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.     

The social context of education and health

This paper stresses that the relationship between education and health cannot be meaningfully analysed in isolation from the economic and cultural matrix of society of which it is an integral part. An examination of the different kinds of education available to Third Worlders shows that formal schooling is generally regarded as a passport to urban employment. It therefore accentuates socioeconomic differentiation. Altogether, education for the sake of increased knowledge and/or improved welfare is a luxury only the wealthier can afford. Moreover, an examination of the culture-specificity of health concepts is taken to show how Western health care is inappropriate in settings where health is seen as an indicator of morality. Numerous case materials are used as evidence for the argument presented here. The final section of the paper devoted to "policy implications" emphasises that low levels of education and health are symbolic of under-development. Formal education or Western type health care are no panacea, nor even palliatives for the poverty syndrome. Appropriate education associated with appropriate health measures may help to alleviate the worst evils of disease.     

The social context of education and health

This paper stresses that the relationship between education and health cannot be meaningfully analysed in isolation from the economic and cultural matrix of society of which it is an integral part. An examination of the different kinds of education available to Third Worlders shows that formal schooling is generally regarded as a passport to urban employment. It therefore accentuates socioeconomic differentiation. Altogether, education for the sake of increased knowledge and/or improved welfare is a luxury only the wealthier can afford. Moreover, an examination of the culture-specificity of health concepts is taken to show how Western health care is inappropriate in settings where health is seen as an indicator of morality. Numerous case materials are used as evidence for the argument presented here. The final section of the paper devoted to “policy implications” emphasises that low levels of education and health are symbolic of under-development. Formal education or Western type health care are no panacea, nor even palliatives for the poverty syndrome. Appropriate education associated with appropriate health measures may help to alleviate the worst evils of disease.     

The political context of health service regulation.

Can regulation work in health services, given the present political context? General issues in the regulatory process are discussed, followed by a consideration of the relevance of these issues to the health care field. Regulatory processes are reviewed for the United States in four areas: credentialling of people, surveillance of delivery systems, quality of materials and technology, and rate-setting or cost control. It is concluded that the process cannot work. Four alternatives are presented and briefly evaluated: tinkering, centralized regulation, national health service, and general nationalization of most major economic sectors.     

Epidemiology and social determinants of health inequalities

BACKGROUND: The general approach of social epidemiology is based on the observation of a strong social stratification of health outcomes within populations: a similar stratification of factors associated with health must therefore also exist according to social status. To explain social differences in health, the natural approach for epidemiologists is to consider an imbalanced distribution of established risk factors according to the social position of individuals. As this approach has largely failed, two main other research areas were recently explored: (i) identification of "new" social risk factors; (ii) research of possible mechanisms of social differences in health. METHODS AND RESULTS: Identification of social risk factors: early events and life course, occupational factors, social relationships (social networks and support, discrimination, neighborhood characteristics), health care. Research of possible mechanisms of social differences in health in the context of specific theoretical frameworks: the materialist model, the psychosocial model and the eco-social model integrating the interaction between individuals'characteristics and their environment. COMPLEX METHODOLOGICAL PROBLEMS: definition and measurement of variables characterizing the social situation of individuals; quantification of social inequalities at population level. Observational methods must often rely on very long-lasting cohorts, and imply statistical methods that account for longitudinal data or are able to manage simultaneously individual and contextual data.     

Work, worklessness and the political economy of health inequalities

This essay argues that work, and the socioeconomic class polarities it creates, plays a fundamental role in determining inequalities in the distribution of morbidity and mortality. This is by means of uneven exposure to physical hazards and psychosocial risks in the workplace, as well as by inequalities in exclusion from the labour market and the absence of paid work. Furthermore, this essay shows that the relationships between work, worklessness and health inequalities are influenced by the broader political and economic context in the form of welfare state regimes. This leads to the development of a model of the political economy of health inequalities, and how different types of public policy interventions can mitigate these relationships. This model is then applied to the case of work and worklessness. The essay concludes by arguing that politics matters in the aetiology of health inequalities.     

