Postneoliberal Public Health Care Reforms: Neoliberalism, Social Medicine, and Persistent Health Inequalities in Latin America

"To do so in a patient-centred way is not particularly lucrative": The effects of neoliberal health care on PrEP implementation and delivery

BACKGROUND

HIV pre-exposure prophylaxis (PrEP) is a highly effective biomedical intervention used by HIV-negative people to prevent HIV acquisition. Despite increased use of PrEP worldwide, several barriers to PrEP implementation have resulted in insufficient uptake, inadequate adherence, and frequent discontinuation. Our objective was to interrogate the social, political, and economic conditions shaping PrEP implementation and delivery among gay, bisexual, queer and other men who have sex with men (GBQM) in Ontario, Canada.

METHODS

Six focus groups and three interviews with 20 stakeholders in Ontario (e.g., healthcare professionals, clinicians, community-based organization staff, and government staff) were conducted between July and October 2021. Participants were asked about the personal, workplace, and structural factors shaping PrEP delivery strategies for GBQM. Transcripts were analyzed using reflexive thematic analysis informed by the political economy of PrEP and employed a critique of neoliberalism.

RESULTS

Participants critiqued the problematic arrangements of the current healthcare system in Canada. Neoliberal governmentality and policies have resulted in inequitable PrEP care by establishing funding structures prioritizing profit and requiring patients and providers to function as individual entrepreneurs. Consequently, healthcare disparities are compounded for marginalized peoples who lack the resources and capacity to navigate existing healthcare systems. Participants identified several pathways to improve the implementation of PrEP, including greater institutional and governmental supports for PrEP and healthcare, leveraging communities and collaboration, and moving beyond risk-based health frameworks.

CONCLUSION

Socio-political-economic changes reflecting post-neoliberal principles are needed to overcome existing barriers to PrEP care, and sexual and reproductive healthcare more broadly.

A critique of the policy discourse on primary health care under the Aardram mission of Kerala

In 2017, the State of Kerala in India, launched the 'Aardram' mission for health. One of the aims of the mission was to enhance the primary health care (PHC) provisioning in the state through the family health centre (FHC) initiative. This was envisaged through a comprehensive PHC approach that prioritized preventive, promotive, curative, rehabilitative and palliative services, and social determinants of health. Given this backdrop, the study aimed to examine the renewed policy commitment towards comprehensive PHC and the extent to which it remains true to the globally accepted ideals of PHC. This was undertaken using a critical discourse analysis (CDA) of the policy discourse on PHC. This included examining the policy documents related to FHC and Aardram as well as the narratives of policy-level actors on PHC and innovations for them. Through CDA we examined the discursive representation of PHC and innovations for improving it at the level of local governments in the state. Though the mission envisaged a shift from the influence of market-driven ideas of health, analysis of the current policy discourse on PHC suggested otherwise. The discourse continues to carry a curative care bias within its ideas of PHC. The disproportionate emphasis on strategies for early detection, treatment and infrastructural improvements meant limited space for preventive, protective and promotive dimensions, thus digressing from the gatekeeping role of PHC. The reduced emphasis on preventive and promotive dimensions and depoliticization of social determinants of health within the PHC discourse indicates that, in the long run, the mission puts at risk its stated goals of social justice and health equity envisioned in the FHC initiative.

Analyzing the effect of health reforms on the efficiency of Ecuadorian public hospitals

This study aims to assess whether Ecuadorian health reforms carried out since 2008 have affected the efficiency performance of public hospitals in the country. We contribute to the literature by shedding new light on the effects on public healthcare efficiency for developing countries when policies move toward health equity and universal coverage. We follow a two-stage approach, wherein the first stage we make use of factor and cluster analysis to obtain three clusters of public hospitals based on their technological endowment; we exploit Data Envelopment Analysis for panel data in the second stage to estimate robust efficiency measures over time. Our innovative empirical strategy considers the heterogeneity of healthcare institutions in the analysis of their efficiency performance. The results show a significant decrease in the average efficiency of low and intermediate technology hospitals after the new constitution was adopted in 2008. The decline in efficiency coincides with the two reforms of 2010 and 2011 that brought on higher social security coverage.

