Welfare State Matters:
A Typological Multilevel Analysis of
Wealthy Countries
Hae-Joo Chung, RPh, MSc
Department of Health Policy and Management,
The Johns Hopkins School of Public Health
Summary of Today’s Presentation





To assess the relevance of ‘welfare-state typologies’ to public
health research,
And to extend the social epidemiology based on the ‘income
inequality paradigm’
We analyzed 3 level conditional hierarchical models of the
population health data from 19 wealthy countries of the last 35
years
As a result, the regime-type effects, especially social
democratic regime type had a strong explanatory power
And we could see that the social democracies had maintained
better population health status for the last 35 years
Welfare State Typologies

Welfare-state typology has been proved to be a useful
explanatory device for the emergence of welfare states,
including national health policies
Huber E and Stephens JD (2001) Development and Crisis of the Welfare State

Three (Esping-Andersen) or four (Huber & Stephens) regimetype clusters based on qualitatively different arrangements
between state, market and family




Esping-Andersen G. (1990) The Three Worlds of Welfare Capitalism
“Liberal” Welfare States
“Wage Earner” Welfare States
“Conservative-Corporatist” Welfare States
“Social Democratic” Welfare States
More generous
The Field of Political · Welfare State
Determinants of Health




The “Relative Income Hypothesis” and “Political and Welfarestate determinants of Health”, two possible mechanisms
Welfare state variables are used to determine the structural
mechanism through which economic inequality affects
population health status
Studies suggest that welfare state variables (e.g., access to
health care) could be important predictors of population health
outcomes
However, only one study included a comprehensive number
of political variables that adjust for economic determinants
Coburn, 2000; Conley & Springer, 2001; Navarro & Shi, 2001; Macinko, Starfield, & Shi, 2003; Macinko, Shi, & Starfield, 2004;
Muntaner, Lynch, Hillemeier, Lee, David, Benach et al., 2002
Methodological Individualism in
Comparative Health Policy Analyses
Country-level fixed-effects models
using panel datasets

Assumes covariances


Country A
Country B
Year
1990
1991
1992
Year
1990
1991
1992
Obs
a
b
c
.
.
.
Obs
a´
b´
c´
.
.
.


Among the observations within
each country
Not between/ among countries
Outcomes of a country are
explained by explanatory
variables of that country
Countries are independent
from each other
These are dependent
These are independent
Aim


To develop a more realistic model for comparative health
policy analyses than widely used country-level fixed effects
model
To examine the change in selected population health
indicators in advanced capitalist countries in the last 35 years
(1965-1994), especially before and after the neo-liberal
welfare reform
Hypothesis
Better
Health
Social
Democracies
Christian
Democracies
Wage
Earner
Liberal
Worse
Health
Generosity of the Welfare-state System
Generosity of the Welfare-state System
[ A “Linear” Distribution ]
[ A Distribution as “Clusters” ]
Countries and Categorizations

19 wealthy countries, 1960 - 1994 (35 years)

Social Democratic





Denmark
Finland
Norway
Sweden
Christian Democratic








Austria
Belgium
France
Italy
Luxembourg*
Netherlands
Switzerland
(West) Germany

Wage Earner




Australia
Japan*
New Zealand
Liberal




Canada
Ireland
The United Kingdom
The United States of America
Outcome Variables and Data Sources

Outcome variables



The infant mortality rate (IMR)
The Low birth weight rate (LBW)
Data source

The OECD Health Data 2000
Three-level Conditional Hierarchical
Mixed-effects Models: A Diagram

Level k: Welfare state regimes




k1=0
k2=0
Level j: Countries



k1=0, 1, 2, 3, or
k2=0, 1
Fixed effects
j=1, 2, 3, …, 19
Random effects

i=0, 1, 2, …, 34
Random effects
k1=2
k2=1
…
Level i: Years

k1=1
…
…
k1=3
Statistical Analyses


Type of the Model
No. of Welfare
State Categories
1
3-level conditional hierarchical
mixed-effects model
4
(SD, CD, WE, L)
1960-1994 (35 years)
2
3-level conditional hierarchical
mixed-effects model
2
(SD, Others)
1960-1994 (35 years)
3
3-level conditional hierarchical
mixed-effects model
2
(SD, Others)
1960-1969, 1970-1979,
1980-1989, 1990-1994,
separately
Years analyzed
Two outcomes (IMR and LBW) were analyzed separately
SAS version 8.2 was used to obtain the estimates through the REML method
Values for Fixed Intercepts for IMR
and LBW in the 4 Regime Types
15.6
16.0
Social Democratic
Christian Democratic
14.0
12.0
15.1
13.0
Wage Earner
Liberal
10.5
All intercepts
p<0.001
10.0
8.0
6.0
4.8
5.5
5.8
4.0
2.0
0.0
IMR (n=665)
LBW (n=475)
6.1
Results from the Analysis with 4
Welfare State Regime Types
Results from the Analysis with 2
Welfare State Groups, 1960-1994



