An exploration in the context of the increasing commercialization of health systems Civil Society politicizing and enhancing Health Equity and Environmental Health in Europe

(1)

Isabel Möller

Civil Society politicizing and enhancing Health Equity and Environmental Health in Europe

An exploration in the context of the increasing commercialization of

health systems

(2)

ii

(3)

iii

Graduate School of Social Sciences

Research Master International Development Studies (RMIDS)

Master’s Thesis

Civil Society politicizing and enhancing Health Equity and Environmental Health in Europe

An exploration in the context of the increasing commercialization of health systems

Isabel Möller

Student Number: 12784508 isabel-moeller@hotmail.de

Date of Submission: 19/11/2021

Place of Submission: Amsterdam, the Netherlands

Thesis Supervisor: Dr. N.R.M. (Nicky) Pouw Second Reader: Dr. C.L. (Courtney) Vegelin

Word Count: 28,791

(4)

iv

Acknowledgements

First and foremost, I want to thank my supervisor, Dr. Nicky Pouw, for all her time and support and for everything I have learned from her throughout the process – especially for oftentimes bringing order into the occasional chaos in my mind. I also want to thank Dr. Courtney Vegelin, my second reader, for her kind support during the entire program.

I want to thank all my interview partners for taking the time to answer my questions during the busy lockdown phases and for their kindness to share their thoughts and insights with me. You motivated and inspired me immensely and I learned a lot from you.

I received tremendous support from my loved ones. My special thanks here go to my mum for always being there for me during all ups and downs of this pandemic-affected research project, and to Bart, for bringing new motivation, balance and joy into all days of the process.

Thank you.

(9)

ix

List of Tables

Table 1: Actor Overview ...31

Table 2: Organizations according to Topic ...50

List of Figures

¹ Figure 1: Conceptual Scheme ...15

Figure 2: Sequential Two-Phase Research Design ...20

Figure 3: Timeline Policy and Related Documents ...41

Figure 4: Comparing Politicization ...63

Figure 5: Updated Conceptual Scheme ...71

1 Microsoft Word does not automatically include the figures into the word count (which have been inserted into the document). A manual count resulted in 435 words that have been included into the overall word count.

(10)

x

Acronyms and Abbreviations

CSO Civil Society Organization

CSDH Commission on Social Determinants of Health EECA Eastern Europe and Central Asia

EU European Union

FENSA Framework of Engagement with Non-State Actors HiaP Health in all Policies (approach)

NHS National Health Service

NCDs Non-communicable Diseases

NGO Non-governmental Organization

PHC Primary Health Care (approach)

SDG Sustainable Development Goal

SQ Sub Question

UHC Universal Health Care (approach)

WHO World Health Organization

(11)

xi

Abstract

In Europe, dramatic levels of health inequities within and between countries persist, alongside environmentally determined ill-health and illbeing. Civil society is increasingly recognized as an actor for change in addressing these major challenges. In European public health governance, the current neoliberal political economic paradigm is manifested in the commercialization of health systems and contrasts a social justice paradigm focused on strengthening socio-economic and environmental health determinants. This research explores how European civil society politicizes and enhances health equity and environmental health by investigating their role, problem perceptions, strategies and impacts. Applying a qualitative mixed methods design, first, the civil society action space is explored by means of a qualitative content analysis of WHO and EU policy and framework documents;

to be followed by semi-structured interviews with civil society representatives from various European countries, combined with a framework analysis of their organizations’ websites and reports. WHO and EU documents call for an intersectoral and participatory governance approach. Yet, according to civil society, pervasive neoliberal ideology inhibits equitable access to health care. Organizations actively politicize health equity and commercialization trends by increasing the topics’ salience and polarization, whereas environmental health organizations vary considerably in their perceptions and strategies. Ultimately, civil society enhances health equity and environmental health by way of advocacy work, the provision of medical services, educative activities and by constituting a bridge between public health stakeholders.

This research contributes to the European public health debate by exploring first, the challenges of health inequities and environmental health hazards through a policy and civil society lens, second, civil society’s role as an actor for change and third, the politicization health determinants; thereby adding to an increased understanding of the problem and transformative strategies among organizations, scholars and activists.

Key words: European public health; health equity; environmental health; civil society; politicization;

determinants of health

(12)

1

Chapter 1: Introduction

1.1. Background

As the social world continues to be shaped by a capitalistic hegemonic logic, particularly through the commercialization of different societal spheres, multifaceted inequalities as well as environmental degradation increase and concurrently impact people in the most direct way: their health (WHO-E, 2019; EC, 2013; GHW 5, 2017).

The dominant neoliberal political economic paradigm heavily compromises population health as power and resources in the public health sphere are unequally distributed (ibid). The Sustainable Development Goal (SDG) 3, emphasizing to leave no one behind when ensuring health and wellbeing for everyone (UNGA, 2015), stands in contrast to ongoing empirical trends: Dramatic levels of health inequities as well as socially and environmentally determined ill-health persist (WHO-E, 2019; EC, 2013; GHW 5, 2017), while discrepancies in health outcomes and access to health care increase when health is handled as commodity (Ceukelaire et al., 2011, 2). While health inequities are a global phenomenon, high-income regions like Europe with generally improving population health outcomes report huge discrepancies in life expectancy and self-assessed health in all European countries (Mackenbach & Kunst, 2012, 155ff.; Eurostat, 2020). Moreover, modifiable environmental determinants of health are responsible for about 23% of all deaths worldwide (Prüss-Üstün et al., 2016, x) with almost 1,5 million deaths in the European region alone (WHO-E et al., 2017) and related to factors such as air pollution, unsafe water or noise (WHO-E, 2010, ii-iii).

When looking at the pervasiveness of both problems, the state and the market fail to truly alleviate and eradicate health inequities and environmental health risks (cf. Bambra, 2016). Policies affecting public health are indirectly determined by a systemic prioritization of European economic competitiveness and profit-making and there exists a one-sided predominance of biomedical and economic knowledge in shaping health systems (De Vos et al., 2004; Kappas et al., 2012; Biehl &

Petryna, 2013). Health is promoted narrowly as an individual condition so that political, socio- economic and environmental determinants are underrepresented in relation to their actual impact (Sengupta et al., 2018; Laverack, 2013). Yet in fact, people’s health is directly affected by a multitude of complex factors outside of behavioral and material determinants such as social relations or relations individuals have with their surrounding ecosystem (e.g. Hancock, 2002; Leviston et al., 2018).

