What is a National Health Policy?
Vicente Navarro, posted on Spirit of 1848 listserv, March 6, 2007
(Note - This article is modified from a speech
delivered by Vicente Navarro to the International
Association of Health Policy, Barcelona, Spain,
August 21, 2006. The article has benefited from
comments by Bo Burström and Margaret Whitehead.)
Unfortunately, most nation states have taken
"health policy" to mean "medical care policy."
Medical care, however, is only one variable in a
nation's health equation. The article describes
what the main components of a national health
policy should be, including (1) the political,
economic, social, and cultural determinants of
health, the most important determinants of health
in any country; (2) the lifestyle determinants,
which have been the most visible types of public
interventions; and (3) the socializing and
empowering determinants, which link the first and
second components of a national health policy:
the individual interventions and the collective
interventions. The author discusses the
indicators that should be used for each component
and for each intervention. The feasibility of
this approach depends to a large degree on the
political will of the national authorities and
the broad understanding of the actual
determinants of health. A good first step is the
National Health Policy plan developed by the
Swedish social democratic government. This
article builds on and expands on that model.
A key objective of a national health policy
should be to create the conditions that ensure
good health for the entire population. Needless
to say, all sectors and agencies in society
should be responsible for creating those
conditions, but the primary responsibility for
ensuring the conditions for good health lies with
the collective agencies that represent the
interests of the population (freely expressed
through democratic institutions)-that is, the
public authorities and their public
administration. Government (at the national,
regional, and local levels), therefore, is the
primary agency responsible for developing a
national health policy. What are the major
components of a national health policy? There are
three main types. The first includes public
interventions aimed at establishing, maintaining,
and strengthening the political, economic,
social, and cultural structural determinants of
good health. They are called structural because
they are part of the political, economic, and
social structure of society and of the culture
that informs them. Although rarely listed in most
national health plans, these are the most
important public policies in determining a
population's level of health. Indeed, there is
very robust scientific evidence that shows, for
example, that countries with lower class, race,
and gender inequalities in standard of living
also have better levels of health for the whole
population (1). Public policies aimed at reducing
social inequalities, therefore, are components of a national health policy.
The second type of intervention includes public
policies aimed at individuals and focused on
changes in individual behavior and lifestyle.
These lifestyle determinants are also very
important and have been the most visible among
national health policies. One reason for the
higher visibility of interventions of this type
is that health policy makers perceive them as
more manageable and easy to deal with than the
first type, the structural determinants. However,
we cannot exclude the possibility that another
reason for this difference in visibility and
frequency is that the lifestyle determinants
focus the responsibility for a population's
health on the individual rather than on the
public institutions that are primarily
responsible for the structural determinants. This
is one reason why conservative and liberal
governments (and also, on many occasions,
progressive governments) tend to emphasize this
second type of intervention over the first type
(which is actually more effective in improving a population's health).
The third type of public intervention, which I
would call socializing and empowering
determinants, links the second type (lifestyle
determinants) with the first (structural
determinants). Socializing and empowering
interventions establish the relationship between
the individual and the collective
responsibilities for creating the conditions to
ensure good health. This type of intervention
would include the encouragement of individuals to
become involved in collective efforts to improve
the structural determinants of health, such as
reducing the social inequalities in our societies
or eliminating the conditions of oppression,
discrimination, exploitation, or marginalization
that produce disease. For example, encouraging
individuals who are exploited to respond to that
exploitation, not only individually but also
collectively (with other persons who are
similarly exploited), is an extremely important
health policy intervention, linking improvement
of the individual's health with improvement of
the health of the exploited population.
Examples of these socializing and empowering
determinants are many. For example, when the
Black Panthers took over parts of the black
neighborhoods in Baltimore (a city with a
population that is 75% African American) in the
1960s and early 1970s, mobilizing unemployed
black youths, drug addiction declined
dramatically among the young, and also among the
entire black population of East Baltimore (2).
