“What’s the problem of “health inequality” represented to be?”: A post-structuralist analysis of English public health policy 1980-2011

Abstract

The analysis of policies designed to address health inequalities, or more broadly speaking “differences in health”, tends to focus on evaluating policies in order to determine their effectiveness and to improve the design of future interventions. Such approaches are concerned with problem-solving as opposed to problem-questioning. Consequently there is little exploration of how the problem of “differences in health” is problematised in these policies, how policy problematisations change over time, and how governable subjects are produced as a result of problematisations of problems.
Bacchi’s (1999, 2009) “What’s the problem represented to be?” framework, informed by Foucault’s theory of governmentality and methods of problematisation, archaeology and genealogy, was used to analyse 32 English public health policy documents in order to address these questions. Following the analysis, three problematisations of “differences in health” and their corresponding governable subjects were identified: the Informational problematisation and the “responsible chooser”; the Constraints problematisation and the “constrained chooser”; and the Paternalistic Libertarian problematisation and the “flawed chooser”.
The archaeological analysis made it possible to identify underlying frameworks of thought which shaped policy problematisations of “differences in health” at specific points in time. The genealogical analysis suggested that while new problematisations emerged over time as the result of contingent conditions allowing for the development of new ideas, ultimately there was a consistent concern across all the period with understanding how individuals make choices about their health and how best to ensure people made healthy choices in order to reduce “differences in health”. This is clearly demonstrated through the identification of subjects as “choosers” and helps to explain the continuing emphasis within public health on creating the “right conditions” to allow individuals to make healthy choices, and to encourage individuals to govern themselves when making choices about their health.