The Co-existence of Health Equity and Welfare State

Editorial

The gradual construction of health - as a fundamental right - and equity as an opportunity to reach its full potential, represents the fair and organised way to eliminate systemic disparities in health/well-being resulting from poor overall living conditions between groups with different levels of underlying social advantage/disadvantage and which are determined by biological, political, legal and economic factors; together with the social norms and institutional mechanisms that control the distribution of power, resources and responsibilities. This requires legitimising focused and sustained governance processes that can be summarised in four steps: 1) identify important health/wellbeing disparities; 2) modify and implement policies, laws, systems, environments and practices that balance inequalities in opportunities; 3) evaluate and monitor efforts using short- and long-term actions to mitigate some social constraints and; 4) actively engage stakeholders most affected by disparities, both in the identification and in the design, implementation and evaluation of promising solutions [1, 2].

To help address these health disparities and promote health equity, there is growing evidence on social determinants as drivers of this discourse; however, policy action has not been commensurate. There are multiple barriers to promoting health equity that clearly point to the importance of collective resources that particularly target the most vulnerable social strata and should matter to states and citizens everywhere. These include: the contemporary economic ethos, the biomedical health perspective, difficulties in cooperating across sectors on the issue, and a lack of will and leadership [3, 4].

To try to reverse this situation, policies have been implemented and developed over time in most modern countries under a socio-political and economic model called the welfare state, in which the government or an established group of institutions provide basic individual and social security to its citizens through various programmes that are distributed in a way that is nuanced by the prevailing political ideology of each country. Welfare state policies tend to establish norms about what is desirable in society and how things should be organised; citizens are then likely to adopt these normative motivations and express preferences that are directly or indirectly in line with five key functions: (1) providing security, (2) (re)distributing resources, (3) shaping social stratification, (4) empowering and incentivising, and (5) socialising individuals. Broadly speaking, the range of problems considered is very wide: public health services, education and training, social support services, crime and imprisonment, and issues related to discrimination in relation to age, gender, ethnicity and religion. The basic pillars of social policy (especially income support, health, education, social services and civil rights) [5, 6, 7, 8].

As public expectations have gradually risen, a number of fundamental problems have been identified for today’s welfare states: declining funding, rising costs and dependence on structural growth, increasing welfare demands and political barriers to change. Even in highly developed welfare states, a stagnant picture emerges, where health disparities have widened, partly because redistributive measures have been implemented without taking into account concurrent developments that have changed the composition of socio- economic groups and made the reduction of health disparities dependent on changes in consumption behaviour. This led to increased income inequality, weaker social safety nets and reduced access to citizen services - aggravating quality of life in the long term [9, 10, 11].

In this regard, more numerous, better targeted and long- term redistributive policies have been proposed; increased coverage and access to programmes aimed simultaneously at interacting on multiple social determinants of health; and, above all, community-based and community-driven efforts are needed to alter environmental, socio-economic and cultural conditions in ways that promote health equity [12, 13, 14].

In this Editorial we have briefly discussed some general issues related to the importance of welfare state policies and health disparities, and summarised some premises in order to underpin appropriate policy recommendations for achieving equity. We invite manuscripts that focus on theorising future institutional change in the field of social policy.