Health Inequalities in European Welfare States

The existence of social inequalities in health is well established. The welfare state (social policy, healthcare, public health policy) can play an important role in mediating the effects of the social determinants of health; however, comparative studies have shown that health inequalities are actually amongst the largest in generous and inclusive welfare states. This project will focus on the following question: why do social inequalities in health persist in European welfare states and what can be done to reduce them? Expected outcomes and the impact of this project include the refinement, testing and development of social inequalities in health theory, the identification of policies and interventions with the potential of reducing health inequalities, and a new policy agenda on how health inequalities can be reduced most effectively. The project consists of six interrelated work packages delivered across three project phases. In the first phase, we will provide theoretical elaboration on the pathways whereby welfare states and healthcare systems influence the aetiology and reduction of social inequalities in health. In the second phase, we will explore and test these pathways using morbidity and mortality indicators. We will also use evidence review methods to examine the effects of macro policy interventions in reducing health inequalities. In the third phase, we will combine the work packages to produce country specific policy toolkits. The project will thus impact on both the academic and policy spheres. We will use a variety of cutting edge data sources at the micro and macro level and employ state-of-the-art statistical techniques, such as counterfactual policy analyses and multilevel models.

Project Summary

The aim of HiNews was to understand why social inequalities in health persist in European welfare states and what can be done to reduce them.  The main findings of the HiNews project can be broadly split into: (1) analysis of new data on the distribution of health inequalities in European welfare states; (2) development of a new health care regimes typology; (3) development of new theoretical approaches to understanding the role of the welfare state in health inequalities; and (4) the first assessment of how the public health policy domain of the welfare state reduces health inequalities.

A special module examining the social determinants of health inequalities in Europe was included in the European Social Survey (2014). This was designed and analysed by HiNEWS team members, resulting in a special supplement of the European Journal of Public Health. We found considerable cross-national variability in the magnitude and patterning of health inequalities and the effects of health conditions, and also access to health care which was found to vary by socio-economic position. In addition, a new health systems typology was developed and used to analyse the role of health care system types in reducing inequalities in mortality amenable to health care. This concluded that educational differences in amenable mortality for European countries exist in all countries, regardless of their health care system type. However, the study also found important variations in inequalities in amenable mortality between countries, indicating a potential role for healthcare system factors.  The HiNEWS team also has developed new institutional approaches to the study of health inequalities in Europe which unpack the role of the welfare state as an institutional arrangement that mediates the effects of socio-economic status and gender on health. Finally, we examined the role of the welfare state in reducing health inequalities through conducting a large evidence review of the role of public health policies. This examined the effects of primary and secondary prevention policies (fiscal, regulation, education, preventative treatment and screening) across seven public health domains (tobacco, alcohol, food and nutrition, reproductive health services, the control of infectious diseases, the environment and workplace regulations). It found that some policy interventions reduced health inequalities (e.g. food subsidy programmes, immunisations), others had no effect whilst some interventions appeared to increase inequalities (e.g. 20 mph and low emission zones).

Our work has highlighted health inequalities across Europe and offers tentative solutions which may be pursued by policy makers to reduce differences in health between groups of people.