Navigating the Health Equity Gap: Bridging Systemic Challenges in Health Promotion Across Welfare States

Abstract

This dissertation examines the capacity of public health systems to advance health promotion and health equity within two contrasting welfare state typologies: Anglo-Saxon liberal welfare states and Nordic social democratic welfare states, with Canada as the central case study. Using political economy as the primary theoretical framework, complemented by historical institutionalism and systems theory, this research explores the systemic barriers that hinder health promotion efforts, particularly in addressing upstream social determinants of health. The dissertation is structured in three parts. The first examines the evolution of health promotion and equity concepts and their integration into public policy frameworks. The second presents findings from a critical literature review, a two-decade analysis of 22 health policies, and thematic insights from 15 in-depth interviews with scholar-practitioners, representing over 250 years of collective public health experience across diverse welfare state contexts. Reflexivity, informed by the author’s 15 years of professional experience in public health systems, ensured critical engagement throughout the research process. The final part synthesizes these findings to identify systemic barriers that impede health promotion as an essential public health function and proposes strategies to overcome these obstacles, drawing lessons from both Anglo-Saxon and Nordic systems. Findings reveal systemic barriers in Anglo-Saxon welfare states, including resource constraints, market-oriented governance, and institutional path dependency, which weaken public health systems’ ability to address social determinants of health effectively. These barriers often manifest in a policy drift, wherein focus shifts from structural determinants to individual behaviours, undermining equity goals. In contrast, Nordic social democratic welfare states demonstrate how integrated governance, sustained investment, and equity-driven frameworks can enhance health promotion. However, persistent relative health inequalities within Nordic systems highlight that no welfare model is entirely free from systemic limitations. This dissertation contributes to health policy scholarship by providing actionable strategic frames to confront systemic barriers, adapt successful strategies, and strengthen health promotion as a core public health function in diverse welfare state contexts through a series of strategic dilemmas.