Neoliberalism 4.0: The Rise of Illiberal Capitalism; Comment on “How Neoliberalism Is Shaping the Supply of Unhealthy Commodities and What This Means for NCD Prevention”

Neoliberal logic and institutional lethargy may well explain part of the reason why governments pay little attention to how their economic and development policies negatively affect health outcomes associated with the global diffusion of unhealthy commodities. In calling attention to this the authors encourage health advocates to consider strategies other than just regulation to curb both the supply and demand for these commodities, by better understanding how neoliberal logic suffuses institutional regimes, and how it might be coopted to alternative ends. The argument is compelling as possible mid-level reform, but it omits the history of the development of neoliberalism, from its founding in liberal philosophy and ethics in the transition from feudalism to capitalism, to its hegemonic rise in global economics over the past four decades. This rise was as much due to elites (the 1% and now 0.001%) wanting to reverse the progressive compression in income and wealth distribution during the first three decades that followed World War Two. Through three phases of neoliberal policy (structural adjustment, financialization, austerity) wealth ceased trickling downwards, and spiralled upwards. Citizen discontent with stagnating or declining livelihoods became the fuel for illiberal leaders to take power in many countries, heralding a new, autocratic and nationalistic form of neoliberalism. With climate crises mounting and ecological limits rendering mid-level reform of coopting the neoliberal logic to incentivize production of healthier commodities, health advocates need to consider more profound idea of how to tame or erode (increasingly predatory) capitalism itself

Globalization and social determinants of health: Introduction and methodological background (part 1 of 3)

Globalization is a key context for the study of social determinants of health (SDH). Broadly stated, SDH are the conditions in which people live and work, and that affect their opportunities to lead healthy lives

Globalization and social determinants of health : promoting health equity in global governance (part 3 of 3)

This article is the third in a three-part review of research on globalization and the social determinants of health (SDH). In the first article of the series, we identified and defended an economically oriented definition of globalization and addressed a number of important conceptual and metholodogical issues. In the second article, we identified and described seven key clusters of pathways relevant to globalization's influence on SDH. This discussion provided the basis for the premise from which we begin this article: interventions to reduce health inequities by way of SDH are inextricably linked with social protection, economic management and development strategy. Reflecting this insight, and against the background of the Millennium Development Goals (MDGs), we focus on the asymmetrical distribution of gains, losses and power that is characteristic of globalization in its current form and identify a number of areas for innovation on the part of the international community: making more resources available for health systems, as part of the more general task of expanding and improving development assistance; expanding debt relief and taking poverty reduction more seriously; reforming the international trade regime; considering the implications of health as a human right; and protecting the policy space available to national governments to address social determinants of health, notably with respect to the hypermobility of financial capital. We conclude by suggesting that responses to globalization's effects on social determinants of health can be classified with reference to two contrasting visions of the future, reflecting quite distinct values

Brain Drain and Regain: The Migration Behaviour of South African Medical Professionals (Migration Policy Series No. 65)

Since the end of apartheid, South Africa has experienced a significant outflow of health professionals. The out-migration of health professionals from the country is part of a broader global trend of health professional migration from the Global South to the Global North. In the health sector, this “brain drain” has led to a significant decline in the quality of care in affected countries. The costs of health professional migration for countries of origin are usually measured in terms of lost investment in training and the gaps in medical care left by their departure. One recent study, for example, estimated that the cost to South Africa in lost investment in training from the emigration of health physicians to Australia, Canada, the United States and the United Kingdom amounts to USD1.4 billion. Previous studies have predicted that medical migration from South Africa is unlikely to subside in the short and medium term as health professionals and trainees exhibit very high emigration potential. This report provides an updated (2013) picture of the state of mind of South African health professionals. It also allows an assessment of whether professional attitudes and perceptions have changed between 2007 and 2013 including (a) whether levels of satisfaction with work and life in South Africa have improved or worsened; (b) whether emigration potential has declined or intensified amongst health professionals and (c) whether the “brain drain” from South Africa is likely to continue. These questions are of particular relevance given various changes in the health sector since 2007. Return migration has been advocated internationally as an antidote to the brain drain and an important downstream benefit for countries of origin in the South. This report therefore provides important new information about the implications of health professional return migration to South Africa. Another strategy adopted by some countries is to use immigration policy as a means of dealing with health professional shortages. South Africa is a destination country for health professionals from some countries although, with the exception of official schemes to temporarily import Cuban and Tunisian doctors, this is not official policy. Significantly, the medical professions have only just appeared on the government scarceskills lists that have been published for nearly a decade. This survey provided an opportunity to profile a sub-group of non-South African doctors to assess whether they are more inclined to remain in the country than their South African counterparts. The current survey was developed in collaboration with the Institute of Population Health at the University of Ottawa as part of a CIHR-funded global project on health professional migration from India, Jamaica, the Philippines and South Africa. The questionnaire was hosted on the MEDpages website and potential respondents were invited by email to complete the survey. A total of 1,383 completed questionnaires were received from physicians, dentists and pharmacists – a response rate of 7%

