It has been increasingly accepted that social determinants of health play a key role alongside material determinants in influencing overall health and health inequality.¹ While this realisation has added a new dimension to the field of health research and policy, we are still a long way from achieving a comprehensive understanding of the causes of, and the solutions to health inequalities. One important reason for this is our limited view of the underlying factors. Virtually all causal models of health status and health inequality that have been used as a basis for policies and strategies take a restricted view of causation, focusing pragmatically on mid-level social determinants, which can be readily measured and/or which are hypothesised to be readily amenable to intervention. Actually however, in terms of the upstream–downstream metaphor,² most major proposals for addressing or eliminating inequalities in health are located too far downstream to do more than address the immediate symptoms or effects of inequality, as opposed to tackling and eliminating the root causes.

It has long been clear that one missing link is the political dimension.^3–7 Despite the near-universal acknowledgement that key elements of politics—such as government, ideology, power and authority—have important impacts on the distribution of a very wide range of health outcomes, researchers have seldom drawn explicitly on the rich discipline of political science (the systematic description and analysis of politics) for concepts or theories which will aid our analysis of current and historical public health policies and practice.

This glossary reflects a (re-)emerging awareness, within the field of public health, of the political dimension of health and health inequalities, and it also attempts to define some of the key concepts from the political science literature in a way which will be of use in future public health analyses. Examples from different domains (healthcare and population health) are provided to highlight how political concepts pervade health.

Words that are underlined are defined in this glossary. Furthermore, as will perhaps become apparent in this glossary, the definition of politics (and of political concepts) is in itself a political act.⁸ Our own selection and definition of terms is therefore somewhat inevitably guided by politics, reflecting our own realistic epistemological position, and particular perspectives; subsequently, this is “a” not “the” politics of health glossary.

AUTHORITY AND LEGITIMACY

Authority is the right to influence the behaviour of others and to obtain compliance through a perceived legitimacy. Governments can thereby have authority regardless of whether they are actually obeyed. Conventionally, authority is contrasted with power. However, in Weber’s concept of legitimate power, authority is actually equated with power. Therefore, any government that is obeyed exercises authority. In the absence of authority, governments can only ensure obedience and order through violence. Authority is often interlinked with the concept of legitimacy. In simple terms, legitimacy means rightfulness; the right to be obeyed and to exercise authority.⁹ Many government health-promotion interventions attempt to influence behaviour on the basis of authority and legitimacy.

CAPITALISM

In its pure form, capitalism refers to any political–economic system in which a free market operates, private property exists, profit is generated through the production of goods and most individuals sell their labour for wages. There is no role for the state. In capitalism, as it actually exists, however, the state is usually a property owner and an employer, and it often acts as a regulator—to provide the optimum economic and political conditions under which profit can be maximised (often on a nation state basis) or to moderate some of the excesses of the system such as poverty and inequality. In this way, the extent of state’s involvement in minimising the adverse effects of capitalism can have a vital impact on health inequalities.¹⁰

CITIZENSHIP

Natural or human rights are those to which people are entitled by virtue of being a human being. Other rights are usually associated with citizenship. Citizenship is “a status bestowed on those who are full members of a community. All who possess the status are equal with respect to the rights and duties with which the status is endowed.”¹¹ There are three types of citizenship rights: civil (freedom of faith, thought, speech and contract), political (right to vote and to be a representative) and social/welfare (right to education, health and income maintenance). Citizenship also entails obligations, such as to pay taxes or to respect others’ rights. Health, or the “right to a standard of living adequate for health and well-being”,^12,13 is an important social citizenship right. Citizens of non-welfare state developed societies, of most dictatorships and of the world’s poorest nations are denied this fundamental right. This is most apparent in the more extreme examples—such as the 45 million US citizens lacking health insurance. However, so-called welfare states may also restrict these rights—as in the UK National Health Service, where access to healthcare is rationed through high charges for drug prescriptions, dentistry and optometry services.

CIVIL SOCIETY

Civil society is used to describe the institutions and organisations, which, while separate from formal government and the state, nonetheless exert authority and influence. Civil society consists of organisations and institutions including schools, hospitals, churches, political parties, trade unions, mass media, cultural and voluntary associations. Generally, the term does not include the institutions and apparatus that make up the state. However, whether civil society is separate from (or a part of) the state, is a contested matter.¹⁴ The fashionable concept of social capital is centred on the hypothesis that public engagement with the agencies of civil society is beneficial for health and quality of life.¹⁵

