature is that of the rights of citizens
to collective employment bargaining, sometimes
through the facilitation of workplace unionization, at other times through employer provision
of
employment
security
and
benefits
(Organisation for Economic Co-operation and
Development, 2004).
This neglect is puzzling as the extent of collective bargaining agreements has been associated with lower rates of poverty and income
inequality, and generally stronger forms of the
welfare state (Swank, 2005) all of which have
been found to be strongly related to health outcomes (Navarro et al., 2004; Innocenti Research
Centre, 2005, 2007). Working under a collective
agreement is certainly related to higher wages
and employment security as well as receipt of
benefits in Canada (Jackson, 2010). The first
indicator of interest examined here is the percentage of workers covered by collective agreements. Closely related to this is the percentage
of workers who are members of unions. This
latter indicator provides a measure of power
balance between workers and owners and managers of the economy (Olsen, 2010).
Another important public policy area is that
of investing in the population through provision
of benefits, supports and services that provide
the prerequisites of health (Raphael and
Bryant, 2006). These investments involve
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OECD has been producing these reports for
decades—with virtually no major corrections
being introduced over that time—it can be
assumed that these indicators are valid. Also,
these indicators are consistent with what is
known about the public policy approaches and
health outcomes of these nations that is found
in the political economy and population health
literature. Though England has been identified
and discussed in Part 1 as a liberal welfare state,
the OECD only provides indicators for the UK
as a whole. These data are used in this article.
The public policy areas examined are those
that have been identified in the literature as
strong determinants of whether a society provides its citizenry with the prerequisites of
health: (i) processes that enable the negotiation
of collective employment agreements that
provide a modicum of employee rights, security
and benefits; (ii) governmental and institutional
activity that distributes national wealth in the
form of benefits, supports and services; (iii) governmental and institutional activity that promotes employment training and reduces
unemployment (active labour policy); and (iv)
governmental and institutional activity that
meets the early child development needs of citizens (Innocenti Research Centre, 2005, 2007,
2008; Commission on Social Determinants of
Health, 2008; Organisation for Economic
Co-operation and Development, 2008a, 2011).
These public policy areas are especially
important in relation to the prerequisites of
health because they serve to manage the extent
of income inequality and poverty within a jurisdiction. Indicators of income inequality and
poverty rates are therefore also examined. Not
surprisingly, these public policy approaches
have been related to health outcomes by international health and social development organisations such as UNICEF (Innocenti Research
Centre, 2005, 2007) and the World Health
Organisation through its numerous reports of
the Commission on Social Determinants of
Health (World Health Organisation, 2008b).
The article therefore looks at some important
population health outcomes that could be
expected to relate to these public policy
differences.
If the provision of the prerequisites of health
is shaped by the form of the welfare state—
which may or may not be accompanied by rhetorical commitments to such provision—two
important questions arise for health promoters:
The political economy of health promotion
PUBLIC POLICY INDICATORS OF THE
PROVISION OF THE PREREQUISITES OF
HEALTH
Public policies establish the environment within
which employees negotiate their wages and
benefits. Collective agreements provide means
by which wages and benefits are negotiated by
employees as a group rather than individuals
being left to do so on their own. The extent of
such agreements is an important determinant of
national-level unemployment and sickness
benefits and pension levels (Swank, 2005).
Collective agreement coverage
Figures 1 and 2 show collective agreement coverage and union density for the 21 OECD nations
classified by welfare state type for 2008 (Venn,
2009; Organisation for Economic Co-operation
and Development, 2010b). Included within these
are the 12 exemplar nations studied in Part 1 of
this article. The key feature is that both the
social democratic and conservative welfare state
workforces—including
all
the
exemplar
nations—have high proportions of their work
forces covered by collective bargaining agreements. The workforces of the Latin states have
somewhat lower levels and the liberal welfare
states—with the exception of Australia whose
rate is not very high—have very low collective
agreement coverage.
The high collective bargaining coverage of the
social democratic welfare states is associated
with very high union densities, which is not the
case for the conservative and Latin welfare
states. Labour unions have traditionally had
strong influence upon public policy in the social
democratic welfare state nations, which has been
related to the growth of the Scandinavian
welfare
state
(Esping-Andersen,
1985).
Conservative and Latin welfare states have relatively low union density, but their high collective
agreement rates are a result of employers
belonging to associations that negotiate collective contracts that are voluntarily applied to
their workforce (Organisation for Economic
Co-operation and Development, 2004). There
are also administrative extension of agreements
in these nations that cover all employers in a
given sector (Organisation for Economic Cooperation and Development, 2004). In liberal
political economies such agreements do not
exist. As a result, the low rates of union membership lead to small proportions of their workforces operating under collective agreements.
Overall public expenditures
Another means by which the prerequisites of
health are provided involve welfare state interventions in the form of collecting revenues
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spending on universal programmes that benefit
virtually all citizens such as early child education and care, employment training, pensions
and provision of community-based health care
and social services (Hemrijck, 2002). At other
times this spending involves provision of adequate benefits to those who are unable to work
because of illness, disability or unemployment
due to the loss of jobs in a changing economy
(Organisation for Economic Co-operation and
Development, 2003, 2011). These expenditures
are especially important with regard to families
with
children
(Esping-Andersen,
2002a;
Innocenti Research Centre, 2005, 2007).
Indicators of these public expenditures that
provide governmental support for active labour
policy and spending for early childhood education and care are examined. Key outcomes
associated with all of these prerequisiteproviding policies should be the extent of
income inequality and poverty, and these indicators are also examined. Finally, health outcomes that may be related to these public
policy activities such as life expectancy, infant
mortality rates and suicide and homicide rates
are looked at.
A shorthand way of thinking about these
potential indicator differences is that nations
that provide the prerequisites of health do so by
ensuring that the meeting of citizens’ needs of
income, housing and employment, health and
social services does not fall by the wayside
against the needs of those who manage the
economy. This usually involves State intervention in the operation of the market economy
(Esping-Andersen, 1985, 2009). Such a balance
is not only seen in the Scandinavian social democratic welfare states but also the Continental
conservative
and
Latin
welfare
states
(Saint-Arnaud and Bernard, 2003; Pontusson,
2005). Such a balance is rather less apparent
among English-speaking liberal welfare states
(Alesina and Glaeser, 2004; Micklewright, 2004;
Pontusson, 2005; Olsen, 2010).
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D. Raphael
through taxation and fees and using them to
provide universal or targeted benefits to the
population. In essence, these transfers offer
direct support to individuals as well as provide
social infrastructure. Bryant points out that
these benefits include cash payments and
in-kind benefits to families, public pensions,
training as part of active labour market policies,
and provision of early childhood, education,
recreational and public health care spending
(Bryant, 2010). Together these public expenditure indicators provide an overall measure of
the extent of the welfare state. Evidence exists
that the extent of expenditures is a potent predictor of the extent to which citizens are provided with numerous prerequisites of health
such as education, food, shelter and health and
social services (Innocenti Research Centre,
2005; Organisation for Economic Co-operation
and Development, 2011). These public
expenditures also include cash transfers that
redistribute income and wealth from top to
lower earners, thereby reducing poverty.
Figure 3 provides the percentage of the gross
domestic product that these 21 OECD nations,
classified by welfare state type, allocate in the
form of overall public expenditures. Of particular note are the distinctively low levels of spending of all six liberal welfare states. (In light of
the significant spending reductions announced
by the newly elected government of the UK, we
can expect the UK to shortly join the other
liberal nations on many of these indicators.)
The top seven spending nations represent a
mixture of social democratic and conservative
welfare states. Latin nations are mid-range in
their spending. It is important to note that the
slight liberal outlier, the UK, has recently
elected a governing coalition that has promised
spending cuts in most government departments
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Fig. 1: Collective agreement coverage, selected OECD nations by welfare state type, 2008. Source: Venn
(Venn, 2009). Note: Block white identifies social democratic welfare states; grey identifies conservative
welfare states; dotted indicates Latin welfare states; and black indicates liberal welfare states as
described by Saint-Arnaud and Bernard (Saint-Arnaud and Bernard, 2003). Figures for Ireland are from
Ireland: Industrial Relations Profile, EIRO, 2009, available at http://www.eurofound.europa.eu/eiro/
country/ireland.pdf.
The political economy of health promotion
117
of between 25 and 40% (Helm et al., 2010). If
this comes to pass, the UK will fall even more
firmly within the liberal spending cluster.
Income inequality and poverty
Income inequality and poverty are excellent
indicators of the extent to which national public
policy manages the distributional effects of
market economies. In every OECD nation
except Switzerland, governmental intervention
in the form of taxes and benefits significantly
reduce the extent of income inequality and
poverty (Rainwater and Smeeding, 2003;
Smeeding, 2004, 2005; Innocenti Research
Centre, 2005).
Figure 4 provides Gini coefficients for income
inequality of the 21 nations classified by welfare
state type (Organisation for Economic
Co-operation and Development, 2008a). Here
the higher levels of income inequality of the
liberal and Latin nations are rather apparent.
The social democratic welfare state nations
show distinctively low levels of income inequality, but similar to findings for the public expenditure findings, the best performing seven
nations are a mixture of social democratic and
conservative nations.
Figure 5 shows a similar picture for the
extent of poverty among families with children
(Organisation for Economic Co-operation and
Development, 2008a). Here the social democratic welfare state nations lead with lower
levels, and the liberal and Latin nations show
the highest poverty levels. The rather good performance of liberal welfare states UK and
Australia is noted, with questions raised as to
whether the newly elected UK government’s
deep austerity programme will influence this
nation’s standing for the worse.
Active labour policy
Active labour policy consists of a variety of programmes that nations use to eradicate high and
persistent unemployment and reduce low pay
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Fig. 2: Union density, selected OECD Nations by welfare state type, 2008. Data Source: Organisation for
Economic Cooperation and Development (Organisation for Economic Cooperation and Development,
2010b). Note: Block white identifies social democratic welfare states; grey shading identifies conservative
welfare states; dotted indicates Latin welfare states; and black indicates liberal welfare states as described by
Saint-Arnaud and Bernard (Saint-Arnaud and Bernard, 2003).
118
D. Raphael
Fig. 4: Gini coefficients of income inequality, selected OECD countries, by welfare state type, mid-2000s.
Source: Organisation for Economic Cooperation and Development (Organisation for Economic Cooperation
and Development, 2008a). Note: Block white identifies social democratic welfare states; grey shading
identifies conservative welfare states; dotted indicates Latin welfare states; and black indicates liberal welfare
states as described by Saint-Arnaud and Bernard (Saint-Arnaud and Bernard, 2003).
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Fig. 3: Total public expenditures as percentage of GDP, selected OECD nations, 2007. Source: OECD Social
Expenditure Database, http://stats.oecd.org/Index.aspx?datasetcode=SOCX_AGG. Note: Block white
identifies social democratic welfare states; grey identifies conservative welfare states; dotted indicates Latin
welfare states; and black indicates liberal welfare states as described by Saint-Arnaud and Bernard
(Saint-Arnaud and Bernard, 2003).
The political economy of health promotion
119
and poverty among the working age population
(Organisation for Economic Co-operation and
Development, 2004). These may include formal
classroom training, on-the-job training programmes, subsidies to private-sector employers,
job-search assistance, training programmes for
youth and direct job creation for adult workers.
Figure 6 documents the liberal welfare state
nations’ rather frugal support of active labour
policy. Here Ireland is an exception among the
liberal welfare states. The Latin welfare state
nations are in the mid- to low-range though
Greece is a very low spender. Similar to previous findings, the top seven nations represent a
mixture of social democratic and conservative
welfare states.
Early child development
Early child development is an important prerequisite of health since the beginnings of life have
strong effects upon health (Irwin et al., 2007).
These experiences are both immediate—shaping
young children’s health—and long-lasting—providing the foundations for either good or poor
health during later periods of the life span. The
quality of early child development is shaped by
the economic and social resources available to
parents and the extent to which governments
provide support and a range of benefits to
families and their children (Esping-Andersen,
2002a; Innocenti Research Centre, 2008).
Figure 7 provides an indicator of public
spending on childcare and early education
(Organisation for Economic Co-operation and
Development, 2010a). There is a clear clustering
of four liberal welfare state nations on the lower
end of support for early child development. All
four social democratic welfare state nations are
among the top seven spenders as are France
and Belgium. The UK and New Zealand break
away from the liberal cluster of lower spending
nations. Greece, with Canada, is an exceptionally low spender.
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Fig. 5: Poverty rates in families with children, selected OECD nations by welfare state type, mid-2000s.
Source: Organisation for Economic Cooperation and Development (Organisation for Economic Cooperation
and Development, 2008a). Note: Block white identifies social democratic welfare states; grey identifies
conservative welfare states; dotted indicates Latin welfare states; and black indicates liberal welfare states as
described by Saint-Arnaud and Bernard (Saint-Arnaud and Bernard, 2003).
120
D. Raphael
Fig. 7: Public expenditure on childcare and early education services as percentage of GDP, selected OECD
nations, by welfare state, 2005. Source: OECD (2010c). Note: Block white identifies social democratic welfare
states; grey identifies conservative welfare states; dotted indicates Latin welfare states; and black indicates
liberal welfare states as described by Saint-Arnaud and Bernard (Saint-Arnaud and Bernard, 2003).
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Fig. 6: Public spending on active labour policy as a percentage of GDP, selected OECD nations, by welfare
state type, 2007. Source: OECD (OECD, 2008b). Note: Block white identifies social democratic welfare
states; grey identifies conservative welfare states; dotted indicates Latin welfare states; and black indicates
liberal welfare states as described by Saint-Arnaud and Bernard (Saint-Arnaud and Bernard, 2003).
The political economy of health promotion
121
HEALTH INDICATORS
Four global indicators of health outcomes are
examined here: life expectancy, infant mortality
and homicide and suicide rates.
Life expectancy
Life expectancy is seen by the OECD as a reflection of living standards, lifestyle and education,
and access to quality health services
(Organisation for Economic Co-operation and
Development, 2009). No obvious pattern is seen
between average life expectancy and welfare
state type (Figure 8). In fact, the top seven spots
are represented equally by each of the four
welfare types. Further examination that looked
at improvements in life expectancy from the
period 1960–2006 found that three of four social
democratic welfare state nations were in the
lower one-third of nations’ increases, and three
of four Latin welfare state nations were in the
top one-third of nations in life expectancy
increases (see Supplementary data, Appendix S1
and S2 as online supplementary information).
Infant mortality
The OECD sees the rate at which babies ,1
year of age die as an indicator of how economic
and social conditions affect the health of
mothers and newborns (Organisation for
Economic Co-operation and Development,
2009). Quite a different picture is seen for
infant mortality rates than is the case for life
expectancy (Figure 9; Organisation for
Economic Co-operation and Development,
2009). Five of the six liberal welfare states are
found in the lowest performing seven nations,
while the predominant members of the top
seven nations are social democratic welfare
states. This is of some significance as infant
mortality is usually seen as especially important:
‘The infant mortality rate is a particularly sensitive indicator that, internationally, well reflects
the overall human development, health and
education status of women and the strength of
the public health environment of a nation’
(Butler-Jones, 2008, p. 23).
Suicides and homicides
The OECD states: ‘The intentional killing of
oneself is evidence not only of personal breakdown, but also of a deterioration of the social
context in which an individual lives’
[(Organisation for Economic Co-operation and
Development, 2009a), p. 27]. Yet, outside of the
low rates of the Latin nations, no clear pattern
is seen for the other welfare types (Figure 10)
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Fig. 8: Life expectancy at birth, among selected OECD nations, 2007. Source: OECD (OECD, 2009b).
Note: Block white identifies social democratic welfare states; grey shading identifies conservative welfare
states; dotted indicates Latin welfare states; and black indicates liberal welfare states as described by
Saint-Arnaud and Bernard (Saint-Arnaud and Bernard, 2003).
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D. Raphael
Fig. 10: Suicide rates among selected OECD nations, 2006. Source: OECD (OECD, 2009c). Note: Block
white identifies social democratic welfare states; grey shading identifies conservative welfare states; dotted
indicates Latin welfare states; and black indicates liberal welfare states as described by Saint-Arnaud and
Bernard (Saint-Arnaud and Bernard, 2003).
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Fig. 9: Infant mortality rates, selected OECD nations by welfare state type, 2007. Source: OECD (OECD,
2010d). Note: Block white identifies social democratic welfare states; grey shading identifies conservative
welfare states; dotted indicates Latin welfare states; and black indicates liberal welfare states as described by
Saint-Arnaud and Bernard (Saint-Arnaud and Bernard, 2003).