Framing health and foreign policy: lessons for global health diplomacy

Global health financing has increased dramatically in recent years, indicative of a rise in health as a foreign policy issue. Several governments have issued specific foreign policy statements on global health and a new term, global health diplomacy, has been coined to describe the processes by which state and non-state actors engage to position health issues more prominently in foreign policy decision-making. Their ability to do so is important to advancing international cooperation in health. In this paper we review the arguments for health in foreign policy that inform global health diplomacy. These are organized into six policy frames: security, development, global public goods, trade, human rights and ethical/moral reasoning. Each of these frames has implications for how global health as a foreign policy issue is conceptualized. Differing arguments within and between these policy frames, while overlapping, can also be contradictory. This raises an important question about which arguments prevail in actual state decision-making. This question is addressed through an analysis of policy or policy-related documents and academic literature pertinent to each policy framing with some assessment of policy practice. The reference point for this analysis is the explicit goal of improving global health equity. This goal has increasing national traction within national public health discourse and decision-making and, through the Millennium Development Goals and other multilateral reports and declarations, is entering global health policy discussion. Initial findings support conventional international relations theory that most states, even when committed to health as a foreign policy goal, still make decisions primarily on the basis of the 'high politics' of national security and economic material interests. Development, human rights and ethical/moral arguments for global health assistance, the traditional 'low politics' of foreign policy, are present in discourse but do not appear to dominate practice. While political momentum for health as a foreign policy goal persists, the framing of this goal remains a contested issue. The analysis offered in this article may prove helpful to those engaged in global health diplomacy or in efforts to have global governance across a range of sectoral interests pay more attention to health equity impacts

No. 65: Brain Drain and Regain: The Migration Behaviour of South African Medical Professionals

Since the end of apartheid, South Africa has experienced a significant outflow of health professionals. The out-migration of health professionals from the country is part of a broader global trend of health professional migration from the Global South to the Global North. In the health sector, this “brain drain” has led to a significant decline in the quality of care in affected countries. The costs of health professional migration for countries of origin are usually measured in terms of lost investment in training and the gaps in medical care left by their departure. One recent study, for example, estimated that the cost to South Africa in lost investment in training from the emigration of health physicians to Australia, Canada, the United States and the United Kingdom amounts to USD1.4 billion. Previous studies have predicted that medical migration from South Africa is unlikely to subside in the short and medium term as health professionals and trainees exhibit very high emigration potential. This report provides an updated (2013) picture of the state of mind of South African health professionals. It also allows an assessment of whether professional attitudes and perceptions have changed between 2007 and 2013 including (a) whether levels of satisfaction with work and life in South Africa have improved or worsened; (b) whether emigration potential has declined or intensified amongst health professionals and (c) whether the “brain drain” from South Africa is likely to continue. These questions are of particular relevance given various changes in the health sector since 2007. Return migration has been advocated internationally as an antidote to the brain drain and an important downstream benefit for countries of origin in the South. This report therefore provides important new information about the implications of health professional return migration to South Africa. Another strategy adopted by some countries is to use immigration policy as a means of dealing with health professional shortages. South Africa is a destination country for health professionals from some countries although, with the exception of official schemes to temporarily import Cuban and Tunisian doctors, this is not official policy. Significantly, the medical professions have only just appeared on the government scarceskills lists that have been published for nearly a decade. This survey provided an opportunity to profile a sub-group of non-South African doctors to assess whether they are more inclined to remain in the country than their South African counterparts. The current survey was developed in collaboration with the Institute of Population Health at the University of Ottawa as part of a CIHR-funded global project on health professional migration from India, Jamaica, the Philippines and South Africa. The questionnaire was hosted on the MEDpages website and potential respondents were invited by email to complete the survey. A total of 1,383 completed questionnaires were received from physicians, dentists and pharmacists – a response rate of 7%

