The Politics of Population Health

1
The Politics of Population Health

• Dennis Raphael, PhD
• School of Health Policy and Management
• York University, Toronto
• Presentation to Nursing 5190.3
• Enhancing Nursing Praxis through Public Policy
• Week 9 February 27 - March 9, 2006

2
Overview of Presentation

• To define public policy and its impact on the
  quality of the social determinants of health
• To identify the political and economic forces
  that influence public policy
• To explore specific examples of public policy and
  their impacts on health and well-being
• To consider the Canadian situation in an
  international context
• To outline policy directions for Canadian society

3

• Defining Population Health and the Social
  Determinants of Population Health

4
Defining Population Health

• Population health focuses on improving the health
  status of the population rather than individuals.
  Focusing on the health of populations also
  requires reducing health inequalities between
  groups.
• One assumption of a population health approach is
  that reductions in health inequities require
  reductions in material and social inequities.
• Source Health Canada. (2004). Population Health
  Approach.

5
What are Social Determinants of Health?

• SDOH are the economic and social conditions that
  influence the health of individuals, communities,
  and jurisdictions as a whole.
• SDOH determine whether individuals stay healthy
  or become ill (a narrow definition of health).
• SDOH also determine the extent to which a person
  possesses the physical, social and personal
  resources to identify and achieve personal
  aspirations, satisfy needs, and cope with the
  environment (a broader definition of health).
• SDOH are about the quantity and quality of a
  variety of resources that a society makes
  available to its members.

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A Policy-Oriented Approach to the Social
Determinants of Health

• early life
• education
• employment and working conditions
• food security
• health services

• housing
• income and income distribution
• social exclusion
• social safety net
• unemployment

Source Raphael, (2004). Social Determinants of
Health Canadian Perspectives. Toronto Canadian
Scholars Press.
7
Defining Public Policy
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What is Public Policy?

• Public policy is a course of action or inaction
  chosen by public authorities to address a given
  problem or interrelated set of problems.
• Policy is a course of action that is anchored in
  a set of values regarding appropriate public
  goals and a set of beliefs about the best way of
  achieving those goals.
• The idea of public policy assumes that an issue
  is no longer a private affair.
• Source Wolf, R. (2005). What is public policy?
  Available at http//www.ginsler.com/html/toolbox.h
  tp

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SDOH and their Public Policy Determinants

• early life income supports, progressive family
  policy, availability of childcare, support
  services
• education support for literacy, public
  spending, tuition policy
• employment and working conditions active labour
  policy, support for collective bargaining,
  increasing worker control
• food security income and poverty policy, food
  policy, housing policy
• health services public spending, access issues,
  integration of services

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SDOH and their Public Policy Determinants

• housing income and housing policy, rent
  controls and supplements, provision of social
  housing
• income and income distribution taxation policy,
  minimum wages, social assistance, social
  assistance levels, family supports
• social exclusion anti-discrimination laws and
  enforcement, ESL and job training, approving
  foreign credentials, support of a variety of
  other health determinants
• social safety net spending on a wide range of
  welfare state areas
• unemployment active labour policy, replacement
  benefits, labour legislation

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Why is this Important?

• Greatest challenge to developed nations is
  sustaining vibrant economies to support the
  quality of life of citizens.
• To do so, it is important to apply a life-cycle
  approach to sustainability of the welfare state.
• Post-industrial society must invest in citizens,
  especially children to support the economy and
  other institutions.
• Supporting children will nurture strong,
  resource and productive adults.
• Promote social inclusion Active versus passive
  income and labour policy.
• Source Esping-Andersen, G. (2002). Why We Need
  a New Welfare State, 2002. New York Oxford
  University Press.

12
Links to Health Literature

• Shaw et al. emphasize the importance of societal
  supports for significant transitions across the
  life span such as entering and leaving school,
  gaining and possibly losing employment, and
  entering retirement.
• These supports include provision of income and
  employment security, equitable distribution of
  resources, and educational and training
  opportunities across the life span.
• How can we evaluate whether nations are committed
  to such goals?
• Source Shaw, M. et al., (1999). The Widening
  Gap. Bristol Policy Press.

