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Welfare state regimes, infant mortality and life expectancy: integrating evidence from East Asia
  1. Ying-Chih Chuang,
  2. Kun-Yang Chuang,
  3. You-Rong Chen,
  4. Bo-Wen Shi,
  5. Tzu-Hsuan Yang
  1. School of Public Health, Taipei Medical University, Taipei, Taiwan
  1. Correspondence to Professor Kun-Yang Chuang, School of Public Health, Taipei Medical University, 250 Wu Hsing Street, Taipei 110, Taiwan; adinma{at}tmu.edu.tw

Abstract

Background This longitudinal study builds on the cross-sectional work of Karim et al and examines the influence of welfare state regime on population health with a particular focus on East Asian welfare states (eg, Hong Kong, Japan, Korea, Singapore and Taiwan).

Methods Data were extracted from the Organisation of Economic Co-operation and Development Data Set, World Development Indicators and Asian Development Bank's key indicators from 1980 to 2006. Infant mortalities and life expectancy were used as health-outcome varables. Thirty-one countries were categorised into six types of welfare regimes: Scandinavian, Anglo-Saxon, Bismarckian, Southern, Eastern European and East Asian. Mixed models were applied to analyse the data with repeated measurements.

Results In keeping with Karim et al, Scandinavian and Eastern European welfare states have lower and higher infant mortalities respectively compared with East Asian welfare states. Eastern European welfare states had a lower life expectancy than East Asian welfare states. Most welfare states had a higher social, health and education expenditure, and higher densities of physicians than East Asian welfare states.

Conclusion East Asian welfare states did not have worse health than most welfare states. Future studies should continue to incorporate East Asian countries in the typology of welfare regimes that include more social, economic, political and healthcare system characteristic variables to provide insight on the mechanism by which welfare-state regimes influence population health.

  • Welfare states
  • east Asia
  • welfare regimes
  • infant mortalities
  • life expectancy
  • health policy
  • health statistics
  • infant mortality
  • social epidemiology

https://doi.org/10.1136/jech.2010.126961

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    Introduction

    Prior studies, focused almost exclusively on USA and European societies, suggested the importance to incorporate East Asian welfare states in investigating the influence of welfare states on population health.1 East Asian welfare states were characterised by low social expenditure and high emphasis on economic growth, as well as strong government intervention in social benefits.2–5 Families and kinships were regarded as important resources for care taking and as safety nets for social protection.2

    Prior studies examining the relationship between welfare states and population health have consistently found that Scandinavian countries had the best population health status.6 However, only one study included East Asian countries in the analysis. Karim et al found significant differences in life expectancy (LE) among some welfare states. Interestingly, Asian welfare states, despite having the lowest social expenditure, did not have the worst health outcomes. This longitudinal study, incorporating data from 1980 to 2006, builds on the cross-sectional work of Karim et al and examines the influence of welfare state regimes on population health.7

    Methods

    Data

    This study used an ecological study design and focused on 31 countries from Europe, North America, Asia and the Pacific region during the 27-year period from 1980 to 2006. Data for Australia, New Zealand, and countries in Europe and North America were obtained from the Organisation of Economic Co-operation and Development data sets and World Development Indicators.8 9 Data for countries in Asia were obtained from the Asian Development Bank's key indicators.10

    Measures

    Infant mortality (IMR) and life expectancy at birth (LE) were selected as outcome variables owing to their wide acceptance as population health indicators.11 This study categorised 31 welfare states into six different types according to Ferrera's classification with the addition of Eastern Europe and East Asia categories (appendix 1).12 Economic variables used in this study were GDP per capita, trade ratio to GDP, total employment rate, male employment rate and female employment rate to delineate economic activities and to reflect the high trade dependency in Asian countries.7 Welfare variables included social, health and education expenditure. These three expenditure indicators were measured as a percentage of GDP.7 11 13 14 Physician density, which indicated the capacity of providing medical services, was measured as the number of physicians per 1000 people.14 Control variables included GDP per capita, age dependency and period effects. Age dependency was constructed as the sum of those <15 and over 65, divided by those between ages 15 and 64. Period effects were included to account for the historical influence of each period, constructed using 2000s as the reference group.

    Analysis

    This study used multilevel random intercept models for data analysis. The variables of welfare state types, economic and welfare characteristics were log-transformed for normality. We fitted the multilevel models using welfare state regime as a fixed-effect variable and examined the effects of welfare regime on IMR, LE and several economic and welfare indicators beyond control variables. This study used the SAS PROC MIXED to fit multilevel models. The estimation method was a restricted maximum-likelihood procedure.15

    Results

    Table 1 shows descriptive statistics for the study variables in three time periods: 1980–1989, 1990–1999 and after 2000. During the study period 1980–1989, The Scandinavian welfare states had the lowest IMR (6.7) and highest LE (75.07), while the Eastern European welfare states had the highest IMR (16.42) and lowest LE (70.54). In terms of economic indicators, the Bismarckian welfare states had the highest GDP per capita and trade ratio to GDP. The total employment rate was highest in Scandinavian welfare states, and lowest in Southern and Bismarckian welfare states. In terms of expenditures, Scandinavian welfare states led in all three expenditure categories, while East European welfare states and East Asian welfare states lagged far behind. Southern welfare states ranked first in physician density, while East Asian welfare states ranked last. Patterns in the 1990s and 2000s are similar to the results in the 1980s. The exceptions are in LE and trade ratio to GDP. The average LE in East Asian welfare states became highest in 2000–2006. The trade ratio to GDP also increased drastically from the 1980s to the 2000s.

