Can human rights discourse improve the health of Indigenous Australians?

OBJECTIVE: Recognition of the poor health outcomes of Indigenous Australians has led to an interest in using human rights discourse as a framework for arguing that the Australian Government has an international obligation to improve Indigenous health. METHOD: This paper explores two potential directions for human rights discourse in this context. The first is the development and elaboration of an asserted 'human right to health'. The second focuses on developing an understanding of the interactions between health and human rights, particularly the underlying social determinants of health, and thereby creating an advocacy framework that could be used to promote the inclusion of human rights considerations into the policy-making agenda. RESULTS: This paper argues that despite the symbolic force of human rights discourse, its capacity to improve the health of Indigenous Australians through international law is limited. This is so irrespective of whether recourse is made to a legal or moral imperative. CONCLUSION AND IMPLICATIONS: The 'human right to health' is limited primarily by several barriers to its implementation, some of which are perpetuated by the current Australian Government itself. Although the potential advocacy capacity of human rights discourse is similarly limited by the hostility of the Government towards the notion of incorporating human rights considerations into its public policy decision making, it does provide a sustainable intellectual framework in which to consider the social and structural determinants of health and maintain these issues on the political agenda.     

Reinventing public health: a new perspective on the health of Canadians and its international impact

STUDY OBJECTIVE: To examine the Canadian origins of the Lalonde Report and its impact on British and American health promotion activities. DESIGN: A brief history of the development of key Canadian documents and their use by politicians and public health activists in the United Kingdom and United States. SETTING: This paper focuses on the impact of the Canadian model on Canada, the United Kingdom and United States. MAIN RESULTS: This paper argues that internal political and economic forces are as important as international trends in determining healthcare policy initiatives. CONCLUSIONS: In the 1970s all the English-speaking developed nations were facing deficits as curative costs rose. Adopting health promotion policies permitted them to shift responsibility back to local governments and individuals while limiting their expenditures. Health and community activists, however, used this concept to broaden their focus to include the social, economic and political determinants of health and thus reinvented public health discourse and practice for the 21st century.     

Political and welfare state determinants of infant and child health indicators: an analysis of wealthy countries

Economic indicators such as income inequality are gaining attention as putative determinants of population health. On the other hand, we are just beginning to explore the health impact on population health of political and welfare state variables such as political orientation of government or type of medical care coverage. To determine the socially structured impact of political and welfare state variables on low birth weight rate, infant mortality rate, and under-five mortality rate, we conducted an ecological study with unbalanced time-series data from 19 wealthy OECD countries for the years from 1960 to 1994. Among the political/welfare state variables, total public medical coverage was the most significant predictor of the mortality outcomes. The low birth weight rate was more sensitive to political predictors such as percentage of vote obtained by social democratic or labor parties. Overall, political and welfare state variables (including indicators of health policies) are associated with infant and child health indicators. While a strong medical care system seems crucial to some population health outcomes (e.g., the infant mortality rate), other population health outcomes might be impacted by social policies enacted by parties supporting strong welfare states (the low birth weight rate). Our investigation suggests that strong political will that advocates for more egalitarian welfare policies, including public medical services, is important in maintaining and improving the nation's health.     

Maintaining population health in a period of welfare state decline: political economy as the missing dimension in health promotion theory and practice

There is increasing recognition in the health promotion and population health fields that the primary determinants of health lay outside the health care and behavioural risk arenas. Many of these factors involve public policy decisions made by governments that influence the distribution of income, degree of social security, and quality and availability of education, food, and housing, among others. These non-medical and non-lifestyle factors have come to be known as the social determinants of health. In many nations--and this is especially the case in North America--recent policy decisions are undermining these social determinants of health. A political economy analysis of the forces supporting as well as threatening the welfare state is offered as a means of both understanding these policy decisions and advancing the health promotion and population health agendas. The building blocks of social democracies--the political systems that seem most amenable to securing the social determinants of health--are identified as key to promoting health. Health promoters and population health researchers need to "get political" and recognize the importance of political and social action in support of health.     

