The persistence of health inequalities in modern welfare states: The explanation of a paradox

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Abstract

The persistence of socioeconomic inequalities in health, even in the highly developed ‘welfare states’ of Western Europe, is one of the great disappointments of public health. Health inequalities have not only persisted while welfare states were being built up, but on some measures have even widened, and are not smaller in European countries with more generous welfare arrangements. This paper attempts to identify potential explanations for this paradox, by reviewing nine modern ‘theories’ of the explanation of health inequalities. The theories reviewed are: mathematical artifact, fundamental causes, life course perspective, social selection, personal characteristics, neo-materialism, psychosocial factors, diffusion of innovations, and cultural capital.

Based on these theories it is hypothesized that three circumstances may help to explain the persistence of health inequalities despite attenuation of inequalities in material conditions by the welfare state: (1) inequalities in access to material and immaterial resources have not been eliminated by the welfare state, and are still substantial; (2) due to greater intergenerational mobility, the composition of lower socioeconomic groups has become more homogeneous with regard to personal characteristics associated with ill-health; and (3) due to a change in epidemiological regime, in which consumption behavior became the most important determinant of ill-health, the marginal benefits of the immaterial resources to which a higher social position gives access have increased.

Further research is necessary to test these hypotheses. If they are correct, the persistence of health inequalities in modern European welfare states can partly be seen as a failure of these welfare states to implement more radical redistribution measures, and partly as a form of ‘bad luck’ related to concurrent developments that have changed the composition of socioeconomic groups and made health inequalities more sensitive to immaterial factors. It is argued that normative evaluations of health inequalities should take these explanations into account, and that a direct attack on the personal, psychosocial and cultural determinants of health inequalities may be necessary to achieve a substantial reduction of health inequalities.

Highlights

► The persistence of health inequalities in the modern welfare states of Western Europe is difficult to explain. ► We hypothesize that it is partly due to persisting inequalities in access to material and immaterial resources. ► We hypothesize that it is partly due to greater intergenerational social mobility and stronger selection. ► We hypothesize that it is partly due to consumption behavior becoming the most important determinant of ill-health. ► Tackling the personal, psychosocial and cultural determinants of health inequalities is needed to reduce health inequalities.

Introduction

The persistence of socioeconomic inequalities in health is one of the great disappointments of public health. All countries, including those ranking high on indices of economic prosperity and human development, have systematic inequalities in mortality and morbidity between citizens with a higher and a lower socioeconomic position, as indicated by education, occupation, income or wealth. These health inequalities are often substantial, and usually amount to between 5 and 10 years difference in average life expectancy at birth, and between 10 and 20 years difference in disability-free life expectancy (Commission on Social Determinants of Health, 2008; Mackenbach et al., 2008; Sihvonen et al., 1998).

This also applies to the highly developed ‘welfare states’ of Western Europe. All Western European countries have created extensive arrangements aiming to reduce socioeconomic inequality and its various consequences. With notable variations all these ‘welfare regimes’ include measures to redistribute income (e.g. by progressive taxation and social security) and a range of collectively financed provisions (e.g. public housing, education, health care, access to culture and leisure facilities) (Esping-Andersen, 1990; Ferrara, 1996).

There is good evidence that welfare policies have contributed to a reduction of inequalities in income, housing quality, health care access and other social and economic outcomes (Esping-Andersen, 1990; Kautto et al., 2001), but they have apparently been insufficient to eliminate health inequalities. Long-term time-series of health inequalities spanning the whole of the 20th century are rare, but English data suggest that while inequalities in mortality narrowed until 1950, they have since then substantially widened (Fig. 1) (Pamuk, 1985; Wilkinson, 1989). If we take 1920–1980 to be the period in which European welfare states (including the British welfare state) were being built up, any narrowing effect on inequalities in mortality must have occurred in its early stages. The widening of mortality inequalities has continued into the 21st century, not only in Britain (Fair Society, Healthy Lives, 2010) but also in other countries with available data. During the last three or four decades, a widening of inequalities in mortality, on a relative and sometimes also on an absolute scale, has been reported for many Western European countries (Fawcett et al., 2005; Mackenbach et al. 2003; Strand et al., 2010; Valkonen et al., 2000). This widening started well before the welfare reforms (with cutbacks in provisions and entitlements) of the 1990s (Fawcett et al., 2005; Strand et al., 2010; Valkonen et al., 2000; Wilkinson, 1989).

