Politics and health in eight European countries: A comparative study of mortality decline under social democracies and right-wing governments

Income Support Policy Packages and Birth Outcomes in U.S. States: An Ecological Analysis

Research suggests that generous social welfare programs play a role in maternal and child health. However, most studies examine a single policy in isolation. Drawing from research documenting low-income families 'packaging' of social policies, we create a novel measure summarizing the value of a collection of income support policies for the working poor. This collection includes: the Supplemental Nutrition Assistance Program (SNAP), the Earned Income Tax Credit (EITC), the minimum wage, and the unemployment insurance (UI) program. Using U.S. state-level administrative data from 1996 to 2014, we estimate fixed effects regression models to examine the relationship between birth outcomes and income support policies (individually and combined). We find that increases in the combined value of the four income supports are significantly associated with reductions in preterm births and low birthweight births, but not infant mortality rates. States with the highest observed levels of combined income support had 14% fewer PTBs and 7% fewer LBWs than states with the lowest levels of income support. Of the four individual income support policies, only unemployment insurance has no significant independent effects. SNAP benefits have the largest and most consistent effects, reducing poor birth outcomes across all three indicators. An annual increase of $1000 in SNAP benefits is associated with a 3% decline in infant deaths, 5% decline in preterm births, and 2% decline in low birthweight births. These results suggest that increasing the generosity of income support policies may be a promising strategy for improving birth outcomes in the United States.

Does Democracy Matter for Public Health?

This study examines the effect of democracy on public health by using panel data of 188 countries over the period 1972-2019. We use various regression methods, such as pooled ordinary least squares, fixed effects, dynamic generalized method of moments (GMM), a split-sample method, and a quadratic model to address econometric issues. The pooled regression supports the positive effect on health, but it does not exist in low-income countries, which can be explained by the threshold effect. The fixed effects regression confirms the positive impact on infant mortality but not on life expectancy, which illustrates the historical and cumulative effect of democracy on life expectancy. The non-linear regression finds a U-shaped relationship between democracy and infant mortality, which is consistent with the fixed effects regression result of the positive effect on mortality in the low-income group. The dynamic GMM regression shows the expected strong relationship between previous health and current health status. Overall, the regression analysis supports the positive effect of democracy on public health.

Educational inequalities in mortality amenable to healthcare. A comparison of European healthcare systems

BACKGROUND

Educational inequalities in health and mortality in European countries have often been studied in the context of welfare regimes or political systems. We argue that the healthcare system is the national level feature most directly linkable to mortality amenable to healthcare. In this article, we ask to what extent the strength of educational differences in mortality amenable to healthcare vary among European countries and between European healthcare system types.

METHODS

This study uses data on mortality amenable to healthcare for 21 European populations, covering ages 35-79 and spanning from 1998 to 2006. ISCED education categories are used to calculate relative (RII) and absolute inequalities (SII) between the highest and lowest educated. The healthcare system typology is based on the latest available classification. Meta-analysis and ANOVA tests are used to see if and how they can explain between-country differences in inequalities and whether any healthcare system types have higher inequalities.

RESULTS

All countries and healthcare system types exhibited relative and absolute educational inequalities in mortality amenable to healthcare. The low-supply and low performance mixed healthcare system type had the highest inequality point estimate for the male (RII = 3.57; SII = 414) and female (RII = 3.18; SII = 209) population, while the regulation-oriented public healthcare systems had the overall lowest (male RII = 1.78; male SII = 123; female RII = 1.86; female SII = 78.5). Due to data limitations, results were not robust enough to make substantial claims about typology differences.

CONCLUSIONS

This article aims at discussing possible mechanisms connecting healthcare systems, social position, and health. Results indicate that factors located within the healthcare system are relevant for health inequalities, as inequalities in mortality amenable to medical care are present in all healthcare systems. Future research should aim at examining the role of specific characteristics of healthcare systems in more detail.

