International research on the social determinants of health and health inequalities has increasingly begun to draw upon the comparative social policy literature. Specifically, research has concentrated on examining, and to some extent explaining, differences in health outcomes between and within developed countries by comparing different types of welfare state regimes and their respective politics and policies.1^–10 Recent calls for further analysis of the political nature of health (and indeed the creation of “political epidemiology”) suggest that it is likely that such research will grow in the future.11 12 However, public health research has to date relied extensively on the typology of welfare state regimes proposed by Esping-Andersen in his 1990 publication (which used 1980 data), The three worlds of welfare capitalism.13 This is despite the fact that within the discipline of social policy, Esping-Andersen’s typology has long been the subject of extensive scholarly criticism and there is in fact a number of competing welfare state typologies that may also be of use in public health research.14^–22 The purpose of this paper is to provide public health researchers and epidemiologists with an up-to-date overview of the social policy literature on welfare state regimes, so that our research can reflect and benefit from the more contemporaneous insights on offer from the “welfare modelling business”.20 21

This paper begins by summarising Esping-Andersen’s seminal work, The three worlds of welfare capitalism; it then presents the various criticisms that this theory received and outlines the resulting alternative welfare state typologies that emerged. It concludes by suggesting new avenues of study in public health that could be explored by drawing upon this broader welfare state regimes literature. Although there are existing reviews of welfare state regime theory, these are somewhat outdated and, perhaps more importantly, they were not written specifically for or publicised to a public health audience.20 21

THE THREE WORLDS OF WELFARE

In The three worlds of welfare capitalism (1990),13 Esping-Andersen presents a typology of 18 Organisation of Economic Cooperation and Development (OECD) welfare states based upon three principles: decommodification (the extent to which an individual’s welfare is reliant upon the market, particularly in terms of pensions, unemployment benefit and sickness insurance), social stratification (the role of welfare states in maintaining or breaking down social stratification) and the private–public mix (the relative roles of the state, the family, the voluntary sector and the market in welfare provision). The operationalisation of these principles, largely using decommodification indexes, leads to the division of welfare states into three ideal regime types (Esping-Andersen; Table 1): Liberal, Conservative and Social Democratic.13

In the Liberal regime countries, state provision of welfare is minimal, benefits are modest and often attract strict entitlement criteria, and recipients are usually means-tested and stigmatised. The Conservative welfare state regime is distinguished by its “status differentiating” welfare programmes in which benefits are often earnings-related, administered through the employer and geared towards maintaining existing social patterns. The role of the family is also emphasised and the redistributive impact is minimal. The Social Democratic regime is the smallest regime cluster. Welfare provision is characterised by universal and comparatively generous benefits, a commitment to full employment and income protection, and a strongly interventionist state used to promote equality through a redistributive social security system.13

GOING BEYOND THE THREE WORLDS OF WELFARE CAPITALISM

The three worlds of welfare capitalism typology has sparked a volatile and ongoing debate and, indeed, much of the burgeoning comparative social policy literature since 1990 can be seen as a “settling of accounts” with Esping-Andersen.21 23 This process has led to the development of alternative typologies, many of which are intended to reflect aspects that were not examined in Esping-Andersen’s original typology, that extend the range of countries included in the analysis, and that take more account of gender, politics or the role of public services.4 16–19 22–37 The criticism has been on three fronts: theoretical, methodological and empirical.

Theoretical critiques

The range of countries and regimes

The range of countries used to construct Esping-Andersen’s typology has met with criticism.17–19 22 Esping-Andersen only examined 18 OECD countries and in doing so he placed both Italy and Japan within the Conservative regime. Some commentators assert that when the Latin rim countries of the European Union (Spain, Portugal, Greece) are added into the analysis, a fourth “Southern” world of welfare emerges into which Italy can also be placed (Bonoli, Ferrera, Liebfreid; Table 1).17^–19 The Southern welfare states are described as “rudimentary” because they are characterised by their fragmented system of welfare provision, which consists of diverse income maintenance schemes, ranging from the meagre to the generous, and a healthcare system that provides only limited and partial coverage.19 Reliance on the family and voluntary sector is also a prominent feature.