DEMOCRACY

In a literal sense, democracy means rule of the people (from the Greek terms demos and kratos). Democracy takes two forms, direct and indirect. It is direct democracy that is most closely derived from the Greek model as all citizens participate in decision making and policy making. Modern models of direct democracy include: participatory democracy in which there is widespread use of advisory referendums and public consultations, and industrial or economic democracy in which workers own companies and/or are involved in decision making.¹⁶ It is, however, indirect democracy in which representatives are elected, which has been the more common model. This is especially the case under Western capitalism where liberal democracy combines representative democracy with the liberal citizenship rights of private property, economic freedom, political equality and limited government.¹⁷ It has been suggested that economic democracy is beneficial for health.¹⁶

EQUALITY

Equality is conceptualised in a number of ways: formal equality, equality of opportunity and social equality. In formal equality, all humans are equal under the law regardless of their personal characteristics (such as religion, race or gender) and have an equal right to do as they wish.¹⁷ This approach, however, is rather limited as it does not acknowledge the restrictions placed on exercising equal individual rights by wealth, social norms or abilities. For example, in most countries all citizens have the formal right to medical treatment but not all can afford to exercise this right. Equality of opportunity focuses on this wider context and advocates removing social barriers, that prevent all citizens from having the same initial opportunities to progress their natural abilities—that is, an equal social opportunity to become naturally unequal.¹⁸ Social equality instead focuses on equality of outcomes such as wages or living conditions.¹⁹ Redistributive equality aims to reduce social inequalities in outcomes by the redistribution of wealth, whereas absolute social equality requires the abolition of all private ownership. Research into redistributive equality has suggested that health and violence are worse in more unequal societies.^16,20,21

FREEDOM

There are two major approaches to thinking about freedom: negative (freedom from) and positive (freedom to). Negative freedom is associated with the absence of constraints on the individual (including those imposed by government), formal equality and legal rights. Negative freedom is associated with liberal market economics, choice and the minimalist state.²² In contrast, positive freedom is not only the right to do something, but also the ability and opportunity to do so.²³ This conceptualisation of freedom is commonly associated with justifications for state intervention—the welfare state enhances freedom by liberating individuals from social disadvantage.⁹ Another positive definition of freedom, derived from Marx, is freedom as lack of alienation made possible through the communal satisfaction of need in a classless society.²⁴ The freedom to choose perspective in debates about healthcare reform,²⁵ therefore, reflects a negative conceptualisation of freedom.

GLOBALISATION

Globalisation is a process through which national economies are becoming more open, and are thus more subject to supranational economic influences and less amenable to national control.²⁶ Globalisation differs from the more longstanding process of internationalisation, whereby certain elements of the economy such as trade are international, while the principal economic units remain national. So, for example, in an internationalised economy, multinationals still have a clear national base within one country and are regulated by the laws of that country; in contrast, in globalisation, production is transnational and corporations become stateless and almost impossible to govern.²⁶ Furthermore, globalisation is not simply a market-driven economic phenomenon, it is also—and very much—a political and ideological phenomenon.^26,27 The emerging effects of globalisation—increased competition and the subsequent decrease in national discretion over domestic economic policy, the breakdown of national coalitions and support for the welfare state, and the hegemony of neoliberal ideology—are important for the future funding of healthcare.

GOVERNMENT

To govern is to rule or exercise control over others. More narrowly, government relates to a set of institutions which together make (legislative), implement (executive) and interpret (judicial system) policies and laws.⁹ There are different types of governments including democratic, authoritarian and totalitarian with correspondingly different health outcomes.²⁸

HEGEMONY

Hegemony is a very sophisticated political concept, associated largely with Gramsci.²⁹ He used the term to describe a relation between classes: a hegemonic class (or part of a class) is one which gains economic dominance and—crucially—the consent of other classes and social forces, through creating and maintaining a system of alliances by means of political and ideological struggle.³⁰ Hegemony represents not only immediate political and economic control, but also the ability of the ruling class to maintain dominance by projecting its own ideological vision of the world so that it is accepted as natural and common sense (thus assertions that “there is no alternative” to the market in terms of reforming healthcare provision).

IDEOLOGY

Ideology is a system of inter-related ideas and concepts that reflect and promote the political, economic and cultural values and interests of a particular societal group.³² Ideologies, like societal groups, are therefore often conflicting and the dominance of one particular ideology within a society to a large extent reflects the power of the group it represents. Ideology can be used to manipulate the interests of the many in favour of the power and privileges of the few.³¹ So, for example, liberal democratic ideology with its emphasis on the individual, the market and the neutral state, can be seen as a reflection of the power of business interests within capitalist society.²⁹ A hegemonic (ie, universally prevailing) ideology is usually one that has successfully incorporated and cemented a number of different elements from other competing ideologies and thereby fuses the interests of diverse societal groups and classes.³² There is emerging evidence that ideology plays a key role in determining mortality and population health.³³ Much more research is required to clarify causal linkages and develop appropriate interventions.