Politics and health outcomes: A path analytic approach

Social and health policies and political participation are associated with each political tradition related to public health outcomes. However, there is a lack of evidence for the relationship between policy and outcomes. This study seeks to determine the relationship between politics, labour and welfare state indicators, economic inequality, and health outcome indicators. Data to test the model was obtained from the Turkish Statistical Institute (TurkStat) that belongs to the 81 provinces of Turkey. Path analysis was used to model the associations between policy, labour and welfare states, economic inequality, and health outcomes. To test the goodness of fit of the model, multiple criteria of model fit indices were utilised. The fit of the respecified path analytic model data is good (normed fit index [NFI] is 0.91, comparative fit index [CFI] is 0.92, goodness of fit index [GFI] is 0.91, and adjusted goodness of fit index [AGFI] is 0.93). Study results illustrate a strong relationship between voter partisanship, employment rate, satisfaction from both social security and health services, and life expectancy at birth and mortality. These results represent an important step towards understanding the elusive relationship between policy and health outcomes. Designing socially inclusive policies, considering labour market opportunities, and enhancing the population's well-being are advisable strategies for policymakers who wish to optimise public health outcomes.

The relationships between income inequality, welfare regimes and aggregate health: a systematic review

Background

: When analysing the relationships between income inequality, welfare regimes and aggregate health at the cross-national level, previous primary articles and systematic reviews reach inconsistent conclusions. Contrary to theoretical expectations, equal societies or the Social Democratic welfare regime do not always have the best aggregate health when compared with those of other relatively unequal societies or other welfare regimes. This article will shed light on the controversial subjects with a new decomposition systematic review method. The decomposition systematic review method breaks down an individual empirical article, if necessary, into multiple findings based on an article's use of the following four components: independent variable, dependent variable, method and dataset. This decomposition method extracts 107 findings from the selected 48 articles, demonstrating the dynamics between the four components. 'The age threshold effect' is recognized over which the hypothesized relations between income inequality, welfare regimes and aggregate health reverse. The hypothesis is supported mainly for younger infant and child health indicators, but not for adult health or general health indicators such as life expectancy. Further three threshold effects (income, gender and period) have also been put forward. The negative relationship between income inequality and aggregate health, often termed as the Wilkinson Hypothesis, was not generally observed in all health indicators except for infant and child mortality. The Scandinavian welfare regime reveals worse-than-expected outcomes in all health indicators except infant and child mortality.

Health Care Public Sector Share and the U.S. Life Expectancy Lag: A Country-level Longitudinal Study

Growing research on the political economy of health has begun to emphasize sociopolitical influences on cross-national differences in population health above and beyond economic growth. While this research investigates the impact of overall public health spending as a share of GDP ("health care effort"), it has for the most part overlooked the distribution of health care spending across the public and private spheres ("public sector share"). I evaluate the relative contributions of health care effort, public sector share, and GDP to the large and growing disadvantage in U.S. life expectancy at birth relative to peer nations. I do so using fixed effects models with data from 16 wealthy democratic nations between 1960 and 2010. Results indicate that public sector share has a beneficial effect on longevity net of the effect of health care effort and that this effect is nonlinear, decreasing in magnitude as levels rise. Moreover, public sector share is a more powerful predictor of life expectancy at birth than GDP per capita. This study contributes to discussions around the political economy of health, the growth consensus, and the American lag in life expectancy. Policy implications vis-à-vis the U.S. Affordable Care Act are discussed.

The effect of regional politics on regional life expectancy in Italy (1980-2010)

BACKGROUND

The evidence on the association between politics and health is scarce considering the importance of this topic for population health. Studies that investigated the effect of different political regimes on health outcomes show inconsistent results.

METHODS

Bayesian time-series cross-section analyses are used to examine the overall impact of regional politics on variations in Italian regional life expectancy (LE) at birth during the period 1980-2010. Our analyses control for trends in and unobserved determinants of regional LE, correct for temporal as well as spatial autocorrelation, and employ a flexible specification for the timing of the political effects.