1.2. Problem Statement and Research Purpose

Inequities themselves are inherently political (Piketty, 2020, 7) and socio-economic and environmental determinants are steered by policies in and around health. Seeing health determinants

(13)

2 as structurally and politically determined instead of static, inalterable variables requires their politicization.

It is widely suggested that civil society of all actors plays an increasingly significant role in addressing health on local, national and supranational levels, described as representing a bottom-up force, endowed with autonomy and closely linked to people and communities (e.g. Greer et al., 2017; CSDH, 2008; Ceukelaire et al., 2011). “it falls upon the amorphous groupings of citizens (civil society) to hold both state and markets to account for actions that embody the environmental sustainability and health equity targets of the SDGs” (GHW 5, 2017, 26). In comparison to other regions in the world, civil society in Europe is particularly present and active in the public health field (Ceukelaire et al., 2011, 3).

Hence, this thesis’ purpose is to zoom in on civil society’s role for transformational change politicizing and enhancing health equity and environmental health in Europe. It thereby focuses on civil society’s perceptions of the two focal topics as well as their strategies and impacts, all embedded in an exploration of civil society’s space for action by understanding the European public health field, its status quo and potential, and the trend of the increasing commercialization of health systems in Europe as the manifestation of the neoliberal political economic paradigm.

This is done by a combination of qualitative methodologies first exploring the EU’s and the World Health Organization’s (WHO) main policy and framework documents on the topics and consecutively interviewing various civil society representatives from different European countries while analyzing their organizations’ websites and reports.

A focus on health equity and environmental health is empirically highly relevant as both represent the two major global problems in international development, social injustice and environmental degradation, yet both in their concrete manifestations in the area of health – including, as outlined in the previous section, their sadly very tangible and immense detrimental consequences.

1.3. Theoretical Approach and Knowledge Gaps

The theoretical framework used for this research consists of various angles and thereby first and foremost of the identification of the neoliberal versus a social justice paradigm which in contrast strengthens socio-economic and environmental health determinants. Second, the literature around health equity and environmental health is explored while third, health politics are understood as deeply shaped by power relations and resource allocation so that Foucault’s concept of biopower is applied onto the European public health sphere. As a last angle, civil society is conceptualized as equipped with agency to politicize the issues – to drag health concerns from the private towards the public and explicitly political sphere, thereby contributing to the (bio)power dynamics at work (cf.

(14)

3 Mooney, 2012). This theoretical framing embeds research questions and eventual findings within broader social sciences and international development research through this thesis’ transformative claim for social justice and health.

This work’s focus on health equity and environmental health is in line with the WHO’s 2030 strategy and no novelty (WHO, 2019a). Yet, no explicit assessment has taken place on the position of European civil society on the matter. Knowing their perceptions on their role, space for action, strategies and impacts not only adds to a more comprehensive scholarly understanding of the status quo in European public health, but also enhances the potential for respective societal change. Empirically, these new insights help to find a common ground and more coherent strategies among scattered organizations in entire Europe and communicate their challenges and ideas to other public health stakeholders, raising the potential to conjointly advance the societally deeply relevant topics. Theoretically, they feed into the ongoing European public health policy discussion in the context of the SDGs– health is an absolute development priority (WHO, 2019b).

Next to a contemporary interpretation of Foucault’s biopower concept, the biggest contributions of this thesis are first, an enhanced understanding of the two focal topics through civil society’s and policy documents’ perspectives; second, the exploration of civil society’s potential as an actor for change in the context of the commercialization of European health systems; and third, an intentional emphasis on the politicization of health determinants.

Filling in the research gaps on these politicization processes means to contribute to this very transformative process, tackling the concrete problem of health systems deterioration at the expense of people’s health in Europe. The chosen topic and theoretical angle resulted in the following research questions around which the thesis chapters are organized.

1.4. Research Questions Main Research Question

How does civil society in Europe politicize and enhance health equity and environmental health against the background of the increasing commercialization of health systems?

Sub Questions

1. How do relevant policy actors in Europe problematize and address concerns around health equity and environmental health and its governance?

2. How can targeted European civil society organizations enhancing health equity and environmental health be characterized?

(15)

4 3. How do civil society organizations in Europe perceive health equity and environmental health and the impact of the commercialization of health systems?

4. What are the targeted civil society organizations main strategies and impacts enhancing health equity and environmental health in Europe?

5. How does civil society politicize health equity and environmental health?

6. How is the civil society action space around these matters defined, enabled and limited?

1.5. Thesis Outline

This thesis comprises eight chapters. In chapter 2, the complete theoretical framework is outlined. In chapter 3, underlying philosophical assumptions, research design, data collection and analysis procedures are explained, thus an overview and reflections on my methodological choices is presented, to be followed by an exploration of the research context in chapter 4 encompassing the European public health policy sphere, including the main actors and current governance trends.

Chapter 5 presents the findings of the conducted European Union (EU) and WHO policy and framework document analysis, answering the first and partly the last sub question. Thereafter, civil society organizations’ (CSOs) characteristics, perceptions of the two focal topics as well as their strategies and impacts (sub questions 2-4) are outlined in chapter 6. Chapter 7 finally presents the findings on the fifth and completes the sixth’s sub questions answer by referring to civil society’s politicization potential and action and presenting enabling as well as limiting factors for their engagement. Ultimately, chapter 8 answers the main research question by integrating all findings. It also comprises theoretical and methodological reflections as well as recommendations for research, policy and practice.

(16)

5

Chapter 2: Theoretical Framework / Literature Review

2.1. Introduction

This chapter first outlines the current scholarly perspective on socio-economic and environmental health determinants and on the concepts of health equity and environmental health (section 2.2.).