The political economy of health promotion
but this is not the case for homicide rates
(Figure 11; Organisation for Economic
Co-operation and Development, 2009b). There,
four of the six liberal welfare states are located
among the worse seven performing nations.
Wilkinson and Pickett among others have commented on how strongly the homicide rate correlated with the extent of income inequality
(Kaplan et al., 1996; Daly et al., 2001; Wilkinson
and Pickett, 2009).
Table 2 summarizes standings of the 12 exemplar nations—differing in their form of welfare
state—on policy indicators related to provision
of the prerequisites of health as well as the
selected health outcomes. A simple metric was
used to generate this table. Based on their score
for each indicator, a nation is identified as
falling into either the top seven, middle seven
or bottom seven of the 21 OECD nations
included in these analyses.
How do the nations that profess commitments
to provision of the prerequisites of health fare
in achieving these commitments? It was proposed earlier (see Table 1) that social democratic welfare state nations’ rhetorical
commitments to the provision of the prerequisites of health would be realized in public
policy activity. As shown in Table 2, the exemplar social democratic nations of Finland,
Norway and Sweden are found to be in the top
or middle one-third of the 21 OECD nations
examined for every indicator of public expenditure. Finland and Sweden are placed high in the
top one-third in terms of employment bargaining and union density indicators as well as
income inequality and poverty. Norway falls in
the top or middle with regard to these indicators. Not surprisingly, virtually all the social
democratic nations’ rankings in income inequality and poverty are among the top performing
nations.
Fig. 11: Homicide rates among selected OECD nations, 2005. Source: OECD (OECD, 2009d). Note: Block
white identifies social democratic welfare states; grey identifies conservative welfare states; dotted indicates
Latin welfare states; and black indicates liberal welfare states as described by Saint-Arnaud and Bernard
(Saint-Arnaud and Bernard, 2003).
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EXPLICIT/IMPLICIT HEALTH
PROMOTION FOCUS AND THE
PROVISION OF THE PREREQUISITES
OF HEALTH
123
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D. Raphael
Table 2: Placement of Exemplar Nations as being among the Top (best performing), Middle, and Bottom (worse performing) one-third of 21 OECD
nations classified as being either social democratic, conservative, Latin or liberal welfare states
Public commitments through
expenditures as % of GDP
Key social determinants
Public
spending
Social democratic
Finland
Middle
Norway
Middle
Sweden
Top
Conservative
Belgium
Top
France
Top
Germany
Top
Latin
Greece
Middle
Italy
Top
Spain
Middle
Liberal
Australia
Bottom
Canada
Bottom
UK
Middle
Health and social outcomes
Active
labour
Early
childhood
Income
inequality
Family
poverty
Union
density
Collective
agreements
Life
expectancy
Infant
mortality
Suicide
rates
Homicide
rates
Top
Middle
Top
Top
Top
Top
Top
Middle
Top
Top
Top
Top
Top
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Welfare state
type
The political economy of health promotion
economic insecurity (Daly
Wilkinson and Pickett, 2009).
et
al.,
2001;
IMPLICATIONS FOR HEALTH
PROMOTERS
Earlier the following key questions were raised:
(i) What are the implications of a nation’s
placement in the welfare state regime typology for health promoters concerned with provision of the prerequisites of health through
public policy activity?
(ii) What are the implications for health promoters’ efforts of the presence or absence of
explicit health promotion commitments to
provision of the prerequisites of health by
governmental authorities through public
policy action?
This analysis suggests that health promoters
must pay attention—regardless of the presence
or absence of explicit governmental commitments to provision of the prerequisites of
health—to how a wide range of public policies
provide these prerequisites. Placing one’s health
promotion activities within the context of the
form of the welfare state of one’s nation seems
to be essential as this placement provides a
context for understanding both the present situation and the means of improving upon it.
There are both general implications of these
findings for health promoters as well as specific
implications for health promoters in each of the
various forms of the welfare state.
General implications
It must be recognized that health promotion is
an explicitly political activity in that it is concerned with the distribution of economic and
social resources amongst the population and the
political forces that shape this distribution. This
point has repeatedly been made in the health
promotion literature but has had little penetration into health promotion consciousness
(Signal, 1998; Seedhouse, 2003; Bambra et al.,
2005; Sparks, 2009).
More recently, the Commission on the Social
Determinants of Health stated: ‘The unequal
distribution of health-damaging experiences ‘is
not in any sense a “natural” phenomenon but is
the result of a toxic combination of poor social
policies and programmes, unfair economic
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The liberal welfare state exemplar nations’
ratings, despite their professed commitments to
provision of the perquisites of health, are predominantly among the bottom one-third—with all
others being in the middle one-third—of
OECD nations in their public expenditures.
Canada is in the bottom one-third of nations on
every indicator of public expenditure, income
inequality and poverty, and collective agreement coverage. Its middle placement with
regard to union density belies a rather low
score. Australia and the UK show similar placement. All income inequality rankings are
among the bottom one-third performing
nations, and poverty rates are either in the
bottom or middle category of the 21 nations
examined.
What is very interesting is the very good performance of the conservative nations on many
of these indicators. Outside of Germany’s
bottom group placement for expenditures on
early childhood, every conservative nation’s
public expenditure scores was among the top
one-third of OECD nations. Union density provided a more mixed picture, but collective
agreement rates were all either among the top
or middle nations. Except for Germany’s
bottom placement for poverty rates, all income
inequality and poverty rates were among the
middle performing nations. Conservative
nations’ lack of explicit health promotion commitments do not seem to interfere with their
public policy approaches towards provision of
the prerequisites of health.
Latin nations’ scores show a very mixed
pattern that suggests performance midway
between the conservative and liberal nations.
The predominant placement for the governmental expenditures, and bargaining and unionization measures, and inequality and poverty rates
is in the middle group of nations, followed by
the bottom placement, and then the top
placement.
In terms of health indicators, the most
obvious differences are seen in infant mortality
where the previously found excellence of the
social democratic and the lesser performance of
the liberal nations are apparent. The Latin
nations show a clear superiority in their lower
suicide rates. Homicide rates appear to reflect
effects associated with income inequality and
the public policies that spawn such inequality
such as reduced social infrastructure, the
income gap between rich and poor, and general
125
126
D. Raphael
To illustrate the concept’s relevance to these
prerequisites of health issues, Bambra created
two indices of de-commodifcation and examined scores of 18 OECD nations for 1998
(Bambra, 2005): cash benefits (e.g. replacement
rates during illness and unemployment, duration
of unemployment illness and benefits, pension
generosity, etc.) and health-care services (e.g.
public health-care coverage and public versus
private expenditure). The social democratic
welfare state nations of Finland, Norway and
Sweden, together with the conservative welfare
state nations of Belgium, France and Austria
were clearly placed in the quadrant reflecting a
greater extent of de-commodification for both
cash benefits and health-care services.
Interestingly, Italy, Denmark and Canada just
made it into this quadrant as well.
The USA and Australia were in the quadrant
representing a lesser extent of de-commodification for both domains, while Ireland, the UK
and New Zealand were low for cash benefits but
high for health-care services. Switzerland,
Germany and the Netherlands were high for
cash benefits but low for health-care services.
A more recent report and re-conceptualization by Menahem creates an index of
de-commodified security that is more closely
related to the concept of provision of the prerequisites of health (Menahem, 2010). He assessed
the approaches of five northern European
nations ( primarily social democratic), seven continental nations (all conservative), three
southern nations (all Latin) and seven liberal
nations towards 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.).
These are the rankings of the nations
included in the study reported in this article
from highest to lowest on his de-commodified
security index: Sweden, Finland, Denmark,
Netherlands, France, Germany, Austria,
Luxembourg, Norway, Switzerland, Belgium,
Italy, Canada, UK, Greece, Spain, Australia,
Ireland and USA. The social democratic
welfare states score highest, followed by the
conservative, Latin and liberal welfare states.
His findings demonstrate how differing welfare
states provide differing degrees of security—
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arrangements, and bad politics’ [(World Health
Organisation, 2008a), p. 1]. What exactly is
involved in the recognition—and then response
to—the conclusion that the provision of the prerequisites of health is a political activity?
Since the broad strokes of public policy
appear to be of vital importance with regard to
the provision of the prerequisites of health,
health promoters must be prepared to become
actively engaged within the political realm in
which public policy is made (Signal, 1998;
Bambra et al., 2005; Raphael, 2006). They must
also consider the political and economic structures as well as the ideological discourses that
so often accompany these societal structures
(Navarro et al., 2004; Grabb, 2007; Raphael,
2009). Recognizing the ideological tendencies
of these differing welfare states should help to
identify the supports and barriers to implementing public policy that provides the prerequisites
of health.
To accomplish this, health promoters must
become familiar with the political economy of
health and the disciplines of public policy analysis and change. Luckily, there are accessible
volumes that provide a comprehensive introduction to the political economy of health
(Navarro, 2002, 2007; Navarro and Muntaner,
2004), public policy analysis and change
(Brooks and Miljan, 2003; Bryant, 2009) and
the political economy of the welfare state
(Esping-Andersen, 1990, 1999, 2009). The
numerous reports of the Commission on Social
Determinants of Health also provide important
information on the public policy components of
prerequisites of health-related issues (World
Health Organisation, 2008b). Some of the implications of some of these issues for health promoters have also been outlined (Raphael and
Bryant, 2006; Raphael et al., 2008).
Another key concept that should become the
basis of health promotion understanding and
activity is that of de-commodification.
According to Eikemo and Bambra: ‘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). Generally, social democratic welfare state nations have exhibited the
greatest extent of de-commodification, the
liberal nations the least. Conservative and Latin
states usually show an intermediate level
(Esping-Andersen, 1990, 1999; Saint-Arnaud
and Bernard, 2003).
The political economy of health promotion
wage earner. Over time, the social democratic,
conservative and Latin welfare state nations
have achieved high collective bargaining rates
that reflect union strength in the social democratic nations and cohesion building or corporatist tendencies in the conservative and Latin
nations.
Liberal nations with their modest benefits targeted to the least well-off—representing the
weakness of labour movements and the dominance of business interests—have been less able
to secure the loyalties of the middle class to the
welfare state. Instead the middle classes have
given their loyalties to the economic marketplace (Esping-Andersen, 1985, 1990). Key to
shifting these loyalties appears to be convincing
the middle classes of the benefits that would
accrue from public policies that provide the prerequisites of health.
There are two key public policy directions
that would shift this landscape. The process of
achieving collective employment bargaining
could be facilitated either through the strengthening of trade unions or the introduction of
cross-sectoral bargaining. The first course of
action is more common in the social democratic
nations, while the second is common among the
conservative and Latin nations. Either—or
both—would serve to strengthen the influence
of workers against the interests of the business
sector. This is especially important in the liberal
nations which appear to have the weakest commitments to providing the prerequisites of
health.
The second policy direction would be to distribute risk across the population through introduction of universalist health and social
assistance schemes that minimize individual susceptibility to adverse life-course and accidental
events (Shaw et al., 1999; Esping-Andersen,
2002b; Seedhouse, 2003). In Canada, the middle
classes have come to support the Medicare
system since it is perceived as reducing risks
associated with disease and illness. Canadians—
like those in other liberal welfare state
nations—need to be provided with other
examples of universal programmes that would
reduce risk and build loyalty to welfare state
policies rather than loyalties to the healththreatening insecurities associated with the
economic marketplace (Leys, 2001; Macarov,
2003). Provision of universal affordable childcare would be one such policy—Pharmacare
would be another—that would gain the support
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which clearly has close proximity to the concept
of the provision of the prerequisites of health to
citizens.
The findings reported here therefore are consistent with earlier ones: ‘Recent public health
research has found a positive relation between
levels of decommodification, income inequality
and measures of population health such as
infant mortality’ [(Bambra, 2007; Eikemo and
Bambra, 2008), p. 4]. This appears to be so
since the extent of de-commodification appears
to represent an ideological commitment on the
part of nations to provide citizens with the
opportunity to live a good quality of life if they
are unable—for a variety of reasons—to earn a
market wage. This commitment appears to not
only support the health of those most likely to
experience adverse living conditions and poor
health, the unemployed, infirm and disabled,
but it also appears to have a general health
enhancing effect across the population serving
to reduce social and health-inequalities by
enhancing the quality and distribution of the
social determinants of health across the population (Graham, 2004, 2007).
Another concept that health promoters need
to become familiar with is how these welfare
state traditions come about. Since these
differences—found to be related to the prerequisites of health—are rather consistent over
time (Swank, 2005), it is important to understand the historical traditions that lead nations
to adopt these different approaches to public
policy. Esping-Anderson and others identify
various factors that shape the form of the
welfare state (Esping-Andersen, 1990; Olsen,
2002; Alesina and Glaeser, 2004). These are the
extent and form of class mobilization, the
extent and form of political coalition building,
and the extent to which the middle classes have
formed loyalties to societal institutions such as
the welfare state or the economic marketplace.
Social democratic nations are marked by
their history of coalition building between
labour and other sectors that have led to the
development of universalist public policies that
have secured the loyalties of the middle class
(Esping-Andersen, 1985, 1990). Conservative—
and in its weaker version, the Latin welfare
state—garnered the loyalties of the middle class
by establishing hierarchical social insurance
schemes that provide a variety of protections
against risk through work-based contributions
directed towards the primary—usually male—
127
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D. Raphael
of the middle class for an expanded welfare
state (Lexchin, 2001; Friendly and Prentice,
2009).
SPECIFIC IMPLICATIONS FOR HEALTH
PROMOTERS WITHIN THE FOUR
WELFARE STATE TYPES
Liberal welfare states
Liberal nations are distinguished by their explicit commitments to provision of the prerequisites of health with rather little seen in terms of
policy indicators of the implementation of these
commitments. In Canada, this state has been
associated with rather significant efforts towards
research related to the prerequisites of health at
the same time that objective conditions deteriorate (Bryant et al., 2011). In this case, knowledge creation, dissemination, translation and
exchange of prerequisites of health-related
information appear to be necessary but insufficient means of creating prerequisites of healthproviding public policy.
Instead, it is especially important for health
promoters in liberal welfare states to acknowledge the structural barriers—related to the
operation of the political and economic
system—to having governmental authorities
implement public policy that provides the prerequisites of health. These include the strong
influence of the business sector, governmental
adherence to this sector’s wishes for deregulation and a weakened welfare state, and the ideological discourse that justifies these imbalances
of power (Grabb, 2007; Raphael et al., 2008;
Langille, 2009). There is strong evidence that
provision of the prerequisites of health by governmental authorities are much more likely—
even in liberal welfare state nations—when
nations are governed by parties such as Labour
in Australia, New Zealand and the UK, and the
New Democratic Party in Canada. The USA
has no significant left party presence, suggesting
that the future concerning the prerequisites of
health is rather bleak.
It is in these liberal nations therefore that
profound shifts in political power are required
Social democratic welfare states
In the social democratic welfare states, the
health promotion rhetoric regarding the provision of the prerequisites of health overlay
longstanding public policy traditions that
emphasize the provision of citizens’ economic
and social security. These nations have economic and political structures—and an accompanying ideological discourse—that support the
health promotion principle of governmental
provision of the prerequisites of health through
public policy activity.
The task for health promoters in these social
democratic welfare states is to continually
reinforce the value of these policy efforts
through continuing research, education and
public policy advocacy. The key message that
needs to be repeated was inadvertently presented in the California Newsreel documentary
Unnatural Causes: Is Inequality Making us Sick
(Adelman, 2008) where a Swedish union
leader—in relation to the rather bleak situation
of unemployed factory workers in the USA—
comments: ‘When you look around, you realize
how lucky you are to live in Sweden’.
By ensuring citizen understanding of the
value of strong de-commodifying public policy,
there will be continuing public support of the
kinds of public policy that has been demonstrated to be of such value in promoting health.
The social democratic welfare states are assisted
in this task since there is a long tradition of
such public policy. As Swank points out:
‘Generally, welfare states are path dependent in
that the cognitive and political consequences of
past policy choices constrain and otherwise
shape efforts at programmatic and systemic
welfare retrenchment’ (Swank, 2005, p. 187).
Conservative and Latin welfare states
The conservative—and to a lesser extent Latin—
nations also implement public policy that
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The recommendations presented in the previous
sections are relevant to all health promoters.
But there are specific issues that arise with
regard to each form of the welfare state.
and such action probably requires the support
of the labour movement and social democratic
parties of the left (Navarro and Shi, 2001;
Brady, 2003, 2009; Navarro et al., 2004). Brady
outlines the components of such a strategy:
build citizen coalitions, shift values and ideology of the public, and strengthen political
parties of the left and ensure their achieving
power (Brady, 2009).
