Health Policy 68 (2004) 63–79
The welfare state as a determinant of women’s health: support for
women’s quality of life in Canada and four comparison nations
Dennis Raphael
a,∗
, Toba Bryant
b
a
School of Health Policy and Management, Atkinson Faculty of Liberal and Professional Studies, York University,
4700 Keele Street, Toronto, Ont., Canada M3J 1P3
b
York Center for Health Studies, York University, 4700 Keele Street, Toronto, Ont., Canada M3J 1P3
Accepted 28 August 2003
Abstract
Thecaseismadethatcharacteristicsassociatedwiththeadvancedwelfarestateinindustrialisednationsareprimarycontributors
to women’s quality of life. This is so since women’s health and well-being are particularly sensitive to decisions made in relation
to the spending priorities of governments, the extent to which services are provided, and the degree to which women are
supported in moves towards equity. Data from the Organization for Economic Cooperation and Development, United Nations
Human Development Program, and other sources are used to examine these influences upon quality of life of women in Canada
as compared to that of women in Denmark, Sweden, the UK and the US. A consistent pattern was seen by which national features
impacting on women’s quality of life are more likely to be seen in nations with a social welfare orientation as compared to
nations with market approaches to policy development.
© 2003 Elsevier Ireland Ltd. All rights reserved.
Keywords: Welfare state; Population health; Women’s quality of life
1. Overview
Quality of life is a holistic construct that views
human health and well-being within the contexts of
proximal and distal environments [1]. It combines ele-
ments of broad societal indicators with the actual lived
experience of people [2]. Emphasis is increasingly be-
ing placed on considering quality of life in particular

of health. A social determinants of health perspective
is increasingly being applied to national approaches
to the formulation of health policy [8,9]. This is espe-
cially the case in the Scandinavian nations.
In this paper, we consider the extent to which these
quality of life issues are supported by governmental
action in Canada and four comparison nations. The
information relevant to these issues comes primarily
from two types of data sources: indicator analyses
from international reports and intensive and detailed
policy analyses of two policy issues of particular
importance to women: childcare provision and gov-
ernmental support for community-based long-term
care.
Canadian data are contrasted with those from Den-
mark, Sweden, the UK, and the US. These nations
have been chosen for an obvious reason: Denmark
and Sweden are nations with a predominantly social
welfare approach to social policy, especially in rela-
tion to issues of concern to women; the UK and US
have a predominantly market-oriented approach to
these same issues [10]. The case is argued that na-
tions with a predominantly welfare state orientation
are more likely to support the quality of life themes
relevant to women’s health and well-being.
2. Defining the welfare state
The welfare state is “ a capitalist society in
which the state has intervened in the form of so-
cial policies, programs, standards, and regulations in
order to mitigate class conflict and to provide for,

employment, and showed the lowest degree of income
inequality and poverty rates. They also had the lowest
percentage of national income derived from capital
investment and the largest from wages. On a key in-
dicator of population health—infant mortality—these
countries had the lowest rates from 1960 to 1996.
Anglo-Saxon liberal political economies had the
lowest expenditures on health care and the lowest cov-
erage by public medical care. Wages were low, and
income inequalities and poverty rates the greatest. Per-
centage of income derived from capital investment was
the highest. The liberal countries have the lowest rates
of improvement in infant mortality rates from 1960 to
1996.
Similar patterns are seen when the US, Canada,
and Sweden are compared on numerous social de-
velopment and population health indicators [14,15].
Sweden fares the best, the US the worse, and Canada
comes up the middle. These findings indicate that
political and economic forces play a strong role in
population health. Population health theory and re-
search in Canada and elsewhere however, focus on a
number of mid-level “social determinants of health”
with little recognition of the role political and eco-
nomic forces play in the quality of these health deter-
minants [16–19]. Before considering these forces, a
brief overview of various conceptualisations of social
determinants of health is provided.
D. Raphael, T. Bryant/ Health Policy 68 (2004) 63–79 65
3. Social determinants of health

