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Welfare state regimes and health outcomes: Exploring a public health puzzle? Dr Clare Bambra.

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Presentation on theme: "Welfare state regimes and health outcomes: Exploring a public health puzzle? Dr Clare Bambra."— Presentation transcript:

1 Welfare state regimes and health outcomes: Exploring a public health puzzle? Dr Clare Bambra

2 ∂ A public health puzzle?  The concept of welfare state regimes used to analyse cross-national differences in population health (3-5 regime types, Esping-Andersen 1990, Ferrera 1996).  Studies have almost invariably concluded that population health is enhanced by the relatively generous and universal welfare provision of the Social Democratic Scandinavian countries, especially when contrasted to the Liberal welfare states.  More recently studies have begun to apply a welfare state regimes perspective to the examination of cross-national differences in the magnitude of health inequalities  In contrast to their comparatively strong performance in terms of overall health, the Social Democratic welfare states do not have the smallest health inequalities (Dahl et al, 2006).  Further, it is the Conservative Continental countries which seem to have the smallest inequalities in health.  Today I will review the literature on welfare state regimes, health and health inequalities with a focus on identifying some of the possible explanations.

3 ∂ Welfare state regimes and population health  Most of the studies have examined infant mortality rates (IMR) or closely related indicators such as low birth weight  Only one study examined international differences in morbidity from a welfare state regimes perspective (Eikemo et al, 2008a).  Studies have consistently shown that IMR vary significantly by welfare regime type - lowest in the Social Democratic, highest in Liberal and Southern

4 ∂ Welfare state regimes and population health  Conley and Springer (2001) found significant differences in IMR in three worlds 1960 to 1992.  Coburn (2004) found that the Scandinavian welfare states had significantly lower IMR, lower overall mortality rates and less mortality at younger ages.  Bambra (2006) IMR for the Liberal (6.7), Conservative (4.5) and Social Democratic (4.0). Moderate correlation between decommodification levels and IMR (r=-0.585, p=0.018).  Navarro et al (2006, 2007) - Scandinavian countries lower IMR - to a lesser extent, increased life expectancy at birth.

5 ∂ Welfare state regimes and population health  Chung and Muntaneer (2007): 20% of the difference in IMR, and 10% for LBW, could be explained by the type of welfare state. Social Democratic countries had significantly lower IMR and LBW rates  Lundberg et al (2008): Policies which supported dual-earner families (but not traditional families) were associated with decreases in IMR. Generosity in basic pension (but not earnings related) associated with decreased old age excess mortality.  Eikemo et al 2008a: after controlling for individual and regional characteristics, around 10% of cross-national differences in self- reported health were due to type of welfare state regime. Scandinavian welfare regime fared best with the lowest rates of limiting long-term illness and poor self-reported health.

6 ∂ Social Democratic Supremacy  Key characteristics of the Scandinavian welfare state package (universalism, generous replacement rates, extensive welfare services) result in narrower income inequalities and higher levels of decommodification, both of which are associated with better population health.

7 ∂ Welfare state regimes and health inequalities  Studies of health inequalities by welfare state regime have tended to focus on morbidity, particularly self-reported health and limiting long-term illness  Studies examine European countries only – Eurothine project  Studies differ in terms of their measures of socio-economic inequality (education n=2, income n=1, social class n=1).  no studies of socio-economic inequalities in mortality which overtly use a welfare state regimes perspective (although Mackenbach et al (2008) examine educational inequalities in mortality in Europe by region)

