The political determinants of health—10 years onBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h81 (Published 08 January 2015) Cite this as: BMJ 2015;350:h81
- Ilona Kickbusch, director
- 1Global Health Programme, Graduate Institute for International and Development Studies, Geneva, Switzerland
Health is a political choice, and politics is a continuous struggle for power among competing interests. Looking at health through the lens of political determinants means analysing how different power constellations, institutions, processes, interests, and ideological positions affect health within different political systems and cultures and at different levels of governance. Bambra et al provide three arguments why health is political1: health is unevenly distributed, many health determinants are dependent on political action, and health is a critical dimension of human rights and citizenship.
Political action on poverty and global health inequalities was the key message given by the first alternative world health report in 2005,2 and it remains the focus of many civil society organisations in global health. In 2008, the final report of the Commission on Social Determinants of Health3 also concluded with the political message that health is shaped ultimately by factors such as “the distribution of money, power and resources at global, national and local levels”—all of which can be tackled only in sectors other than health.
There is currently a renewed politicisation of health at all levels of governance, from the local to the global—within governments, global institutions, and the private sector, and through civil society organisations. This reflects that politics does not just take place in government through elite politicians, it permeates society and encompasses “all the processes of conflict, cooperation and negotiation in taking decisions about how resources are to be owned, used, produced and distributed.”4
Health has increasing relevance for political legitimacy and the economy, it is critical to fiscal policies and to the social state. That means it affects the interests of many stakeholders and society at large. It has also become integral to processes of globalisation related to trade, commerce, foreign policy, and security. Most recently the Lancet and the University of Oslo’s Commission on Global Governance for Health put the political determinants of health at the centre of its work and analysed the political origins of health inequity as well as the power disparities and dynamics across a range of policy sectors.5 The politics of the recent Ebola outbreak in west Africa provide further illustration of how political determinants shape the responses to outbreaks.6
“Lack of political will” is often cited as the main reason for failing to deal with factors affecting health. Sometimes it is difficult to discern any difference between advocacy and analysis; indeed, many a public health researcher has turned advocate when confronted by evidence of unacceptable health inequalities. Yet Mackenbach has rightly warned of “romantic illusions” in the face of messy problems.7 Instead he highlights that public health professionals need a much better understanding of how politics work and what politics can achieve. Public health professionals have long argued for health to be placed “higher on the political agenda” and for policies to be “evidence based.” However, training has not equipped them well to analyse political context and understand complexities, and to frame arguments and act effectively in the political arena. Indeed, public health organisations have little political influence in most countries and their input is fragmented at the global level.
Public health research has yet to deliver (and get the financing for) more studies that can inform political choices by providing empirical evidence not only on the effect of political variables on population health7 but also on the effect of such decisions on politics. The recent work on the introduction of austerity policies and their subsequent health effects around the globe are a step in this direction; Stuckler and Basu show how political decisions have led to growing health inequalities and increasing rates of disease and death.8 More importantly, their comparative data also show how different political choices have resulted in significant variation of health and political effects across countries. Such studies illustrate how health and politics are framed by “the inherited institutional environment (both formal and informal), by the political culture and by the differing degrees and forms of power which participants bring to the process, and by their interests and ideologies.”4
The key political debates in public health revolve around the primacy of economic over social policies (often referred to as neoliberalism), charity versus entitlements, and concepts of liberty. By its very nature the politics of health is ideological: it takes positions on the role and responsibilities of the state, markets, and individuals. But the issues at stake go beyond distribution of resources; exercising “power over the biological lives of individuals and peoples has become the greater part of political power, and, conversely, control over one’s biology is becoming a central focus for political action.”9 Any analysis of political determinants will require a positioning within political theory and political philosophy. From such a base it can face and debate difficult dilemmas head on, such as Martyn’s10 and Davies’11 provocative questions in relation to the trade-off between health and political freedom.
The time is right to engage in a serious joint intellectual endeavour to further explore the political determinants of health. It can bring together work that is being done under various headings: politics of health, global health, political epidemiology,12 health political science,13 and political economy of health. Above all it requires a willingness to bring together a public health perspective reared on causality, evidence, determinants, and interventions with a lens that deals with the nature of power, systems, wicked problems, uncertainty, and complexity.
Cite this as: BMJ 2015;350:h81
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.