Labor market and health. SESPAS Report 2010

The labor market, where the supply of labor meets demand, determines employment and working conditions, with positive and negative effects on the active population's health and that of their families. Labor markets are also affected by national and international social and economic policies. Unemployment, precarious contracts and new types of employment have been shown to be related to exposure to living and working conditions that cause physical and mental health problems. Some collectives, such as manual, young or immigrant workers, are more vulnerable to labor market fluctuations and more frequently experience adverse employment and working conditions. The current situation in Spain is now highly worrysome. In Spain, in 2009, more than 1.2 million workers lost their jobs. The unemployment rate has doubled in 5 years, from 9% in 2005 to 18% in 2009. Temporary contracts account for 24% of all job contracts. Economic and employment policies are urgently needed to reverse this situation, which unquestionably has a negative effect on people's health and wellbeing.     

Are pro-welfare state and full-employment policies possible in the era of globalization?

There is a widely held belief in U.S. and European economic, political, and academic circles that economic globalization has considerably diminished states' power to follow public policies identified with the social democratic tradition, such as full-employment policies, comprehensive and universal provision of welfare state services, and state regulatory interventions in labor markets and economic policies. And large sectors of the European center-left and left parties believe that European monetary integration made expansionist and full-employment policies practically impossible, except when realized at the European continental level. This article presents empirical information that questions these positions. It documents how specific governments in Europe have been able to carry out such public policies during these years of economic globalization and monetary integration. Some countries (such as Sweden and Finland) that had carried out these policies then later weakened their implementation did so in response to political changes mostly unrelated to globalization of the economy or monetary integration. The article also analyzes and documents how countries that had followed expansionist and full-employment policies have responded to the globalization of financial markets.     

The impact of public employment on health and health inequalities: evidence from China

Because the public and private sectors often operate with different goals, individuals employed by the two sectors may receive different levels of welfare. This can potentially lead to different health status. As such, employment sector offers an important perspective for understanding labor market outcomes. Using micro-level data from a recent Chinese household survey, this study empirically evaluated the impact of employment sector on health and within-sector health inequalities. It found that public sector employment generated better health outcomes than private sector employment, controlling for individual characteristics. The provision of more job security explained an important part of the association between public sector employment and better health. The study also found less health inequality by social class within the public sector. These findings suggest that policymakers should think critically about the "conventional wisdom" that private ownership is almost always superior, and should adjust their labor market policies accordingly.     

Globalization,global health,and access to healthcare

It is now commonly realized that the globalization of the world economy is shaping the patterns of global health, and that associated morbidity and mortality is affecting countries' ability to achieve economic growth. The globalization of public health has important implications for access to essential healthcare. The rise of inequalities among and within countries negatively affects access to healthcare. Poor people use healthcare services less frequently when sick than do the rich. The negative impact of globalization on access to healthcare is particularly well demonstrated in countries of transitional economies. No longer protected by a centralized health sector that provided free universal access to services for everyone, large segments of the populations in the transition period found themselves denied even the most basic medical services. Only countries where regulatory institutions are strong, domestic markets are competitive and social safety nets are in place, have a good chance to enjoy the health benefits of globalization.     

The political context of social inequalities and health

This analysis reflects on the importance of political parties, and the policies they implement when in government, in determining the level of equalities/inequalities in a society, the extent of the welfare state (including the level of health care coverage by the state), the employment/unemployment rate, and the level of population health. The study looks at the impact of the major political traditions in the advanced OECD countries during the golden years of capitalism (1945-1980) -- social democratic, Christian democratic, liberal, and ex-fascist -- in four areas: (1) the main determinants of income inequalities, such as the overall distribution of income derived from capital versus labor, wage dispersion in the labor force, the redistributive effect of the welfare state, and the levels and types of employment/ unemployment; (2) levels of public expenditures and health care benefits coverage; (3) public support of services to families, such as child care and domiciliary care; and (4) the level of population health as measured by infant mortality rates. The results indicate that political traditions more committed to redistributive policies (both economic and social) and full-employment policies, such as the social democratic parties, were generally more successful in improving the health of populations, such as reducing infant mortality. The erroneous assumption of a conflict between social equity and economic efficiency, as in the liberal tradition, is also discussed. The study aims at filling a void in the growing health and social inequalities literature, which rarely touches on the importance of political forces in influencing inequalities. The data used in the study are largely from OECD health data for 1997 and 1998; the OECD statistical services; the comparative welfare state data set assembled by Huber, Ragin and Stephens; and the US Bureau of Labor Statistics.     

