The Political Economy of Health: A Research Agenda for Addressing Health Inequalities in Canada
Publication: Canadian Public Policy
Volume 41, Number Supplement 2
Abstract
Abstract
Public policy creates health inequalities among Canadians by inequitably distributing the social determinants of health (SDOH). Political decisions by authorities bring about these public policies, yet to date there has been little resistance to these decisions by the Canadian public. This article proposes a research agenda for investigating why this might be the case by considering a) Canada’s identification as a liberal welfare state; b) the relative power and influence of the corporate and business sector, labour, and civil society in shaping SDOH-related public policy-making; c) how population health researchers and public health practitioners understand health inequalities and their role in reducing them; and d) the public’s understanding of SDOH and public policy-making.
Résumé
Les politiques publiques créent des inégalités de santé parmi les Canadiens parce qu’elles entraînent une répartition inégale des déterminants sociaux de la santé dans la population. Ces politiques sont le résultat de décisions politiques, auxquelles les Canadiens ont pourtant peu réagi jusqu’à maintenant. Dans cet article, je suggère un programme de recherche afin d’étudier pourquoi il en est ainsi. Je propose d’examiner: a) le fait que le Canada soit un État-providence libéral; b) le pouvoir et l’influence relatifs du monde des affaires, du monde syndical et de la société civile en matière de conception des politiques liées aux déterminants sociaux de la santé; c) la façon dont les chercheurs en santé de la population et les professionnels de la santé publique comprennent les inégalités de santé et le rôle qu’ils jouent pour les réduire; et d) la compréhension qu’a le public des déterminants sociaux de la santé et de la conception des politiques publiques.
Introduction
This article outlines a research agenda for identifying the structural sources of health inequalities in Canada.1 It suggests that Canadian public policy, under the increasing influence of the corporate and business sector, generates health inequalities by skewing the distribution of the social determinants of health (SDOH). The World Health Organization (WHO) identifies SDOH as “the conditions of daily life – the circumstances in which people are born, grow, live, work, and age” and how they result from the “inequitable distribution of power, money, and resources – the structural drivers of those conditions of daily life – globally, nationally, and locally” (WHO 2008, 26).2
Canadian public policy does little to address SDOH because the logic inherent in the country being a liberal welfare state has rather little to say about addressing the structural sources of health inequalities (Navarro and Shi 2002; Raphael 2012). This is because the market—rather than the state—is its dominant institution. This makes public policy especially susceptible to the influence of the corporate and business sector and of growing economic globalization, which elicits public policy-making that skews the distribution of SDOH.3 While no form of the welfare state is immune from these influences, the liberal welfare state is least prepared to resist them.
Why do these health-threatening political decisions go unchallenged by the Canadian public? To answer this question requires examination of a) the implications of Canada being a liberal welfare state; b) how the relative power and influence of the corporate and business sector, labour, and civil society shape SDOH-related public policy-making; c) how population health researchers and public health practitioners understand health inequalities and their role in reducing them; and d) the public’s understanding of SDOH and public policy-making and how these are shaped by the power and influence of these sectors.
The Political Economy of Health
Canadian research into health inequalities is imbued with the pluralistic notion that public policy-making is a rational, ideas-driven process (Bryant 2012). Research is carried out and disseminated on the assumption that it will inform policy-making to reduce health inequalities (NCCDH 2008).
In Canada, there are two good reasons to question this approach: 1) decades of research on how to reduce health inequalities through public policy action on SDOH has not influenced the agendas of governing authorities (Bryant et al. 2011; Hancock 2011), and 2) evidence is accumulating that public policy is made in the interests of sectors of society with power and influence rather than the population as a whole (Langille 2009; Raphael 2015).4
The political economy literature examines how economic and political systems create public policies that distribute economic and other resources (Coburn 2010). Those occupying various social locations5 differ in power and ability to influence public policy-making and therefore receive different levels of economic and other resources (Raphael 2010). Since citizens are provided with justifying ideologies for these distributions—such as neo-liberalism6—by these same powerful groups, most come to accept them (Grabb 2007). These social inequalities7 eventually lead to health inequalities (Graham 2007).