After understanding this work’s two focal topics, the adopted theoretical framework based on the politicization of health determinants is introduced (section 2.3.). Furthermore, after depicting the meta-relationship of political economic power structures and health along the lines of Foucault’s conceptualization of biopower and biopolitics (section 2.4.), the assumed prevalence and implications of two major paradigms of health governance are explicated; the current neoliberal (section 2.5.) and the social justice paradigm (section 2.6.). Section 2.7. presents the conceptualization of civil society while section 2.8 summarizes the identified theoretical knowledge gaps. The chapter is concluded by showcasing the conceptual scheme (section 2.9.) and providing some final reflections (section 2.10.).

This work’s underlying philosophy is neither solely based on structural nor on agency components combining critical political economic perspectives with the exploration of civil society’s potential for change (cf. section 3.2.). Definitions and conceptualizations are often understood broadly as meaning ascribed to them can differ. This constructivist, relativist and interpretivist philosophy allows for a combination of various complementary theoretical angles enabling a more comprehensive and complex understanding of the matter (cf. section 3.2.).

2.2. Central Concepts: Health Equity and Environmental Health

Health is most prominently understood as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity [and] one of the fundamental rights of every human being” (WHO, 2020). The health of a person and a society is essentially determined by factors outside of the medical sphere and health provision, as scholars find that social health determinants impact a person’s health status to 80% (cf. Hood et al., 2016, 132). Most determinants of health are part of wider political economic decision-making and an integrated part of what is referred to as the discipline of public health (cf. Bambra, 2016).

2.2.1. Socio-economic and Environmental Determinants of Health

Socio-economic and environmental determinants are the often less visible factors determining people’s health: Horton (2020) for instance denounces the recent Covid-19 pandemic as a “syndemic”

(874), as the result of two types of diseases, the Covid-19 virus and non-communicable diseases (NCDs) caused by conditions clustered within social groups corresponding to inequalities embedded

(17)

6 in our society (ibid, 874): “the aggregation of these diseases […] exacerbates the adverse effects of each separate disease” (ibid, 874), as the virus is most dangerous in the face of already vulnerable organisms. NCDs such as the chronic conditions like diabetes, heart or respiratory diseases, - their frequency strongly related to socio-economic and environmental determinants – are not only generally harmful for the ones affected but also pose risks in the face of a pandemic (cf. Horton, 2020).

Moreover, infectious diseases have already in the 19^th and 20^th century been successfully politically battled by improving living and working conditions such as sanitation and nutrition (Bambra, 2016, 208).

2.2.2. Health Equity

Health equity, in contrast to health equality, means not to provide everyone with the same care, but to ensure the optimal outcomes for all groups (Sturmberg, 2018, 242). Even though health inequities are discussed widely in academia and public policy debates, in the global and European reality, they prevail (Bambra, 2016; Shaw et al, 2005). Health disparities are manifested in terms of mortality (e.g.

differences of life expectancy in years), morbidity (e.g. per disease (Figueras & McKee, 2012, 118)), or wellbeing (e.g. differences in life satisfaction (Quick & Abdallah, 2016, 31)) and exist within as well as between countries (e.g. Mackenbach & Kunst, 2012, 155ff.). Health inequities are considered wicked problems as researching and addressing them cuts across academic disciplines, government departments and budgets due to their interrelatedness and multi-layered character (Williams, 2007, 16). They are racialized, gendered and classed (Christoffersen, n.d., 9). Even though gaps exist according to age, sex and many attributes (Quick & Abdallah, 2016), this work focuses on the socio- economic and the political dimension of health equityrelated for instance to access to health care, education, housing or working conditions (cf. Figueras & McKee, 2012; Bambra, 2019). Only providing the example of mortality; over the last decades, relative gaps in Western and Eastern Europe among different socio-economic groups have been almost universally on the rise (Mackenbach et al., 2018, 6443).

Health inequities do not represent a dichotomy but a gradient (Marmot, 2004, 83). Poverty and deprivation are considered the most important determinants of health inequities and are often intertwined with localities and places (Williams, 2007, 7ff.). With diminishing socio-economic status, for instance also psycho-social stress increases as well as the prevalence of unhealthy behaviour in terms of nutrition or substance use (Figueras & McKee, 2012, 160). Even socio-economic inequities per se are unhealthy as in an unequal society, the “bird-brained thinking” (Dorling, 2015, 332f.) of constant competition has population-wide negative neurological and psychological consequences (ibid).

(18)

7 2.2.3. Environmental Health

Whereas environmental health is sometimes depicted as the reciprocal impacts of people on the environment as well as its impact on human health (Moeller, 2005, 1), it is more prominently defined unidirectional. The environment is thereby understood as “the circumstances, objects, or conditions by which one is surrounded” (Merriam-Webster Dictionary, 2021a). These factors range from narrow focuses such as controlling specific physical and chemical hazards to broader social and built environments (Frumkin, 2016, 45) and includes issues such as air pollution, neighbourhood design, effects from climate change or toxic waste (ibid). “[Environmental Health] aims both to control and prevent environmental hazards and to promote health and well-being through environmental strategies” (ibid, 45), yet it remains defined more by its challenges than by its approaches (Moeller, 2005, 1). Many disciplines contribute to these strategies such as epidemiology, toxicology, urban planning, communications, law and ethics (Frumkin, 2016, 45).

Adverse environmental determinants of health are generally more prevalent under already harmful socio-economic conditions – for instance in socially deprived neighbourhoods, the exposure to indoor and outdoor air or noise pollution or risky working conditions is elevated (cf. Moeller, 2005; Hancock, 2002, 45f.). The health of the planetary and built environment has profound consequences for people’s physical, mental, emotional and spiritual health and wellbeing (ibid, 545ff.). Environmental modifiable determinants are crucial for people’s health as they cause about 23% of deaths worldwide (Prüss-Üstün et al., 2016, x).

