Different roads to national health

Public Health Policies and Social Inequality
April 30, 1999

The Labour government has released the word inequality from confinement in samizdat publications and is allowing it to range freely across a brave new world of social and economic policy. Memories of Conservative ministers of health struggling, in the manner of Humpty Dumpty, to explain why systematic, stratified "variations" in health were not "inequalities" seem distant indeed.

Whether or not the much-vaunted third way is going to provide a solution to socioeconomic inequality or inequalities in mortality and morbidity remains arguable. But at least inequality is once again an allowable topic of polite conversation in the coffee-house. What is more, the government's papers on public health, the development of health action zones, and the work of the Social Exclusion Unit suggest that some of that talk is making its way into policy. Social scientists can only rejoice that the subject is back on the agenda.

For policy analysts interested in what is going on elsewhere, Charles F. Andrain's wide-ranging survey systematically compares public policies, social inequality and health in eight industrialised countries. At first glance, the countries and health-care systems he selects seem something of a ragbag, but political scientists work by building and testing models. Following the lead of Gosta Esping-Andersen's The Three Worlds of Welfare Capitalism , Andrain constructs three models into which the diverse array of systems can be slotted: the entrepreneurial (US and Canada), the organic corporatist (Germany, the Netherlands, Japan and France), and the social democratic (Sweden and Britain).

Having described the main features of these models and their variations, Andrain then goes on to look at the different ways in which public health policies and programmes can be explained. What theories explain the tendency of different countries to adopt programmes more or less typical of each of the models? Is it to do with how health and its causes are understood in different cultural world views? What part do organisational structures and political parties play? Are these more important than the motives, perceptions and actions of individuals making rational choices in the policy marketplace?

In the book's third and final part, Andrain examines whether the policies in these countries actually have any impact on the people's health and examines three criteria by which their impact can be evaluated: equality, effectiveness and satisfaction.

Andrain is to be admired for reviewing and comparing information on health-care systems from such a range of countries. However, the shared characteristics of the systems within a given model and the variations between systems in different models are often less clear-cut than the construction of the typology implies. Notwithstanding the shared reliance on occupation-based insurance schemes of the health-care systems in the organic corporatist model, for example, the differences between, say, the Netherlands and Japan cast doubt on the model's meaningfulness as an organising principle. Moreover, in view of the move towards some kind of mixed economy of care in many western health systems, including Sweden and Britain, Andrain's constructs sometimes seem to obscure as much as they reveal.

Despite this and a tendency to conceptual over-complication, Andrain's comparisons suggest that the Labour government's current attention to the wider causes of inequalities in health, and the development of partnerships across public and voluntary bodies inside and outside the health-care system, are necessary steps in developing public policies that will make a real difference to people's health.

Gareth Williams is professor of sociology, University of Salford.

Public Health Policies and Social Inequality

Author - Charles F. Andrain
ISBN - 0 333 72695 2
Publisher - Macmillan
Price - £47.50
Pages - 292

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