From preventive eugenics to slippery eugenics: Population control and contemporary sterilisations targeted to indigenous peoples in Mexico

Eugenic ideas in Mexico were popularised after the Mexican Revolution (1910-1920) as a way of 'modernising' and 'civilising' the nation. As a result, eugenic ideas were able to linger and be maintained through different departments, institutions, and individuals from all disciplines. After eugenics was considered a pseudoscience, its practices and ideas continued through population control measures that targeted indigenous populations for sterilisation, a trend that still prevails. The purpose of this article is to explore the legacies of eugenics in current sterilizations procedures mostly targeted at indigenous communities in Mexico. I offer the term 'slippery eugenics' to account for the legacies of eugenics in Mexico which, in this specific case, resurface in the systematic forced and coerced sterilisation procedures targeted at indigenous communities.

Beyond political will: unpacking the drivers of (non) health reforms in sub-Saharan Africa

BACKGROUND

Lack of political will is frequently invoked as a rhetorical tool to explain the gap between commitment and action for health reforms in sub-Saharan Africa (SSA). However, the concept remains vague, ill defined and risks being used as a scapegoat to actually examine what shapes reforms in a given context, and what to do about it. This study sought to go beyond the rhetoric of political will to gain a deeper understanding of what drives health reforms in SSA.

METHODS

We conducted a scoping review using Arksey and O'Malley (2005) to understand the drivers of health reforms in SSA.

RESULTS

We reviewed 84 published papers that focused on the politics of health reforms in SSA covering the period 2002-2022. Out of these, more than half of the papers covered aspects related to health financing, HIV/AIDS and maternal health with a dominant focus on policy agenda setting and formulation. We found that health reforms in SSA are influenced by six; often interconnected drivers namely (1) the distribution of costs and benefits arising from policy reforms; (2) the form and expression of power among actors; (3) the desire to win or stay in government; (4) political ideologies; (5) elite interests and (6) policy diffusion.

CONCLUSION

Political will is relevant but insufficient to drive health reform in SSA. A framework of differential reform politics that considers how the power and beliefs of policy elites is likely to shape policies within a given context can be useful in guiding future policy analysis.

Translating economic evaluations into financing strategies for implementing evidence-based practices

BACKGROUND

Implementation researchers are increasingly using economic evaluation to explore the benefits produced by implementing evidence-based practices (EBPs) in healthcare settings. However, the findings of typical economic evaluations (e.g., based on clinical trials) are rarely sufficient to inform decisions about how health service organizations and policymakers should finance investments in EBPs. This paper describes how economic evaluations can be translated into policy and practice through complementary research on financing strategies that support EBP implementation and sustainment.

MAIN BODY

We provide an overview of EBP implementation financing, which outlines key financing and health service delivery system stakeholders and their points of decision-making. We then illustrate how economic evaluations have informed decisions about EBP implementation and sustainment with three case examples: (1) use of Pay-for-Success financing to implement multisystemic therapy in underserved areas of Colorado, USA, based in part on the strength of evidence from economic evaluations; (2) an alternative payment model to sustain evidence-based oncology care, developed by the US Centers for Medicare and Medicaid Services through simulations of economic impact; and (3) use of a recently developed fiscal mapping process to collaboratively match financing strategies and needs during a pragmatic clinical trial for a newly adapted family support intervention for opioid use disorder.

CONCLUSIONS

EBP financing strategies can help overcome cost-related barriers to implementing and sustaining EBPs by translating economic evaluation results into policy and practice. We present a research agenda to advance understanding of financing strategies in five key areas raised by our case examples: (1) maximize the relevance of economic evaluations for real-world EBP implementation; (2) study ongoing changes in financing systems as part of economic evaluations; (3) identify the conditions under which a given financing strategy is most beneficial; (4) explore the use and impacts of financing strategies across pre-implementation, active implementation, and sustainment phases; and (5) advance research efforts through strong partnerships with stakeholder groups while attending to issues of power imbalance and transparency. Attention to these research areas will develop a robust body of scholarship around EBP financing strategies and, ultimately, enable greater public health impacts of EBPs.

Needs and resources of people with type 2 diabetes in peri-urban Cochabamba, Bolivia: a people-centred perspective

BACKGROUND

The rising prevalence of type 2 diabetes results in a worldwide public healthcare crisis, especially in low- and middle-income countries (LMICs) with unprepared and overburdened health systems mainly focused on infectious diseases and maternal and child health. Studies regarding type 2 diabetes in LMICs describe specific interventions ignoring a comprehensive analysis of the local factors people see influential to their health. This study aims to meet this research gap by exploring what people with type 2 diabetes in Bolivia need to maintain or improve their health, how important they perceive those identified needs and to what extent these needs are met.

