Challenges in work, health and well-being exam summary
De Swaan (1988). The beginnings of social security in Western
Europe and the United States.
This article gives a broad historical view of Western Europes social security systems
Germany: Period of Bismarck (during 19th century) is considered to be the origin of social protection:
more of a political strategy for state formation.
Britain: National insurance at first an initiative of the Government. Churchill (early 1900) advocates
employers to contribute to social insurance.
France: Compulsory national insurance came late (1930). Coalition between workers unions, large-
scale employers and the state.
Compulsory national insurance laws of the countries
o Germany in 1880
Accident Insurance
Disability Insurance
Sickness insurance
o Britain in 1908 (and 1911)
Pensions Act: excluded employers. General taxes were used.
Health Insurance: for all workers
1911 Act: includes employers’ contributions and workers
o France 1930
Health Insurance
Disability Insurance
Pension
1958 Unemployment insurance: organized employers and workers come to an
agreement.
The American Big Bang
o Before the social security system, there was the urban political machine system (1900).
Mostly about returning favors and only on community level
o After prosperity: Financial crisis in 1929 and big changes under president Roosevelt.
Social Security Act (1935): revolutionary law for America introducing pensions.
A minimum pension for everybody, even if they saved a little
State pensions were funded by national aid
Unemployment insurance, tax deduction for employers
o Delayment social legislation further explained: states were competing within one national
economy
“Verzuiling” played a big role in the Netherlands, stopped after 1950
The Dutch landscape changed fast after WW2 because of rapid industrialization, increasing amount of
salary workers and decreasing amount of Christians.
Social legislation laws followed soon after.
Zee van der and Kroneman (2007). Bismarck or Beveridge: a beauty
contest between dinosaurs.
Health systems can be divided into two subcategories:
o National Health Services (NHS), founded by Beveridge
o Social Security (based) Health care systems (SSH), founded by Bismarck
The inclusion of a country's system into one of the two categories is mainly based on the way the
systems are funded
The question “which system is better” has not been answered yet, but has been studied by:
o Javier Elola (1996): published a paper comparing NHS- and SSH-systems on: health outcomes,
health care costs and expenditures and population satisfaction. He did not find differences in
health outcomes between both systems, lower health care costs and better cost-containment
in NHS-systems and higher population satisfaction in SSH-systems.
o Saltman and Figueras (2004) compared NHS and SSH on a wide range of criteria varying from
life expectancy, user satisfaction, waiting lists, health care expenditures, fairness in financing,
1
, quality ratings etcetera, etcetera. The authors conclude that the relationships (between type
of system and criterion) vary 'depending on the parameter of performance being assessed'.
They do not find differences in health outcomes between SSH systems and what they call
'northern tax funded countries', a subgroup within the NHS category; they find slightly worse
results for 'equity' (mostly funding indicators) in SSH systems and higher population
satisfaction rates in the SSH-group.
In this paper we would like to improve the evidence-base for discussion about pros and cons of NHS-
systems versus SSH-systems using a set of well accepted general performance indicators and testing
the robustness of Elola's findings by using time series data instead of a single point in time.
Research focused on health outcome, costs and satisfaction
Answers to the research questions:
1. Are there indeed no systematic differences in health outcome between NHS- and SSH-
systems over a longer period in time (1970–2003)?
Our study revealed a strong improvement in life expectancy and a reduction in infant
mortality regardless of the system.
In our time series, since the 1980s, SSH systems showed slightly favorable mortality
rates compared to NHS systems, a persistent difference that continued to exist over
time.
Also for the life expectancy at birth, SSH systems persistently performed better than
NHS systems since the 1980s, although the differences are small.
Infant mortality rates showed a converging trend without any difference between
both systems since the beginning of the 1980s.
2. Do NHS-systems indeed spend less on health care as % of GDP and per capita and are they
better in cost control over the same period in time?
The costs of NHS systems are persistently lower compared to SSH systems over time
both in terms of health expenditure per capita and as percentage of GDP (although
the latter is the case only since 1985, before this time NHS systems were consuming
a larger part of the GDP).
3. Is, indeed, the population in SSH-systems more posi- tive about its health care system than in
NHS-systems?
The third research question was: is the population in SSH systems more positive
about its health care system than in NHS systems. Elola's conclusion that SSH
systems receive greater public support is supported by our study.
4. Question 4 If differences exist, do they converge over time?
The results of our study show that, except for infant mortality rates, this
convergence did not take place yet.
This is not in line with the hypothesis of Elola, who argued that health care reforms
were directed towards convergence between both systems.
Dekker, P., et al (2004). Social Europe: Annex to the State of the
European Union
The regulations governing social security and the labor market differ in every Member State of the
European Union.
Despite differences, it is possible to classify the different Member States broadly on the basis of their
social security legislation and labor market policy.
This chapter looks at the classifications devised by Esping-Andersen, following which we subject this
classification to empirical testing and give a description of the different types of welfare state.
