Health and social security reforms in Latin America: the convergence of the World Health Organization, the World Bank, and transnational corporations.

International financial institutions have played an increasing role in the formation of social policy in Latin American countries over the last two decades, particularly in health and pension programs. World Bank loans and their attached policy conditions have promoted several social security reforms within a neoliberal framework that privileges the role of the market in the provision of health and pensions. Moreover, by endorsing the privatization of health services in Latin America, the World Health Organization has converged with these policies. The privatization of social security has benefited international corporations that become partners with local business elites. Thus the World Health Organization, international financial institutions, and transnational corporations have converged in the neoliberal reforms of social security in Latin America. Overall, the process represents a mechanism of resource transfer from labor to capital and sheds light on one of the ways in which neoliberalism may affect the health of Latin American populations.     

Why neoliberal health reforms have failed in Latin America

This paper reviews Latin American neoliberal health reforms sponsored by the IMF and the World Bank, and analyzes the impact on the region of decentralization and privatization, the two basic components of the reforms. The second part of the paper examines in some detail the Chilean and Colombian reforms, the two countries that have implemented closely the principles of the neoliberal reform. The two case studies confirm that neoliberal reforms do not improve quality of care, equity, and efficiency. In the discussion the authors identify the beneficiaries of the reforms: transnational corporations, consultant firms, and the World Bank's staff. The recognition of the beneficiaries helps to explain some of the reasons behind the Word Bank continuing pressures to implement neoliberal health reforms in spite the growing evidence of their failures.     

Privatization of health services in less developed countries: an empirical response to the proposals of the World Bank and Wharton School.

Academics and World Bank officials argue that, by reducing out-of-pocket expenditures, expanded private insurance may improve access to needed health services in less developed countries. In this empirical response, the authors examine this recommendation through observations from their research on privatization of health services in the United States, Argentina, Chile, and Mexico. Privatization, either through conversion of public sector to private sector insurance or by expansion of private insurance through enhanced participation by corporate entrepreneurs, generally has not succeeded in improving access to health services for vulnerable groups. Although the impact of privatization has differed among the Latin American countries studied, expansion of private insurance often has generated additional co-payments, which have increased rather than decreased out-of-pocket expenditures, thereby worsening access to needed services. Privatization usually has improved conditions for private corporations and has led to higher administrative costs. To address the devastating problems of access to services worldwide, we must find ways to enhance the delivery of public sector services and must move beyond conventional wisdom about market-based policies such as privatization.     

Excerpts from Joseph Stiglitz's speech to the World Bank, April 1999.

The Journal has published several articles critical of the World Bank and the International Monetary Fund. These articles have shown the damage caused by the neoliberal policies advocated by these agencies to the health and quality of life of the people in countries where such policies are carried out. Published here are excerpts of a speech given by Joseph Stiglitz, senior economist of the World Bank, in which he finally recognizes the damage these policies have caused in Russia, where life expectancy has fallen quite dramatically during the years of neoliberal reform. The question triggered by his speech is why the World Bank continues its neoliberal policies.     

The World Bank, pharmaceutical policies, and health reforms in Latin America.

Health care systems spend a relatively high percentage of their resources on the purchase of medicines, and the poor spend a disproportionate amount of their income on pharmaceuticals. There is ample evidence in the literature that drugs are very poorly used. World Bank-led health reforms aim at improving equity, efficiency, quality, and users' satisfaction, and it will be difficult to achieve these goals without making medicines accessible and affordable. The purpose of this article is to examine the adequacy of World Bank pharmaceutical policies, as recommended in various Bank documents, for Latin America and to examine the implementation of the policy recommendations. The authors found that the World Bank identified and recommended a set of pharmaceutical policies that matched the needs of the region. But, as revealed through fieldwork and a review of the literature, the recommended pharmaceutical interventions were left out of the health reforms, and most of the loans that included pharmaceutical interventions allocated funds only to the purchase of drugs. The authors formulate four hypotheses that may explain the lack of congruence between the recommended policies and the strategies financed by World Bank health reform loans to the Latin American region.     

Neoliberalism as a class ideology; or, the political causes of the growth of inequalities.