8 ∂ StudyMeasure of inequality Typology, Data source, Countries Summary of Results* MenWomen Absolute Prevalence Rate Difference Relative Prevalence OR (95% CI) Absolute Rate Difference Relative OR (95% CI) Eikemo et al (2008b) Education - average education versus one sd below average Ferrera (1996) ESS N= 23 Bismarckian6.41.19 (1.14-1.24)5.71.25 (1.20-1.30) Anglo-Saxon9.61.35 (1.23 – 1.48)8.21.29 (1.18-1.41) Scandinavian10.51.44 (1.35-1.53)12.11.54 (1.44-1.64) Southern14.81.57 (1.47-1.69)17.31.69 (1.58-1.81) Borrell et al (2007) Education – no or primary education versus tertiary education Navarro and Shi (2001) Eurothine N= 11 Social Democracy4.56 (2.96-7.06)4.56 (3.10-6.71) Christian Democratic 5.54 (4.26-7.20)6.40 (5.19-7.90) Liberal6.13 (4.57-8.24)7.55 (5.57-10.24) Late Democracy6.89 (4.99-9.50)8.07 (6.20-10.49) Eikemo et al (2008c) Income – top versus bottom income tertiles Ferrera (1996) ESS N= 23 Bismarckian 9.81.68 (1.50 – 1.89)11.61.81 (1.62 – 2.03) Southern 10.91.79 (1.46 – 2.19)14.82.14 (1.77 – 2.57) Scandinavian 13.01.97 (1.70 – 2.27)15.82.14 (1.84 – 2.49) Anglo-Saxon 17.42.86 (2.12 – 3.70)17.42.73 (2.17 – 3.44) Espelt et al (2008) Social Class – Education aspects = secondary or more versus less than secondary Navarro and Shi (2001) HR&A N=9 Christian Democratic 11.21.24 (1.12-1.37)12.71.31 (1.19-1.45) Social Democratic13.31.43 (1.26-1.63)13.71.36 (1.21-1.52) Late Democracies18.91.87 (1.45-2.42)24.21.75 (1.39-2.21)

9 ∂ Summary  Research expectation that health inequalities will be smaller in the more generous and egalitarian Social Democratic Scandinavian welfare state regimes and largest in the Southern and Liberal regimes.  However, as was suggested by Dahl et al (2006) and has been shown in this review of the literature, the research to date suggests that the picture is far more complicated – big challenge to PH and WS theory.  Self-reported health - various studies, smallest inequalities in the Bismarckian, largest in the Southern or Liberal.  Only Borrell et al (2007) found the smallest inequalities in the Social Democratic regime.

10 ∂ A public health puzzle? The puzzle is therefore two-fold: (1)why, when overall population health is better in the Social Democratic countries are health inequalities not the smallest in the Social Democratic regimes (2)why, given their overall performance in terms of population health, are (self-reported) health inequalities the smallest in the Bismarckian regime countries?

11 ∂ Some thoughts …  Artefact  Selection  Culture and Behaviour  Materialist  Psychosocial  Lifecourse

12 ∂ Artefact 1 Differences are not real but based on the measures used:  Differences between educational/class/income studies (Eikemo x 2, Borrell), differences in which groups are compared especially in the education studies  Typology choice (Borrell v Eikemo)  Countries included – some countries more key to each regime than others, Borrell et al results may be because Germany and the Netherlands are not included in the Conservative regime  Welfare states regime concept flawed (Kasza, 2002) – Denmark, UK.  Are the bottom groups the same in each country? Low education group in Soc Dem will be better educated than the low education group in Southern, size of these groups in each country.

13 ∂ Artefact 2  Cross-sectional studies not longitudinal  Debate about whether cross country comparisons of self-reported health are accurate in terms of SES (Mitchell v Burstrom) – morality study had similar results (Mackenbach et al, 2008).  Comparisons are relative and so Soc Dem countries are victims of their own success by raising the health of the middle class. Achievement (Lundberg). The worst off in Soc Dem are better off in absolute terms than the worst off in other regimes (Navarro)  Is it a puzzle at all – should we expect PH policies which promote better overall health to also reduce inequalities? Determinants of inequalities differ from social determinants of health in general (Krieger).

