Political Implications of “socioeconomic determinants of health”

黃嵩立

陽明大學 公共衛生研究所東吳大學 人權學程碩士班

The meaning of politics

Andrew Heywood, Politics, 2007

Three dimensions of Power (Lukes, 1975)

1. The power of A to influence the behavior of B. This exercise of power is observable and is tied to public conflicts over interests (such as access to resources- education, housing, health care etc). It is performed in the public arena as part of decision-making processes. (A 規定 B 哪些事情可以做 )

2. The power of A to define the agenda, preventing B from voicing their interests in pubic (policy) decision-making processes. Potential issues and conflicts are kept off the agenda to the advantage of A and to the detriment of B. The use of this type of power can be obvious or concealed. (A 規定 B 哪些事情可以討論 )

3. The power of A to define the values and beliefs B ought to hold (e.g. what counts as fair, or who gets what). B’s perceptions and preferences are molded by A in such a way that B accepts that these are the norm. This dimension of power is played out, for example, in processes of socialization, the control of information, and the control of the mass media. (A 規定 B 事情該怎麼看 / 感覺 才正常 )

Empowerment, not just health care

• 只是提供醫療照護，並不足以維護健康• Empowerment operated along three dimensions:

– Material: need basic material requisites for a decent life

– Psychosocial: need to have control over their lives, (esteem, dignity, decent position in the society)

– Political: need political voice and participation in decision-making processes.

• e.g. women’s reproductive health and social freedoms

Case studies 1: SEWA (India)

• The Self-Employed Women’s Association – include workers who earn a living through their own small

businesses or wage labor and do not receive regular salaries– SEWA operates like a trade union and organizes women into

cooperatives. Membership has grown rapidly from 30,000 in 1996 to 318,527 in 2000.

– It also provides various services such as banking, child-care, legal aid, and vocational instruction.

– Wholesale vegetable shop 減少剝削– Voice against harassment– Collectively organized health insurance and Bank

SEWA

• 職業部門– 訓練 , 技術– 成立合作社 保障權利

• 服務部門– Child care, slum upgrading programs

• 行銷機構• 儲蓄與貸款機構• SEWA 保險• 顧問部門

Case Study 2: Bolsa Familia (Brazil)

• Conditional income transfer (Bolsa Familia)– School Stipend, Food Stipend, Food Card, and Fuel

Support Programs– Conditionalities stipulated that children between

seven and 15 years of age should regularly be attending school, and that children from birth to six years of age should be monitored regularly.

– Training and assistance to parents

Case study 3: Sweden

• Norrbotten: high unemployment, poor health1. management training with a focus on positive health effects and

health promotion;2. improving the work environment and worker safety; 3. providing information resources for the expansion of

professional networks; 4. supporting the rehabilitation of individuals who have been long-

term unemployed

• Vasterbotten Intervention Program– Comprehensive community health program to reduce

cardiovascular diseases involving health professionals

The health gradient • 現象• Probable mechanisms: accumulation of chronic stress physiological changes – Employment

• Job security• Job control• Occupational stress/hazard

– Lifestyle factors ( 菸 , 酒 , 飲食 , 運動 )– Environmental threat (pregnancy to adulthood)– Social cohesion – Medical care

如何看待健康不平等• 在一個相對富足的社會 , 例如台灣• 兩種意義 , 兩種討論

– ｢標準以下｣的貧困與缺乏• 社會中的弱勢者• What types of intervention?

– 階梯式的不平等 (Health gradient)• Health gradient 靠中間的部分 , 要如何處理 ?• 除了最高所得組 , 其他所有的組都要降低死亡率 ,

向有錢人看齊 • What types of intervention?

Is health inequality morally acceptable?

• The health inequality would be unjust if it is avoidable, unnecessary, and unfair?– Males live shorter than females is it avoidable?– Some occupations have higher health risk is it

necessary? (is it voluntary?)– If the society provides incentives for people, so that

wealth would not be the same for everyone is it necessary?

– Some social class or ethnic groups engage in heavy smoking/drinking is it unfair?

Public health policies• Principles (political philosophy, ethics):

– Fairness, justice, equality

• Politics: Who gets what, when, how? (ideology, political parties)– Stability of power, the next election!

