The Political Economy of Health Promotion Dennis Raphael, PhD School of Health Policy and Management, York University, Toronto, Canada Presentation at the 20th IUHPE World Conference on Health Promotion. Geneva, Switzerland, July 13, 2010

Key Health Promotion Concepts Prerequisites of Health/SDOH – peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice, and equity. Citizen Empowerment –People cannot achieve their fullest health potential unless they are able to take control of those things which determine their health. Important Role for Public Policy –Health promotion policy combines diverse but complementary approaches including legislation, fiscal measures, taxation and organizational change. Source: Ottawa Charter for Health Promotion

Dominant Political Ideologies 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 peoples health. Bambra, C., Fox, D., & Scott-Samuel, A. (2005). Towards a politics of health. Health Promotion International, 20(2),

Health Promotion and Welfare States Esping-Andersen (1990) identifies three types of welfare state: Liberal, Conservative and Social Democratic Liberal -- State provision of welfare is minimal, benefits are modest and often attract strict entitlement criteria, and recipients are usually means-tested and stigmatized Conservative -- Status differentiating welfare programs in which benefits are often earnings related, administered through the employer, and geared towards maintaining existing social patterns. The role of the family is also emphasized and the redistributive impact is minimal. Social Democratic -- Welfare provision is characterized by universal and comparatively generous benefits, a commitment to full employment and income protection, and a strongly interventionist state used to promote equality through a redistributive social security system. Source: Bambra, C. (2009). Welfare State Regimes and the political Economy of Health. Humanity and Society, 33, (1&2), , Table 2, p. 105.

What is the central institution in society – in terms of shaping the distribution of resources? The state (government)? The family? The market?

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),

Source: Organization for Economic Cooperation and Development (2006). Trade Union Members and Union Density. Available at and Organization for Economic Cooperation and Development (2009). Growing Unequal: Income Distribution and Poverty in OECD Countries Figure 5.a2.1, p.154.

Explicit Health Promotion Governmental statements about the importance of providing the prerequisites of health through public policy activity Health sector statements about promoting health through public policy and community- level activities Governmental and health sector statements about promoting health through behaviour change related to healthy living or healthy lifestyle choices.

Statements about Health Promotion Finland, Norway, Sweden (social democratic) Finland: The Government Resolution on the Health 2015 Public Health Programme defines reducing health differences between population groups as a central goal. Norway: A National Strategy to Reduce Social Differences in Health (2007) provides a ten year perspective for developing policies and strategies to reduce health inequities. Sweden: The Public Health Objectives Bill (2003) calls for decisive measures to improve public health through action on social policy, healthcare policy, labour market and working life policy, housing policy, education policy and environmental policy. Source: Hogstedt, C. et al (2008). Health for All? A Critical Analysis of Public Health Policies In Eight European Countries. Stockholm: Swedish National Institute of Health.

Statements about Health Promotion France, Germany, Netherlands (conservative) France: In the end, even if interest in health promotion increased in France over the past 10 years … it remains hindered by a system still very centred on curative care and a lack of political consideration for health determinants (Guillaumie, 2007). Germany: The German approach to health promotion differs from the US approach. Lifestyle issues of health are part of a structural approach which primarily aims at influencing health-related living and working conditions (ODonnell, 2001)

Statements about Health Promotion France, Germany, Netherlands (conservative) Netherlands: It can be concluded that in The Netherlands the process of putting equality in health on the political agenda has been successful. There is a broad consensus that such inequalities are unfair, and that avoidable inequalities should be reduced… To what extent has this (political) awareness and concern been followed by initiatives to reduce socioeconomic inequalities in health? … the interventions and policies evaluated.. all had an experimental character. They should, however, be seen within the context of a longer tradition of policies to reduce socioeconomic inequalities generally, and socioeconomic inequalities in health specifically (Stronks, 2003). The Dutch Green Paper (2004) ´Living longer in good health´ expressed the Ministers worries about the unequal distribution of poor health, illness and premature death between population groups…The memorandum, however, strongly emphasises the individuals responsibility for their own behaviour and health. It states, for example, that Prevention policy will only achieve success if we hold citizens directly accountable for their own behaviour (Droomers et al., 2008).

Statements about Health Promotion Australia, Canada, UK (liberal) Australian state governments have provided explicit statements about health equity and addressing health inequalities and developed action plans. Canada has long history of providing statements about the determinants of health but has been a clear laggard in acting upon these principles. UK: 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 (Whitehead and Bird, 2008).

Implicit Health Promotion Governmental and institutional activity that manages the extent of income inequality and poverty Governmental and institutional activity that promotes employment training and reduces unemployment (active labour policy) Governmental and institutional activity that meets the childcare needs of citizens

Source: OECD Social Expenditure Database (2010). Red-SD Blue-Con Orange-Latin Black-Lib

Public Policy towards Key SDOH Income inequality, poverty Active labour policy Early child development

Source: Organisation for Economic Co-operation and Development. (2008). Growing Unequal: Income Distribution and Poverty in OECD Nations. Paris: Organisation for Economic Co- operation and Development. Income Inequality in Selected OECD Countries, mid-2000s

Source: Organisation for Economic Co-operation and Development. (2008). Growing Unequal: Income Distribution and Poverty in OECD Nations. Paris: Organisation for Economic Co- operation and Development.

Public Expenditure On Childcare And Early Education Services, Per Cent Of GDP, Selected OECD Nations, 2005

Source: Social Expenditure Database, OECD Paris: OECD.

Health Indicators Life expectancy Infant mortality Suicides Homicides

Source: OECD (2009). Health at a Glance, Table 1.1.1, p. 17. Paris: OECD.

Source: OECD (2009). OECD Family Database, Table CO1.1, p. 3. Paris: OECD.

Source: OECD (2009). Health at a Glance, Table 1.7.1, p. 29. Paris: OECD.

Source: OECD (2009). OECD Regions at a Glance, Table 28.1, p Paris: OECD.

In Canada – and other liberal nations, analysis has suggested…

Business Sector Influence Civil Society Including Labour Influence The State – Government Policies that Provide Citizen Security Balance: The Post-World War II Consensus

Business Sector Influence Civil Society Including Labour Influence The State – Government Polices that Provide Citizen Security Imbalance: The Post-1975 Scene

Implications Attention must be paid to both explicit and implicit aspects of health promotion Both health and quality of life considerations should enter into public policymaking Links between health indicators and form of the welfare state are not always obvious Liberal welfare states arguably show the worse indicators of health and quality of life Politics plays a key role in shaping the quality and distribution of the social determinants of health How do I get an EU Passport?

Dennis Raphael