14 ∂ Health Selection  Are the social consequences of ill health greater in the Soc Dem countries? Are people who have ill health more likely to be concentrated in lower social groups?  Indirect selection? Seems unlikely given the extensive employment legislation and so forth in Soc Dem countries (although some evidence from the UK that such protection has the opposite effect – e.g. DDA – and deters employment Bambra and Pope, 2007).  Selection more influential in respect to income related inequalities than educational ones - unlikely to explain the results of the studies of educational inequalities in health

15 ∂ Culture and Behaviour  Inequalities in smoking higher in the SD countries (mature stage of the smoking epidemic – Mackenbach et al, 2008),  Differences in smoking between the most educated and the least educated ranged from 2.0 – 3.8 in the Social Democratic countries, whereas in the Conservative countries, the inequalities were far smaller (<2.0) (Mackenbach et al., 2008).  Similarly, inequalities in deaths from cardiovascular disease were higher in the Social Democratic countries as compared to the Conservative countries  Health behaviours - universal health messages taken up by middle classes first (Dahl et al, 2006): everyone gains but the mc do so faster.

16 ∂ Materialist  Social Democratic countries have the smallest income inequalities and offer largely universal welfare services.  However, lower levels of income inequality do not negate inequalities in exposure to the other material determinants of health (Diderichsen, 2002).  Social inequalities in access to services remain even within universal systems (inverse care law).  Tentative evidence to suggest that inequalities in total avoidable mortality (as a result of diseases amenable to medical intervention) are higher in the Social Democratic countries than elsewhere (Stirbu, 2008).  Insider/outsider – immigrants, unemployed.

17 ∂ Psychosocial  Higher levels of social capital etc in Ch Dem countries?  Relative deprivation and thwarted expectations of social mobility in the SD welfare states ( Yngwe et al, 2003).

18 ∂ Lifecourse  Lifecourse epidemiology has highlighted how different causal mechanisms and processes may be behind the social gradient in different diseases (Bartley, 2004).  This may also be the case in terms of the inequalities in different welfare state regimes. For example, Whitehead et al (2000) found that lone mothers in both Britain (Anglo-Saxon) and Sweden (Social Democratic) were more likely to report poor health than couple mothers but the pathways leading to the health disadvantage of lone mothers were very different in the two countries with poverty and worklessness being the primary issues in Britain, but not in Sweden.  Extrapolating from this example, it is possible to suggest that the same outcomes (socio-economic health inequalities) may be present in different welfare state regimes, but as a result of differing causal mechanisms.  The welfare state regimes approach is perhaps therefore only able to offer a rough guide to explaining inequalities when what is needed is a more nuanced comparison of specific policies (Lundberg, 2008).

19 ∂ Beyond welfare state regimes?  Is the puzzle real or artefact?  Explanations are speculative  Some explanatory power in the cultural behavioural perspective, but generally the “puzzle” is a challenge to conventional public health thinking.  Theory development needed here.  Perhaps move beyond Social Democratic exceptionalism? Explore why the Conservative countries have the smallest health inequalities.  Alternatively, perhaps comparative health research should simply move beyond welfare state regimes - compare fewer countries on more precise policy areas.

