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Social Policy as a Determinant of Health: The Contribution of the
Social Economy
This summary is primarily based on a paper and presentation by Yves
Vaillancourt, Director of the Laboratoire de recherche sur les politiques
et les pratiques sociales at the Université du Québec in Montréal, and a
response by Pat Armstrong, Canadian Health Services Research
Foundation/Canadian Institutes of Health Research Chair in Health Services
and Nursing Research. The presentations were prepared for The Social
Determinants of Health Across the Life-Span Conference, held in Toronto in
November 2002.
The opinions expressed in this publication are those of the
authors and do not necessarily reflect the views of Health
Canada.
PDF
Version (5 pages, 46 KB)
In Quebec, the term "social economy" is widely used and
refers to a vast array of groups, mostly non-profit organizations
including advocacy groups, voluntary organizations and other
community-based organizations, including cooperatives. The term is
not widely used in English Canada but is most close to the term
"voluntary and community sector" (which includes organizations
dealing with both voluntary and paid work) (Vaillancourt, Aubrey,
Tremblay and Kearney, 2002). At the Economic and Employment Summit
in Quebec in 1996, social economy organizations were defined as
follows (Chantier de l'économie sociale, 1996):
Social economy organizations produce goods and services with a
clear social mission and have these characteristics and
objectives:
The mission is services to members and community and not
profit-oriented.
Management is independent of government.
Workers and/or users use a democratic process for
decision-making.
People have priority over capital.
Participation, empowerment, individual and collective
responsibility are key values.
Current Situation
Organizations in the social economy play a major role in many spheres
of economic and social life, in particular in the areas of health and
social services, labour market integration and other social policy areas
that affect health. The importance of the non-profit sector varies
substantially from one country to another, but can exceed 10% of total
employment in countries such as Holland, Ireland and Belgium (Defourny et
al., 1999).
In Quebec, the social economy represents more than 120,000 jobs in
8,000 organizations of which 3,000 are cooperatives. The social economy
generates about 7% of the province's income (Chantier de l'économie
sociale, 2001). The Department of Health and Social Services alone
finances more than 2,500 organizations.
Community-based organizations are particularly active in four areas
related to the social determinants of health:
Homecare services: Not-for-profit
organizations now employ 5,500 workers in 103 community-based
organizations that offer services to 62,400 clients across the province
(MinistÅre de l'Industrie et du Commerce, 2002).
Day care services: The 1997 Quebec Family
policy announced that day care services would become universally
available for a minimal fee of five dollars per day per child. This
innovative program stimulated an increase of day care spaces from 78,000
in 1998 to 145,000 in 2002. Early childhood day care centres employ
22,000 people. This makes it the third most important employer in
Québec, outside of the public sector (Vaillancourt, Aubrey, jetté and
Tremblay, 2002).
Social housing: Since the 1960s, 49,000
cooperative and non-profit housing units have been created in Quebec
(Vaillancourt and Ducharme, 2001).
Job creation and integration: Many
community-based organizations are actively creating jobs and providing
employment services for victims of social exclusion.
Women account for over 80% of workers providing care in both the public
sector and the social economy (Armstrong, 2002). They also provide most of
the unpaid, domestic care for children and family members who are ill or
in need of assistance.
Factors that Affect the Issue
Mainstream trends in health reform are caught up in a bipolar
state/market model that tends to exclude the social economy and take
advantage of the unpaid caring work provided by families. The social
economic sector is not recognized as a significant capacity builder and
the important work of community organizations is still too timidly
acknowledged (Vaillancourt, Aubrey, Tremblay and Kearney, 2002). As a
consequence, many people in the public health sector in Quebec do not
understand that leaders in the social economy are key allies in advocating
action on the non-medical determinants of health.
This lack of recognition also leads to insufficient funding from
governments, even though their services are meeting a need that the
private sector cannot or does not want to adequately address. As a result,
many voluntary organizations must deal with difficulties related to poor
financing, such as manpower shortages, low wages and high turnover
(MinistÅre de l'Industrie et du Commerce, 2002; Vaillancourt and Jetté,
1999a; 1999b; 2001). If governments believe that community-based
organizations can ensure quality services in which users and producers
have a say, more resources must be allocated for them to do so.