Another example is what occurred among coal
miners in Appalachia (West Virginia) in the
1970s, when they mobilized and went on strike to
protest unhealthy working conditions (3). They
paralyzed mine operations for several months,
creating a situation in which the mine owners and
employers almost lost control and called for the
Army to take over the mines. In that
mobilization, each miner fought not only
individually but collectively to improve the
health of all coal miners and, in that struggle,
their own health improved as well as the health
of the entire population. As both cases show,
facilitating the linkage of the individual's
fight for better health with the collective
struggle for better health is an extremely
important public intervention for improving the population's health as a whole.
Empowering vulnerable populations is thus an
essential component of a national health policy.
Educating people to act not only individually but
also collectively, making them aware of the
commonality of their problems and encouraging
them to act both individually and collectively to
resolve them, is an important dimension of a
national health policy. Indeed, the linkage of
the individual with the collectivity is an
important function of public health
interventions. Let's analyze each type of intervention in more detail.
STRUCTURAL DETERMINANTS: POLITICAL, ECONOMIC,
SOCIAL, AND CULTURAL HEALTH POLICY INTERVENTIONS
The agents that carry out interventions of this
type are collective (i.e., they are not
individual persons), including political parties,
trade unions, neighborhood associations, and
others. The subjects of these interventions, too,
are not individual persons but public and private
institutions whose actions affect the conditions
that ensure good health for the entire
population. These interventions can be summarized as follows.
Public Policies Aimed at Encouraging Participation and Influence in Society
These extremely important interventions are aimed
at facilitating the development of institutions
and practices that create the conditions for
persons (as members of social classes, genders,
races, ethnic backgrounds, regions, or nations)
to make decisions about and control their own
lives. Interventions of this type are aimed at
establishing institutions and practices that
minimize popular alienation and
powerlessness-conditions that cause a huge amount
of pathology and ill-health (4). Of particular
importance are interventions aimed at providing
political and social instruments (such as
political parties, trade unions, neighborhood
associations, social movements, patients' groups)
for the population and its different components.
These instruments then facilitate and stimulate
the population's active involvement in its
members' political and social lives, deciding on
the matters that affect their lives. Of special
importance is the existence of political and
social instruments that enable groups who feel
marginalized, discriminated against, oppressed,
or exploited to defend their interests, because
breaking with such conditions is a key element
for the full realization (including good health)
of these populations. It is important, however,
for these groups to establish alliances with
other groups that experience similar conditions,
thus broadening their social base to strengthen
their power. In that respect, the segregation of
the political actions of such groups-as in the
United States, which has many "issue-oriented
movements," such as feminists, seniors,
minorities, and others, but no strong class-based
movement or party such as a social democratic or
labor party that could relate different types of
exploitations-can result in less improvement of
health than if there were a larger political
party and movement that could mobilize across
issues. Women, seniors, and African Americans and
other minorities in the United States have fewer
social and health rights and worse health
indicators than their counterparts in countries
with less powerful women's, seniors', or minority
movements but larger class-based labor
movements-as in Sweden, for example (5). To make
this observation (empirically verifiable) is not
to engage in class reductionism but rather to
clarify that most women, seniors, and minorities
are among the working classes, and if these
groups combined their struggle for better health,
working within common political and social
instruments, they could achieve greater influence
and power. Actually, there is robust scientific
evidence for a direct relationship between
duration of governance of a country by labor
parties and the improvement of its population's
health (6). Indicators of these determinants of health are as follows:
1. Indicators of class, gender, and race power,
such as years of government by progressive
political parties, strength of class-based unions
(as opposed to business-based or corporatist unions), and others
2. Types of democratic institutions facilitating
representativeness, such as proportional
representation (based on the principle of one person, one vote)
3. Absence of barriers to electoral participation
4. Ideological diversity and plurality of the
media plus accessibility to the media, for all sectors of the population
The limited existence of these elements (as in
the United States) considerably constrains the
possibility of a population breaking with
alienation and achieving good health. In
developed countries, in fact, the evidence shows
that the more democratic a society is, the
healthier it is (6, p. 234). The poor health
indicators in the United States are also based on
its very limited democracy (7). If people feel
they have good, representative institutions and
instruments, they feel better and more confident
that they can control their own lives and improve
their health. The fact that the majority of
people in Sweden feel positive about their
representative institutions (with high electoral
participation) while the majority in the United
States feel negative about their representative
institutions (with very low electoral
participation) explains the lower rate of
alienation and powerlessness in Sweden than in
the United States (8). This has enormous
consequences for the health of the populations
living in these countries: very good health
indicators in Sweden; very poor indicators in the United States.