Esping-Andersen (1990, 1999) identifies key ways in which welfare states provide economic and social security to their members. While his framework was not designed to understand health inequalities, its key features—such as stratification, de-commodification, and the relative roles of the state, market, and family in providing economic and social security—have proven attractive to health inequality researchers (Eikemo and Bambra 2008). The features of one form of the welfare state, the liberal, of which Canada is one, makes it difficult to address health inequalities through public policy. Esping-Andersen’s analysis of the sources of the welfare state also suggests how public policy-making can be shifted in the service of reducing health inequalities (Raphael 2013b).
Worlds of Welfare
Modern welfare states take different forms: the social democratic, conservative, and liberal (Esping-Andersen 1990).8 Their central features are a) the extent and means by which they maintain or reduce social stratification and b) the ways in which they allow citizens to lead a decent life independent of involvement in the labour market (de-commodification) (Eikemo and Bambra 2008). Both stratification (greater stratification leads to greater inequality) and de-commodification (greater de-commodification leads to less inequality) affect the distribution of SDOH and depend in large part on the roles played by the state, market, and family in providing citizens with economic and social security (Raphael and Bryant 2015).9 Saint-Arnaud and Bernard (2003) specify the distinctive characteristics of these welfare states in Figure 1.
Applying Esping-Andersen’s (1990) typology of welfare states, broad-stroke analysis suggests that the social democratic welfare state fares best when equitably distributing SDOH (Raphael 2013a, 2013b), reducing infant mortality and increasing life expectancy (Brennenstuhl, Quesnel-Vallée, and McDonough 2012), and limiting absolute health inequalities (Bambra 2011). This is particularly true when compared to the liberal welfare state.
However, findings from these broad-stroke analyses are not always consistent, and researchers have suggested specifying the public policies that shape health inequalities across the life course (Bergqvist, Åberg Yngwe, and Lundberg 2013; Brennenstuhl, Quesnel-Vallée, and McDonough 2012; Raphael and Bryant 2015).10 In the following sections, this article does both: broad-stroke and public policy analyses of how Canadian public policy shapes the distribution of SDOH and creates health inequalities.
Canada: A Liberal Welfare State
The liberal welfare state’s distinguishing aspect is that its key institution is the market (Saint-Arnaud and Bernard 2003). The state provides fewer economic and social supports for the population, universal benefits are sparse, and state provision of modest benefits is targeted at the least well-off (Esping-Andersen 1990, 1999). Since the market is less managed through legislation and regulations, the distribution of wages and benefits is more skewed; these are all features found in analyses of the Canadian SDOH scene (Raphael 2013a, 2013b).
Another distinguishing aspect is its weak labour sector, a result of the fact that the political apparatus cedes economic dominance to the business and corporate sector (Jackson 2010). Organizing the workplace is difficult, and there are many obstacles, so that only 28 percent of Canadians are members of unions and covered by collective agreements (OECD 2015c).11 As a result, the distribution of income—as well as SDOH associated with income, such as housing and food security—is more skewed in liberal welfare states (Raphael 2013b).
Liberal welfare states collect fewer revenues through taxes and provide fewer public programs and benefits (Pontusson 2005). Total public social expenditure as a percentage of gross domestic product shows Canada to be among the lowest of the OECD nations (18 percent for 2012) (OECD 2015b).12 Spending on programs and benefits for age groups across the life course (early childhood care and education for children, active labour policy for adults, and pensions for the elderly) are also among the lowest of the OECD nations (OECD 2015b). If a person is unable to participate in the paid employment market due to unemployment, sickness, or disability, the benefits available are very low (OECD 2014).
Figure 1: Ideological Variations in Forms of the Welfare State
Source: Saint-Arnaud and Bernard (2003, figure 1, p. 503).