Is globalization good for your health?

Four points are made about globalization and health. First, economic integration is a powerful force for raising the incomes of poor countries. In the past 20 years several large developing countries have opened up to trade and investment, and they are growing well--faster than the rich countries. Second, there is no tendency for income inequality to increase in countries that open up. The higher growth that accompanies globalization in developing countries generally benefits poor people. Since there is a large literature linking income of the poor to health status, we can be reasonably confident that globalization has indirect positive effects on nutrition, infant mortality and other health issues related to income. Third, economic integration can obviously have adverse health effects as well: the transmission of AIDS through migration and travel is a dramatic recent example. However, both relatively closed and relatively open developing countries have severe AIDS problems. The practical solution lies in health policies, not in policies on economic integration. Likewise, free trade in tobacco will lead to increased smoking unless health-motivated disincentives are put in place. Global integration requires supporting institutions and policies. Fourth, the international architecture can be improved so that it is more beneficial to poor countries. For example, with regard to intellectual property rights, it may be practical for pharmaceutical innovators to choose to have intellectual property rights in either rich country markets or poor country ones, but not both. In this way incentives could be strong for research on diseases in both rich and poor countries.     

Globalization and health: results and options

The last two decades have witnessed the emergence and consolidation of an economic paradigm which emphasizes domestic deregulation and the removal of barriers to international trade and finance. If properly managed, such an approach can lead to perceptible gains in health status. Where markets are non-exclusionary, regulatory institutions strong and safety nets in place, globalization enhances the performance of countries with a good human and physical infrastructure but narrow domestic markets. Health gains in China, Costa Rica, the East Asian "tiger economies" and Viet Nam can be attributed in part to their growing access to global markets, savings and technology. However, for most of the remaining countries, many of them in Africa, Latin America and Eastern Europe, globalization has not lived up to its promises due to a combination of poor domestic conditions, an unequal distribution of foreign investments and the imposition of new conditions further limiting the access of their exports to the OECD markets. In these developing countries, the last twenty years have brought about a slow, unstable and unequal pattern of growth and stagnation in health indicators. Autarky is not the answer to this situation, but neither is premature, unconditional and unselective globalization. Further unilateral liberalization is unlikely to help them to improve their economic performance and health conditions. For them, a gradual and selective integration into the world economy linked to the removal of asymmetries in global markets and to the creation of democratic institutions of global governance is preferable to instant globalization.     

The importance of the political and the social in explaining mortality differentials among the countries of the OECD, 1950-1998.

This article analyzes (within the conceptual frame defined in the previous article) the impact of political variables such as time of government by political parties (social democratic, Christian democratic or conservative, liberal, and ex-dictatorial that have governed the OECD countries during the 1950-1998 period) and their electoral support on (1) redistributional policies in the labor market and in the welfare state; (2) the income inequalities measured by Theil and Gini indexes; and (3) health indicators, such as infant mortality and life expectancy. This analysis is carried out statistically by a bivariate and a multivariate analysis (a pooled cross-sectional study). Both analyses show that political variables play an important role in defining how public and social policies determine the levels of inequalities and affect the level of infant mortality. In general, political parties more committed to redistributional policies, such as social democratic parties, are the most successful in reducing inequalities and improving infant mortality. Less evidence exists, however, on effects on life expectancy. The article also quantifies statistically the relationship between the political and the policy variables and between these variables and the dependent variables--that is, the health indicators.     