RESULTS

In the period from 1980 to 1995, we find no evidence that the communist, left-oriented coalitions and Christian Democratic, centre-oriented coalitions have had an effect on regional LE. In the period from 1995 onwards, after a major reconfiguration of Italy's political regimes and a major healthcare reform, we again find no evidence that the Centre-Left and Centre-Right coalitions have had a significant impact on regional LE.

CONCLUSION

The presented results provide no support for the notion that different regional political regimes in Italy have had a differential effect on regional LE, even though Italian regions have had considerable and increasing autonomy over healthcare and health-related policies and expenditures.

Political determinants of progress in the MDGs in Sub-Saharan Africa

Sub-Saharan Africa (SSA) lagged furthest behind in achieving targets for the millennium development goals (MDG). We investigate the hypothesis that its slow progress is influenced by political factors. Longitudinal data on three health MDG indicators: under-five mortality, maternal mortality and HIV prevalence rates were collated from 1990 to 2012 in 48 countries. Countries were grouped into geo-political and eco-political groups. Groupings were based on conflict trends in geographical regions and the International Monetary Fund's classification of SSA countries based on gross national income and development assistance respectively. Cumulative progress in each group was derived and main effects tested using ANOVA. Correlation analysis was conducted between political variables - POLITY 2, fragile state index (FSI), voter turnout rates, civil liberty scores (CLS) and the health variables. Our results suggest a significant main effect of eco-political and geo-political groups on some of the health variables. Political conflict as measured by FSI and political participation as measured by CLS were stronger predictors of slow progress in reducing under-five mortality rates and maternal mortality ratios. Our findings highlight the need for further research on political determinants of mortality in SSA. Cohesive effort should focus on strengthening countries' political, economic and social capacities in order to achieve sustainable goals beyond 2015.

Burden and cost of neurological diseases: a European North-South comparison

OBJECTIVES

To address the relationship between years lived with a disability (YLDs), prevalence and cost of neurological diseases, and to test whether there is a European North-South gradient for national health expenditure, disability, costs and prevalence of neurological diseases.

MATERIALS AND METHODS

Information on costs, prevalence and YLDs referred to 2010 were taken from the Study on the Cost of Disorders of the Brain and from the Global Burden of Disease study; data on health expenditure were taken from OECD reports. Selected conditions were as follows: brain tumours, stroke, dementia, Parkinson's disease, epilepsy, multiple sclerosis, migraine and tension-type headache; selected countries were from North (Denmark, Finland, Norway, Sweden) and South (Greece, Italy, Portugal, Spain) Europe. The association between the variables for each condition was tested using Spearman's correlation; Wilcoxon signed ranks test was used to test North-South Europe differences.

RESULTS

Correlations were largely non-significant (except for stroke). YLDs and cost were generally lower in South-European countries, and prevalence was lower in North-European countries, but no significant differences were found.

CONCLUSIONS

Health expenditure, YLDs, costs and prevalence of neurological conditions were generally not correlated across the eight countries. A clear North-South gradient was found for health expenditures, and partially for YLDs, costs and diseases' prevalence. We hypothesized that this is a consequence of the expansion of morbidity of neurological conditions connected to ageing, that health and welfare systems of selected countries were not prepared to face.

Religion, Poverty, and Politics: Their Impact on Women's Reproductive Health Outcomes

OBJECTIVE

This study sought to explore the relationship(s) between U.S. states of selected social determinants of health (SDH) and three women's reproductive health outcomes including abortion, teen births, and infant mortality rates (IMR).

DESIGN AND SAMPLE

The data from multiple population surveys were used to establish on a state-by-state basis, the interactions between selected SDH (religion, voting patterns, child poverty, and GINI) and their policy effects on three women's reproductive health outcomes (abortion, teen births, and IMRs) using publicly available national databases.

MEASURES

Child poverty rates and the GINI coefficient were analyzed. Religiosity information was obtained from the Pew Forum's surveys. Voting results were collected from the 2008 congressional and presidential races and were used as proxy measures for conservative- versus liberal-leaning policies and policy makers.

RESULTS

Using multiple regression analysis, higher IMRs were associated with higher religiosity scores. Lower abortion rates were associated with voting conservatively and higher income inequality. Higher teen birth rates were associated with higher child poverty rates and voting conservatively.