20 ∂ Bambra, C. (2006), 'Health status and the worlds of welfare', Social Policy and Society, 5, 53-62. Bambra, C. and Pope, D. (2007), 'What are the effects of anti- discriminatory legislation on socio-economic inequalities in the employment consequences of ill health and disability? ' Journal of Epidemiology and Community Health, 61, 421-426. Bartley, M. (2004), Health Inequality: An Introduction to Theories, Concepts and Methods, Cambridge, Polity Press. Borrell, C., Espelt, A., Rodrı´guez-Sanz, M., Navarro, V. and Kunst, A. (2007), 'Explaining variations between political traditions in the magnitude of socio-economic inequalities in self- perceived health. ' Taclking Health Inequalities in Europe: Eurothine, Rotterdam, Erasmus Medical Center. Burstrom, B. and Fredlund, P. (2001), 'Self rated health: Is it as good a predictor of subsequent mortality among adults in lower as well as in higher social classes?' Journal of Epidemiology and Community Health, 55, 11, 836-840. Chung, H. and Muntaner, C. (2007), 'Welfare state matters: A typological multilevel analysis of wealthy countries. ' Health Policy, 80, 328-339. Coburn, D. (2004), 'Beyond the income inequality hypothesis: class, neo-liberalism, and health inequalities', Social Science & Medicine, 58, 1, 41-56. Conley, D. and Springer, K. (2001), 'Welfare state and infant mortality', American Journal of Sociology, 107, 768-807. Dahl, E., Fritzell, J., Lahelma, E., Martikainen, P., Kunst, A. and Mackenbach, J. (2006), 'Welfare state regimes and health inequalities', in Siegrist J. and Marmot M. (eds.), Social inequalities in health, Oxford Oxford University Press. Diderichsen, F. (2002), 'Impact of income maintenance policies', in Mackenbach, J. and Bakker, M. (eds.), Reducing inequalities in health: a European perspective, London, Routledge. Eikemo, T., Bambra, C., Judge, K. and Ringdal, K. (2008a), 'Welfare state regimes and differences in self-perceived health in Europe: a multi-level analysis. ' Social Science and Medicine, 66, 2281-2295. Eikemo, T.A., Huisman, M., Bambra, C. and Kunst, A. (2008b), 'Health inequalities according to educational level under different welfare regimes: a comparison of 23 European countries.' Sociology of Health and Illness, 30, 565-582. Eikemo, T., Bambra, C., Joyce, K. and Dahl, E. (2008c), 'Welfare state regimes and income related health inequalities: a comparison of 23 European countries. ' European Journal of Public Health, 18, 593-599. Espelt, A., Borrell, C., Rodrı´guez-Sanz, M., Muntaner, C., Pasarı´n, M., Benach, J., Schaap, M., Kunst, A. and Navarro, V. (2008), 'Inequalities in health by social class dimensions in European countries of different political traditions', International Journal of Epidemiology, 37, 1095-1105. Esping-Andersen G. (1990), The three worlds of welfare capitalism, London, Polity. Ferrera, M. (1996), 'The southern model of welfare in social Europe', Journal of European Social Policy, 6, 17-37. Kasza, G. (2002), 'The Illusion of Welfare Regimes', Journal of Social Policy, 31, 271-287. Krieger, N. (2008), 'Ladders, pyramids and champagne: the iconography of health inequities', Journal of Epidemiology and Community Health, 62, 1098-1104. Lundberg, O., Yngwe, M., Bjork, L. and Fritzell, J. (2008), 'The Nordic Experience: Welfare states and Public Health (NEWS)', Stockholm, Centre for Heath Equity Studies. Mackenbach, J., Stirbu, I., Roskam, A., Schaap, M., Menvielle, G., Leinsalu, M. and Kunst, A. (2008), 'Socioeconomic Inequalities in Health in 22 European Countries', New England Journal of Medicine, 358, 2468- 81. Mitchell, R. (2005), 'The decline of death – how do we measure and interpret changes in self-reported health across cultures and time? ' International Journal of Epidemiology, 34, 306-308. Navarro, V., Muntaner, C., Borrell, C., Benach, J., Quiroga, A., Rodríguez-Sanz M, Vergés, N. and Pasarín, M. (2006), 'Politics and health outcomes', Lancet, 368, 1033-1037. Stirbu, I. (2008), 'Inequalities in health: does health care matter?' Rotterdam, Erasmus MC. Whitehead, M., Burström, B. and Diderichsen, F. (2000), 'Social policies and the pathways to inequalities in health: a comparative analysis of lone mothers in Britain and Sweden', Social Science & Medicine, 50, 255-270. Yngwe, M., Fritzell, J., Lundberg, O., Diderichsen, F. and Burstrom, B. (2003), 'Exploring relative deprivation: Is social comparison a mechanism in the relation between income and health?' Social Science and Medicine, 57, 1463-1473 References

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