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The Welfare Regime Debate and Health Care Provision

Do we need a Southern Regime Type?

Hausarbeit (Hauptseminar) 2010 25 Seiten


Table of Contents


2.The Welfare Regime Debate
2.1 Esping-Andersen’s Three Worlds of Welfare Capitalism
2.2 Criticism of Esping-Andersen
2.3 The Southern Regime Type

3.Health Care in Southern Countries
3.1 The Spanish Health Care System
3.2 The Portuguese Health Care System
3.3 The Italian Health Care System
3.4 The Greek Health Care System

4.A Southern Regime in Health Care?

5.Measuring Welfare Regimes in Health Care – Where do we group the Southern Countries?
5.1 Clare Bamba’s Decommodification Index for Health Care
5.2 Applying the Decommodification Index for Health Care to the Southern Welfare Regime

6. Conclusion


Appendix: Summary of other course topics (parts of paper 1)

1. Introduction

The welfare regime typology of the Danish sociologist Gøesta Esping-Andersen has become a modern social science classic and is widely used as a theoretical foundation for all kinds of research projects. However, his three-folded model differentiating regimes on the basis of welfare provision has also been challenged. Many studies have criticized Esping-Andersen for his non-acknowledgement of a Southern welfare regime including Greece, Spain, Portugal and Italy. The argument is that welfare provision in these countries has to be distinguished from other welfare regimes. Differences result from the influence of long-standing traditionalistic dictatorships which fostered the persistence of catholic (or orthodox) traditions and the strong role of the family in welfare provision. These historic circumstances have produced fragmented welfare states which provide partly extensive state-led services, e.g. in health care, but have very limited benefits in other areas. The question remains whether “the peculiarities of these cases are variations within a distinct overall logic [or] a wholly different logicper se”, as Esping-Andersen (1999, p.90) has formulated it.

Claire Bamba (2005) has challenged Esping-Andersen’s welfare regime typology focusing on health care and identified two additional subcategories. Bamba argued that health care provision is a very distinguished feature of the welfare state and countries may follow a different logic in their health care services than they pursue in other branches of their welfare states. The identification of ever more welfare regimes does not make the research field more accessible. It should be asked whether countries cannot, as Bamba started it, be grouped in the typology of Esping-Andersen but according to areas of welfare provision. This paper argues that Southern countries can be included in Esping-Andersen’s typology when looking at welfare areas independently and thus do not form an independent regime. The only clear difference they show is that their health care services and other areas of welfare state support follow different logics, which is also true for other countries such as the United Kingdom. Moreover, following Katrougalos (1996) it is argued that the distinctive features of Southern countries are based on the incompleteness of the development of their welfare states which have undergone considerable transformations in the last 30 years.

The paper is structured as follows: Adjoining this introduction, the second chapter outlines Esping-Andersen’s welfare typology, summarizes the most prominent criticisms and portraits the state of research on the Southern regime type. The third chapter gives overviews of the health care systems in Southern countries and compares them to see whether they really form a new welfare regime. The fourth chapter outlines Claire Bamba’s decommodification index for health care and compares it to data from Southern countries while chapter five summarizes the findings and draws up a conclusion.

2. The Welfare Regime Debate

2.1 Esping-Andersen’s Three Worlds of Welfare Capitalism

The set-up of welfare states is decisive for population health. The amount of spending on social infrastructure and the targeting of government support forms the macro-political environment that influences population health and may foster health inequalities. Korpi and Palme (1998) pointed out that more encompassing welfare states support more inclusive public policies which benefit all parts of society. This leads to lower inequality and poverty positively influencing population health. Policies, however, which are targeted exclusively at the poor, tend to sustain existing inequalities. Therefore, to understand variations in population health amongst countries, it is of importance to discuss the differences in existing welfare state regimes.

The most influential typology of welfare states was developed by Gøsta Esping-Andersen in his book “The three worlds of welfare capitalism”. Esping-Andersen differentiates between regimes types on three main principles: decommodification, social stratification and the public-private mix. Decommodification is the extent to which an individual’s welfare is independent from the market, and that individual is able to receive a social service as a matter of right. The second category defines the role of the welfare state in breaking down or maintaining social stratification. The last principle, public-private mix, looks at the relative roles that the state, the family, the market and the voluntary sector fulfill in a certain welfare regime.

Esping-Andersen (1990) operationalized these categories using decommodification indexes based on cash benefits in the areas of pensions, unemployment and sickness. He identified three major welfare regimes: the liberal, the conservative and the social democratic welfare state. The main characteristics of these regimes are summarized in the table below.

Figure 1: Welfare State Typology according to Esping-Andersen

Abbildung in dieser Leseprobe nicht enthalten

2.2 Criticism of Esping-Andersen

Esping-Andersen’s typology is widely used in public policy research, especially in the field of health. Yet, his approach has also been criticized. Criticism has been pronounces especially on his theoretical underpinnings, on methodological questions and the empirical validity of his results. Methodological limitations have been identified in the set-up of the decommodification indexes relating to their additive character, the internal weighting and averaging. Empirical validity has been questioned on the basis of equivocated calculations in the original text that led to miscategorizations of countries. The most prominent critique has been the use of only one standard deviation around the mean to differentiate between regimes. This, by set-up, allowed only for a threefold typology (Bamba 2007).

