5.1. Introduction
This chapter shifts from the generally assessed empirical context towards this work’s findings on the most central policy and framework documents. It answers sub question 1 by outlining how relevant policy actors in Europe problematize and address concerns around health equity and environmental health as well as their governance. Moreover, it partly answers sub question 6 on how civil society’s space for action is defined, enabled and limited by focusing on role of EU and WHO. Chapter 7 later provides the second part of the answer by considering civil society perceptions on the matter.
Even though many, often private stakeholders determine European public health governance, meta policy directions are still given by (in)directly democratically elected leaders from the United Nations, in this case mostly the WHO and the WHO Regional Office for Europe (13 analysed documents) or from the EU (10 analysed documents). Identifying as the main European institutions for public health policy making (Paget et al., 2017, 52), their 23 for this research most relevant documents are analysed here.
Section 5.2. provides an overview of the most important policy and framework documents8. Section 5.3. summarizes the most central policy goals, values and priorities found while section 5.4. shows how the neoliberal paradigm is interwoven in health policies as well as presented next to, as if in line with the social justice paradigm. Section 5.5. outlines the dominant problematizations and approaches of health equity and environmental health in WHO and EU policies, while section 5.6. shows their interpretation of civil society’s role. Finally, section 5.7. describes three identified trends (and demands) in health, health equity and environmental health policy making and governance followed by conclusions (section 5.8).
5.2. Policy and Framework Document Overview
Figure 3 portrays the analysed documents which are organized alongside various parameters: their type (title), if they correspond to the policy definition adopted in this work (colour): (cf. section 3.7);
their author (in brackets) as well as their period of validity (timeline) starting in 2008 as the financial crisis constituted a turning point in health policy making (cf. section 2.5.).
8 see list with document short forms, full names and references in Annex 8
41 The documents turned out to vary in their significance for this work. The policy framework and strategy “Health 2020” (D23) represents a cornerstone for health equity and environmental health governance due to its elaborate description of challenges and approaches (D23). Most in line with this work’s approach is nevertheless the “Helsinki Statement on Health in all Policies” (HIAP) (WHO &
MSAHF, 2013) (cf. section 5.7.1.), especially regarding its strong emphasis on health equity (16ff.).
Figure 3: Timeline Policy and Related Documents
5.3. General Observations and Reflections
This work includes a wide array of policy-related document types such as declarations, communications or policy frameworks. To a certain extent, they are all part of health policy making, and general patterns can be identified – for instance, various themes and keywords arise repeatedly across diverse parameters. These include universal health coverage and primary health care (D10, 3;
D9, 49) (cf. section 4.3.1.), the right to health (D2, 2), health promotion and disease prevention (D6, 30; D22, 1) and access to health care (D17, 8). Hence, various elements of the social justice paradigm are indeed present in WHO and EU health policy making (cf. section 2.6).
9 The references in this chapter mostly represent examples of documents; mostly, many documents refer to one element / hypothesis simultaneously
42 Alongside the key words, certain values and goals are repeatedly referred to, including solidarity in health (D11, 2), an intended focus on vulnerable groups (D20, 8), social justice (D1, 1), the principle to leave no one behind (D12, 1) as well as efficiency, productivity (both D3, 5) and the resilience of health systems (D17, 2).
The EU and especially the WHO highly prioritize and rhetorically stress the theme of health equity which stands in contrast to the persistence of the empirical gap in life expectancy, healthy life years and self-assessed health between societal groups (cf. section 4.3.3.). The theme of environmental health also gains importance over time and is a consistent part of WHO policy.
