Introduction

Equity in health is about everyone attaining their full health potential by not experiencing avoidable circumstances that would prevent this. 2 Promoting health equity through the enactment of public policy that equitably distributes the social determinants of health and provides access to health care is a dominant theme in public health literature across the globe. 3 Achieving such equity has become increasingly difficult in this era of neoliberalism and this is especially the case in nations identified as liberal welfare states such as Canada, the United States of America (USA), and the United Kingdom (UK)4–7 Neoliberalism is problematic for health as it advocates free market capitalism involving retrenchment of the welfare state, privatization of public institutions, imposition of austerity, and deregulation of business practices, all identified as threatening health. 4

There are different approaches to understanding how public policies are developed and implemented which are relevant to achieving health equity.8,9 These include pluralist approaches to policy change that assume that transmitting ideas and research findings to governing authorities will lead to progressive change. Another approach posits that institutionalist analyses of governmental structures that shape the making of public policy will facilitate authorities’ responsiveness to change. Finally, there are a variety of political economy models that offer insights into how economics and politics inform public policymaking that shape the distribution of resources necessary for health and the organization and delivery of health care.

We argue that even then, the scope of many of these political economy models is limited to critique of existing circumstances and fail to offer an alternative to the capitalist economic system that is responsible for the lack of health equity. These pluralist, institutionalist and political economy approaches have not been particularly successful in achieving health equity in the liberal welfare states of Canada, USA, and UK where the market, rather than the state, is the dominant societal institution.4,10–12

In this article we argue that achieving health equity requires recognition of the inherent contradictions -- common to all forms of capitalist welfare states – between the core requirement of capitalist economies of capital accumulation or profit making and social reproduction or the ongoing functioning of society.13,14 We see these contradictions as having become so great in Canada, the USA and UK as to have created a polycrisis in the quality and distribution of the social determinants of health and the organization and delivery of health care. Amidst this polycrisis, promoting health equity is difficult, if not impossible.15,16

We provide three paths forward for promoting health equity in these nations: (1) increasing redistribution and social spending by governments and managing the market economy within existing economic and political structures; (2) moving towards social democratic or conservative models of governance common to the Nordic social democratic and Continental conservative nations respectively; or (3) building a post-capitalist socialist future. Of these three paths, we argue that the third – movement towards a post-capitalist socialist society – is the preferred way forward. A substantial body of literature in the critical materialist stream of political economy (defined below) literature supports this view and is making its way into mainstream health equity discourse.