Canadian public policy-making at both the federal and the provincial levels only occasionally deviates from the liberal model (Saint-Arnaud and Bernard 2003). Canadians opted for the development of medicare when they recognized that the economic marketplace was incapable of developing a universally accessible health care system (Wiktorowicz 2010). This quasi-socialist commitment to health care—as well as to elementary and secondary education—does not occur for other SDOH, such as guaranteed employment, provision of living wages and employment benefits, available and affordable child care, or housing and food security, among others (Raphael 2015). This can be attributed to the ongoing success of the corporate and business sector in advancing economic justice as opposed to social justice being the criterion for distributing economic and social resources (Hofrichter 2003; Teeple 2000).13 Figure 2 depicts these processes as being related to the balance of societal power and influence and shows how they come to create health inequalities in the liberal welfare state.
The power and dominance of the business and corporate sector in the liberal welfare state translates into public policy that inequitably shapes the distribution of SDOH in a whole range of public policy areas: employment security (Tremblay 2009) and working conditions (Jackson 2009), early childhood education and provision of child care (Friendly 2009), housing (Shapcott 2009), and health and social services (McGibbon 2009). A greater proportion of the population is exposed to these problematic SDOH, resulting in a rather significant incidence of material and social deprivation (OECD 2013), adoption of health-threatening behaviours, and psycho-social stress (OECD 2014). The results are the health inequalities that manifest among Canadians across the life course.14 Yet these structural processes tend to remain unacknowledged as the Canadian public tends to vote for liberal parties15 and offers relatively weak support for the state playing a primary role in providing and redistributing resources.16
Note: Shaded boxes depict the focus of the proposed research agenda.
Figure 2: Pathways by Which the Relative Strengths of the Business, Labour, and Civil Society Sectors in the Liberal Welfare State Act in Concert with Voter Political Activity and Public Opinion to Produce Public Policy That Shapes the Quality and Distribution of SDOH
Source: Adapted from Raphael (2015).
Emerging Threats to Health
There are further emerging SDOH-related threats to which the liberal welfare state is especially susceptible. These include the economic and social effects of economic globalization, as manifested through free trade and other agreements (Labonté and Schrecker 2007a, 2007b, 2007c). There are three major pathways by which this is occurring: labour markets (and the rise of precarious employment), housing markets (speculative investments and affordability), and social-protection measures (changes in the scope and redistributive aspects of social spending and taxation) (Labonté et al. 2015).
Employment is becoming increasingly precarious, and income inequality is growing as wages for the majority of Canadians stagnate (Statistics Canada 2013; Tremblay 2009). Housing affordability is decreasing, and Canadians are spending increasing proportions of their incomes on this necessity (Bryant et al. 2011; Shapcott 2009). As governments strive to reduce both corporate and personal taxes for the wealthy, revenues are unavailable to respond to the need for social investment and citizen support (Langille 2009). Banting and Myles (2013) describe this as the fading of redistributive politics in Canada.
The threats posed by globalization and the endorsement of neo-liberal ideology are not unique to liberal welfare states. In Scandinavia, some retrenchment of the welfare state has occurred; this is especially the case in Sweden, where a centre-right government from 2006 to 2014 reduced the levels of benefits so that income inequality and poverty levels grew markedly (Raphael 2014a).17 Among conservative welfare states, Germany may be transforming into a liberal welfare state by altering its social insurance system (Siegel, Vogt, and Sundmacher 2014).
These shifts are the result of the greater influence on public policy-making of the business and corporate sector in an age of economic globalization (Langille 2009). Accompanying shifts—if justification is persuasively presented—occur in public attitudes about the state’s role in managing the economy and providing economic and social security. Right-wing elements gain influence as resentment increases about immigration from the developing world. Anti-immigration parties stoke racist and xenophobic tendencies and weaken citizen support for the inclusive welfare state.18
Retrenchment in social democratic and conservative welfare states is not as dramatic as in liberal welfare states, where policy-makers are more receptive to neo-liberal notions (Swank 2005). These findings suggest that shifting SDOH-related public policy-making in Canada requires understanding the role that power and influence play in public policy-making and citizens’ attitudes toward the state’s role in providing economic and social security.