There are several explanations for the gap between the prioritization in meta policies and unmet objectives: as outlined in chapter 4, public health policy making mainly takes place in the national instead of the supranational context and most states do not have a coordinated approach to tackle health inequities. Moreover, documents mostly highlight health equity and environmental health when they are part of a specific health agenda. Yet, as soon as they concern general European policy strategies with health as a sub-theme or solely affecting health, priorities change towards the competitiveness and growth of the health industry (e.g. D7; D3). Hence, the topics’ high prioritization within health policy is outweighed by the leverage of other policy fields’ agendas. This impression confirms the utter need for a comprehensive HIAP approach addressing socio-economic and environmental health determinants in policies outside of the health sector (cf. section 5.7.1.). The high salience of especially health equity in health policy agendas must yet be judged relatively to the WHO’s shrinking leverage (cf. section 4.2.2). One must also assume a general gap between rhetorical attention and their (financial) implementation.
As expected, one observes that the WHO’s priorities are indeed to improve health equity and environmental health whereas for the EU, these goals stand among many others – looking at major documents such as “Europe 2020” (D13) or the “EU Budget Recovery Plan” (D7), it becomes clear that the economic considerations by far supersede any genuine concern to address health determinants.
5.4. Presence and Framing of the Neoliberal Paradigm
It is difficult to interpret the WHO’s and EU’s underlying ideological assumptions regarding this works topic. Their rhetoric and agenda setting nevertheless show certain patterns and trends. The economic perspective on health is pervasively highlighted, mostly in EU documents. Policies repeatedly refer to financial costs and benefits when talking about the current challenges for health systems including limited resources, the general ageing of the population resulting in a higher prevalence of illness, the rise of chronic diseases, accessibility of health systems, increasing costs for treatments, shortages of
43 health professionals and the need for new skills (cf. for D21, 1; D2; D23, 12). The arguments are often based on a necessary recovery from the financial crisis (D17, 2; D13, preface).
No explicit push for privatization could be identified. Yet, the repetitive reliance on market values and goals as competitiveness, efficiency, growth and cost-saving (cf. D23, 11, 139; D16, 2; D3, 5) in European health policy making confirm Ferreira & Mendes’ (2018) notion of commodifying processes by way of an increase of private logic and market principles (Toebes, 2016). By asking how to avoid and shorten hospitalizations (D17, 12f.), by looking at health care as a health industry (D23, 52) or by using phrases such as “Good health is an asset and a source of economic and social stability” (Margaret Chan, WHO Director General in ibid, 8), health is primarily understood as a precondition for wealth creating a value system that delegitimizes the inherent value health possesses for an individual. Health is yet repeatedly defined as a precondition for productivity (D3, 14; D23, 52). This understanding leads to a different approach towards health. By focusing on the functionality of a person, The provision of care and medicines takes place for the re-establishment of the asset of an economically and socially functioning member of a market-based society; constituting an unsustainable short-term perspective on health.
Many policy-related documents (D4, D20, D23, D11) align profit-making goals and the rights- and social justice-value based objectives next to each other: “What is important is to create a pattern of overall economic and social development which leads to greater economic growth, as well as greater solidarity, cohesion and health” (D20, 5). The “Tallinn Charter” even stands “for health and wealth”
(D11, 1) and “Health 2020” (D23) puts both strands of arguments in different sections. Rarely, a concrete way is pointed out how exactly the neoliberal and the social justice paradigm can be combined, or at what point they intersect, or how the pursuit of wealth may compromise the pursuit for health and likewise; only rarely acknowledging a possible inherent conflict or a gradient.
The “Pharma Strategy” (D16) constitutes an exception by expressing the intention to enforce EU competition rules to impede incidences where affordable medicines are prevented of entering the market by pharmaceutical companies (7) admitting that investment in health does not focus on unmet needs “due to the absence of commercial interest” (4). Also, the “Rio Declaration” (D9) and “Health 2020” (D23) identify a misled distribution of power, money and resources and demand redistributionist measures, for instance by addressing power imbalances between sectors (ibid, 67).
Yet, the general omnipresent hesitation to confront and integrate the frequently repeated lists of formulated policy objectives diminishes the credibility and depth of analysis.