Furthermore, research into East Asian welfare states (South Korea, Taiwan, Hong Kong, Singapore) has suggested that these countries, including Japan, form a further Confucian welfare state regime.24 28 37 The Confucian welfare state is characterised by low levels of government intervention and investment in social welfare, underdeveloped public service provision, and the fundamental importance of the family and voluntary sector in providing social safety nets. This minimalist approach is combined with Confucian social ethics (obligation for immediate family members, thrift, diligence, and a strong education and work ethic).37 Overall, the Confucian welfare state regime could be considered as combining some elements of the Liberal, Conservative and Southern regimes.

In addition, Castles and Mitchell (1993) cross-classified the same 18 OECD nations used by Esping-Andersen and examined their high- and low-aggregate expenditure levels, and their high and low degrees of benefit equality. On the basis of this analysis, they argued that the UK, Australia and New Zealand constitute a Radical, targeted form of welfare state, one in which “the welfare goals of poverty amelioration and income equality are pursued through redistributive instruments rather than by high expenditure levels” (Castles and Mitchell; Table 1).22 In the same vein, Korpi and Palme describe the existence of a Targeted welfare state regime (Korpi and Palme; Table 1).32

The gender-blind “worlds of welfare”

It has been argued that the analysis behind The three worlds of welfare capitalism typology was “gender-blind” (androgynous).34 35 Aside from the overt absence of women in Esping-Andersen’s analysis, the critique revolves around three other issues: the gender-blind concept of decommodification, the unawareness of the role of women and the family in the provision of welfare, and the lack of consideration given to gender as a form of social stratification.33^–35 These criticisms suggest limitations to the comprehensiveness and generalisability of the Three Worlds thesis – especially in regard to any claims about women, welfare and the family.

The gender-blind critique of Esping-Andersen has led to both theoretical attempts to “gender” his analysis, and also, the construction of alternative welfare state typologies in which gender has been a more overt and centralised part of the analysis.16 25 29 31 34^–36 Most notable amongst these new typologies are the defamilisation approaches that examine the extent to which welfare states, and welfare state regimes, facilitate female autonomy and economic independence from the family.16 25 29 31 The difference made to the composition, and number, of welfare state regimes made by the addition of a defamilisation-based analysis, however, is contested and is rather dependent on how the concept is operationalised.16 However, to date, there has been no exploration of defamilisation and health or indeed how the relationship between gender and health varies by welfare state regime.

The “illusion” of welfare state regimes

This critique focuses on Esping-Andersen’s decision to organise the principle of classification around the study of social transfers: pensions, sickness benefits and unemployment benefits.20 26 27 30 This ignores the fact that welfare states are also about the actual delivery of services such as healthcare, education or social services.30 It is suggested that countries vary in terms of the emphasis that they place upon welfare state services and/or social transfers.2730 However, Esping-Andersen’s regimes concept generalises about all forms of welfare state provision on the basis of social transfers.38 This has led some to question the validity of the regimes concept itself as it assumes that most of the key social policy areas within a welfare regime will reflect a similar, across the board, approach to welfare provision; and second, that each regime type itself reflects “a set of principles or values that establishes a coherence in each country’s welfare package”.38

This has resulted in the production of alternative typologies based on the extent of services provided by different welfare states.26 27 30 These are often substantially different in composition from The three worlds of welfare capitalism. For example, Kautto’s comparison of the balance between expenditure on social transfers and welfare services in 15 European countries concluded that welfare states could indeed be divided into three regimes but these were very different in composition and emphasis from Esping-Andersen’s The three worlds of welfare capitalism (Kautto; Table 1).30 Similarly, a typology based on the comparison of the decommodification of healthcare services and social transfers in 18 OECD countries led to a fivefold typology suggesting subgroups within both the Conservative and Liberal regimes (Bambra; Table 1).27

Taking the logic of this critique further still, researchers from the field of political economy have suggested that analysing “political” regimes may prove to be a more fruitful research paradigm.4 7 In addition to criticising The three worlds of welfare capitalism,4 7 they have also highlighted the limited nature of the other alternative typologies, which, in common with Esping-Andersen, focus too much on the characteristics of welfare states to the exclusion of a thorough examination of the policies and politics underpinning and supporting them. Subsequently, a more historical–political analysis led to the development of a fourfold political typology of welfare states (Navarro and Shi; Table 1) in which Greece, Spain and Portugal form an ex-Fascist regime.4