Economic and Social Determinants
These are the interventions that aim at creating
security and facilitating accomplishment. They include the following.
Full-employment policies aimed at creating good,
well-paid, satisfying jobs. High or full
employment is good for everyone's health,
including those who are not employed. Access to
plenty of jobs gives everyone a greater sense of
security-including those who do not currently
have a job (because they feel they could easily
get one if they wanted to)-than does a high
unemployment or low employment rate. Not being
able to work because one cannot get a job creates
huge health problems (9). These unhealthy
consequences of unemployment are due not only to
lack of resources but also to the feelings of
insecurity that unemployment entails. Indicators
of full-employment policies include:
1. Percentage of adult population working, and
extent of wage differentials in the labor force
2. Levels of unemployment
3. Long-term unemployment
Social security and welfare state policies
provide a sense of security to people who are at
risk, providing them with the instruments,
knowledge, practice, and resources to feel secure
and have a chance to progress. The indicators of
these interventions are the social rights in
existence in a society (access to medical care,
education, home care, child care, social
services, public housing, and pensions for
elderly persons and people with disabilities) and
the resources for developing these rights.
Populations of countries with higher social
rights and public social resources (including
public funds and legislative power) are healthier
than those of countries with lower social
protections (1). Indicators of such policies are:
1. Percentage of elderly people and people with
disabilities who get good public pensions
2. Percentage of population covered by public
medical care, and resources for public medical care
3. Percentage of children in public child care
and pupils/students in primary, secondary, and
tertiary education (including vocational and
university education), and public resources invested in these services
4. Percentage of elderly people and people with
disabilities who receive home care services, and
public resources invested in these services
Policies on Reduction of Inequalities
Policies that reduce social inequalities
(including income inequalities) by class and by
gender, race, ethnicity, and region diminish the
distance between social classes (and
occupational, educational, and income groups
within each social class) as well as between
genders and among races, ethnic groups, and
regions. Social inequalities can generate
pathology and reduce the opportunities for
persons to become healthier (10). Policies on
reducing inequalities should include measures
aimed at diminishing the social distances among
all classes and groups, not only between rich and
poor. There is strong empirical evidence that the
most effective intervention to save lives and
decrease mortality would be one that guaranteed a
mortality rate for all social classes that is the
same as that of the upper class (11). In this
sense, antipoverty programs and programs aimed at
preventing social exclusion (which characterize
the Blair government's approach to reducing
inequalities in Great Britain) are very important
components of inequality-reducing policies, but
they are just one component, and not the most
effective. Policies aimed at reducing
inequalities among all sectors of the population
(that is, universal policies rather than
antipoverty or anti-exclusion policies), such as
those carried out by the social democratic
governments in Sweden, are more effective in
reducing mortality and morbidity (including among
the poor and/or excluded groups) than are
poverty-oriented policies (12). Key indicators for these types of policies are:
1. The redistributive impact of public
interventions by the welfare state (e.g., changes
in income distribution measured by the Gini or
Theil indicators, before and after welfare state
interventions). These public policies, enacted to
reduce social inequalities, should be part of a
broader policy directed at the causes of these
inequalities, including the reduction and
elimination of relations of oppression,
discrimination, exploitation, and domination.
2. Changes in the percentage of national income
derived from salaries. Empirical evidence shows
that countries with a greater amount of income
derived from property and a lesser amount from
labor have worse health indicators. In this
respect, the United States and Sweden represent
the two ends of the spectrum (6). Policies aimed
at reducing the percentage of income derived from
capital and policies aimed at increasing the
percentage derived from labor, as well as fiscal
and economic policies aimed at redistributing
resources, are effective in improving the health of populations.
