Deconstructing the Financialization of Healthcare

Financialization is promoted by alliances of multilateral ‘development’ organizations, national governments and owners and institutions of private capital. In the healthcare sector, the leveraging of private sources of finance is widely argued as necessary to achieve the Sustainable Development Goal 3 target of universal health coverage. Employing social science perspectives on financialization, the authors of this article contend that this is a new phase of capital formation. The article traces the antecedents, institutions, instruments and ideas that facilitated the penetration of private capital in this sector, and the emergence of new asset classes that distinguish it. The authors argue that this deepening of financialization represents a fundamental shift in the organizing principles for healthcare systems, with negative implications for health and equality.     

Striking health workers: Precarity and healthcare in neoliberal Kenya

Precarity is increasingly a condition of life for Kenyan health workers as even professionals face costs of living and forms of debt that exceed their (unstable) salaries. Years of austerity and chronic scarcity have eroded healthcare infrastructures and rendered crises part of everyday work. Based on ethnographic fieldwork in Kenya from 2018 to 2020, we explore health workers’ experiences and concerns about the precarity of their working conditions, livelihoods, health and futures amidst the government's attempts to experiment with ‘universal health coverage’ (UHC) and improve access to healthcare. While UHC appears to call for greater state responsibility for healthcare futures, healthcare provision is being further outsourced and privatized, underlining that seemingly progressive health policies like UHC are sustaining and replicating neoliberal trends.     

A political economy approach to the allocation of health care resources: the case of remote areas of Queensland

This article describes and accounts for the existing distribution of medical services in remote areas. In contrast to traditional geographical approaches which have sought to explain problems associated with service provision in remote areas in terms of high costs of overcoming vast distances and low population thresholds, it is argued that such geographical and economic factors alone are an insufficient basis for explanation. Rather, it is necessary to view this issue in the broader context of existing ideology that underpins the procedures relating to the allocation of society's scarce resources, and the role of political and bureaucratic processes that are responsible for health care inequities. The adoption of apolitical economy framework recognises the problem of resource allocation as essentially a political matter requiring an analysis of power relations.     

Health centre visits among the elderly with chronic ailments: Evidence from the Kanchanaburi Demographic Surveillance System, 2004, Thailand

This study deployed statistical and spatial (GIS) analyses to test the effects of geographic, demographic and occupational factors in predicting health centre visits among the elderly (≥60 years) with chronic ailments in Kanchanaburi Province, western Thailand. Datasets from the Kanchanaburi Demographic Surveillance System (2004 baseline survey and a 2006 project follow-up) comprised five land-use landscape and occupational strata: urban/semi-urban (industrial), rice field, plantation crop, upland and mixed economy. Travel distance to the nearest health centre was calculated following transportation routes and the GPS coordinates of individual home locations, and the number of healthcare visits under the national free universal coverage (UC) scheme reported for the previous year was used as a dependent variable in regressions. Broadly, the study found that distance was not a significant predictor of the rate of elderly health centres visits for those with co-residing spouses and/or adult children (77% of sample), and for the elderly still working (48% of the sample) who were the least likely to access healthcare. Owning motorised vehicles did not encourage visits, which also varied by land-use and occupational strata.     

Political Science and U.S. Health Policy in the Era of the Affordable Care Act

Few laws have a profound and lasting impact on an entire political system. The Affordable Care Act (ACA), despite its incremental nature and bipartisan heritage, has been one of those remarkable landmarks. Even a decade after its passage, the political struggle is far from over, as the ACA is still facing near constant threats from the incumbent president, Congress, the courts, statehouses, attorneys general, and governors across the nation. How have political scientists responded to the continued struggle? This article provides an overview of the effects of health reform and the ACA on political science research since 2008. While political scientists have written much about the subject, coverage has been distinctly uneven within the discipline. Indeed, it has almost been entirely confined to scholars of public and health policy. Nonetheless, there have been important contributions across disciplinary fields. This article provides an overview of contributions embedded within the study of federalism, policy feedback effects, and political framing. It concludes by emphasizing the need for more engaged scholarship on health policy issues from across the entire discipline, and by highlighting other areas of study that could benefit from broader attention by political scientists.     