To conclude, by sketching a picture of big financial constraints for health systems, promising potential for the health industry but simultaneously reminding oneself to also consider access to health care
44 and equity concerns, the EU ensures that health inequities persist. It is yet indeed possible to imagine an agenda firmly based on the principles and policy tradition of Alma Ata (cf. 3.3.1.) representing a different value base for members states to consider.
5.5. Problematizations and Approaches
When it comes to health equity, environmental health as well as other recurrent goals and concepts, interestingly, the policy-related documents seem to be very coherent in the way they describe and problematize them. Repeatedly, the same rhetoric, key words, even phrases are used.
5.5.1. Health Equity
As mentioned before, health equity is highly prioritized in WHO and EU documents (cf. D9, D21, D17, D11, D22, D13) and portrayed in a similar way than in scholarly literature (cf. section 2.2.). Related to the neoliberal notion of one’s own responsibility for health, just as in theory, health inequities are often portrayed as related to certain lifestyle and behavioural choices of individuals (D6, 30; D3, 4; cf.
section 2.2.2.). Individuals should be encouraged towards a “culture of health” (D23, 48) along lifestyle indicators such as smoking, exercise and obesity (13) which strongly reminds of Christoffersen’s (n.d.) health meritocracy concept (section 2.5.). Yet, structural components such as social and environmental health determinants are as well frequently referred to (cf. D10, 10; D9, 5; D2, 4).
The WHO condemns health inequities as unacceptable (D1, 1; D9, 1) and focuses on enhancing community resilience, education, employment and reducing poverty (D23, 13) by use of a life-course approach (D10, 10); the “Rio Declaration” (D9) emphasizes the need for a comprehensive intersectoral approach (see 5.7.1.). “Solidarity in health” (D20) lists (growing) health disparities between European regions, between society sections, between rural and urban areas or for instance a 14-year gap of life expectancy for men between EU member states (2); lamenting that currently only few policies evaluate their impacts on equity (9). Causes and obstacles for health equity are generally well elaborated, coherent and often repetitive. Strategies for instance include countering exclusionary societal processes (D23, 133) and creating economic incentives for healthy choices (D16, 8). Policies also refer to a prevalent hesitancy to fight health inequities due to their inherent complexity (D2, 2).
45 5.5.2. Environmental Health
The WHO estimates a very high environmentally caused burden of disease related to the rise of NCDs, air pollution, effects of climate change, inadequate water and sanitation, chemical hazards and other environmental health risks (D18, 4ff.). Environmental hazards in Europe cause 13 million deaths each year and lead to cardiovascular and respiratory diseases, lung cancer, to stress, depression, water-borne diseases and accidents (ibid, 6, 16ff.). The WHO has ambitions to triple health-related climate finance by 2023 (D10, 32) and the recent “EU Budget Recovery Plan” (D7) announces the allocation of EUR 94.4 billion to Horizon Europe for health- and climate-related research and innovation activities (11).
The EU on the other hand published the “EU Action Plan: Towards Zero Pollution for Air, Water and Soil” (EC, 2021) which has not been included in the original analysis but sets targets such as zero harmful pollution by 2050 and generally provides a compass for all relevant EU policies to include pollution prevention (3). As part of the European Green Deal, its 2030 pollution targets include the reduction of 55% of the health impacts of air pollution and a 30% reduction of the share of people chronically disturbed by noise through transport (3). It thereby goes hand in hand with the SDG agenda and setting aside questions of the extent of the European Commission’s ambitions and the action plan’s implementation, this policy constitutes a major step towards enhanced environmental health in Europe – moreover, it explicitly assigns civil society an important watchdog role (14).
In the documents, the discourse around environmental health is dominated by a security rhetoric including words such as “harm”, “hazard”, “exposure” or, very pervasively, “risk” (ibid, 3, 16; D14, 1ff.) – interestingly in contrast to the rhetoric around health inequities which constitutes a different type of phenomenon: no external root-causes for ill-health but the unequal distribution of factors determining health, including environmental ones. The intrinsic connection between health inequities and environmental health is often stressed in policy-related documents as vulnerable and socio-economically disadvantaged groups are majorly exposed to environmental hazards (D18, 8.; D2, 3).