This thesis portrays the environment not as anything external to health but as intrinsically related and as approached at best transdisciplinary (cf. Kjaergard et al., 2013, 567). This work’s understanding of health within its social and natural environment is not oriented at modern Western contemporary anthropocentric world views defining ill-(health) as disturbances of body systems and (mal)functioning organs (Kappas et al., 2021). Instead, it rejects the dichotomy of health or illness and explicitly acknowledges non-hegemonic knowledge, conceptualizing the unity of nature and society and valuing the community and the environment over the individual ‘interest’ (ibid; Gudynas, 2011).

2.3. The Politicization of Socio-Economic and Environmental Health Determinants

One must acknowledge that inequality is inherently ideological and political (Piketty, 2020, 7) as are all fundamental determinants of health ”aris[ing] from the unequal distribution of economic and political power” (Bambra, 2016, 207). Yet, prevalent policy approaches shy away from recognizing deep structural and social causes and focus on the provision of health services and behavioural

(19)

8 interventions (cf. Williams, 2007). Kickbusch (2015) among other scholars talks about political determinants of health themselves,

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 (ibid, 1).

Empirically, the units of analysis of political determinants are closely linked to those of politicized socio-economic and environmental determinants. While for instance the politicization of socio- economic determinants would mean to put factors like education, housing and poverty policies on the political agenda in the interest of health, a political health determinants lens would look at which parties, institutions or power and resource allocations would enable such decision-making. Even though political determinants of health play a crucial role in politicization processes, they are not part of the theoretical lens applied to this work’s topic – the political character of health determinants is primarily analysed by zooming in on the politicization of socio-economic and environmental health determinants.

The concept of politicization is primarily located in the poverty or broader development discourse (cf.

Bebbington, 2007; Williams, 2004) but is broadly applicable as an “act of making something a political issue” (Oxford L. Dict., 2020) or entering the political, including the public and government sphere (Mishra, 2011, 155f.). Politicizing an issue such as health means a greater public discussion or the extension of state control to being explicitly responsible (Wood, 2016), presuming the possibility to explore alternatives and activate political agency to interfere with power dynamics (ibid; Mooney, 2012).

Researchers commonly define the degrees of politicization by means of their salience (e.g. importance and awareness of the focal issue) and polarisation (e.g. extreme positions or disagreement) (Kauppi &

Wiesner, 2018, 227; van der Brug et al., 2015, 2). Typologies of politicization relate to whether politicization is regarded as bottom-up or top-down process and whether it can be related more to structure or agency developments (ibid, 9ff.). Politicization is related to agenda-setting, to the definition of a problem as a political issue, to the relative attention compared to other issues but also to party competition in terms of positional disagreement and the extent to which there are polarized positions (ibid, 5ff.). For an issue to be politicized, it needs to be characterized by either increased salience or disagreement (cf. ibid, 7).

Looking at the current state of affairs, there are renewed politicization trends in health all across global institutions, governments, the private and the civil society sector due to the increasing relevance of health for policy making, the economy and political legitimacy (Kickbusch, 2015, 1). The politics of health are inherently ideological and take on positions on the role of different stakeholders (ibid, 2).

(20)

9 Entering the field of health politics, this work intentionally takes on the position of the social justice paradigm as opposed to the current hegemonic neoliberal ideology. Health politics are thereby also concerned with the use and distribution of power over the biological (ibid, 2), so that to understand this manifestation, the theoretical foundation for the connection between health, the body, the biological and the political power dimension must be laid.

2.4. Biopower and Biopolitics

Biopower, “the acquisition of power over man insofar as man is a living being” (Foucault, 2003 [1975/6], 239), is always addressed to a population (cf. Christoffersen, n.d., 11). Exerted within the frame of biopolitics, it administers life and populations as politics’ subject (cf. Harcourt, 2009, 13f.) Since the biological came under state control in the 19^th century, in modern European society, the sovereign’s, the government’s right to kill transformed into the right to make live and to let die through the man-as-body mode and the man-as-species mode (Foucault, 2003 [1975/6], 241ff.).

Biopower is exerted on for instance the number of deaths or “endemics” (ibid, 243): the extension, intensity and duration of prevalent diseases in society by way of controlling relations among humans, or the environmental and climatic conditions in which they live as well as the built environment, housing, the “urban problem” (ibid, 245). Thus, biopower is the form political power takes in public health, exercised for instance via the social effects of health policies (Adams, 2017). Through disciplinary and regulatory mechanisms, the population, the body, the biological, life itself is thereby turned into a scientific and political problem, into a power’s problem. (Foucault, 2003 [1975/6], 245ff.).

According to Christoffersen (n.d.), biopower is expressed for instance through the WHO and through hegemonic national public health regimes, mostly centred in the Global North (3). This power’s function, the function of public health, is to “improve life, to prolong its duration, to improve its chances” (Foucault, 2003 [1975/6], 254) but also to kill – in the sense of indirect murder such as to let die by increasing the risk of or exposure to death (ibid). According to Foucault (2003 [1975/6]), the power of death is exercised through racism, through separating out (254f.).

The concept of biopower helps to understand how closely medicine and political power are intertwined in an entirely normalized way via the conditions a population is surrounded with (cf. ibid).

It also provides a critical lens to look at biopolitics and public health regimes. Already Friedrich Engels (referred to in Helmers (2021, 36) provides an early example of the expression of biopower (before the concept was established) by his radical comparison of murder as it is commonly understood and

(21)

10 of murder through inaction on societal working and living conditions under which the 19^th century working class in England lived and died at early age.

In recent times, the discourse around health is dominated by neoliberal ideology: “The key political debates in public health revolve around the primacy of economic over social policies (often referred to as neoliberalism)” (Kickbusch, 2015, 1). Yet, for instance in academia and civil society, questions around the allocation of political power in health are posed and addressed (ibid). One can summarize these two opposing paradigms and their implications on the health of people and societies as follows.

