The Politics of Population Health

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					The Politics of Population Health
             Dennis Raphael, PhD
   School of Health Policy and Management
           York University, Toronto

       Presentation to Nursing 5190.3
Enhancing Nursing Praxis through Public Policy
    Week 9: February 27 - March 9, 2006
        Overview of Presentation
• To define public policy and its impact on the
    quality of the social determinants of health
•   To identify the political and economic forces
    that influence public policy
•   To explore specific examples of public policy
    and their impacts on health and well-being
•   To consider the Canadian situation in an
    international context
•   To outline policy directions for Canadian
    society
 Defining Population
Health and the Social
  Determinants of
 Population Health
         Defining Population Health
• Population health focuses on improving the
  health status of the population rather than
  individuals. Focusing on the health of
  populations also requires reducing health
  inequalities between groups.
• One assumption of a population health
  approach is that reductions in health
  inequities require reductions in material and
  social inequities.
• Source: Health Canada. (2004). Population Health
  Approach.
What are Social Determinants of Health?
• SDOH are the economic and social conditions that
  influence the health of individuals, communities, and
  jurisdictions as a whole.
• SDOH determine whether individuals stay healthy or
  become ill (a narrow definition of health).
• SDOH also determine the extent to which a person
  possesses the physical, social and personal resources
  to identify and achieve personal aspirations, satisfy
  needs, and cope with the environment (a broader
  definition of health).
• SDOH are about the quantity and quality of a variety
  of resources that a society makes available to its
  members.
  A Policy-Oriented Approach to the
    Social Determinants of Health
• early life                 • housing
• education                  • income and
• employment and       income distribution
  working conditions • social exclusion
• food security      • social safety net
• health services    • unemployment

Source: Raphael, (2004). Social Determinants of Health:
Canadian Perspectives. Toronto: Canadian Scholars Press.
Defining Public Policy
            What is Public Policy?
• Public policy is a course of action or inaction
  chosen by public authorities to address a given
  problem or interrelated set of problems.
• Policy is a course of action that is anchored in a
  set of values regarding appropriate public goals
  and a set of beliefs about the best way of
  achieving those goals.
• The idea of public policy assumes that an issue is
  no longer a private affair.
• Source: Wolf, R. (2005). What is public policy? Available at
  http://www.ginsler.com/html/toolbox.htp
            SDOH and their Public Policy
                  Determinants
• early life – income supports, progressive family policy,
    availability of childcare, support services
•   education – support for literacy, public spending,
    tuition policy
•   employment and working conditions – active labour
    policy, support for collective bargaining, increasing
    worker control
•   food security – income and poverty policy, food policy,
    housing policy
•   health services – public spending, access issues,
    integration of services
           SDOH and their Public Policy
                 Determinants
• housing – income and housing policy, rent controls
    and supplements, provision of social housing
•   income and income distribution – taxation policy,
    minimum wages, social assistance, social assistance
    levels, family supports
•   social exclusion – anti-discrimination laws and
    enforcement, ESL and job training, approving foreign
    credentials, support of a variety of other health
    determinants
•   social safety net – spending on a wide range of
    welfare state areas
•   unemployment – active labour policy, replacement
    benefits, labour legislation
              Why is this Important?
• Greatest challenge to developed nations is sustaining vibrant
    economies to support the quality of life of citizens.
•   To do so, it is important to apply a life-cycle approach to
    sustainability of the welfare state.
•   Post-industrial society must invest in citizens, especially
    children to support the economy and other institutions.
•   Supporting children will nurture “strong, resource and
    productive adults.”
•   Promote social inclusion: Active versus passive income and
    labour policy.
•   Source: Esping-Andersen, G. (2002). Why We Need a New
    Welfare State, 2002. New York: Oxford University Press.
         Links to Health Literature
• Shaw et al. emphasize the importance of societal
  supports for significant transitions across the life span
  such as entering and leaving school, gaining and
  possibly losing employment, and entering retirement.
• These supports include provision of income and
  employment security, equitable distribution of
  resources, and educational and training opportunities
  across the life span.
• How can we evaluate whether nations are committed
  to such goals?
• Source: Shaw, M. et al., (1999). The Widening Gap.
  Bristol: Policy Press.
Spending on Transfers
           or
What is the Depth of the
   Welfare State?
     Public Social Expenditure as Percentage
               of GDP, 1980-2001
35

30

25

20

15

10
       1980          1985          1990          1995          2000          2001

      Canada         United States           United Kingdom              Sweden

Source: OECD (2004). Social Expenditure Database http://www.oecd.org/els/social/expemditure.
         Government Spending on Various
       Programs as a Function of GDP, 2001
10
 9
 8
 7
 6
 5
 4
 3
 2
 1
 0
      Old Age          Survivors       Incapacity         Health           Family

           Canada       United States       United Kingdom         Sweden
 Source: OECD (2004). Social Expenditure Database http://www.oecd.org/els/social/expenditure
And its Effects on
 Child Poverty?
Source: Innocenti
Research Centre.
(2005). Child poverty
in rich countries, 2005,
Innocenti report card
No.6. Florence:
Innocenti Research
Centre.


