Health Policy 68 (2004) 63–79 The welfare state as a determinant of women’s health: support for women’s quality of life in Canada and four comparison nations Dennis Raphael a,∗ , Toba Bryant b a School of Health Policy and Management, Atkinson Faculty of Liberal and Professional Studies, York University, 4700 Keele Street, Toronto, Ont., Canada M3J 1P3 b York Center for Health Studies, York University, 4700 Keele Street, Toronto, Ont., Canada M3J 1P3 Accepted 28 August 2003 Abstract The case is made that characteristics associated with the advanced welfare state in industrialised nations are primary contributors to women’s quality of life This is so since women’s health and well-being are particularly sensitive to decisions made in relation to the spending priorities of governments, the extent to which services are provided, and the degree to which women are supported in moves towards equity Data from the Organization for Economic Cooperation and Development, United Nations Human Development Program, and other sources are used to examine these influences upon quality of life of women in Canada as compared to that of women in Denmark, Sweden, the UK and the US A consistent pattern was seen by which national features impacting on women’s quality of life are more likely to be seen in nations with a social welfare orientation as compared to nations with market approaches to policy development © 2003 Elsevier Ireland Ltd All rights reserved Keywords: Welfare state; Population health; Women’s quality of life Overview Quality of life is a holistic construct that views human health and well-being within the contexts of proximal and distal environments [1] It combines elements of broad societal indicators with the actual lived experience of people [2] Emphasis is increasingly being placed on considering quality of life in particular relation to national and local policy environments [3] Davies et al [4] consider how women’s economic vulnerability in nations such as Canada makes them ∗ Corresponding author Tel.: +1-416-7362100; fax: +1-416-7365227 E-mail address: draphael@yorku.ca (D Raphael) especially sensitive to regressive changes in social policy [5] Women in their assigned role of caregivers of both their children and relatives are most likely to be impacted by changes in social assistance policies, changes to employment insurance eligibility, and provision of health and social services, among others [6] These are the kinds of policies that show systematic differences among nations with social welfare versus market orientations to social policy While a wide range of conceptualisations of quality of life are available, the Canadian Policy Research Networks recently identified—based on a broad consensus-building exercise—priority themes for considering quality of life [7] These themes are—in order of identified importance—political rights and general 0168-8510/$ – see front matter © 2003 Elsevier Ireland Ltd All rights reserved doi:10.1016/j.healthpol.2003.08.003 64 D Raphael, T Bryant / Health Policy 68 (2004) 63–79 values, health, including health care, education, environment, social programs, personal well-being, community, economy and employment, and government These themes show many similarities with the increasingly important literature on the social determinants of health A social determinants of health perspective is increasingly being applied to national approaches to the formulation of health policy [8,9] This is especially the case in the Scandinavian nations In this paper, we consider the extent to which these quality of life issues are supported by governmental action in Canada and four comparison nations The information relevant to these issues comes primarily from two types of data sources: indicator analyses from international reports and intensive and detailed policy analyses of two policy issues of particular importance to women: childcare provision and governmental support for community-based long-term care Canadian data are contrasted with those from Denmark, Sweden, the UK, and the US These nations have been chosen for an obvious reason: Denmark and Sweden are nations with a predominantly social welfare approach to social policy, especially in relation to issues of concern to women; the UK and US have a predominantly market-oriented approach to these same issues [10] The case is argued that nations with a predominantly welfare state orientation are more likely to support the quality of life themes relevant to women’s health and well-being 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” ([11], p 15) There are differences within welfare states that may profoundly influence the health of citizens [3,12] These issues are especially important as Canada is increasingly being influenced by US market-oriented policy approaches [13], nations already with market orientations are becoming even more polarised in income and wealth distribution, and nations with so- cial welfare approaches are striving to resist market influences [8] Navarro and Shi [10] identify nations predominantly governed from 1945 to 1980 by social democratic (Sweden, Finland, Norway, Denmark, and Austria), Christian democratic (Belgium, Netherlands, Germany, France, Italy, Switzerland), or liberal Anglo-Saxon (Canada, Ireland, UK, US) political