WEALTH, EQUITY AND HEALTH-CARE - A CRITIQUE OF A POPULATION HEALTH PERSPECTIVE ON THE DETERMINANTS OF HEALTH

In this paper we examine the recent ascendancy of a ''population healt h'' perspective on the ''determinants of health'' in health policy cir cles as conceptualized by health economists and social epidemiologists such as Evans and Stoddart [Evans and Stoddart (1990) Producing healt h, consuming health care. Social Science & Medicine 31(12), 1347-1363] . Their view, that the financing of health care systems may actually b e deleterious for the health status of populations by drawing attentio n away from the (economic) determinants of health, has arguably become the ''core'' of the discourse of ''population health''. While applaud ing the efforts of these and other members of the Canadian Institute f or Advanced Research for ''pushing the envelope'', we nevertheless hav e misgivings about their conceptualization of both the ''problem'' and its ''solutions'', as well as about the implications of their perspec tive for policy. From our critique, we build an alternative point of v iew based on a political economy perspective. We point out that Evans and Stoddart's evidence is open to alternative interpretations- and, i n fact, that their conclusions regarding the importance of wealth crea tion do not directly reflect the evidence presented, and are indicativ e of an oversimplified link between wealth and health. Their view also lacks an explicit substantive theory of society and of social change, and provides convenient cover for those who wish to dismantle the wel fare stale in the name of deficit reduction. Our alternative to the '' provider dominance'' theory of Evans and Stoddart and colleagues stres ses that the factors or forces producing health status, which Evans an d Stoddart describe, are,contained within a larger whole (advanced ind ustrial capitalism) which gives the parts their character and shapes t heir interrelationships. We contend that this alternative view better explains both how we arrived at a situation in which health care syste ms are as costly or extensive as they are, and suggests different poli cy avenues to those enunciated by Evans, Stoddart and their confrires. (C) 1998 Published by Elsevier Science Ltd. All rights reserved.