Methodological issues

The limitations of Esping-Andersen’s methodology have also been exposed. Attention has been placed particularly upon the additive nature of the decommodification indexes, weighting within the indexes, the reliance upon averaging, and the use of one standard deviation around the mean to classify the countries into regimes (which meant that only a threefold classification was possible: regime classification is either above [Social Democratic], below [Liberal] or within [Conservative] one standard deviation around the mean).13 14 22 39^–41 This method has a noticeable impact on the classification of certain countries, eg. the UK which, if a different cut-off point was used, may not have fallen within the Liberal regime.14 42 These concerns led to the utilisation of more statistically robust methodologies (most notably cluster analysis), the results of which have challenged the accuracy of the threefold typology by identifying four or five different types of welfare state (Kangas, Ragin, Pitzurello; Table 1).39^–41

Empirical validity

Somewhat inevitably, this has led to the questioning of the ongoing empirical validity of The three worlds of welfare capitalism typology. Recently Esping-Andersen’s study was replicated and the results differed substantially from the original.43 In addition, it has been found that the miscalculation of the mean and standard deviation in the original Three worlds of welfare capitalism data led to the misclassification of three borderline countries (Japan, UK and Ireland).10 Furthermore, an updated analysis of decommodification using data from 1998/9 has suggested that the relationships between the 18 OECD countries have changed significantly and that the composition of welfare state regimes is not static.10 Taken together, these pieces of research bring into question the extent to which The three worlds of welfare capitalism still exist, and indeed, at least in empirical terms, the extent to which they ever did.14

PUBLIC HEALTH RESEARCH BEYOND THE THREE WORLDS OF WELFARE CAPITALISM

In light of this overview, it seems somewhat bizarre that public health research has been near oblivious to these substantial developments in social policy research since the publication of The three worlds of welfare capitalism in 1990 and that, with the notable exception of work by the political economy school,2–4 7 epidemiological research utilises Esping-Andersen’s typology in a surprisingly uncritical manner. Indeed, a recent overview of welfare states and health inequalities makes scant mention of the existence of alternative regime typologies.6 Furthermore, Esping-Andersen’s typology is often used to justify the choice of case study countries and subsequent findings are implicitly applied to all other countries in that particular regime.1 Although The three worlds of welfare capitalism is clearly an acceptable starting point in terms of examining within and between welfare state differences in health, it is vital for the ongoing utility of public health research in this area that in the future it is able to more adequately reflect, and therefore benefit from, the evolution of welfare state regime theory. More awareness of the wider regimes literature and going beyond The three worlds of welfare capitalism will be a useful first stage and one to which hopefully this paper has contributed.

Looking further ahead, there needs to be more critical engagement with the concept of regimes starting with an awareness that they are in fact “ideal types”. In practice, welfare provision varies extensively between countries of the same regime type.38 For example, research has indicated that some countries are more central to a particular regime than others (eg. Sweden or the USA) and offer a more coherent approach across both social transfers and welfare services.27 Other countries’ profile (and therefore regime type) can vary extensively depending on which factors are used in regime construction. One avenue for future research would therefore be to examine the competing typologies and establish which works best in terms of health outcomes and public health research. For example, cluster analysis techniques could be used to create health-based taxonomies of welfare states which could be compared with existing welfare state typologies (Table 1).16

This work would also enable more theoretical advancement in terms of how welfare state regimes are expected to impact on health and health inequalities.6 This is especially the case in terms of welfare states, gender and health where, for example, there is the opportunity to develop both theoretical and empirical accounts of how welfare state regimes may moderate the relationship between gender and health status. Indeed, concepts from the wider comparative social policy literature, such as defamilisation, could also be unpacked and operationalised in relation to health.16 25 29 31

To date, much of the engagement by public health researchers with the regimes literature has been at the overall population level.1–4 7–10 There has been little research examining how different population subgroups fare in different welfare state regimes (for example, women, immigrant groups, lone mothers, etc.).5 44 Furthermore, the political economy of health research could be progressed by comparing countries that are the most similar in terms of welfare state provision, identifying areas of difference and exploring how these may contribute to cross-national differences in health and health inequalities. These types of research would help overcome some of the more banal generalisations inherent within regime research and would perhaps provide the opportunity for better advice to policy-makers on specific interventions. Similarly, the life course approach to health inequalities could be extended to examine variation in countries from different welfare state regimes.45 Ultimately though, for this area of research to expand, there is a clear need for increased dialogue and more joint research between social policy analysts and epidemiologists.