Politics, welfare regimes, and population health: controversies and evidence

In recent years, a research area has emerged within social determinants of health that examines the role of politics, expressed as political traditions/parties and welfare state characteristics, on population health. To better understand and synthesise this growing body of evidence, the present literature review, informed by a political economy of health and welfare regimes framework, located 73 empirical and comparative studies on politics and health, meeting our inclusion criteria in three databases: PubMed (1948-), Sociological Abstracts (1953-), and ISI Web of Science (1900-). We identified two major research programmes, welfare regimes and democracy, and two emerging programmes, political tradition and globalisation. Primary findings include: (1) left and egalitarian political traditions on population health are the most salutary, consistent, and substantial; (2) the health impacts of advanced and liberal democracies are also positive and large; (3) welfare regime studies, primarily conducted among wealthy countries, find that social democratic regimes tend to fare best with absolute health outcomes yet consistently in terms of relative health inequalities; and (4) globalisation defined as dependency indicators such as trade, foreign investment, and national debt is negatively associated with population health. We end by discussing epistemological, theoretical, and methodological issues for consideration for future research.     

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.     

Achieving population health goals: perspectives on measurement and implementation from Australia

Health goals and targets have been widely used to indicate strategic direction and priority for health improvement on a population basis. This paper provides an overview of Australia's experience in using health targets and considers the relevance of this experience for Canada. It gives special attention to the challenge of developing a broadly based set of targets that reflect the social, economic and environmental determinants of health alongside more traditional measures of health status. It examines how the technical challenge of measurement, the bureaucratic barriers between government departments, and the political conservatism inherent in federal systems of government present formidable barriers to effective action on comprehensive national health targets. The paper concludes with a reminder of the need for inter-sectorial action to address the determinants of health. Based on the Australian experience, it suggests for Canada an ideal combination of a national population health framework to guide direction and priority, to be implemented through action at a more local level, through well-defined partnerships.     

Politics and health in eight European countries: A comparative study of mortality decline under social democracies and right-wing governments

Recent publications have argued that the welfare state is an important determinant of population health, and that social democracy in office and higher levels of health expenditure promote health progress. In the period 1950–2000, Greece, Portugal, and Spain were the poorest market economies in Europe, with a fragmented system of welfare provision, and many years of military or authoritarian right-wing regimes. In contrast, the five Nordic countries were the richest market economies in Europe, governed mostly by center or center-left coalitions often including the social democratic parties, and having a generous and universal welfare state. In spite of the socioeconomic and political differences, and a large gap between the five Nordic and the three southern nations in levels of health in 1950, population health indicators converged among these eight countries. Mean decadal gains in longevity of Portugal and Spain between 1950 and 2000 were almost three times greater than gains in Denmark, and about twice as great as those in Iceland, Norway and Sweden during the same period. All this raises serious doubts regarding the hypothesis that the political regime, the political party in office, the level of health care spending, and the type of welfare state exert major influences on population health. Either these factors are not major determinants of mortality decline, or their impact on population health in Nordic countries was more than offset by other health-promoting factors present in Southern Europe.     

Social determinants of health in Canada's immigrant population: results from the National Population Health Survey

As part of the Metropolis project--a large-scale investigation of immigration and integration, including well-being of immigrants in a number of areas of social life--in this paper we investigate the social determinants of health in Canada's immigrant population using Canada's National Population Health Survey (NPHS). Specifically, we examine differences in health status and health care utilization between immigrants and non-immigrants, immigrants of European and non-European origin, and immigrants of < 10 years and > 10 years' residence in Canada. We also examine social determinants of health care utilization and health status in immigrants and non-immigrants, and evaluate the utility of large-scale, national databases for these purposes. Our conceptual approach draws upon a 'population health' perspective, which suggests that the most important antecedents of human health status are not medical care inputs and health behaviours (smoking, diet, exercise, etc.), but rather social and economic characteristics of individuals and populations. We find no obvious, consistent pattern of association between socio-economic characteristics and immigration characteristics on the one hand, and health status on the other, in the NPHS data. This does not mean that socio-economic factors in Canada are not influential in shaping immigrants' health status. In fact, the results of the logistic regression models calculated for immigrants and non-immigrants on four outcome variables in this study suggest that socio-economic factors are more important for immigrants than non-immigrants, although in ways that defy a simple explanation. The complexity of immigrants' experiences, combined with the inherent limitations of cross-sectional survey data are discussed as major limitations to this kind of research.     