The political economy of health promotion
CONCLUSION
Findings indicate that it is important to consider
what nations actually do in the realm of public
policy—rather than say in their statements and
documents—about providing the prerequisites
of health. The liberal welfare states of
Australia, Canada and England are usually held
out as leaders in health promotion. But despite
their governmental authorities’ commitments to
the provision of the prerequisites of health,
these nations actually have a rather poor track
record of providing the prerequisites of health
through public policy action when compared
with numerous other OECD nations, many of
which have given little explicit attention to this
health promotion concept. The main task in
these liberal welfare states is to build social and
political movements that will demand prerequisites of health-supporting public policy.
The social democratic welfare states of
Finland, Norway and Sweden have no such problems: their commitments to the provision of
the prerequisites of health are manifested in
their public policy activity. Their performance
on a variety of prerequisites of health-related
indicators shows the positive effects of their
commitments. The value of such commitments
and the public policy that supports these commitments needs to be reinforced through
research, education and public policy advocacy.
In contrast, the conservative—and to a
similar though lesser extent Latin—nations
provide the prerequisites of health in the relative absence of explicit health promotionrelated commitments. The problem here is that
the lack of recognition of the health-related
aspects of their public policy directions leads to
a neglect of evaluation of the health-related
effects of these public policy directions. The
task here is to educate policy makers and the
public as to the health-related components of
public policy and strengthen the link between
health prerequisites and public policy activity.
The analyses presented here also suggest that
public policy indicators of the provision of the
prerequisites of health and health outcomes
should be included in health promotion analyses
and advocacy. Especially important policy indicators include collective agreement coverage
and union density and state commitment to the
provision of the prerequisites of health through
the collection of revenues and expenditures that
benefit the citizenry. Also of importance is the
collection of data on income inequality and
poverty rates as these are potent predictors of a
variety of health-related outcomes.
It is important to collect data on intermediate
impact policy indicators such as income inequality and poverty rates because some of the
health effects of commitments to provide the
prerequisites of health may take time to materialize. Infant mortality rate however, is a sensitive indicator of population health and
was closely linked to these policy indicators.
Life expectancy—less linked to these policy
indicators—may take time to reflect shifts in the
provision of the prerequisites of health.
A similar disparity is seen in the case of suicide
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supports the prerequisites of health but do so
with rather less explicit recognition of their
health promotion implications. Suggestions that
these nations lag behind in health promotion
activities are not entirely accurate. They may not
explicitly emphasize health promotion concepts
such as the provision of the prerequisites of
health but actually do a rather good job of
implementing them. Political ideology and politics—rather than health promotion rhetoric—
therefore play a key role in conservative and
Latin welfare states’ provision of the prerequisites of health. Such policy efforts need to be
supported in the conservative welfare states and
strengthened in the Latin welfare states. Some of
the suggestions provided for the liberal welfare
states about supporting the labour movement
and parties of the left would apply here as well.
In addition, one of the themes running
through the national case reports for the conservative and Latin welfare states presented in
Part 1 of this article was that governmental authorities’ lack of recognition of the health-related
aspects of their public policy making resulted in
a failure to track and evaluate any healthinequalities reducing effects of such policy
(Raphael, 2013). One task then for health promoters is to impress upon policy makers that
their efforts to promote economic and social
security of their citizens—associated with these
welfare states’ emphasis upon societal solidarity
and reduction of risk (Saint-Arnaud and
Bernard, 2003)—may also have beneficial health
effects. Directing attention to other nations’
activities and carrying out public education as to
the importance of the prerequisites of health
would assist in this task.
129
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D. Raphael
Latin welfare states—where receptivity to these
principles is less, building of broad social and
political movements in support of prerequisites
of health-related public policy may be necessary
(Raphael, 2009). An essential component of
such activity would be educating the public as
to the vital role that prerequisites of health—
and their public policy antecedents—play in
shaping their health (Raphael, 2006).
SUPPLEMENTARY DATA
Supplementary data are available at HEAPRO
online.
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Health Promotion International Advance Access published May 28, 2014
Health Promotion International
doi:10.1093/heapro/dau044
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PERSPECTIVES
Beyond policy analysis: the raw politics behind
opposition to healthy public policy†
Health Policy and Equity, York University, 4700 Keele Street, Room 418, HNES Building, Toronto,
Ontario M3J 1P3, Canada
*Corresponding author. E-mail: [email protected], http://www.yorku.ca/health/people/index.
php?dept=&mid=162284
†
Material in this article was first presented in a keynote address at the conference Health Promotion
Research: An International Forum in Trondheim, Norway, August 7, 2012.
SUMMARY
Despite evidence that public policy that equitably distributes
the prerequisites/social determinants of health (PrH/SDH) is
a worthy goal, progress in achieving such healthy public
policy (HPP) has been uneven. This has especially been the
case in nations where the business sector dominates the making
of public policy. In response, various models of the policy
process have been developed to create what Kickbusch calls a
health political science to correct this situation. In this article
I examine an aspect of health political science that is frequently neglected: the raw politics of power and influence.
Using Canada as an example, I argue that aspects of HPP
related to the distribution of key PrH/SDH are embedded
within issues of power, influence, and competing interests
such that key sectors of society oppose and are successful in
blocking such HPP. By identifying these opponents and
understanding why and how they block HPP, these barriers
can be surmounted. These efforts to identify opponents of
HPP that provide an equitable distribution of the PrH/SDH
will be especially necessary where a nation’s political economy
is dominated by the business and corporate sector.
INTRODUCTION
There are many aspects of a health political
science. These include analysis of policy content,
policy processes, policy actors and the politics
behind decision-making by authorities (Clavier
and de Leeuw, 2013a). One useful way of illustrating these different aspects is Kingdon’s model of
agenda setting (Kingdon, 1984). Kingdon argues
that for an issue to make it onto the public policy
agenda three streams need to align to create a
policy window: problems, proposals and politics.
The problems stream is about policymakers recognizing the importance of an issue; the proposals
stream involves the process of developing possible
solutions and the politics stream is about the
ideologies and belief systems of ruling authorities
and the ability of advocacy and opposition groups
to have their views acknowledged (de Leeuw et al.,
2013). Concerning the importance and problematic
The arguments for developing and implementing
healthy public policy (HPP) that strengthens
and equitably distributes the prerequisites/social
determinants of health (PrH/SDH) are longstanding and appear—at least to many health
promoters—to be persuasive (Milio, 1986; World
Health Organization, 1986, 2008a; Leppo et al.,
2013). Nevertheless, it has been long been noted
that these concepts are contested with implementation anything but assured (Milio, 1986; Graham,
2004; Robert Wood Johnson Foundation, 2010).
In response, it has been argued that attention be
directed to the public policy processes that would
facilitate its implementation (Clavier and de
Leeuw, 2013b). Kickbusch calls this new field of
study health political science (Kickbusch, 2013).
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DENNIS RAPHAEL*
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D. Raphael
aspects of the last stream, Milio (1986) long ago
noted:
These choices ( policy decisions) are political decisions. The answers come most often from those who
are organized to protect their interests, not necessarily from all segments of the population who will
be affected by the policies ( p. 84).
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 (p. 187).
The neglect of politics, power and ideology in the
HPP literature should not be surprising as much
of the HPP literature has been concerned with
specific health issues such as tobacco and alcohol
use, diet and physical activity, environmental concerns about pesticides use and exposure to toxins,
spatial issues of neighbourhood organization and
healthcare related to access and coverage rather
than the distribution of the PrH/SDH (Milio,
1986; Luginaah et al., 2001; Stuckler and Siegel,
2011; Lazar et al., 2013; McQueen, 2013). These
former issues certainly involve aspects of politics,
power and ideology, especially in relation to interests that profit from the distribution of tobacco
and junk food, lack of government regulation of
industry and development, and favoured status of
the health care industry over the public health
sector (Milio, 1986; de Leeuw, 1989). de Leeuw
argues that many of these issues can transcend leftright political commitments (de Leeuw, 2013).
But there are other more contentious areas
where the raw politics (Clavier and de Leeuw,
2013a) of power and influence may play a greater
role: PrH/SDH issues of income and wealth distribution, tax structures, provision of shelter and food
security, employment and working conditions, the
availability of health and social services and the
ability of individuals and communities to control
these PrH/SDH. It is in these areas that deal with
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Efforts have been made to apply these and other
insights from the public policy literature to
health promotion and HPP issues (Signal, 1998;
Bryant, 2002; Bambra et al., 2005). It has been
noted that many of these applications consider
the public policy making process to be a rational
ideas-driven process with less analysis of the
underlying politics that drive public policymaking.
As Bambra et al. (Bambra et al., 2005) state:
control and distribution of economic resources
where we can expect that competing societal interests would be more likely to manifest opposition to
HPP that equitably distributes the PrH/SDH.
In addition, the resurgence of neo-liberal
ideology in the past three decades—an ideology
that believes that governments should withdraw
from managing the economy thereby ceding
more power and influence to the business and
corporate sector is also affecting the distribution
of the PrH/SDH (Coburn, 2001, 2004; Harvey,
2007; Navarro, 2007). Yet, it is uncommon to see
explicit examination of how this ideology is
shaping the quality and distribution of the PrH/
SDH and what would be the forces supporting
such ideology (Bryant, 2013).
Another reason for the neglect of the raw politics of power and influence in HPP is that providing an equitable distribution of PrH/SDH is less
contentious in many nations where it is supported
across the political spectrum. Many Western
European nations have made efforts to assure that
citizens are provided with the PrH/SDH necessary
for health (Raphael, 2013a, b). This however may
be less the case in nations identified as Liberal
welfare states such as Australia, Canada, New
Zealand, the UK and USA (Navarro and Shi,
2001). Political economists use the term Liberal
to refer to the form of capitalism that emerged in
England during the late 18th century (EspingAndersen, 1990). It is an approach that favours
the unimpeded operation of the capitalist economic system and reifies individual initiative at
the expense of government intervention into the
operation of the economic system.
It is in these Liberal countries where opposition
to the equitable distribution of PrH/SDH may be
organized to resist these forms of HPP. And it is in
these nations that the promise and hope of rational
ideas-driven HPP approaches to the PrH/SDH
continues to be pursued (Public Health Agency of
Canada and Health Systems Knowledge Network,
2007; Health Council of Canada, 2010).
But it is not only the Liberal welfare states that
see opposition to the equitable distribution of
the PrH/SDH. All developed nations have been
subject to welfare state retrenchment that can
skew the distribution of the PrH/SDH (Eikemo
and Bambra, 2008). Even welfare state powerhouse Sweden is beginning to resemble the problematic Liberal welfare state profile (Raphael,
2014). Why is this and what are the implications
for developing HPP that assures the equitable
distribution of the PrH/SDH?
Beyond policy analysis
HEALTHY PUBLIC POLICY IS ABOUT
POWER, INFLUENCE AND RESOURCE
ALLOCATION
Health promotion is the process of enabling
people to increase control over, and to improve,
their health (World Health Organization, 2013).
It is recognized that much of this involves access
to the PrH/SDH of income, food, shelter, employment and working conditions, and health and
social services through implementation of HPP
(World Health Organization, 1986, 2008b). Four
key statements—among others—exemplify the
World Health Organization’s emphasis upon
developing HPP that provides an equitable
distribution of PrH/SDH: the Ottawa Charter,
Adelaide Recommendations, Belfast Declaration,
and Helsinki Statement on Health in All Policies.
The importance of healthy public policy
The Ottawa Charter on Health Promotion outlined how the basic prerequisites of health—or
social determinants in modern usage—of peace,
shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and
equity are shaped by public policy: Health promotion policy combines diverse but complementary
approaches including legislation, fiscal measures,
taxation and organizational change. HPP is public
policy that supports rather than threatens health.
The Adelaide Recommendations on Healthy
Public Policy emphasized the importance of HPP
and how it should be characterized by an explicit
concern—and accountability for—health and
equity in all areas (World Health Organization,
1988). Public policy should create supportive
environments that enable people to lead healthy
lives: Health for All will be achieved only if the
creation and preservation of healthy living and
working conditions become a central concern in
all public policy decisions.
The Belfast Declaration on Healthy Cities
called for an explicit concern with reducing inequalities and addressing poverty through local
action (World Health Organization, 2003). It saw
cities as prime sites for such activity such that
good city planning and strategic partnerships for
health would promote governance that assured
that citizens have a key role in developing health
promoting city policies and plans.
The Helsinki Declaration on Health in All
Policies reaffirmed the importance of public policy
action to support health: Health in All Policies is an
approach to public policies across sectors that systematically takes into account the health implications
of decisions, seeks synergies and avoids harmful
health impacts in order to improve population health
and health equity. . . It includes an emphasis on the
consequences of public policies on health systems,
determinants of health and well-being (World
Health Organisation, 2013). (The term Health in
All Policies appears to have superseded the use of
Healthy Public Policy. It assumes that governments
are interested in applying it in their policymaking, a
point I am not convinced of in many cases.)
Despite these—and other—WHO declarations and charters on the importance of HPP and
the PrH/SDH (World Health Organization,
2009), there is little literature on why these
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The social inequality and political economy literatures provide insights into how powerful interests can shape the making of public policy to
skew the distribution of PrH/SDH among differing social classes, genders and races, among
other social identities (Grabb, 2007; Coburn,
2010). These literatures not only identify potential barriers to HPP, but also provide means of
overcoming these barriers.
In this article, I explore the value of identifying
the specific sector of society—the business and
corporate sector—which opposes HPP that provides an equitable distribution of the PrH/SDH. I
do not deny the importance of careful application
of public policy theories and analyses to determining means of promoting the PrH/SDH-related
HPP agenda. But I move beyond policy analysis
to consider how focus on the raw politics of power
and influence can identify and confront these
problematic sectors.
The approach I take also calls for a critical
analysis of the concept of intersectoral cooperation in building of HPP. The intersectoral approach employs a consensus model of society
which may not be appropriate in cases where
there is sectoral opposition to HPP that equitably distributes the PrH/SDH (Bryant, 2009).
Finally, the focus here is on wealthy developed
nations with special emphasis on the Canadian
scene, but the analysis can be extended to lowand middle-income nations. Concern with the influence of raw politics on HPP will especially be
the case where a nation’s political economy is
dominated by the business and corporate sector.
The Appendix provides an historical context for
such an analysis.
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Page 4 of 17
D. Raphael
The role of power and influence in resource
allocation
The idea that power shapes resource allocation
that can affect health is not new. As early as 1845
Friedrich Engels argued the owners and managers of the economic system created the profound material and social deprivation that led to
early mortality among the working class in
England (Engels, 1845/1987). During the same
period Rudolph Virchow pointed to the lack of
democratic institutions as driving the typhus epidemic in Upper Silesia, a Polish province of
Prussia (Virchow, 1848/1985). And more recently,
the World Health Organization’s Commission on
Social Determinants of Health stated that the inequitable distribution of health enhancing and
damaging experiences was the result of ‘poor
social policies and programmes, unfair economic
arrangements, and bad politics’ (World Health
Organization, 2008a).
A basic tenet of the social inequality literature
is that power and influence varies among those of
different classes, statuses and parties or associations (Grabb, 2007). Karl Marx and Friedrich
Engels identified social class as a key indicator of
the power to shape the distribution of income
and wealth (Marx and Engels, 1848). Max Weber
recognized the importance of social class and
added status factors of occupation, gender and
religion as indicators of the power to access societal resources (Weber, 1922/2013). Parties were
professional associations that also gained power
and influence. For Weber—as well as Marx and
Engels—the politics of everyday life was essentially a struggle among individuals for power and
influence.
Class determines one’s power and influence in
the economic sphere of life. The owners and
managers of business can shape the operation of
the political and economic systems. Wright
argues that the rather strong term ‘oppression’
can be applied when those who control the economic system extract resources for themselves to
such an extent that others suffer material deprivation and this relation is coercively enforced
through legislation (Wright, 1994). Status and
party also affords power and influence through
the social-honour or prestige spheres of life and
can lead to skewing of the distribution of PrH/
SDH. All these kinds of power create varying
access to material resources resulting in differing
life chances—including health (Kitchen, 2005).
The political economy literature extends these
insights by considering how the power and influence of these classes, occupations and parties act
through political and economic systems to distribute resources (Bryant, 2009; Coburn, 2010).
Both literatures are concerned with Who gets
what, how, and why?; a phrase denoting the
essence of politics in a society (Lasswell, 1936/
2011). Since the ability to control the PrH/SDH
is shaped by the ability to influence society
through the operation of the economic and political systems, a neglect of the role of power and
influence in the HPP literature related to the
PrH/SDH is problematic (Bambra et al., 2005;
Raphael and Bryant, 2006).
