The project consists of six interrelated work packages delivered across three project phases. In the first phase, we have provided theoretical elaboration on the pathways whereby welfare states and healthcare systems influence the etiology and reduction of social inequalities in health. In the second phase, we have explored and tested these pathways using morbidity and mortality indicators. We have also used evidence review methods to examine the effects of macro policy interventions in reducing health inequalities.
Work Package A: Theoretical pathways between welfare states and social inequalities in health
The aims of WP-A are twofold: Firstly, WP-A will provide a critical overview of existing theories linking welfare states and social inequalities in health. Secondly, WP-A will develop new “institutional approaches to inequality” to explain why social inequalities in health persist in welfare states. By combining these two aims, WP-A will form the theoretical basis of the research conducted in WP-B, WP-C, WP-D and WP-E. A theoretical model, based on existing theories and newly created theories, will be developed in months 1-6. The main theoretical pathways will be tested in the other work packages in months 7-30 of the project. Finally, in months 31-36, WP-A will use the findings from these tests of the theoretical pathways to modify the theoretical framework and inform the policy dissemination work of WP-F.
Work Package B: Typologies of healthcare systems and social inequalities in health: a comparative analysis of 25 European countries
European societies have put increasing resources into healthcare provision, yet whether these increased resources always lead to improved population health and smaller social inequalities in health remains unclear. This uncertainty is rooted in the lack of comparative studies on the relationship between healthcare system inputs and health inequalities outputs. This WP addresses this gap. Based on earlier work, macro-indicators of healthcare systems will be selected, including health expenditure, private co-payments, healthcare personnel, medical technology, preventive healthcare, and institutional indicators (e.g., access regulation and provider remuneration).
WP-B will also improve theoretical understanding of welfare state and healthcare systems (with WP-A) by developing new typologies of healthcare systems. These typologies will be contrasted with existing typologies of the welfare state. Its main empirical contribution is demonstrating (in collaboration with WP-C and WP-D) the effects of healthcare systems on social inequalities in health. WP-B will also use the findings from WP-C and WP-D, to identify and highlight those healthcare system contexts that are particularly suited for reducing social inequalities in health in particular types of welfare states, healthcare systems, and countries – thereby supporting WP-E and WP-F.
Work Package C: The welfare state, healthcare systems, and social inequalities in mortality
WP-C has three aims:
- to calculate inequalities in mortality by different social indicators
- to identify the key-contributing causes of death with specific reference to healthcare systems
- to calculate the potential for reducing inequalities in mortality
WP-C first aims to quantify the magnitude of social inequalities in mortality in European welfare states by all-cause and cause-specific mortality. The second strategy is to explore whether social inequalities in mortality in European welfare states are driven by the same causes – some causes of death are driven by specific risk factors, such as smoking (for lung cancer) or a poorly performing healthcare system (for mortality amenable to healthcare). In particular, we aim at providing a novel contribution to the literature by focusing on the role of healthcare systems (using the classification identified in WP-B and drawing on the theoretical work of WP-A) in examining to what extent – and why – social inequality in mortality amenable to healthcare varies across European countries. When we have identified the magnitude of inequalities in the key contributing causes of death, we will calculate the potential for reducing inequalities amenable to healthcare by tackling key social and institutional determinants, which will vary between European welfare states, such as cash benefits, provision of unpaid care and unmet need. These factors are usually associated with social status, and may therefore explain part of the inequalities in mortality (amenable to healthcare) between social groups. The availability of the prevalence of these risk factors is scarce, but the upcoming module of the European Social Survey (from WP-D) will provide us with key estimates for some risk factors that were previously unavailable (i.e. unpaid care and unmet need). In this way, we can analyse more deeply which mechanisms of the healthcare system contribute to inequalities and identify the entry-points for policy (WP-E).
Work Package D: The welfare state, healthcare systems and social inequalities in morbidity
By having access to the unique social determinants of health module in the 7th wave of the European Social Survey, WP-D will:
- map social inequalities in morbidity across Europe. Previous research has established that social inequalities in morbidity vary strongly across welfare states. However, existing studies have relied on general summary measures of morbidity (e.g., self-rated health). WP-D will produce the first comparable European overview of social inequalities in specific measures of morbidity
- (WP-D examines to what extent mechanisms explaining social inequalities in morbidity vary across European countries. Based on the overview of existing theories in WP-A, hypotheses are derived and tested on the explanatory power of risk factors such as lack of material resources, health damaging behaviour, and low social status. We will link specific welfare state and healthcare system (WP-B) indicators to social inequalities in morbidity
- Thirdly, new institutional theories (derived in WP-A) will also be tested in WP-D. This is done by using input from WP-B on the connection between institutions and healthcare systems, and by using institutional theories on multiple (intersectional) disadvantage created in WP-A. Whereas earlier work on social inequalities in morbidity has largely ignored the role of multiple disadvantage, we will derive and test hypotheses on the role of multiple disadvantage based on socioeconomic status, social ties, gender, and ethnicity contribute to social inequalities in morbidity.
Work Package E: Evidence reviews of welfare state, healthcare system and public health policy interventions to reduce social inequalities in health
WP-E will empirically examine the impact on social inequalities in health of specific policies and interventions that fall within three broad policy domains (social welfare, public health, health care) as this will help to establish causality and, most importantly, identify effective interventions that could be implemented across different European countries. WP-E therefore aims to review the international evaluation literature to identify institutional policies and interventions that have evidence of causal effectiveness in reducing social inequalities in health. The three evidence reviews will assess the effects of a range of welfare state interventions (social policies, public health policies, healthcare system policies) on social inequalities in health and identify those that have evidence of effectiveness in reducing health inequalities. These will inform the policy toolkits of WP-F. The evidence reviews will also identify gaps in the intervention evidence base where new research is required.
Work Package F: Policy toolkits to understand and reduce social inequalities in health in Europe
WP-F will produce policy toolkits for each of the 25 European countries as well as for the European Union. These will:
- Provide policy-accessible summaries showing the theoretical and system context of social inequalities in health (WP-A, WP-B); their extent and determinants (WP-C, WP-D); and examples of effective interventions to reducethem (WP-E)
- Calculate “policy risk-scenarios” – country specific models of the potential impacts of policies on social inequalities in health
The “policy risk-scenarios” will clearly only be indicative but they do provide the opportunity for comparative welfare state and health inequalities research to go beyond mere description and to provide indications of where and how policymakers can act on the determinants of social inequalities in health. This will enhance the impact of the project.