Until the end of the 1980s, caring work in the public sector with
decent wages and high rates of unionization meant job security and
relatively good jobs for many women (Armstrong and Cornish, 1997). Reforms
that move these jobs to the social economy or eliminate them could lead to
lower paid jobs and/or an increased burden on women in families who have
had to voluntary fill in the gaps in caring for children, spouses and
older people who are ill or disabled. The Quebec Women' Federation and
others have argued that shifting good jobs in the public sector to poor
jobs in the social economy would increase inequality for women (Boivin and
Fortier, 1999). Thus, a consensus has been developed in Quebec that sees
the social economy sector and the public sector as complimentary, and that
there should be no job substitution.
Increasingly, since people are sent home from hospital "quicker and
sicker", unpaid women caregivers are asked to do highly skilled tasks,
such as inserting catheters and applying oxygen masks. Without adequate
training and support, women who are pushed to do these tasks may provide
poor care and end up in poor health themselves. In Québec, such
professional services remain the responsibility of the public sector.
Because women give birth and live longer than men they are also the
majority of patients requiring care. Their relative poverty means that
women have fewer financial resources and are more dependent on social
services than men (especially older women). Aboriginal women and women
from immigrant, refugee and visible minority communities often face racism
and language and cultural barriers as well.
Effects of the Social Economy on Health
The social economy can contribute in many ways to the health and
well-being of individuals, families and communities.
The values at the heart of the social economy and the democratic
rules that govern them facilitate the empowerment of users and workers
within organizations that provide direct services. The Independent
Living Movement is an example of such empowerment where users, instead
of being considered passive beneficiaries, become active participants in
the decisions that concern them. This is directly opposite to
traditional welfare policy reforms that consider the user solely as the
receiver of social policy. The empowerment of workers also has positive
impacts on the quality of life in the workplace, and on employees'
health and well-being.
The social economy has the capacity to mobilize civil society to
instigate social policy reform, thus contributing to "citizen
empowerment" or "active citizenship". The development of early childhood
day care services in Québec since the 1970s and the new family policy
put in place in 1997 are examples of this.
The social economy can exert a positive influence on the values and
practices of public and for-profit organizations. These include more
democratic forms of governance in the public sector, increased openness
to the empowerment of users and workers, and increased participation by
local communities and their networks.
Over the last 30 years, a large number of social economy have developed
innovative practices in response to increasing health and social problems
(Vaillancourt, 2002; Vaillancourt and Dumais, 2002). Examples in Quebec
include:
AccÅs-Cible (Santé Mentale et Travail) is an organization that offers
job integration activities to individuals with mental health problems.
Over the last 14 years, AccÅs-Cible welcomed over 800 persons in group
workshops, office skill learning, employment services and professional
training practice. Some 60% of participants found a job that helped them
take better control on their life and health (Dumais, 2001).
It is well known that care and stimulation in early childhood has
positive effects on development and future health. The non-profit
orientation of day care services and the democratic participation of
parents and staff on the boards of day care centres are distinguishing
feature of Quebec's program. This empowering environment is a positive
determinant of well-being, not only for children and parents but also
for the entire community.
Increasingly, social economy enterprises provide domestic services
(cleaning and maintenance, meal preparation, etc.) to an aging
population or people with temporary or permanent disabilities.
Partnership relations are established with local public sector agencies
(CLSCs), which ensure that appropriate referrals are made.
Social housing with community support is a new practice that allows
vulnerable people to have a decent home, to make their own decisions and
assume normal tenant responsibilities (Vaillancourt and Ducharme, 2001;
Jetté, Thériault, Mathieu and Vaillancourt, 1998; Thériault, Jetté,
Mathieu and Vaillancourt, 2001). For example, social economy
organizations deliver community support services (onsite
janitor-supervisors and visits by service workers) for people who have
unstable housing connected to substance abuse, mental health problems
and HIV/AIDS.
While many caregivers (who are almost all women) are rewarded by
providing care, when they are conscripted into voluntary care roles their
emotional and physical health is likely to be negatively affected. Some
women need to interrupt their careers in order to provide care for family
members, thus losing their financial base and status for the future. The
development of social economy services that are not provided by the public
sector (such as house cleaning) can provide much needed help for these
women.