(HDR) (United Nations Development Program [26]
and the Organization for Economic Cooperation and
Development’s Society at a Glance Report (SGR) [27]
present a wide range of information concerning hu-
man development and well-being in member nations.
Many indicators map onto the quality of life priority
areas outlined by the Canadian Policy Research Net-
works framework. Some indicators refer to the entire
population of men and women while some are specif-
ically concerned with women. But all indicators illu-
minate the state of political and economic forces that
influence the quality of life of women in Canada and
elsewhere.
4.1. Political rights and general values
The quality of political rights and general values
are not easily captured in indicator analyses. In a re-
cent work, we considered these issues in relation to
Canada’s adherence to the Convention to Eliminate All
Forms of Discrimination Against Women (CEDAW)
[28,29]. The conclusion reached in various reports to
the United Nations by Canadian women’s groups and
most recently by the United Nations CEDAW Com-
mittee itself is that Canada is not working to imple-
ment the provisions of the Convention through the ex-
ercise of women’s political rights:
The Committee acknowledges the State party’s
complex federal, provincial and territorial political
and legal structures. However, it underlines the
federal Government’s principal responsibility in
implementing the Convention. The Committee is

Canada Denmark Sweden UK US
HDI (rank) 3 14 2 13 6
Life expectancy 78.8 76.2 79.7 77.7 77.0
GDP per capita 27840 27627 24277 23509 34142
Education index 0.98 0.98 0.99 0.99 0.98
Human poverty index (rank) 12 5 1 15 17
Percentage in poverty (%) 12.3 9.5 6.7 15.1 15.8
<50% median income (%) 12.8 9.2 6.6 13.4 16.9
<Functional literacy (%) 16.6 9.6 7.5 21.8 20.7
Adequate sanitation (%) 100 100 100 100 100
Physicians/100,000 229 290 311 164 279
Public Can$ as percentage of GDP (%) 6.6 6.9 6.6 5.8 5.7
Private Can$ as percentage of GDP (%) 2.7 1.5 1.3 1.2 7.1
Total Can$ as percentage of GDP (%) 9.3 8.4 7.9 7.0 12.8
Spending per capita 1939 2785 2145 1675 4271
Source: HDR [26].
The HDR also provides a number of indicators of
national commitment to health. As compared to the
social welfare nations, Canada has fewer physicians
and spends less public money on health care. How-
ever, with the relatively high percentage of funds be-
ing expended privately, Canada spends more on health
care than all nations except the US.
4.3. Education
As noted in Table1, Canada scores high on a relative
index of enrolment density, yet falls behind the social
welfare nations on an indicator of functional literacy.
Table 2 shows the HDR indicators for public spend-
ing on education. Canada scores midway between the
social welfare and market economy nations.

less net replacement value for short- and long-
term assistance recipients than all other comparison
nations.
4.6. Personal well-being
National statistics from surveys on incidence of
crime are available and are presented in Table 5.No
clear pattern is seen among the nations in these statis-
tics.
Income distribution is increasingly being identified
as an indicator of societal and personal well-being
[39–42]. A number of indicators are available re-
lated to income distribution and incidence of poverty
D. Raphael, T. Bryant/ Health Policy 68 (2004) 63–79 67
Table 3
Energy and the environment indicators in Canada and four comparison nations, 1997
Canada Denmark Sweden UK US
Electricity consumption 15260 6030 14138 5384 11994
Carbon dioxide emissions in tons per capita 15.3 10.1 5.5 9.2 19.9
Source: HDR [26].
among nations and among populations within Canada
(Table 6).
While Canada is second only to the US in GDP per
capita, its distribution of income is midway between
the social welfare and market-oriented nations. The
Gini index ranges from 0.00 (perfect equality) to 1.0
(all income controlled by one person). Table7 provides
insight into the situation of single women in Canada,
though these figures do not make a distinction between
male and female single parents.
A detailed analysis of the current state of Canadian