Proposed Research Agenda
Canadian researchers have accumulated ample evidence about how public policy shapes SDOH and comes to create health inequalities (see the unshaded areas of Figure 2) (Raphael 2009). The shaded areas represent areas of needed inquiry: the role that sectoral power plays in SDOH-related public policy-making and Canadians’ ideological commitments toward the state’s role in distributing SDOH. Another area of needed inquiry is how Canadian population health research and public health communities approach these issues.
Brennan (2012) shows how growing business and corporate power is tightly related to growing income inequality and weakening organized labour influence, while Banting and Myles (2013) relate the declining influence of organized labour and civil society to the fading of redistributive politics. To date, research has not linked these changes in power and influence to specific aspects of SDOH-related public policy-making. There is a need to document these effects and make this information available to the Canadian public.
More directly to the issue at hand, research is needed into how population health researchers, and health care and public health workers, think about SDOH. The public health community is certainly engaged in SDOH-related activities, but there is a lack of consensus as to the definition of SDOH, the sources of their inequitable distribution, and how to respond to this distribution (NCCDH 2015).
To illustrate this lack of consensus about SDOH among these communities, seven different SDOH discourses have been identified (Raphael 2011b). These range from seeing SDOH as identifying those requiring greater health care and social services to identifying how those who profit from social inequality create health inequalities. These discourses shape the activities undertaken by population health researchers and public health workers (Brassolotto, Raphael, and Baldeo 2014; Raphael et al. 2005). If the sources of health inequalities are structural in origin, then it is necessary for population health researchers and public health workers to gain an understanding of them.
Inquiry is required into how influential disease associations such as the Heart and Stroke Foundation, Canadian Cancer Society, and Canadian Diabetes Association address SDOH (Raphael 2010). One example is that the Heart and Stroke Foundation has little to say about SDOH and the public policies that inequitably distribute them despite the evidence implicating public policy in the incidence of cardiovascular disease (Raphael 2014b).19
There has been virtually no Canadian research into policy-makers’ understanding of SDOH (e.g., Lavis 2002) and no inquiry into how they see their activities being shaped by issues of influence and power. We also know little about how elected officials view their policy positions as being related to SDOH, if at all. Such research could provide insights into how elected representatives—including those in power as well as in opposition—could make SDOH part of their policy platforms and activities.20 These types of inquiries require researchers to apply ethnographic methods of qualitative inquiry, and they have been carried out, for example, with public health officials and workers (Brassolotto, Raphael, and Baldeo 2014).
Finally, another area of potential inquiry is citizens’ views of the state’s role in providing economic and social security, which include SDOH (Coburn 2010; Langille 2009; Reutter et al. 2006). One of the key insights made by Esping-Andersen (1990) is that in liberal welfare states, the population gives its allegiance to the market rather than to the state; thus, we need to find out more about Canadians’ understanding of SDOH and how public policy shapes their distribution (Shankardass et al. 2012). Without such understanding, Canadians are unable to force their governments to address SDOH (Lofters et al. 2014).21 Related to this, researchers need to understand Canadians’ political preferences and determine whether they are related to their thinking about how economic and other resources should be distributed. These inquiries must be framed within a context that recognizes that SDOH and their distribution have not been explicitly placed on the policy agenda of any major political party.22
Conclusion
Reducing health inequalities by improving the distribution of SDOH requires analysis of the political and economic structures of society and the forces that shape public policy-making. It is important to examine the politics of the welfare state and how the structures and processes of the liberal welfare state shape Canadians’ understanding of SDOH, their distribution, and the means of addressing these issues.
Addressing these issues and understanding the barriers to action requires inquiry into what role those researching and working to address SDOH—public policy-makers, elected officials, and the public—see for public policy. Many features of Canada’s liberal welfare state will make such efforts difficult. Evidence exists, however, that Canadian values continue to be generally sympathetic to an SDOH-oriented approach to public policy-making (Reutter et al. 2006). We need to understand why Canadians are not being informed about these issues and whether, if they were, they would demand that policy-makers address them.23
Footnotes
1
This article uses the term health inequalities rather than health inequities as the former term is more common. Health inequalities are differences in health outcomes among groups, while health inequities are differences that are avoidable and unfair. In reality, most health inequalities are avoidable and unfair, essentially making the two terms interchangeable.