Which societal sector might oppose equitable
distribution of the PrH/SDH? These literatures
would suggest the owners and managers of business with the support of citizens who come to
agree with these views would be these villains.
This citizen support may be misguided (‘false consciousness’) whereby individuals come to hold the
very beliefs and attitudes that work against their
own self-interest (Wilson, 1983), one example
being people living in poverty supporting the
public policies that create their adverse living
conditions.
The power and influence of owners and managers is channelled through control of the
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principles have been taken to heart by policymakers in some nations but not others (Raphael,
2013b). Rather than seeing these differences as
reflecting the presence or lack of evidence (every
nation’s policymakers have access to this information), or organizational capacity of governments and advocacy groups, they may be due to
national differences in the power and influence
of societal sectors to shape public policy.
The social inequality and political economy literatures provide signposts of how the assertion
of power and influence by particular sectors acts
though economic and political systems to shape
the making of public policy that distributes the
PrH/SDH. Various ways of describing these different groups whose interests conflict in a society
exist: classes, occupations, elites etc. I use the
term sectors as it is used in the political economy
literature to differentiate between the interests
of business, organized labour and civil society,
where the State mediates these interests. Such
insights may help explain why so few HPP initiatives that address the PrH/SDH have been implemented in Canada, as one example (Low and
Therault, 2008; Hancock, 2011).
Beyond policy analysis
POLITICS AND THE DISTRIBUTION
OF THE PRH/SDH
A fundamental goal of HPP should be assuring
that PrH/SDH are equitably distributed such that
no one experiences material and social deprivation that threatens health (Labonte, 1986; World
Health Organization, 1986). The importance of
the distribution of the PrH/SDH is seen in Hillary
Graham’s distinction between the PrH/SDH
proper and their distribution (Graham, 2004). The
former points out their general importance while
the latter inquiries into how equitable or inequitable distributions come about. Analysing public
policy is key to such understandings and begs the
question: why does public policy distribute PrH/
SDH more equitably—with resultant differences
in extent of health inequalities—in some jurisdictions and not others? (Bambra, 2012; Raphael,
2013a, b).
The answer is in the politics of these jurisdictions. For Bambra et al., politics influences health
and the distribution of PrH/SDH through four
Fig. 1: Depiction of Pathways by which the Relative Strengths of the Business, Labour, and Civil Society
Sectors act in concert with Form of the Welfare State and Voter Political Activity and Public Opinion to
produce Public Policy that shapes the Quality and Distribution of the PrH/SDH (Adapted from Raphael, 2014).
Downloaded from http://heapro.oxfordjournals.org/ at York University Libraries on May 28, 2014
economic and political systems which creates
public policy that skews the distribution of the
PrH/SDH. As will be discussed, the ability of
these differing sectors to shape public policy—
and the resultant distribution of the PrH/SDH—
depends upon their relative power and influence
in relation to the labour movement and civil
society. The following sections depict how these
effects manifest through a range of political activities. Figure 1 provides a model of these processes.
At the top of Figure 1, there are the three key
sectors that influence the entire public policy
process. The Business and Corporate Sector is
centrally placed as it has the greatest potential in
capitalist societies—and all wealthy developed
nations are capitalist—to shape aspects of economic and political systems, public policy making
and the quality, and distribution of the PrH/SDH.
It also has the ability to shape the attitudes and
values of the public through its creation of ideological discourse—the ways society members
come to think about these issues (Grabb, 2007).
Page 5 of 17
Page 6 of 17
D. Raphael
somewhat interrelated aspects: Politics as Power,
Politics as Government, Politics as Public Life,
and Politics as Conflict Resolution (Bambra et al.,
2005). All are interrelated such that when the
power of differing sectors is balanced within a
society, quality of the other aspects of politics is
enhanced.
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Politics as power
Politics is the process through which desired outcomes are achieved in the production, distribution and use of resources in all areas of social life
(Bambra et al., 2005). In wealthy developed
countries—all of which are capitalist economies—sectors whose interests compete are
business, labour and civil society. The State acts
as mediator of these interests (Bryant, 2009).
The business and corporate sector has power
and influence through its control of the economic
and political systems (Bryant, 2009). It possesses
various levers of power—primarily its ability to
move and invest capital—that shape how governments develop and implement public policies that
distribute the PrH/SDH. In regard to this distribution, the business sector usually favours less
provision of social and economic security and
advocates for weakened government management
of employment practices, and fewer support programmes and benefits, all of which results in less
redistribution of income and wealth (Leys, 2001;
Macarov, 2003; Langille, 2009). Its call for lower
taxes—especially for the corporate sector and the
wealthy—weakens governmental ability to provide
benefits and supports that provide economic and
social security to the population (Menahem, 2010).
Indeed, Scambler asks whether workers’ illness
can be a side-effect of excessive profit-making by
capitalists (Scambler, 2009).
The organized labour sector usually supports
greater redistribution through higher taxation on
the business and corporate sector and the
wealthy, stronger government management of
the workplace and greater provision of supports
and benefits (Navarro et al., 2004). It gains power
and influence through the percentage of the
population that belong to trade unions and its
alliance with governing parties of the left (Brady,
2009; Bryant, 2009; Navarro and Shi, 2001). The
civil society sector gains power and influence
from its ability to influence public opinion and
shape public policy through networks of agencies, organizations and other non-governmental
institutions (Brady, 2009). And of course, the
citizenry itself has influence through its ability to
elect representatives to governments.
The balance of power among sectors differs
among nations with resulting impacts on the distribution of the PrH/SDH (Raphael, 2013b). It
has long been noted that public policy approaches
of the Nordic nations of Denmark, Finland,
Norway and Sweden act such that the distribution
of PrH/SDH is more equitable than in the
Anglo-Saxon nations of Australia, Canada, New
Zealand, UK and USA (Navarro and Shi, 2002;
Innocenti Research Centre, 2005; Health Council
of Canada, 2010). [Denmark provides a conundrum for a welfare state analysis in that its life expectancy is very low in comparison with other
wealthy developed nations. Its infant mortality
rate, however, is very favourable and there is evidence that it has begun to explicitly address issues
of health equity in its public policy (Povlsen et al.,
2014)].
The nations of Continental Europe such as
Belgium, France, Germany and the Netherlands
fall midway between the Nordic and Anglo-Saxon
nations. In both the Nordic and Continental
nations consultation and communication among
these sectors is common, sometimes institutionalized and sometimes informal (Swank, 2002).
This is usually not the case in the Anglo-Saxon
nations, a situation that is sometimes called ‘disorganized capitalism’ (Offe, 1985).
For Esping-Andersen, variations in power and
influence are related to qualitatively different
welfare state regimes that overlap with the Nordic,
Anglo-Saxon and Continental categories (EspingAndersen, 1990, 1999). Social Democratic welfare
states—the Nordic nations—are distinguished by
their strong commitments to State provision of
citizen economic and social security—a concept
that appears closely related to provision of the
PrH/SDH. The Liberal welfare states—the AngloSaxon nations—generally rely upon the economic
marketplace to distribute economic and social
resources. (There is some variation among Liberal
welfare states with Australia, Canada, New
Zealand and UK providing universal healthcare
and somewhat more inclusive welfare systems
than the USA, but these nations have distinctive
common characteristics consistent with their
Liberal designation.) The Conservative welfare
states—the Continental nations—are distinguished by their emphasis upon social insurance
programmes that reduce economic and social
risks among wage earners. The Latin welfare state
is a less developed form of the Conservative
Beyond policy analysis
business sector to block HPP that distributes the
PrH/SDH would be stronger under the Liberal
welfare state regime and closely associated with
politics as government.
Politics as government
Politics as government is concerned with the art of
government and activities of the State (Bambra
et al., 2005). Government is responsible for the
making of public policy that influences the distribution of the PrH/SDH. Its most obvious manifestation is its providing citizens with economic and
social security through a wide range of public
policy areas such as education and training, family,
labour, shelter, taxation, and health and social services among others (Raphael, 2012c). And not surprisingly, this aspect is linked to the welfare regime
typology described earlier (Raphael, 2013b).
The Social Democratic welfare states of Finland,
Norway and Sweden have become HPP leaders
through proactive approaches towards public
policy that provides quality and equitable distribution of the PrH/SDH (Backhans and Burstrom,
2012; Fosse, 2012; Mikkonen, 2012). This is in
contrast to Liberal welfare states—typified by
Australia, Canada, New Zealand, UK and USA—
where modest supports and programmes are targeted and subject to means-testing (Raphael,
2013a, b). The Conservative and Latin welfare
states’ social insurance programmes provide citizens with economic and social security midway
between these welfare regimes.
The most obvious manifestation of these politics as government differences is the amount of
public and social spending expenditures for citizens across the life span. Social Democratic and
Conservative—and to a lesser extent Latin—
nations are more generous and encompassing in
citizen support—child benefits, employment
training and support, public pensions—than
Liberal nations (Pontusson, 2005; Olsen, 2010).
Not surprisingly, poverty rates and extent of
income inequalities parallel these spending differences (Raphael, 2013b).
Electoral politics and political history explain
much of the variation among these nations’ willingness to develop HPP that address the PrH/
SDH. Social Democratic nations have seen more
widespread governance by social democratic
parties of the left that maintain a healthy skepticism towards the capitalist economic system
(Esping-Andersen,
1985;
Rainwater
and
Smeeding, 2003; Brady, 2009). Their universalist
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welfare state (Spain, Portugal, Italy and Greece)
(Saint-Arnaud and Bernard, 2003). In both the
Social Democratic and Conservative—and to
some extent the Latin—welfare states there is significant coordination of employment and wage
structures across economic sectors and among
unions (Pontusson, 2005; Swank, 2005). These
serve to provide higher proportions of the labour
force working under collective agreements than
the Liberal welfare state nations (Organisation for
Economic Co-operation and Development, 2013).
This both limits the power and influence of the
business and corporate sector and makes the implementation of equitable PrH/SDH-related HPP
more likely.
In terms of the issue of power and influence and
the ability of specific societal sectors to support or
oppose the making of PrH/SDH-related HPP, in
the Social Democratic regime organized labour
has come to have significant influence—by virtue
of its strong membership and alliances with governing parties of the left—in the making of public
policy (Einhorn and Logue, 2003). The primary
ideological inspiration of this regime is Equality
that is implemented through public policies
made by its dominant institution, the State
(Saint-Arnaud and Bernard, 2003). In contrast,
the Liberal welfare regime’s primary ideological
inspiration is Liberty as manifested through its
primary institution, the Marketplace. Here public
policy is shaped in the interest of business and the
efficient—and profitable for business—operation
of the economic system. Such policy can also lead
to suppression of unions by making organizing
more difficult. Here, the organized labour movement tends to be weak, and in many instances civil
society organizations have less influence upon the
public policy process (Raphael, 2012c).
Not surprisingly, the Social Democratic
regime’s quality and distribution of the PrH/SDH
are clearly superior to what is seen in the Liberal
welfare regime (Raphael, 2013b). The third
welfare regime, the Conservative—and the undeveloped Latin—has the Family as its dominant
institution, supported by social insurance programmes—usually forged by cooperation of the
State and the Marketplace that provide economic
and social security (Saint-Arnaud and Bernard,
2003). Its primary ideological inspiration is
Solidarity. It maintains status differences and the
quality and distribution of the PrH/SDH under
this welfare regime falls midway between the
Social Democratic and Liberal (Raphael, 2013b).
This analysis suggests that the ability of the
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D. Raphael
Politics as public life and as conflict resolution
The third and fourth forms of politics are about
daily life and the expression and resolution of conflicts through compromise, conciliation, negotiation
and other strategies (Bambra et al., 2005). One way
of thinking about politics as public life is the
amount of citizen involvement—and therefore
power and influence—through civil society organizations. Interestingly, such involvement appears to
be much higher in Social Democratic welfare
states than under the Liberal welfare regime
(Saint-Arnaud and Bernard, 2003; Wijkström,
2004). In contrast to the common sense view that in
a well-developed welfare state that takes care of its
citizens through benefits and programmes, citizen
involvement would be less, it is actually greater
(Rostila, 2013). Citizen involvement is a key tenet
of the Healthy Cities Movement (World Health
Organization, 2003). Not surprisingly, there is evidence that PrH/SDH-related HPP is more likely
when such participation is higher (Saint-Arnaud
and Bernard, 2003; Raphael, 2012c).
In terms of politics as conflict resolution, we
see greater citizen involvement in the day-to-day
affairs of municipal governments in the Social
Democratic welfare regime than elsewhere
(Schraad-Tischler, 2011). Cynicism towards government and belief that governments are corrupt
are lower in Social Democratic welfare states
(Saint-Arnaud and Bernard, 2003; SchraadTischler, 2011). Governments that provide social
justice stimulate citizen involvement in the
day-to-day affairs of governance, activities of
local institutions and agencies (Rostila, 2013;
Wijkström, 2004).
The implications of this analysis are that differing forms of the welfare state will have differing
power balances and imbalances. In the Liberal
welfare state the forces that favour the provision
of quality and equitable distributions of the PrH/
SDH through the making of HPP will generally
be at a disadvantage. Arguments for HPP may
not be as persuasive since they will run afoul of
those societal sectors with more influence with
policymakers. The result is the blocking of public
policies that will enhance the equitable distribution of the PrH/SDH. While form of the welfare
state will provide differing receptivity to these
issues, they in themselves will not completely
determine governmental action. Other aspects in
Figure 1 play a role.
ECONOMIC GLOBALIZATION AND THE
PRH/SDH: CANADA CASE STUDY
Economic globalization provides an illustration
of how power and influence, politics and form of
the welfare state comes together to influence
public policy that shapes the distribution of the
PrH/SDH. Labonte and Schrecker and Friel
et al. have provided especially useful insights into
how economic globalization and associated trade
agreements are shaping the making of HPP and
the ability of governments to equitably distribute
the PrH/SDH (Labonte and Schrecker, 2007a, b, c;
Friel et al., 2013). These effects are noticeable
across developed and developing nations and it is
probably in the latter case where the effects of
power and influence upon the distribution of PrH/
SDH are particularly stark (Kim et al., 2000;
Labonté et al., 2009).
It is frequently argued that increasing economic
globalization requires that national jurisdictions compete in a ‘race to the bottom’ by which
employment standards are weakened, wages
lowered and government revenue collection and
social programmes reduced in order to compete
in the international marketplace (Swank, 2005;
Teeple and McBride, 2010). National jurisdictions, it is said, have no choice but to succumb to
these economic pressures with a resulting deterioration in the distribution of the PrH/SDH. Not
surprisingly, this argument is usually supported
by the business sector (Leys, 2001; Langille,
2009).
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and generous benefits and programmes secured
the loyalties of the middle and working classes for
a State role in resource provision and redistribution
(see Figure 1) (Esping-Andersen, 1990, 1999). The
Liberal welfare state has little of this skepticism
and embraces free market ideology, one result of
which is the inequitable distribution of the PrH/
SDH (Raphael, 2013a, b). The Conservative
welfare state is also sceptical of unbridled capitalism and has been historically influenced by the
Church (Esping-Andersen, 1990, 1999). Here, the
business and corporate sector is more likely to recognize the benefit of the status quo and promote
social and economic solidarity (Saint-Arnaud and
Bernard, 2003). The result of all this is a wide
range of differences in public policies, the dominant difference emerging between the ‘social economies’ of Europe and the Liberal welfare state
regime associated with the Anglo-Saxon heritage
(Pontusson, 2005).
Beyond policy analysis
business and corporate sector since the 1980s has
come to dominate the public policymaking process
with resultant declines in the quality and equitable
distribution of the PrH/SDH (Scarth, 2004; Healy,
2008; Langille, 2009; Raphael, 2009b). Evidence is
available that the processes contributing to these
declines in Canada include growing corporate
concentration, declines in union density and the
skewing of income and wealth among the top 1%
of Canadians (Brennan, 2012).
The quality and distribution of many PrH/
SDH are in decline. Income and wealth inequality is increasing as are job insecurity, temporary
and part-time work (Curry-Stevens, 2009;
Tremblay, 2009). Since 2000 wages have stagnated for 60% of the population and for those
not employed, unemployment and social assistance benefits continue to fall behind the rate of
inflation (National Council of Welfare, 2010). As
a result food and housing insecurity is growing
(McIntyre and Rondeau, 2009; Shapcott, 2009).
As an overall indicator of the PrH/SDH situation,
consider that 50% of Canadians would have difficulty meeting their financial obligations if their
paycheck was delayed by 1 week (Nanos
Research, 2012). Much of this is due to the lack of
public policy that manages the activities of the
business and corporate sector (Bryant et al.,
2011). Canadian governments’ tax reductions
have also made less resources available for governments to address PrH/SDH issues through
HPP (Langille, 2009).