METHODS

From March until May 2019, 33 persons with type 2 diabetes from three periurban municipalities of the department of Cochabamba participated in this study. The concept mapping methodology by Trochim, a highly structured qualitative brainstorming method, was used to generate and structure a broad range of perspectives on what the participants considered instrumental for their health.

RESULTS

The brainstorming resulted in 156 original statements condensed into 72 conceptually different needs and resources, structured under nine conceptual clusters and four action domains. These domains illustrated with vital needs were: (1) self-management with use of plants and the possibility to measure sugar levels periodically; (2) healthcare providers with the need to trust and receive a uniform diagnosis and treatment plan; (3) health system with opportune access to care and (4) community with community participation in health and safety, including removal of stray dogs.

CONCLUSIONS

This study identifies mostly contextual factors like low literacy levels, linguistic problems in care, the need to articulate people's worldview including traditional use of natural remedies with the Bolivian health system and the lack of expertise on type 2 diabetes by primary health care providers. Understanding the needs and structuring them in different areas wherein action is required serves as a foundation for the planning and evaluation of an integrated people centred care program for people with type 2 diabetes. This participative method serves as a tool to implement the often theoretical concept of integrated people centred health care in health policy and program development.

Invisible and Insecure in Rural America: Cultivating Dignity in Local Food Security Initiatives

The United States’ neoliberal approach to governance promotes structural inequalities that shape individuals’ sense of dignity. We employ qualitative in-depth interviews and ethnographic field study to examine dignity construction via daily experiences with food access and foodways. Situating our study within a rural Oklahoma community with high food insecurity rates, we ask: How does structural inequality impact individuals’ daily experiences with dignity construction? How is a sense of dignity influenced by daily experiences with food access and foodways within the context of community-based food initiatives? We address structural inequality and the resulting social hierarchy of food security, focusing on three overlapping social arenas—relational, individual, and institutional. Relational interactions in food access spaces promote dignity when interactions are characterized by symmetrical social encounters. Dignity in the individual arena centers on foodways, cultural or familial traditions, and role-taking as a food provider. In the institutional arena, dignity is influenced by structures and operational approaches. Our research contributes to literatures informing policies and strategies employed by community-led, rights-based food aid systems in advanced capitalist nations. Efforts prioritize and promote human dignity, despite neoliberal, advanced capitalist governments’ failure to address structural inequalities as a root cause of food insecurity.

A framework for explaining the role of values in health policy decision-making in Latin America: a critical interpretive synthesis

BACKGROUND

Although values underpin the goals pursued in health systems, including how health systems benefit the population, it is often not clear how values are incorporated into policy decision-making about health systems. The challenge is to encompass social/citizen values, health system goals, and financial realities and to incorporate them into the policy-making process. This is a challenge for all health systems and of particular importance for Latin American (LA) countries. Our objective was to understand how and under what conditions societal values inform decisions about health system financing in LA countries.

METHODS

A critical interpretive synthesis approach was utilised for this work. We searched 17 databases in December 2016 to identify articles written in English, Spanish or Portuguese that focus on values that inform the policy process for health system financing in LA countries at the macro and meso levels. Two reviewers independently screened records and assessed them for inclusion. One researcher conceptually mapped the included articles, created structured summaries of key findings from each, and selected a purposive sample of articles to thematically synthesise the results across the domains of agenda-setting/prioritisation, policy development and implementation.

RESULTS

We identified 5925 references, included 199 papers, and synthesised 68 papers. We identified 116 values and developed a framework to explain how values have been used to inform policy decisions about financing in LA countries. This framework has four categories - (1) goal-related values (i.e. guiding principles of the health system); (2) technical values (those incorporated into the instruments adopted by policy-makers to ensure a sustainable and efficient health system); (3) governance values (those applied in the policy process to ensure a transparent and accountable process of decision-making); and (4) situational values (a broad category of values that represent competing strategies to make decisions in the health systems, their influence varying according to the four factors).

