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.

6. early life education employment and working conditions food security health services housing income and income distribution social exclusion social safety net unemployment A Policy-Oriented Approach to the Social Determinants of Health Source: Raphael, (2004). Social Determinants of Health: Canadian Perspectives. Toronto: Canadian Scholars Press.

7. Defining Public Policy

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

9. 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 SDOH and their Public Policy Determinants

10. 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 SDOH and their Public Policy Determinants

11. 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.

13. Spending on TransfersorWhat is the Depth of the Welfare State?

14. 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

16. 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, 1990’s 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.

19. Political and Economic Forces that Influence Public Policy

20. GostaEsping-Andersen: The Modern Welfare State

21. 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.

22. 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.

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

24. 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.

26. 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.

27. 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 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.

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.

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

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 80’s, mid 90’s 2000 Source: OCED (2005). Society at a Glance 2005. Paris: OECD.

38. Social expenditures and child poverty—the U.S. is a noticeable outlier, Economic Policy Institute, July 23, 2004

39. 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.

40. Resistance: The Future of the Welfare State

41. Society and Health: Where are We Now? Social Determinants of Health “Individual Lifestyle Choices” Individual Health and Illness

42. 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

47. Dennis Raphaeldraphael@yorku.caThis presentation and other presentations and related papers are available at:http://www.atkinson.yorku.ca/draphael