Neoliberalism is the dominant ideology permeating the public policies of many governments in developed and developing countries and of international agencies such as the World Bank, International Monetary Fund, World Trade Organization, and many technical agencies of the United Nations, including the World Health Organization. This ideology postulates that the reduction of state interventions in economic and social activities and the deregulation of labor and financial markets, as well as of commerce and investments, have liberated the enormous potential of capitalism to create an unprecedented era of social well-being in the world's population. This article questions each of the theses that support such ideology, presenting empirical information that challenges them. The author also describes how the application of these neoliberal policies has been responsible for a substantial growth of social inequalities within the countries where such policies have been applied, as well as among countries. The major beneficiaries of these policies are the dominant classes of both the developed and the developing countries, which have established worldwide class alliances that are primarily responsible for the promotion of neoliberalism.     

In Mozambique, a less than helpful hand.

World Bank loan policies in Mozambique have almost killed off the country's cashew-processing industry by requiring the removal of the export tariff on raw cashews, a tax that Mozambique had instituted to ensure the cashew supply for local factories.     

From cooperation to competition in national health systems--and back?: impact on professional ethics and quality of care

Ethical behaviour in health workers is the jewel in the crown of health services. Health system policies need to nurture a professional service ethic. The primary health care policy envisioned a national health system led by the public sector and based on a philosophy of cooperation. A common theme of 'health sector reform' in OECD countries, introduced in the context of neoliberalism, has been the use of 'managed competition' to increase efficiency. Some countries that flirted with health system competition have returned to cooperation. Market relationships tend to be oppositional and to stimulate self-seeking behaviour. Health system relationships should encourage patient and community centred behaviour. The World Bank and bilateral donors have exported health sector reform theories from the north to the south, involving privatization and marketization policies. This is despite the lack of evidence on their desirability or feasibility of implementing them. Private health care has increased in many developing countries, more as a result of economic crisis and liberalization than specific health sector reforms. Much of this private practice is unlicensed and unregulated, and informal privatization has had a damaging effect on health worker ethics. The lead policy should be reconstruction of the public health system, involving decentralization, democratization and improved management. Commonsense contracting of an existing private sector is different from a policy of proactive privatization and marketization. Underlying the two approaches is whether health care should be viewed as a human right best served by socialized provision or a private good requiring governments only to correct market failures and ensure basic care for the poor. It is a matter of politics, not economics.     

The impact of privatization on access in Tanzania

In the late 1980s, many developing countries were forced to adopt structural adjustment policies as a condition for securing loans from the International Monetary Fund (IMF) and the World Bank. One of the World Bank's recommended policies was to change the mix of private and public health facilities. This study, based on fieldwork done in Tanzania in 1993, examines the impact of this policy on health-care accessibility in two northern Tanzanian districts, one rural and one urban. Accessibility was measured in terms of equality and equity of coverage. The placement of the very few government clinics opened during the years 1985-1993 did much more to improve coverage than the haphazard location of many new private clinics. Equity was not improved as very few clinics were placed in demographically needy areas.     

Pro-poor health policies in poverty reduction strategies

Since 1999, the International Monetary Fund and World Bank have required low-income countries soliciting for debt relief and financial support to prepare a Poverty Reduction Strategy Paper (PRSP). The objective of this study is to arrive at a systematic assessment of the extent to which the first batch of interim PRSPs actually addresses the health of the poor and vulnerable. A literature study was used to design and test a semi-quantitative approach to assess the pro-poor focus of health policies in national documents. The approach was applied to the existing interim proposals for 23 Highly Indebted Poor Countries. Results show that a majority of proposals lack country-specific data on the distribution and composition of the burden of disease, a clear identification of health system constraints and an assessment of the impact of health services on the population. More importantly, they make little effort to analyze these issues in relation to the poor. Furthermore, only a small group explicitly includes the interests of the poor in health policy design. Attention to policies aiming at enhancing equity in public health spending is even more limited. Few papers that include expenditure proposals also show pro-poor focused health budgets. We conclude that our systematic assessment of a new international development policy instrument, PRSP, raises strong concerns about the attributed role of health in development and the limited emphasis on the poor, the supposed primary beneficiaries of this instrument. There is a need and an opportunity for the international development community to provide assistance and inputs as poor countries shift their policy thinking from an interim stage to fully developed national policies. This paper presents a menu of analytical and policy options that can be pursued.     