Cultural Interventions
Cultural interventions are aimed at creating a
culture of solidarity rather than a culture of
competition. A strong sense of competition
creates enormous insecurity and stress, which
produces a lot of pathology. This was shown when
Thatcher's liberal policies were established and
developed in Great Britain, with a consequent
fall in the rate of mortality decline across all
age groups (13). A culture of high competition
that focuses on individual competitiveness
(reflected in the slogan "everyone should fly on
their own") is unhealthy, because this creates anxiety and frustration.
Some cultural traits can also be very unhealthy,
such as the excessive commercialization of
society and the preponderance of the values of
egocentrism, narcissism, consumerism, violence,
and hedonism, which also create stress and
frustration. This value contamination, one of the
worst public health problems in society, should
be a wakeup call for public authorities to
intervene in the value-generating systems-from
the schools to the media-to discourage and
eliminate unhealthy values. The definition of
beauty as "young and sexy," for example, is very
exploitative; it generates great frustration
among the majority of people who are not young or
sexy (but feel they must strive to appear so in
order to be accepted in our society). Also, the
ubiquitous presence, in most countries, of
members of the upper middle class as the main
characters in television programs creates
frustration among viewers, most of whom are
working class (whose lives are rarely presented
in the media). Indicators of cultural interventions include:
1. Number of educational programs that embrace
solidarity rather than competition
2. Degree of violence in television programs
3. Degree of reproduction of class, race, and gender stereotypes in the media
Healthier Working Life Interventions
These interventions aim at creating safe,
satisfying, creative, and enjoyable work. There
is strong evidence to suggest that the nature,
type, and conditions of work are among the most
important variables determining a population's level of health (3).
Indicators of healthier working life interventions include:
1. Self-reported work-related health status
2. Index of accumulation of risk factors
3. Index of job strain and job conditions
4. Index of workers' satisfaction with their work
5. Workers' self-perceived level of control over their working conditions
Environmental and Consumer Protection
This protection is aimed at improving the
physical environment for workers, consumers, and
residents, thus ensuring conditions that protect
and promote health. Indicators of such interventions include:
1. Percentage of population exposed to unhealthy noise levels
2. Nitrogen dioxide levels in outdoor settings
3. Levels of persistent chemical substances in breast milk
4. Injury incidence (deaths, and numbers of
injured treated in medical care institutions) per
100,000 workers in different environments
Secure and Favorable Conditions During Childhood and Adolescence
Interventions of this type are among the most
effective ways of reducing poverty and preventing
social exclusion. Here, again, there is plenty of
evidence that children and adolescents in
families that are poor feel excluded (14). It is
therefore of great importance to provide good
remedial education from birth to age 18
(including good child care services) and good
jobs for parents (especially for single mothers)
in order to prevent social exclusion. Indicators
of such types of interventions include:
1. Percentage of children (ages 0 to 3 years) in
public child care centers, by social class
2. Level of education of preschool children
3. Percentage of youngsters who finish primary
and secondary school and enter and complete tertiary education, by social class
4. Indicators of students' and teachers' influence in the schools
Health Care Interventions That Promote Health
These policies should emphasize public health
interventions, both outside and within medical
care services that cover the entire population.
The medical care services should be designed in a
way that facilitates access, comfort, and
satisfaction for users and the population at
large. Also, health promotion should be a key
element of the medical care system, and all
health personnel (particularly physicians and
other health professionals) should be trained in
the political, economic, social, and cultural
determinants of health as well as in individual
lifestyle interventions. Indicators of
interventions that promote health include:
1. Percentage of population covered by the public
medical care system and by public health services
2. Percentage of adult population working in health services
3. Percentage of public expenditures in health
care that are spent on primary care
4. Indicators of accessibility to health care services
5. Indicators of power resources held by public
health agencies to sanction delinquent corporate or business behavior
6. Percentage of people in the population who smoke or are alcoholics
7. Percentage of unwanted pregnancies
8. Percentage of television and radio time dedicated to health promotion
9. Rates of food poisoning in the population
10. Level of citizens' satisfaction with health
care received and information provided
11. Percentage of population vaccinated against communicable diseases
12. Rates of HIV/AIDS
LIFESTYLE INTERVENTIONS
Lifestyle interventions, as the name indicates,
are aimed at changing the unhealthy behaviors of
individuals. These are the most classical
interventions and the most visible components of
health promotion. They include the following.
