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Achim Hurrelmann. Steffen Schneider. Karin Gottschall. Thomas Rixen. Peter Starke. Michael Dobbins. Kerstin Martens. Natascha Zaun. Tonia Bieber. Lutz Leisering. Home Contact us Help Free delivery worldwide. Free delivery worldwide. Bestselling Series. Harry Potter. Self-rated health is the most common health measure and is used in four studies [ 13 , 52 — 54 ] and morbidity measures are generally more common. Four studies examine population health and all studies report that the Nordic countries have the best health, but findings differ by various factors. One study finds that young Icelandic people have better self-rated health than American people but that the opposite is found after age 50 [ 52 ].

Another finds that although the Nordic countries are still in the lead, the Southern countries are catching up rapidly regarding mortality related measures of health [ 55 ]. A third study finds that self-rated health seems to be the best in Sweden, Norway and Denmark but is actually the worst in Finland [ 53 ]. Finally, a fourth finds that self-rated health is the best in Social democratic countries compared to other European countries and this effect is largely mediated by more equal income distribution [ 13 ].

Five studies have an inequality approach to population health. One study finds that the effects of affluence and self-rated health are weaker in Iceland [ 52 ]. A third uses the Gini coefficient as a measure of inequality and finds that the Nordic countries have the lowest scores which seems to be related to better self-rated health and a higher Gini coefficient score is negatively related to self-rated health [ 13 ]. Another study finds that education has more effect on health morbidity in Western and Southern Europe and that it is insignificantly related in Northern Europe [ 54 ].

Another study finds that inequalities in health are smaller in the United States than in Denmark [ 51 ], in contrast to the results of the studies mentioned above which all find positive results for the Nordic countries. An Additional file shows further information on study characteristics and results [see Additional file 4 : Geographical comparisons]. There is great variation in the results presented in the studies when grouped according to what typology they have used, making it problematic to draw generalisable conclusions regarding where population health is better and inequalities in health are the smallest.

The variation in findings across studies applying a regime approach is not possible to understand as a result of the regime typology chosen or the amendments used and we still find a patchy picture with contradictory findings. Nevertheless, since the studies in this category also differ in several other aspects it is still possible that theoretical and empirical differences could account for the diversity in findings.

The studies were initially grouped according to the main outcome; i. Results differed in numerous ways, for example with time, by gender, by measures of population health and health inequalities, making it difficult to draw any conclusions. The studies were then grouped according to use of health outcome. The studies in this review have used either morbidity- or mortality related measures and although these are both valid measures of health, they might give different results. The two big groups that are classified as mortality related measures are life expectancy and infant mortality.

The studies that look at life expectancy find that East Asian countries have higher life expectancy than other regimes. The studies that examine infant mortality find that the Nordic countries have the lowest rates of infant mortality. Few studies examine inequalities and do not give any clear results. Studies that look at morbidity measures such as self-rated health find mixed results. Some find that the Nordic countries have better self-rated health while others find that other regimes have better health.


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No consensus regarding which regime has the best health can be found; some find that Liberal countries have better health than Conservative, and others find the opposite. No clear pattern is seen for inequalities in self-rated health; there is no consensus of which regime has the smallest. The studies were then listed according to the number of countries of which the studies are based but no apparent pattern could be found. Finally, the studies were grouped according to the type of data used.

All studies using ESS data, except for one, which does not find any significant differences between the typologies, find that other countries, and not the Nordic countries, have the best health. Most of these studies use self-rated health as health outcome. It seems as though other countries have smaller inequalities compared to the Nordic countries.

Most of these use infant mortality as a measure of health. Regarding inequalities in health, it is difficult to draw any conclusions. The Institutional approach is the second largest of the three groups with 14 studies fitting the criteria. The studies have been classified according to main type of policy area: family [ 15 , 16 , 56 — 59 ], pensions [ 17 , 59 — 61 ], economic assistance and unemployment benefits [ 58 , 62 , 63 ] and access to health care [ 64 — 66 ].

Two articles cover several policy areas [ 58 , 59 ]. It is more common to use mortality measures used 15 times as health indicator than it is morbidity measures used 10 times. Universal family policies seem to be beneficial for all, not only those who use it. They find that generous family policies provide protection from poor health, poverty and unemployment to mothers in general and particularly to lone mothers. An Additional file shows further information on study characteristics and results [see Additional file 5 : Family benefits].

There seems to be general agreement of generous pensions being related to better health and higher life expectancy. Most studies suggest that basic security pensions are associated with lower old age excess mortality [ 59 , 61 ] and a higher life expectancy [ 17 ].

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For further information on study characteristics and results see an Additional file [see Additional file 5 : Pension benefits]. Universal systems of economic assistance [ 62 ] and unemployment benefits [ 58 , 63 ] seem to be associated with a healthier population. This seems to apply to the whole population, not only to the health of the unemployed [ 58 ]. An Additional file shows further information on study characteristics and results [see Additional file 5 : Economic assistance and unemployment benefits].

Absolute inequalities in mortality by socioeconomic status income and education seem to decrease with universal health care. However, the relative gap seems to increase, i. For further information on study characteristics and results [see Additional file 5 : Access to health care].