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Spending on TransfersorWhat is the Depth of the
Welfare State?
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Public Social Expenditure as Percentage of GDP,
1980-2001
Source OECD (2004). Social Expenditure Database
http//www.oecd.org/els/social/expemditure.
15
Government Spending on Various Programs as a
Function of GDP, 2001
Source OECD (2004). Social Expenditure Database
http//www.oecd.org/els/social/expenditure
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And its Effects on Child Poverty?
17
Source Innocenti Research Centre. (2005). Child
poverty in rich countries, 2005, Innocenti report
card No.6. Florence Innocenti Research Centre.
Figures are for the years around 1998-2001.
18
Pre-Transfer and Post-Transfer Poverty Rates in
Canada and other Nations, 1990s
Source Nelson, K. (2004). Mechanisms of poverty
alleviation Anti-poverty effects of non-means
and means-tested benefits in five welfare states.
Journal of European Public Policy, 14, 371-390.
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• Political and Economic Forces that Influence
  Public Policy

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• Gosta Esping-Andersen
• The Modern Welfare State

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Esping-Andersen Typology of Welfare States I

• Social Democratic (e.g., Sweden, Norway, Denmark,
  Finland), Liberal (UK, USA, Canada, Australia),
  and Conservative (Germany, France, Italy,
  Portugal) welfare states form a continuum of
  government support to citizens.
• These supports range from high government
  intervention welfare systems in the Social
  Democratic countries to residual welfare systems
  as seen in Liberal political economies.
• Conservative nations (e.g., Germany, France,
  Italy fall midway in their provisions.
• Source Esping-Andersen, G. (1999). Social
  Foundations of Post-Industrial Economies. New
  York Oxford University Press.

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Esping-Andersen Typology of Welfare States II

• The Liberal welfare state sees means-tested
  assistance, modest universal transfers, and
  modest social-insurance plans.
• Means-testing refers to benefits in the Liberal
  welfare state being primarily geared to
  low-income groups.
• Social assistance is limited by traditional,
  liberal work-ethic attitudes that stigmatize the
  needy and attribute failure to individual, rather
  than, societal failures.
• Liberal nations limit welfare benefits since it
  is believed generous benefits lead to a
  preference for welfare dependency rather than
  gainful employment.
• Source Esping-Andersen, G. (1999). Social
  Foundations of Post-Industrial Economies. New
  York Oxford University Press.

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Social Democratic Regimes

• SD regimes present higher levels of union
  density.
• SD regimes have gt levels of social security and
  public employment expenditures, gt public health
  care expenditures, and gt extensive health care
  coverage.
• SD nations implemented full employment
  strategies, attained high rates of female
  employment, and the lowest levels of income
  inequality and poverty.
• SD nations had the lowest of income derived
  from capital investment and the largest from
  wages.
• On a key indicator of population health infant
  mortality SD countries had the lowest rates
  from 1960 to 1996.
• Source Navarro, V., Shi, L. (2002). The
  Political Context of Social Inequalities and
  Health. In V. Navarro (Ed.), The Political
  Economy of Social Inequalities Consequences for
  Health and Quality of Life. Amityville, NY
  Baywood.

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Anglo-Saxon Liberal Regimes

• Anglo-Saxon liberal political economies had the
  lowest health care expenditures and the lowest
  coverage by public medical care.
• Had greater incidence of low wage earnings,
  higher income inequalities, and the highest
  poverty rates.
• These economies derived the greatest proportion
  of income from capital investment rather than
  wages.
• These economies had the lowest improvement rates
  in infant mortality rates from 1960 to1996.
• Source Navarro, V., Shi, L. (2002). The
  Political Context of Social Inequalities and
  Health. In V. Navarro (Ed.), The Political
  Economy of Social Inequalities Consequences for
  Health and Quality of Life. Amityville, NY
  Baywood

25
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.
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Power Relations and the Welfare State

• Power relations -- electoral behaviour and trade
  union solidarity -- interact with civic behaviour
  -- trust in government, corruption and cynicism
  to produce labour market and welfare state
  policies.
• When these policies ameliorate social and
  economic inequalities, population health as
  measured by infant mortality, cause-specific
  mortality, and life expectancy should improve.

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Predictors of Declines in Infant Mortality and
Increases in Life Expectancy in OECD Nations

• Increasing support for social democratic parties
• Increases in the proportion of citizens voting
• Increases in public health care coverage
• Increases in the proportion citizens employed
• Increases in female labour force participation
• Increasing income equality
• Increases in national wealth
• SourceNavarro, V., et al.(2004). The importance
  of the political and the social in explaining
  mortality differentials among the countries of
  the OECD, 1950-1998. In V. Navarro (Ed.), The
  Political and Social Contexts of Health.
  Amityville NY Baywood Press.