parties They then compare these nations on key political, economic, and population health indicators The focus here is on their findings related to social democratic and liberal Anglo-Saxon governance The social democratic political economies showed higher levels of union density, that is, a greater proportion of workers belonging to organised labour unions, social security expenditures, and public employment levels They had the largest public expenditure in health care from 1960 to 1990, and greatest health care coverage of citizens These nations instituted full employment strategies, achieved high rates of female employment, and showed the lowest degree of income inequality and poverty rates They also had the lowest percentage of national income derived from capital investment and the largest from wages On a key indicator of population health—infant mortality—these countries had the lowest rates from 1960 to 1996 Anglo-Saxon liberal political economies had the lowest expenditures on health care and the lowest coverage by public medical care Wages were low, and income inequalities and poverty rates the greatest Percentage of income derived from capital investment was the highest The liberal countries have the lowest rates of improvement in infant mortality rates from 1960 to 1996 Similar patterns are seen when the US, Canada, and Sweden are compared on numerous social development and population health indicators [14,15] Sweden fares the best, the US the worse, and Canada comes up the middle These findings indicate that political and economic forces play a strong role in population health Population health theory and research in Canada and elsewhere however, focus on a number of mid-level “social determinants of health” with little recognition of the role political and economic forces play in the quality of these health determinants [16–19] Before considering these forces, a brief overview of various conceptualisations of social determinants of health is provided D Raphael, T Bryant / Health Policy 68 (2004) 63–79 65 Social determinants of health 4.1 Political rights and general values Social determinants of health are the non-medical and non-lifestyle factors that influence population health [8,20] The Ottawa Charter for Health Promotion identifies prerequisites for health of peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity [21] Health Canada’s determinants of health—only some of which are social determinants—are income and social status, social support networks, education, employment and working conditions, physical and social environments, biology and genetic endowment, personal health practices and coping skills, healthy child development, and health services [22] A UK working group identifies social determinants of health of the social [class health] gradient, stress, early life, social exclusion, work, unemployment, social support, addiction, food, and transport [23] Recent Canadian work synthesises these formulations into 10 social determinants of health—early life, education, employment and working conditions, food security, health services, housing, income and income distribution, social exclusion, the social safety net, and unemployment and job insecurity [24,25] It is evident that governmental support of these social determinants of health overlap with the quality of life themes presented by the Canadian Policy Research Networks The quality of political rights and general values are not easily captured in indicator analyses In a recent work, we considered these issues in relation to Canada’s adherence to the Convention to Eliminate All Forms of Discrimination Against Women (CEDAW) [28,29] The conclusion reached in various reports to the United Nations by Canadian women’s groups and most recently by the United Nations CEDAW Committee itself is that Canada is not working to implement the provisions of the Convention through the exercise of women’s political rights: Examining the factors supporting women’s quality of life: indicator analyses from five nations The Committee acknowledges the State party’s complex federal, provincial and territorial political and legal structures However, it underlines the federal Government’s principal responsibility in implementing the Convention The Committee is concerned that the federal Government does not seem to have the power to ensure that governments establish legal and other measures in order to fully implement the Convention in a coherent and consistent manner ([30], p 5) This UN report is consistent with a number of reports produced by women’s groups in Canada that speak of the systematic denial of women’s political and economic rights resulting from government actions [31–35] Similar official and shadow CEDAW reports are available for Sweden, and the UK [36–38] The US is the only industrialised country that has not ratified CEDAW 4.2 Health, including health care The United Nations’ Human Development Report (HDR) (United Nations Development Program [26] and the Organization for Economic Cooperation and Development’s Society at a Glance Report (SGR) [27] present a wide range of information concerning human development and well-being in member nations Many indicators map onto the quality of life priority areas outlined by the Canadian Policy Research