Societal Approaches to Understanding. How Income and Income Inequality Affect Health. Part

Social Policy and Population Health The Importance of Policy • 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. Current policies that emphasize deficit reduction and private sector economic growth can be unhealthy for people. These policies may increase economic inequalities, environmental degradation, social intolerance and violence. • CPHA Action Statement on Health Promotion, 1996 Human and Income Poverty in Canada and Four Comparison Nations, 2000 0 2 4 6 8 10 12 14 16 18 Canada Denmark Sweden 1 5 11 UK USA Ranking 15 17 Source: United Nations Human Development, Report, 2002 People Lacking Functional Literacy Skills in Canada and Four Comparison Nations, 1998 25 20 15 10 5 0 21.8 16.6 20.7 Percentage 9.6 7.5 Canada Denmark Sweden UK USA Source: United Nations Human Development Report, 2002 Population Below Income Poverty Line of 50% of Median Income in Canada and Four Comparison Nations, 1998 18 16 14 12 10 8 6 4 2 0 16.9 12.8 9.2 Percentage 13.4 6.6 Canada Denmark Sweden UK USA Source: United Nations Human Development Report, 2002 Inequality in Consumption or Income in Canada and Four Comparison Nations, 2000: Share Held by Richest and Poorest 10% of the Population 35 30 25 20 15 10 5 0 Percentage Held 23.8 27.7 20.5 3.6 20.1 3.7 30.5 2.8 2.2 UK 1.8 USA Canada Denmark Sweden Source: United Nations Human Development Report, 2002 Richest 10% Poorest 10% Child Poverty in Lone-Parent and Other Families in Canada and Four Comparison States, 2000 60 55.5 51.6 45.6 50 40 30 15.8 13.8 20 10.4 13.3 6.7 3.6 10 1.5 0 Canada Denmark Sweden UK USA Poverty Rate (%) Source: Innocenti Report Card on Child Poverty in Rich Nations, June 2002 Other Families Lone-Parent Poverty Rate (%) Percentage of Persons Living in Poverty in LoneParent Working and Non-Working Families in Canada and Four Comparison States, 1994 73.0 80 72.0 65.0 70 60 50 40 30 20 10 0 26 34.0 39 24.0 23 4 10 Canada Denmark Sweden UK USA Source: Society at a Glance, OECD, 2001 Non-Working Single Working Single Percentage of GDP Spent Priorities in Public Spending: Public Expenditure on Education and Health as a Percentage of GDP in Canada and Four Comparison Nations, 1995-1998 10 8 6 4 6.96.6 8.1 6.9 8.3 6.6 5.3 5.8 5.4 5.7 2 0 Canada Denmark Sweden UK USA Source: United Nations Human Development Report, 2002 Education Health 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 Percentage of GDP Spent 18.2 20 33.3 16.8 18 30.5 15.1 16 13.6 13.7 14 21.6 12 10.2 1.5 9.0 16 10 8.0 7.0 8 6.7 6 4 2 0 Total Spending as Percentage Canada Denmark Sweden UK Cash Benefits Services 35 30 25 20 15 10 5 0 of GDP USA Total Spending Net Replacement Rates at the Earnings Levels of 2/3 of an Average Production Worker In the First Month of Benefit Receipt and For Long-Term Benefit Recipients, in Canada and Four Comparison Nations, 1999 Canada Denmark Sweden UK Single Short-term 62% Long-term 35% Married Couple Short-term 65% Long-term 57% Couple - 2 children Short-term 69% Long-term 77% Lone Parent - 2 children Short-term 67% Long-term 77% 89% 67% 77% 84% 73% 73% USA 59% 10% 94% 94% 95% 92% 89% 82% 77% 100% 90% 100% 96% 100% 88% 88% 83% 95% 69% 81% 59% 18% 51% 61% 51% 51% ____________________________________________________________________________ Source: SGR Report (OECD, 2001). Long-Term Care Spending as a Percentage of GDP in Canada and Four Comparison Nations, 1995. Source: International Reform Monitors Newsletters, 2002 Total Spending as Percentage of GDP Percentage of GDP Spent 3.0 2.5 2.0 1.5 1.0 0.8 1.5 0.5 0.0 2.7 2.2 2.2 3 2.7 2.5 2 1.0 1.3 1.3 0.7 1.5 1 0 0.5 0.3 0.0 0.0 Private Spending 0.3 UK 0.6 Canada Denmark Sweden Public Spending USA Total Spending Social Policy, Health Determinants and Health in the USA and Canada Today Policy Decisions Create Poverty and Economic Inequality • Changing tax structures in the USA and Canada • Does globalization make this inevitable? • How does economic inequality come about? Rising Together and Drifting Apart - USA Changes in Family Income 1947-79 and 1979-1998 1947-79 1979-98 120% 100% 80% 60% 40% 20% 0% 20% 0% 0% 0% nd 2 dle 2 rth 2 Mid Fo u Seco 0% op 2 T 5% To p -20% B m o tto The Wealth Gap in the USA Distribution of Net Worth, 1997 4.4% 10.7% Top 1% 0.5% 11.4% 40.0% Next 4% Next 5% Next 10% Next 20% 11.2% Middle 20% Bottom 40% 21.9% Economic Inequality and Health: Policy Implications • Poverty and economic inequality is on the rise in the USA and Canada • Poverty is bad for health • Economic inequality is dangerous for the health of all of us • Policy decisions create poverty and economic inequality • Citizens can influence policy decisions to improve health 45 40 35 30 25 20 15 10 5 0 Low Income % Q1-Richest Q2 Q3 Q4 Q5-Poorest 1971 1986 1991 1996 Source: Wilkins et al., 2002 Policy Directions and Population Health • The policies that Canada has developed to improve population health reflects its more egalitarian structure. Examples include various tax and economic transfer policies that help to limit income differences across the country, as well as provision of important social services... If a healthy population is the goal, we must enter the political arena and fight to maintain the social contract that has sustained Canada as one of the world leaders in health. • Stephen Bezruchka, CMAJ, 2001 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. -- Poverty Profile, 1998. Ottawa: National Council of Welfare Reports, Autumn, 2000. Implications of Increasing Family Poverty Given the disturbing increases in income inequality in the United States, Great Britain, and other industrial countries, it is vital to consider the impact of placing ever larger numbers of families with children into lower SES groups. In addition to placing children into conditions which are detrimental to their immediate health status, there may well be a negative behavioural and psychosocial health dividend to be reaped in the future. Why Do Poor People Behave Poorly? Variation in Adult Health Behaviours and Psychosocial Characteristics by Stages of the Socioeconomic Life Course, J.W. Lynch, G.A. Kaplan, & J.T. Salonen. Social Science and Medicine, 1997, 44, 809-819. -- Policy Trends Responsible for Shift Towards Home Rather than Hospital Care for Canadians • • • • debt/deficit pressures, a recognition of the limits to health care, increasing technology and associated costs, and the increasing perception of health as a business leading to: • increased privatization with negative effects upon women as a) care recipients; b) health care workers and c) informal caregivers within the home (Armstrong, 2002). US/Canada Disparities in Infant Mortality Mortality rate ratios (Canada=1.0) 1.5 1.4 1.3 US/Can 1.2 1.1 1 1970 1975 1980 1985 1990 1996 Source: Wilkins et al., 2002 US-Canada Life Expectancy Trends Years (at birth), total both sexes 79 78 77 76 75 74 73 72 71 70 1971 1976 1981 1986 1991 1996 Canada USA Source: Wilkins et al., 2002 Source: Dunn, 2002 Components of the Index of Social Health Children infant mortality child abuse children in poverty Youth teen suicide drug abuse HS drop-outs Adults unemployment weekly earnings health insurance coverage Elderly - Poverty among those 65 and over - Out-of-pocket health cost for those 65 and over All Ages -homicides -alcohol-related traffic fatalities - social assistance rates -access to affordable housing - gap between rich and poor Source:Brink & Zeesman, HDRC, 1997 Reducing Health Inequalities We consider that without a shift of resources to the less well off, both in and out of work, little will be accomplished in terms of a reduction of health inequalities by interventions addressing particular downstream’ influences. -- Report of the Acheson Independent Inquiry into Inequalities in Health, 1998, p. 33. Social Policy, Health, and the Welfare State The Role of Values and Principles in Public Health and Health Promotion The public ideas – and the language associated with them – which currently envelop us are those of the market, corporatism, fiscal restraint, and globalization, ideas which are driving the near universal dismantling of the welfare state, and eroding any notion we might have of the common good. Health promotion represents one possibility for countervailing ideas: ideas about equity, social justice, interdependence, the common good. -- Robertson, 1999, p. 130 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 • - Coburn, 2000. Defining the Welfare State • The welfare state is 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, G. (2000). Globalization and the decline of social reform. Forces that Led to the Development of the Welfare State • Strong national identities at end of WWII • Need to rebuild Western economies after WW II • Strength of labour unions within national labour boundaries • Perceived threat of “socialist” alternatives • Political compromise to avoid boom-bust cycles of the economy • - - Teeple, G. (2000). Globalization and the decline of social reform. Forces Leading to the Decline of the Welfare State • Weakened national identities as a result of trade agreements • Internationalization of investment thereby weakening nationally-based labour unions • Political compromises between business, labour and governments becoming unnecessary • Perceived threat of “socialist” alternatives removed • Slowing of economies and concentration of corporate and media ownership • - - Teeple, G. (2000). Globalization and the decline of social reform.