#PHTwitJC 15 Summary & Qs: Welfare regimes & health inequalities

Sunday 24 June 2012,  note earlier start time of 7.00 pm (UK time).

All are welcome to contribute (see ‘about’ tab above if you’re unsure about how to join in a Twitter # chat ). We will be discussing:

Hurrelman, Rathman & Richter (2010) Health inequalities and welfare state regimes: a research note. Journal of Public Health, 19: 3-13. DOI:  10.1007/s10389-010-0359-1  available here   

figuring out how the welfare state gets under our skin’

The paper presents a review of evidence relating to health inequalities in developed welfare states. The authors  apply  an analysis based on welfare state regime typologies, with a view to developing a theoretical model for future research. The relationship between welfare regime type, economic inequality and health inequality is of particular interest.


The most commonly-used welfare regime typology is by Esping-Andersen (1990) who described ‘liberal’ (e.g. UK, USA), ‘conservative/corporatist’ (e.g. Germany, France) and ‘social democratic’ (e.g. Sweden, Denmark) types of advanced welfare state.

For further explanation of terminology relating to welfare regimes and typologies, see this glossary (in JECH –paywall).

The review

Much previous research indicates that there is greater economic equality, and better overall health, in the Nordic (social democratic) welfare estates than in other groups of countries.  However, the evidence about the relationship between welfare regime type and health inequalities  is more mixed –i.e. it appears that economic equality and good health outcomes  do not inevitably lead to smaller health inequalities. In the paper this is termed the ‘Scandinavian welfare paradox of health’; it has also been called the ‘Nordic puzzle’ (Bambra 2012). The ‘conservative’ welfare regimes (e.g. France, Germany) actually tend to have the lowest health inequalities.

Hurrelman et al’s proposed framework

Having reviewed existing frameworks, Hurrelman et al conclude that they are too limited to shed much light on the above paradox, and on the complex relationships between politics, economy, society and health.  They propose a new explanatory framework that acknowledges determinants at macro (welfare state architecture), meso (living conditions) and micro levels (population group/individual health) , in addition to mediating factors relating to health and public policy (p. 8, see below).

In the model, the degree of ‘health sensitivity ‘ of public policy is presented as an important influence on health outcomes and health equality. The authors suggest that the key innovation of the model is to include non-economic /non-material factors as influences on health and its distribution (p.9):

The authors conclude that further research needs to investigate whether ‘egalitarian’ welfare regimes with strong state intervention actually weaken informal social and health support mechanisms, and individual agency.   They present policy directions for each welfare regime type that enhance their ‘health sensitivity’ and maximise opportunities to reduce health inequalities.

Questions for discussion

  1. Does the paper have clear aims ,and are they addressed?
  2. Is the review of existing literature on welfare regimes and health persuasive? Any surprising findings?
  3. How comprehensive is the authors’ new explanatory  framework of influences on welfare and health (p8 and above)?  Does it raise any questions; anything missing?
  4. How could research be designed that applies and tests the framework?
  5. Are the authors’ conclusions and suggestions for public policy shifts valid and workable?
  6. What do you think about the idea of ‘welfare regimes’ – is it still relevant?
  7. What does the paper add to our understanding of  the impact of public policy on health?
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