Most studies in this approach seem to agree that generous policies and benefits are associated with health in a positive way for all people in a population, not only those who are directly affected or targeted and receive the actual benefit. The Expenditure approach is the smallest of the three approaches, only eight studies fit the criteria. There is perhaps an increased tendency of using this approach for cross-country comparisons of population health see Additional file 2 for detailed timelines of publication year.

Two studies use a health inequality perspective and both examine inequalities by education and were published in One study covers both social and health spending, three studies cover social spending only, and four cover health spending only. The selected studies use various health measures, nine different in total. Some studies analyse several health measures and others look at only one. By categorising the health outcomes into either an outcome related to mortality or morbidity, one finds that different mortality outcomes are the most common 11 compared to 4.

Some studies find that health spending is associated with life expectancy and maternal mortality [ 67 ], general mortality and a reduction of life years lost [ 68 ], and lower infant mortality rates [ 69 ]. One study finds that social spending on health is negatively correlated with health for women and unrelated for men [ 48 ]. The authors suggest that a reason for this might be that additional spending on health might have little effect on OECD countries since expenditure levels are already high in many of these countries.

One study [ 70 ] looks at inequalities and finds that in countries where the government spends a lot of money on healthcare and has a highly modernised labour market the relative risk of lower educated people being in poor health is smaller. An Additional file shows further information on study characteristics and results [see Additional file 6 : Health spending]. Two studies find that social spending is associated with life expectancy, infant mortality, potential years of life lost [ 67 ], and mortality [ 71 ].

One study [ 17 ] finds conflicting results; the relationship between social spending and life expectancy vary from cross-section to cross-section. The study finds that initial investment in social policy leads to increases in life expectancy but after a certain level of spending, the extra spending does not contribute that much. The study looking at health inequalities [ 5 ] finds that social spending seems to be associated with lower education based inequalities in health among women and, to a lesser degree, among men.

Additionally, those with primary education benefit more from high social transfers than those with tertiary education. For further information on study characteristics and results see an Additional file [see Additional file 6 : Social spending]. Most studies in the Expenditure approach agree that social and health spending is associated with increased levels of health in one way or the other. The studies that do not find these positive associations do not see consistent findings over time.


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These studies also show evidence that after a certain level of spending additional spending does not contribute that much, showing a curvilinear association. Both studies with the inequality perspective find that spending is beneficial for those with lower educational status. Both studies examine self-rated health and therefore no conclusions can be drawn regarding mortality which is the most common use of measure in this approach.

The starting point for this review has been the mixed and contradictory findings arising from research on welfare state characteristics and health and health inequalities. This area evidently needs to be further explored in order to fully understand the inconsistent results and is of importance not only to welfare research but also to epidemiology.

The results in this review add an important piece to the puzzle by clarifying and describing why previous studies have not been able to come to unequivocal conclusions. Our analytical approach has been to sort the relevant studies found according to their approach to measure welfare state characteristics, something that to our knowledge, has not been done before. Of the three main types regime, institutional and expenditure , the Regime approach is by far the most common. However, while the fundamental approach is the same for these studies we find large variations in the theoretical basis as well as the countries and regime types included.

Most followers are using de-commodification as their starting point. However, even when we sort studies according to the regime theory employed and the amendments made to these, results are diverse and contradictory. Hence, it is not inconsistencies between different theories or different empirical applications of these that is the only or main problem, but a more general problem with welfare state regimes when applied to outcomes such as health and health inequalities.

A further problem is that different health measures are used, which adds to the complexity of drawing conclusions about where health is the best and health inequalities the smallest since choice of measure will highly affect the outcome and the conclusions drawn. When stratifying our material according to type of health measure used some consistent results can be found regarding levels of mortality. Morbidity related measures show mixed results and may reflect data and reporting problems. However, in search for consistencies regarding health inequalities, not much added clarity is achieved.

Many researchers in comparative welfare regime and health research agree that welfare states cluster together into certain regimes. However, there is less agreement about which typology to apply and when, and this therefore remains an open issue. Since there is no total agreement about which typology to use, several classifications have emerged, many of which are rather similar and overlap each other, all intending to capture the essence of a welfare state.

These typologies have sometimes emerged on unclear grounds, for example, it seems as though some have emerged based on the country data available to each author and not on strong theoretical grounds. By adding a regime such as the Eastern European regime, the picture becomes more complete, but it also becomes more complex and this tends to change the whole focus of the study. These studies tend to find that Central and Eastern European countries fare the worst. The health situation in former communist countries is an important and complicated issue in its own right.

However, while this is likely to be linked to social and policy factors it is questionable if the addition of these countries to the existing and already conflicting research is especially helpful. This field of research has a long history of debate.

The U.S. Welfare System's Transformation and Its Future

Many critics have pointed out that there are problems with typologising. Generousness or universalism in other parts of the welfare state, e. The UK for example, is usually placed in the Liberal regime group, but at the same time, it has a universal health system free of charge. On the other hand, many researchers refer to Southern, Northern and other groups of countries in a way that suggest an underlying idea about fundamental commonalities in those groups including Mackenbach.