This paradoxical situation is made even more puzzling by the lack of association between the extent or intensity of welfare policies in a country on the one hand, and the magnitude of its health inequalities on the other hand. Comparative studies have found that socioeconomic inequalities in mortality and morbidity are not smaller in countries with relatively universal and generous welfare policies (e.g. the Nordic countries) than they are in other countries (e.g. the United Kingdom with its more liberal welfare regime, or Southern European countries with their more family-based welfare arrangements). This was first observed for the 1980s (Mackenbach et al., 1997) and then confirmed for the 1990s (Mackenbach et al., 2008) and 2000s (Eikemo, Huisman, Bambra, & Kunst, 2008; Eikemo, Bambra, Joyce, & Dahl, 2008), and applies both to relative and absolute measures of health inequalities. Recent reviews have concluded that the association between welfare regimes and health inequalities is inconsistent (Beckfield & Krieger, 2009; Muntaner et al., 2011).

Table 1 illustrates this for absolute inequalities in mortality in a sample of Western European countries. Within Western Europe, both relative and absolute inequalities in total mortality tend to be smallest in the South, e.g. in the regions of Turin and Madrid. This is primarily due to small inequalities in mortality from cardiovascular disease (among men and women) and cancer (among women) (Mackenbach et al., 2008). In the North of Europe, Sweden tends to have relatively small inequalities in mortality, but Norway's inequalities in mortality are considerably larger than those seen in the South or in England/Wales, partly because of large inequalities in smoking-related causes of death (Mackenbach et al., 2008; Van der Heyden et al., 2009).

In this paper I will explore the explanation of this paradox. What explains the persistence and even widening of socioeconomic inequalities in health in the highly developed welfare states of Western Europe, and the lack of association between generousness of welfare policies and the magnitude of health inequalities? Although this question has been discussed before (Bambra, 2011; Dahl et al., 2006; Eikemo & Huijts, 2009; Hurrelmann et al., 2011), clear hypotheses have not emerged. I will review current scientific theories on health inequalities, and evaluate what elements they could contribute to an explanation of the paradox. My approach resembles that of Bambra (2011), but while the latter study's main conclusion is that “[existing] theories provide little insight into the issue” and that this “public health puzzle highlights the limitations of existing theories” (p. 744), I will argue that some of these theories do suggest plausible hypotheses on the explanation of the paradox. I will also review a wider range of potentially relevant theories. The conclusions of the analysis will then be used to discuss some policy implications, starting with the question of what these explanations would imply for the normative evaluation of health inequalities in modern welfare states. The main purpose of this paper is to generate hypotheses, and to provide a starting point for further scientific discussion.

Section snippets

The three components of social stratification

Socioeconomic inequalities in health ultimately derive from social inequality. An analysis of why health inequalities persist should therefore be based on an understanding of social stratification. According to general sociological theory, systems of social stratification are made up of three components, each of which can vary between societies and over time: (1) mobility mechanisms that “sort” individuals into social strata, (2) allocation rules that distribute resources to social strata, and

Synthesis

Only some of the reviewed theories can provide a plausible and specific explanation for the persistence and even widening of health inequalities in the advanced welfare states of Western Europe. The ‘mathematical artifact’, ‘fundamental causes’ and ‘life course’ theories reframe the problem in different (and potentially useful) terms but do not provide a specific explanation for the paradox. ‘Neo-materialist’ and ‘psychosocial’ theories help us to understand why health inequalities persist,

Acknowledgment

The author would like to thank Dr Mauricio Avendano, Dr Terje Eikemo and Dr Frank van Lenthe for their comments on a previous version of this paper. The valuable comments of the anonymous reviewers have also helped to further improve this paper and clarify its reasoning.

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