Canada low-income cut-offs—an indicator similar to
the poverty marker used by OECD.
4.7. Economy and employment
As noted, Canadian per capital income is second
to the US among the comparison nations. However,
income is distributed more unequally than in the so-
cial welfare nations. The following tables provide evi-
dence concerning income inequality between men and
women and level of unemployment in Canada and the
comparison nations.
Canadian women, like women elsewhere, do not
participate in paid employment activity to a similar
extent as men. Yet they overall spend more hours
on combined employment and household duties than
men [44]. Canadian unemployment rates—applying
to those able and/or seeking employment—are high
as compared to both the social welfare and market
economy-oriented nations (Table8). The female rate is
similar to that of men. Youth unemployment rates are
also relatively high in Canada, though the female rate
is lower than that for males. Finally, Canada’s percent-
age of unemployed that are long-term unemployed—
this group does not include those with disabilities—is
relatively low as compared to all nations except the
US. The low US rate may reflect the lack of available
Table 5
Reports of being a victim of crime as percentage of total population
in Canada and four comparison nations, 1999
Canada Denmark Sweden UK US
Property crime (%) 10.4 7.6 8.4 12.2 10.0

benefits for the long-term unemployed that may ei-
ther force individuals to find employment of some
sort or make such long-term unemployed individuals
“invisible”.
Table 9 provides figures related to spending in sup-
port of government action to support prospects of gain-
ful employment, job skills of the labour force, and the
functioning of the labour force. These include public
Table 8
Gender inequality in economic activity and unemployment levels in Canada and four comparison nations, 1999
Canada Denmark Sweden UK US
Female economic activity (%) 60.1 61.7 62.5 52.8 58.8
As percentage male rate (%) 82 84 89 74 81
Unemployment rate (%) 6.8 4.7 4.7 5.5 4.0
Female rate as percentage male rate (%) 96 123 87 79 105
Youth unemployment (%) 12.6 6.7 11.9 11.8 9.3
Female rate as percentage male rate (%) 81 107 93 77 92
Long-term as percentage total rate (%)
Male 12.2 20.1 33.1 33.7 6.7
Female 10.0 20.0 27.7 19.0 5.3
Source: HDR [26].
Table 9
Active and passive labour market public spending, as percentage
of GDP Canada and four comparison nations, 1999
Canada Denmark Sweden UK US
Active spending (%) 0.50 1.75 1.8 0.4 0.2
Passive spending (%) 1.0 3.1 1.7 0.75 0.25
Total spending (%) 1.5 4.85 3.5 1.15 0.45
Source: SGR [27].
employment services and administration, labour mar-

tween men and women in full-time unionised jobs was
18%; in non-unionised full-time jobs, 25%. These data
are consistent with the analysis of Baker and Fortin
[13] concerning the enhancing effects for income en-
joyed by women in unionised positions.
In the Society at a Glance Report, the OECD calcu-
lated the gender wage gap for member nations from the
mid- to late-1990s in terms of female median full-time
earnings as a percentage of male median full-time
earnings. The differences were as follows: Canada,
30%; Denmark, 12%; Sweden, 17%, UK, 23%, and
the US, 22%.
Finally, Hadley considered various indicators of in-
come inequality between Canadian men and women.
Women’s income as a percentage of men’s income for
full time, full year employment was 72.5%; for hourly
wages, 80%; for those with university degrees, 74%;
for all men and women, 63%; and median after tax
income, 61%.
4.8. Government
The United Nation provides a gender empowerment
index and provides data on women’s participation in
government. These data are provided in Table 10.
Canada ranks relatively high in this index. Nonethe-
less, Canada’s seats in parliaments held by women is
low, though Canada does well comparatively on the
other ratings. A consistent picture emerges from these
analyses. Canada performs well in just about every in-
dicator of general quality of life and women’s quality
of life as compared to the UK and the US. Canada