Social inequalities in 'sickness': European welfare states and non-employment among the chronically ill

The aim of this paper is to examine educational inequalities in the risk of non-employment among people with illnesses and how they vary between European countries with different welfare state characteristics. In doing so, the paper adds to the growing literature on welfare states and social inequalities in health by studying the often overlooked 'sickness'-dimension of health, namely employment behaviour among people with illnesses. We use European Union Statistics on Income and Living Conditions (EU-SILC) data from 2005 covering 26 European countries linked to country characteristics derived from Eurostat and OECD that include spending on active labour market policies, benefit generosity, income inequality, and employment protection. Using multilevel techniques we find that comprehensive welfare states have lower absolute and relative social inequalities in sickness, as well as more favourable general rates of non-employment. Hence, regarding sickness, welfare resources appear to trump welfare disincentives.     

Reconceptualizing the nature and health consequences of work-related insecurity for the new economy: the decline of workers' power in the flexibility regime.

This article aims to reconceptualize job insecurity in a manner relevant to shifts in the power relations of work that have accompanied globalization, in order to assess the implications for workers' health. The linkage between job insecurity and health has been well established, but little formal theorizing has analyzed the mechanisms responsible. Implicitly, however, the assumption remains that its role as a stressor is limited to the realm of job strain, whereby workers lack control over a threatened employment situation. Within this framework, job insecurity and related dimensions of power remain locked in the "box" of the standard employment relationship, precluding an analysis of work-related insecurity in the new context of globalization. In contrast, the author constructs a model of work-related insecurity that takes into account current shifts in the balance of power toward employers, which in turn has undermined the fundamental quid pro quo associated with the standard postwar model of employment. She proposes that job insecurity is no longer a mere temporary break in an otherwise predictable work-life pattern but rather a structural feature of the new labor market. Emerging contingencies associated with the New Economy, "flexibilized" employment relationships, and diminution of workers' power have constituted work-related insecurity as a chronic stressor with several implications for long-term health outcomes at the individual and societal levels.     

Neoliberalism as a class ideology; or, the political causes of the growth of inequalities.

Neoliberalism is the dominant ideology permeating the public policies of many governments in developed and developing countries and of international agencies such as the World Bank, International Monetary Fund, World Trade Organization, and many technical agencies of the United Nations, including the World Health Organization. This ideology postulates that the reduction of state interventions in economic and social activities and the deregulation of labor and financial markets, as well as of commerce and investments, have liberated the enormous potential of capitalism to create an unprecedented era of social well-being in the world's population. This article questions each of the theses that support such ideology, presenting empirical information that challenges them. The author also describes how the application of these neoliberal policies has been responsible for a substantial growth of social inequalities within the countries where such policies have been applied, as well as among countries. The major beneficiaries of these policies are the dominant classes of both the developed and the developing countries, which have established worldwide class alliances that are primarily responsible for the promotion of neoliberalism.     

Widening or narrowing inequalities in health? Comparing Britain and Finland from the 1980s to the 1990s

This paper sheds light on the debate about whether class inequalities have given way to new divisions by employment status, by comparing changes in health inequalities among British and Finnish men and women between 1986 and 1994. Britain experienced high unemployment in the 1980s whereas Finland experienced a sudden increase of unemployment in the early 1990s. We examine how these contrasting labour market situations have influenced changes in health inequalities by employment status and social class using comparable population surveys. In Finland health inequalities by employment status narrowed among men, whereas in Britain they widened or remained stable, with a less strong pattern of change for women. We found similar or slightly larger health inequalities by class among all adults than among the currently employed, with larger class inequalities in Finland than in Britain. We conclude that in countries with high levels of unemployment, there are smaller class inequalities in health among the employed labour force because of the greater chance of a 'healthy worker effect'.     