Figures are for the
years around 1998-
2001.
Pre-Transfer and Post-Transfer Poverty Rates in
       Canada and other Nations, 1990’s
30                                                  28.8                 28.3

25                              23
          21
20                                   18.6
                                                           16.4
15
               11.4
10

 5                                                                              3.3

 0
        Canada                  USA                   UK               Sweden
                         Pre-Transfer               Post-Transfer
Source: Nelson, K. (2004). Mechanisms of poverty alleviation: Anti-poverty effects of non-means
and means-tested benefits in five welfare states. Journal of European Public Policy, 14, 371-390.
Political and Economic
Forces that Influence
      Public Policy
   Gosta Esping-
     Andersen:
The Modern Welfare
       State
          Esping-Andersen Typology of
                Welfare States I
• Social Democratic (e.g., Sweden, Norway, Denmark,
  Finland), Liberal (UK, USA, Canada, Australia), and
  Conservative (Germany, France, Italy, Portugal)
  welfare states form a continuum of government
  support to citizens.
• These supports range from high government
  intervention welfare systems in the Social Democratic
  countries to residual welfare systems as seen in
  Liberal political economies.
• Conservative nations (e.g., Germany, France, Italy fall
  midway in their provisions.
• Source: Esping-Andersen, G. (1999). Social Foundations of
  Post-Industrial Economies. New York: Oxford University Press.
           Esping-Andersen Typology of
                 Welfare States II
• The Liberal welfare state sees means-tested
  assistance, modest universal transfers, and modest
  social-insurance plans.
• Means-testing refers to benefits in the Liberal welfare
  state being primarily geared to low-income groups.
• Social assistance is limited by traditional, liberal 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.
                     Social Democratic Regimes
• SD regimes present higher levels of union density.
• SD regimes have > levels of social security and public
  employment expenditures, > public health care
  expenditures, and > extensive health care coverage.
• SD nations implemented full employment strategies,
  attained high rates of female employment, and the
  lowest levels of income inequality and poverty.
• SD nations had the lowest % of income derived from
  capital investment and the largest from wages.
• On a key indicator of population health – infant
  mortality – SD countries had the lowest rates from
  1960 to 1996.
•   Source: Navarro, V., & Shi, L. (2002). The Political Context of Social Inequalities and Health. In
    V. Navarro (Ed.), The Political Economy of Social Inequalities: Consequences for Health and
    Quality of Life. Amityville, NY: Baywood.
                 Anglo-Saxon Liberal Regimes
• Anglo-Saxon liberal political economies had the
  lowest health care expenditures and the lowest
  coverage by public medical care.
• Had greater incidence of low wage earnings,
  higher income inequalities, and the highest poverty
  rates.
• These economies derived the greatest proportion
  of income from capital investment rather than
  wages.
• These economies had the lowest improvement
  rates in infant mortality rates from 1960 to1996.
•   Source: Navarro, V., & Shi, L. (2002). The Political Context of Social Inequalities and
    Health. In V. Navarro (Ed.), The Political Economy of Social Inequalities: Consequences
    for Health and Quality of Life. Amityville, NY: Baywood
Source: Saint-Arnaud, S., & Bernard, P. (2003). Convergence or resilience? A
hierarchial cluster analysis of the welfare regimes in advanced countries. Current
Sociology, 51(5), 499-527.
Power Relations and the Welfare State
• Power relations -- electoral behaviour and
  trade union solidarity -- interact with civic
  behaviour -- trust in government, corruption
  and cynicism – to produce labour market and
  welfare state policies.
• When these policies ameliorate social and
  economic inequalities, population health as
  measured by infant mortality, cause-specific
  mortality, and life expectancy should improve.
 Predictors of Declines in Infant Mortality and
Increases in Life Expectancy in OECD Nations
 • Increasing support for social democratic
     parties
 •   Increases in the proportion of citizens voting
 •   Increases in public health care coverage
 •   Increases in the proportion citizens employed
 •   Increases in female labour force participation
 •   Increasing income equality
 •   Increases in national wealth
 Source:Navarro, V., et al.(2004). The importance of the political and the
   social in explaining mortality differentials among the countries of the
   OECD, 1950-1998. In V. Navarro (Ed.), The Political and Social Contexts
   of Health. Amityville NY: Baywood Press.
Source: Rainwater,
L., & Smeeding, T.
M. (2003). Poor Kids
in a Rich Country:
America's Children in
Comparative
Perspective. New
York: Russell Sage
Foundation.
       Key Tenets of Neo-liberalism
• Markets are the most efficient allocators of
  resources in production and distribution;
• Societies are composed of autonomous
  individuals (producers and consumers)
  motivated chiefly by material or economic
  considerations;
• Competition is the major market vehicle for
  innovations
• “There is no such thing as society.”
• Source: Coburn, D. (2000). Income inequality, social
  cohesion and the health status of populations: The role of
  neo-liberalism. Social Science & Medicine, 51(1), 135-146.
                 Neo-Liberalism
• Considering that Canada and the UK are already
  identified as a liberal political economy within
  Esping-Andersen’s typology, they may be especially
  susceptible to neo-liberal ideology (see
  Vandenbroucke (2002) for a discussion of European
  Union resistance to neo-liberal influences.
• And, indeed many have argued that this has been
  the case in Canada. The growth of the welfare state
  in Canada leveled off in the early 1980’s, and since
  1990 there has been a drastic decline in public
  expenditures in support of a variety of welfare state
  policies.
Hulchanski, D. (2002). Can Canada Afford to Help Cities, Provide Social
Housing, and End Homelessness? Why Are Provincial Governments Doing So
Little? Toronto: Centre for Urban and Community Studies.
Hulchanski, D. (2002). Can Canada Afford to Help Cities, Provide Social
Housing, and End Homelessness? Why Are Provincial Governments Doing So
Little? Toronto: Centre for Urban and Community Studies.
    Canada
in Comparative
  Perspective
    Child Poverty in Lone-Parent and Other Families
     in Canada and Three Comparison States, 2000

