Yunus Centre for Social Business & Healthresearching the relationship between poverty alleviation and health

Social enterprise, health inequalities and the social determinants of health

Michael J. Roy PhDSUNY Albany, 15 July 2016

Agenda

1. A statement of the problem2. About social enterprise3. Some hypotheses/theories of change4. Development of ‘empirically informed’ conceptual

models5. So what?

Whatishealth?• The Constitution of WHO (1946) states that good health is a state of

complete physical, social and mental well-being, and not merely theabsence of disease or infirmity.

• Health is a resource for everyday life, not the object of living, and is apositive concept emphasizing social and personal resources as well asphysical capabilities.

• Health is a fundamental human right, recognized in the UniversalDeclaration of Human Rights (1948). It is also an essential component ofdevelopment, vital to a nation's economic growth and internal stability.Along with traditional and unequivocal arguments on social justice andthe importance of health, it is now accepted that better health outcomesplay a crucial role in reducing poverty.

Whatare‘healthinequalities’

• The‘preventableandunfair’differencesinhealthstatusbetweensocialgroups,populationsandindividuals(Whiteheadetal.2001)

• Describedasthe‘scandalofourtimes’(Dorling2013) since“therighttolifeitselfisatstake”(McCartneyetal.2013,p.222

Trendsinmalelifeexpectancy:Scotland

Richest 20%

Poorest 20%

Source: Chief Medical Officer for Scotland (2012)

(Source:McCartney,2012)

In Iraq, life expectancy is 67. Minutes from Glasgow city centre, it's 54In deprived inner city area of Calton, the chance of surviving to old age is lowest in UK

Lifeexpectancy(male)Andorra(highest):80.6UnitedKingdom:75.9

GazaStrip:70.5Calton,Glasgow:53.9

Liberia:38.9Swaziland(lowest):32.5

Source: Gillan (2006)

• ThereissomethingelsegoingoninGlasgowthatcannotbeexplained‘simply’intermsofpovertyalone,asthecomparativestudiesofdifferentcitiesshow

• Therearecountlesstheoriesastowhatiscausingthis‘Glasgoweffect’:“likelytobeacomplexarrayoffactorsactinginconcert”(Royetal,2013)

(Source: Walsh et al, 2010)

It’s not just deprivation!

Despitethis…

• Themedicalmodelofhealth– thathealthissimplytheabsenceofdiseaseordisability,theresponsibilityofindividualsistominimiseexposureto‘riskfactors’– remainsbyfarthedominantdiscourse.

Theoryofcausationofhealthinequalities

Source: Scottish Government (2014)

SowhatdoImeanbysocialenterprise?

A social enterprise is a trading entity whose surpluses arereinvested for the benefit of social objectives rather than fordistribution to shareholders or owners (Borzaga andDefourny, 2001; Nyssens, 2006)

Source:Defourny andNyssens(2012);originalbasedonPestoff (1998,2005)

Socialenterpriseishighlycontested!

• Ridley-Duff and Bull (2011: 100): “social enterprises offereither a partial or a complete rejection of established rules ofinternational capitalism”

• Aim to “create wealth in communities and keep it there. Theytrade on a ‘not-for-personal-profit’ basis, re-investing surplusback into their community…effecting social, economic andenvironmental…outcomes” (Teasdale, 2012: 105-106).

• A (potential) means of exploring ‘alternative economicspaces’ (Leyshon et al., 2003; Lionais, 2010)

• Unlocking the “social and economic capacities latent in eventhe most deprived communities” (Amin et al., 2003: 27)

• Social enterprises act to remedy/ameliorate social conditions (“factors in the social environment”): addressing their social mission is their primary purpose

• So if ALL social enterprises act on the social determinants of health then can ALL social enterprises be viewed as providers of public health?

"This ends the debate decisively. Health care is an important determinant of health. Lifestyles are important determinants of health. But... it is factors in the social environment that determine access to health services and influence lifestyle choices in the first place.”Director-General Dr Margaret Chan, at the launch of the final report of the WHO Commission on Social Determinants of Health, 2008.