Analysing changes of health inequalities in the Nordic welfare states

This study examined changes over time in relative health inequalities among men and women in four Nordic countries, Denmark, Finland, Norway and Sweden. A serious economic recession burst out in the early 1990s particularly in Finland and Sweden. We ask whether this adverse social structural'development influenced health inequalities by employment status and educational attainment, i.e. whether the trends in health inequalities were similar or dissimilar between the Nordic countries. The data derived from comparable interview surveys carried out in 1986/87 and 1994/95 in the four countries. Limiting long-standing illness and perceived health were analysed by age, gender, employment status and educational attainment. First, age-adjusted overall prevalence percentages were calculated. Second, changes in the magnitude of relative health inequalities were studied using logistic regression analysis. Within each country the prevalence of ill-health remained at a similar level, with Finns having the poorest health. Analysing all countries together health inequalities by employment status and education showed no major changes. There were slightly different tendencies among men and women in inequalities by both health indicators, although these did not reach statistical significance. Among men there was a suggestion of narrowing health inequalities, whereas among women such a suggestion could not be discerned. Looking at particular countries some small changes in men's as well as women's health inequalities could be found. Over a period of deep economic recession and a large increase in unemployment, particularly in Finland and Sweden, health inequalities by employment status and education remained broadly unchanged in all Nordic countries. Thus, during this fairly short period health inequalities in these countries were not strongly influenced by changes in other structural inequalities, in particular labour market inequalities. Institutional arrangements in the Nordic welfare states, including social benefits and services, were cut during the recession but nevertheless broadly remained, and are likely to have buffered against the structural pressures towards widening health inequalities.     

The political context of social inequalities and health.

This analysis reflects on the importance of political parties, and the policies they implement when in government, in determining the level of equalities/inequalities in a society, the extent of the welfare state (including the level of health care coverage by the state), the employment/unemployment rate, and the level of population health. The study looks at the impact of the major political traditions in the advanced OECD countries during the golden years of capitalism (1945-1980)--social democratic, Christian democratic, liberal, and ex-fascist--in four areas: (1) the main determinants of income inequalities; (2) levels of public expenditures and health care benefits coverage; (3) public support of services to families; and (4) the level of population health as measured by infant mortality. The results indicate that political traditions more committed to redistributive policies (both economic and social) and full-employment policies, such as the social democratic parties, were generally more successful in improving the health of populations. The erroneous assumption of a conflict between social equity and economic efficiency is also discussed. The study aims at filling a void in the growing health and social inequalities literature, which rarely touches on the importance of political forces in influencing inequalities.     

Why do health labour market forces matter?

Human resources for health have been recognized as essential to the development of responsive and effective health systems. Low- and middle-income countries seeking to achieve universal health coverage face human resource constraints – whether in the form of health worker shortages, maldistribution of workers or poor worker performance – that seriously undermine their ability to achieve well-functioning health systems. Although much has been written about the human resource crisis in the health sector, labour economic frameworks have seldom been applied to analyse the situation and little is known or understood about the operation of labour markets in low- and middle-income countries. Traditional approaches to addressing human resource constraints have focused on workforce planning: estimating health workforce requirements based on a country’s epidemiological and demographic profile and scaling up education and training capacities to narrow the gap between the “needed” number of health workers and the existing number. However, this approach neglects other important factors that influence human resource capacity, including labour market dynamics and the behavioural responses and preferences of the health workers themselves. This paper describes how labour market analysis can contribute to a better understanding of the factors behind human resource constraints in the health sector and to a more effective design of policies and interventions to address them. The premise is that a better understanding of the impact of health policies on health labour markets, and subsequently on the employment conditions of health workers, would be helpful in identifying an effective strategy towards the progressive attainment of universal health coverage.     

Is globalization undermining the welfare state? The evolution of the welfare state in developed capitalist countries during the 1990s.

The authors analyze the evolution of macro-indicators of social and economic well-being during the 1990s in the majority of developed capitalist countries, grouped according to their dominant political traditions since the end of World War II. Their analysis shows that, despite the economic globalization of commerce and finance, "politics still matters" in explaining the evolution of the welfare states and labor markets in these countries; the impact of the globalization of financial capital in forcing reductions in the financial resources available for welfare state purposes has been exaggerated.     