Networks framework Some indicators refer to the entire population of men and women while some are specifically concerned with women But all indicators illuminate the state of political and economic forces that influence the quality of life of women in Canada and elsewhere A number of indicators from the HDR [26] map onto this quality of life theme The overall Human Development Index takes into account general life expectancy, GDP per capita, and education Table shows that Canada performs very well in the overall index, though it has lost its #1 rank of the last few years However, a more sensitive indicator—human and income poverty—which considers incidence of poverty and numbers of citizens lacking functional literacy, finds Canada occupying a position midway between social welfare nations of Denmark and Sweden and the market-oriented UK and US This pattern repeats itself in many of the analyses that follow 66 D Raphael, T Bryant / Health Policy 68 (2004) 63–79 Table Human development and human and income poverty and commitment to health in Canada and four comparison nations, 1999 Canada Denmark Sweden UK US 78.8 27840 0.98 12 12.3 12.8 16.6 100 229 6.6 2.7 9.3 1939 HDI (rank) Life expectancy GDP per capita Education index Human poverty index (rank) Percentage in poverty (%) 65 years with formal 17.0 help at home (%) Source: [58–67] UK 2.2 2.7 1.3 1.3 2.2 2.7 0.7 1.0 7.0 8.7 5.7 5.1 20.3 11.2 16.0 5.5 D Raphael, T Bryant / Health Policy 68 (2004) 63–79 age is lower (7.5%) than Sweden’s (8.7%) and may reflect the greater incidence of care being provided at home 8.1 Long-term care policy situation (adapted from International Reform Monitors, 2002) Canada: Canada’s national health care act stipulates the provision of health care to be an entitlement However, administration of health care is a provincial responsibility The federal government provides block funding to provinces that includes long-term care Long-term care does not come under the Canada Health Act and therefore there is wide disparity among provinces in availability of services Provincial governments are responsible for setting policy, planning, monitoring and regulations Financing comes from a mix of fees and tax financing In some provinces, these fees are very low, in others, higher [78] Differences exist among provinces in integration of long-term care with the general health care system In some, municipalities have responsibilities; providers include both non-profit and private for-profit companies There is a very small income tax credit for caregivers in the home Denmark: Denmark has a National Health Service that is tax financed with low co-payments and mostly public providers Ninety-seven percent of the population is covered by social insurance, the others are privately insured The funding of long-term care is a responsibility of municipalities and is primarily tax-financed Municipalities determine entitlements for benefits and contract with private nursing homes or non-profit organisations Health insurance covers medical treatment in acute cases and home care Agreements between regional health care authorities and municipalities responsible for long-term care are in place to provide a range of services Caregivers of terminally ill patients are entitled to social assistance of a cash benefit equal to 1.5 times their own sickness benefit Sweden: Health care is provided by a tax-financed national health service that uses government-employed physicians and private doctors with service agreements Health care is largely free or provided at low costs to the patient Long-term care is primarily tax financed, with 9% related to personal fees Municipalities are responsible for providing and financing 73 social services There are few individual or private providers Legislation enshrines the right to remuneration for assistance/caregivers The economic support can be used to hire one or more private assistance through local authorities A government system provides “Cash Benefits for Closely Related Persons” through the special assistance system for a maximum 60 days in case of serious illness The replacement rate is 75% of income Caregivers also have the right to unpaid leave UK: The provision of long-term care is financed by the central government but is the responsibility of local authorities The department of social security has some responsibilities with respect to financing of residential care The National Health Service provides general health care, geriatric services, mental health care and beds without patient payment Municipalities act as primarily non-profit organisations but provide health services that require out of pocket payments that vary from region to region Individuals are free to hire their own caregivers and by-pass the public system There is no general assistance for caregivers but an Invalidity Care Allowance is available to caregivers of disabled citizens US: The US health insurance system has both a private and public component Medicare and Medicaid are joint federal/state programs Medicare (13.2% of services) provides medical services for those over 65 years of age Medicaid (10.8% of services) provides medical and other services for the poor Medicare pays for a portion of short-term care in nursing homes; the rest is paid privately, primarily