Canada—in despite of repeated political commitments
to such a program—has no national childcare program
in contrast to other nations. Doherty et al. [48] have
identified a number of policy trends that have weak-
ened any move towards increasing the availability of
quality childcare for Canadian women. These include
the reinforcing of decentralist tendencies in govern-
ment, which resulted in part from anxieties about
Quebec separation, governmental dealing with fiscal
pressures through reduced social and health expendi-
tures, and federal withdrawal from program respon-
sibility through power devolution to the provinces.
Bashevkin [49,50] documents the Canadian, UK,
and US governmental retreat from its childcare
commitments.
The resulting changes in childcare in the 1990s
have involved decreasing affordability of childcare
for Canadian families, decreasing availability of af-
fordable spaces for working families, reductions in
quality of childcare through reduced provincial and
territorial funding, and reduced regulation. There have
also been reductions in community infrastructure that
support quality such as availability of affordable edu-
cational programs in early childhood education [51].
These effects have reduced women’s choices regard-
ing participation in the paid work force; reduced their
choices regarding the type of childcare they use; de-
creased supports for mothers who are neither engaged
in the paid work force nor students; and increased the
likelihood of stress among mothers ([48], p. 32). The

Research Unit at the University of Toronto [46] and
outputs from the OECD Thematic Review of Early
Childhood Education and Care Policy [52]. The latter
was a 12-nation study of OECD nations that did not
include Canada. Data from these reports were com-
bined to provide a composite picture of the nature of
childcare in Canada and the comparison nations.
6.1. Women, motherhood, and employment in
Canada and elsewhere
Besides the obvious human development benefits of
providing children with stimulating, safe, and quality
childcare, the availability of childcare allows women
to have gainful employment. Table 11 shows the per-
centage of married/cohabiting mothers and percentage
of lone mothers that are employed in Canada and the
four comparison nations while Table 12 summarises
paid maternity leave benefits. Table 13 shows percent-
age of children receiving out-of-home childcare.
7. Childcare and early child education policy
situation
About half of Canadian children are in out-of-home
childcare arrangements; significantly less than that
seen for Denmark and Sweden with its state-supportive
system. The figures for the UK are strikingly low.
Bertram and Pascal [53] note that “Current provision
of education and care for under 3’s in the UK is un-
even, of mixed quality and in short supply These
D. Raphael, T. Bryant / Health Policy 68 (2004) 63–79 71
Table 12
Provisions for paid maternity leave in Canada and four comparison

parents. The funding strategies are mixed, but come
primarily from parent fees. Only 10% of Canadian
children have access to regulated childcare [69].
According to the International Reform Monitor
[58–67], Canadian provincial governments provided
Table 13
Proportion of young children who use out-of-home child care fa-
cilities up to mandatory schooling age in Canada and four com-
parison nations, 1998 and 1999
Canada Denmark Sweden UK US
0–3 year olds (%) 44 58 48 2 26
3 years to mandatory
age (%)
50 83 79 60 71
Source: [69].
subsidised childcare for some low-income parents,
but supply is inadequate to the demand and cutbacks
have worsened the situation in some provinces. Most
families still must use private, unregulated childcare.
The most enlightened province is Quebec where sub-
sidised childcare has been introduced for all children.
The pursuit of family-friendly workplaces on the part
of employers remains in its infancy in Canada. The
National Child Benefit is available to low-income
families but most provinces claw these back from
families on social assistance.
Denmark: Danish governments provide universal
education for children 5–7, and provides childcare
from 6 months to 6 years for working parents. Govern-
ment funding is supplemented by income-related par-