Variance components for ‘year’ and ‘country’-level random-effects
are highly significant
All fixed-effects intercepts for ‘welfare state regime types’ are highly
significant
F-test is significant for both outcomes
Change in Excess Infant Mortality Rate
and Excess Low Birth Weight Rate:
Social Democracies vs Others
0.50
0.43
0.40
(μ0 -μ1)
μ0
0.40
0.28
0.30
0.27
0.22
0.20
0.26
0.25
0.21
LBW
IMR
0.10
IMR
0.00
1960-1969
1970-1979
1980-1989
1990-1994
Variance Components
LBW
IMR
100%
100%
8.7
80%
5.3
4.9
1.5
0.6
22.0
80%
0.48
0.69
2.9
60%
0.56
0.60
0.66
0.49
0.68
60%
1.5
0.7
40%
44.4
22.3
40%
0.6
20%
9.8
Overall
(19601994)
19601969
Error
0.51
0.53
2.5
20%
0%
0.53
16.4
0.23
19701979
Country
19801989
19901994
Welfare State
0%
Overall
(19601994)
0.06
19601969
Error
0.19
19701979
Country
0.11
19801989
0.06
19901994
Welfare State
Summary




Our results provide a more appropriate account of country
and regime effects than the usual pooled regression analysis
used in comparative health policy analysis.
Our results confirm that countries as clusters or groups share
certain characteristics pertaining to them, as opposed to
countries as individuals
The Social Democratic regime was significantly different from
other countries as a whole
During the era of welfare state retrenchment, the difference in
the low birth weight rate between social democracies and
other countries was magnified
These Findings Could Be Due to,

The development of domestic welfare state social policies







universal access to health care
higher female employment in the labor market
higher unemployment compensation
subsidies to single mothers and divorced women
active labour-market intervention to ensure full employment,
especially among women
Or any supra-national structure: EU, NAFTA, etc.
Or the geographical proximity (policy diffusion)
Implications of the Different Pattern
between IMR and LBW



The Social Democratic countries managed to maintain a
healthier social environment, including smaller economic
inequality, even after 1979, the era of welfare state
retrenchment
This finding is also consistent with Huber & Stephens’ (2001)
finding: in the changed environment of the 1980s, “the active,
service-oriented Social Democratic welfare states were in a
stronger position than the passive, transfer-oriented Christian
Democratic welfare states” (p.321)
This statement also applies to the Liberal and Wage Earner
welfare states that had started “ideologically driven cuts”
(p.320) in the state welfare funding much earlier in time
Contributions and Limitations
CONTRIBUTIONS


This study shows that populationlevel health indicators, such as
infant mortality rate and low birth
weight, have components of
variance at the welfare state type
supranational level (15% to 50%
or more of the total variability)
This study combined a longitudinal
approach with a multi-level
modeling approach to get stronger
inferences
LIMITATIONS


We do not know for sure if the
observed distinctive
characteristics in population health
are because of policy/ political
differences or just reflections of
geographical difference. (i.e., All
Social Democratic Countries are
located in Nothern Europe,
whereas all Liberal countries are
outside Europe, except the UK,
which is a island)
We do not know what aspect of
welfare state regimes resulted in
the difference in population health
levels
Conclusion and Future Directions
CONCLUSION




Welfare state policies affecting
maternal and child health indicators
begin at a supranational level
Comparative health policy studies
should not consider countries as being
independent from one anther
The differences in population health
indicators among these countries
distribute as distinctive clusters of
welfare state regime types
More protective types of welfare state
regimes, namely Social Democratic
countries as a group, were able to
provide a more population healthfriendly environment to its citizens in
the last 35 years
FUTURE DIRECTIONS

Future studies should investigate the
specific welfare regime features (i.e.,
by using explanatory variables) that
account for welfare regime effects on
maternal and child health and other
related population health indicators
References














