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Health inequalities related to informal

employment: gender and welfare state variations
in the Central American region

L Rodriguez-Loureiro, A Vives, J Martínez Franzoni & M Lopez-Ruiz

To cite this article: L Rodriguez-Loureiro, A Vives, J Martínez Franzoni & M Lopez-Ruiz (2019):
Health inequalities related to informal employment: gender and welfare state variations in the
Central American region, Critical Public Health, DOI: 10.1080/09581596.2018.1559923

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CRITICAL PUBLIC HEALTH
https://doi.org/10.1080/09581596.2018.1559923

RESEARCH PAPER

Health inequalities related to informal employment: gender and

welfare state variations in the Central American region
a,b,c
L Rodriguez-Loureiro , A Vivesd,e,f, J Martínez Franzonig and M Lopez-Ruiz a,b,c,h

a
CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; bCenter for Research in Occupational Health,
Pompeu Fabra University, Barcelona, Spain; cIMIM (Hospital del Mar Medical Institute), Barcelona, Spain; dHealth
Inequalities Research Group, Employment Conditions Knowledge Network (GREDS – EMCONET), Department of
Political and Social Sciences, Universitat Pompeu Fabra, Barcelona, Spain; eDepartamento de Salud Pública,
Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago de Chile, Chile; fCenter for Sustainable
Urban Development (CEDEUS), Conicyt/Fondap, Santiago de Chile, Chile; gInstitute of Social Research, University
of Costa Rica, San José, Costa Rica; hFacultad Latinoamericana de Ciencias Sociales (FLACSO), Salamanca, Spain

ABSTRACT ARTICLE HISTORY

People engaged in informal employment are not insured by any labour Received 18 April 2018
or social protection. Welfare state regimes could affect the relationship Accepted 13 December 2018
between informal employment and health. This study aimed to assess KEYWORDS
the relationship between informal employment and health status in the Informal employment;
non-agricultural working population in Central America, by welfare state welfare state regimes; health
regime and gender. Based on a sample of 8680 non-agricultural workers inequalities; occupational
(First Central American Survey of Working Conditions and Health), we health; Central America
conducted Poisson regression models with robust variance to obtain
prevalence ratios (PR) and their confidence intervals (95% CI) of poor
health status (self-perceived and mental health) of workers with informal
employment versus those with formal employment. Models were
adjusted by age and occupation and stratified by welfare state regime
and gender. We found that prevalence of poor health status was highest
among women and workers in informal employment. Positive associa-
tions between informal employment and poor self-perceived health
were found in familialist and highly familialist countries for both genders,
being highest in women in familialist countries (PR: 1.39, 95% CI:
1.08–1.80). Significant associations were only found for poor mental
health among women in familialist countries (PR: 1.24, 95% CI:
1.01–1.53) and men in highly familialist countries (PR: 1.34, 95% CI:
1.00–1.79). Our results suggest that universal social protection policies
could reduce the negative effects of informal employment on health
status for both women and men. Future development of labour and
social policies integrating a gender perspective might be crucial to
address health inequalities related to informal employment in Latin
American countries.

Introduction
Informal employment encompasses a set of jobs that are not regulated or insured by any labour
regulation or social protection. Such employment represents an important social determinant of health,
affecting over half of the non-agricultural working population in low- and middle-income countries
(CSDH, 2008). Notably, informal employment often entails hazardous work conditions, such as long

CONTACT L Rodriguez-Loureiro lrloureiro92@gmail.com

Supplementary material can be accessed here.
© 2019 Informa UK Limited, trading as Taylor & Francis Group
2 L. RODRIGUEZ-LOUREIRO ET AL.

