Elsevier

Health Policy

Volume 104, Issue 2, February 2012, Pages 99-127
Health Policy

Review
Welfare states, flexible employment, and health: A critical review

https://doi.org/10.1016/j.healthpol.2011.11.002Get rights and content

Abstract

Objectives

The aim of this literature review is to identify whether differences between welfare regimes can manifest diverse consequences for the health effects of insecure and precarious employment, as well as to address challenging issues and implications for future research.

Methods

By searching PubMed, PsychINFO, Stork Social Science Citation Index, and Index Lilac, from 1988 to June 2010, a total of 104 original articles were selected (65 on job insecurity; 39 on precarious employment).

Results

After classifying selected empirical studies according to a six-regime welfare state typology (Scandinavian, Bismarckian, Southern European, Anglo-Saxon, Eastern European, and East Asian), this systematic review reveals that welfare regimes may be an important determinant of employment-related health. Precarious workers in Scandinavian welfare states report better or equal health status when compared to their permanent counterparts. By contrast, precarious work in the remaining welfare state regimes is found to be associated with adverse health outcomes, including poor self-rated health, musculoskeletal disorders, injuries, and mental health problems.

Conclusions

Future research should be conducted by employing conceptual models that specify how macro-economic processes, country-level welfare factors, and individual employment histories and environments relate to employment-related health inequalities.

Introduction

Flexible employment (job insecurity and precarious employment), as a global phenomenon, has emerged as a consequence of the dramatic socio-economic changes that characterized Western capitalist economies during the final decades of the 20th and the beginning of the 21st centuries. The “globalization” of economic activity, and in particular the accelerating internationalization of trade, investments, and finance [1], is increasingly acknowledged as a driving force behind changes to work and living conditions around the world [2], [3]. An important evolution in contemporary labour markets concerns the rise of forms of flexible employment that reduce security [4], [5]. The concept of precarious employment is introduced as a way of describing the key underlying features of flexible forms of employment (e.g., contract work, temporary work, part-time work, and daily work). There are four dimensions to these underlying features: continuity (i.e., temporality), vulnerability (i.e., powerlessness), protection (i.e., lack of benefits) and income (i.e., low levels of earnings) [6]. Many precarious jobs can have an involuntary nature, and the mobility of temporary workers and the periodicity of their engagements hinders to a great extent the demarcation between unemployment and temporary employment. While precarious workers seem to share a common experience of insecurity, the use of job insecurity as a variable in studies are oriented mostly towards assessing the effects of flexibility on productivity in a given company, which explains their use of perceived job insecurity, change resistance, and effort and willingness to leave a job as the main dependent variables of analysis [7], [8], [9]. A link to health has been established through the association of precarious employment with higher levels of job insecurity. The intersection of precarious employment and job insecurity may stem from one of four experiences: (1) the threat of becoming jobless, (2) continuously accepting less pay as the price that needs to be paid in order to remain employed, (3) the instability of employment status, or (4) more unbalanced power relations between employees and their employers [6]. Further down the explanatory filter, these features of flexible labour markets are generally thought of as being conducive to less favourable health outcomes due to their associations with lower material well-being, adverse physical and psychosocial working conditions, less positive social contacts, and weaker support from supervisors and (non-precarious) co-workers [6], [10], [11].

