In This Article Expand or collapse the "in this article" section Welfare States, Public Health and Health Inequalities

  • Introduction
  • General Overviews
  • The Nature of Welfare States
  • Recent Developments in Welfare State Literature
  • Welfare States and the Distribution of Resources
  • Welfare States and Children’s Well-being

Public Health Welfare States, Public Health and Health Inequalities
Toba Bryant, Dennis Raphael
  • LAST REVIEWED: 28 March 2018
  • LAST MODIFIED: 28 March 2018
  • DOI: 10.1093/obo/9780199756797-0178


Health inequalities are observable differences in health outcomes between socioeconomic groups. Most of these differences are preventable. They can also be considered unjust and unfair, usually referred to as health inequities. In this article we use the more popular term of “health inequalities” and recognize the injustice and unfairness that creates them. Health researchers and others offer differing interpretations concerning the sources of health inequalities. These inequalities are commonly seen among those occupying different social locations such as social class (i.e., education, income, occupation), gender, and race, among others. The experience of different social locations leads to social inequalities associated with wealth, influence, power, and access to economic and social resources. Social inequalities cause health inequalities. Public policy can exacerbate or mitigate the extent of the social inequalities that create health inequalities. Indeed, WHO Director-General Margaret Chang noted that health inequalities exist because “the wrong policies are in place.” Health inequalities, and their social inequality antecedents, are therefore not unfortunate or inevitable outcomes, but amenable to public policy. One useful approach to understanding the sources of social and health inequalities among developed nations has been to consider the development of various forms of the welfare state that reached its apex following the Second World War. The term “welfare state” refers to the complex of public policies by which the state intervenes in the operation of the market economy to provide economic and social security to societal members. It does so by improving living and working conditions and ultimately health outcomes. Much of the welfare state literature is not specifically concerned with health inequalities. Yet many concepts embedded in the welfare state—such as the provision of economic and social security, political power and influence, extent of stratification and decommodification, and the role of the state versus the market and family/charity in distributing economic resources—are implicated in understanding the sources of health inequalities and the means to reduce them. Generally the literature presents four main approaches to analyzing the impact of the welfare state. These include: (1) the welfare state regimes approach; (2) the expenditure approach; (3) specific public policy approach; and (4) examining particular populations such as children, women, the unemployed, and other vulnerable populations. This article is limited to the English-language literature on the welfare state.

General Overviews

The works identified in this bibliography are concerned with welfare states, welfare states and health inequalities, and general health outcomes. These differ by country due to welfare state processes and welfare state–oriented responses to health inequalities. These differences are generally not related to the provision of health care, as every developed nation with the exception of the United States offers universal health care. There are also brief sections on welfare states and children’s well-being, as well as a database for examining these issues. The modern welfare state usually refers to the social and health reforms that governments in developed political economies implemented following the Second World War, although the sources of at least one form of the welfare state are to be found in the Bismarkian welfare state in Continental Europe during the late 1800s. Of particular interest has been the typology of social democratic, conservative, and liberal welfare states created by Esping-Andersen 1990 and how each distributes the economic and social resources that can create or limit the creation of social and health inequalities. Welfare state analysis therefore has generated much interest in assessing how and to what extent states address public policy issues that create or limit the social inequalities that create health inequalities. Many of the materials presented are advanced writings on the sources of the welfare state, how it has changed over time, and how it has experienced retrenchment in some countries. Many attribute the decline of the welfare state (and its redistributive politics) to the rise of neoliberalism and economic globalization triggered by the oil crisis of 1973. Teeple 2000 argues that the welfare state moderates the adverse outcomes produced by the capitalist economic system, which by itself has no means to respond to the adverse outcomes it may produce. Any declines of the welfare state therefore should increase the social inequalities that create health inequalities and should be resisted. The material that follows, therefore, explores the role welfare states play in creating, maintaining, and hopefully reducing health inequalities.

  • Esping-Andersen, G. 1990. The three worlds of welfare capitalism. Princeton, NJ: Princeton Univ. Press.

    Identifies the origins of the Social Democratic, Conservative, and Liberal welfare regimes. Esping-Andersen explores how welfare states can use public policy to decommodify the provision of social resources to populations. Welfare states also stratify the population with implications for understanding the extent of social inequalities. He considers the balance between the state and market in distributing economic and social supports to citizens.

  • Teeple, G. 2000. Globalization and the decline of social reform: Into the twenty first century. Aurora, ON: Garamond.

    Teeple sees the welfare state as being threatened by the rise of economic and political forces associated with global capitalism. He warns about the consequences of weakened welfare states, including declining national sovereignty, increasing economic inequality, and increasing insecurity for citizens.

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