working hours or unsafe workplaces (Sauma, 2003). Moreover, the lack of social protection can influence
other life dimensions, like access to health care services (Dachs et al., 2002). Informal employment is
reportedly associated with unfavourable health outcomes, including psychological, dermatological,
respiratory, and musculoskeletal disorders (Giatti, Barreto, & Comini, 2008; Ludermir & Lewis, 2003; Pick,
Ross, & Dada, 2002). Groups with an elevated risk of poverty, such as women and the elderly, are often
engaged in informal employment, implying that this may constitute their only gateway to the labour
market (Carr & Chen, 2004; Ruiz, Vives, Martínez-Solanas, Julià, & Benach, 2017). Studies conducted in
Brazil demonstrate that women engaged in informal employment are more likely to present poorer
mental health outcomes (Ludermir & Lewis, 2005; Santana, Loomis, Newman, & Harlow, 1997). When
compared with formal employment profiles, worse health outcomes associated with informal employ-
ment profiles are systematically found (Lopez-Ruiz, Artazcoz, Martínez, Rojas, & Benavides, 2015).
The Central American region has one of the highest proportions of informal employment world-
wide, constituting 62% of total non-agricultural employment in 2011 (ILO, 2011). However, the
percentages vary widely among countries, ranging from 36% in Costa Rica, to 66% in El Salvador
and 77% in Guatemala (ILO, 2013). These variations may be explained by contextual elements, such as
political power or economic policies. Cross-country comparative epidemiological studies have consis-
tently used welfare state regimes to understand how macro-level determinants influence population
health (Bambra, 2007). Welfare state regimes are important social determinants of health, which reflect
the social structure and power relations within a society and, thus, their formulation should include
a gender perspective (Borrell et al., 2014). Additionally, they are closely related to labour market
regulations and social policies (Artazcoz, 2014), and thus may mediate the effects of informal employ-
ment on health status. Literature suggests that negative work environments, precariousness, and
unemployment have a lower impact on health in regimes characterized by universalism and
comprehensive social provision of welfare (Bambra, Lunau, Van der Wel, Eikemo, & Dragano, 2014).
Such countries are often also successful in reducing gender inequalities, adopting policies that assume
a dual-earner family model, and addressing key social determinants of health, such as income and
unpaid care work. In contrast, the remaining regimes continue to show a strong gender-based division
of labour and weaker social provision, which reportedly contributes to worse health outcomes
(Artazcoz et al., 2014).
However, existing studies of health inequalities in relation to welfare state regimes are restricted to
high-income countries. The author Juliana Martínez Franzoni examined social welfare patterns in Latin
American countries from a gender perspective, analysing four dimensions: (1) labour commodification
(the labour market’s ability to provide decent employment); (2) welfare decommodification (the ability to
guarantee the population’s well-being through redistributive policies, without labour market
involvement); (3) welfare familization (the volume of unpaid care work within families); and (4) regime
performance (the effectiveness of public expenditure and resource allocation) (Martínez Franzoni, 2008a).
Through this research, three main regimes were identified in Latin America. In the state productivist regime
(Argentina and Chile), social protection is enacted with the aim of workforce development and main-
tenance, but welfare decommodification relies on individual purchasing power. The state protectionist
regime (Brazil, Costa Rica, Mexico, Panama, and Uruguay) entails the strongest state presence and higher
levels of welfare decommodification. Both the state productivist and protectionist regimes involve high
levels of labour commodification. The last regime comprises two subgroups, the familialist regime
(Colombia, Ecuador, El Salvador, Guatemala, Peru, Dominican Republic, and Venezuela) and the highly
familialist regime (Bolivia, Honduras, Nicaragua, and Paraguay). Both subgroups involve only marginal
state provision, with welfare largely provided through community and family arrangements. Social
policies are weak, labour markets are unable to absorb labour force, and households become production
units to counterbalance low provision from the state. Consequently, large families, migration, and
international remittances are common in these countries. Compared to the familialist regime, the highly
familialist regime has different social policy performance, with lower outreach, and greater roles of families
and international organizations (Martínez Franzoni, 2008b).
 CRITICAL PUBLIC HEALTH 3

To our knowledge, no prior studies address how welfare state regimes affect the relationship
between informal employment and health. Thus, our aims were to assess the relationship between
health status (self-perceived and mental health) and informal employment within the Central
American non-agricultural working population; and to examine whether patterns of association
differed in accordance with welfare state regimes and gender.

Methods
Sources of information
Our analysis examined information from the First Central American Survey of Working Conditions
and Health (Spanish acronym: I ECCTS), a cross-sectional study conducted within a representative
sample of 2004 individuals from each of the six Spanish-speaking countries in the region: Costa Rica,
El Salvador, Guatemala, Honduras, Nicaragua, and Panama. Interviewer-administered questionnaires
were conducted at the participants’ homes between July and December 2011 (Benavides et al., 2014).