With time comes change, and all is well if all countries in each welfare state cluster move forward together, but this is seldom the case. Countries will have different experiences and might well move in different directions at different paces. A country can with time go through policy changes in eligibility, structures or financing that could technically and potentially reposition it from one regime cluster to another.

For example, Kvist et al. Kuivalainen and Nelson [ 76 ] find that the social assistance in the Nordic countries is moving closer to some of the features and outcomes of other regimes in terms of benefit generosity and poverty outcomes. They conclude that the Nordic social assistance classification into a separate model of social welfare is not as distinct as it was 20 years ago.

A recent OECD report about income inequalities finds that in Sweden, many times seen as the archetypical Nordic country, the relative income poverty rate has increased the most during the last 20 years and particularly among children and youth. If this continues the Nordic countries might experience poverty rates similar to those in several Liberal and Conservative welfare states meaning that one of the most significant features of the Nordic welfare states will disappear [ 76 ].

We do not assert that this can be extended as a general conclusion. Rather, the Regime approach has been important for welfare state research, and especially so perhaps for analyses of the welfare state as a dependent variable. It can also be highly informative for descriptive purposes.

But as a tool for analyses of how policies and institutions that impact on the wider social determinants of health actually affect health inequalities, it is simply too crude and imprecise. When adding the fact that few studies in practice adopt the same Regime approach although many use the same labels , there is no wonder that the results produced are diverging and even conflicting.

Radical Welfare State Retrenchment - A Comparative Analysis | P. Starke | Palgrave Macmillan

To our knowledge this has not yet been applied to health and health inequalities outcomes, but given that this approach produces a more nuanced picture where also countries outside the traditional OECD countries can be included [ 80 ], it seems more promising than more traditional ways of clustering countries. Both of these do, however, still represent a clustering of countries, and although they are likely to be more promising than the different ideal types typically employed in the studies included in our review, several of the caveats are likely to apply.

Another major difference between these two approaches and the Regime approach is that where the Regime approach has to rely on country cluster average differences, the Institutional and Expenditure approaches give us a variable approach. This means that we can allow for countries to differ in their policies in different areas of interest social protection, family policies, health care policies, labour market policies etc. This, in turn, is likely to increase the policy relevance of studies as well as our understanding of the processes involved when health inequalities are generated.

While the Institutional and Expenditure approaches are more promising in principle for health inequality research, there are to date a limited number of studies of this kind. Yet, the clear impression from taking these studies combined is still that more social spending and more generous social rights lines up with lower mortality, better health and, probably, smaller health inequalities.

When looking directly at institutional social rights or social spending the relations between policies and health outcomes becomes uncovered in a much clearer way. It is important to stress that the Institutional approach to a large extent was formulated as a critique of the Expenditure approach. The latter has been accused of being faulty since it does not address two of the main features of a welfare state; social citizenship and social rights.

There have also been doubts regarding that high spending means nothing more than extensive social problems. Kangas and Palme [ 8 ] find that the advanced rich countries seem to use roughly the same amount of their GDP on welfare. Even though spending levels are similar, the distributional consequences can be greatly divergent. However, this critique has also led to adaptations and procedures to take differences in need into account, thereby closing the gap between the two approaches in empirical terms at least [ 5 , 82 ].

But, the Institutional approach focusing on legislated social rights has shortcomings too. It tends to capture the principles for certain type cases, while the lived experience of people in need of social protection can be something else. It might also be important to include several dimensions of social rights, like coverage and replacement rates, to get a balanced picture. In contrast to spending data, such data on the legislated rights are not produced routinely but requires large efforts to collect. Hence, there are weaknesses and strengths to both approaches, and in relation to outcomes like health inequalities, they are likely to be complementary rather than mutually exclusive.

This review was based on empirical studies published in peer-reviewed journals.

The Welfare State as Crisis Manager

There is a small risk that other studies of welfare states and health inequalities are to be found in e. We have set the starting point for the literature search to and relevant studies prior to this year have been missed in our search. However, we started off by revising the three large reviews [ 3 , 4 , 9 ], which are based partly on studies prior to , and their results are also somewhat inconsistent regarding welfare research and health inequalities.

This indicates that studies prior to would not contribute much to the overall picture. In addition, the Publication timelines [see Additional file 2 ] indicate that the number of studies increases over time, which means that the risk that we have missed important studies prior to is small. Most importantly, however, it is necessary to notice that the three approaches identified are unbalanced; the Regime approach is by far the largest.

While this means that our conclusions regarding the Regime approach are fairly well underpinned, conclusions regarding the merits of the Institutional and Expenditure approaches are based on a small number of studies. While this reflects the reality, it is important to keep in mind when evaluating our conclusions.

For example, if more studies are produced using these two approaches it may well be that less consistent results emerge also for them. The wider social determinants of health, the causes of the causes, are of great importance for health and well-being, and the collective resources in terms of social protections and services provided by the welfare state are likely to be more important for those that have fewer resources in their own control. From this follows that a range of welfare state policies are important for health and health inequalities, but the question is how we best can study this in more detail.

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