Mapping Social Inequalities in Health across OECD Welfare States

In my Ph.D. project I am doing research on cross-national social health inequalities. There are several reasons why it is worth to zoom in on this already intensively researched field:

First, social inequalities in health exist all over the world. 

  • Health inequalities are differences in health between different social groups defined by education, income, occupation, age, gender, social status etc. For example…
    • …in Germany, among 45-64 years old men, 45% of those with less than 60% of the median income perceive their own health as poor while only 12.5% do so among those who earn 150% or more of the median income (Lampert et al., 2018).
    • … in Glasgow, a man born in the affluent west end of the city (Jordanhill) can, on average, expect to life 14.3 years longer than a man born in the more deprived area of the city (Bridgeton). For women, the gap is 11.7 years (NHS Health Scotland, 2019).
      Health inequalities exist in all countries but differ across regions and countries (Bambra & Eikemo, 2009; dem Knesebeck, Verde & Dragano, 2006; EU, 2013; Hu et al., 2016; Mackenbach et al., 2017).

Second, health inequalities are unjust to the extent that they are avoidable (Braveman, 2016; Braveman, 2008). Research on how to avoid them is therefore necessary.

Third, results from existing country-comparative research on health inequalities are inconclusive. 

  • To get ideas about which institutional arrangement, welfare regimes or policies are particularly increasing or decreasing health inequalities, we might want to compare health inequalities across countries.
  • Making use of welfare regime approaches, for example Esping-Andersen’s Three Worlds of Welfare Capitalism (1990), we expect Scandinavian countries (Denmark, Sweden, Norway) to have small health inequalities due to their universal, generous and egalitarian welfare systems. On the opposite, we would expect Anglo-Saxon welfare states (UK, USA, Canada, Ireland, etc.) to have large health inequalities.
  • The existing literature, however, is puzzling. Some scholars find evidence for small health inequalities in the Scandinavian regimes (Borrell et al., 2009; Miething, Lundberg & Geyer, 2013; Sanders et al., 2009), many find inconclusive results (Bambra et al., 2010; Bambra, Netuveli & Eikemo, 2010; Eikemo et al., 2008b; Eikemo et al., 2008a; Espelt et al., 2008; Pongiglione & Sabater, 2014) and some even find opposing evidence (McNamara et al., 2017). Whenever Scandinavian welfare regimes are found to have medium or large health inequalities, people speak of a health inequality paradox (Mackenbach, 2017, 2012).

For these reasons, I am interested in the real size of health inequalities in different countries and in the role of institutions in determining health inequalities. I assume that apples and oranges has been compared so far and that the puzzle resolves itself if the circumstances of comparison are payed more attention to. There are two dimensions on this – a technical and a substantial.

First, on account of the technical dimensions, studies need to be designed more carefully meaning for example that health inequalities measured by education are not the same as those measured by income or that relative and absolute health inequalities can differ within a country. The meaning of the operationalizations must be considered carefully. To describe the field and the differences across studies, I conduct a systematic search and review to identify all studies relevant to the field of country-comparative health inequality research (Rave & Rumohr, 2016). Using linear probability models, I measure the effects of a variety of study design aspects on the likelihood of finding a health inequality paradox.  

Second, on account of the substantial side, I assume that welfare regimes cannot capture the complex and diverse effects of welfare institutions on health inequality. An institution that overall lowers social inequality may not necessarily lower health inequality. Therefore, I develop a theoretical framework that allows to identify institutions that affect health inequality. By using meta-data from existing studies collected through a systematic search, I conduct a meta-regression in which I first estimate the level of health inequalities within countries and then estimate the size if institutional effects on health inequalities.