CONCLUSIONS

It is an effort to consolidate and explain how different social values are considered and how they support policy decision-making about health system financing. This can help policy-makers to explicitly incorporate values into the policy process and understand how values are supporting the achievement of policy goals in health system financing.

TRIAL REGISTRATION

The protocol was registered with PROSPERO, ID=CRD42017057049 .

A debate over the link between Salvador Allende, Max Westenhöfer, and Rudolf Virchow: contributions to the history of social medicine in Chile and internationally

In the history of Latin American social medicine, numerous works have presented a harmonious link between Rudolf Virchow, Max Westenhöfer, and Salvador Allende, which establishes the origin of ideas of Latin American social medicine in a prestigious European source, represented by Virchow. A key to that story is that Allende was a student of Westenhöfer, a disciple of Virchow who lived in Chile three times (1908-1911, 1929-1932, and 1948-1957). Based on primary sources and contextual data, this article problematizes the relationship between Allende and Westenhöfer, and questions the influence of Virchow in Chilean social medicine.

The implications of Neoliberalism on African economies, health outcomes and wellbeing: a conceptual argument

Not only did the 2015 Ebola Outbreak in West African countries leave the whole of the sub-Saharan region with a sense of uncertainty and panic, it was also a stress test to Africa's and the wider world's capacity to respond to and mitigate humanitarian crises in the twenty-first century. One plausible conclusion drawn from the spread and impact of the pandemic is that the pace of health infrastructure development in sub-Saharan Africa has lagged behind its population and economic growth posted in the last decade (2003-2013). An exhaustive audit of health infrastructure and remedial measures is, therefore, critical in navigating Africa to sustainable growth and development in the next decade. For the next charge of growth and development to not only be robust but also more sustainable and resilient to major emergencies (such as Ebola), there is a need to edify the state of healthcare across the continent to ensure the optimisation of the human resource and to redress the gap aggravated by loss of human-hours due to poor health.

Social inequities and contemporary struggles for collective health in Latin America

As part of a planned series from Global Public Health aimed at exploring both the epistemological and political differences in diverse public health approaches across different geographic and cultural regions, this special issue assembles papers that consider the legacy of the Latin American Social Medicine and Collective Health (LASM-CH) movements, as well as additional examples of contemporary social action for collective health from the region. In this introduction, we review the historical roots of LASM-CH and the movement's primary contributions to research, activism and policy-making over the latter-half of the twentieth century. We also introduce the special issue's contents. Spanning 19 papers, the articles in this special issue offer critical insight into efforts to create more equitable, participatory health regimes in the context of significant social and political change that many of the countries in the region have experienced in recent decades. We argue that as global health worldwide has been pushed to adopt increasingly conservative agendas, recognition of and attention to the legacies of Latin America's epistemological innovations and social movement action in the domain of public health are especially warranted.

Work-related illness, work-related accidents, and lack of social security in Colombia

The impacts of neoliberal or market-based social security reforms in health have been extensively studied. How such reforms transformed employment-related insurance and entitlements, however, has received significantly less attention. This study aims to understand how the employment insurance system operates in Colombia and to assess how the experience of workers seeking social security entitlements relates to the system's structure. We conducted an ethnographic study of the Colombian Occupational Risk System between May 2014 and March 2016, with two main components: 1) analysis of the system itself through in-depth interviews with 32 people working in leadership positions and a systematic review of the system's most important legislation, and 2) a study of people who experienced problems receiving entitlements and were challenging the assessment of their work-related illness or accident. We conducted in-depth interviews with 22 people, followed up with half of them, and reviewed their case files. We found that difficulties accessing health care services, payments for medical leave, job reassignments, severance packages, and filing for pension benefits were common to all cases and resulted from overwhelming bureaucratic and administrative demands. Regional and national evaluation bodies dictate whether a given illness or accident is work-related, and establish a percentage of Loss of Wage Earning Capacity (LWEC). People's disabled bodies rarely reached the threshold of 50% LWEC to qualify for disability pensions. The lengthy process that workers were forced to endure to obtain work-related entitlements always involved the judiciary. The three competing for-profit financial sectors (health insurance, pension funds, and Occupational Risk Administrators) actively challenged workers' demands in order to increase their profits. We conclude that these for-profit sectors work contrary to the principles that sustain social security. Indeed, they push sick and disabled workers to unemployment, informality, economic dependence, and ultimately dire poverty.