NEO-LIBERALISM

The crisis of the welfare state in the late 1970s led to the re-emergence of liberal economics (eg, the Thatcher and Reagan governments): neo-liberalism (neo meaning new). Neo-liberalism resurrected market economics and emphasised the importance of the free market vis-à-vis state intervention, deregulation of the economy, cuts in public expenditure (welfare state retrenchment), privatisation of state-owned companies, flexible working practices, and an increased emphasis on the individual and the family compared to the wider society (with a corresponding rise in the emphasis placed on traditional morality and responsibility).^26,34 Neo-liberalism is strongly associated with the US, but with economic globalisation it has increasingly become an almost universal hegemonic ideology, the effects of which can be seen in the policies of numerous developed and developing countries. For example, in England the Blair government has created a healthcare market by providing financial incentives to ensure competition between public and private providers of NHS clinical services (http://www.KeepOurNHSPublic.com).³⁵

PATRIARCHY

Patriarchy describes the institutionalisation of male supremacy within civil society, the (capitalist) economy and the state. Patriarchy has been described as “a relationship of dominance and subordinance … sturdier than any form of segregation and more rigorous than class stratification, more uniform and, certainly more enduring”.³⁶ More simply, it is defined as the systematic domination of women by men and domination of men by other men.³⁷ It has been used to analyse the nature of male–female relationships and their effects on adverse social and economic outcomes for women, and more recently for men.³⁸ In terms of health, cross-national research has demonstrated a strong association between the extent of patriarchy and the male mortality rates in a country.³⁹

POLITICS

There are at least four widely used definitions of the political^7,40:

• Politics as government: politics is primarily associated with the art of government and the activities of the state.

• Politics as public life: politics is primarily concerned with the conduct and management of community affairs.

• Politics as conflict resolution: politics is concerned with the expression and resolution of conflicts through compromise, conciliation, negotiation and other strategies.

• Politics as power: politics is the process through which desired outcomes are achieved in the production, distribution and use of scarce resources in all the areas of social existence.

Healthcare is considered to be political only if the first definition is used, whereas in the last definition all aspects of health, including health inequalities, form part of the political system.⁷

POWER

At the general level, power is about the ability to achieve a desired outcome—power to do something—but more narrowly, it is used to mean power over something or someone and to make decisions.⁹ Influence is the external ability to have some effect on the content of these decisions. Research has linked lack of power and control with premature mortality and the social gradient of health.¹

SOCIAL JUSTICE

Social justice “stands for a morally defensible distribution of benefits or rewards in society … it is therefore about who should get what”.⁹ Three aspects of social justice have been identified: to each according to need, to each according to right and to each according to deservedness.⁴¹ In social justice according to need, material benefits such as income, housing, health services and so on, should be allocated on the basis of human need alone.⁴² In social justice according to rights, associated with liberal democratic ideology, distribution within society is based on individual worth: those who work hard have the right to what they have earn (eg, a right to own property).⁴³ In the conceptualisation of deservedness, distribution is based on moral worth and natural justice. Distribution reflects individual endowments and abilities, and attempts to intervene are against the laws of nature.^44–46 Health has been identified as a basic need, and therefore as an issue of social justice (according to needs).⁴⁷

STATE

Like many of the other concepts in this glossary, the state is an “essentially contested concept”.⁴⁸ There is, therefore. no agreed definition of the state, although perhaps the most widely used is the narrow liberal democratic pluralist theory of the state as simply the institutions of central and local government, the police, the army and the civil service. The state is considered to be neutral and independent—above any party political disputes or the conflicts of economic interests. Political power is therefore dispersed among a wide variety of social groups that compete with one another for dominance and control over the independent institutions of the state. The state can also be seen as the embodiment of the collective will. On the other extreme, though, Marxists (most notably Althusser) broaden the parameters of the state to include many aspects of civil society including schools, the healthcare system, the professions (such as medicine) and the media.¹⁴ Disputes about the role of the state underpin many discussions about healthcare—that is, how much should be publicly provided (by the state), and even health status—individual versus collective (state) responsibility.

WELFARE STATE

Countries described as welfare states are usually those in which a substantial proportion of welfare is regulated, provided or paid for through the agency of a formal and institutionalised public welfare system.⁴⁹ Conventionally, the phrase “welfare state” has been used in a narrow sense, as a shorthand for the state’s role in education, health, housing, poverty relief, social insurance and other social services.⁵⁰ However, other commentators prefer to use a broader definition of the welfare state as a particular form of state or a specific type of society—social democratic.⁴⁹ In this conceptualisation, the term is now used only to refer to countries (such as Sweden or Norway) in which there are public commitments to full employment, and a universal benefit system.⁵¹ Social democratic welfare societies (such as Norway or Sweden) have higher life expectancy and a less stark social gradient of health than other developed countries.²¹