Non-Medical prescribing policies: A global scoping review

BackgroundAuthorizing health care providers other than physicians to prescribe medicines (i.e., non-medical prescribing, NMP) has been used to improve access to healthcare in many countries. This paper aimed to identify the scope of policies facilitating NMP worldwide and investigate the relationship of such policies with a country’s physician to population ratio and economic status.MethodsA hierarchical search strategy was used. First, we compiled a list of countries and territories (n = 216) based upon World Bank record. Then, we collected relevant information for each country by using country name combined with key terms in PubMed, Google, and World Health Organization (WHO) country pharmaceutical profiles. Countries’ socio-economic status and physician to population ratio were determined using data from the World Bank.ResultsLegislation allowing NMP was found for 117 of 216 (54%) countries and territories. The most prevalent policy identified was that of autonomous prescribing authority (59%). Countries with low or high incomes and those with low or high physician to population ratios (<1/1000 or >3/1000) had the highest concentration of policies for NMP rights.ConclusionDespite the varied scope of relevant policies, NMP has been implemented in countries of varied income levels and physician to population ratios. Future research is warranted to empirically examine its impact on access to care.     

Plundering the poor: the role of the World Bank in the Third World

The World Bank, the most important so-called development assistance agency, annually dispenses billions of dollars to Third World governments, ostensibly to "develop" their economics through a variety of loan projects. But even a superficial analysis reveals that the Bank is the perfect mechanism to help (i.e., subsidize) the large transnational corporations from the industrial countries to expand their industrial, commercial, and financial activities in the Third World, at the expense of the latter and particularly at the expense of the rural and urban proletariat. This article discusses Cheryl Payer's recent book, The World Bank: A Critical Analysis, in which she analyzes the Bank's role in the Third World and sets forth the major reasons why poverty, hunger, and malnutrition, as well as unemployment, and all the adverse social phenomena associated with them, are on the increase.     

Collective action and veto players in public policy: the sanitation policy in Brazil (1998-2002)

In 1999, the federal government has committed itself to the IMF with the privatization of the sanitation and other public services, seeking resources to address the fiscal crisis. He proposed the bill 4147/01 as the regulatory framework that would provide the necessary security for investors interested in acquiring the state-owned sanitation enterprises. Against this initiative, a coalition of industry interests mobilized in order to veto the adoption of privatization: the National Front for Environmental Sanitation (FNSA). This paper identifies the actors, the agenda and the interests involved in this political coalition. It shows that the coalition acted decisively as an instance of veto, limiting the effects of the agreement with the IMF on the public policy of sanitation in Brazil this time.     

Ravaging the poor: the International Monetary Fund indicted by its own data.

Recent International Monetary Fund studies on the impact of its structural adjustment programs on the poorest nations reveal that most have stagnated or declined economically. The IMF's requirement that these countries increase exports despite falling world commodity prices has been a principal cause of their economic malaise. Meanwhile, IMF loan conditions demanding lower government expenditures have led to sharp reductions in general social spending, from which the wealthiest quintile of the population receives a disproportionately larger share of outlays for health and education.     

The World Bank and pharmaceuticals

Within less than a decade the World Bank has become the largest single source of finance (loans) for health in low and middle income countries as well as a major player in the field of pharmaceuticals. Often 20-50% of the recurrent government health budget in developing countries is used to procure drugs. Drugs are among the most salient and cost-effective elements of health care and often a key factor for the success of a health sector reform. However, pharmaceuticals are frequently being used irrationally, mainly due to market imperfections in health care, such as information asymmetries, leading to serious health problems and a heavy financial burden on the health system. Lending priorities set by the World Bank could be used to promote public health sector reform, leading to the rational use of affordable and available drugs of good quality in developing countries. This report provides the first analysis of World Bank activity in the pharmaceutical sector worldwide. The analysis of 77 staff appraisal reports, describing the planning phase of World Bank country projects, shows that 16% of the total World Bank health, nutrition and population budget, or approximately US$1.3 billion, has been committed to loans or credits supporting pharmaceutical activities in the programme countries between 1989-95. Roughly US$1.05 billion has been committed to procurement of drugs and medical equipment. Only 5% of the total pharmaceutical sector lending is committed to software components such as drug policy work and rational use of drugs. No more than 45% of the projects were developed in collaboration with pharmaceutical expertise. The World Bank is recommended to improve its pharmaceutical sector involvement by promoting drug policy research and development including national and international dialogue on pharmaceutical issues to ensure rational use of both drugs and loans. In this, the World Bank has an advantage given its experience from working with both the private and the public sector, its in-house expertise in health economics, and lastly its ability to be listened to by governments through its power.     