out of pocket rather than through private insurance [81] Medicaid pays for nursing home care for those on very low incomes and almost no financial assets Medicare and Medicaid will provide a range of home services for eligible patients (usually the very poor or those without any financial resources) Support of caregivers is limited to home care financed by Medicare and Medicaid Conclusion: the welfare state and women’s quality of life The findings concerning women’s quality of life in Canada are consistent with the analysis of Fast and Keating’s [82] who identified four key changes 74 D Raphael, T Bryant / Health Policy 68 (2004) 63–79 in the Canadian policy environment: Reduced government expenditure on health, income security, and social services; push towards the privatisation of health and continuing care; shift from institutional to community-based health and community care; and increased geographic inequity in health and social service delivery Mainstream economic and political analyses attempt to explain deteriorating policy environments as reflecting the readjustment of market forces and changing family dynamics [83] However, research from a more critical perspective offers a rather less benign view of the forces that drive the weakening of social infrastructure along the lines seen in the UK and US and to a lesser extent in Canada 9.1 Decline of the welfare state Teeple [11] sees increasing income and wealth inequalities and the weakening of social infrastructures within Canada and elsewhere as resulting from the ascendance of concentrated monopoly capitalism and corporate globalization Transnational corporations— many with home bases in the US—actively apply their increasing power to oppose reforms associated with the welfare state to reduce labour costs The forces that led to the development of the welfare state at the end of World War II were strong national identities, the need to rebuild Western economies, the strength of labour unions within national labour boundaries, the perceived threat of socialist alternatives, and a consensus for political compromise to avoid the boom-bust cycles of the economy These forces led to policies that supported a more equitable distribution of income and wealth through social, economic, and political reforms such as progressive tax structures, and social programs, and governmental structures that mitigated conflicts between business and labour, among others These forces are now in decline Since 1974, a fundamental change has occurred in the operation of national and global economics The rise of transnational corporations that can easily shift investments across the globe serves to pressure nations into acceding to their demands for changes that reverse reforms associated with the welfare state International trade agreements are one way to weaken both national identities and nationally based labour unions Trade is now international, but unions continue to be nationally based With such a power shift, business has less need to develop political compromises among themselves, labour, and governments The decline of the Soviet Bloc, and its diffuse threat of supporting working class revolt, has also removed incentives for compromise by business with employees and labour in general Finally, the overall slowing of economic growth has reduced resources available for the welfare state Increased concentration of corporate and media ownership helps assure that justification for these changes, delivered in the form of neo-liberal ideology, is now the dominant discourse related to political and economic processes [84,85] To illustrate, nationally based labour unions have little influence when the economies of nations are increasingly globalized Labour demands in one nation simply lead to companies moving elsewhere Neo-liberal political ideology serves the needs of global corporations attempting to maximise profits by weakening local legislation that assures livable wages, workplace and environmental safety, and communal structures that support health Every public service and communal structure is now seen as ripe for privatisation Social and economic conditions have deteriorated for the mass of citizens as national and more local governments either remain helpless to resist the power of transnational corporations or become complicit in these activities Indeed, Laxer [86] argues that “Everywhere in the world, multinational business has launched a frontal assault on the state (p 163).” Others argue: The process of the internationalization of capitalism has fostered deep-seated economic and social changes that have helped to erode—the social contract—the predominant understandings about core economic and social relationships—that was built during the post-war era ([87], p 4) The power of capital has been strengthened by threats to relocate if its demands for enhanced flexibility with regard to taxes, state regulation, and labour market policies are not met by policy-makers The neo-liberal political agenda has both shaped and been advanced by globalization ([88], p 13) D Raphael, T Bryant / Health Policy 68 (2004) 63–79 9.2 Neo-liberalism as a justifying discourse Coburn [84,85] considers how neo-liberalism— through its emphasis on the market as the arbiter of societal values and resource