Various scholars have supported a wider welfare regime typology. They argue that Esping-Andersen could not grasp more variation because of the limited range of countries (18 OECD countries) he chose for analysis. Concrete proposals are the existence of a specific Southern European and East Asian welfare regime. Castles and Mitchell (1993) argued for a forth radical welfare state including the UK, Australia and New Zealand, in which spending is low because redistribution is used to reach important welfare goals. Another theoretical limitation is that Esping-Andersen does not take the particularities of women in welfare state regimes into account. Specifically, his concept of decommodification has been challenged as gender-blind. He has also been alleged of having ignored the role of women in supplying welfare and of gender as a type of social stratification. These limitations let to the development of alternative, more gender-open approaches. The most prominent is defamilization studies, which focus on the extent to which the autonomy and economic independence of women is supported by a certain welfare state regime (Bamba 2007).

In summary, it can be said that differences between welfare state models clearly exist and that there are at least three welfare state regimes in OECD countries. Categorizing them is not easy and the division in ever more regimes might not be helpful to reach a more satisfying theoretical foundation for a comparison of welfare state regimes. Therefore, it will in the following be looked at the Southern welfare states to see whether they form a different regime type, especially when focusing on health care provision.

2.3 The Southern Regime Type

Esping-Andersen has been criticized for not taking the Southern European countries into account. In his first analysis, he did neither include Spain nor Portugal nor Greece. Later, however, he grouped them as conservative welfare regimes. Yet, he acknowledged the presence of traditional family solidarity and dependency as characteristic features of their welfare set-ups that differentiate them from other conservative countries such as Germany or Austria. Yet, Esping-Andersen did not believe that Southern countries, because of these specificities, followed an overall different logic in their welfare provision that would allow for the establishment of a fourth welfare regime type (Moreno Mínguez 2005). Various studies have questioned this belief and argued that the Southern countries indeed belong to an independent regime category (Figure 2).

Figure 2: Welfare State Typologies that include a Southern Regime Type

Abbildung in dieser Leseprobe nicht enthalten

Taken from Bamba (2007)[1]

The assumption that Mediterranean countries form a distinct welfare state regime is based on their similar recent history. All four countries[2]became democracies after years of repressive authoritarian regimes.[3]Moreover, the Southern countries (excluding Greece) are characterized by a strong Catholic tradition and Roman culture (Arts & Gelissen 2002). Their welfare systems have been described as basic with limited population coverage in some areas, while health care provision and pensions are rather extensive. Mostly, they are fragmented along occupational lines and the family still plays a major role in the provision of welfare (Bamba 2007). In terms of social protection expenditure, however, Southern European countries score high in OECD comparison, after a massive increase in spending levels since re-democratization.

Figure3: Social Expenditure as % of GDP in OECD Countries in 2007[4]

Abbildung in dieser Leseprobe nicht enthalten

Data from OECD, own graphic

Welfare provision in Mediterranean countries is exemplified by a dual set-up incorporating both elements of Bismarckian and Beveridgian traditions (Flaquer 2000). All Southern countries have tax-financed national health care systems, guarantee their citizens a right to health care and provide a high degree of public services. In other welfare state areas there is, however, little public support. Income maintenance systems are occupation-centered and means-tested. Generally, no national statutory minimum income scheme exists. In Southern countries, the male breadwinner model persists giving those who work in core sectors of the labor market extensive protection, while workers with insecure labor contracts, mostly young people and women, are hardly safeguarded. Therefore, the Southern labor markets have been classified as divided between insiders and outsiders (Flaquer 2000). As Esping-Andersen (1999: 153) summarized the problem: “the high wages and job security enjoyed by (chiefly male) insiders, in effect, are also what causes the exclusion of their sons, daughters, and wives”, and this again sustains traditional family models. Still, it has been emphasized that large differences exist also between Southern countries. While for example Spain and Portugal emphasize health care spending, in Italy and Greece old age and survivors’ pensions are extensive (Flaquer 2000).

Also in health care provision, considerable differences exist between the Southern countries. This will be outlined in the following by short overviews of the individual systems. To consider the argumentation in favor of a Southern regime type, special attention will be given to the development of the systems under the recent dictatorships.


[1] Further studies on the Southern welfare regime were carried out by Castles (1995), Jurado and Naldini (1996), Moreno (1996) and Trifiletti (1999).

[2] This paper will concentrate on Spain, Portugal, Italy and Greece, when talking about the Southern welfare regime, as these countries are undisputed part of this proposed fourth type of the welfare state.

[3] Italy however democratized already in 1945 which is hardly comparable to the other three countries that faced repressive regimes until the 1970s. Greece re-established democracy in 1974; Spain became a constitutional monarchy in 1978 and ended the re-democratization process with first elections in 1981 and in Portugal the Carnation Revolution ended military dictatorship in 1974.

[4] The OECD Social Expenditure Data is based on public and mandatory private sector social expenditure at program level classified under 13 social policy areas (Old age cash benefits, disability cash benefits, occupational injury and disease, sickness benefits, services for the elderly and disabled people, survivors, family cash benefits, family services, active labor market programs, unemployment, public expenditure on health, housing, other contingencies).


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Hertie School of Governance
Welfare Regime Debate Health Care Provision Southern Regime Type



Titel: The Welfare Regime Debate and Health Care Provision