Therefore, strategies around social and environmental health determinants should come together (D23, 36).
The established intersectoral environment and health process guides environmental health governance in Europe and is used for the implementation of the SDG agenda (D5, 3). Yet, the WHO Global Strategy on Health, Environment and Climate Change (D18) judges the current governance mechanisms as failing at addressing the cross-cutting nature of the challenge (6).
46 5.5.3. The Politicization of Health Determinants
To determine how civil society politicizes health equity and environmental health, one must first establish to what extent the topics are already politicized in the European public health policy arena.
The field of health in general is here explicitly recognized as a politically contested issue dependent on the distribution of resources (D23, 47). Also, the EU’s health budget has been drastically increased when comparing the “Third Health Programme” (D21) with the “EU4Health” (D22) budget planning (1;1).
When it comes to action on health determinants, political will is decisive (D10, 17; D1, 1; D18, 7; cf.
section 2.2) as well as political commitment (D2, 4). The topics of environmental health and especially health equity are salient, which represents a strong politicization indicator (section 2.3), yet seldom visibly connected to concrete instruments. The WHO declares health inequities as politically determined and thereby unacceptable (D23, 12), thus presenting institutional awareness of the issue.
No explicit expression of the polarization indicator (section 2.3.) can be found in the documents but is yet perceivable when thinking of the unresolved contradictions between simultaneously expressed, often unaligned policy goals.
Comparing institutions, the WHO policies meet the politicization indicators in terms of agenda-setting and rhetoric, whereas EU policy documents do not reveal a clear positioning. Comparing topics, health equity is more politicized than environmental health, as it is more salient and identified as a political issue.
5.6 Civil Society
Concerning the institutional space for civil society, rhetorically, there seems to prevail an overall very welcoming and enabling environment for their involvement in policy making, advocacy and social mobilization (cf. D9, 4; D23, 68ff.; D19, 6ff.; D13, 4). Being close to the people (D2, 5), contributions from civil society also include the implementation of enhancing socio-economic determinants of health (D9, 4), engaging and empowering communities, providing services, addressing complex and stigmatized issues (D23, 15, 140f.), accounting and monitoring (D2, 6) and facilitating interaction with health care professionals, the research community and the media (D16, 24; D19, 12). Civil society yet faces various challenges such as a perceived lack of capacity, skills and funding (ibid, 12).
Health 2020 (D23) describes civil society as “a key actor in formulating, promoting and delivering change” (15). Often, political concern for environmental health represents a belated reaction to civil
47 society pressures (ibid, 127). Moreover, CSOs’ involvement is required to combat challenging health inequalities (D6, 11).
The mentioned contributions and associated hopes in policy are largely congruent with those of scholars (section 2.7.). Thus, following the WHO and EU rhetoric, the civil society action space seems promising. The call for their increased involvement in decision-making could even be described as a trend. Nevertheless, many documents mention civil society alongside other actors such as research institutions, the media, but also private foundations and companies (D16, 1ff.; D10, 6; D8). The
“FENSA” (D8) incorporates the involvement of private sector entities and philanthropic foundations next to NGOs and thereby transfers (bio)power to each party – according to GHW 5 (2017, 259) in an uncritical manner. This confirms Patnaik’s (2021) claim that the WHO itself is a main driver of multilateralism.
5.7. Trends in Health, Health Equity and Environmental Health Governance
All in all, three essentially interlinked demands and trends have been discovered defining the current European public health landscape. They include first, a call for more attention on non-health sectors’
impacts on health, thus intersectoral cooperation via the effective implementation of the HIAP approach; second, a generally more comprehensive and holistic understanding of health and its interlinkages with the environment and society; and third, more participatory governance, thus health politics that involve more actors and citizens themselves. All three developments encompass dealing with a higher degree of complexity.