Although all Member States of the European Union have a different social security system, they can
nonetheless be grouped into a number of clusters or types.
o The liberal welfare state, which in Europe includes the United Kingdom and Ireland.
These countries offer fairly limited collective provisions and the target group of
those provisions is limited to those who cannot meet their own needs in any other
way.
The better-off groups have to cover their own risks through private arrangements or
employee benefits provided by their company.
The government often encourages such schemes through the tax system.
2
, o The social- democratic welfare states; this category mainly includes the Scandinavian
countries (Denmark, Sweden and Finland).
Reducing income differentials is a prime objective in these countries, and their social
security systems are largely universalist, in that all inhabitants are entitled to
collective provisions for a large number of social risks.
The conditions for access to the system are generous and benefits are generally high.
The policy in general is strongly geared to encouraging people into work, since high
employment is an absolute necessity in this type of welfare state.
An active integration policy is in place to help the unemployed and incapacitated for
work back into employment quickly.
o Corporatist welfare states; within Germany, Austria, France and Belgium are the main
examples of this.
These countries are characterized by schemes specifically aimed at different
occupational groups.
Civil servants are privileged because of their links with the state.
Because of these separate programmes for different occupational groups, the
various schemes are funded mainly through the levying of premiums; employees pay
collectively for their own provisions.
This also means that the relationship between contributions paid and benefits
received later is stronger than in the liberal and social- democratic countries.
o Mediterrenean
The Netherlands is a hybrid between social-democratic and corporatist.
o The Netherlands has a fixed basic pension to which every inhabitant is entitled, something
which is a common feature of the social-democratic countries.
o On the other hand, leave arrangements in the Netherlands are relatively limited and
supplementary pensions are organized on an individual sector basis; these are typical
corporatist features. The activity rate is on the low side.
In order to test Esping-Andersen’s theoretical classification of welfare states, several areas of the
systems operating in the present 15 eu Member States were analysed:
o Labour market
o (State) pension
o Widow’s pension
o Unemployment
o Incapacity for work
o Leave arrangements
o Subsistence benefit
o The funding of provisions
The analysis shows that the first dimension on the horizontal axis correlates to the size of the total
welfare state, the level of taxes, the amount spent on labour market programmes, unemployment
benefits and the degree of universalism in the schemes.
Social democratic countries
o Denmark is the clearest representative of the social-demo- cratic model. A key reason for this
is that Denmark has relatively extensive provisions, spending more on reintegration
programmes for jobseekers.
3
De Swaan (1988). The beginnings of social security in Western
Europe and the United States.
This article gives a broad historical view of Western Europes social security systems
Germany: Period of Bismarck (during 19th century) is considered to be the origin of social protection:
more of a political strategy for state formation.
Britain: National insurance at first an initiative of the Government. Churchill (early 1900) advocates
employers to contribute to social insurance.
France: Compulsory national insurance came late (1930). Coalition between workers unions, large-
scale employers and the state.
Compulsory national insurance laws of the countries
o Germany in 1880
Accident Insurance
Disability Insurance
Sickness insurance
o Britain in 1908 (and 1911)
Pensions Act: excluded employers. General taxes were used.
Health Insurance: for all workers
1911 Act: includes employers’ contributions and workers
o France 1930
Health Insurance
Disability Insurance
Pension
1958 Unemployment insurance: organized employers and workers come to an
agreement.
The American Big Bang
o Before the social security system, there was the urban political machine system (1900).
Mostly about returning favors and only on community level
o After prosperity: Financial crisis in 1929 and big changes under president Roosevelt.
Social Security Act (1935): revolutionary law for America introducing pensions.
A minimum pension for everybody, even if they saved a little
State pensions were funded by national aid
Unemployment insurance, tax deduction for employers
o Delayment social legislation further explained: states were competing within one national
economy
“Verzuiling” played a big role in the Netherlands, stopped after 1950
The Dutch landscape changed fast after WW2 because of rapid industrialization, increasing amount of
salary workers and decreasing amount of Christians.
Social legislation laws followed soon after.
Zee van der and Kroneman (2007). Bismarck or Beveridge: a beauty
contest between dinosaurs.
Health systems can be divided into two subcategories:
o National Health Services (NHS), founded by Beveridge
o Social Security (based) Health care systems (SSH), founded by Bismarck
The inclusion of a country's system into one of the two categories is mainly based on the way the
systems are funded
The question “which system is better” has not been answered yet, but has been studied by:
o Javier Elola (1996): published a paper comparing NHS- and SSH-systems on: health outcomes,
health care costs and expenditures and population satisfaction. He did not find differences in
health outcomes between both systems, lower health care costs and better cost-containment
in NHS-systems and higher population satisfaction in SSH-systems.
o Saltman and Figueras (2004) compared NHS and SSH on a wide range of criteria varying from
life expectancy, user satisfaction, waiting lists, health care expenditures, fairness in financing,
1
, quality ratings etcetera, etcetera. The authors conclude that the relationships (between type
of system and criterion) vary 'depending on the parameter of performance being assessed'.