Interventions on Safe Sexual Behavior and Good Reproductive Health
These interventions are aimed at developing
sexuality as a human right, separating enjoyment
and pleasure from reproduction. Sexuality should
be seen as an enjoyable activity and a component
of human caring, and positive views about sex
should be promoted. Information about sexuality
should be available to all age groups, starting
with the young. People should be able to express
their sexual identity freely, without
discrimination, and reproductive health
information and care should be available to all
persons who may benefit from it. Indicators of these interventions include:
1. Number of pregnancies and abortions per 1,000 women under 20 years of age
2. Incidence of Chlamydia infections in the 15 to 29 age group
3. Percentage of population that receives information on sex and sexuality
4. Availability of methods of contraception to the population
5. Analysis of media content to evaluate
television and radio programs and avoid
commercialization, exploitation, and stereotyping of sexual behavior
6. Redefinition of exploitative standards of
beauty (such as equating it with "young and sexy") that create frustration.
Increased Physical Activity
This is an important but not highly visible
health-enhancing intervention that prevents,
among other diseases, hypertension and type 2
diabetes, which are increasing among obese and
sedentary people. The public authorities should
promote physical activity in preschools, schools,
and centers of work and learning, and should
encourage the use of bicycles and walking.
Indicators of such intervention include:
1. Percentage of population physically active for at least 30 minutes per day
2. Percentage of youngsters (ages 15 to 29 years)
who have had a physical examination
3. Percentage of physical space in an urban
center that is dedicated to physical activity
4. Availability of physical exercise centers per 10,000 inhabitants per year
5. Availability of physical exercise centers
adapted to elders and persons with disabilities
6. Percentage of the population walking or
cycling in relation to total personal transportation methods
Good Eating Habits and Safe Food
This type of intervention addresses one of the
most important aspects of improving health,
because at least 30 percent of disease can be
related to eating behaviors. Being overweight is
now one of the main health problems in developed
countries. It is imperative, therefore, that (a)
good and healthy food should be widely available
to the whole population, including a wide variety
of food choices; (b) food should be safe, with
delinquent corporate behavior, as well as
restaurants responsible for food poisoning,
strongly penalized; (c) the public should be
fully informed about the caloric content and
composition of all food products; and (d ) the
public should be educated about the relationship
between food and health. Indicators of these interventions include:
1. Body mass index (BMI)
2. Percentage of population eating at least 500
grams of fruit and/or vegetables every day
3. Percentage of infants breastfed (exclusively,
at the age of 4 months and 6 months)
4. Incidence of Campylobacter and Salmonella infections
Reductions in Tobacco and Alcohol Consumption, Drug Use, and Excessive Gambling
Tobacco addiction is a disease and should be
cured by helping the individual control his or
her addiction. The tobacco industry should be
prohibited from encouraging that addiction.
Tobacco advertising targeted to the young should
be made illegal, and advertising should be
restricted to certain forums, with restriction of
ads on radio and television. Tobacco should be
highly taxed, with the collected funds assigned
to programs aimed at curing tobacco addiction.
Tobacco industry contributions to political
parties or candidates or to political and social
causes should be outlawed. Smoking should be
forbidden in all public spaces, restaurants, theaters, streets, and workplaces.
Alcohol consumption should also be reduced (it
has increased in the countries of the
Organization for Economic Cooperation and
Development), and alcoholic beverages should be
taxed according to their alcohol content. Alcohol
consumption should be allowed only in restricted
areas and not in public places, such as streets, theaters, or sports forums.
Individuals who are addicted to drugs should be
assisted and not penalized (except when drugs are
consumed in public places), but the distribution
of drugs should be strongly penalized.