2
SDOH are the economic and social conditions that shape health. Canadian researchers outline 14 of these: Aboriginal status, disability status, early life, education, employment and working conditions, food security, gender, health services, housing, income and income distribution, race, social exclusion, social safety net, and unemployment and employment insecurity (Mikkonen and Raphael 2010). SDOH such as Aboriginal status, disability status, gender, and race are social locations that interact with societal conditions to shape health.
3
Graham (2007) distinguishes between SDOH and their distribution. Since the primary concern in this article is health inequalities, focus is on the distribution of SDOH.
4
The WHO Commission on SDOH also recognizes this. “This unequal distribution is not in any sense a ‘natural’ phenomenon but is the result of policies that prize the interests of some over those of others – all too often of a rich and powerful minority over the interests of a disempowered majority” (WHO 2008, 31).
5
“An individual’s social locations consist of her ascribed social identities (gender, race, sexual orientation, ethnicity, caste, kinship status, etc.) and social roles and relationships (occupation, political party membership, etc.)” (Anderson 2011, n.p.).
6
Neo-liberalism is an ideology that argues that governments should not manage the economy but cede power and influence to the business and corporate sector (Coburn 2010). It justifies shifts in public policy that skew the distribution of SDOH.
7
“Social inequality can refer to any of the differences among people (or the socially-defined positions they occupy) that are consequential for the lives they lead, most particularly for the rights or opportunities they exercise and the rewards or privileges they enjoy” (Grabb 2007, 1).
8
The social democratic welfare state arose during the early 20th century, influenced by socialist political and economic thought (Esping-Andersen 1990). It is generally suspicious of capitalism and manifests itself in the Nordic nations of Denmark, Finland, Norway, and Sweden. Universal benefits and strong redistributive processes have led to broad public support for the state’s role in providing citizens with economic and social security. Generous benefits are supported by strongly progressive levels of taxation. This type of welfare state strives to reduce stratification and increase de-commodification. The conservative welfare state was a reaction to the laissez-faire capitalism of the 19th century. Ruling circles, influenced by Church doctrine, wanted to maintain social stability yet maintain class distinctions. This type of welfare state provides economic and social security primarily through the use of social insurance paid for by employees. There is less concern with gender equity than in the social democratic welfare state. The Continental nations of Belgium, France, Germany, and the Netherlands represent this type of welfare state. It maintains stratification but provides significant de-commodification. The Latin welfare state is seen by Saint-Arnaud and Bernard (2003) as an undeveloped form of the conservative welfare state. The liberal welfare state is a result of economic and political developments in the United Kingdom since the Industrial Revolution, which extended to its former colonies of Canada, the United States, and Ireland (Esping-Andersen 1990). Its distinctive aspect is providing modest benefits to the citizenry and identifying the economic marketplace as the primary source of economic and social security. The citizenry recognizes this and looks to the market rather than the state for economic and social security. This type of welfare state does little to reduce stratification and provides the least de-commodification.
9
In the social democratic welfare state, the state is primarily responsible for providing economic and social security. In the liberal regime, this role is played by the economic marketplace and individuals’ ability to participate in paid employment. The conservative welfare state strengthens a family’s ability to provide economic and social security through employment-related social insurance schemes (Esping-Andersen 1990, 1999).
10
Raphael and Bryant (2015) suggest that the form of the welfare state reflects distinctive historical and cultural antecedents—including power dynamics and cultural value orientations—that shape welfare state tendencies. Like Bergqvist, Åberg Yngwe, and Lundberg (2013) and Brennenstuhl, Quesnel-Vallée, and McDonough (2012), they suggest moving beyond these broad-stroke analyses to specify the public policies that shape the health of those occupying different social locations at important periods of the life course.