Study population and sample

The survey obtained information from 12,024 workers, aged 18 years or older, from the six included
countries. Following the International Labour Organization (ILO) recommendations, we excluded
agricultural activities, as they must be studied separately due to their different characteristics and
to facilitate comparability of data regarding informal employment between countries (ILO, 2003).
Moreover, we also excluded persons occupied in the armed forces, since their labour arrangement
is completely different to the other occupations. Additionally, we only included employers with
fewer than five employees as a proxy of employers of the informal sector (ILO, 2003). Employers
with more than five employees (proxy of employers of the formal sector) were not included
because the limited number of cases did not allow comparability between both groups. After
applying the above-mentioned exclusion criteria, the study sample comprised 8680 non-
agricultural workers with ages ranging from 18 to 90 years.

Variables
The health outcomes assessed were poor self-perceived health and poor mental health. To collect data
regarding self-perceived health, the respondents were asked to describe how they perceived their
general health using a Likert scale with five potential responses. This variable was dichotomized as
good self-perceived health for answers of ‘very good’ or ‘good’, or poor self-perceived health for answers
of ‘fair’, ‘poor’, or ‘very poor’ (Idler & Benyamini, 1997). Self-perceived health is considered a powerful
predictor of mortality, health services utilization and functional ability in older ages (Jylhä, 2009).
Information regarding mental health was obtained using the 12-item General Health Questionnaire
(12-GQH). This variable was also dichotomized as good mental health (score <4) or poor mental health
(score ≥4), using a cut-off point recommended for Latin American countries (Goldberg et al., 1997).
The main independent variable was social security coverage (yes or no) as a proxy of informal
employment. Lack of social security is the most important dimension for measuring informal
employment and is the strongest predictor of poor health (Lopez-Ruiz et al., 2015; Ruiz, Tarafa
Orpinell, Jódar Martínez, & Benach, 2015). Descriptive analyses of the sample also included other
variables related to employment conditions, like employment situation (employee, self-employed,
or employer with <5 employees) and type of contract for employees (written, oral, or no contract);
economic activity (industry, construction, services, trade, or home services); workplace (building,
land, home, street, transportation, other house, or other); paid working hours per week (<30 hours,
30–48 hours, or >48 hours); and caring for children (yes or no) (view supplementary material).
4 L. RODRIGUEZ-LOUREIRO ET AL.

The covariables were age (18–30 years, 31–50 years, or ≥51 years) and occupation (manage-
ment, scientific technicians, or professionals; clerical workers and technical professionals; service
workers and vendors; or unskilled workers). All analyses were stratified by gender and welfare state
regime, i.e. state protectionist (Costa Rica and Panama), familialist (El Salvador and Guatemala), and
highly familialist (Honduras and Nicaragua).

Statistical analysis
Using Poisson regression models with robust variance, we obtained the prevalence ratio (PR) and
95% confidence interval (CI) for poor health (both self-perceived and mental health) in association
with informal employment (without social security coverage) compared to formal employment
(with social security coverage). Models were adjusted for age and occupation, and stratified by
welfare state regimes and gender.