Indicators of these interventions include:
1. Self-reported tobacco use
2. Self-reported exposures to environmental tobacco smoke
3. Percentage of restaurants and public places in
violation of smoking, alcohol, and drug restrictions
4. Total consumption of alcohol
5. Mortality and injuries due to alcohol consumption
6. Percentage of drivers intoxicated by alcohol
7. Percentage of population taking drugs (self-reported and police-reported)
8. Mortality due to narcotics-related diseases and injuries
9. Prevalence of excessive gambling
EMPOWERMENT STRATEGIES
Empowerment strategies should help individuals
link their personal struggle for improved health
with the collective struggle to improve
everyone's health. There is robust evidence to
show that individuals who are aware of their
health limitations and the causes of these
limitations can improve their health if they link
their own struggle for better health with the
struggles of other persons who share their
limitations. As noted above, young people with
drug addictions who became members of the Black
Panthers in the 1960s and 1970s improved their
own health (i.e., stopped taking drugs) and the
health of their neighborhoods. Black
Panther-controlled areas became drug-free areas.
And the coal miners of West Virginia who went on
strike to improve their working conditions
improved both their own health and the health of their community.
Individual commitment to improving other people's
health improves one's own health-that is,
commitment and solidarity are good for your
health. Commitment means a desire to serve
others; solidarity means development of networks
of support in a joined cause to improve
individual and collective health. Moreover, a
collective response strengthens individual
efforts to gain power, thus empowering the
individual. These linkages between individual
response and the collective, based on commitment
and solidarity, are critical to achieving the
structural determinants of good health.
Collective action (political empowerment, using
the term political in the broad sense of the
collective expression of power) is of extreme
importance to producing a healthy society. Its
opposite is either acceptance or alienation
(individual and collective). Acceptance of
exploitation, however, would not be unhealthy if
the person who is exploited were unaware of being
exploited. A person may believe she lives in
poverty, for example, because God wants her to be
poor (what Mother Teresa called "the gift of
poverty"). Poverty is thus seen as a welcome
stage that helps individuals get to heaven, their
final and most important destination (their stay
on Earth being merely a transition). It is highly
unlikely, however, that poverty and inequality
are welcome to those who suffer them.
Poverty and inequality will be increasingly
resisted because all the available information
shows that inequality (and the social distance it
creates) is frequently based on exploitation-that
is, the wealthy classes are healthier because the
poorer classes are less wealthy and less healthy.
The perception of this social distance as
exploitative is the basis for the widely held
opinion in Western societies that society is not
fair, that there is too much inequality. Indeed,
opinion polls show that large majorities in the
developed countries believe there is too much
inequality in their societies (15). Needless to
say, those at the top, the 20 to 25 percent of
the population in the upper income brackets (who
hold enormous power and influence in Western
societies and are the healthiest sectors of the
population), want the other 75 to 80 percent to
believe that those at the top are there because
of merit-that they deserve it; that this distance
in status is a natural event; and that the
current social order requires an acceptance of
this situation so as to maintain itself. The
problem is that increasing numbers of people do
not believe that merit is the real criterion for
social standing. The awareness of exploitation is
one of the greatest threats for those at the top.
The response to an awareness of exploitation can
be twofold. One response can be individual, which
can create serious pathology (both individual and
collective) as a consequence of frustration.
Contrary to prevalent cultural ideas, such as the
image of the solitary cowboy single-handedly
dispatching the gang of bad guys, individual
responses are inefficient and of limited value.
The individual response of young black persons in
East Baltimore to their exploitation is
unhealthy, because it may take the form of anger,
frustration, alcoholism, drug addiction and
crime. This huge amount of energy, individually
channeled, is of limited value and is unproductive for society.
The other possible response to exploitation is
for that young person to join a group of
youngsters to respond to and struggle together
against that exploitation. This is the healthier
alternative. The sense of commitment, struggle,
solidarity, and hope for a better future are the
healthier solutions, linking individual lifestyle
determinants with structural determinants. This
long tradition of linking the individual and
collective struggles (which has characterized the
history of the labor movement, among other
movements) predates the faulty concept of "social
capital," widely used by some researchers in the
field of inequality, which trivializes the
concept of solidarity and its purpose. The famous
Putnam vision (16) of encouraging social
capitalists to be even better capitalists (as one
of his chapter titles phrases it) and to win in
the competitive world is different from the
concept of solidarity. It is the opposite of what
healthy social behavior should be and the
opposite of what is advocated here-that is, to
link the struggle for individual liberation and
health with the collective struggle. The
objective should not be to enhance
competitiveness in our societies but rather to enhance solidarity (17).
