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Background
It is now widely acknowledged that welfare states are important determinants of health as they mediate the social determinants of health. 1 Welfare state provision varies extensively, but typologies have been put forward to categorise them into distinctive types-welfare state regimes . 1-3 Welfare state regimes have increasingly been used within social epidemiology to analyse cross-national differences in population health. 4-8 These studies have almost invariably concluded that population health is enhanced by the relatively generous and universal welfare provision of the Social Democratic Scandinavian countries, especially when contrasted to the Anglo-Saxon welfare states. 4-8 The different types of welfare state and their constituent countries are described in box 1 . However, in contrast to their comparatively strong performance in terms of overall health, data from most, but not all, of the recent comparative studies of health inequalities in the general population suggest that the Scandinavian welfare states do not have the smallest health inequalities. 9-12 For example, Mackenbach et al 9 's Europe wide study of inequalities in mortality found 'no evidence for systematically smaller inequalities in health in countries in northern Europe (Scandinavia)'. Indeed, relative inequalities in mortality were smaller in the Southern (Italy, Spain, Portugal) and Bismarckian (Netherlands, Belgium, Germany, France) countries. 9 Data are provided from three other example studies of health inequalities in Europe in table 1 . 10 12 Given the higher levels of social expenditure in the Scandinavian welfare states, the smaller income inequalities, and the commitment to equality underpinning the Social Democratic welfare model in Scandinavia, it has long been something of a 'puzzle' in public health as to why the Scandinavian countries do not have the smallest health inequalities. 13-15 This essay draws upon the theories of health inequalities to scrutinise this puzzle. 16-20
Box 1 Welfare state regimes 1
Liberal/residual
In the welfare states of the liberal regime (UK, USA, Ireland, Canada, Australia), state provision of welfare is minimal; social transfers are modest and often attract strict entitlement criteria; and recipients are usually means-tested and stigmatised. In this model, the dominance of the market is encouraged both passively, by guaranteeing only a minimum, and actively, by subsidising private welfare schemes. The liberal welfare state regime thereby minimises the decommodification effects of the welfare...