Results
Description of the countries
A list of selected indicators of the Central American countries is presented in Tables 1 and 2. Table
1 presents indicators of labour commodification. It can be observed that, except from Nicaragua,
the proportion of employed men was much higher than the proportion of employed women in all
countries. However, women were more frequently engaged in informal employment than men.
Familialist countries had overall higher rates of non-agricultural informal employment. Among
people with informal employment in the familialist countries, contrary to the state protectionist
countries, women were engaged in informal employment more frequently as employers or self-
employed. In state protectionist countries, women in informal employment were employed more
frequently as domestic workers (23%), while in highly familialist countries they were employed
more frequently as family contributors. The highly familialist countries had the lowest gross
national income per capita.
Table 2 shows selected indicators of welfare decommodification, familization and regime
performance. Regarding welfare commodification, we can observe great differences between
countries in public social expenditure. The state protectionist countries showed considerable
gaps in the social public expenditure between countries. In the familialist countries, there were
differences within regimes regarding the expenditure allocation. For instance, in the familialist
countries, El Salvador invested more in public health compared to Guatemala, while in the highly
familialist countries, Honduras invested more in education than Nicaragua. Nicaragua and
Guatemala had the greatest average household size, surpassing Honduras and El Salvador, respec-
tively. Highly familialist countries had the greatest proportion of young mothers. Nevertheless,
Guatemala and Honduras had dramatic proportions of households with female headship (82% and
78%, respectively) and the highest dependency ratio (85% and 70%), much higher than their
regime counterpart. Highly familialist countries also had the highest proportions of population
in situation of poverty. Regarding health indicators, differences within regimes were observed, with
Panama and Guatemala performing worse than Costa Rica and El Salvador, respectively (i.e.
maternal mortality ratio was 23 in Panama compared to 11 in Costa Rica; and was 40 in
Guatemala compared to 17 in El Salvador). The lowest gender inequality index was found in
Costa Rica, and the lowest Gini index in Nicaragua.
Additionally, a detailed description of the studied sample is available as supplementary material
(view Supplementary Material).
Table 1. Selected indicators of labour commodification in Costa Rica, Panama, El Salvador, Guatemala, Honduras and Nicaragua, by gender.
State protectionist Familialist Highly familialist
Costa Rica Panama El Salvador Guatemala Honduras Nicaragua
Source Year Women Men Women Men Women Men Women Men Women Men Women Men
Labour commodification
Employment-to-population ratio (%) ILO 2011 38.5 67.2 43.5 75.8 45.0 74.6 37.6 81.5 37.9 78.5 62.9 83.8
% Non-agricultural informal employment (%) ILO 2011 37.2 29.9 37.9 39.6 71.7 59.7 80.2 70.5 75.3 71.0 78.7 70.7
Informal non-agricultural employment by status in employment (%) ILO 2011
Employers/self-employed 48.6 56.6 53.6 60.3 57.9 40.9 - - 57.2 41.9 55.7 45.5
Contributing family workers 4.6 1.8 4.7 1.6 8.7 5.3 - - 14.9 6.5 10.6 5.2
Employees 46.7 41.6 41.7 38.2 33.5 53.8 - - 27.9 51.6 33.7 49.2
In the formal sector 10.9 17.9 18.4 28.4 7.4 20.7 - - 13.0 23.0 6.9 16.0
In the informal sector 13.3 22.4 0.9 7.9 11.5 31.6 - - 6.4 27.6 9.1 29.9
Domestic workers employed by households 22.5 1.3 22.5 1.9 14.5 1.6 - - 8.6 1.0 17.8 3.3
GNI per capita (2011 PPP$) UNDP 2011 9370 16,500 11,425 20,696 5587 9061 3913 9393 2766 4885 2417 6089
GNI: Gross national income per capita; 2011 PPP$: Purchasing Power Parity $ from 2011; ILO: International Labour Organization; UNDP: United Nations Development Program.
GNI: Sum of value added by all resident producers (not including subsidies) plus net receipts of primary income from abroad; PPP considers price differences among countries;
employment-to-population ratio (%): proportion of the working-age population (>15 years old) that is employed, either as an employee of self-employed; % Non-agricultural
informal employment as a total of the total employment.
CRITICAL PUBLIC HEALTH
5
 6

Table 2. Selected indicators of welfare commodification, welfare familization and regime performance in Costa Rica, Panama, El Salvador, Guatemala, Honduras and Nicaragua.
State protectionist Familialist Highly familialist
Source Year Costa Rica Panama El Salvador Guatemala Honduras Nicaragua
Welfare decommodification
Total public social expenditure CEPAL 2009–2010
% GDP 22.5 9.8 13.5 8.1 11.8 9.8
US$ per capita 1718 759 463 232 243 146
Public education expenditure CEPAL 2009–2010
% GDP 7.2 3.4 3.8 3.3 7.6 4.4
US$ per capita 549 262 132 96 157 66
Public health expenditure CEPAL 2009–2010
% GDP 6.5 2.1 4.2 1.3 3.4 2.9
L. RODRIGUEZ-LOUREIRO ET AL.