Interestingly, public attitudes have not shifted
in parallel with governmental tax reductions. In
fact, Canadians are willing to pay more taxes and
tax the rich to reduce inequality, yet these views
have not influenced Canadian governments to do
so (Fitzpatrick, 2012; Ipsos Reid, 2013). In addition, there is public concern with growing inequality that offers a means of remobilizing the
Canadian public to pressure governments to
respond (Vincent, 2014).
Canadian researchers and advocates’ activities
usually work within a pluralist model of policy
change by which the quality of ideas and related
evidence are seen as shaping forms of public
policy (Bryant et al., 2011). Creating and providing evidence to policymakers as to the benefits of
PrH/SDH-related HPP should assure implementation of such policy. Pluralism seems an adequate approach when the interests of the
business and corporate, organized labour and
civil society sectors are balanced such as appears
to be the case in the Social Democratic and the
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However research evidence indicates that national responses to the imperatives of economic
globalization are primarily determined by the
internal politics of the nation (Swank, 2002;
Coburn, 2004; Banting and Myles, 2013). The
Social Democratic and the Conservative welfare
states—it is unclear where the Latin states fall—
have been more able to resist these pressures
than Liberal welfare states. Much of this is attributed to differences in the power and influence of
societal sectors, ideology of ruling parties as well
as the general tendency for nations to continue
on their accustomed public policy trajectories, a
process political economists call path dependency
(Swank, 2002). The policy process in Liberal
welfare states, already dominated by the business
and corporate sector, has fewer means of resisting
pressures for welfare state retrenchment that
makes the distribution of PrH/SDH less equitable
(Eikemo and Bambra, 2008). An illustration of
this can be seen in the case of Canada, where
recent events have weakened an already undeveloped welfare state (Bryant et al., 2011).
Canada has been a leader in developing health
promotion concepts and there is no shortage of
researchers identifying the importance of HPP
that would equitably distribute PrH/SDH or
advocates for its implementation. Indeed, Public
Health Agency of Canada documents (Public
Health Agency of Canada, 2007), Canadian
Senate reports (Senate Subcommittee on
Population Health, 2008a, b) and arms-length
federally funded agencies such as the Canadian
Institute for Health Information (Canadian
Institute for Health Information, 2002) and the
Health Council of Canada (Health Council of
Canada, 2010) call for a HPP approach that
equitably distributes the PrH/SDH.
But Canada has been a laggard in implementing HPP (Collins and Hayes, 2007; Bryant et al.,
2011; Hancock, 2011). This is especially the case
regarding HPP that shapes the distribution of the
PrH/SDH as Canada presents one of the worse
profiles among wealthy developed nations with
indications that the profile is further decaying
(Bryant et al., 2011; Raphael, 2013b). Indeed,
issues of PrH/SDH are not on the public policy
agenda at any governmental level in Canada. In
this, Canada is similar to the situation in the
USA (Bezruchka, 2012).
In terms of the model provided in Figure 1,
Canada, being a Liberal welfare state has historically neglected making public policy that equitably
distributes the PrH/SDH. Worse, the Canadian
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D. Raphael
THE VALUE OF IDENTIFYING HPP
OPPONENTS
Knowing this, what is the value of explicitly identifying these opponents of PrH/SDH-related
HPP? Various PrH/SDH discourses exist, each
of which has implications for the form and
content of HPP. Some limit HPP to issues associated with access to necessary services and promoting healthy behaviours among those exposed
to adverse PrH/SDH. Others emphasize building
HPP that address the distribution of the PrH/
SDH and identifying ideological barriers to
implementing such HPP (see Table 1).
But the specific issue examined here is to what
extent is it helpful to identify those ‘villains’ who
promote HPP that skews the distribution of PrH/
SDH? (Discourse 7 in Table 1). In this approach
individuals and groups who through their undue
influence upon governments create and benefit
from the less equitable distribution of PrH/SDH
are identified. As example, it can be argued that
since the corporate and business sector in Canada
lobby for (i) shifting the tax structures to favour
itself and the wealthy; (ii) reducing public expenditures that benefit the majority of the population;
(iii) controlling wages and limiting employment
benefits and (iv) relaxing labour standards and
protections, they should be identified as opponents
of the PrH/SDH-related HPP enterprise (Chernomas
and Hudson, 2007; Langille, 2009).
Table 1: Varying discourses on HPP and the distribution of the PrH/SDH
PRH/SDH discourse
Key concept
1. PRH/SDH as identifying those in need of health and social
services
Health and social services should be responsive to peoples’
material living circumstances. HPP aims to improve access
and quality of these services
Health behaviours (e.g. alcohol and tobacco use, physical
activity and diet) are shaped by living circumstances. HPP
aims to make the healthy choice the easy choice
Material living conditions operating through various
pathways—including biological—shape health. Implicit
assumption that policymakers will respond to evidence with
appropriate HPP
Material living conditions systematically differ among those in
various social locations such as class, disability status,
gender and race. Implicit assumption that policymakers will
respond with appropriate HPP
Public policy analysis should form the basis of PRH/SDH
analysis and advocacy efforts. Explicit call for the making of
HPP to address these issues
Public policy that shapes the PRH/SDH reflects the operation
of jurisdictional economic and political systems. Explicit
call for the making of HPP to address these issues with
recognition that nations tend to follow established public
policy paths
Explicit call for the making of HPP to address these issues
with recognition that specific societal sectors both create
and benefit from the existence of social and health
inequalities. Need to identify these opponents and build
political and social movements to defeat them in the public
policy domain
2. PRH/SDH as identifying those with modifiable medical
and behavioural risk factors
3. PRH/SDH as indicating the material living conditions that
shape health
4. PRH/SDH as indicating material living circumstances that
differ as a function of group membership
5. PRH/SDH and their distribution as results of public policy
decisions made by governments and other societal
institutions
6. PRH/SDH and their distribution result from economic and
political structures and justifying ideologies
7. PRH/SDH and their distribution result from the power
and influence of those who create and benefit from health
and social inequalities
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stronger Conservative welfare states, but falls
short when public policy is made in the service of
the business and corporate sector in the Liberal
welfare states. It certainly has not led to PrH/
SDH-related HPP in Canada.
A materialist analysis of public policymaking
however draws attention to these power and influence imbalances (Bryant, 2009). David Langille
for instance argues the deterioration of the quality
and distribution of the PrH/SDH has come about
through macro-level changes in economic policy
spurred on by political specific actors (Langille,
2009). Systematic attacks on organized labour
have strengthened the power and the influence of
the business and corporate sector making it difficult to resist retrenchment of welfare programmes
that provide economic and social security.
Beyond policy analysis
But, who exactly are these specific actors and
how can we reduce their undue influence upon
public policy? Langille (Langille, 2009) identifies
the business and corporate sector and their allies:
business associations, conservative think tanks,
citizen front institutions and conservative lobbyists as culpable:
Langille argues that promoting PrH/SDHrelated HPP can be achieved by educating and
organizing citizens to force policymakers to
promote health through HPP (Wright, 1994).
This approach is not new and is seen in particularly pointed analysis of the political economy of
health from the mid-1850s right up to the present
(see Appendix). What does this analysis add to
efforts to promote PrH/SDH-related HPP? Is it
more useful than assuming that good ideas and
evidence should carry the day? And what activities would flow from such an analysis?
Since research and advocacy efforts should
correct these imbalances in power and influence
Langille (Langille, 2009) proposes educating the
public and using their strength in numbers to
promote HPP to oppose this agenda. Educating
the public in regards to the PrH/SDH has not
been a priority of any governing authorities in
Canada and in response, grassroots activity has
done so. On the public health front a local public
health unit in Ontario created a video animation
Let’s Start a Conversation about Health and Not
Talk about Health Care at All (Sudbury and
District Health Unit, 2011). It has been adapted
for use by no less than 14 other public health
units in Ontario (out of the total of 36), numerous others across Canada and jurisdictions in the
USA and Australia (Raphael, 2012a).
Mikkonen and Raphael created a public primer
on the PrH/SDH entitled Social Determinants of
Health: The Canadian Facts that has been downloaded over 200 000 times since April 2010; 85%
of these downloads by Canadians (Mikkonen and
Raphael, 2010). And a new Canadian organization
Upstream Action aims to create a movement to
create a healthy society through dissemination to
the public of evidence-based, people-centred ideas
(Upstream, 2013). The purpose of these activities
is to create a groundswell of public interest in and
support for HPP that will force policymakers to
take the PrH/SDH seriously.
Efforts are occurring in the workplace through
greater union organization and increasing public
recognition of the class-related forces that shape
public policy (Zweig, 2000, 2004; Jackson, 2009,
2010). To this end, there is interest in building
links between those concerned with creating
HPP and the organized labour movement
(Lewchuk et al., 2008; Lewchuk et al., 2013).
Such an alliance is consistent with findings that
PrH/SDH are more likely to be distributed equitably when the organized labour movement is
strong (Navarro and Shi, 2001; Navarro, 2009).
Activities are also occurring in the electoral
and parliamentary arena. Social democratic
parties are more receptive to—and successful at—
implementing public policies that reduce social inequalities and health inequities (Navarro and Shi,
2002; Swank, 2005; Brady, 2009; Raphael, 2012c).
Therefore, the recent 2011 elevation of the social
democratic New Democratic Party (NDP) in
Canada to the Official Opposition in Ottawa is a
positive development. The NDP intends to raise
the PrH/SDH in its next election campaign (New
Democratic Party of Canada, 2013). It has undertaken a cross-Canada consultation to develop
means of raising this issue in the next national
election scheduled for 2015.
Finally, identifying ‘villains’ can boost citizen
motivation and build a social movement to
improve the quality and equitable distribution of
the PrH/SDH. Langille (Langille, 2009) argues:
By identifying the political actors behind what are
often seen as impersonal market forces, citizens
come to understand that progressive change is possible—and how they might improve the social
determinants of health . . . If citizens are to reassert
their power and restore democracy, they will first
have to raise public awareness about the threat of
corporate control ( p. 305).
IMPLICATIONS FOR BUILDING HPP
THAT ADDRESSES THE PRH/SDH
The argument presented does not deny the importance of knowledge development and transmission and developing and applying models of
policy analysis and change that can facilitate the
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The driving forces shaping our social determinants
of health have been the owners and managers of
major transnational enterprises—the men who
have defined our corporate culture and wielded an
enormous influence over public policy. Their main
instrument has been macroeconomic policy, which
they have used to set constraints on the role and
scope of government. They have pushed for
Canadian governments to adopt a free market or neoliberal approach to macroeconomic policy (p. 305).
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D. Raphael
most pleasant or easiest way to conceive of and
act upon the PrH/SDH through HPP, but may
prove to be the most useful in the long term.
APPENDIX. HISTORICAL CONTEXT:
IDENTIFYING THOSE OPPOSING
EQUITABLE DISTRIBUTION OF THE
PRH/SDH
Friedrich Engels
In view of all this, it is not surprising that the workingclass has gradually become a race wholly apart from
the English bourgeoisie. The bourgeoisie has more in
common with every other nation of the earth than
with the workers in whose midst it lives. The workers
speak other dialects, have other thoughts and ideals,
other customs and moral principles, a different religion and other politics than those of the bourgeoisie.
Thus they are two radically dissimilar nations, as
unlike as difference of race could make them, of
whom we on the Continent have known but one, the
bourgeoisie (Engels, 1845/1987).
In the Condition of the Working Class in England
(1845) German political economist Friedrich
Engels studied how poor housing, clothing, diet and
lack of sanitation led directly to the infections and
diseases associated with early death among
working people in England. Engels identified material living conditions, day-to-day stress and the
adoption of health-threatening behaviours as the
primary contributors to social class differences in
health. Engels was not benign in his critique: he
used the term social murder to refer to the fact that
these life-threatening conditions resulted from the
operation of the economic system and that [T]he
bourgeoisie places hundreds of proletarians in such
a position that they inevitably meet a too early and
an unnatural death, one which is quite as much a
death by violence as that by the sword or bullet.
Rudolf Virchow
The bureaucracy would not, or could not, help the
people. The feudal aristocracy used its money to
indulge in the luxury and the follies of the court,
the army and the cities. The plutocracy, which draw
very large amounts from the Upper Silesian mines,
did not recognize the Upper Silesians as human
beings, but only as tools or, as the expression has it,
‘hands.’ The clerical hierarchy endorsed the wretched neediness of the people as a ticket to heaven
(Virchow, 1848/1985).
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making of PrH/SDH-related HPP (Clavier and de
Leeuw, 2013b). It does assert however that these
activities must be buttressed by critical analyses of
power relations within societies and how these
power relations shape the politics of a society.
These critical analyses may be less important in
nations where these issues are less contentious.
But even then, threats to HPP that equitably distribute the PrH/SDH are arising even in the social
democratic Nordic nations (Raphael, 2014).
These threats exist in the form of welfare state retrenchment associated with a return to behavioural approaches—or lifestyle drift—to health
promotion (Backhans and Burstrom, 2012).
Alternatives approaches that mobilize the public
and create pressure for PrH/SDH-related HPP
and build support for the organized labour movement and parties of the left are necessary
(Navarro and Shi, 2002; Raphael, 2012c).
Health promoters are faced with a difficult
task. Most of their activities—especially if they
are employed by the State—involve working to
improve the quality and distribution of the PrH/
SDH through individual interactions, community
work and developing public policy recommendations that may be ignored (Raphael, 2006). If my
analysis is correct, they will have to engage more
directly in building social and political movements that can shift the distribution of influence
and power (Raphael, 2012b). They may be able
to do this through public education as part of
their employment and urging their professional
associations into a stronger advocacy role
(Bryant et al., 2007; Raphael, 2009a; Raphael
et al., 2008). They may also have to engage in political activity as citizens outside of their employment (Raphael, 2006, 2011).
To summarize, the importance of identifying
the societal sectors who oppose PrH/SDHrelated HPP and responding to these threats to
HPP will be greatest in nations where the business and corporate sector hold greater sway:
Canada, the UK and the USA (Scambler,
2002; Hofrichter, 2003; Chernomas and Hudson,
2007). The extent to which it is useful in other
liberal nations such as Australia and New
Zealand, the conservative nations of Continental
Europe and the social democratic Nordic nations
should be the subject of further analysis. Putting
faces to ‘villains’ threatening the health of citizens can harness citizen energies in the service of
PrH/SDH-related HPP. It can promote citizen
engagement in all forms of the politics that can
move this agenda forward. It may not be the
Beyond policy analysis
Graham Scambler
The GBH (Greedy Bastards Hypothesis) states,
without a hint of hyperbole, that Britain’s persisting – even widening – health inequalities might
reasonably be regarded as the (largely unintended)
consequences of the ever-adaptive behaviours of its
(weakly globalized) power elite, informed by its
(strongly globalized) capital executive (Scambler,
2002).
British sociologist Graham Scambler developed
the Greedy Bastards Hypothesis (GBH) in order
to make explicit that class did matter and that
one particular class was shaping public policy in
their service with adverse health effects for most
others. In his analysis, growing health inequalities are the results of the activities of a ‘core
“cabal” of financiers, CEOs and Directors of
large and largely transnational companies, and
rentiers’. More recently Scambler has written: So
the GBH charged leading capitalists and politicians with what the likes of Engels and Virchow
in the nineteenth century called homicide. As
Michael Marmot has more recently averred, policies can kill, and when these are reflexively
enacted their architects shouldn 0 t be surprised to
find themselves liable to prosecution in the event
of a regime change (Scambler, 2012).
David Coburn
Contemporary business dominance, and its accompanying neo-liberal ideology and policies, led to
attacks on working class rights in the market (e.g.,
by undermining unions) and to citizenship rights as
expressed even in the liberal (market-dependent)
version of the welfare state enacted in most of the
Anglo-American nations. Labour’s lessened
market power and fragmentation, and the shredding of the welfare state also led to major increases
in social inequality, poverty, income inequality and
social fragmentation [(Coburn, 2004), p. 44].
Canadian sociologist Coburn describes how the
power of capital in the form of economic globalization and justified through neo-liberal ideology
acts through form of the welfare state to shape
the quality and distribution of the PrH/SDH. His
initial work on neo-liberalism provoked much
debate and continues to influence the field
(Coburn, 2000). Coburn places his work firmly
within the materialist political economy tradition.