ers offer subsidised childcare facilities; the vast ma-
jority do not. After welfare reform, more low-income
families with children need to find and hold jobs.
72 D. Raphael, T. Bryant / Health Policy 68 (2004) 63–79
Federal employees are entitled to 24 h work-leave for
child-related activities.
8. Home care
Home care enables individuals with major or more
minor limitations to live at home and/or in sup-
portive housing. Home care services can assist in
preventing, delaying or replacing long-term care or
acute care alternatives. Such services include pro-
fessional services, medical supplies, homemaking
and attendant care, and maintenance and preventive
care ([71],p.1).
A number of reports and analyses have identified
home care as an issue of tremendous importance for
Canadian women’s quality of life [71–75]. This is so
since 67% of recipients of home care are women [76];
the overwhelming majority of home care providers
are women [75]; and the informal caregiving that is
given in the home—especially when formal care is not
available—is primarily provided by women [77].
There have also been profound changes in the
organization of health care in many provinces with
increasing shifting of care from the hospital to the
community. Since home care does not take place
in hospitals, it is not necessarily covered under the
Canada Health Act and is under provincial control.
A wide range of services is available across Canada,

issues pointed to a continuing crisis in home care that
differentially impacts the health and well-being of
the sexes with women being affected more adversely.
The authors recommended the establishment of a
Canada Home and Community Care Act that would
be based on the principles of the Canada Health Care
Act, would be publicly accountable, would offer good
wages and working conditions, and offer appropriate
care with choices.
Comparative data concerning home care are pro-
vided in a series of documents prepared by the
OECD and also provided by specific sources within
each nation. For example, the data for Canada
were provided by OECD [27] and the Caledon
Institute.
Canada spends less on long-term care than any com-
parison nation. This is in sharp contrast to the so-
cial welfare nations of Denmark and Sweden [80].
Table 14 bears this out, showing the percentage of
total spending on long-term care in Canada is 1.1%,
compared to 2.2% in Denmark and 2.7% in Sweden.
It spends even less that the US and the UK. Its rate
of institutionalisation of individuals over 65 years of
Table 14
Long-term care statistics for Canada and four comparison nations,
1995
Canada Denmark Sweden US UK
Total spending on
LTC
1.1 2.2 2.7 1.3 1.3

ipalities have responsibilities; providers include both
non-profit and private for-profit companies. There is
a very small income tax credit for caregivers in the
home.
Denmark: Denmark has a National Health Ser-
vice that is tax financed with low co-payments and
mostly public providers. Ninety-seven percent of the
population is covered by social insurance, the others
are privately insured. The funding of long-term care
is a responsibility of municipalities and is primarily
tax-financed. Municipalities determine entitlements
for benefits and contract with private nursing homes
or non-profit organisations. Health insurance cov-
ers medical treatment in acute cases and home care.
Agreements between regional health care authorities
and municipalities responsible for long-term care are
in place to provide a range of services. Caregivers of
terminally ill patients are entitled to social assistance
of a cash benefit equal to 1.5 times their own sickness
benefit.
Sweden: Health care is provided by a tax-financed
national health service that uses government-employed
physicians and private doctors with service agree-
ments. Health care is largely free or provided at low
costs to the patient. Long-term care is primarily tax
financed, with 9% related to personal fees. Munici-
palities are responsible for providing and financing
social services. There are few individual or private
providers. Legislation enshrines the right to remuner-
ation for assistance/caregivers. The economic support

Medicaid pays for nursing home care for those on very
low incomes and almost no financial assets. Medicare
and Medicaid will provide a range of home services
for eligible patients (usually the very poor or those
without any financial resources). Support of caregivers
is limited to home care financed by Medicare and
Medicaid.
9. Conclusion: the welfare state and women’s
quality of life
The findings concerning women’s quality of life
in Canada are consistent with the analysis of Fast
and Keating’s [82] who identified four key changes
74 D. Raphael, T. Bryant / Health Policy 68 (2004) 63–79
in the Canadian policy environment: Reduced gov-
ernment expenditure on health, income security, and
social services; push towards the privatisation of
health and continuing care; shift from institutional to
community-based health and community care; and
increased geographic inequity in health and social
service delivery.
Mainstream economic and political analyses at-
tempt to explain deteriorating policy environments
as reflecting the readjustment of market forces and
changing family dynamics [83]. However, research
from a more critical perspective offers a rather less
benign view of the forces that drive the weakening of
social infrastructure along the lines seen in the UK
and US and to a lesser extent in Canada.
9.1. Decline of the welfare state
Teeple [11] sees increasing income and wealth in-