2.5. The Neoliberal Paradigm and the Commercialization of Health Systems

Since about 1975 but especially following the financial crisis 2008, health and health systems in Europe are heavily affected by neoliberal ideology and policies such as austerity and privatization measures (Gaffney & Muntaner, 2018; Gooijer, 2007, x). Neoliberalism can generally be defined as

a theory of political economic practices that proposes that human well-being can best be advanced by liberating individual entrepreneurial freedoms and skills within an institutional framework [of] private property rights, free markets and free trade. (Harvey, 2007, 22)

According to the literature, the manifestation of neoliberalism in European health systems is their commercialization (cf. Mackintosh & Koivusalo, 2005; Mooney, 2012). Commercialization is broader than marketization or liberalization – “introducing competition into an industry” (Toebes, 2006, 5) – or privatization, “the sale or transfer of state-owned assets into private hands” (Mackintosh &

Koivusalo, 2005, 4) manifesting itself through the provision of and investment in health care through market relationships by for instance private contracting, supply and financing through private insurance and individuals (ibid, 3). By indirectly adopting commercial behaviour, commercialization is similar to commodification, the “increase of private logic within public health systems” (Ferreira &

Mendes, 2018, 2160) in terms of the adoption of marketized principles of management (ibid, 2161;

Toebes, 2006).

The commercialization and marketization of health systems under the neoliberal ideology is currently actively promoted (cf. Mackintosh & Koivusalo, 2005, 3) but should be looked at critically. Already Polanyi (2001 [1944]) wrote about the market and its inherent need for expansion, turning basic elements of society such as land, labour and money into “fictitious commodities” (71ff.), thus commodities not produced to be sold on a market; their increased embeddedness in a way subordinating the very substance of society to market logic (ibid, xxiv; 75). Also, Helmers (2021) describes commercialization trends in health as a subsumption of societal exchange and medical

(22)

11 practices under capitalist logic (ibid, 25²). What place does the health of a person take in a market society and in what ways has it been turned into a fictitious commodity already? To what extent would a market society à la Polanyi desire to make live, and to what extent, to let die?

Harvey (2007) further describes how markets such as health care are created comprising simultaneous privatization and commodification processes by “open[ing] up new fields for capital accumulation in domains formerly regarded off-limits to the calculus of profitability” (35). Yet, these processes often have negative effects on equity, e.g. on the accessibility of care for poor and disadvantaged people (Toebes, 2006; Ferreira & Mendes, 2018). Scholars particularly debate the impacts of (European) austerity policies resulting from the 2008 financial crisis; stating they caused less quality health care, weaker European health care systems and increases in co-payments for drugs etc. (Gaffney &

Muntaner, 2018, 123); or by contrast that they did not affect health gaps caused by disparities in education (cf. Mackenbach et al., 2018).

Sandel (2000) provides two major objections against the commodification of spheres that have previously been external to the market: coercion and corruption. Coercion entails people buying or selling on a market under conditions of inequality or due to economic necessity (ibid, 94); in the case of health care for instance through the common separation between public and often higher quality private health care, the ladder only accessible for socio-economically advantaged groups (cf. Ferreira

& Mendes, 2018); or generally access to health care or medicines. Corruption on the other hand refers to the degrading effect on the “commodity” by way of market valuation (Sandel, 2000, 94). Health care could for instance be compromised through misled reductionism in the understanding and consequently the approach to health care – “commensuration” describes the process how something becomes quantified and simplified (Espeland & Sauder, 2007, 16) – empirically for instance through the introduction of DRG (Diagnosis Related Groups) systems that categorize pathologies alongside fixed allowances (cf. Gooijer, 2007, 178). These developments can lead to a neglect of person-centred health care and needs-based approaches confusing patients with consumers (cf. ibid.; cf. Helmers, 2021).

The biopower attributed with the neoliberal hegemony is not only able to transform cognition around health, it thereby also misaligns responsibilities of health from the public to the private sphere; by way of the subjectivation (“Subjektivierung” (83)) of disease causes³ (Kühn, 2007): according to Christoffersen (n.d.), “health meritocracy” (6) or “the ideology of personal responsibility for health [as a corollary to the political project of neoliberalism] is perhaps more entrenched than ever” (11). This

2 Freely translated by author

3 Freely translated by author

(23)

12 dominant depoliticizing narrative works by blaming poor health among socio-economically disadvantaged groups overly by means of their behaviour such as nutrition, smoking and drinking habits (“moral underclass discourse”) (McCartney et al., 2008, 661). The “redistributionist discourse”

on the contrary proposes structural changes (McCartney et al., 2008, 661) and can be associated with the social justice paradigm.

2.6. The Social Justice Paradigm

As the Global Health Watch 5 (2017) report calls for new paradigms that question the current political order in health governance, this work suggests that such a multi-layered paradigm, or its outlines, already exist when looking at the multitude of supplementary calls from scholars criticizing the role of the market in health, emphasising health determinants and calling for social and environmental justice in health.

This paradigm invites a broader systemic approach around education, housing or employment when facing challenges such as a syndemic (a pandemic correlated with social factors) (cf. Horton, 2020).

Instead of trying to correct individual behaviour, it enhances opportunity structures (cf. Williams, 2007, 14) and focuses more on health promotion and disease prevention (Baum, 2007, 91). It stands for a shift in biopower dynamics to make live by providing the structural, political, socio-economic and environmental conditions needed for people’s and a population’s health to thrive for which political will is considered to be decisive (Ceukelaire et al., 2011, 1; Kickbusch, 2015, 1).

The paradigm includes the right to health which legally only exists vis-à-vis the state, having to ensure the availability, accessibility, acceptability and quality of health care systems, nowadays also via third parties such as private suppliers (Toebes, 2006, 118ff.). It thereby calls for entitlement to health instead of a charity narrative (cf. Kickbusch, 2015, 1).

The social justice paradigm implies to reverse the trend of medicalization (“Medikalisierung”) (Helmers, 2021, 26) which puts social problems into medical responsibility; by way of focusing less on biomedical and economic and more on socially informed knowledge in specific areas around health (ibid). In terms of environmental health for instance, it turns by tendency away from the ‘localist’

model focusing on health data and economic growth to ultimately automatically advance environmental health by reducing “environmental burdens” (485) through technological advances; it rather turns towards the ‘globalist’ model promoting degrowth and systemic changes (Borowy, 2013, 485).