US$ per capita 500 166 143 39 70 44

Welfare familization
Average household size UN Latest available* 3.5 3.7 4.1 4.8 3.9 5.2
% Female headship UN Latest available* 35.0 38.0 44.0 82.0 78.0 52.0
% Young mothers (15–19 years old) CEPAL Latest availableϕ 13.0 15.0 15.0 16.0 18.0 20.0
% Population <14 years old CEPAL 2010 24.9 29.3 32.0 41.4 36.8 34.5
% Population >65 years old CEPAL 2010 6.5 6.8 6.9 4.4 4.3 4.5
Dependency ratio CEPAL 2010 45.8 56.4 63.7 84.7 69.8 63.9
Regime performance
% Population in situation of poverty CEPAL 2005–2010 18.9 25.8 47.9 54.8 68.9 61.9
Life expectancy at birth WHO 2008–2010 79 77 72 69 69 74
Infant mortality rate WHO 2009 10 16 15 33 25 22
Mortality rate <5 years old WHO 2009 11 23 17 40 30 26
Maternal mortality ratio WHO 2008 44 71 110 110 110 100
Hospital beds per 10,000 inhabitants WHO 2000–2010 99 89 84 51 67 74
Doctors per 10,000 inhabitants WHO 2000–2010 13.2 15.0 16.0 NA 5.7 3.7
% Drinking water coverage in urban areas PAHO 2009 99.0 99.0 98.0 90.0 95.5 90.0
% Sanitation coverage in urban areas PAHO 2009 96.0 98.0 99.0 77.0 78.0 56.0
Gender inequality index (GII) UNDP 2011 0.317 0.522 0.440 0.525 0.510 0.477
Gini index NIS 2010 0.508 0.519 0.457 0.590 0.540 0.350
UN: United Nations; CEPAL: Economic Commission for Latin America and the Caribbean (Spanish Acronym); WHO: World Health Organization; NA: not available; PAHO: Pan American Health
Organization; NIS: National Institute of Statistics of each country.
*Nicaragua 2005; El Salvador 2007; Panama 2010; Honduras and Costa Rica 2011; Guatemala 2014; ϕCosta Rica 2000; Honduras 2001; Guatemala 2002; Nicaragua 2005; El Salvador
2007; Panama 2010.
% Female headship: % Lone mothers with children under 15 years old; dependency ratio: ratio between the number of persons younger than 15 and older than 65 compared to the
total population aged between 15 and 65; infant mortality rate: death among children under the age of 1, per 1000 live births; mortality rate <5 years old: death among children
under the age of 5, per 1000 live births; maternal mortality ratio: number of female deaths per 100,000 live births by causes aggravated by or related to problems during
pregnancy; gender inequality index (GII): measures gender inequality through three dimensions (reproductive health, empowerment and economic status) – thus, the higher the
index, the greater the gender gap.
 CRITICAL PUBLIC HEALTH 7

Prevalence of poor health

Data in Table 3 clearly show that the prevalence of poor self-perceived health was lowest in the
state protectionist countries, higher in the familialist countries and highest in the highly familialist
countries, regardless of gender and social security coverage. Moreover, in all regimes the preva-
lence of poor self-perceived health was higher among women compared to men, and higher
among workers with informal employment compared to those with formal employment. Among
people with informal employment, the rates of poor self-perceived health in the state protectionist,
familialist and highly familialist regimes, respectively, were 21%, 34% and 46% in women, and 18%,
32% and 35% in men. Prevalence of poor mental health did not follow the same pattern in
accordance with welfare state regimes or gender; in fact, prevalence of poor mental health was
highest in the familialist regime for both genders.

Social security coverage and health

Table 3 presents the results of the regression models. In the state protectionist countries,
informal employment was not associated with poor self-perceived health or poor mental health.
Among women in familialist countries, informal employment was significantly associated with
both poor self-perceived health (adjusted PR: 1.39, 95% CI: 1.08–1.80) and poor mental health
(aPR: 1.24, 95% CI: 1.01–1.53). Among women in highly familialist countries, we found a positive
but non-significant association between informal employment and poor self-perceived health.
Among men, informal employment was significantly associated with poor self-perceived health in
familialist and highly familialist countries and was significantly associated with poor mental
health in highly familialist countries (aPR: 1.34, 95% CI: 1.00–1.79).