continue to be nationally based. With such a power
shift, business has less need to develop political
compromises among themselves, labour, and govern-
ments. The decline of the Soviet Bloc, and its diffuse
threat of supporting working class revolt, has also
removed incentives for compromise by business with
employees and labour in general. Finally, the overall
slowing of economic growth has reduced resources
available for the welfare state. Increased concentra-
tion of corporate and media ownership helps assure
that justification for these changes, delivered in the
form of neo-liberal ideology, is now the dominant
discourse related to political and economic processes
[84,85].
To illustrate, nationally based labour unions have
little influence when the economies of nations are
increasingly globalized. Labour demands in one na-
tion simply lead to companies moving elsewhere.
Neo-liberal political ideology serves the needs of
global corporations attempting to maximise profits
by weakening local legislation that assures livable
wages, workplace and environmental safety, and com-
munal structures that support health. Every public
service and communal structure is now seen as ripe
for privatisation. Social and economic conditions
have deteriorated for the mass of citizens as national
and more local governments either remain helpless to
resist the power of transnational corporations or be-
come complicit in these activities. Indeed, Laxer [86]
argues that “Everywhere in the world, multinational

Nonetheless, some nations have been able to resist
these trends. As just one example, the current National
Swedish Health Policy contains numerous action areas
to improve population health [89]. These activities are
the responsibility of the National Institute of Public
Health. The six main strategies outlined are as follows:
• Increase social capital in the Swedish society: This
includes efforts to decrease social inequality, coun-
teract discrimination of minority groups and pro-
mote local democracy.
• Promote better working conditions: The most im-
portant issues are to decrease long-term negative
stress, promote employees’ influence at work and
achieve more flexible working hours.
• Improve conditions for children and young people:
Improve social support for families with children.
Support and strengthen health promoting schools.
• Improve the physical environment: Co-ordinate the
work for sustainable environment with the struggle
for improved health.
• Promote healthy life styles. Solidarity with those
who are most vulnerable for lifestyle risks.
• Provide good structural conditions for public
health work at all societal levels: Support to and
co-ordination of research and education in public
health science.
In summary, the Swedish public health goals are
relatively few and their structure is not very sophis-
ticated compared with other countries. However,
there are two significant qualitative aspects of the

[93]. Caregiving in the US is seen to be in a crisis
situation and has strong implications for the qual-
ity of American women’s and their children’s lives
[94,95].
The Canadian Policy Research Network’s quality
of life initiative identified cross-cutting themes of
accessability; personal security/control; availability;
and equity/fairness. Women’s quality of life is in-
fluenced by the extent to which women have access
to the resources that are normally available to those
within a society [96]. The roles that society thrusts
upon Canadian women of child rearing and caregiving
makes access to these resources—such as childcare
and home care—especially important [97]. Equality
of opportunity is an empty phrase unless society—
and the governments it elects—are willing to make
76 D. Raphael, T. Bryant / Health Policy 68 (2004) 63–79
the policy decisions that support women in their lives
[98]. This is the meaning of equity and fairness.
In terms of contemporary analyses of women’s
quality of life, these policy changes in Canada—and
elsewhere—have been considered for their impact on
Canadian women’s quality of life [49,50,99]. These
kinds of policy-oriented quality of life analyses are
rarely done in relation to women’s health [100–102].
As such, these analyses should complement more
traditional approaches to considering women’s health
and well-being in Canada and other nations [103].
Acknowledgements
Portions of this work were supported financially

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