Crisis económico-financiera y salud en España. Evidencia y perspectivas. Informe SESPAS 2014

The objectives of the SESPAS 2014 Report are as follows: a) to analyze the impact of the economic crisis on health and health-related behaviors, on health inequalities, and on the determinants of health in Spain; b) to describe the changes in the Spanish health system following measures to address the crisis and assess its potential impact on health; c) to review the evidence on the health impact of economic crises in other countries, as well as policy responses; and d) to suggest policy interventions alternative to those carried out to date with a population health perspective and scientific evidence in order to help mitigate the impact of the economic downturn on health and health inequalities. The report is organized in five sections: 1) the economic, financial and health crisis: causes, consequences, and contexts; 2) the impact on structural determinants of health and health inequalities; 3) the impact on health and health-related behaviors, and indicators for monitoring; 4) the impact on health systems; and 5) the impact on specific populations: children, seniors, and immigrants. There is some evidence on the relationship between the crisis and the health of the Spanish population, health inequalities, some changes in lifestyle, and variations in access to health services. The crisis has impacted many structural determinants of health, particularly among the most vulnerable population groups. Generally, policy responses on how to manage the crisis have not taken the evidence into account. The crisis may contribute to making public policy vulnerable to corporate action, thus jeopardizing the implementation of healthy policies.     

Inequality in the social consequences of illness: how well do people with long-term illness fare in the British and Swedish labor markets?

The demand for unskilled labor has collapsed across industrialized societies, including Britain and Sweden, and rates of unemployment and economic inactivity have increased. The result is a reduction in total employment, primarily among men. These trends could be expected to hit particularly hard those people with chronic illness. The study tests two opposing hypotheses: (1) the increasingly flexible, deregulated labor market in Britain would result in an increased number of new jobs, and thus better employment opportunities for unskilled workers, including those with chronic illness; (2) the more regulated labor market in Sweden, with the associated health and social policies, would provide greater opportunities for jobs and job security for workers with chronic illness. Analysis of data on men from the British General Household Survey and the Swedish Survey of Living Conditions, 1979-1995, showed that employment rates were higher and rates of unemployment and economic inactivity were lower in Sweden than in Britain, and the differences in these rates across socioeconomic groups and between those with and without chronic illness were smaller in Sweden. The results support the hypothesis that active labor market policies and employment protection may increase the opportunities for people with chronic illness to remain in work.     

The scorecard on globalization 1980-2000: its consequences for economic and social well-being.

The era of globalization has brought substantially less progress than was achieved in the preceding 20 years. This study by the Center for Economic and Policy Research concludes that the data provide no evidence that the policies associated with globalization have improved outcomes for developing countries, and its findings challenge economists and policymakers who cite globalization as an engine of growth while pressing for policies that strengthen the trend. The study also served as a backdrop to the release of the United Nations Development Program's Human Development Report on July 11, 2001. Using standard measures of economic growth, health outcomes, education, and literacy, the CEPR study compares the progress achieved during the period preceding globalization, 1960-80, with the period from 1980 to 2000, which was characterized by the reduction of tariff and nontariff barriers to trade, the removal of restrictions on international investment flows, and increasing intervention by the International Monetary Fund and World Bank on a wide range of economic and policy issues. While the evidence presented here does not prove that the policies associated with globalization were responsible for the deterioration in economic performance, it does present a very strong prima facie case that some structural and policy changes implemented during the last two decades are at least partly responsible for these declines.     

Poverty and health sector inequalities

Poverty and ill-health are intertwined. Poor countries tend to have worse health outcomes than better-off countries. Within countries, poor people have worse health outcomes than better-off people. This association reflects causality running in both directions: poverty breeds ill-health, and ill-health keeps poor people poor. The evidence on inequalities in health between the poor and non-poor and on the consequences for impoverishment and income inequality associated with health care expenses is discussed in this article. An outline is given of what is known about the causes of inequalities and about the effectiveness of policies intended to combat them. It is argued that too little is known about the impacts of such policies, notwithstanding a wealth of measurement techniques and considerable evidence on the extent and causes of inequalities.