Robert Chenomas and Ian Hudson
Income power and privilege have been shifted
towards those who own and control the corporate
world and away from the majority of the North
American public, with the express democratic
consent of that very public . . . The current conservative policy environment has made our society less
healthy, more dangerous, less stable, more unequal,
less fair, and more inefficient (Chernomas and
Hudson, 2007).
These Canadian economists argue in Social
Murder and other Shortcomings of Conservative
Politics (2007) that corporate power and the ideology that justifies it has come to dominate public
policy. The approach is not only misguided and
wrong but responsible for increased illness and
death and the suffering that goes with it. They
state: Most readers will no doubt be aware that
modern corporations have acquired such vast
power that they are above the law – or more precisely that they have a huge influence on what the
law says – and that this has many harmful effects
on the public and the environment (pp. 6–7).
Vicente Navarro
It is not inequalities that kill, but those who benefit
from the inequalities that kill. The Commission’s
studious avoidance of the category of power (class
power, as well as gender, race, and national power)
and how power is produced and reproduced in political institutions is the greatest weakness of the
report . . . It is profoundly apolitical, and therein lies
the weakness of the report [(Navarro, 2009), p. 15].
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German physician Rudolf Virchow’s was a trailblazer in identifying how societal policies determine health. In 1848, Virchow’s Report on the
Typhus Epidemic in Upper Silesia argued that
lack of democracy, feudalism, and unfair tax policies in the province were the primary determinants of the inhabitants’ poor living conditions,
inadequate diet and poor hygiene that fuelled the
epidemic. He stated that Disease is not something
personal and special, but only a manifestation
of life under modified (pathological) conditions.
Arguing Medicine is a social science and politics
is nothing else but medicine on a large scale,
Virchow drew the direct links between politics,
social conditions and health. If medicine is to fulfil
her great task, then she must enter the political and
social life. Do we not always find the diseases of
the populace traceable to defects in society?
Page 13 of 17
Page 14 of 17
D. Raphael
Political economist Vicente Navarro’s work
focuses on how politics and political ideology and
how they influence governance within capitalist
economies are important sources of the public
policies that create health inequalities. As editor
of the International Journal of Health Services, he
provides a forum for critical analyses of the political economy of health. Three volumes bring
together many of these articles (Navarro, 2002,
2007; Navarro and Muntaner, 2004).
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Page 17 of 17
Chapter 10
Applying the Lessons from
International Experiences
Toba Bryant
Introduction
The evidence presented in this volume describes a continuum of governmental policy activity
across nations that tackle inequalities. These range from comprehensive coordinated policy in
Scandinavia to an apparent absence of governmental policy concern in Canada and the US.
Britain and Northern Ireland and Australia present mid-level responses. The sources of these
differences lie in differing aspects of each nation’s state, their power relations within the society,
and the extent of social determinants of health-related policy. These differences, in turn, lead to
differences in social inequalities and health inequalities as well as the willingness to tackle them.
The task for those concerned with tackling health inequalities within each nation is to either
maintain (if health inequalities are being addressed) or shift (if they are not) the characteristics
of these contributing components in a manner that enhances governmental authorities’ ability
and willingness to tackle health inequalities. This is basically the task of implementing public
policy. In the cases where these desired activities are not occurring, it is one of implementing
public policy change. What models of public policy change are available for taking on these
tasks and which will be most appropriate for each nation’s situation?
This chapter examines different models of public policy change and their relevance for
tackling health inequalities through governmental activity. Policy change is an adjustment to an
existing public policy or set of related public policies. It usually refers to a new course of action
aimed at addressing a problem or issue identified by government and others as having negative social implications (Howlett, Ramesh & Perl, 2009). One form of policy change is called
incremental and involves small changes to existing public policy. Some examples of incremental
change to existing public policies would be providing additional resources to enable hospitals
and community health clinics to offer health services to those who show the worse health outcomes, such as homeless people or victims of domestic violence. Such changes do not usually
involve change in the overall goals and objectives of a policy area. Policy change can also be
paradigmatic in that it involves a significant shift in policy goals and objectives. Some examples
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of this would be a nation’s effort to tackle health inequalities as a significant public policy goal
involving a thorough realignment of existing public policy in a range of areas.
In this chapter a variety of existing models of public policy implementation and change are
examined for their relevance to the issue of tackling health inequalities through public policy
activity. These models include what are called pluralist models concerned with democratic processes, policy paradigms, a learning model of policy change, and others that involve a political economy approach. As examples, pluralism is concerned with how citizens can get involved with
groups that advocate for certain public policies (Brooks & Miljan, 2003).
Learning models consider how governmental institutions use knowledge and ideas in the
policy change process (Hall, 1993). And political economy approaches consider the role that
politics and economics play in public policy development (Armstrong, Armstrong & Coburn,
2001). It is this latter approach that explicitly examines the roles political ideology and power,
the market and the state, and civil society play in shaping public policy decisions on health and
social issues. It will be argued that the political and economic configuration in each country
will determine which of these models—pluralist, learning, or political economy—will be most
appropriate to bring about public policy action that tackles health inequalities.
Models of Policy Change
Implementing public policy—either maintaining desired policy or creating desired policy—is
critical to tackling health inequalities. International declarations related to health promotion,
such as the Ottawa Charter, and more recent ones concerned with tackling health inequalities
developed by the World Health Organization and others identify the development of healthy
public policy as a cornerstone of the new public health (Equity Action, 2012; World Health
Organization, 2008, 2009). Indeed, Margaret Chan, WHO director-general, states: “Health
inequities exist because the wrong policies are in place” (Equity Action, 2012).
In nations where health inequalities are not being addressed, the evidence on the importance of developing health-supporting public policy through action on the social determinants
of health has not been acknowledged and certainly not acted upon. In Canada and the US, the
field of “health promotion” has limited itself to raising issues of changing individuals’ healthrelated behaviours, such as tobacco and alcohol use, lack of physical activity, and unhealthy
eating to prevent disease and illness, rather than developing public policies that tackle the primary sources of health inequalities: differing living circumstances (Raphael, 2008). Canadian
and American governments have not demonstrated the will to act on the social determinants
of health in order to reduce the social inequalities that create health inequalities. The task here
is to shift public policy toward addressing these issues.
The opposite situation is seen in the Scandinavian nations of Finland, Norway, and Sweden. The task here is to maintain these public policy initiatives and defend against threats
to them. The task in Britain and Northern Ireland and Australia is to maintain the advances
undertaken and build further momentum. What models of public policy change are available to guide these activities?
Three general public policy change models, pluralism, policy paradigms (one form of learning models), and political economy are used in the following sections to help identify what
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267
may be required to tackle health inequalities within each of the nations examined in this
volume. These three have been selected because they represent the scope of such theories.
Pluralism is a model of democratic participation that focuses on how interest groups influence
governments to make specific forms of public policy. It assumes that governments make public
policy on the basis of an analysis of costs and benefits, and is a principal approach in the public
policy analysis literature. This is especially the case in North America.
The policy paradigms model is consistent with historical institutionalism. It is a learning model
of policy change concerned with the role that established governmental and other institutions
play in the public policy process (Hall, 1993). A key aspect of this model is the importance of
ideas and how these are both embedded in institutions and serve as sources of public policy activity. The model conceives these institutions and their ideas as structuring the public policy-making
process. The model examines various types of policy change, but focuses on paradigmatic policy
change as opposed to processes associated with incremental change.
The political economy model of policy change is a structural and materialist approach that
conceives politics as flowing from how the economy distributes power and resources. It emphasizes how political ideology and the relative power of the market versus the state shape public policy-making (Armstrong et al., 2001; Bryant, 2005; Coburn, 2000). In contrast to the
emphasis on the role of different groups in putting forth ideas to be subjected to cost and benefit analysis (pluralism), and the role played by institutions’ accepted ideas (policy paradigms),
political economy is concerned with how societal structures produce and distribute economic,
political, and social resources. Public policy is a result of particular groups having more control
and influence over these processes, thereby shaping public policy-making to meet their, rather
than others’, needs and desires.
These models will be used to identify the approaches and actions required in different countries to tackle health inequalities. All three models will have insights useful for advancing the
tackling health inequalities agenda. In Canada and the United States, where tackling health
inequalities are not on the public policy agenda, addressing them will require paradigmatic
change in the goals and objectives of public policies as well as forcing the political will to take
action. Such activities will be best assisted by the insights provided by a political economy
analysis of the situation.
In countries further along in tackling health inequalities, such as the Scandinavian countries of Finland, Norway, and Sweden, where power imbalances are less salient than in Canada
and the US, the pluralist and policy paradigms models may provide more immediately useful insights. The British and Northern Ireland and Australian scenes may benefit equally by
insights provided by all three models of public policy change.
Pluralism
Pluralism is one of the most widely used approaches for examining the public policy-making
process (Howlett et al., 2009). Developed in the US, it continues to be the dominant theoretical approach for studying politics and public policy-making there and in Canada. Corporatism
is a similar theory of politics and public policy-making that was developed in Europe around
the same time as pluralism (Howlett et al., 2009). Pluralism considers interest groups as key
societal influences on the public policy process. This perspective considers that the complexity
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of governance of modern society and society itself precludes direct political participation of
individual citizens in the policy process (Brodie, 2005). Citizens, therefore, join groups to promote their preferences and interests. Politics is seen as the competition among interest groups
to influence public policy. Citizens can belong to a number of groups that advance their concerns such that memberships among interest groups frequently overlap (Howlett et al., 2009).
The role of the state is to mediate this competition among different groups and the ideas they
bring to the political process. Critics argue, however, that pluralism has an underdeveloped
understanding of the inequalities—economic, political, and social—that exist in modern capitalist societies, making such objective mediation unlikely.
Pluralists do recognize that not all groups are equal in their ability to influence the political process or to access government (Howlett et al., 2009). These inequalities in influence are
attributable to their lack of financial and other resources. Nevertheless, on this point, McLennan argues, “It is impossible to read the standard works [on pluralist theory] without getting
the sense that resources, information and the means of political communication are openly
available to all citizens, that groups form an array of equivalent power centres in society, and
that all legitimate voices can and will be heard” (McLennan, 1989, 32). Indeed, pluralism
implies that citizens and citizen groups can present their ideas to government with the assumption that they will receive a fair hearing (Bryant, 2010).
Pluralism is a consensus model of policy change as it assumes that decisions will be
based on meeting the common good for most societal members (Bryant, 2009). It emphasizes evidence and ideas, and how experts, lobbyists, and citizen groups can build support
for a particular position on public policy-making (Bryant, 2010). It also assumes that
regardless of the positions groups may argue to government, these groups will not meet
predetermined resistance to their ideas. In terms of trying to influence policy-makers to
tackle health inequalities, for example, by having governments ensure that all citizens have
access to economic and social resources to promote their health, those favouring health
equity will have as much chance of success as those opposing forms of public policy that
reduce social and health inequalities.
Clearly, this is not necessarily the case and the Canadian and US scenes provide ample
evidence of this. This is apparent in Canada, where despite decades of document and
report making containing evidence on the importance of tackling health inequalities by
government civil servants and various professional public health associations, governmental authorities have resisted taking on these issues through public policy activity. The US
scene is even more obvious in demonstrating how political and economic power comes to
shape public policy-making. Here social inequalities in income and wealth and minimal
government intervention in the operation of the market economy—the prime sources of
health inequalities—are actually celebrated by many governing authorities rather than
seen as causes for concern. The British and Northern Irish and Australian experiences are
also replete with examples of governments coming to power that are actively opposed to
public policy that tackles health inequalities.
In spite of the limitations of pluralism for explaining and addressing the Canadian and US
scenes, it does provide some useful insights for those concerned with tackling health inequalities. In Finland, Norway, and Sweden, where concern with strengthening the social deter-
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269
minants of health to tackle health inequalities is most advanced, pluralism can further our
understanding of how public policy-makers, governing and opposition parties, and elements
of civil society have come together to tackle health inequalities and the social inequalities that
spawn them. Pluralism also has insights as to how various societal groups come to influence
public policy in Britain and Northern Ireland and Australia when governing parties receptive
to such ideas have come to power.
Policy Paradigms
Policy paradigms is related to a school of thought called historical institutionalism that considers how institutions of governments structure politics and public policy outcomes (Hall &
Taylor, 1996).
Policy paradigms grew out of an attempt to explain different patterns of policy change
(Hall, 1993). The concept of a “policy paradigm” refers to governments’ social learning where
social learning is defined as “a deliberate attempt to adjust the goals or techniques of policy in
response to past experience and new information” (Hall, 1993, 275). According to this definition, policy change is integrally related to learning from previous experiences. Social learning
emphasizes the role of ideas and their interpretation in policy-making. This social learning
process is dominated by officials and highly placed experts, and this is especially the case when
the issues at hand are highly technical policy fields.
A particular aim of the model is to differentiate between the learning processes associated with normal policy change and more radical or paradigmatic policy change (Bourjolly,
Hirschman & Zieber, 2004). These processes involve the acceptance or rejection of particular
sets of ideas, and these ideas are advanced by both state and non-state actors. But these ideas
have to be processed through the larger political system (Baumgartner & Jones, 1993) such
that “Policy makers work within a framework of ideas and standards that specify not only the
goals of policy and the kind of instruments that can be used to attain them, but also the very
nature of the problems” they are intended to address (Hall, 1993, 279). Hall, for example,
argues that the framework in which politicians function is grounded in the terminology (or
ideas) through which policy-makers understand their scope of activity. Yet much of these ideas
“[are] taken for granted and … unamenable to scrutiny as a whole” (Hall, 1993, 279).
The interpretive framework or policy paradigm involves ideas embedded within existing
political, social, and economic institutions. The terms “policy legacies” and “path dependency”
refer to how past policies shape policies being made in the present. In terms of the present
inquiry, this refers to some of the reasons why some nations find it so difficult to think differently about tackling health inequalities. This is the case because they are following the same
approaches that have served them so well in the past—that is, ignoring these issues. In these
cases, moving governmental policy-making toward tackling health inequalities—and this is
most apparent in Canada and the US—would require rather radical new ways of thinking. It
also helps illuminate why the tackling of health inequalities in Britain and Northern Ireland
represented significant policy shifts and why these ideas about tackling health inequalities
are so easily implemented in Finland, Norway, and Sweden as they are consistent with longstanding policy directions.
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The policy paradigms model, therefore, distinguishes between different orders of change,
identifying normal and paradigmatic patterns of policy change. The aim in developing the
model was to learn more about the varieties of policy change. The model identifies three levels
of policy change:
First-order change: First-order change has elements of incrementalism, “satisficing,” and
“routinized” decision-making (Hall, 1993). Such alterations can be minor adjustments to
policy, such as changes in monthly social assistance and pension payments, or providing additional resources to community health centres or institutions to provide a particular program to
serve people who are homeless or victims of domestic violence. The overall goals of policy, its
instruments, and the context of policy-making remain the same.
Second-order change: Second-order change generally involves the development of new policy
instruments and a move toward strategic action (Hall, 1993). Second-order change may occur
at less frequent intervals than first-order changes. Both first- and second-order changes tend
to “preserve the broad continuity” (Hall, 1993) in terms of the overall goals of a policy area.
In other words, the policy goals and objectives remain the same, but the policy instruments
may change. For example, government officials may want to discourage smoking (Howlett et
al., 2009). Initially, they may use public education on the risks of smoking in the hopes that
people will change their behaviour in response to the information provided. If this does not
produce the desired result of encouraging many people to quit smoking and dissuading young
people from smoking, then they may opt for increased taxation of tobacco products. This typically entails more government activity than simply distributing information. Taxation involves
deliberate efforts to directly influence the preferences and behaviours of citizens to stop or not
start smoking. First- and second-order changes, then, are instances of normal policy change
because they alter policy without changing the overall goals of a policy paradigm.
Third-order change: In contrast to first- and second-order policy changes, third-order paradigmatic policy change is manifested by a radical shift in the overall terms of policy discourse associated
with the “received paradigm” (Hall, 1993). It tends to be a more disruptive process and may involve
sporadic yet well-defined activity. One common example is that of the shift from Keynesian welfare
state to monetarist models of macroeconomic regulation in Britain. It has been suggested that this
shift involved simultaneous changes in all three components of policy: the instrument settings, the
instruments themselves, and the hierarchy of goals behind policy (Hall, 1993).
The development of the welfare state in Canada, the UK, and other western European
countries after World War II also represented a paradigmatic shift from a residual model of
limited or no government involvement to an institutional approach of significant government intervention and activity in social provision (Teeple, 2000). The welfare state involved
high government intervention in such social programs as housing, health care, unemployment
insurance, and pensions. The experiences of citizens during the Depression of the 1930s and
social science knowledge informed this shift.
