Political Economy of Health

Political economy of health approaches consider health and health care as shaped by the relationships between individuals and societies, markets and the state, and economic and political systems.35,36 The origins of political economy are in the writings of seventeenth- and eighteenth-century philosophers James Stuart, Jean-Baptiste Colvert, Adam Smith, David Hume, and Francois Quesnay. 37 These works emphasize the role of the market over the state in promoting well-being with the best example being Adam Smith’s famous notion of the ‘invisible hand,’ whereby state policies are less effective in advancing social welfare than the self-interested market exchanges of individuals. 38 These market-oriented ideas dominate contemporary governing authorities’ and public discourses on the role of markets and states in producing and distributing resources in capitalist societies. These dominant approaches do not consider how the class interests of the business and corporate sector take precedence over those of workers or those unable to work because of lack of jobs, illness, disability, or discrimination.

Considering this neglect of class issues, it is surprising that many in the health equity field usually assume that the “political economy of health” is concerned with addressing imbalances in power and influence that block the promotion of health equity.36,39 But as noted by Harvey:When political economy is invoked in the [public health] literature, it is not always explicitly defined. In those instances when it is defined, no standard definition is evident. This is especially problematic because various theoretical traditions that employ the term “political economy” -- such as Keynesian, neo-classical, neoliberal, institutional, rational choice, and Marxian—approach questions of political economy in often widely discrepant ways. 40 (p. 294)

We employ the stream of political economy identified by David Coburn as critical materialist political economy (CMPE). 41 As a political economy approach CMPE is concerned with economics and politics. CMPE is materialist in that it sees societal structures and processes as shaped by material relations of power and influence organized along class lines. Therefore, resource production and distribution – including the social determinants of health and health care -- emanate from these relations. A materialist analysis also sees the ideas a society and its members hold about the nature of society, health, and health care as shaped by these same material conditions.42,43

CMPE is critical in that it posits that people within society may not have accurate understanding of how their society actually works. If they do not, CMPE aims to shift these views such that they can now ask how things could be different. Thus, CMPE examines how the material conditions of life – the economic base of society -- shapes the political structures and processes of a society and the dominant ideas – the superstructure – common to a society. 44 CMPE has proven useful in explorations of the quality and distribution of the social determinants of health,45–47 the sources of food insecurity, 48 women’s employment, 49 children’s health and well-being, 50 policymakers’ perspectives on health equity, 51 the role of polemic in public policy change, 52 the commodification of knowledge work, 53 the organization of call centres in India, 54 and the environmental crisis. 55

Within CMPE, two key mechanisms are capital accumulation -- or profit making -- and social reproduction -- or the wellbeing of society. When out of balance, they produce contradictions that makes the achievement of health equity difficult, if not impossible. We see the contemporary form of capitalism – neoliberal global capitalism – as producing contradictions of such magnitude that a polycrisis of both health determinants and health care now exists.

One example of the value of a CMPE approach – although not so named at that time -- is seen as early as 1979 in Doyal and Pennell’s volume The Political Economy of Health which examined in detail the adverse effects of capitalism upon health and the need to replace it:It follows from this that the demand for health is in itself a revolutionary demand and one which must be taken seriously in the broader struggle for socialism in both developed countries and the third world. 56 (p. 297)

Many CMPE concepts such as the health impacts of neoliberalism;57–61 how corporate power and influence shape health;62–68 the commercial determinants of health;69–76 financialization;77,78 and even the adverse health effects of capitalism79–87 are now part of the health equity literature.

However, unlike Doyal and Pennell, 56 most of these analyses are limited to critiquing capitalism and proposing means of managing its adverse effects. There is infrequent analyses of how these structures and processes are integral to capitalist economies such that what may be required for achieving health equity is radical transformation or replacement of the capitalist economic system. Indeed, frequently works on health equity and the social determinants of health often do not even mention capitalism or socialism or do so in passing.88–98 Why is this the case? In the words of primary care physician, historian, and sociologist Howard Waitzkin:Most of us find that it is difficult to imagine a viable path from capitalism to post-capitalism (the ‘TINA’ perspective, that is, “There Is No Alternative”). Because it is hard to imagine a viable path from capitalism to post-capitalism, most people addressing our world’s challenges assume that capitalism will continue to exist. Therefore, we engage in peculiar ways of struggling to improve our most important problems without confronting capitalism, even though we recognize that capitalism generates these problems and continues to make them worse. 99 (p. 1)