allocations—serves to support these regressive political and economic forces Additionally, implementing neo-liberal economic policies fosters income and wealth inequalities, weakens social infrastructure, dissipates social cohesion, and threatens civil society Raphael considers how the one aspect of neo-liberal ideology—the exaggerated emphasis on reducing taxes—directly benefits the wealthy and powerful and translates into both increasing economic inequality and the weakening of communal institutions that support women [40] Nonetheless, some nations have been able to resist these trends As just one example, the current National Swedish Health Policy contains numerous action areas to improve population health [89] These activities are the responsibility of the National Institute of Public Health The six main strategies outlined are as follows: • Increase social capital in the Swedish society: This includes efforts to decrease social inequality, counteract discrimination of minority groups and promote local democracy • Promote better working conditions: The most important issues are to decrease long-term negative stress, promote employees’ influence at work and achieve more flexible working hours • Improve conditions for children and young people: Improve social support for families with children Support and strengthen health promoting schools • Improve the physical environment: Co-ordinate the work for sustainable environment with the struggle for improved health • Promote healthy life styles Solidarity with those who are most vulnerable for lifestyle risks • Provide good structural conditions for public health work at all societal levels: Support to and co-ordination of research and education in public health science In summary, the Swedish public health goals are relatively few and their structure is not very sophisticated compared with other countries However, there are two significant qualitative aspects of the Swedish policy, which may be of interest: 1) The 75 targets are formulated in terms of the determinants of health 2) A very thorough work has been carried out in order to achieve consensus of and raise political support for the targets The preliminary strategies and goals are supported by five of six political parties in the Swedish parliament ([89], p 9–10) In the Swedish case study contained in Reducing Inequalities in Health: A European Perspective [90], Burstrom et al [91] point out that: For many years Sweden has pursued equality-oriented health and social policies, active labour market policies and family-oriented policies that have resulted in higher levels of workplace participation, less income inequality, lower poverty rates and smaller socioeconomic inequalities in the distribution of poverty than in most other countries (p 281) With the expected results: Compared to many other countries, Sweden has low mortality rates, high life expectancy, and favourable health indicators across all socioeconomic groups (p 281) It is obvious from our analysis that policies associated with the social welfare states of Denmark and Sweden are clearly beneficial to women and enhance their quality of life Yet, in Canada there is increasing evidence of a shift in policy orientation towards the market-oriented policies associated with the UK and the US [92] Such a direct does not bode well for Canadian women and their quality of life [93] Caregiving in the US is seen to be in a crisis situation and has strong implications for the quality of American women’s and their children’s lives [94,95] The Canadian Policy Research Network’s quality of life initiative identified cross-cutting themes of accessability; personal security/control; availability; and equity/fairness Women’s quality of life is influenced by the extent to which women have access to the resources that are normally available to those within a society [96] The roles that society thrusts upon Canadian women of child rearing and caregiving makes access to these resources—such as childcare and home care—especially important [97] Equality of opportunity is an empty phrase unless society— and the governments it elects—are willing to make 76 D Raphael, T Bryant / Health Policy 68 (2004) 63–79 the policy decisions that support women in their lives [98] This is the meaning of equity and fairness In terms of contemporary analyses of women’s quality of life, these policy changes in Canada—and elsewhere—have been considered for their impact on Canadian women’s quality of life [49,50,99] These kinds of policy-oriented quality of life analyses are rarely done in relation to women’s health [100–102] As such, these analyses should complement more traditional approaches to considering women’s health and well-being in Canada and other nations [103] Acknowledgements Portions of this work were supported financially by Health Canada’s Population and Public Health Branch References [1] Lindstrom B Quality of life: a model for evaluating health for all Soz Praventivmed 1992;37:301–6 [2] Raphael D, Renwick R, Brown I, Steinmetz B, Sehdev H, Phillips S Making the links between community structure and individual well-being Community quality of life in Riverdale, Toronto, Canada Health and Place 2001;7(3):17– 34 [3] Navarro V, editor 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