                   60                                                       55.5
                               51.6
Poverty Rate (%)




                   50                                         45.6
                   40
                   30
                   20                                  13.3          15.8
                        10.4                 6.7
                   10                  1.5
                    0
                        Canada         Sweden            UK            USA
                        Source: Innocenti Report Card on Child Poverty in
                                     Rich Nations, June 2002
                                      Other Families   Lone-Parent
                           Public Social Expenditure by Broad Social
                          Policy Areas as Percentage of GDP in Canada
                               and Four Comparison Nations, 1997.
                           20                   18.2 33.3                                    35
                           18
Percentage of GDP Spent




                                                                                             30
                           16                        15.1




                                                                                                  Percentage of GDP
                                                                                                  Total Spending as
                                                                13.6                         25
                           14
                           12                                          21.6
                                10.2                                                         20
                           10          16.9                            8.0
                                                                                 9.0
                                                                                       16
                            8                                                          7.0   15
                                       6.7
                            6                                                                10
                            4
                                                                                             5
                            2
                            0                                                                0
                                Canada           Sweden              UK            USA

                                   Cash Benefits          Services        Total Spending
                                         Source: Society at a Glance, OECD, 2001
     Income Inequality – Gini Coefficient
       Canada, USA, UK, and Sweden,
          Mid 80’s, mid 90’s 2000
40
                          35.7
35                                            32.6
30         30.1

25                                                          24.3
20
15
10
5
0
     Canada           USA              UK            Sweden
             Mid 1980's          Mid 1990's          2000
Source: OCED (2005). Society at a Glance 2005. Paris: OECD.
Social expenditures and child poverty—the U.S. is a noticeable outlier,
               Economic Policy Institute, July 23, 2004
         Canadian Policy Directions
It has become obvious that people on the low
end of the income scale are cut off from the
ongoing economic growth that most Canadians
are enjoying. It is also obvious that in these
times of economic prosperity and government
surpluses that most governments are not yet
prepared to address these problems seriously,
nor are they prepared to ensure a reasonable
level of support for low-income people either
inside or outside of the paid labour force.

Source: Poverty Profile, 1998. Ottawa: National Council
of Welfare Reports, Autumn, 2000.
Resistance: The Future
  of the Welfare State
         Society and Health:
         Where are We Now?

          Social Determinants of Health


     “Individual Lifestyle Choices”

Individual Health and Illness
        Society and Health:
  How Far Upstream Should We Go?

                      Welfare State

      Social Determinants of Health


Population Health
                   Union Density Rate
           Canada, USA, UK, and Sweden, 2000
                                                                                         79
80
70
60
50
40               38
                                                                 29
30
20                                       13
10
  0
          Canada                     USA                      UK                  Sweden
 Source: Navarro, V. et al. (2004). The importance of the political and the social in explaining mortality
differentials among the countries of the OECD, 1950-1998. In V. Navarro (Ed.), The Political and Social Contexts
of Health. Amityville NY: Baywood Press.
       Self-Positioning on “Left” of Political Scale,
      Canada, USA, UK, and Sweden, 1990, 2000
     35                                                                               34

     30                                                                         28
                                                                26
     25                                                    24
                      21
     20
                 16                   17 18
     15
     10
       5
       0
             Canada                  USA                    UK              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.
Alesina, A., &
Glaeser, E. L.
(2004).
Fighting
poverty in the
US and
Europe: A
world of
difference.
Toronto:
Oxford
University
Press.
% of GDP in
 Transfers




                         Degree of Proportional Representation
Source: Alesina, A. & Glaeser, E. L. (2004). Fighting Poverty in the US and Europe: A World
of Difference. Toronto: Oxford University Press
          Dennis Raphael
         draphael@yorku.ca
This presentation and other presentations
  and related papers are available at:

 http://www.atkinson.yorku.ca/draphael

				
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