The Italian welfare state after the financial crisis

The essential characteristics of the Italian welfare state as it developed after the Second World War generated social cleavages and inequities that affected the Italian economy and provided grist for future reforms. At the same time, the welfare state provided political actors with incentives and resources that constrained attempts at reform. With the financial crisis beginning in 2008, serious reform was no longer optional. But austerity politics have generated pressures for changes to the welfare state which are unlikely to moderate most of the underlying inequities generated by the post-war system. Going forward, Italian policymakers must chart a path that is informed by efforts to overcome the pathologies of the past without further undermining the social and economic health of the country.     

Free Health Clinics,Resistance and the Entanglement of Christianity and Commodified Health Care Delivery

Abstract: Free clinics are an important part of the US health care safety net and their numbers are rising. This article offers a critical analysis of the politics of free health clinics in Milwaukee, Wisconsin. It uses the geographies of resistance literature to assess free clinics as a response to the neoliberalization of health care delivery. It underlines the multiple political spaces free clinics occupy as a result of the entanglements of a diverse range of identities and practices within the clinic space. In Milwaukee, the primary entanglement occurs between the progressive Christian identity inspiring the practices of the free clinic's volunteers and the commodified identity of the corporate non‐profit health care systems that dominate health care delivery in the city. This research suggests that understanding the transition from oppositional identities, such as progressive Christianity, to resistance is an important next step in constructing more robust responses to neoliberal capitalism and other exploitive social relations.     

Return to reason: reviving political realism in western foreign policy

Twenty‐first‐century political crises stretching from Europe to the Middle East and the Asia–Pacific have undermined the worldview that governed post‐Cold War western thinking about a liberal end of history. This worldview assumed that shared norms and transnational institutions would transform the state based‐order. In this context, the use of force is considered appropriate only for humanitarian ends meeting a set of predetermined axioms laid down in chapter 7 of the UN Charter. Yet for any strategy to be effective—in an international order subject to change—a clear political aim is required, which might deviate from the general rule. Preoccupied with universal postulates, legal normativism has lost sight of the particular. The argument put forth in this article is that the failure of contemporary western foreign policy in the twenty‐first century to address this limitation or to prioritize political ends has led to strategic confusion from Afghanistan to Syria and Ukraine. In this context, it might be useful to reappraise the utility of abstract rationalist approaches to global governance and return instead to an earlier understanding of statecraft that avoided premature generalizations and treated norms as maxims of prudence rather than axioms requiring universal application.     

Environmental health and vulnerable populations in Canada: mapping an integrated equity‐focused research agenda

The uneven distribution of environmental hazards across space and in vulnerable populations reflects underlying societal inequities. Fragmented research has led to gaps in comprehensive understanding of and action on environmental health inequities in Canada and there is a need to gain a better picture of the research landscape in order to integrate future research. This paper provides an initial assessment of the state of the environmental health research field as specifically focused on vulnerable populations in Canada. We present a meta‐narrative literature review to identify under‐integrated areas of knowledge across disciplinary fields. Through systematic searching and categorization, we assess the abstracts of a total of 308 studies focused on the past 30 years of Canadian environmental health inequity research in order to describe temporal, geographical, contextual and epistemological patterns. The results reveal that there has been significant growth in Canadian research documenting the uneven distributions and impacts of environmental hazards across locations and populations since the 1990s, but its focus has been uneven. Notably, there is a lack of research aimed at integrating evidence‐based and policy‐relevant evaluation of environmental health inequities and how they are created and sustained. Areas for future research are recommended including more interdisciplinary, multimethod and preventive approaches to resolve the environmental burden placed on vulnerable populations and to promote environmental health equity.     

The Political Economy of Unemployment Insurance based on Individual Savings Accounts: Lessons from Chile

In recent years, unemployment protection systems based on individual savings have been instituted in several developing countries. Chile was one of the first to establish such a system, which at the time was widely cited as a model for other countries. This article discusses the particular political context in which the Chilean system was created before examining how it works in terms of coverage and levels of benefits received by unemployed workers. The authors undertake a detailed analysis of the administrative data produced by the system and conclude that the insurance covers only a small proportion of the unemployed, as most workers generally had precarious jobs that did not allow them to contribute to the system consistently. The Chilean case illustrates how difficult it is to establish functioning unemployment insurance in developing countries with precarious labour markets. Based on the interaction between employment characteristics and the conditions imposed by the benefit system, the article assesses the efficacy of the Unemployment Insurance Savings Accounts (UISA) system and analyses whether it can indeed serve as a model for other developing countries.     