(24)

13 This paradigm demands first, to recognize the need for a discussion about who has and should have the power over resources in health, second, to define health as a political economic issue and third, shift the power to the citizens (Mooney, 2012, 177), thus, to increasingly politicize realms of health governance. Kickbusch (2015) states that engaging in health politics always means discussing the roles of the state, the market and individuals (1). This work adds the exploration of the role of civil society in enhancing and politicizing health equity and environmental health.

2.7. Civil Society

Theories around civil society have been controversially discussed. Historically, the definitions split into two categories (Islamoglu, 2015, 707f.). The first defines civil society as a political community where state and society commonly ensure social harmony (ibid). Gramsci and Foucault’s renowned critical views on how civil society reproduces societal hegemonic consent critically adhere to this unified perspective (cf. Hardt, 1995). The second category, the liberal view, describes civil society as autonomous or standing in opposition to the state (Islamoglu, 2015, 707). Hegel for instance originally distinguished between the “civil” sphere and the “political” state (Hardt, 1995, 5ff.).

The relationship between civil society and the state is investigated critically in this work. In health matters, it is so far described as complementary (e.g. Olafsdottir et al., 2014, 176) and contrasting due to diverging logics of approaching health concerns (Vaeggemose et al., 2018, 128).

In Europe, civil society is mostly represented through civil society organizations, even though there prevails a certain ambiguity of what they currently constitute: While some scholars include community groups, research institutions, workers unions and loose associations (cf. Malinowska-Sempruch et al., 2006, 625), others use civil society interchangeably with non-governmental organizations (NGOs) (Kutay, 2017). Others systematically distinguish them, associating civil society with non-profit voluntary associations and as an umbrella term for various types of associations such as NGOs, and NGOs on the other hand as more political in their specific legal status (Beinare & McCarthy, 2011, 890). Yet, there is consent on the fact that European CSOs are typically engaged in advocacy, service provision, policy and information-related work (e.g. ibid, 892; Olafsdottir et al., 2014, 174). A common narrative describes CSOs as “addressing gaps and cracks” (Phillimore et al., 2019, 361) in health care service provision due to their unique potential to combine medical, social and structural issues, tailoring person-centred health approaches that are often impossible for traditional health agents (ibid, 371).

(25)

14 2.8. Theoretical Knowledge Gaps

This work mainly adheres to the works of Mackintosh & Koivusalo (2005), Mooney (2012), Bambra (2016), Ceukelaire et al. (2011), Kickbusch (2015) and Foucault (2003 [1975/6]).

Civil society in Europe is active in public health (cf. Ceukelaire et al., 2011). It is invested in health equity as political action on poverty and health inequalities constitutes the focus on many CSOs (Kickbusch, 2015, 1). Apart from empirical information, not much literature can be found on European civil society specifically addressing environmental health. Therefore, this work takes an explicitly exploratory stance towards civil society’s role in environmental health.

Moreover, there is not much literature on health or its social determinants from a political economy perspective (Mooney, 2012, 29). Does civil society politicize health equity and / or environmental health? Kauppi & Wiesner (2018) plead for more qualitative research to explore politicization processes and public discourse developments (231). Kickbusch (2015) demands a “serious joint intellectual endeavour” (2) exploring the political side, the political economy of health from a public health perspective, not shying away from complexity, wicked problems, power dynamics, and uncertainty (2). This work represents the first transformative attempt combining the commercialization framework with agency-loaded civil society activity, zooming in on their politicization potential as well as on their role in health equity and environmental health governance.

2.9. Conceptual Scheme

This thesis deploys the concept health equity instead of health equality thereby ensuring a needs- based approach focusing on alleviating health gaps structurally disadvantaging marginalized groups and socio-economically the disadvantaged. Health equity remains thereby defined as “the absence of systematic disparities in health (or in the major social determinants of health)” (Braveman & Gruskin, 2003, 254).

Furthermore, this work adopts the unidirectional environmental health definition as an academic or public health field “that addresses physical, chemical, biological, social, and psychosocial factors in the environment.” (Frumkin, 2016, 45) due to its prominence and this work’s focus on health determinants instead of the environment per se.

Among various related terms, ‘commercialization’ describes the neoliberal manifestation in European public health and the concurrent trends most comprehensively, including privatization tendencies as well as the broader adoption of private market logic in the public sphere (cf. section 2.5).

(26)

15 This thesis is oriented at Raus et al.’s (2018) adoption of the WHO’s definition of civil society⁴: “the space for collective action around shared interests, purposes and values, generally distinct from government and commercial for-profit actors” (3) adding the intrinsic potential of civil society for societal and political change, especially in health (cf. e.g. Ceukelaire et al., 2011). Civil society thereby breaks out of traditional market or state structures, allowing for new political possibilities (Greer et al., 2017, 5).

Figure 1: Conceptual Scheme

Civil Society’s (sub question (SQ) 2) relationship to and (potential) politicizing effect on health equity and environmental health (SQ 5), the core of this thesis, is expressed through the yellow arrow (cf.

Figure 1). Next to perceptions of the two focal topics it includes the perception of the (shadow of) commercialization (SQ 3), strategies and impacts (SQ 4) and space for action (SQ 6). Commercialization is thereby understood as the political economic background against which the political (bio)power play takes place. Politicization is conceptualized and operationalized (Annex 1) as a catalysator, present in the linkages between all concepts and connecting them among each other.

4 Not available anymore on WHO website

(27)

16 2.10. Conclusion

This chapter presents a multi-layered theoretical framework. On a meta-perspective, the dominating neoliberal political economic paradigm contrasts the social justice paradigm. On the intermediary level, the former is manifested in the commercialization of health systems, equipping institutions and actors in the European public health sphere with biopower, thus power in health politics, power to shape health determinants. These decisions are then on the most empirical level affecting health equity and environmental health – which can potentially be politicized and enhanced by civil society, an actor operating mainly outside of the market and the state.

Biopower’s function to make live, to let die, to separate out (cf. section 2.4.) represents the foundation for a critical lens on the inaction or inadequate action of actors holding biopower; action that should be taken towards reducing people’s exposure to death, risk of dying, or to improve the conditions of their daily lives – especially targeted on marginalized groups and minorities. By acknowledging socio- economic and environmental health determinants as inherently modifiable, this theoretical framework suggests that their governance must be addressed as a political issue.