    View this table:
    Table 1

    Means of variables by welfare state regimes and years

    Table 2 shows the result of multilevel modelling. Each column represents a random intercept model to examine whether East Asian welfare states differ from other welfare states in LE, IMR, and other economic and welfare characteristics, while controlling for GDP per capita, age dependency and period effects. Welfare-state regime alone explained 45.8% and 49.2% of the variance in IMR and LE. Only Scandinavian and Eastern European welfare states differed significantly from East Asian welfare states. East Asian welfare states had significantly higher IMR than Scandinavian welfare states but had significantly lower IMR and longer LE than Eastern European welfare states.

    View this table:
    Table 2

    Effects of welfare state regimes on infant mortality, life expectancy, economic characteristics and welfare characteristics

    While having worse IMR than Scandinavian welfare states, East Asian welfare states also had a significantly lower GDP, total employment rate, female employment rate, physician density, and social, education and health expenditures than Scandinavian states. While having better health outcomes than Eastern European welfare states, East Asian welfare states also had a higher GDP, higher male employment, lower physician density, and lower social and health expenditure than East European states.

    Discussion

    In keeping with the findings of Karim et al, we found that East Asian welfare states do not have worse health than most welfare states. However, some different results were reported in our study. Karim et al suggested that while LE differed significantly by welfare state, IMR did not differ by welfare state. In contrast, our study found that East Asian welfare states had a significantly higher IMR than Scandinavian welfare states, but had a significantly lower IMR and longer LE than Eastern European welfare states. One explanation may be that correlation between welfare states and population health is strongly dependent on the years chosen in the study period. Since there is a large discrepancy in IMR and LE among welfare states in 1980s, a longitudinal study is more likely to reveal the differences.

    To explain why Scandinavian welfare states exhibit a better population health status than East Asian welfare states, a comparison between these two welfare states revealed significant differences in female employment rate, which may have contributed to the IMR difference between them. Scandinavian welfare states provide a better employment environment, as well as more generous parental-care benefit, for females, and thus lower IMR. In contrast, our study found that East European welfare states have worse population health as well as lower GDP and lower participation in labour market, compared with East Asian welfare states. Previous studies have shown a negative relationship between unemployment and self-rated health in European countries, and a non-linear relationship between GDP and health.16 The non-linear relationship could possibly explain why other welfare states had a much higher GDP than East Asian welfare states, but not necessarily better health. Such a finding seems to indicate that the positive relationship between GDP and health diminishes after reaching a certain GDP level.

    Cultural factors may partly explain why East Asian welfare states did not have worse population health. A more traditional family model which fosters a closely knit network, a strong sense of obligation and social support, and the substitution of public care with informal care may buffer the impact of lower public expenditure.17 It is not clear why East Asian welfare states had a lower physician density without exhibiting the worst health. It is possible that low co-payment and high physician output in East Asian welfare states might alleviate the negative effect of low physician density on health, as in the case of Taiwan with its national health insurance system, with low co-payment and high volume of services, that covers up to 99% of its population while at the same time having a lower physician density than other welfare states.18

    Our analyses contain some limitations, which may interfere the results. Causal inference should be interpreted with caution since IMR and LE might influence welfare-state policies rather than the other way around. The categorisation of welfare-state regimes to better represent variations in population health is still under debate, although recent literature has widely used classifications based on Ferrera's classification.1 19 20 Some variables, such as historical contexts and healthcare system characteristics may be excluded, since no suitable data are available. For instance, the recent political liberation, party competition in elections and social movement, particularly in Taiwan and Korea, has led to a significant increase in welfare commitment, which has translated to an expansion of coverage and social security.2 5 6 Political factors and historical backgrounds are difficult to capture and were not available for inclusion in the analysis.

    This longitudinal study supports Karim's study that East Asian Welfare states do not exhibit worse health than other welfare states. Future research should analyse the process by which economic, societal and welfare characteristics influence population health in East Asian welfare states and verify the reasons why and how such a process differs from other welfare states.

    What is already known on this subject

    • Welfare-state factors are important determinants of population health, and this has been clearly demonstrated in welfare states of Europe, North America and Australasia.

    • Karim et al found that Asian welfare states, despite having the lowest social expenditure, interestingly did not have the worst health outcomes in a cross-sectional study.

    What this study adds

    • Longitudinal analysis showed that East Asian welfare states, characterised by lower social, education and health expenditure as well as lower physician density, did not have a worse population health profile than most welfare states.

    • East Asian welfare states had significantly higher IMR than Scandinavian welfare states, but had significantly lower IMR and longer LE than Eastern European welfare states.

    Appendix 1 Categorisation of welfare-state regimes

    ScandinavianAnglo-SaxonBismarckianSouthernEastern EuropeanEast Asian
    DenmarkAustraliaAustriaGreeceCzech RepublicHong Kong
    FinlandCanadaBelgiumItalyHungaryJapan
    NorwayIrelandFrancePortugalPolandRepublic of Korea
    SwedenNew ZealandGermanySpainSlovakSingapore
    UKLuxembourgSloveniaTaiwan
    USAThe Netherlands
    Switzerland

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    Footnotes

    • Funding This study was supported by the National Science Council of Taiwan Grant No 98-2410-H-038-004-MY2 to Y-CC.

    • Competing interests None.

    • Ethics approval All research was approved by the ethics committee at Taipei Medical University, School of Public Health and conforms to the principles of the Declaration of Helsinki.

    • Provenance and peer review Not commissioned; externally peer reviewed.