Elsevier

The Lancet

Volume 372, Issue 9650, 8–14 November 2008, Pages 1633-1640
The Lancet

Articles
The role of welfare state principles and generosity in social policy programmes for public health: an international comparative study

https://doi.org/10.1016/S0140-6736(08)61686-4Get rights and content

Summary

Background

Many important social determinants of health are also the focus for social policies. Welfare states contribute to the resources available for their citizens through cash transfer programmes and subsidised services. Although all rich nations have welfare programmes, there are clear cross-national differences with respect to their design and generosity. These differences are evident in national variations in poverty rates, especially among children and elderly people. We investigated to what extent variations in family and pension policies are linked to infant mortality and old-age excess mortality.

Methods

Infant mortality rates and old-age excess mortality rates were analysed in relation to social policy characteristics and generosity. We did pooled cross-sectional time-series analyses of 18 OECD (Organisation for Economic Co-operation and Development) countries during the period 1970–2000 for family policies and 1950–2000 for pension policies.

Findings

Increased generosity in family policies that support dual-earner families is linked with lower infant mortality rates, whereas the generosity in family policies that support more traditional families with gainfully employed men and homemaking women is not. An increase by one percentage point in dual-earner support lowers infant mortality by 0·04 deaths per 1000 births. Generosity in basic security type of pensions is linked to lower old-age excess mortality, whereas the generosity of earnings-related income security pensions is not. An increase by one percentage point in basic security pensions is associated with a decrease in the old age excess mortality by 0·02 for men as well as for women.

Interpretation

The ways in which social policies are designed, as well as their generosity, are important for health because of the increase in resources that social policies entail. Hence, social policies are of major importance for how we can tackle the social determinants of health.

Funding

Swedish Ministry of Health and Social Affairs.

Introduction

When addressing the wide range of social determinants of health, an equally wide range of policies needs to be considered.1 In a general sense, social determinants of health consist of resources through which the individual can control and direct their conditions of life.2 Consequently, lack of such resources will increase the risks for poor health and premature mortality. Resources are generated within the family and in the market, but also through the welfare state. Although there is a range of resources that are important to health, economic resources are central since they can easily be transformed into other types of resources. Also, economic resources can be directly reallocated by the welfare state through social policies, including programmes such as unemployment insurance, sickness insurance, family support, and pensions, and also by means of subsidised or free services such as child care, health care, or elderly care.

There are large variations across welfare states in the guiding principles behind policy schemes as well as the ambition of these schemes. As a consequence, there are large variations in the proportion of the relevant population covered by specific programmes and in how generous these programmes are. In addition to the benefits provided, welfare state institutions and policies can improve people's ability to generate resources in the market, for example through active labour market policies or by implementing policies that enhance women's labour force participation. Thereby, different welfare state set-ups will have consequences in terms of the resources available to individuals, and especially the amount of resources available to those in low-income or middle-income groups.

The Nordic countries (Denmark, Finland, Iceland, Norway, and Sweden) have developed a distinct type of welfare state. Some typical characteristics include universal social policy programmes, equality in opportunities and outcomes as explicit goals for social policies, a large public sector with extensive transfer programmes and services, high employment rates, and high taxes to finance these programmes. Some other countries have opted for more market-based policy solutions, where the responsibility of the welfare state is mainly restricted to poverty relief, whereas others have arranged welfare programmes along occupational categories and with a strong focus on social protection schemes supporting the traditional family model where the man is the main income-earner.3

Differences in principles and generosity can be noted in national variations in poverty rates, where countries with universal social policies (such as the Nordic countries) have much lower poverty rates than countries with an emphasis on residual and targeted social policies (such as the UK and the USA).4 In particular, the Nordic countries have low poverty rates among vulnerable groups like children, single parents, and elderly people.5, 6

Since social policies could therefore have an important effect on key social determinants of health, we need to ask whether welfare state characteristics are conducive to better population health. Here we ask to what extent social policy solutions typical for the Nordic countries, but applied to different extents in different countries at different points in time, are important for mortality. Although comparisons between countries or groups of countries can partially answer this question, analyses of variations in the generosity of specific programmes provide a more precise test. We therefore do not simply compare Nordic countries with two or three groups of other welfare state types, but focus directly on the output of these social policy programmes and their consequences for public health.

We focus on two types of welfare state programmes—namely, family support and pensions. Family and pension policies will affect economic resources and poverty rates among children and their parents and elderly people, respectively, and can therefore be important for health and wellbeing early and late in life. Our aim was to study the levels of generosity in these programmes, and to what extent variations in generosity are linked to variations in mortality across 18 countries of the Organisation for Economic Co-operation and Development (OECD) during the post-World War 2 era. On the basis of these and other findings from a larger project focusing on the Nordic experience of welfare states and public health (the NEWS project7), undertaken as a contribution to the Commission on Social Determinants of Health,8 we also discuss the possibility of generalising the findings of our study to other countries.

Section snippets

Data sources

Information on indicators of policy characteristics were derived from the Social Citizenship Indicator Program.9 These data include information on legislated social rights in 18 countries from 1930 to 2000. Only benefits that are legislated in the statutory systems, typically in social insurance and assimilated programmes, were included. These benefits (net of taxes) were calculated for different types of model households and expressed as a ratio to an average production worker's wage (net of

Results

At the start of the 20th century, life expectancy was higher in the Nordic countries than in any other country in Europe. Within these countries, Finland had the lowest life expectancy during the early 1960s (table 1). However, towards the end of the century, Finland's position became increasingly similar to the other Nordic countries, a period also characterised by expansion of the welfare state and public welfare institutions. Denmark, on the other hand, showed a less favourable trend with

Discussion

Nordic countries, with the exception of Finland, have had an early public health advantage, which has persisted, although most countries have caught up with these rates and Japan has surpassed the Nordic countries. The dual-earner type of family support—combining universalism with employment orientation—is important both to alleviate poverty and for cross-national variation in infant mortality. Family policy transfers have had a direct and positive effect on household income, thus reducing

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