Just to be clear…the ‘big idea’ is that:

• By acting to address one or more aspects of social vulnerability

• Achieving the means to do so in some broader trading activity / hybrid ‘resource mix’

• Gains in health and well-being may be realised from any social enterprise, regardless of whether this is explicitly stated as part of their social mission

“…provide limited evidence that social enterprise activity can impact positively on mental health, self reliance/ esteem and health behaviours, reduce stigmatization and build social capital, all of which can contribute to overall health and well-being. No empirical research was identified that examined social enterprise as an alternative mode of healthcare delivery.” (Roy et al, 2014:182)

Howdotheywork?:Aworkinghypothesis

SOCIALENTERPRISE:- socialmission- trading- noshareownership

ENGAGEMENT

COMMUNITY Improvedhealthandwell-being

ASSETSAND‘DEFICITS’

INDIVIDUAL

Socialcohesion

Connectedness

SOCIALENTERPRISE:- socialmission- trading- noshareownership

ENGAGEMENT

COMMUNITY Improvedhealthandwell-being

ASSETSAND‘DEFICITS’

INCOME

Socialcohesion

Connectedness

Howdotheywork?:Aworkinghypothesis

SOCIALENTERPRISE:- socialmission- trading- noshareownership

ENGAGEMENT

SAFETY/TRUST Improvedhealthandwell-being

ASSETSAND‘DEFICITS’

CONFIDENCE

Socialcohesion

Connectedness

Howdotheywork?:Aworkinghypothesis

Hypotheticalmodel(Royetal,2014)

Building an empirical base• Toexaminehowsocialenterprisepractitionersthinkabout andexplain theirimpactuponhealthandwell-being,irrespectiveofwhethertheyexplicitlyintend toimpactuponhealthandwell-beingornot.– Canwe‘map’thissomehow?Thatis,the‘causalpathways’toproduceanempiricallyinformedconceptualmodel?

Methods

• Indepthsemi-structuredinterviews(andafocusgroup)with13socialenterprisepractitionersaroundGlasgow

• Fourstagesamplingprocess:purposive,maximumvariation(Mason,2002)samplingofsocialenterprises(onarangeofvariablese.g.size,age,location,typeofbusiness,geographicalfocusetc)

• Analysis:CriticalRealist-inspired‘CausationCoding’method(Saldaña,2013).Pictorialcausalnetworks(MilesandHuberman1994)employedtounderstandanddemonstrate‘causalpathways’or‘generativemechanisms’containedinpractitionerdiscourses.Abductiveinference.

• Antecedentvariables>Mediatingvariables>Outcomes

“therejustwasn’tanythingpositiveforhertohookonto,shewasjustinadownwardspiral…Therehasbeenrealprogressionforherthroughgainingtheseskills…shenowdoesn’thaveaproblemwithalcohol,shelooksafterherself…shehasbecomeavolunteer…andishelpingassistandleadotheryoungpeople.”(Fiona)

improvingknowledgeandskills>improvedhealthbehaviours/decreaseinillicitordangerousbehaviours

Physical Health

“…shenowhasafuture.She’snotsittingathomerelyingongrants,relyingonbenefits.Sheisnowdoingsomethingforherself.Ithinkit’sgivingsomebodyafuture.”(Doreen)

providingworkthatismeaningful>peoplehaveanimprovedsenseofpurposeandmeaning

Mental Health

“theyactuallyhaveaninteractionwithamember

ofthepublicthattheywouldn'tnormallygeta

chancetotalkto…andtheideaisthatitempowersthepersontokindofjoinback

tosociety.”(Christine)

Social Determinants

facilitating,encouragingcontactbetweenpeople>vulnerablepeople(suchas

homelesspeopleinthiscase)feellessmarginalised

‘empiricallyinformed’conceptualmodel(Royetal,forthcoming)

So what?• Notintendedtobethe“truth”byanymeans,merelyasa

plausiblestartingpointforfutureresearch• Inotherwords:aplatformforfutureempiricalenquiry• Hopefullyencouragesabroaderandmoreimaginative

considerationofwhatactuallyconstitutesapublichealth‘intervention’

• AlsoimpliesthattheThirdSectorandother‘non-obvious’actorshaveanimportantroletoplayinaddressingcontemporaryandfuturepublichealthchallenges

• New field of scientific enquiry at the interface between social enterprise and public health has started to emerge internationally, presenting significant scope for future research activity

• Evidence of CIHR:IPPH being interested in this agenda (workshop in Toronto Feb 2015)

• Major (£1.96m / $CAN 3.8m) five year programme grant co-funded by the UK’s Medical Research Council and Economic and Social Research Council, commenced in early 2014: Developing Methods for Evidencing Social Enterprise as a Public Health Intervention (see www.commonhealth.uk)

In summary: key messages

Thank you!michael.roy@gcu.ac.uk