(28)

17

Chapter 3: Research Methodology

3.1. Introduction

To understand the research design and to interpret this work’s intentions and results in the right light, first this thesis’ underlying philosophical assumptions are outlined (section 3.2.) alongside the applied transformative paradigm (section 3.3.). After briefly describing the operationalization of key concepts from chapter 2 (section 3.4.), section 3.5. explicates the units of analysis and observation followed by the introduction of this work’s research design (section 3.6.). Afterwards, the methodological choices and approaches are described including sampling criteria (section 3.7.), data collection (section 3.8.) and data analysis procedures (section 3.9.). The chapter concludes with reflections regarding ethical conduct and positionality (section 3.10.) as well as considerations regarding limitations and quality of this thesis (section 3.11.), rounding up with concluding remarks (section 3.12.).

3.2. Ontological and Epistemological Position

This thesis is based on the ontological post-modernist and constructivist assumption that reality is constructed by the mind and people as social actors cannot know if reality does or does not exist (Robson & McCartan, 2016, 17ff.). This research is primarily but not solely concerned with people’s motivations and the meanings they associate with phenomena. From this view, the question if an (inaccessible) world outside of these meanings exists becomes irrelevant: seeing concepts such as health as constructs without any intrinsic meaning, they are captured as what is ascribed to them by the social world (Babbie, 2007, 125f.). This way, for instance policy documents “objectively” exist, but more importantly, the meaning that has been associated with them has to be interpreted. I therefore adhere to an interpretivist epistemological world view, “grasping the subjective meaning of social action” (Bryman, 2008, 694), whereby social action is grounded in the reality social subjects describe as “objective”. This way, the identified umbrella paradigms in chapter 2 are of course also constructs that help to associate and understand meaning ascribed to privatization processes or civil society action (which in turn constitute other social constructs).

Focusing on these subjective dimensions, I adopt a rather relational than substantialist approach considering terms and units as inherently dynamic (cf. Emirbayer, 1997). Biopower relations evolve and how health equity for instance is perceived and publicly approached is an unfolding process. This relational, interpretivist worldview underlies all overlapping contexts under review. It enables an integration of various theoretical angles on different layers (cf. chapter 2) which ultimately constitute an array of associated social constructs.

(29)

18 3.3. Transformative Paradigm

These underlying philosophical views are not inherent but complementary to the chosen transformative paradigm for this study, adhering to the notion of constructed realities shaped by values (cf. Mertens, 2007). For ‘transformative scholars’, this philosophical worldview does not go far enough, so that in addition a normative purpose is needed at the expense of a more value-neutral, inductive constructivist approach (cf. Creswell & Creswell, 2018, 47). For transformation, it is essential to contribute to the struggle for social justice and to be aware of his or her own (political) position in a reflected manner (Mertens, 2007). I explicitly adhere to this paradigm and its axiology. My definition of a paradigm thereby represents the shared beliefs among social scientists regarding the choice to intentionally emphasize social change and power dynamics in research (Morgan, 2007, 50; Mertens, 2007). The role of civil society is highly political and linked to the power (im)balances between various stakeholders in the field of public health in Europe. Civil society engages in these shifting relational power dynamics and possesses transformative potential for social change, so that the transformative paradigm is perfectly in line with this work’s topic and intentions.

Stating that social change is possible and achievable equips civil society and policy communities with agency. Yet epistemologically, this thesis does not position itself at this unilateral ‘agency’ end of the

‘structure – agency spectrum’ but recognizes crucial structural constraints and conditions, or structure and agency as two faces of one coin (cf. Brock et al., 2017, 152).

3.4. Operationalization of Key Concepts

The concepts in the operationalization table, fully displayed in Annex 1, derive from the theoretical framework and include health equity, environmental health, civil society (in public health) and the commercialization of health systems. The concept of politicization is used as a catalysator connecting the concepts among each other and biopower is not operationalized as an independent concept but as inherent to the politicization catalysator.

As visible in the table, health equity, as relevant for this thesis, is manifested in its dimensions concerning the socio-economic determinants of health as well as their politicization; the same goes for environmental health. Civil society is operationalized according to the dimensions of its motivation (including perceptions), governance, strategies and impacts. The commercialization of health systems is operationalized in line with its theory according to privatization trends and broader commodification processes.

(30)

19 3.5. Units of Analysis and Units of Observation

My unit of analysis, thus the phenomenon I am analysing, is how European civil society politicizes and enhances health equity and environmental health by way of their respective problematization, civil society’s space for action, strategies and impacts. Complementary units of analysis include trends of commercialization of European health systems, the politicization of the two focal topics as well as governance conditions and challenges.

The units of observation, all analysed qualitatively, include policy and framework documents as well as interviews with civil society representatives and civil society document and website content. Even though rhetoric, framing and discourse is looked at, no explicit discourse analysis, but qualitative content and framework analyses are conducted.

Most of the units of analysis are analysed using both strand of data or directly triangulated data such as the comparison of the problematization of health equity and environmental health between policy- related documents and civil society perceptions. The same goes for civil society’s space for action in European public health governance, politicization, commercialization and general governance trends.

Civil society’s strategies and impacts are mainly drawn solely from interview and website data.

3.6. Research Design

Research designs as “types of inquiry” (Creswell & Creswell, 2018, 49) provide strategies for methodological procedures (ibid). The transformative paradigm traditionally adheres to a mixed methods design, defined conventionally as a combination of qualitative and quantitative methodologies, but being not confined to it (ibid, 34; Mertens, 2012).