I also disagree with the widely used concept of
"social cohesion," which I consider to be
profoundly conservative. As a matter of fact,
this concept was established by the conservative
and Christian Democratic traditions as a response
to the labor movement's struggle to change
society (18). Social cohesion can exist
side-by-side with enormous exploitation. There
are many cohesive societies, where the social
order is widely accepted, but where cohesiveness
masks widespread exploitation and high levels of
disease. In fact, a healthy intervention may be
needed to facilitate a collective response, by
those who are exploited, against that very cohesiveness.
There is a need to favor the concept and use of
solidarity and a solidarious society as an
alternative to a highly competitive society in
which social capital helps individuals compete
better. The ideas outlined in this article
present an alternative to the dominant and
hegemonic views in our societies. Still, we have
recently witnessed some developments that are
encouraging. Among them is the Swedish social
democratic government's national health plan,
which includes many of the structural and
individual determinants of health and represents
a gigantic step in the correct direction. It is
important to expand these interventions along the
lines outlined in this article, as well as to
include the empowerment strategies referred to
here. As it now stands, Sweden's national health
plan is the most progressive such plan in
existence. It is developing a strategy that far
surpasses the narrow, reductionist view that
tends to limit health policy to medical care
interventions. Still, more needs to be done. I
hope this article will help to define the
pointers for a road toward better health.
REFERENCES
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Political and Economic Determinants of Population
Health and Well-Being. Baywood, Amityville, NY, 2004.
2. Navarro, V. The Health Situation of East
Baltimore. Department of Health Policy and
Management, School of Hygiene and Public Health,
Johns Hopkins University, 1978.
3. Navarro, V. Crisis, work and health. In
Crisis, Health and Medicine: A Social Critique,
ed. V. Navarro. Tavistock, London, 1986.
4. Marmot, M. The Status Syndrome: How Social
Standing Affects Our Health and Longevity. Owl Books, New York, 2005.
5. Navarro, V., et al. Politics and health
outcomes. Lancet 368:1033-1037, 2006.
6. Navarro, V. (ed.). The Political and Social
Contexts of Health. Baywood, Amityville, NY, 2004.
7. Navarro, V. Dangerous to Your Health:
Capitalism in Health Care. Monthly Review Press, New York, 1998.
8. Vagero, D. Do health inequalities persist in
the new global order? A European perspective. In
Inequalities in the World, ed. G. Therborn. Verso, London, 2006.
9. Burström, B., et al. Winners and losers in
flexible labor markets: The fate of women with
chronic illness in contrasting policy
environments-Sweden and Britain. Int. J. Health Serv. 33:199-218, 2003.
10. Wilkinson, R. The Impact of Inequality: How
to Make Sick Societies Healthier. New Press, New York, 2005.
11. Benach, J. Analysis of Mortality
Differentials by Social Class. Papers of the
Department of Health Policy, Pompeu Fabra University, Barcelona, 2005.
12. Whitehead, M., and Burström, B. Evaluation of
the UK and of the Swedish Health Policies.
Seminar on Health Inequalities, Johns Hopkins
University Fall Institute, Barcelona, November 4, 2005.
13. Wilkinson, R. Unhealthy Societies: The
Afflictions of Inequality. Routledge, London, 1996.
14. Esping-Andersen, G. A child centered social
investment strategy. In Why We Need a New Welfare
State, ed. G. Esping-Andersen. Oxford University Press, Oxford, 2002.
15. The International Value Survey, 2003 and 2005.
16. Putnam, R. Bowling Alone: The Collapse and
Revival of American Community. Simon and Schuster, New York, 2000.
17. Navarro, V. A critique of social capital. In
Political and Economic Determinants of Population
Health and Well-Being, ed. V. Navarro and C.
Muntaner. Baywood, Amityville, NY, 2004.
18. Navarro. V. Why some countries have national
health insurance, others have national health
services, and the United States has neither. Int.
J. Health Serv. 19:383-404, 1989.
Direct reprint requests to: Dr. Vicente Navarro
Department of Health Policy and Management Johns
Hopkins University 624 North Broadway, Room 448
Baltimore, MD 21205 e-mail: [log in to unmask]
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