Discussion
To our knowledge, this is the first study to examine the relationship between non-agricultural
informal employment and health status, with comparisons between genders and different welfare
state regimes. Here, we report four main findings. First, the rate of poor self-perceived health was
clearly lowest in state protectionist regimes, higher in familialist regimes and highest in highly
familialist regimes. Second, in all regimes, we found poorer self-perceived health and mental health
status among women and workers with informal employment. Third, in familialist and highly
familialist countries, informal employment was positively and significantly associated with poorer
self-perceived health in both genders. Fourth, informal employment was associated with a higher
prevalence of poorer mental health only among women in familialist countries and men in highly
familialist countries.

State protectionist countries

Interestingly, our findings in state protectionist countries did not show that informal employment
was associated with poorer health status among men or women. We hypothesize that the lower
prevalence of poor health and the narrower health differences within the state protectionist
regimes may result from the relatively stronger role of the state, which provides social benefits
regardless of employment formality status.
While European and Central American regions obviously differ in wealth and other socio-cultural
and political factors, several studies in high-income countries show that Scandinavian countries,
which are characterized by a strongly interventionist state and universalism, have an overall better
health status than other European countries (Chung & Muntaner, 2007). Analyses of employment
conditions indicate that the Scandinavian regime apparently counters the negative health effects
of stressful work environments, poor work–life balance, job insecurity, precariousness or
 8

Table 3. Number (n) and prevalence (%) of reported poor health status (self-perceived health and mental health) according to social security coverage, and association (PR) of not having social
security coverage and poor health status in non-agricultural working population, by gender and welfare state regimes. Central America, 2011.
State protectionist Familialist Highly Familialist
L. RODRIGUEZ-LOUREIRO ET AL.

n % PR 95% CI aPR 95% CI N % PR 95% CI aPR 95% CI n % PR 95% CI aPR 95% CI

Women
Poor self-perceived health
Social security coverage 103 19.4 1.00 1.00 67 19.4 1.00 1.00 160 37.8 1.00 1.00
No social security coverage 62 21.0 1.08 (0.82; 1.42) 1.02 (0.77; 1.36) 473 33.8 1.74 (1.39; 2.17)*** 1.39 (1.08; 1.80)* 562 45.8 1.23 (1.06; 1.43)** 1.10 (0.92; 1.32)
Poor mental health
Social security coverage 89 17.9 1.00 1.00 94 31.0 1.00 1.00 113 28.0 1.00 1.00
No social security coverage 59 20.9 1.19 (0.89; 1.58) 1.10 (0.82; 1.49) 485 37.8 1.26 (1.05; 1.51)* 1.24 (1.01; 1.53)* 329 28.0 1.00 (0.82; 1.21) 0.90 (0.71; 1.14)
Men
Poor self-perceived health
Social security coverage 104 14.5 1.00 102 22.0 1.00 1.00 72 24.4 1.00 1.00
No Social Security Coverage 69 18.2 1.26 (0.97; 1.65) 1.77 (0.91; 1.53) 506 32.3 1.47 (1.23; 1.77)*** 1.28 (1.06; 1.55)* 317 34.5 1.42 (1.16; 1.74)*** 1.31 (1.06; 1.62)*
Poor mental health
Social security coverage 100 14.4 1.00 1.00 159 36.8 1.00 1.00 46 16.2 1.00 1.00
No social security coverage 56 15.7 1.22 (0.94; 1.59) 1.26 (0.96; 1.65) 519 35.9 1.02 (0.89; 1.17) 0.95 (0.82; 1.10) 190 21.5 1.31 (1.00; 1.73)† 1.34 (1.00; 1.79)*
aPR: Prevalence ratios adjusted by age and occupation
†
* p value < 0.05; ** p value < 0.01; *** p value < 0.001; p value < 0.06
 CRITICAL PUBLIC HEALTH 9

