Welfare State Matters:
A Typological Multilevel Analysis
of Wealthy Countries
Summary of Today’
Today’s Presentation
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Hae-Joo Chung, RPh, MSc
Department of Health Policy and Management,
The Johns Hopkins School of Public Health
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The Field of Political · Welfare State
Determinants of Health
Welfare State Typologies
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Welfare-state typology has been proved to be a useful
explanatory device for the emergence of welfare states,
including national health policies
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Huber E and Stephens JD (2001) Development and Crisis of the Welfare State
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Three (Esping-Andersen) or four (Huber & Stephens) regimetype clusters based on qualitatively different arrangements
between state, market and family
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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
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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
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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
More generous
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
CountryCountry-level fixedfixed-effects models
using panel datasets
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Assumes covariances
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Country
Country A
A
Country
Country B
B
Year
Year Obs
Obs
1990
1990 aa
1991
1991 bb
1992
1992 cc
..
..
..
Year
Year Obs
Obs
1990
1990 a´
a´
1991
1991 b´
b´
1992
1992 c´
c´
..
..
..
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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
Aim
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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
These are dependent
These are independent
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Hypothesis
Countries and Categorizations
Social
Democracies
Christian
Democracies
Better
Health
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19 wealthy countries, 1960 - 1994 (35 years)
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Social Democratic
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Wage
Earner
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Liberal
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Generosity of the Welfare-state System
Generosity of the Welfare-state System
[ A “Linear” Distribution ]
[ A Distribution as “Clusters” ]
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Outcome Variables and Data Sources
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Outcome variables
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The infant mortality rate (IMR)
The Low birth weight rate (LBW)
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Canada
Ireland
The United Kingdom
The United States of America
k1=0
k1=0, 1, 2, 3, or
k2=0, 1
Fixed effects
k1=1
kk22=0
=0
k1=2
k1=3
kk22=1
=1
…
j=1, 2, 3, …, 19
Random effects
…
i=0, 1, 2, …, 34
Random effects
…
Values for Fixed Intercepts for IMR
and LBW in the 4 Regime Types
Statistical Analyses
3-level conditional hierarchical
mixed-effects model
Liberal
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Level i: Years
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1
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Austria
Belgium
France
Italy
Luxembourg*
Netherlands
Switzerland
(West) Germany
Australia
Japan*
New Zealand
Level j: Countries
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Type of the Model
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Level k: Welfare state regimes
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The OECD Health Data 2000
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ThreeThree-level Conditional Hierarchical
MixedMixed-effects Models: A Diagram
Data source
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Wage Earner
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Christian Democratic
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Worse
Health
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Denmark
Finland
Norway
Sweden
No. of Welfare
State Categories
4
(SD, CD, WE, L)
Years analyzed
15.6
16.0
1960-1994 (35 years)
12.0
15.1
Social Democratic
Christian Democratic
14.0
13.0
Wage Earner
Liberal
10.5
All intercepts
p<0.001
10.0
2
3-level conditional hierarchical
mixed-effects model
2
(SD, Others)
1960-1994 (35 years)
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3-level conditional hierarchical
mixed-effects model
2
(SD, Others)
1960-1969, 1970-1979,
1980-1989, 1990-1994,
separately
8.0
6.0
4.8
5.5
5.8
6.1
4.0
2.0
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Two outcomes (IMR and LBW) were analyzed separately
SAS version 8.2 was used to obtain the estimates through the REML method
0.0
IMR (n=665)
LBW (n=475)
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Results from the Analysis with 4
Welfare State Regime Types
Results from the Analysis with 2
Welfare State Groups, 19601960-1994
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Change in Excess Infant Mortality Rate
and Excess Low Birth Weight Rate:
Social Democracies vs Others
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
Variance Components
LBW
IMR
100%
100%
8.7
0.50
0.43
0.40
80%
5.3
4.9
(μ0 -μ1)
μ0
0.27
0.22
0.20
0.6
80%
0.26
0.25
0.21
60%
0.69
44.4
22.3
40%
2.5
0.6
0%
1990-1994
Overall
(19601994)
19601969
Error
Summary
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0.66
0.49
0.68
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
0.51
0.53
20%
0.23
9.8
IMR
1980-1989
0.53
16.4
20%
1970-1979
0.60
0.7
40%
IMR
0.00
0.56
60%
1.5
LBW
0.10
1960-1969
0.48
2.9
0.28
0.30
1.5
22.0
0.40
19701979
Country
19801989
19901994
Welfare State
0%
Overall
(19601994)
0.06
19601969
Error
0.19
0.11
19701979
Country
19801989
0.06
19901994
Welfare State
These Findings Could Be Due to,
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The development of domestic welfare state social policies
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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)
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Implications of the Different Pattern
between IMR and LBW
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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
Conclusion and Future Directions
CONCLUSION
FUTURE DIRECTIONS
Contributions and Limitations
CONTRIBUTIONS
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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
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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
LIMITATIONS
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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
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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
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