Embedded gender and social changes underpinning inequalities in health: An ethnographic insight into a local Spanish context

Despite growing interest in the social determinants of health and contributions from studies focussing on the analysis of explanations to enhance our understanding of the interactions between gender identities, embodied experiences and structural inequalities between men and women, few research papers have devoted attention to this perspective in the Spanish context. This study is an empirical exploration of lay knowledge, for an enhanced understanding of health inequalities in this context, from an ethnographic standpoint based on a phenomenological approach. Specifically, our aim is to study the lay perceptions of men and women regarding their gender identity and living conditions as health determinants within different "contexts" of their everyday lives, namely: the personal context; the home context; and the neighbourhood context. Fifty eight in-depth interviews and three focus groups were held between January 2005 and January 2007, and analysed using a hermeneutic method. Our findings show how disease-coping strategies or the perceived loss of social cohesion are linked to the gender system. They also point to how the dynamics of social change have developed around a strong division between the productive and reproductive arenas. Approaching these issues from different "contexts" provides insights into the explanations for the gendered patterning of mortality and morbidity, as well as furthering our understanding of the basis for social embodiment of gender differences and health inequalities in the context studied. In the discussion of our findings, we place emphasis on the implications that informal caring has for these processes and also take into account contributions of the "lay approach" to study and understand social determinants and health inequalities.     

The political and administrative context of primary health care in the Third World

Despite increasing knowledge about technical aspects of Primary Health Care (PHC), there has been as yet only limited research into political and administrative influences on the effectiveness of PHC programs. A three-stage model of the policy process is developed as a framework for organizing the relationships between elements of (1) the national political setting and PHC policy formulation; (2) the implementing agency and program administration; and (3) the community setting and service delivery. Drawing upon the literature on PHC and related programs, hypotheses are proposed for each of these stages as a basis for future study and practical application. Possible output indicators are suggested for each stage of the model. Several basic methodological issues must be addressed in the design of empirical research on political-administrative factors, including variable selection, identification of data sources, and choice of analytical approach. It is hoped that this review will encourage more systematic investigation in this area.     

The social context of health selection: a longitudinal study of health and employment

Health selection out of the labour force has received considerable attention by analysts attempting to disentangle the "true" biological dimensions of ill-health from its social meaning. Rejecting this dualistic separation, we argue that the effect of health on labour force participation is an inherently social process reflecting differential access to material and symbolic rewards that are structured by social position. Using longitudinal data from the US-based Panel Study of Income Dynamics, we examine the extent to which structural arrangements, including those designated by gender, race, education and age, differentially affect the risk of a labour market exit when health is compromised. Individuals employed at entry into the study (from 1984-1990) were followed for the duration of the study or until they left the labour force. Analyses were stratified by gender and age (25-39 and 40-61 years at baseline). We found suggestive evidence that the hazard of labour market exit in the context of perceived ill-health depended on gender, race and education, but in ways that were not constant across each of these social positions. For example, men may be more vulnerable to the labour market effects of poor health, but only in the younger group, black men were less likely to leave the labour force than white men, and education mattered, but only among younger women and older men. While these patterns may reflect differential access to disability pensions or other work-related benefits, we suggest that a more detailed analysis of trajectories of health and employment. as well as the meaning of health states would be useful in further elucidating the social dimensions of health selection.     

The impact of political context upon the health policy process in Pakistan

BACKGROUND: Analysis of the political context is important for the understanding of a health policy and its success, because contextual factors may significantly influence the health policy process and health. This article describes how the political context in Pakistan influences the health policy process. METHODS: We used qualitative research methods based on document analysis and interviews of relevant actors in analysing the impact of the political context on the health policy process. Document analysis included policy documents and official reports of the health ministries, health-related departments and international agencies. Interviewees included relevant actors involved in the health policy process at local, provincial, national and international levels. RESULTS: Pakistan has experienced unbalanced power structures and frequent changes in government, which has disturbed health resources and has resulted in a centralized health system that hinders wider participation and disrupts health policy-making, planning and implementation. CONCLUSION: It is concluded that the political context has had a negative influence on the health policy process in Pakistan.     

The role of personal social networks on health inequalities across European regions

The role of personal social networks on health inequalities is little understood. Theoretically, the characteristics of social network features can contribute to, both, increase and attenuate health inequalities. Few empirical studies that focus on the interaction between socioeconomic position and social networks provide little insight on the topic. Using data from the Survey of Health, Ageing and Retirement in Europe, this study analyses the moderation role of personal social networks on health inequalities in later life among northern, central, and southern European regions. Social advantages of higher socioeconomic individuals are re-enforced by the quality of social connections and the provision of social support. In turn, health inequality is attenuated by marital partnership and participation on social activities that benefits more the health of people at lower socioeconomic positions. Furthermore, results suggest that the influence of social network features on health inequalities is shaped by regions’ different policy commitments to familiarization/defamilialization pressures.