Although the social economy, like the private for-profit sector,
provides employment of varying quality, women who work in low paying
caring roles within the social economy usually have few benefits. In some
parts of Canada, women who are welfare recipients may be conscripted into
these jobs, regardless of their interest or experience. All of these
situations can lead to poorer health among women caregivers in the short-
and long-term.
Implications for Policy, Practice and Research
It has been demonstrated in Quebec (and elsewhere) that providing
support for the social economy can effectively address current and urgent
health and social policy issues, including:
affordable, universal day care
social housing with community support as a viable alternative to
institutionalization
job integration programs for vulnerable and socially excluded
citizens
the need to help an aging population remain independent in their own
homes and communities.
The move toward more community care through social economy
organizations can decrease the burden for natural helpers, who in the vast
majority of cases are women. However, policy-makers must ensure that this
support is realized and accessible (and not just "promised"), and that it
is not provided at the expense of secure public sector jobs for women.
Even when the social economy makes breakthroughs at the policy level,
the gains remain precarious unless health departments and other areas of
government enact policies that:
provide sustainable and adequate funding which enables organizations
to strengthen and develop their activities, and maintain their
independence and empowering ways of working
recognize the contribution of the social economy
do not force not-for-profit organizations to adopt private sector
management and assessment models in order to compete with private
enterprises
support local control and the participation of representatives from
the social sector in decision-making and consultation processes
ensure social economy organizations an even greater role as partners
in the social policy area.
specifically take gender and culture into account
do not shift all of the less profitable and more burdensome work to
the social economy sector while allowing for the expansion of profitable
private services
support the integration of acute health care with care in the
community, as opposed to separating the two in favour of the medical
model over the social determinants of health.
Leaders in health can look to expanding alliances with organizations in
the social economy in their efforts to improve living conditions that
affect health and well-being.
When it comes to caring work, gender inequities within households and
in the labour market must be recognized and addressed. A social economy
approach devoted to the democratic organization of work should positively
promote equity by ensuring that care work is both more equally rewarding
and equally distributed. Given what we know about the determinants of
health, such equity would necessarily contribute to improved health for
women.
References
Armstrong P. (2002). The Contribution of the Social Economy: A
Response. A presentation given at The Social Determinants of Health
across the Life-Span Conference held in Toronto in November 2002.
Armstrong P and Cornish M. (1997). Restructuring Pay Equity for a
Restructured Workforce: Canadian Perspectives. Gender, Work and
Organization 4:2 (April 1997):67-86.
Boivin L and Fournier M. (1998). L'Économie Sociale:l'Avenir d'une
Illusion. Montréal: Fides.
Chantier de l'économie sociale (1996). Osons la solidarité.
Rapport du groupe de travail sur l'économie sociale, Sommet sur l'économie
et l'emploi, Québec.
Chantier de l'économie sociale (2001). De nouveau nous osons.
Document de positionnement stratégique, Montreal.
Defourny J., Develtere P. and Fonteneau B. (Eds) (1999). L'Économie
sociale au Nord et au Sud. Brussels: De Boeck Université.
Dumais L. (2001). AccÅs-cible (SMT) : Monographie d'un organisme
d'aide Ä… l'insertion pour les personnes ayant des problÅmes de santé
mentale. Montreal : UQAM, Cahiers du LAREPPS 01-06.
Jetté C., Thériault L., Mathieu R. and Vaillancourt Y. (1998).
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LAREPPS.
MinistÅre de l'Industrie et du Commerce (2002). Portrait des
entreprises en aide domestique. Québec: gouvernement du Québec, 67 p.
Thériault L. Jetté C., Mathieu R. and Vaillancourt Y. (2001).
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Vaillancourt Y. (2002). Le modÅle québécois de politiques sociales
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de recherche en politiques publiques (IRPP) (English Version coming in
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Vaillancourt Y., Aubry F., Tremblay L and Kearney M. (2002). Social
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Vaillancourt Y., Aubry F., Jetté C. and Tremblay L. (2002).
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Vaillancourt Y. and Dumais L. (2002) "Introduction ", in
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Last Updated: 2004-03-23
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