They do not find differences in health outcomes between SSH systems and what they call
'northern tax funded countries', a subgroup within the NHS category; they find slightly worse
results for 'equity' (mostly funding indicators) in SSH systems and higher population
satisfaction rates in the SSH-group.
In this paper we would like to improve the evidence-base for discussion about pros and cons of NHS-
systems versus SSH-systems using a set of well accepted general performance indicators and testing
the robustness of Elola's findings by using time series data instead of a single point in time.
Research focused on health outcome, costs and satisfaction
Answers to the research questions:
1. Are there indeed no systematic differences in health outcome between NHS- and SSH-
systems over a longer period in time (1970–2003)?
Our study revealed a strong improvement in life expectancy and a reduction in infant
mortality regardless of the system.
In our time series, since the 1980s, SSH systems showed slightly favorable mortality
rates compared to NHS systems, a persistent difference that continued to exist over
time.
Also for the life expectancy at birth, SSH systems persistently performed better than
NHS systems since the 1980s, although the differences are small.
Infant mortality rates showed a converging trend without any difference between
both systems since the beginning of the 1980s.
2. Do NHS-systems indeed spend less on health care as % of GDP and per capita and are they
better in cost control over the same period in time?
The costs of NHS systems are persistently lower compared to SSH systems over time
both in terms of health expenditure per capita and as percentage of GDP (although
the latter is the case only since 1985, before this time NHS systems were consuming
a larger part of the GDP).
3. Is, indeed, the population in SSH-systems more posi- tive about its health care system than in
NHS-systems?
The third research question was: is the population in SSH systems more positive
about its health care system than in NHS systems. Elola's conclusion that SSH
systems receive greater public support is supported by our study.
4. Question 4 If differences exist, do they converge over time?
The results of our study show that, except for infant mortality rates, this
convergence did not take place yet.
This is not in line with the hypothesis of Elola, who argued that health care reforms
were directed towards convergence between both systems.
Dekker, P., et al (2004). Social Europe: Annex to the State of the
European Union
The regulations governing social security and the labor market differ in every Member State of the
European Union.
Despite differences, it is possible to classify the different Member States broadly on the basis of their
social security legislation and labor market policy.
This chapter looks at the classifications devised by Esping-Andersen, following which we subject this
classification to empirical testing and give a description of the different types of welfare state.
Although all Member States of the European Union have a different social security system, they can
nonetheless be grouped into a number of clusters or types.
o The liberal welfare state, which in Europe includes the United Kingdom and Ireland.
These countries offer fairly limited collective provisions and the target group of
those provisions is limited to those who cannot meet their own needs in any other
way.
The better-off groups have to cover their own risks through private arrangements or
employee benefits provided by their company.
The government often encourages such schemes through the tax system.
2
, o The social- democratic welfare states; this category mainly includes the Scandinavian
countries (Denmark, Sweden and Finland).
Reducing income differentials is a prime objective in these countries, and their social
security systems are largely universalist, in that all inhabitants are entitled to
collective provisions for a large number of social risks.
The conditions for access to the system are generous and benefits are generally high.
The policy in general is strongly geared to encouraging people into work, since high
employment is an absolute necessity in this type of welfare state.
An active integration policy is in place to help the unemployed and incapacitated for
work back into employment quickly.
o Corporatist welfare states; within Germany, Austria, France and Belgium are the main
examples of this.
These countries are characterized by schemes specifically aimed at different
occupational groups.
Civil servants are privileged because of their links with the state.
Because of these separate programmes for different occupational groups, the
various schemes are funded mainly through the levying of premiums; employees pay
collectively for their own provisions.
This also means that the relationship between contributions paid and benefits
received later is stronger than in the liberal and social- democratic countries.
o Mediterrenean
The Netherlands is a hybrid between social-democratic and corporatist.
o The Netherlands has a fixed basic pension to which every inhabitant is entitled, something
which is a common feature of the social-democratic countries.
o On the other hand, leave arrangements in the Netherlands are relatively limited and
supplementary pensions are organized on an individual sector basis; these are typical
corporatist features. The activity rate is on the low side.
In order to test Esping-Andersen’s theoretical classification of welfare states, several areas of the
systems operating in the present 15 eu Member States were analysed:
o Labour market
o (State) pension
o Widow’s pension
o Unemployment
o Incapacity for work
o Leave arrangements
o Subsistence benefit
o The funding of provisions
The analysis shows that the first dimension on the horizontal axis correlates to the size of the total
welfare state, the level of taxes, the amount spent on labour market programmes, unemployment
benefits and the degree of universalism in the schemes.
Social democratic countries
o Denmark is the clearest representative of the social-demo- cratic model. A key reason for this
is that Denmark has relatively extensive provisions, spending more on reintegration
programmes for jobseekers.
3