A new approach to global health institutions? A case study of new vaccine introduction and the formation of the GAVI Alliance

There is an emerging research agenda to analyse empirically the forces driving changes in global health governance. This study applies analytical tools from international relations research to explain the formation of international health regimes. The study utilizes two explanatory perspectives: individual leadership, and the interests of key non-state actors in the formation process, using the case of the formation of the Global Alliance for Vaccines and Immunization (GAVI) from 1995 to 1999. The case study is based on material from interviews with key actors, an archival review of documents from the Children’s Vaccine Initiative (CVI), and published literature. Findings show that the regime formation process was initiated by individuals who were primarily affiliated to scientific communities and who led to the World Bank and the Gates Foundation becoming champions of a new coordinating mechanism for new vaccine introduction. Negotiations in the regime formation process were between a small group of founding agencies with divergent interests regarding immunization priorities. The case also sheds light on the authority of the WHO and the resources of the Gates Foundation in driving the process towards the final structure of the alliance. The paper discusses the potential contribution of the international relations approach compared to policy research as a way of understanding the institutional dynamics of global health, particularly in respect of relations between countries and non-state actors.     

政治经济紧缩与卫生服务——基于1995—2011年27个欧洲国家费用变化的跨国分析

在经济衰退期间卫生支出为何呈现出多样化？本文采用1995—2011年27个欧洲国家的数据,对可能引起卫生支出变化的政治、经济和卫生体系等关键因素进行评估。纠正之前存在的时间趋势,采用随机效应模型和固定效应模型对2013年欧盟统计局、国际货币基金组织和世界银行的数据进行了测量和评估。研究发现,政府卫生支出的削减与经济衰退的程度关系不大;执政党的意识形态也不会对政府卫生支出产生很大影响。相反,税收每减少100美元,卫生支出将减少2.72美元。在控制可能的混淆因素后,国际货币基金组织贷款国家比非贷款国家更有可能削减政府卫生支出。在欧盟成员国中,与经济条件和政党意识形态等因素相比,向国际金融机构贷款、税收减少以及实施削减政策等可能更会导致政府卫生支出的削减。     

Are pro-welfare state and full-employment policies possible in the era of globalization?

There is a widely held belief in U.S. and European economic, political, and academic circles that economic globalization has considerably diminished states' power to follow public policies identified with the social democratic tradition, such as full-employment policies, comprehensive and universal provision of welfare state services, and state regulatory interventions in labor markets and economic policies. And large sectors of the European center-left and left parties believe that European monetary integration made expansionist and full-employment policies practically impossible, except when realized at the European continental level. This article presents empirical information that questions these positions. It documents how specific governments in Europe have been able to carry out such public policies during these years of economic globalization and monetary integration. Some countries (such as Sweden and Finland) that had carried out these policies then later weakened their implementation did so in response to political changes mostly unrelated to globalization of the economy or monetary integration. The article also analyzes and documents how countries that had followed expansionist and full-employment policies have responded to the globalization of financial markets.     

Mediational pathways connecting secondary education and age at marriage to maternal mortality: A comparison between developing and developed countries

While studies have shown that maternal mortality rates have been improving worldwide, rates are still high across developing nations. In general, poor health of women is associated with higher maternal mortality rates in developing countries. Understanding country-level risk factors can inform intervention and prevention efforts that could bring high maternal mortality rates down. Specifically, the authors were interested in investigating whether: (1) secondary education participation (SEP) or age at marriage (AM) of women were related to maternal mortality rates, and (2) adolescent birth rate and contraceptive use (CU) acted as mediators of this association. The authors add to the literature with this current article by showing the relation of SEP and AM to maternal mortality rates globally (both directly and indirectly through mediators) and then by comparing differences between developed and developing/least developed countries. Path analysis was used to test the hypothesized model using country level longitudinal data from 2000 to 2010 obtained from United Nations publications, World Health Organization materials, and World Bank development reports. Findings include a significant correlation between SEP and AM for developing countries; for developed countries the relation was not significant. As well, SEP in developing countries was associated with increased CU. Women in developing countries who finish school before marriage may have important social capital gains.