Two decades of scholarship on precarious employment arrangements have not generated precise conclusions on the relationship between precarious employment and health. This is due to several factors: some inconsistent results in the majority of empirical studies, the lack of a sound interpretative framework that is capable of facilitating an understanding of different social and employment realities; and limited contextual and labour market-related variables that interact with individual employment situations [12], [13]. With regard to the contextual influences, we hypothesize that these are largely reflected in the development of different legal and social employment protection standards (some higher, some lower) that have been applied to vulnerable workers. Often, contextual differences at the cross-national level are classified according to welfare state regimes. Esping-Andersen [14] identifies three main types of welfare-state capitalisms, whereby each type is characterized by a specific degree of decommodification. The first group of Social-Democratic welfare states is characterized by universalistic welfare regimes providing full-employment policies, strong union movements, and generous and pro-egalitarian governmental benefits. The second group of Corporatist-Conservative or Christian-Democratic welfare states combine some public welfare services with compulsory private insurance schemes that are distributed according to work performance or family income. Public welfare expansion is less central in Christian-Democratic than in Social-Democratic welfare states, which may create inequalities stemming from weaker commitments to redistributive policies. Finally, Liberal welfare states are linked to residual public services (often of poorer quality) and a market-based organization of social insurance for the largest part of the population. This model accounts for historical and quantitative considerations pertaining to a number of variables including welfare expenditure, average benefit equality, union functioning and capacity, unemployment rates, long-term patterns of welfare state development, and/or women's material position and labour participation rates [15]. Employment relations are at the center of welfare states and play an important role in the social determinants of health [9]. However, researchers have extensively debated Esping-Andersen's “The Three Worlds of Welfare Capitalism.” Theoretical and empirical criticisms have taken aim at the dislocation of certain countries [16], the omission of gender [17], and a range of methodological errors [18]. Alternative typologies have been proposed using more recent data and more refined analyses. For example, Ferrera [16] and other researchers have suggested a four-regime welfare typology: Anglo-Saxon, Bismarckian, Scandinavian, and Southern European [16], [19], [20]. While the first three regimes in this list are for the most part a reflection of Esping-Andersen's earlier typology, this work adds a new and important element to comparative analysis: the Southern European welfare regime. This regime has been described as embodying “the periphery of the core,” presenting a clear distinction between itself and its Bismarckian and Anglo-Saxon counterparts [16]. Current research has also contributed to the further expansion of conventional welfare regime typologies so as to account for Eastern European [21], [22], [23], [24] and East Asian welfare state regimes [25], [26].

So far, several literature reviews have dealt with various aspects of the relationship between flexible employment and health outcomes [12], [13], [27], but systematic studies addressing the relevance of welfare state regimes have yet to be conducted. Therefore, the aim of this systematic review is (1) to identify whether welfare state regimes can account for variation in the relationship between flexible employment and health outcomes, (2) to investigate and compare conceptualizations of job insecurity and precarious employment in the context of increased labour market flexibility, and (3) to address some challenging issues and implications for future research.

Section snippets

Methods

We detected relevant studies on the health-related impacts of flexible employment (job insecurity and precarious employment) by searching PubMed, PsychINFO, Stork Social Science Citation Index, and Index Lilac. Our search was limited to the years between 1988 and June 2010. This is because previous evidence suggests a rapid increase in job insecurity from 1985 to 1995, and studies on precariousness and employment-related health emerged starting from 1988 [10], [12], [13], [27]. The key words

Results

We identified 330 studies, and after screening their abstracts, 201 studies were selected for further consideration. A total of 104 original articles (65 on job insecurity; 39 on temporary employment) were relevant to our study purpose. We allocated these articles into one of six welfare state regimes: Scandinavian (Sc), Bismarckian (B), Anglo-Saxon (A-S), Southern European (S), Eastern European (EE), and East Asia (EA). Adapting Ferrera's four-regime welfare typology mentioned above [16], two

Discussion

Our systematic literature review has investigated two relevant epidemiological areas of study on flexible employment: job insecurity and precarious employment. Although precarious employment, together with the experience of job insecurity, appears to incur higher risks of experiencing several health problems when compared to secure employment, the heterogeneity of results within the published literature have made it impossible to attain unequivocal conclusions. After stratifying these studies

Conclusions

We have reviewed two relevant epidemiological areas of study in the investigation of flexible employment: job insecurity and precarious employment. After allocating selected empirical studies into one of six welfare regime-types, our systematic literature review reveals that the comprehensive employment policies of Scandinavian welfare states may help to moderate an array of negative health-related consequences associated with precarious employment and job insecurity. Whereas precarious workers

Acknowledgements

We appreciate the comments, on previous drafts, of Artazcoz L, Moncada S, Porthé V, Llorens C, González S, Iglesias M, Lucarda G, Recio A, Beechinor T; of personal de la biblioteca del Mar de la UPF. This research program is supported by FIS 02/0939, MEC/FEDER SEC2003-01189/PSCE, RSESP C003/09 i SCR. Support to CAMH for the salary of fellows and infrastructure has been provided by the Ontario Ministry of Health and Long Term Care. The views expressed here do not necessarily reflect those of the

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