FAIR SHARES FOR THE ZONE: ALLOCATING HEALTH-CARE RESOURCES FOR THE NATIVE POPULATIONS OF THE SIOUX LOOKOUT ZONE, NORTHERN ONTARIO

The purpose of this paper is to explore issues of healthcare resource allocation for a Canadian native population, that of Sioux Lookout Zone, within the context of the total provincial population. We argue that a fair share of provincial health resources for any population must be based on a population needs approach. The paper begins by establishing a method to measure a fair share of healthcare resources. It goes on to establish why a fair share is important in the light of native health conditions in general and with respect to this specific population. The fair share is then calculated and illustrated with reference to particular health-care programs. Finally, there is discussion of the methodological and policy issues that arise from this research.     

A Covering Tour Model for Planning Mobile Health Care Facilities in SuhumDistrict, Ghama

The provision of adequate primary health care in developing countries is often troublesome. The problem is to provide a sufficient number of facilities to be geographically accessible, yet few enough to be properly stocked and staffed. In many less developed countries accessibility problems are exacerbated by extensive rainy seasons in which travel is only possible on paved roads. Using the covering tour model we investigate the use of mobile facilities to resolve this dilemma in Suhum District, Ghana. The model minimizes a mobile facility's travel while serving all population centers within range of a feasible stop. Computational results show that in the rainy season the model cannot provide full coverage; over six percent of the population is beyond a covering distance of eight kilometers. In the dry season, 99 percent of the population can be served by a tour at a covering distance of seven kilometers.Beyond a distance of four kilometers, the dry season problem becomes a trade-off between the distance traveled by healthcare patrons and mobile facilities. These results illustrate the importance of flexibility of mobile systems: if accessibility cannot be provided in all seasons it may still be provided at favorable times of the year.     

Political Ecologies of Global Health: Pesticide Exposure in Southwestern Ecuador's Banana Industry

Pesticide exposure in Ecuador's banana industry reflects political economic and ecological processes that interact across scales to affect human health. We use this case study to illustrate opportunities for applying political ecology of health scholarship in the burgeoning field of global health. Drawing on an historical literature review and ethnographic data collected in Ecuador's El Oro province, we present three main areas where a political ecological approach can enrich global health scholarship: perceptive characterization of multi‐scalar and ecologically entangled pathways to health outcomes; critical analysis of discursive dynamics such as competing scalar narratives; and appreciation of the environment‐linked subjectivities and emotions of people experiencing globalized health impacts. Rapprochement between these fields may also provide political ecologists with access to valuable empirical data on health outcomes, venues for engaged scholarship, and opportunities to synthesize numerous insightful case studies and discern broader patterns.     

Charity and self‐help: Migrants' social networks and health care in the homeland (Respond to this article at http://www.therai.org.uk/at/debate)

This article examines the delivery of healthcare by Haalpulaar immigrants' village association in France to their rural villages in Senegal. In the context of the neo‐liberal reforms in Senegal, the Haalpulaar immigrants have been very active in funding community project in the health sector for their communities of origin left to fend for themselves by the State. Haalpulaar migrants associations like TAD (Thilogne Association Developpement) and Fuuta Santé are improving access to healthcare in the Senegal River valley through the remittances of biomedicine, medical equipment as well as the organization of annual health caravans with the participation of French health professionals and local partners.     

Simple Transfers,Complex Outcomes: The Impacts of Pensions on Poor Households in Brazil

Drawing on quantitative survey data and in‐depth interviews, this article seeks to map out the potential direct and indirect effects of simple cash transfers on households in impoverished rural and urban settings. Brazil is shown to have an extensive system of old age pensions, which affords almost universal coverage to households containing older people. These benefits have a significant impact on levels of poverty and vulnerability in recipient households. They also facilitate access to essential healthcare items, such as drugs, which are seldom freely available through the state health system. The in‐depth interviews reveal that pensions can have important effects on intra‐household relations, but these effects were not generalizable nor easily captured by quantitative survey tools. There was clear evidence that pensions reduced the propensity of older people to remain economically active, but this must be understood in a context of limited employment opportunities for all age groups and a high prevalence of disability. Overall, the article demonstrates the complex effects of a relatively simple cash transfer, which policy makers need to take into account.     

Environmental Justice and the Allocation Of Risk: The Case of Lead and Public Health

This paper examines conceptual and methodological issues in the analysis of environmental justice through use of the case of lead-exposure health risks. Researchers face important obstacles in measuring variable risks among population subgroups. The case of lead exposure, however, illustrates the dramatic potential where adequate data exist for identifying and correcting significant inequities in risk exposure. Despite sharp reductions in the general population's exposure to lead since the 1970s, substantial numbers of minority and low-income children continue to exhibit unacceptably high blood-lead levels due primarily to exposure to lead-based paint. Resolving environmental inequities in this and similar instances requires solid documentation of the risk and better integration of equity issues with other policy demands such as the call for cost-effective environmental policy.     