CONCLUSIONS

This study shows that selected SDH may have substantial impacts on women's reproductive health outcomes at the state level. Significant inequalities exist between liberal and conservative states that affect women's health outcomes.

US infant mortality and the President's party

BACKGROUND

Infant mortality rates in the US exceed those in all other developed countries and in many less developed countries, suggesting political factors may contribute.

METHODS

Annual time series on overall, White and Black infant mortality rates in the US were analysed over the 1965-2010 time period to ascertain whether infant mortality rates varied across presidential administrations. Data were de-trended using cubic splines and analysed using both graphical and time series regression methods.

RESULTS

Across all nine presidential administrations, infant mortality rates were below trend when the President was a Democrat and above trend when the President was a Republican. This was true for overall, neonatal and postneonatal mortality. Regression estimates show that, relative to trend, Republican administrations were characterized by infant mortality rates that were, on average, 3% higher than Democratic administrations. In proportional terms, effect size is similar for US Whites and Blacks. US Black rates are more than twice as high as White, implying substantially larger absolute effects for Blacks.

CONCLUSIONS

We found a robust, quantitatively important association between net of trend US infant mortality rates and the party affiliation of the president. There may be overlooked ways by which macro-dynamics of policy impact microdynamics of physiology, suggesting the political system is a component of the underlying mechanism generating health inequality in the USA.

Persisting problems related to race and ethnicity in public health and epidemiology research

A recent and comprehensive review of the use of race and ethnicity in research that address health disparities in epidemiology and public health is provided. First it is described the theoretical basis upon which race and ethnicity differ drawing from previous work in anthropology, social science and public health. Second, it is presented a review of 280 articles published in high impacts factor journals in regards to public health and epidemiology from 2009-2011. An analytical grid enabled the examination of conceptual, theoretical and methodological questions related to the use of both concepts. The majority of articles reviewed were grounded in a theoretical framework and provided interpretations from various models. However, key problems identified include a) a failure from researchers to differentiate between the concepts of race and ethnicity; b) an inappropriate use of racial categories to ascribe ethnicity; c) a lack of transparency in the methods used to assess both concepts; and d) failure to address limits associated with the construction of racial or ethnic taxonomies and their use. In conclusion, future studies examining health disparities should clearly establish the distinction between race and ethnicity, develop theoretically driven research and address specific questions about the relationships between race, ethnicity and health. One argue that one way to think about ethnicity, race and health is to dichotomize research into two sets of questions about the relationship between human diversity and health.

Understanding the role of welfare state characteristics for health and inequalities - an analytical review

Background

The past decade has witnessed a growing body of research on welfare state characteristics and health inequalities but the picture is, despite this, inconsistent. We aim to review this research by focusing on theoretical and methodological differences between studies that at least in part may lead to these mixed findings.

Methods

Three reviews and relevant bibliographies were manually explored in order to find studies for the review. Related articles were searched for in PubMed, Web of Science and Google Scholar. Database searches were done in PubMed and Web of Science. The search period was restricted to 2005-01-01 to 2013-02-28. Fifty-four studies met the inclusion criteria.

Results

Three main approaches to comparative welfare state research are identified; the Regime approach, the Institutional approach, and the Expenditure approach. The Regime approach is the most common and regardless of the empirical regime theory employed and the amendments made to these, results are diverse and contradictory. When stratifying studies according to other features, not much added clarity is achieved. The Institutional approach shows more consistent results; generous policies and benefits seem to be associated with health in a positive way for all people in a population, not only those who are directly affected or targeted. The Expenditure approach finds that social and health spending is associated with increased levels of health and smaller health inequalities in one way or another but the studies are few in numbers making it somewhat difficult to get coherent results.

Conclusions

Based on earlier reviews and our results we suggest that future research should focus less on welfare regimes and health inequalities and more on a multitude of different types of studies, including larger analyses of social spending and social rights in various policy areas and how these are linked to health in different social strata. But, we also need more detailed evaluation of specific programmes or interventions, as well as more qualitative analyses of the experiences of different types of policies among the people and families that need to draw on the collective resources.