  • Bambra, C.L. & Eikemo, T.A. (2009). Welfare state regimes, unemployment and health. A comparative study of the relationship between unemployment and self-reported health in 23 European countries. Journal of Epidemiology and Community Health, 63(2), 92–98.
  • Bambra, C.L; Gibson, M; Sowden, A.J; Wright, K; Whitehead, M. & Petticrew, M. (2010). Tackling the wider social determinants of health and health inequalities. Evidence from systematic reviews. Journal of Epidemiology and Community Health, 64(4), 284–291.
  • Bambra, C.L; Netuveli, G. & Eikemo, T.A. (2010). Welfare state regime life courses. The development of western European welfare state regimes and age-related patterns of educational inequalities in self-reported health. International Journal of Health Services, 40(3), 399–420.
  • Borrell, C; Espelt, A; Rodríguez-Sanz, M; Burström, B; Muntaner, C; PasarÍn, M.I; Benach, J; Marinacci, C; Roskam, A.J; Schaap, M; Regidor, E; Costa, G; Santana, P; Deboosere, P; Kunst, A.E. & Navarro, V. (2009). Analyzing differences in the magnitude of socioeconomic inequalities in self-perceived health by countries of different political tradition in Europe. International Journal of Health Services, 39(2), 321–341.
  • Braveman, P. (2016). Health Difference, Disparity, Inequality, or Inequity - What Difference Does It Make What We Call It? An Approach to Conceptualizing and Measuring Health Inequalities and Equity. In: M. Buchbinder, M. R. Rivkin-Fish, & R. L. Walker (Eds.), Understanding Health Inequalities and Justice: New Conversations across the Disciplines, (pp. 33–63). Chapel Hill: The University of North Carolina Press.
  • Braveman, P. (2008). Health Inequalities. In: H. K. Heggenhougen (Ed.), International Encyclopedia of Public Health, (pp. 189–197). Oxford: Academic Press.
    dem Knesebeck, O. von; Verde, P.E. & Dragano, N. (2006). Education and Health in 22 European Countries. Social Science and Medicine, 63(5), 1344–1351.
  • Eikemo, T.A; Bambra, C.L; Joyce, K. & Dahl, E. (2008a). Welfare state regimes and income-related health inequalities. A comparison of 23 European countries. The European Journal of Public Health, 18, 593–599.
  • Eikemo, T.A; Huisman, M; Bambra, C.L. & Kunst, A.E. (2008b). Health inequalities according to educational level in different welfare regimes. A comparison of 23 European countries. Sociology of Health & Illness, 30, 565–582.
  • Espelt, A; Borrell, C; Rodríguez-Sanz, M; Muntaner, C; PasarÍn, M.I; Benach, J; Schaap, M; Kunst, A.E. & Navarro, V. (2008). Inequalities in health by social class dimensions in European countries of different political traditions. International Journal of Epidemiology, 37(5), 1095–1105.
  • Esping-Andersen, G. (1990). The Three Worlds of Welfare Capitalism. (Reprinted 2016). Cambridge: Polity Press.
    EU [European Union] (2013). Health inequalities in the EU. Final report of a consortium. Consortium lead. Sir Michael Marmot. European Commission Directorate-General for Health and Consumers.
  • Hu, Y; van Lenthe, F.J; Borsboom, G.J; Looman, C.W.N; Bopp, M; Burström, B; Dzúrová, D; Ekholm, O; Klumbiene, J; Lahelma, E; Leinsalu, M; Regidor, E; Santana, P; Gelder, R. de & Mackenbach, J.P. (2016). Trends in socioeconomic inequalities in self-assessed health in 17 European countries between 1990 and 2010. Journal of Epidemiology and Community Health.
  • Lampert, T; Kuntz, B; Hoebel, J; Müters, S. & Kroll, L.E. (2018). Gesundheitliche Ungleichheit. In: Statistisches Bundesamt (Destatis), & Wissenschaftszentrum Berlin für Sozialforschung (WZB) (Eds.), Datenreport 2018: Ein Sozialbericht für die Bundesrepublik Deutschland, (pp. 302–314). Bonn: Bundeszentrale für politische Bildung (bpb). Available from
  • Mackenbach, J.P. (2017). Nordic paradox, Southern miracle, Eastern disaster: persistence of inequalities in mortality in Europe. European journal of public health, 27(suppl_4), 14–17.
  • Mackenbach, J.P. (2012). The persistence of health inequalities in modern welfare states. The explanation of a paradox. Social Science and Medicine, 75(4), 761–769.
  • Mackenbach, J.P; Hu, Y; Artnik, B; Bopp, M; Costa, G; Kalediene, R; Martikainen, P; Menvielle, G; Strand, B.H; Wojtyniak, B. & Nusselder, W.J. (2017). Trends In Inequalities In Mortality Amenable To Health Care In 17 European Countries. Health affairs (Project Hope), 36(6), 1110–1118.
  • McNamara, C.L; Toch-Marquardt, M; Balaj, M; Reibling, N; Eikemo, T.A. & Bambra, C.L. (2017). Occupational inequalities in self-rated health and non-communicable diseases in different regions of Europe: findings from the European Social Survey (2014) special module on the social determinants of health. European journal of public health, 27(suppl_1), 27–33.
  • Miething, A; Lundberg, O. & Geyer, S. (2013). Income and health in different welfare contexts. A comparison of Sweden, East and West Germany. Scandinavian Journal of Public Health, 41, 260–268.
  • NHS Health Scotland (2019). Measuring health inequalitues. Available from, accessed 29 May 2019.
  • Pongiglione, B. & Sabater, A. (2014). The Role of Education at Young and Older Ages in Explaining Health Inequalities in Europe. Population, Space and Place.
  • Rave, A. & Rumohr, E. (2016). Socioeconomic health inequalities, their variation across countries, welfare regimes and methodological concepts. A systematic review (protocol). PROSPERO CRD42016035779. Available from, accessed 05 May 2016.
  • Sanders, A.E; Slade, G.D; John, M.T; Steele, J.G; Suominen-Taipale, A.L; Lahti, S; Nuttall, N.M. & Allen, P.F. (2009). A cross-national comparison of income gradients in oral health quality of life in four welfare states: application of the Korpi and Palme typology. Journal of Epidemiology and Community Health, 63(7), 569–574.

Protocol Systematic Review

Rave, A. & Rumohr, E. (2016). Socioeconomic health inequalities, their variation across countries, welfare regimes and methodological concepts. A systematic review (protocol). PROSPERO CRD42016035779. Available from PROSPERO, last accessed 05 May 2016.