28
Source Rainwater, L., Smeeding, T. M. (2003).
Poor Kids in a Rich Country America's Children
in Comparative Perspective. New York Russell
Sage Foundation.
29
Key Tenets of Neo-liberalism

• Markets are the most efficient allocators of
  resources in production and distribution
• Societies are composed of autonomous individuals
  (producers and consumers) motivated chiefly by
  material or economic considerations
• Competition is the major market vehicle for
  innovations
• There is no such thing as society.
• Source Coburn, D. (2000). Income inequality,
  social cohesion and the health status of
  populations The role of neo-liberalism. Social
  Science Medicine, 51(1), 135-146.

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Neo-Liberalism

• Considering that Canada and the UK are already
  identified as a liberal political economy within
  Esping-Andersens typology, they may be
  especially susceptible to neo-liberal ideology
  (see Vandenbroucke (2002) for a discussion of
  European Union resistance to neo-liberal
  influences.
• And, indeed many have argued that this has been
  the case in Canada. The growth of the welfare
  state in Canada leveled off in the early 1980s,
  and since 1990 there has been a drastic decline
  in public expenditures in support of a variety of
  welfare state policies.

31
Hulchanski, D. (2002). Can Canada Afford to Help
Cities, Provide Social Housing, and End
Homelessness? Why Are Provincial Governments
Doing So Little? Toronto Centre for Urban and
Community Studies.
32
Hulchanski, D. (2002). Can Canada Afford to Help
Cities, Provide Social Housing, and End
Homelessness? Why Are Provincial Governments
Doing So Little? Toronto Centre for Urban and
Community Studies.
33
Canada in Comparative Perspective
34
Child Poverty in Lone-Parent and Other Families
in Canada and Three Comparison States, 2000
35
Public Social Expenditure by Broad Social Policy
Areas as Percentage of GDP in Canada and Four
Comparison Nations, 1997.
Source Society at a Glance, OECD, 2001
36
Income Inequality Gini Coefficient Canada,
USA, UK, and Sweden, Mid 80s, mid 90s 2000
Source OCED (2005). Society at a Glance 2005.
Paris OECD.
37
(No Transcript)
38
Social expenditures and child povertythe U.S. is
a noticeable outlier, Economic Policy Institute,
July 23, 2004
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Canadian Policy Directions

• It has become obvious that people on the low
  end of the income scale are cut off from the
  ongoing economic growth that most Canadians are
  enjoying. It is also obvious that in these times
  of economic prosperity and government surpluses
  that most governments are not yet prepared to
  address these problems seriously, nor are they
  prepared to ensure a reasonable level of support
  for low-income people either inside or outside of
  the paid labour force.
• Source Poverty Profile, 1998. Ottawa
  National Council of Welfare Reports, Autumn, 2000.

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• Resistance The Future of the Welfare State

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Society and Health Where are We Now?
Social Determinants of Health
Individual Lifestyle Choices
Individual Health and Illness
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Society and Health How Far Upstream Should We
Go?
Welfare State
Social Determinants of Health
Population Health
43
Union Density Rate Canada, USA, UK, and Sweden,
2000
Source Navarro, V. et al. (2004). The
importance of the political and the social in
explaining mortality differentials among the
countries of the OECD, 1950-1998. In V. Navarro
(Ed.), The Political and Social Contexts of
Health. Amityville NY Baywood Press.
44
Self-Positioning on Left of Political
Scale,Canada, USA, UK, and Sweden, 1990, 2000
Source Inglehart, R. et al. Human Beliefs and
Values A Cross-cultural sourcebook based on the
1999-2002 values survey. Delegacion Coyoacan
Siglo XXI Editores.
45
Alesina, A., Glaeser, E. L. (2004). Fighting
poverty in the US and Europe A world of
difference. Toronto Oxford University Press.
46
of GDP in Transfers
Degree of Proportional Representation
Source Alesina, A. Glaeser, E. L. (2004).
Fighting Poverty in the US and Europe A World of
Difference. Toronto Oxford University Press
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Dennis Raphaeldraphael_at_yorku.caThis
presentation and other presentations and related
papers are available athttp//www.atkinson.yor
ku.ca/draphael