More recently, governments in Canada, the UK, and elsewhere have undertaken another
paradigmatic shift (Leys, 2001; Teeple & McBride, 2010). They have privatized some health
care services, deregulated the market in many areas, and reduced governmental supports and
benefits to citizens. These changes now signify a paradigmatic shift in the role of government
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271
in the opposite direction than was the case after World War II. This new shift is premised on
an ideological belief—neo-liberalism—that the market is more appropriate than the state for
allocating resources (Coburn, 2000; Teeple, 2000).
These shifts from one paradigm to another—although supposedly based on ideas—may
be more politically than scientifically determined. While arguments mounted by competing
factions, positional advantages within a broader institutional framework, resources of various
competing political actors, and external factors all play a role, their adoption is primarily determined by the politics of the day and the ideology of governing authorities.
In a significant study of the shift from Keynesianism to monetarism in Britain from
1970 to 1989, British politicians intervened when social scientists were unable to resolve
the dispute between the Keynesian and the monetarist paradigms (Hall, 1993). The politicians assessed the merits of the paradigms on political terms. Advancing its own political
agenda and policy ideas, the government launched a new era in macroeconomic policymaking in Britain, drawing on social science insofar as it supported the shift to monetarist
economic policy. Certainly a similar analysis can be provided as to why some governing
authorities adopt the tackling of health inequalities as important foci of public policymaking activity while others do not.
The Political Economy of Policy Change
Political economy is a materialist perspective on politics and the political process. It is materialist as it considers ideas and institutions to emanate from the way in which a society organizes
the production and distribution of social and economic resources (Armstrong et al., 2001;
Coburn, 2010). Politics and economics are considered to be interrelated and as fundamentally
shaping public policy outcomes (Armstrong et al., 2001). This perspective directs attention to
the relationship between public policy-making and the economic, political, and social lives of
different people, geographic areas, or societies. The state, the market, political power, political
ideology, and civil society are considered to be constituent parts of the whole (Armstrong et
al., 2001). The whole is shaped by the mode of production, which is capitalism. Issues such as
social and health inequalities, as well as patriarchy, sexism, and racism, are examined in relation to the operation of the economic and political system. A political economy perspective
also focuses on how gender, social class, and race/ethnicity operate as different forms of social
stratification that create social and health inequalities (Armstrong, 2004).
Of recent interest in the literature is the role of neo-liberalism, an ideology that advocates unfettered free enterprise as the means to foster economic growth and social well-being
(Coburn, 2001, 2004). The political economy perspective is consistent with a focus on the
social determinants of health, and how political and economic environments shape the distribution of social and economic resources within a society.
At the heart of the political economy approach to these issues is a commitment to address
social and health inequalities. This can best be accomplished by making explicit the role
that institutions, especially the state, play in contributing to health inequalities. Societies in
which the market is the most important institution tend to have more pronounced social
and health inequalities (Grabb, 2007; Leys, 2001). This is so because differences among
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groups on the basis of social class, gender, race, and other identities are accentuated. Applying a political economy perspective enables consideration of dominant economic interests
that influence policy change, often impeding the tackling of health inequalities. Through
such an analysis, a political economy perspective can identify means of shifting public policy
toward addressing health inequalities.
The Scandinavian countries of Finland, Norway, and Sweden are especially committed to
tackling social and health inequalities. They have embraced the social determinants concept
and used it to guide the development of public policies that tackle health inequalities. They
do so through provision of a comprehensive welfare state that supports health and reduces
economic and social insecurity. That this is so easily done is a result of their being social
democratic welfare states, where the economic and political systems are oriented toward promoting equality through state intervention in the operation of the market economy (Navarro
& Shi, 2002; Saint-Arnaud & Bernard, 2003). The opposite is the case in the liberal nations
of Canada and the US, where the market economy is the dominant institution and governmental intervention in its operation is minimized. Australia and Britain and Northern Ireland
represent the effects of social democratic parties of the left gaining power nationally in longestablished liberal welfare states.
Models of Public Policy Change and Implications for
Tackling Health Inequalities
In Chapter 9, Raphael presents Figure 9.2, which locates the nations discussed in this volume
on the Action Spectrum for Addressing Health Inequalities.
Finland, Norway, and Sweden as Comprehensive Coordinated Policy
Raphael locates the Scandinavian countries of Finland, Norway, and Sweden at the level of
“Comprehensive coordinated policy.” This means that the national governments in these
countries not only have tackling health inequalities on their public policy agendas, but have
implemented systematic activities to address them. As Whitehead (1998) noted, Sweden had
health inequalities on its public policy agenda as early as the 1930s. The state is deemed the
most important institution and best positioned to distribute these resources to citizens (SaintArnaud & Bernard, 2003). While these countries have ratcheted back public spending in some
social and health policy areas, they are still well ahead of the other countries examined in this
volume (Organisation for Economic Co-operation and Development, 2011). Nevertheless,
the Scandinavian countries have also experienced insreased income inequalities in recent years.
A pluralist analysis would suggest that those in favour of these approaches have been able to
have them placed on the public policy agenda through well-organized advocacy and lobbying
by citizen and other groups. The policy paradigms analysis would explain this as a predictable outcome of well-established policy directions that have their source in the well-developed
Scandinavian welfare state, which has apparently served policy-makers and the public well.
There is little doubt that by any objective set of indicators, overall health and quality of life is
good in Scandinavia, and this is especially the case when compared to liberal welfare states such
as Canada and the US.
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273
But even then, these historical developments must be placed within the context of the
operation of their economic and political systems. It is here that a political economy analysis
provides useful insights into how the organization of the state versus the market, power balances among various groups, and the development of decommodifying public policy help to
explain the Scandinavian concern with tackling health inequalities. Further analyses are presented in the following sections.
Canada and the US as Edging toward Measurement
At the other extreme, Figure 9.2 locates Canada as barely at the “Measurement” level. The US
is not even there. Governments in these countries are not themselves directly involved in measuring health inequalities. Nor are these activities part of any organized governmental activity
concerned with tackling health inequalities. National and state/provincial/territorial governments in both countries generally fail to acknowledge the existence of health inequalities as
significant areas of public policy concern.
Moreover, these failures to tackle health inequalities are not raised by opposition parties in
Canada and the US, and the general public is woefully unaware of these issues. In Canada,
opposition parties highlight how Aboriginal Canadians are disadvantaged in health outcomes,
but issues of social disadvantage among Canadian Aboriginals are not placed within a health
inequalities framework. For example, much media attention focused on the appalling living
conditions in the Aboriginal community of Attawappiscat and how, in an historic first, the
International Red Cross delivered emergency supplies to this community, but these issues
operate outside of any kind of health inequalities policy framework (Berthiaume, 2012).
All three models of policy change provide insights as to how this has come to be the case. In
Canada (less so in the US), a variety of organizations and agencies have raised issues of tackling
health inequalities, but these activities are not well organized and have certainly not placed
these issues on a public policy agenda in either nation (pluralist perspective). Among Canadian and American policy-makers, health—and policy initiatives related to its promotion—are
equated with health care and healthy lifestyles (policy paradigms perspective).
Shifting public policy concern from a focus on biomedical approaches to health and public
education about avoiding health-threatening behaviours will require a paradigmatic shift to one
of instituting public policy that addresses the inequalities in living circumstances that spawn
health inequalities. The lack of organized advocacy and lobbying efforts will make this difficult.
But even then, such a shift in Canada and the US would be resisted by powerful economic
and political forces that favour current policy directions that create social inequalities (Langille, 2009). These interests and their proposed policies drive the growth of income and wealth
inequalities and reduce government benefits and supports to citizens (political economy perspective). Clearly, these analyses help explain both the present situation in these nations and the
formidable barriers to having governing authorities adopt a tackling health inequalities agenda.
Australia: Midway between Isolated Initiatives and More Structured Developments
Australia is located midway between the “Isolated initiatives” and “More structured developments” levels. Tackling health inequalities has made it onto the public policy agenda in
Australia and this is in large part a result of the Community Health Program (CHP) intro-
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Tackling Health Inequalities
duced by the Whitlam Labor government in 1971. A primary purpose of the CHP was to
address health inequalities by developing multidisciplinary approaches to address health in a
specific geographic area. The CHP—while a single initiative—nonetheless provided a foundation for further action to reduce health inequalities. There has been a systematic national
approach to addressing Indigenous health.
Concern with tackling health inequalities has ebbed and waned, it appears, alongside the
election and defeat of Labor governments at the national and state levels. Again, these developments can be explained through recourse to the policy change models. Australians have a
tradition of supporting the “fair go,” which makes governments at least somewhat receptive
to a tackling health inequalities agenda (pluralist perspective). Its governing authorities have
experiences with a variety of health policy agendas, making these governments less rigid than
might be the case in Canada and the US (policy paradigms perspective). But all of these activities are embedded within a liberal welfare state that generally reverts to a preference for less
rather than more state intervention in the operation of the market economy (political economy
perspective). When Labor governments are elected, there is a move toward tackling a health
inequalities agenda, but even then these efforts are modest as compared to the cases of Finland,
Norway, and Sweden.
Britain and Northern Ireland: More Structured Developments
Britain and Northern Ireland have had tackling health inequalities on their public policy agendas for some time now. The devolution of power to Scotland, Wales, and Northern Ireland
has led to some divergence in addressing health inequalities in the three regions. For example,
Scotland covers prescription fees, abolished university tuition fees, and expanded home care
provision to seniors. Prior to devolution, however, the United Kingdom underwent a paradigmatic shift toward tackling health inequalities, which began with the commissioning by the
newly elected Labour government of the Acheson Review (Acheson, 1998). Health inequalities
became a cornerstone of its health policy and a wide range of intersectoral governmental initiatives were undertaken. Opinion is mixed as to the success of these initiatives (Hills, Sefton &
Stewart, 2009; Hills & Stewart, 2005).
By the time of the election of the Labour government in 1997, the growth of social and
health inequalities had become a widespread public concern and tackling these were a part of
Labour’s election platform (pluralist perspective). The newly elected government undertook a
variety of initiatives, but these were embedded with the ongoing operation of the UK’s political
and economic system, which is associated with rather higher income and wealth inequalities.
There was also a general reluctance to undertake governmental interventions in the marketplace associated with the UK’s liberal welfare state (policy paradigms perspective). Critiques of
the government’s approach toward tackling health inequalities have focused on the unwillingness to address broad issues of income and wealth inequality by concentrating on the needs of
the most disadvantaged (political economy perspective).
Even these developments are now threatened by the election of a Conservative-Liberal
Democratic Coalition government, which has vowed to cut government expenditures by 40
percent (Bryant et al., 2011). Moving toward the approaches of the Scandinavian nations
requires consideration of the many barriers to such action in the UK. Even so, the tackling
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275
health inequalities situation in the UK should be cause for envy among those in Canada and
the US concerned with these issues.
Implications
This analysis identified some of the features of nations’ situations and how these shape governmental approaches toward tackling health inequalities. The 2008 economic crisis has been
associated with varying degrees of reduced public spending on health and social programs,
but it appears that these declines are most apparent in the nations that have to date resisted
tackling health inequalities. While even Finland, Norway, and Sweden have controlled growth
in expenditures and, to some extent, reduced them, the extent of this retrenchment is less than
is the case in other nations in this inquiry. Again we see the role played by established societal
approaches to public policy-making as well as the distinct economic and political features of
each nation.
The political economy perspective, therefore, offers the most useful explanation for explaining governmental authorities’ action or inaction on tackling health inequalities. By integrating
politics and economics, the perspective highlights the relationship between tackling health
inequalities and the economic, political, and social structures of these societies. It recognizes
the role of dominant economic interests, such as the corporate sector, in shaping public policies on health in countries in which the market is the dominant institution as in Canada and
the US. Similarly, by bringing together political and economic issues, the political economy
perspective helps explain the considerable progress on tackling health inequalities in Finland,
Norway, and Sweden and the more modest successes in Australia and Britain and Northern
Ireland.
Tackling health inequalities in Finland, Norway, and Sweden has become such a part of
their public policy agenda that all major political parties accept the need to address this issue.
While there may be some retrenchment and curtailing of the comprehensive range of health
and social programs and other supports made available to their populations, their continued
existence is probably not under threat. In Australia and Britain and Northern Ireland, tackling
health inequalities seems to depend on whether the Labour Party controls national and state
governments. Even then, these authorities are embedded within long-existing economic and
political structures associated with the liberal welfare state.
In summary, the political economy approach, which highlights the influence of economic
and political interests in whether governing authorities tackle health inequalities, provides the
most useful insights into why and how nations tackle health inequalities. It points out how,
in the case of Canada and the US as well as Britain and Northern Ireland and Australia, the
defining features of the liberal welfare state shape the extent of health and social inequalities
and limit governmental authorities’ willingness to tackle them.
Pluralism also offers some helpful analysis of the current situation, especially in the Scandinavian countries. A pluralist approach highlights the importance of information on health
inequalities for governments to take action to tackle inequalities. In short, advocacy groups
and others who present these ideas should not experience government resistance to addressing
these ideas. This suggests that continuing to advocate for the tackling of health inequalities will
help to keep these issues on the public policy agenda in these nations. One means of main-
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taining state receptivity to these issues is to keep these issues front and centre for governing
authorities, the media, and the general public.
Shifting the Components of Governmental Authorities’
Willingness to Tackle Health Inequalities
In the previous chapter, nations were also described as to how their characteristics fit into the
various components of Figure 9.4. These were the “State,” “Power relations,” and “SDOHrelated public policies.” What do each of the public policy change models suggest needs to
be understood about these situations, and what needs to be done to have governments tackle
health inequalities? For convenience of presentation, three distinct clusters of nations are used
to organize this analysis. These are (1) the Scandinavian nations of Finland, Norway, and
Sweden; (2) Britain and Northern Ireland, and Australia; and (3) Canada and the US.
The State
Table 10.1 provides some suggestions as to how aspects of the state could be influenced to promote the tackling of health inequalities. Those suggested by a pluralist approach would emphasize
the development and strengthening of citizen groups in order to build support for and pressure
governing authorities to tackle health inequalities. Clearly, this is more of a task for Canadians
and Americans concerned with tackling health inequalities than is the case elsewhere.
The policy paradigms approach suggests taking account of governmental structures and the
need to maintain those supportive of a tackling health inequalities approach and change those
opposed to such an agenda. In Canada and the US, such a shift will require a paradigmatic
change in public policy-making, which is not to be taken lightly. In Australia and Britain
and Northern Ireland, those structures that have been established need to be supported and
opposition to their weakening opposed. In Finland, Norway, and Sweden, successes need to be
recognized and care taken not to have these successes ignored and/or reversed. Table 10.1 identifies the critical importance of proportional representation in the electoral process, which can
strengthen the influence of supporters of policies associated with tackling health inequalities.
Finally, in federal states such as Australia, Canada, and the US, means must be identified to
enhance the ability of the central government to shape public policy-making across all levels of
government. In Canada, this was the case when the central government guided policy development during the 1970s and 1980s by making available to the provinces and territories funding
for medicare and social assistance.
Power Relations
Table 10.2 provides some suggestions for maintaining or shifting power relations in a manner
that would favour the tackling of health inequalities by governmental authorities. A pluralist
analysis would identify differences in tackling health inequalities as reflecting differences in
public support and group advocacy for such an approach. The clear implication is to strengthen
these activities with the goals of influencing public policy-making.
The policy paradigms approach points out how the three clusters differ in their economic
and political structures toward a wide range of issues. Such an analysis highlights the barriers
to institutional change, and this is especially the case in Canada and the US. Clearly, the model
Applying the Lessons from International Experiences
277
Table 10.1
State Institutions and Models of Policy Change—Welfare Regime, Electoral
Process, Central vs. Federal System
Pluralism
Policy
Paradigms
Political
Economy
Proportional
Representation
Finland, Norway,
and Sweden
Maintain public support for the Nordic
welfare state.
Australia and Britain Canada and the US
and Northern Ireland
Continue to build
Educate the public as
public support for
to the social deterpolicy initiatives.
minants of health
inequalities.
Recognize the proWork to maintain
Evaluate and comfound barriers to parastate structures and
municate the Nordic
interest in intervening digmatic shifts among
welfare state parawell-established liberal
in the operation of
digm’s successes in
promoting health and the established market welfare states.
economy.
well-being.
Work to offset corRecognize that forWork to maintain
porate and business
social democratic ide- ward movement will
als behind the Nordic require ongoing vigi- interests’ dominance
of the policy agenda.
lance against market
welfare state.
forces.