Going beyond The three worlds of welfare capitalism: regime theory and public health research

International research on the social determinants of health has increasingly started to integrate a welfare state regimes perspective. Although this is to be welcomed, to date there has been an over-reliance on Esping-Andersen's The three worlds of welfare capitalism typology (1990). This is despite the fact that it has been subjected to extensive criticism and that there are in fact a number of competing welfare state typologies within the comparative social policy literature. The purpose of this paper is to provide public health researchers with an up-to-date overview of the welfare state regime literature so that it can be reflected more accurately in future research. It outlines The three worlds of welfare capitalism typology, and it presents the criticisms it received and an overview of alternative welfare state typologies. It concludes by suggesting new avenues of study in public health that could be explored by drawing upon this broader welfare state regimes literature.     

Collective lifestyles as the target for health promotion

The last five years have witnessed intense debate among health researchers in Canada regarding the overlap of the health promotion and population health discourses. Meanwhile, strong currents within health promotion have attempted to move the field beyond a focus on individual behaviour towards the influence of social environments on health, although the tendency is often to fall back on individual behaviour modification as the primary lever for change. The Population Health research agenda bypasses behavioural determinants of health and explores instead social determinants. This body of knowledge provides useful insight for addressing some of the tensions in the health promotion discourse. This paper explores two of these tensions: whether individuals at risk or general populations should be targeted for change; and whether lifestyle is an individual or a collective attribute. We propose the notion of collective lifestyles as a heuristic for understanding the interaction between social conditions and behaviour in shaping health.     

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.     

Cracking the nut of health equity: top down and bottom up pressure for action on the social determinants of health

The Commission on the Social Determinants of Health (CSDH) was established to advise on ways in which understanding of the social determinants of health can affect practical action to improve population health equitably. This paper considers the factors that are necessary to encourage governments to adopt policies that aim at doing this. It argues that knowledge, while essential, is insufficient. Governments need a commitment to the values of fairness and justice and an ability to cope with the complexity of responding to social determinants beyond exhorting individuals to change their behaviour. The role of civil society is crucial in advocating for governments to do this. The presence of linking social capital is also crucial to creating a social and political environment in which fairness is promoted. A case study of the poor health status of the Aboriginal peoples in Australia is used to illustrate the importance of social capital.     

Rethinking Immigrant Tuberculosis Control in Canada: From Medical Surveillance to Tackling Social Determinants of Health

Current tuberculosis control strategies in Canada rely exclusively on screening and surveillance of immigrants. This is consistent with current public health discourse that attributes the high burden of immigrant tuberculosis to the exposure of immigrants to infection in their country of origin. The effectiveness of control strategies is questionable given the evidence that many immigrants are at higher risk of tuberculosis reactivation because of risk factors such as poverty, malnutrition and overcrowded housing. This paper argues that the absence of policies that address poverty-related disadvantages among immigrants makes these populations more vulnerable to the reactivation of their tuberculosis long after they have been exposed in their countries of birth. Policies for tuberculosis prevention in the Aboriginal population attend to their poverty and other social determinants of health. Effective health prevention policy for tuberculosis within the immigrant population must take similar direction.     

Economic inequality, working-class power, social capital, and cause-specific mortality in wealthy countries.

This study tests two propositions from Navarro's critique of the social capital literature: that social capital's importance has been exaggerated and that class-related political factors, absent from social epidemiology and public health, might be key determinants of population health. The authors estimate cross-sectional associations between economic inequality, working-class power, and social capital and life expectancy, self-rated health, low birth weight, and age- and cause-specific mortality in 16 wealthy countries. Of all the health outcomes, the five variables related to birth and infant survival and nonintentional injuries had the most consistent association with economic inequality and working-class power (in particular with strength of the welfare state) and, less so, with social capital indicators. Rates of low birth weight and infant deaths from all causes were lower in countries with more "left" (e.g., socialist, social democratic, labor) votes, more left members of parliament, more years of social democratic government, more women in government, and various indicators of strength of the welfare state, as well as low economic inequality, as measured in a variety of ways. Similar associations were observed for injury mortality, underscoring the crucial role of unions and labor parties in promoting workplace safety. Overall, social capital shows weaker associations with population health indicators than do economic inequality and working-class power. The popularity of social capital and exclusion of class-related political and welfare state indicators does not seem to be justified on empirical grounds.     

