social policy and population health. the importance of policy policies shape how money, power and...
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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
5
1
1517
11
02468
1012141618
Canada Denmark Sweden UK USA
Ran
kin
g
Source: United Nations Human Development, Report, 2002
People Lacking Functional Literacy Skills in
Canada and Four Comparison Nations, 1998
9.67.5
21.8 20.716.6
0
5
10
15
20
25
Canada Denmark Sweden UK USA
Source: United Nations Human Development Report, 2002
Per
cen
tage
Population Below Income Poverty Line of 50% of Median Income in Canada and Four Comparison
Nations, 1998
9.26.6
13.4
16.9
12.8
02468
1012141618
Canada Denmark Sweden UK USA
Source: United Nations Human Development Report, 2002
Per
cen
tage
Inequality in Consumption or Income in Canada and Four Comparison Nations, 2000: Share Held by Richest and
Poorest 10% of the Population
20.5 20.1
27.7 30.5
2.8 3.6 3.7 2.2 1.8
23.8
05
101520253035
Canada Denmark Sweden UK USA
Source: United Nations Human Development Report, 2002
Per
cen
tage
Hel
d
Richest 10% Poorest 10%
Child Poverty in Lone-Parent and Other Families in Canada and Four Comparison States, 2000
3.6 1.513.3 15.8
51.6
13.86.7
45.655.5
10.4
0102030405060
Canada Denmark Sweden UK USA
Source: Innocenti Report Card on Child Poverty in Rich Nations, June 2002
Pov
erty
Rat
e (%
)
Other Families Lone-Parent
Percentage of Persons Living in Poverty in Lone-Parent Working and Non-Working Families in
Canada and Four Comparison States, 1994
34.024.0
65.073.0
26
10 4
23
39
72.0
01020304050607080
Canada Denmark Sweden UK USASource: Society at a Glance, OECD, 2001
Pov
erty
Rat
e (%
)
Non-Working Single Working Single
Priorities in Public Spending: Public Expenditure on Education and Health as a Percentage of GDP in
Canada and Four Comparison Nations, 1995-1998
8.1 8.3
5.3 5.46.6 6.9 6.6 5.8 5.7
6.9
0
2
4
6
8
10
Canada Denmark Sweden UK USA
Source: United Nations Human Development Report, 2002
Per
cen
tage
of
GD
P S
pen
t
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
10.2
16.818.2
13.6
9.06.7
13.715.1
8.0 7.0
30.533.3
21.6
161.5
02468
101214161820
Canada Denmark Sweden UK USAPer
cen
tag
e o
f G
DP
Sp
ent
0
5
10
15
20
25
30
35
To
tal Sp
end
ing
as Percen
tage
of G
DP
Cash Benefits Services 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, 1999Canada Denmark Sweden UK USA
Single Short-term 62% 89% 77% 73% 59%Long-term 35% 67% 84% 73% 10%
Married CoupleShort-term 65% 94% 77% 88% 59%Long-term 57% 94% 100% 88% 18%
Couple - 2 childrenShort-term 69% 95% 90% 83% 51%Long-term 77% 92% 100% 95% 61%
Lone Parent - 2 childrenShort-term 67% 89% 96% 69% 51%Long-term 77% 82% 100% 81% 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
0.8
2.2
2.7
1.00.7
0.30.0 0.0
0.30.6
2.2
2.7
1.3 1.31.5
0.0
0.5
1.0
1.5
2.0
2.5
3.0
Canada Denmark Sweden UK USA
Per
cen
tag
e o
f G
DP
Sp
ent
0
0.5
1
1.5
2
2.5
3
To
tal Sp
end
ing
as Percen
tage
of G
DP
Public Spending Private Spending 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 - USAChanges in Family Income 1947-79 and 1979-1998
-20%
0%
20%
40%
60%
80%
100%
120%
1947-79 1979-98
The Wealth Gap in the USADistribution of Net Worth, 1997
40.0%
21.9%
11.2%
11.4%
10.7%4.4% 0.5%
Top 1%
Next 4%
Next 5%
Next 10%
Next 20%
Middle 20%
Bottom 40%
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
Low Income
0
5
10
15
20
25
30
35
40
45
1971 1986 1991 1996
Q1-RichestQ2Q3Q4Q5-Poorest
%
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
1
1.1
1.2
1.3
1.4
1.5
1970 1975 1980 1985 1990 1996
US/Can
Mortality rate ratios (Canada=1.0)
Source: Wilkins et al., 2002
US-Canada Life Expectancy Trends
70
71
72
73
74
75
76
77
78
79
1971 1976 1981 1986 1991 1996
Canada
USA
Years (at birth), total both sexes
Source: Wilkins et al., 2002
Source: Dunn, 2002
Components of the Index of Social Health
Children Youth Adults infant mortality teen suicide unemployment child abuse drug abuse weekly earnings children in poverty HS drop-outs health insurance
coverage
Elderly All Ages - Poverty among those -homicides 65 and over -alcohol-related traffic fatalities - Out-of-pocket health - social assistance rates cost for those 65 and over -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.