11
As of 2012, union density is lowest in liberal welfare states (Australia, 18 percent; Canada, 28 percent; United Kingdom, 26 percent; United States, 11 percent) and highest in social democratic welfare states (Denmark, 67 percent; Finland, 69 percent; Norway, 54 percent; Sweden, 68 percent) (OECD 2015c). It is generally low in conservative welfare states (Belgium, 55 percent; France, 8 percent; Germany, 18 percent; the Netherlands, 18 percent) but is offset by the fact that the great majority of employees work under collective agreements negotiated by employer associations and unions (Belgium, 96 percent; France, 92 percent; Germany, 61 percent; the Netherlands, 84 percent) (OECD 2015a). No such situation exists in liberal welfare states, with the result that collective agreements in Canada are at the same level as union membership (29 percent).
12
Liberal welfare states are distinctively low in public social expenditure (Australia, 19 percent; Canada, 18 percent; United Kingdom, 24 percent; United States, 20 percent), while social democratic welfare states are higher (Denmark, 31 percent; Finland, 30 percent; Norway, 23 percent; Sweden, 28 percent). Conservative welfare states score rather high as well (Belgium, 31 percent; France, 33 percent; Germany, 26 percent; the Netherlands, 24 percent).
13
The social justice versus economic justice dichotomy concerns whether individuals have an inherent right to receive the resources necessary for their well-being from the state or whether they are entitled to resources earned through their participation in the market economy (Hofrichter 2003).
14
Canada falls short in addressing the needs of vulnerable groups, such as people of Aboriginal descent (Smylie 2009), children (Raphael 2014c), persons with disabilities (Rioux and Daly 2010), people of colour (Galabuzi 2009), women (Pederson, Raphael, and Johnson 2010), and those unable to work, either due to illness or lack of employment opportunities (Raphael 2011a).
15
Welfare state researchers consider both the Liberal and Conservative parties to be “liberal” political parties.
16
Recent developments, however, are cause for optimism. The New Democratic Party (NDP) recently won an electoral majority in Canada’s most conservative province, Alberta, on a platform of reviewing corporate oil royalties and making the provincial income tax more progressive. Similarly, polling numbers suggest that the NDP has a shot at winning the federal election in October 2015 (http://www.threehundredeight.com/.
17
In 2014, a centre-left Swedish government was restored to power.
18
In Canada, recent instances of politicians—including the prime minister—attacking Muslim cultural traditions are examples of this (Bryden 2015).
19
The Heart and Stroke Foundation reports annual revenues of $198,000,000 (http://tinyurl.com/l3m9q56) yet states that it lacks the resources necessary to address SDOH (http://www.guelphmercury.com/opinion-story/4618868-slam-at-heart-foundation-board-was-unfair).
20
To date, the NDP, ostensibly a social democratic party on the left, has mentioned SDOH in its policy document but not made them a major issue in the 2015 election campaign(http://www.libbydavies.ca/sites/default/files/file-uploads/HealthCareMessage-EN (2).pdf).
21
Corresponding to weakening allegiance to the state is growing citizen disengagement from the political process. This is especially apparent among voters aged 18 to 24 (Howe 2011) and low-income Canadians (Schellenberg 2004).
22
However, specific SDOH such as income distribution, employment security, and working conditions have been identified as concerns of Canadians and in some cases are being discussed by the federal Liberals (http://petition.liberal.ca/income-inequality-disparity-economy/) and NDP (http://www.ndp.ca/news/ndp-moves-against-conservative-income-splitting-scheme).
23
An example of how this might be done is provided by Ryan Meili. The author of A Healthy Society: How a Focus on Health Can Revive Canadian Democracy (2006), Meili twice ran for the NDP leadership in Saskatchewan on an SDOH platform. He now heads Upstream, a national movement to raise the profile of SDOH (http://www.thinkupstream.net/ryanmeili).
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Canadian Public Policy
Volume 41 • Number Supplement 2 • November 2015
Pages: S17 - S25
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© Canadian Public Policy / Analyse de politiques.
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Published in print: November 2015
Published online: 11 November 2015
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Canadian Public Policy 2015 41:Supplement 2, S17-S25
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