From Mid-Level Policy Analysis to Macro-Level Political Economy; Comment on “Developing a Framework for a Program Theory-Based Approach to Evaluating Policy Processes and Outcomes: Health in All Policies in South Australia”

This latest contribution by the evaluation research team at Flinders University/Southgate Institute on their multiyear study of South Australia’s Health in All Policies (HiAP) initiative is simultaneously frustrating, exemplary, and partial. It is frustrating because it does not yet reveal the extent to which the initiative achieved its stated outcomes; that awaits further papers. It is exemplary in describing an evaluation research design in which the research team has excelled over the years, and in adding to it an element of theory testing and re-testing. It is partial, in that the political and economic context considered important in examining both process and outcome of the HiAP initiative stops at the Australian state’s borders as if the macro-level national and global political economy (and its power relations) have little or no bearing on the sustainability of the policy learning that the initiative may have engendered. To ask that of an otherwise elegant study design that effectively engages policy actors in its implementation may be demanding too much; but it may now be time that more critical political economy theories join with those that elaborate well the more routine praxis of public policy-making

Is the Alma Ata vision of comprehensive primary health care viable? Findings from an international project

BACKGROUND: The 4-year (2007 2011) Revitalizing Health for All international research program (http://www. globalhealthequity.ca/projects/proj_revitalizing/index.shtml) supported 20 research teams located in 15 lowand middle-income countries to explore the strengths and weaknesses of comprehensive primary health care (CPHC) initiatives at their local or national levels. Teams were organized in a triad comprised of a senior researcher, a new researcher, and a 'research user' from government, health services, or other organizations with the authority or capacity to apply the research findings. Multiple regional and global team capacityenhancement meetings were organized to refine methods and to discuss and assess cross-case findings. OBJECTIVE: Most research projects used mixed methods, incorporating analyses of qualitative data (interviews and focus groups), secondary data, and key policy and program documents. Some incorporated historical case study analyses, and a few undertook new surveys. The synthesis of findings in this report was derived through qualitative analysis of final project reports undertaken by three different reviewers. RESULTS: Evidence of comprehensiveness (defined in this research program as efforts to improve equity in access, community empowerment and participation, social and environmental health determinants, and intersectoral action) was found in many of the cases. CONCLUSION: Despite the important contextual differences amongst the different country studies, the similarity of many of their findings, often generated using mixed methods, attests to certain transferable health systems characteristics to create and sustain CPHC practices. These include: 1. Well-trained and supported community health workers (CHWs) able to work effectively with marginalized communities 2. Effective mechanisms for community participation, both informal (through participation in projects and programs, and meaningful consultation) and formal (though program management structures) 3. Co-partnership models in program and policy development (in which financial and knowledge supports from governments or institutions are provided to communities, which retain decision-making powers in program design and implementation) 4. Support for community advocacy and engagement in health and social systems decision making These characteristics, in turn, require a political context that supports state responsibilities for redistributive health and social protection measures.IS

Health Promotion in an Age of Normative Equity and Rampant Inequality

The world was different when the Ottawa Charter for Health Promotion was released 30 years ago. Concerns over the environment and what we now call the ‘social determinants of health’ were prominent in 1986. But the acceleration of ecological crises and economic inequalities since then, in a more complex and multi-polar world, pose dramatically new challenges for those committed to the original vision of the Charter. Can the 2015 Sustainable Development Goals (SDGs), agreed to by all the world’s governments, offer a new advocacy and programmatic platform for a renewal of health promotion’s founding ethos? Critiqued from both the right and the left for, respectively, their aspirational idealism and lack of political analysis, the SDGs are an imperfect but still compelling normative statement of how much of the world thinks the world should look like. Many of the goals and targets provide signals for what we need to achieve, even if there remains a critical lacuna in articulating how this is to be done. The fundamental flaw in the SDGs is the implicit assumption that the same economic system, and its still-present neoliberal governing rules, that have created or accelerated our present era of rampaging inequality and environmental peril can somehow be harnessed to engineer the reverse. This flaw is not irrevocable, however, if health promoters – practitioners, researchers, advocates – focus their efforts on a few key SDGs that, with some additional critique, form a basic blueprint for a system of national and global regulation of capitalism (or even its transformation) that is desperately needed for social and ecological survival into the 22nd century. Whether or not these efforts succeed is a future unknown; but that the efforts are made is a present urgenc