• Policies (government, institutions, laws): – Effective, cost-effective, adverse consequences

• Implementation (bureaucracy, resource, culture): – Enforceability, practicalities

Possible mechanisms

• Democracies allow for more space for • social capital (for example, social networks,

pressure groups)• opportunities for empowerment• better access to information• better recognition by government of people’s

needs

The spectrum of political ideology • Ideology: an action-oriented belief system, an

interrelated set of ideas that in some way guides or inspires political action

The New Right

Ideology 表現在哪些政策 ? – 舉例

• 政教關係• 對 “非正統” 行為的態度 (e.g. 同性戀 )• 稅負高低 : insurance, charity, or robbery?• 福利政策 :

why is the poor man poor?does welfare breeds dependency?

• 勞工政策 : does state intervention– Protect the workers?– Damage the business?

Liberalism• Breakdown of feudalism and the growth of market or

capitalist society– Individualism, freedom– Equality (esp. legal and political equality)– Toleration (different ideas)– Consent (authority should be based on consent)– Constitutionalism

• Classical liberalism: negative view of freedom; minimal state, economic liberalism (Laissez-faire capitalism)

• Modern liberalism: positive view of freedom; more sympathetic to state intervention (big government in US)

Conservatism

• A political ideology generally characterized by a belief in the virtue of the status quo and general acceptance of traditional morality, also a belief in individualism and minimal government intervention in the economy and society.

• Ronald Reagan: Government is not the solution to the problem. Government is the problem.

Conservatism

• Elements: tradition, pragmatism, human imperfection, organicism, hierarchy, authority

• Paternalistic conservatism: duty and social obligation of the privileged (in order to maintain a cohesive and stable hierarchy)

• The New Right: combination of – Neoliberalism: the market and the individual

(entrepreneur)– Neoconservatism: traditional values of family,

religion and the nation

Neoliberal Ideology (a) the state (or “the government”) must reduce its

interventions in economic and social activities; (b) labor and financial markets must be deregulated

in order to liberate the enormous creative energy of the market; and

(c) commerce and investments must be stimulated by eliminating borders and barriers to the full mobility of labor, capital, goods, and services.

Socialism

• Revolutionary socialists– Communists– Fundamentalist principles of common ownership

and planning • Reformist socialists

– Social democrats – Welfare, redistribution, economic management – After the breakdown of communism, becoming

closer to modern liberalism

Redistributive Policies –Social Democratic Parties

• high union density (% of the working population enrolled in unions)

• high social security expenditures (as % of GDP)• high taxation (as % of GDP)• high public employment in health services, education,

and welfare (as % of the working-age population)• high redistributive effect of the state (% reduction of

income inequality affected by direct taxes and transfer payments)

Conservative LiberalBelief in natural law (God or

something above human)Belief in positive law

Belief in established institutions (constitution, cultural institutions of church, family)

Faith in progress (we can change the world)

Preference for liberty over equality

Preference for equality over liberty

Suspicion of power - and of human nature

Belief in the benevolence of government and individuals

Belief in exceptionalism (people have a fundamental right to profit from their gifts)

Belief in the perfectibility of human beings

Belief in the individual Belief in the community

• Lancet 2006; 368: 1033–37

American Journal of Economics and Sociology, 1989.

Copyright ©2007 BMJ Publishing Group Ltd.

Pickett, K. E et al. BMJ 2007;335:1080

Correlation between income inequality and the Unicef index of child wellbeing in 23 rich countries

UNICEF index of child wellbeing• Material wellbeing• Health and safety

– Infant mortality*

• Educational wellbeing– Math score*

• Peer and family relationships– Peers are kind*

• Behaviors and risk– Teenage birth rate*, victim of bullying*, overweight

• Subjective wellbeing

Some policy reforms related to the UK labor market, 1980 – 1995

• Reforms to loosen state regulation of the labor market– Withdrawing employment protection from part-time

and temporary workers• Reforms to reduce the power of the unions• Reforms to social security to reduce income levels

of unemployed relative to those in work and to increase work incentives

• Reforms to promote self-employment and reduce employers’ hiring costs