unemployment (Bambra et al., 2014; Dragano, Siegrist, & Wahrendorf, 2011; Lunau, Bambra,
Eikemo, Van Der Wel, & Dragano, 2014). A likely explanation is that these states reduce the
consequences of an impaired labour market, and thus reduce health inequalities, via their uni-
versalist policies of social protection and income redistribution (Benach et al., 2014). This supports
our main hypothesis explaining our present results, particularly since previous studies of the
Central American working population report that the great majority of persons engaged in informal
employment have precarious employment (Lopez-Ruiz et al., 2015).
The social security system in Costa Rica, which sustains health insurance and pensions, is based
on a mixed structure with a combination of contributory protection for directly insured workers
and their economically dependent relatives, and non-contributory protection for non-insured
populations and their relatives (Román Vega, 2013). Between 2003 and 2008 in Costa Rica, the self-
employed population that contributed to the pension system increased from 21% to 65%, and the
health insurance coverage system increased from 38% to 82% (Román Vega, 2013). In contrast,
Panama has no mixed system, but the state aims to reduce poverty through non-contributory
mechanisms focused on the various needs and risks existing at each stage of life (Rodríguez Mojica,
2013). This enables the guarantee of social transfers as individual rights, rather than as family
benefits, which are normally based on traditional family models that reinforce the role of women as
caregivers (Torada Máñez, Lexartza Artza, & Martínez Franzoni, 2012).
In the future, it would be interesting to investigate other Latin American countries, and to
compare our present findings with similar countries in the region.

Familialist and highly familialist countries

As expected, familialist and highly familialist countries showed higher prevalence of poor health
outcomes. In these countries, informal employment was associated with poor self-perceived
health among both genders. These results are consistent with previous reports of worse health
status among workers with informal employment compared to those with formal employment
(Giatti et al., 2008; Loría Bolaños, Partanen, Berrocal, Álvarez, & Córdoba, 2005; Pick et al., 2002).
A possible interpretation is the lack of access to social benefits, such as pensions and health
insurance. Our present study showed that over three-quarters of the economically active popula-
tion in familialist and highly familialist countries lacked social security coverage, which is in
agreement with official data regarding informal employment.
Importantly, the studied familialist and highly familialist countries have dual insurance systems,
operated by both the Ministry of Health and the Institute of Social Security (Sánchez-Ancochea &
Martínez Franzoni, 2015). The Ministry of Health aims to insure the whole population, but is largely
focused on highly deprived populations and has serious deficiencies in service provision. The Institute of
Social Security offers services of better quality, but only serves workers with formal employment. This
structure is highly inefficient and depletes public expenditures, necessitating increased private health
expenditure in all countries, except El Salvador (Sánchez-Ancochea & Martínez Franzoni, 2015). Informal
employment, poverty and health care system organization are considered barriers to health care system
access (Martínez Franzoni, 2010). The greater risk of shouldering catastrophic health care expenditures
sustains the devastating ‘snowball effect’ of informal employment, which further impacts other life
dimensions (e.g. housing quality) and affects entire families and communities, likely contributing to the
worse self-perceived health among these workers (Ruiz et al., 2017).
In fact, this might be the situation in the great majority of the Latin American countries, where
structural adjustment interventions fostered by intergovernmental organizations (such as the
World Bank or the International Monetary Fund) have favoured the development of targeted social
assistance policies. Therefore, social protection policy in these countries consists in addressing
population in situation of poverty, rather than in improving and extending the coverage of social
protection, aimed to correct market failures (Stubbs & Kentikelenis, 2018). Hence, formal and
informal workforce have access to different benefits that differ enormously in quality and maintain
10 L. RODRIGUEZ-LOUREIRO ET AL.

intergenerational poverty situations. Lower levels of welfare decommodification and a greater

segmentation of social protection policies might produce important health inequalities. More
than 30 years after the implementation of the neoliberal policies in the 1980s, introducing the
labour market deregulation, informal employment still accounts for almost two-thirds of the
working population in the whole region. A greater intervention of the states in order to provide
decent employment and achieve universal social protection might be a necessary path to follow in
the region in order to diminish inequalities and improve health outcomes.

