Beyond ‘commercial determinants’: shining a light on privatization and political drivers of health inequalities

In a recent review in EJPH of existing frameworks of the determinants of health, Maani et al.1 argue that the omission of an explicit reference to the so-called commercial determinants of health (i.e. the factors that adversely influence health, which stem from the profit motive) may obscure private sector responsibility and deflect attention to other social determinants. The recent focus on corporate and commercial determination is mainly driven by the fact that progress in combating non-communicable diseases (NCDs) has been inadequate and disappointingly slow. We agree with Maani et al. that greater attention must be paid to the health impact of commercial interests. A clear distinction can then be made between the determinants of health and how their distribution is driven by commercial and political interests. The Dahlgren–Whitehead ‘rainbow’ model illustrates the different levels of health determinants.2 We do not suggest to include commercial interests as just another determinant, but to include them in the framework as a force driving the development and social patterning of determinants. Our Diderichsen framework3 can be used to illuminate this more explicitly. We will use an adaptation of that shown in figure 1, to illustrate the point of disagreement. Pathways of the commercial and political determination of health inequalities. Adapted from model by Diderichsen et al., 20013 Pathways of the commercial and political determination of health inequalities. Adapted from model by Diderichsen et al., 20013 We take particular issue with the narrow conceptualization of ‘commercial determinants’ by those, like Maani et al.1 (p. 660), defining them as ‘tobacco, alcohol, and food and beverage companies and other harmful commodity producers’ whose activities are drivers of NCDs. This definition ignores the growing role that commercial companies play in other sectors of importance for health development and equity, such as privatization of education and care services. In these sectors, the privatization is a result of an interplay between market forces and political interest, where the latter often initiates the process. We shall illustrate this with the help of figure 13 provide examples from a possibly unexpected context: the tax-financed public services in two Scandinavian welfare states. Our framework on the pathways generating health inequalities (figure 1) outlines the pathways from early child development and education to social position (Pathway I), as well as the processes mediating the health effect of social position (II), the unequal vulnerability to that effect (III), and modification of the consequences of disease (IV). Education: early child development and schooling influence both health and future educational achievement and labour market position (Pathway I in figure 1). One important policy to reduce health inequality, therefore, has been to reduce educational inequalities, narrowing the gap in educational achievement by parental social status, e.g. and thereby boosting social mobility. To this end, a central aim of education policy in Sweden for decades has been to integrate children from across the social spectrum into a public system that offers the same high quality of schooling for all. This policy successfully resulted in reduced differences in educational achievement across the social spectrum. Since the early 1990s, however, this positive development has been reversing, and the gap in educational achievement between top and bottom of the social scale has now increased by 16%. Increasing segregation along socioeconomic and ethnic divides has been found to be the main source of this worsening trend.4 The drivers of this segregation have been political decisions to promote privatization. Forcing municipalities to open bidding for running services to private companies and introducing voucher systems to allow public money for each pupil to be ‘spent’ on a ‘free choice’ of school have created a quasi-market for schools and the increasing number of for-profit and non-profit private schools has reinforced the segregation.4 Tobacco and alcohol: in contrast to all other West European countries, female life expectancy in Denmark stalled from 1975 to 1995 due to a cohort effect among women born in 1915–45. Danish life expectancy still lags behind all other West European countries and Denmark is performing badly in efforts to reduce social inequalities in mortality. The higher mortality in Denmark is almost entirely linked to higher consumption of alcohol and tobacco, which also plays a major role in the health inequalities5 (see Pathway II). Policies to control this consumption have been weak compared to other countries,6 a situation which has been driven by political influences. Cigarette prices declined in real terms from 1966 to 2019, and WHO notes that Denmark still lacks an overall strategy to protect from the harms of tobacco and that the ‘tobacco industry is influential in Danish policy-making and not properly regulated with respect to transparency, donations or corporate social responsibility efforts’.6 Denmark is a small country with huge multinational tobacco- and alcohol industries. ‘Scandinavian Tobacco Group’ is the largest producer of cigars in Europe and USA with 3bn cigars produced per year. ‘House of Prince’ produce 20bn cigarettes annually and the Carlsberg group is a multinational brewery group with 140 brands with a dominating market share in Europe and worldwide. Primary health care: equitable access to primary health care services plays a critical role in the ability to meet the unequal health care needs of the population, limits differential vulnerability (Pathway III) and reduces inequalities in medical and social consequences of disease (Pathway IV). A prerequisite is that basic health services are available and used according to need. In Stockholm, a purchaser–provider split in health care was introduced in the early 1990s. A needs-based resource allocation formula was implemented to create a ‘level playing field’ and ensure equity in access to care.7 Since 2007, there has however been a strong political drive to privatize primary care and the needs-based allocation was abandoned so it would not interfere with the push for privatization. The proportion of for-profit providers in Stockholm increased sharply.8 One of the most conspicuous consequences has been a shift from needs-based to a profit and demand-based allocation of primary care, with an expansion of primary care mainly in high income areas. As a result of these market-based reforms, health care utilization in primary care has increased (from traditional very low levels in Sweden), but the increase has predominantly been among higher income groups,8 widening inequalities in access to care. In conclusion, our examples illustrate that the interaction between commercial and political driving forces is critical and both need to be made more visible. In some cases, transnational companies are so strong that they can hold back the protection of the people from harmful products for decades. In other cases, the political priorities under the heading of ‘free choice’ of services start a process of market mechanisms and privatization that is taken over by commercial forces, creating increasingly unequal outcomes, a process that is very difficult to reverse. The drive to ‘bring commercial determinants of health out of the shadows’1 must encompass the wider forces of privatization and ideologies of their political determination. The identification of determinants of health is the starting point. The importance of commercial and political drivers of these determinants must then be analyzed in an international and national context. None declared.