Maintain proportional All three policy models suggest means of
representation in the
promoting electoral reform toward proporelectoral process.
tional representation through public education, restructuring government, and balancing
political power.
suggests the need to strengthen political parties of the left by shifting electoral behaviour and
strengthening unions’ ability to organize the workplace.
Both this model and the political economy approach make clear that tackling health
inequalities is a profoundly political activity that requires more than the collection of evidence
and advocacy in favour of such an approach. The importance of changing electoral behaviour and strengthening labour unions in order to shift public policy in social determinants of
health-related policy areas seems essential.
Social Determinants of Health-Related Public Policy
Finally, Table 10.3 outlines how each model of policy change would make sense of the differing public policy profiles present in the nations of this inquiry. The task in Finland, Norway,
and Sweden is to mobilize public opinion to support the structures associated with the social
democratic welfare state. Contrasting their situations with those seen in Canada and the US
would help meet these objectives.
278
Tackling Health Inequalities
Table 10.2
Power Relations and Models of Policy Change—Electoral Behaviour, Trade
Union Strength, and Civil Society Coalitions
Pluralism
Policy
Paradigms
Political
Economy
Finland, Norway,
and Sweden
Plurality of interests
has historically supported public policies
that promote health
equity.
Australia and Britain
and Northern Ireland
Plurality of interests
that support health
equity has varied over
time such that policy
directions are inconsistent.
Long-standing Nordic Shifting political
traditions promote
fortunes of social
receptivity to tackling democratic parties
health inequalities.
limit long-standing
institutional commitments.
Shifting political
Relative balance
fortunes of social
between business,
labour, and civil soci- democratic parties
ety promotes progres- provide inconsistent
public policy activity.
sive public policy.
Canada and the US
Plurality of interests
has never coalesced
around tackling health
inequalities through
public policy action.
Dominance of corporate and business
interests make tackling
health inequalities by
governments difficult.
Dominance of economic interests makes
raising issues of health
inequalities difficult.
In Australia and Britain and Northern Ireland, these efforts will be more difficult, but successes have to be acknowledged and continuing barriers recognized. In Canada and the US,
significant efforts must be undertaken to educate the public in order to shift the economic
and political structures that have shaped public policy-making. These are not easy tasks as the
chapters on Canada and the US make clear.
Implications
The political contexts in Canada and the United States are similar in many ways. None of the
political parties in Canada or in the US has demonstrated willingness to tackle health inequalities. There is support for such an approach in Canada, with think tanks such as the Canadian
Centre for Policy Alternatives and various NGOs raising the importance of addressing the
social determinants of health in Canada. In the US, the situation is much worse. Few advocacy
organizations have addressed the importance of tackling health inequalities. In both Canada
and the US, researchers investigate and demonstrate the extent of inequalities, but governments and their political cultures and institutions resist these ideas.
There is much more activity taking place in Australia and Britain and Northern Ireland.
Elections of social democratic labour parties at the federal level in Australia, England, and
Applying the Lessons from International Experiences
279
Table 10.3
SDOH-Related Public Policy and Models of Policy Change
Pluralism
Policy
Paradigms
Political
Economy
Finland, Norway,
and Sweden
Continue to advocate
for strong welfare
state.
Australia and Britain
and Northern Ireland
Advocate for continuing strengthening of commitment
to address health
inequalities.
Maintain strong com- Strengthen institumitments to provision tional support for
of economic and social provision of economic
security to citizens.
and social security to
citizens.
Maintain strong
commitment to social
democratic principles
in public policy.
Canada and the US
Educate the public
as to the deficiencies
of the Canadian and
American welfare
states.
Confront and lobby
for changes to weak
and inadequate
economic and social
security provided to
citizens.
Recognize significant Strengthen citizen
sectors that resist state action that supports
provision of economic public policy in the
and social security.
service of all.
Scotland have contributed to greater receptiveness to policy innovations to reduce health
inequalities. Policy paradigms helps make sense of these developments, but the political
economy identifies more explicit levers to bring about change. It highlights the role of
social democracy in recognizing the unequal distribution of resources leading to growing
health inequalities.
There is an increasing literature as to how to bring about these kinds of changes, and these
clearly involve building social and political movements in favour of the kinds of policies that
are well developed in the Finnish, Norwegian, and Swedish case studies, and less developed in
the Australian, and British and Northern Irish case studies.
What Would a Tackling Health Inequalities Governmental Agenda
Look Like in Canada?
The Health Council of Canada recently provided an analysis of what is needed to have governments address the “determinants of health” through what is called “a whole-of-government”
approach (Health Council of Canada, 2010). The Health Council’s emphasis on the determinants of health is rooted in sometimes explicit, other times implicit, concern with promoting
“health equity” and reducing “health inequities.”
The Health Council report provides a “Checklist for Whole-of-Government or Intersectoral Work.” While it was developed to address the determinants of health, it can be taken
280
Tackling Health Inequalities
as specifying what values, information, and government infrastructure would be needed to
tackle health inequalities. It specifies the Values and Commitment, Information and Data, and
Governmental Infrastructure that would be required to undertake these activities, as is presented
in Appendix A.
While the Health Council identifies targets for action, it is important to consider that
this chapter—and the previous one—have identified the considerable barriers to having these
components implemented in Canada. These barriers are generally neglected in most Canadian
governmental and institutional reports that address issues of promoting health equity and tackling health inequalities, instead seeing the failure to address these issues as the result of a lack of
information on health inequalities and/or a failure of bureaucratic organization.
Toward the Future
The above examination shows that the countries are at different stages in tackling health
inequalities. Absolutely essential for the tackling of health inequalities is an engaged citizenry
that will place these issues on the public policy agenda. Without this, governing authorities can
easily let the tackling of health inequalities give way to other issues that may arise. What are the
specific issues that need to be highlighted?
The broad public policy directions required in Canada and the US will expand the welfare
state to embrace a broader range of universal social and health programs. This will ensure that
all citizens have access to the social determinants of health, including education, unemployment insurance, employment opportunities, and housing security, among others. In the US,
similar to Canada, this requires “a commitment to act upon general guidelines” (Bezruchka,
this volume). Specifically, Bezruchka recommends: “The overarching aim would be to decrease
economic inequality throughout the nation and to use the proceeds from that effort to foster
a healthy early life environment for families. An important first step would be putting in place
generous supports for antenatal and parental paid leave and community support for families
and children, including those in utero and young infants.” In terms of broad public policy
directions, these should include challenging political, social, economic, and education underpinnings of health inequalities.
The national government in Australia must expand its commitment to Aboriginal health
to other populations experiencing disadvantage. Baum et al. (this volume) note that Australia
has a well-developed welfare state, but health inequities persist. In particular, Baum et al. argue
that: “Concerted policy action is required to use progressive taxation and other revenue raising
methods to ensure funding for redistributive policies. Political leadership will be required to
create the political will to institute a systematic approach to reducing inequities.”
The UK has a well-established tradition of research on health inequalities. Moreover, the
UK was the first country in Europe to try to reduce health inequalities (Smith & Bambra, this
volume). Smith and Bambra call for research collaboration between academics and policymakers to “co-produce research” on health inequalities. They also call for enhanced public
health advocacy and work with communities. Similar to Canada and the United States, UK
citizens must be made aware of “the actors and forces influencing policies in ways which are
likely to be counter-productive for health inequalities” (Navarro, 2009).
Applying the Lessons from International Experiences
281
The three Scandinavian countries are further along in addressing health inequalities compared to the other countries examined. Finland has a well-developed welfare state, but these
programs can be strengthened. Mikkonen recommends greater focus on “the implementation and monitoring of Finnish policy measures and programs” to reduce health inequalities
(Mikkonen, this volume). Specifically, Mikkonen calls for a permanent structure sufficiently
resourced to monitor health inequalities in Finland. This would include enhancing the health
impact assessments of different policy initiatives. Mikkonen adds there is a “need to look at
the impacts of these policies on the lowest socio-economic groups and readiness to formulate
alternative policy recommendations if required.”
In Norway, the emphasis on upstream public policies to reduce health inequalities by focusing on social determinants is relatively new (Fosse, this volume). The new Norwegian Public Health Act has yet to be assessed for its impact on health inequalities. Nonetheless, that
country is well on its way to tackling health inequalities. Income redistribution appears to be
central to this policy initiative and should go some distance in addressing social and health
inequalities. As Fosse notes, the emphasis on upstream policy approaches is radical and one
not generally pursued in Canada or the US. Norway’s experience illustrates the importance of
social democratic principles in bringing about action to reduce health inequalities.
Finally, Sweden has had a long history of concern with reducing health inequalities. Backhans and Burström assert that: “Health equity should be a goal that most Swedish politicians
across the left-right spectrum can endorse, particularly in a country with such a strong egalitarian legacy. There is nothing that leads us to believe that the political majority will change
anytime soon. Therefore, new strategies are clearly needed by public health advocates to bring
politicians on board” (Backhans & Burström, this volume).
What You Can Do
Figure 10.1 provides a model that, while developed to explain the incidence of poverty in
wealthy developed nations, can easily be applied to the tackling of health inequalities (Brady,
2009). In it the outcome “Poverty” is replaced with “Tackling health inequalities.” The components of the model are (1) ideologies and interests, (2) welfare generosity, (3) leftist politics,
and (4) latent coalitions.
Ideologies and Interests
This is similar to the issue of characteristics of the state and its receptivity to problems associated with tackling health inequalities. As noted, willingness to tackle health inequalities is
closely related to the form of welfare regime and the economic and political forces that shape
existing ideologies and interests. It is important to recognize the dominant and conflicting
ideologies and interests in a society and how these determine whether or not health inequalities
will be tackled through public policy action.
Welfare Generosity
There are profound differences in the extent to which each nation’s welfare state provides supports to its citizens. In Canada and the US, these supports are minimal. In Finland, Norway,
282
Tackling Health Inequalities
Figure 10.1
Components of Brady’s Institutionalized Power Relations Theory
Applied to the Tackling of Health Inequalities
Leftist
politics
Ideologies
and
interests
Latent
coalitions
Tackling
health
inequalities
Welfare
generosity
Source: Adapted from D. Brady, Rich democracies, poor people: How politics explain poverty (New
York: Oxford University Press, 2009), Figure 1.2, p. 14.
and Sweden, they are rather more extensive. Britain and Northern Ireland and Australia provide mid-level portraits. Consistent with the analyses provided in this volume, social welfare
expenditures, social security transfers, extent of decommodification of necessary supports and
benefits, government expenditures, and public health spending are all related to the tackling of
health inequalities. Greater spending and transfers, and greater decommodification are associated with greater public policy activity. Welfare generosity is a key issue that needs to be raised
and confronted when resistance to increasing it is encountered.
Leftist Politics
The analysis provided in this volume indicates that the generosity of the welfare state and the
tackling of health inequalities are strongly related to the strength of institutionalized leftist political influence; that is, the ability of parties of the left—such as the Social Democrats in Europe,
Labour in Australia and the United Kingdom, and the New Democrats in Canada—to gain and
hold political power. It also refers to the ability of these left political parties to influence governing
parties to implement public policies under the threat of electoral defeat. The tackling of health
inequalities is a profoundly political issue and this reality must not be ignored.
Latent Coalitions
Latent coalitions refer to groups of citizens who may come together under differing circumstances to support a more generous welfare state. These would include groups and citizens
Applying the Lessons from International Experiences
283
concerned with the social determinants of health, such as housing, early life, income and
income distribution, employment and working conditions, social exclusion, food insecurity,
and unemployment and job security, among others. The absence of such a vibrant sector will
make the tackling of health inequalities difficult.
Implications
The implications of this analysis for what you can do to promote the tackling of health inequalities seem clear (Raphael, 2011):
Welfare generosity:
Strengthen left political actors:
Build latent coalitions:
Ideologies and interests:
Advocate
for more generous supports and benefits
social democratic parties of the left
Join/support an advocacy group
Recognize barriers and build support for action
Join/support
Further examples of what you can do to help move governmental authorities toward tackling
health inequalities are available (Bryant, 2009, 2010; Raphael, 2009, 2010).
Conclusion
Public education on the importance of tackling health inequalities is essential. The general
public must be made aware of the extent of health inequalities and the means by which they
can be tackled. Those working in the health field need to understand how the policy change
process brings about social and political change and how they can contribute to educating and
mobilizing citizens about health inequalities.
The tackling of health inequalities is strongly influenced by the political ideology of the government of the day. Public spending on health and social programs is a key indicator of government commitment to achieving health equity. A key characteristic of the presence of this
commitment is the influence of social democratic principles. All countries, except the US, have
an active social democratic party, and most, except Canada, have elected social democratic
governments at the national level. This makes a huge difference in whether health inequalities appear on the public policy agenda, and whether the political will exists to take action to
reduce health inequalities.
The Scandinavian countries demonstrate that this tends to be the case. The UK has
a strong research tradition on health inequalities. Moreover, the Labour government of
Tony Blair initiated significant policy action from 1997 to 2009. These activities are now
threatened by the election of the Conservative-Liberal Democratic Coalition in 2010.
Canada and the US have a number of profound barriers to putting the tackling of health
inequalities on the public policy agenda.
By analyzing some of these barriers and providing means of making sense of the differences presented among nations, this volume has attempted to identify the means by which
the tackling of health inequalities can be placed on the agenda of those nations where it is
being neglected, and strengthened and extended where it is already an issue of governmental
concern. This is an ongoing project that requires ongoing citizen engagement in the day-to-day
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Tackling Health Inequalities
politics of public policy-making. As Frank Fischer (2003) states in his analysis of the future of
participatory policy-making:
The case for democracy derives from its basic normative rationale from the principle that government decisions should reflect the consent of the governed. Citizens in a democracy have
the right—even obligation—to participate meaningfully in public decision-making and to be
informed about the bases of government policies. (p. 205)
Critical Thinking Questions
1. What do you think are the critical determinants of how a nation goes about tackling
health inequalities through public policy activities?
2. Which of the three broad policy change models presented in this chapter best explain how
the nations in this inquiry are tackling health inequalities?
3. What would each model suggest as to the reasons why a nation is either tackling or not
tackling health inequalities? What would each suggest be done to move this agenda forward?
4. What are some of the things you could do to have your nation’s governing authorities
tackle health inequalities?
Recommended Readings
Bambra, C., Fox, D., & Scott-Samuel, A. (2003). Towards a new politics of health. Liverpool: Politics of
Health Group. Retrieved from: http://www.pohg.org.uk/support/downloads/pohg-paper1.pdf.
This volume recognizes that “In a period when the importance of politics and public policy as determinants of health is routinely acknowledged at the highest political levels … there remains a continuing absence of serious debate about the ways in which political power, relations and ideology
influence people’s health.” This report provides a detailed overview of how politics and public policy
shape health.
Bryant, T. (2009). An introduction to health policy. Toronto: Canadian Scholars’ Press Inc.
With a strong comparative and international element, this volume analyzes the process, implementation, and outcomes of health policy in Canada and elsewhere. It has entire chapters devoted to
theories of public policy change and influences upon public policy-making.
Bryant, T., Raphael, D., & Rioux, M. (Eds.). (2010). Staying alive: Critical perspectives on health, illness,
and health care (2nd ed.). Toronto: Canadian Scholars’ Press Inc.
Staying Alive provides various perspectives on the issues regarding health, health care, and illness.
In addition to the traditional approaches of health sciences and the sociology of health, this book
shows the impact that human rights issues and political economy have on health. This volume takes
up these issues as they occur in Canada and the United States within a wider international context.
Signal, L. (1998). The politics of health promotion: Insights from political theory. Health Promotion
International, 13(3), 257–263.
This article examines three theories of pluralism, the new institutionalism, and political economy and
their contributions to understanding and explaining health promotion.
Applying the Lessons from International Experiences
285
Recommended Websites
European Community Health Policy: tinyurl.com/2s83r9
The European Community addresses a full scope of health policy, including living conditions and
health care. The website identifies health policy priorities for the European Union and links to health
policy resources.
International Health Impact Assessment Consortium: http://www.liv.ac.uk/ihia
Based at the University of Liverpool in the United Kingdom, this excellent website provides a wide
range of information and resources on the impact of policies and programs on the health of a population. It provides access to articles, research, and case studies on health policy issues.
Politics of Health Group: www.pohg.org.uk
The Politics of Health website is based at the University of Liverpool in the United Kingdom. The
Politics of Health Group (PoHG) consists of people who believe that power exercised through politics and its impact on public policy are of critical importance for health. PoHG is a UK-based group,
but has a clear international perspective and members throughout the world.
Public Policy at the Robert Gordon University: www2.rgu.ac.uk/publicpolicy
This introduction to social policy examines social welfare and its relationship to politics and society.
It focuses on the social services and the welfare state.
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