Wealth and health: the need for more strategic public health research

This article argues that public health researchers have often ignored the analysis of wealth in the quest to understand the social determinants of health. Wealth concentration and the inequities in wealth between and within countries are increasing. Despite this scare accurate data are available to assist the analysis of the health impact of this trend. Improved data collection on wealth distribution should be encouraged. Epidemiologists and political economy of health researchers should pay more attention to understanding the dynamics of wealth and its consequences for population health. Policy research to underpin policies designed to reduce inequities in wealth distribution should be intensified.     

The state, class and the allocation of health resources in southern Africa

In Africa the literature specifically linking the state, class and the allocation of health resources is sparse, and the evidential base for health research is inadequate and difficult to interpret. This paper looks at some of the ways in which state, class and health may be related in southern Africa. The region provides useful comparisons because of the starkness of the relationships between class and race and disease patterns and health care in much of the sub-continent; the different types of state and class structure within southern Africa; and the changes in ideology and to some extent health practice which came with the political independence of some of its component parts. Using both historical and contemporary data, it pinpoints the importance of analysing the specific and changing form of the state in the different countries of the region, in order to understand the social determinants of disease and the allocation of health resources, and looks at the significance of class, race, ethnicity and gender in the incidence of health and the state's response. It highlights the specific colonial legacies, continuing imperial linkages and location of countries in the international division of labour which inhibit changes in health care. Within the region, the migrant labour system and South Africa's aggressive policies of destabilisation create particular problems for weak states and for individuals within them attempting to implement more progressive health care programmes. The paper also argues that the ideological role played by health care has to be understood, and shows the diverse uses to which it is put across the region. The paper concludes that while the position of the state in the international and regional economy, its specific form and the nature of its class relations are predictors in some sense of health and health care, a variety of micro-level political and social decisions and mediations have also to be taken into account. While most of the countries of the region are in some sense part of the 'periphery', and a product of colonialism, these labels are insufficient to explain the differences between them in terms of disease patterns and health care systems. The specificities of internal social dynamics, local class ethnic and gender struggles and political conflicts are also crucial.     

Testing relationships among determinants of health, health policy, and self-assessed health status in Quebec.

By removing financial barriers, the Canada Health Act (1984) equalized access to health care services in Canada. Yet class, educational, and geographical disparities in individual and population health status persist. Recent health reform policies in Quebec assert that health and well-being are a function of income, educational level, housing conditions, employment, and other socioeconomic factors. They suggest that health policy should encompass social policies that influence individual and community socioeconomic factors which in turn affect health. Against the backdrop of these reforms, this study tests the importance of socioeconomic factors as a determinant of health--while controlling for other known determinants through a logistic regression model--with data from the Santé Quebec health surveys 1987 and 1992-93. The results confirm the importance of economic security as a determinant of individual health. This effect appears to operate through an individual income variable and through the community-level variable of regional unemployment. The importance of the income effect declined between 1987 and 1992-93. This may indicate that an increased focus on the socioeconomic determinants of health has reduced inequalities in health. It may also mean that health inequalities appear inevitable until health care policy merges completely with broader health and social policies. But such integration may well conflict with economic (and political) imperatives of the post-Fordist capitalist system.     

What determines health? To where should we shift resources? : Attitudes towards the determinants of health among multiple stakeholder groups in Prince Edward Island, Canada

The population health perspective has become significant in academic and policy discourse. The purpose of this paper is to assess its significance among health care practitioners and administrators as well as the general public. Respondents in Prince Edward Island, Canada were asked to rank the broad determinants of health and comment on to where resources should be shifted to improve the health of the population. Important variations are noted between the groups with family physicians and front-line staff being similar in perceptions to the general public on most determinants than other groups. The paper concludes with discussion on the relevance of the findings for population health research and health policy.