Enforcing ‘Progress’: A Story of an MDG 5 Indicator and Maternal Health in Malawi

Considering the importance of metrics in current systems of global health accountability, this article analyses the dynamics behind a maternal health indicator. To achieve the target of Millennium Development Goal 5 (MDG 5) and increase the proportion of births attended by ‘skilled health personnel’, some districts in Malawi in 2010 introduced information campaigns to promote births in hospitals and a fine to punish mothers who delivered outside of biomedical health institutions. The study is based on ethnographic research in one Malawian village. While many mothers described the ill treatment and bad conditions in maternity wards, most women still started to publicly sanction institutional births. This apparent contradiction can be understood by looking at the positions and motivations of the various actors who participated in the performance of MDG 5 in the village and how their projects became tied to the focus on improving the indicator. Rather than expressing a demand for the existing maternal health services as such, the ethnography suggests that the actors’ practices expressed hopes and claims to wider material improvements in a context of inequality. The article highlights dynamics that are concealed if we restrict the analysis to one of biopower, and expands the purview of the study of metrics into the spaces which indicators are intended to represent.     

Classical Central Places as Protected Thresholds

Previous research efforts demonstrate the use of location covering in the spatial structuring of central places within a single-good context. In a multilevel context, this paper similarly develops a mathematical programming approach to the siting of central places based on the “protection” of inner (or threshold) markets. The objective function maximizes both market coverage of demand and market overlap, subject to an upper bound on market overlap; this allows the formation of different market structures consistent with the various K-valued central place systems of Christaller and Lösch. Siting examples serve to illustrate the working of the protected threshold model in isotropic settings. Furthermore, ways in which the present model might be extended for other situations are examined.     

The Politics of Welfare Exclusion: Immigration and Disparity in Medicaid Coverage

The rapid growth of the immigrant population in the United States, along with changes in the demographics and the political landscape, has often raised questions for understanding trends of inequality. Important issues that have received little scholarly attention thus far are excluding immigrants’ social rights through decisive policy choices and the distributive consequences of such exclusive policies. In this article, we examine how immigration and state policies on immigrants’ access to safety net programs together influence social inequality in the context of health care. We analyze the combined effect of immigration population density and state immigrant Medicaid eligibility rules on the gap of Medicaid coverage rates between native‐ and foreign‐born populations. When tracking inequality in Medicaid coverage and critical policy changes in the post‐PRWORA era, we find that exclusive state policies widen the native‐foreign Medicaid coverage gap. Moreover, the effect of state policies is conditional on the size of the immigrant population in that state. Our findings suggest immigrants’ formal integration into the welfare system is crucial for understanding social inequality in the U.S. states.     

Geographic information system‐based evaluation of spatial accessibility to maternal health facilities in Siaya County,Kenya

Maternal mortality is a major problem in middle‐income and low‐income countries, and the availability and accessibility of healthcare facilities offering safe delivery is important in averting maternal deaths. Siaya County, in Kenya, has one of the highest maternal mortality rates in the country—far more than the national average. This study aimed to evaluate geographic access to health facilities offering delivery services in Siaya County. A mixed‐methods approach incorporating geographic information system analysis and individual data from semi‐structured interviews was used to derive travel time maps to facilities using different travel scenarios: AccessMod5 and ArcGIS were used for these tasks. The derived maps were then linked to georeferenced household survey data in a multilevel logistic regression model in R to predict the probability of expectant women delivering in a health facility. Based on the derived travel times, 26 per cent (13,140) and 67 per cent (32,074) of the estimated 46,332 pregnant women could reach any facility within one and two hours, respectively, while walking with the percentage falling to seven per cent (3,415) and 20 per cent (8,845) when considering referral facilities. Motorised transport significantly increased coverage. The findings revealed that the predicted probability of a pregnant woman delivering in a health facility ranged between 0.14 and 0.86. Significant differences existed in access levels with transportation‐based interventions significantly increasing coverage. The derived maps can help health policy planners identify underserved areas and monitor future reductions in inequalities. This work has theoretical implications for conceptualising healthcare accessibility besides advancing the literature on mixed methodologies.