5.7.1. An Intersectoral Approach
Most analysed documents confirm the theoretical argument that economic, agricultural, trade and intellectual property rights, educational, food systems and their directives produce highly relevant health determinants (cf. section 2.3.). The WHO demands a more cross-cutting, intersectoral way forward (D23, 62 & 129; D18, 6ff.; 10ff.; D9, 2) as other sectors are even more important for health than the health sector itself (D23, 125) via their impacts on nutrition, housing, neighbourhoods, exposure to environmental risks and financial standing (cf. D10, 10; D15, 1; D3, 6).
The HIAP approach represents this intersectoral approach aiming to generally move health up the policy agenda and strengthen policy dialogue on health and its determinants, thus making it a priority across sectors (D23, 14f.). The health sector must thereby lead and coordinate the process (D18, 10).
48 5.7.2. A More Comprehensive and Holistic Approach
Most of this trend has been explicated in section 3.3.4. as it majorly relates to environmental health governance yet can also be found in policy agendas (D16, 24; D18, 7). The “WHO Global Strategy on Health, Environment and Climate Change” (D18) repeatedly calls for a more holistic understanding and approach towards environmental health governance (8ff.; 11). This emphasis also comprises the One Health approach, thus expanding the connection between human, animal and environmental health, for instance to fight antimicrobial resistance (D23, 129; D18, 8). The one health approach is interdisciplinary and cross-sectoral, thus closely linked to the HIAP approach (ibid, 11).
5.7.3. Governance: Participation of Society
The WHO calls for a transformation of governance from state-centred to more participatory, collaborative governance – the ladder including civil society and other actors such as local governments which are closer to the people (cf. for instance D23, 3ff.). This transformation is expressed first, via the adoption of the whole-of-society approach (cf. D10, 10; D15, 1), a form of collaborative governance mobilizing communities, culture and media, engaging the private sector, civil society and individuals as well as various sectors (D23, 15); and second, via the adoption of the whole-of-government approach (cf. D10, 10; D18, 11) which happens simultaneously on various levels from global to local involving groups outside of the government by building trust, common ethics and a cohesive culture (ibid, 14). Simultaneously, the EU adopted a policy shift in 2012 to push its support for civil society further, highlighting their watchdog role around climate change and the environment (D19, 1).
5.8. Conclusion
Regarding sub question 1, how health equity and environmental health and their governance are problematized and addressed by relevant policy actors, this research comes to a multi-layered conclusion: first, the EU and the WHO constitute the most relevant policy actors and second, elements from the neoliberal and the social justice paradigm have been identified as priorities of both actors.
Yet, the EU focuses more on the economy of health and the WHO – with its mandate solely around health – targets health equity and environmental health more specifically and ambitiously.
Interestingly, neoliberal and social justice goals and values are presented in juxtaposition without defining their confrontation, so that their concrete approach often remains unclear. Third, both focal topics but especially health equity are highly salient and prioritized in the documents. Fourth, nevertheless, both topics remain constant challenges due to policy making around health, not by
49 neglecting or misunderstanding them within health policy making as fifth, their problematization is closely oriented at theory.
Regarding sub question 6, how the civil society action space is defined, enabled and limited, one can conclude that the WHO’s somewhat clear positioning towards the social justice paradigm constitutes an enabling factor whereas its comparative lack of necessary (bio)power in contrast to emerging actors (section 4.2.2.) diminishes civil society’s prospects to enhance health equity and environmental health. Also, the EU’s policy making does not seem to challenge power relations apart from (partially) joining in the demands for more cross-sectoral, holistic and participatory governance structures which strongly calls for civil society action. One could even conclude that this thesis is on the forefront of joining the most recent health policy trends of more comprehensive and whole-of-society governance focusing on health determinants.
Chapter 7 adds the civil society perspective on their action space.
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