Welfare state regimes, gender and health

The greater difference between the familialist and highly familialist countries relates to the intersection
with gender. Informal employment was significantly associated with poor mental health only among
women in familialist countries, and among men in highly familialist countries. Prior investigations have
also demonstrated an association between informal employment and poor mental health only in
women (Lopez-Ruiz, Benavides, Vives, & Artazcoz, 2017; Ludermir & Lewis, 2005; Santana et al., 1997).
However, among women in highly familialist countries, informal employment was not associated with
poor mental health.
A possible explanation that likely contributes to the similar mental health status between
women with formal versus informal employment in highly familialist countries is that the social
security system is less effective for women compared to men, and thus women with formal
employment may still experience a precarious situation. This is likely attributed to specific char-
acteristics of female labour insertion, including lower wages and more interruptions to their
working life due to unemployment, maternity and care responsibilities. These factors may prevent
women from making adequate contributions to receive social benefits, such as retirement or
disability pensions (Ulshoefer, 1994). Our present results suggested that women in highly familialist
countries experienced the same burden of unpaid care work regardless of their social security
coverage. Unpaid care work is reportedly the main pillar of vulnerability and poverty situations
among women, but not among men (Torada Máñez et al., 2012). The role of the state is even more
marginal in highly familialist countries than in familialist countries, which may result in a situation
where the social provision of care relies entirely on families. In fact, this is a key aspect of highly
familialist countries.
Among men in highly familialist countries, we found that informal employment was significantly
associated with poor mental health. This result may be explained by the inefficient labour
commodification and the lack of skilled labour. One-third of men in our sample without social
security coverage in highly familialist countries had a high education level (university degree and
secondary education), but only 17% of these men worked in non-manual occupations (results not
shown). The skilled workforce is therefore employed in jobs with lower wages, no expectation of
promotion and no social protection. This status incongruence is a work-related psychosocial hazard
and may be a cause of job strain. Workers with incongruent work status report overall poorer
psychosocial well-being (Burke, 2000).
To better understand gender-related health inequalities related to informal employment in
different welfare state regimes, future analyses must include gender-sensitive variables, such as
caring for children or hours of unpaid care work.

Limitations
Our study had several limitations. The presently used welfare regime typology was developed
based on data from the period of 1990–2000. During those years, the global economy underwent
substantial changes, which may have resulted in changes in redistributive and social policies before
the survey was conducted in 2011, influencing the validity of the classification. Nonetheless,
separate analysis by country revealed similar characteristics within regimes, and the typology
 CRITICAL PUBLIC HEALTH 11

dissemination was performed only three years before the survey was conducted, supporting the
legitimacy of our results. However, this typology should be reassessed in future studies.
In addition, the use of self-perceived health deserves further consideration. It has been shown to
be a good independent indicator of mortality. However, the mechanisms involved in how people
process and evaluate their own health status and which factors influence their answers still remain
unclear (Jylhä, 2009). Moreover, relative differences among population groups have been reported,
meaning that socioeconomic and cultural differences provide different frameworks of evaluation
(Lang & Delpierre, 2009). Nevertheless, self-perceived health has been recommended for compar-
isons among different populations. It is comprehensive and non-specific, capturing not only the
mere absence of disease, but also other dimensions of health not well captured by other health
indicators. Thus, interpretations based on outcomes of this indicator should be done carefully,
bearing in mind that it is a measure of a determined population’s perception of health rather than
an approximation to objective indicators of health (Huisman & Deeg, 2010).
There are also possible biases inherent to survey-based cross-sectional studies. Although our
results are consistent with data in the previous literature, we cannot dismiss the possibility that our
study may present reverse causation. However, even if some workers have informal employment
because of an already existing illness or condition, this is likely only true for a small part of the
working population, since over 60% is engaged in informal employment (ILO, 2011).

Conclusions
Our results suggest that the relationship between health inequalities and informal employment
depends on the welfare regime, i.e. the degree of social protection. State protectionist regimes
enact social policies that strongly favour universalism, which apparently reduces health inequalities
related to informal employment among both women and men. On the other hand, familialist and
highly familialist countries provide lower levels of social protection from the state, and security
coverage appeared to have a differential effect on health status within these regimes. We also
observed gender-related health inequalities under the familialist and highly familialist regimes,
which may reflect how gender roles are shaped by the moderating role of welfare states. Our paper
provides evidence of the effectiveness of the implementation of the measures recommended by
the WHO Commission on the Social Determinants of Health to reduce health inequalities (CSDH,
2008). Creating extended social protection schemes covering paid workers engaged in informal
employment is crucial in order to improve the living conditions of these populations, having
a greater impact in low- and middle-income countries, where informal employment is dramatically
high. Based on our analysis, we recommend that future development of social protection policies
should advance towards universalism, integrating a gender perspective.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit
sectors.

ORCID
L Rodriguez-Loureiro http://orcid.org/0000-0003-0092-3748
M Lopez-Ruiz http://orcid.org/0000-0003-3453-0408
12 L. RODRIGUEZ-LOUREIRO ET AL.

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