Abbott, A., & DeViney, S. (1992). The welfare state as transnational event: evidence from sequences of policy adoption.
Social Science History, 16(2), 245-274.
Alesina, A., & Glaeser, E. (2004). Fighting Poverty in the Us and Europe: A World of Difference Oxford: Oxford University
Press
Breen, R., & Rottman, D.B. (1998). Is the national state the appropriate geographical unit for class analysis? Sociology,
32(1), 1-21.
Castles, F., & Mitchell, D. (1993). Worlds of welfare and families of nations. In F.G. Castels (Ed.), Families of Nations: Public
Policy in Western Democracies (pp. 93-129). Brookfield, VT: Dartmouth.
Cho, Y. (2001). Confusionism, conservatism, or liberalism? A study on the typology of Korean Welfare State. Korean Journal
of Sociology, 35(6), 169-191.
Coburn, D. (2000). Income inequality, social cohesion and the health status of populations: The role of neo-liberalism. Social
Science and Medicine, 51(1), 135-146.
Conley, D., & Springer, K. (2001). Welfare state and infant mortality, American Journal of Sociology pp. 768-807).
Esping-Andersen, G. (1990). The Three Worlds of Welfare Capitalism Princeton: Princeton University Press
Esping-Andersen, G. (1999). Social Foundations of Postindustrial Economies Oxford: Oxford University Press
Goodman, R., & Peng, I. (1996). The East Asian Welfare States: Peripatetic Learning, Adaptive Change and Nation-Building.
In G. Esping-Andersen (Ed.), Welfare States in Transition.London: SAGE.
Hong, K. (1991). A Qualitative comparative study on the welfare state typology: Interventionist, Liberal, and Confucian
Welfare State, A Study of Korean Welfare System (pp. 119-151). Seoul: Na-Nam.
Huber, E., & Stephens, J. (2001). Development and Crisis of the Welfare State- Parties and Policies in Global Markets
Chicago: University of Chicago Press
Jones, C. (1993). The pacific challenge: Confucian Welfare States. In C. Jones (Ed.), New Perspectives on the Welfare
State in Europe.London: Routledge.
Korpi, W., & Palme, J. (2003). Class politics and "new polibcs" in the context of austerity and globalization: Welfare state
regress in 18 countries 1976-1995. Sociologisk Gorskning, 4, 45-85.
References (Cont’d)












Littlell, R., Smith, G., & Harper, S. (1996). SAS System for Mixed Models Cary, NC: SAS Institute Inc.
Lynch, J., Smith, G., Harper, S., Hillemeier, M., Ross, N., Kaplan, G., & Wolfson, M. (2004). Is income inequality a
determinant of population health? Part 1. A systematic review. Milbank Quarterly, 82(1), 5-99.
Macinko, J., Starfield, B., & Shi, L.Y. (2003). The contribution of primary care systems to health outcomes within
Organization for Economic Cooperation and Development (OECD) countries, 1970-1998. Health Services Research, 38(3),
831-865.
Macinko, J.A., Shi, L.Y., & Starfield, B. (2004). Wage inequality, the health system, and infant mortality in wealthy
industrialized countries, 1970-1996. Social Science & Medicine, 58(2), 279-292.
Muntaner, C., Lynch, J., Hillemeier, M., Lee, J., David, R., Benach, J., & Borrell, C. (2002). Economic inequality, workingclass power, social capital and cause-specific mortality in wealthy countries. International Journal of Health Services, 32(4),
629-656.
Navarro, V., & Shi, L. (2001). The political context of social inequalities and health. Social Science and Medicine, 52(3), 481491.
Navarro, V., Borrell, C., Benach, J., Muntaner, C., Quiroga, A., Rodriguez-Sanz, M., Verges, N., Guma, J., & Pasarin, M.
(2004). The importance of the political and the social in explaining mortality differentials among the countries of the OECD,
1950-1998. International Journal of Health Services, 33(3), 419-494.
Preston, S.H. (1975). The changing relation between mortality and level of economic development. Population Studies, 29(2),
231-248.
Rodgers, G. (1979). Income and inequality as determinants of mortality: An international cross-section analysis. Population
Studies, 33(3), 343-351.
Shi, L., Macinko, J., Starfield, B., Wulu, J., Regan, J., & Politzer, R. (2003). The relationship between primary care, income
inequality, and mortality in US states, 1980-1995. The Journal of the American Board of Family Practice, 16, 412-422.
Wagstaff, A., & van Doorslaer, E. (2000). Income inequality and health: What does the literature tell us? Annual Review of
Public Health, 21, 543-567.
Wilkinson, R. (1996). Unhealthy Societies: The Afflictions of Inequality New York: Routledge