Democratization and life expectancy in Europe, 1960-2008

Over the past five decades, two successive waves of political reform have brought democracy to, first, Spain, Portugal and Greece, and, more recently, Central and Eastern European countries. We assessed whether democratization was associated with improvements in population health, as indicated by life expectancy and cause-specific mortality rates. Data on life expectancy at birth, age-standardized total and cause-specific mortality rates, levels of democracy and potential time-variant confounding variables were collected from harmonized international databanks. In two pooled cross-sectional time-series analyses with country-fixed effects, life expectancy and cause-specific mortality were regressed on measures of current and cumulative democracy, controlling for confounders. A first analysis covered the 1960-1990 period, a second covered the 1987-2008 period. In the 1960-1990 period, current democracy was more strongly associated with higher life expectancy than cumulative democracy. The positive effects of current democracy on total mortality were mediated mainly by lower mortality from heart disease, pneumonia, liver cirrhosis, and suicide. In the 1987-2008 period, however, current democracy was associated with lower, and cumulative democracy with higher life expectancy, particularly among men. The positive effects of cumulative democracy on total mortality were mediated mainly by lower mortality from circulatory diseases, cancer of the breast, and external causes. Current democracy was associated with higher mortality from motor vehicle accidents in both periods, and also with higher mortality from cancer and all external causes in the second. Our results suggest that in Europe during these two periods democratization has had mixed effects. That short-term changes in levels of democracy had positive effects in the first but not in the second period is probably due to the fact that democratization in Central and Eastern Europe was part of a complete system change which caused major societal disruptions.

Political conditions and life expectancy in Europe, 1900-2008

The rise of life expectancy in Europe has been a very uneven process, both in time and space. This paper aims to identify instances in which major political conditions are likely to have influenced the rise of life expectancy, focusing on formation and dissolution of states and supranational blocs and on differences between political regimes (democratic vs. authoritarian non-communist and communist rule). Data on life expectancy, cause-specific mortality and political conditions were compiled from existing data sources. Possible relations between political conditions and life expectancy were studied by direct comparisons of changes in life expectancy in countries with different political conditions but similar starting levels of life expectancy. We found that formation and dissolution of states often went together with convergence and divergence of life expectancy, respectively, and that otherwise similar countries that did or did not become part of the Soviet bloc had distinctly different life expectancy trajectories. Democratically governed states had higher life expectancies than authoritarian states throughout the 20th century. The gap narrowed between 1920 and 1960 due to rapid catching up of infectious disease control in both non-communist and communist authoritarian states. It widened again after 1960 due to earlier and more rapid progress in democratic states against cardiovascular disease, breast cancer, motor vehicle accidents and other causes of death that have become amenable to intervention. We conclude that the history of life expectancy in Europe contains many instances in which political conditions are likely to have had a temporary or more lasting impact on population health. This suggests that there is scope for further in-depth studies of the impact of specific political determinants on the development of population health in Europe.

Health at advanced age: social inequality and other factors potentially impacting longevity in nine high-income countries

This article surveys the evolution of health at advanced age in nine high-income countries over the last three decades, and the variables that might explain that evolution. Life expectancy at age 65 for males and females is used as summary indicator to conceptualize "health at advanced age." A comparison of the nine countries - Canada, Denmark, France, Japan, Spain, Sweden, Switzerland, the United Kingdom, and the United States - reveals excellent health performance for Japan, which has the greatest proportion of elderly people in the population and also the best health indicators for both males and females; the United States and Denmark perform poorly. Of all nine countries, the United States has the youngest population, the highest income per capita, and the greatest expenditure on health care, but also the highest levels of income inequality and relative poverty, and lacked universal health care coverage during the study period. Experts have considered that these three factors have probably contributed to the poor progress in the health of the elderly in the United States in recent decades. Tobacco consumption appears to be a key influence on the health of the elderly and probably explains to a large extent - with a lag of several decades - the differential evolution of health in these countries.