As explained in section 3.2., the concepts applied to this research are epistemologically regarded as social constructs which must be interpreted so that the meaning ascribed to them can be understood in relation to other social constructs prevalent in our intersubjective world. Understanding these concepts and their complex social meanings requires to explore them in their context. Quantifying them would fragment and simplify their meanings. Hence, this thesis’ underlying philosophical assumptions as well as the complex theoretical multi-angled approach point towards a qualitative research design enabling an improved understanding of the complex meanings society ascribes to phenomena (ibid). Qualitative methods counterbalance the otherwise prevailing emphasis on rather simplistic knowledge based on measurements. Also, the sub questions and the concept operationalization comprise numerous open questions about civil society perceptions and approaches so that methods based on data interpretation are needed. Qualitative methodology strongly supports

(31)

20 the transformative aim, emphasizing the existence and importance of researchers and participants’

values (ibid; cf. Robson & McCartan, 2016). As none of the prominent qualitative research design typologies apply to this case and there anyway does not typically exist an agreed upon structure in qualitative designs (Creswell, 2007, 41), I will refrain from a label and illustrate my methodological strategy in my own words.

Figure 2: Sequential Two-Phase Research Design PHASE 1: EXPLORATORY

PHASE 2: EXPLORATORY AND CONVERGENT

This thesis’ aims to first understand the institutional space around the topics of health equity and environmental health. Looking at how challenges are perceived and addressed and what role civil society plays in this field provides the cornerstone for understanding civil society’s perceptions and

Qualitative Content Analysis of Policy and Framework Documents (Secondary Data Analysis)

- Problematization and approach to health equity and environmental health (SQ 1)

- Health governance approach, including privatization and the inclusion of market-based principles (SQ 1)

- Civil society’s space for action (SQ 6)

- Characterization of civil society organizations, networks, platforms and the field (SQ 2)

- Problematization of health equity and environmental health in context of commercialization (SQ 3) and in governance context (SQ 1)

Strategies and impacts of civil society (SQ 4) Civil society’s space for action (SQ 6)

- Politicization of health equity and environmental health (SQ 5) Semi-Structured Interviews with Civil Society Representatives (Primary Data Collection)

Integrated Framework Analysis of Interview Transcripts and Civil Society Websites and Reports

(Primary and Secondary Data Analysis)

Sampling of policy and framework documents

Inductive and deductive coding, memo writing, grouping, analysis and interpretation according to themes

Sampling of civil society

representatives and their documents

Conduct and

transcribe interviews

Integrated inductive and deductive coding, memo writing, framework analysis table guides subsequent analysis

Integration of text and transcript data:

interpretation

> Triangulate findings

(32)

21 observations– ultimately together one can sketch a picture of how they enhance and politicize the public health fields. The methodological emphasis lies with investigating the civil society perspective – nonetheless without the precondition of being able to embed these views in the respective governance and policy space.

This work uses a sequential and later convergent research approach consisting of two exploratory and complementary sequences (cf. Figure 2). The first phase, exploring the institutional space, sets the stage and is used as input for the main methodological focus: the primary data collection through semi-structured interviews with civil society representatives. Ultimately, the findings from both phases are triangulated. Individual sub questions are partly answered by a combination of the different stages (see Figure 2). The converged methodologies have the same underlying epistemology and context (cf. section 3.2. and chapter 4) even though representing different types of data (cf.

section 3.11.), so that triangulation can take place.

3.7. Sampling

Sampling strategies determine the type of data and eventual character of the study. Refraining from a country comparison, this work’s attention is shifted from national cases towards the comprehensive sketching of trends regarding the commercialization of health systems and the advancement and politicization of health equity and environmental health through civil society. It is impossible within this work’s scope to answer the research question representatively for all 53 countries, but feasible to paint a picture of the current processes.

3.7.1. Sampling of Policy Documents

Policy-related documents were chosen purposive and criteria-oriented (cf. Suri, 2011) and via internet searches: The documents…

1. had to concern either the topic of health equity, environmental health, the commercialization of health or constitute central documents for European health governance in general

2. were chosen in the period from the financial crisis up until now, as this event was crucial for European health governance (cf. chapter 2).

In total, 23 documents were chosen, all concerning the supranational level mostly representing the approaches of the European Commission and the WHO Regional Office for Europe. The documents included policies, thus “high-level overall plan[s] embracing the general goals and acceptable procedures especially of a governmental body” (Merriam-Webster Dictionary, 2021b) which are

(33)

22 mostly expressed through strategic action plans but also indirectly through policy-related framework documents such as statements, charters, fact sheets, policy frameworks, communications and declarations. Thus, the documents’ relevance for the topic was considered more important than their specific document type; the sampling process revealed that document types and their characteristics often overlap and that the exclusive consideration of often thin narrow-defined policy documents would omit crucial data.

3.7.2. Sampling of Civil Society Organizations, Networks and Platforms

Also concerning the “entities” in which civil society is organized, categories overlap immensely. I started to only consider civil society organizations legally recognized as an organization but soon realized that many “entities” such as civil society networks or so-called “action platforms” often do the same work and do not have a significantly different work structure. For reasons of convenience, I will still refer to these various “entities” as “organizations” in a broad sense.

I excluded organizations working for profit or that were associated with political parties – yet, I accepted organizations that received donations from their government and the European Union, also to use this information for the interpretation of potential biases in their responses. Other sampling criteria include that civil society “organizations” require …

1. to work either on global, regional, national or local level if a geographical focus of their work is located in the European region

2. a formal presence in the field of at least 5 years to be capable to provide extensive insights 3. engagement on the topics of health equity, environmental health or against the

commercialization of health systems in Europe

In total, about 100 civil society representatives were contacted, 16 interviewed and 1 interview was excluded as in hindsight, they did not meet the criteria of political independence. Methodologically, I used a purposive internet search (cf. Suri, 2011) having in mind the criteria above combined with

“exponential non-discriminative snow-ball sampling” (BRM Business Research Methodology, n.d., para 5).

3.7.3. Sampling of Civil Society Documents

Civil society documents complemented the interview data but the written information was often accessible in a more structured and detailed form. The “civil society documents” consist of the target organizations’ websites and reports. Next to the internet search showing the organization’s website

An exploration in the context of the increasing commercialization of health systems Civil Society politicizing and enhancing Health Equity and Environmental Health in Europe

Isabel Möller

Civil Society politicizing and enhancing Health Equity and Environmental Health in Europe