Neoliberal Health Policy Research Articles

“It’s like asking for a necktie when you don’t have underwear”: Discourses on patient rights in southern Karnataka, India

BackgroundEnsuring patient rights is an extension of applying human rights principles to health care. A critical examination of how the notion of patient rights is perceived and enacted by various actors through critical discourse analysis (CDA) can help understand the impediments to its realization in practice.MethodsWe studied the discourses and discursive practices on patient rights in subnational policies and in ten health facilities in southern Karnataka, India. We conducted interviews (78), focus group discussions (3) with care-seeking individuals, care-providers, health care administrators and public health officials. We also conducted participant observation in selected health facilities and examined subnational policy documents of Karnataka pertaining to patient rights. We analyzed the qualitative data for major and minor themes.ResultsPatient rights discourses were not based upon human rights notions. In the context of neoliberalism, they were predominantly embedded within the logic of quality of care, economic, and consumerist perspectives. Relatively powerful actors such as care-providers and health facility administrators used a panoply of discursive strategies such as emphasizing alternate discourses and controlling discursive resources to suppress the promotion of patient rights among care-seeking individuals in health facilities. As a result, the capacity of care-seeking individuals to know and claim patient rights was restricted. With neoliberal health policies promoting austerity measures on public health care system and weak implementation of health care regulations, patient rights discourses remained subdued in health facilities in Karnataka, India.ConclusionsThe empirical findings on the local expression of patient rights in the discourses allowed for theoretical insights on the translation of conceptual understandings of patient rights to practice in the everyday lives of health system actors and care-seeking individuals. The CDA approach was helpful to identify the problematic aspects of discourses and discursive practices on patient rights where health facility administrators and care-providers wielded power to oppress care-seeking individuals. From the practical point of view, the study demonstrated the limitations of care-seeking individuals in the discursive realms to assert their agency as practitioners of (patient) rights in health facilities.

The contemporary crisis of hallway healthcare: Implications of neoliberal health policy on the rise of emergency overcrowding.

The provision of hallway healthcare is a growing concern within contemporary healthcare systems. Hallway healthcare or hallway medicine is defined as the use of unconventional spaces, such as hallways, to provide patient care in the acute care setting. Negative effects associated with the prevalence of hallway healthcare may hinder the healing trajectory of vulnerable and ageing populations. Nurses have an intimate role in the provision of care and can offer valuable insight for the advocacy of high quality and safe patient care. Moreover, hallway healthcare is associated with the development of suboptimal working conditions that have resulted in negative impacts on the nursing profession. The authors seek to better understand the occurrence of this phenomenon by exploring the development of healthcare policies in relation to the neoliberal tenets of, individualism, free market via deregulation and privatization, and decentralization. This article provides an analysis of the historical evolution of hallway healthcare and neoliberalism. Furthermore, the authors aim to explore and demonstrate how the COVID-19 pandemic has shed light on the inefficiency of neoliberalism ideologies for healthcare. Based on the analysis, the authors shall provide suggestions for nurses and stakeholders to enact meaningful change in an international context.

Governing families that care for a sick relative: the contributions of Donzelot's theory for nursing.

According to the literature, the family is now considered to be the most important resource for the care and support of a sick family member. Families are being increasingly invited and trained to play a utilitarian role, not just as family caregivers, but as healthcare agents. Healthcare institutions, based on neoliberal health policies, are encouraging them to perform increasingly complex and professionalized tasks. The burden associated with this expanded healthcare function, however, is significant (fatigue, emotional distress and exhaustion). The aim of this article was to present French sociologist Jacques Donzelot's theoretical perspective on governing through the family. According to Donzelot, such a government is exercised through various power techniques, including the instrumentalization of the family role and the transfer to families of the responsibility for health care. This author describes how healthcare institutions call on the family to perform hospital and biomedical practices within the home. A spin-off of neoliberalism, the practices of governing through families specifically target women, who are considered to be the pillar of the family. Donzelot's perspective is very relevant to nursing, but is still rarely mobilized in the discipline. His critical perspective allows for a re-reading of relations of power and mechanisms of surveillance and control of families, issues that are often overlooked in nursing research.

How the Institutional and Policy Context Shapes the Establishment of Nurse Practitioner Roles and Practice in New Zealand's Primary Health Care Sector.

The implementation of the nurse practitioner (NP) workforce in primary health care (PHC) in New Zealand has been slow, despite ongoing concerns over persisting health inequalities and a crisis in the primary care physician workforce. This article, as part of a wider institutional ethnography, draws on the experiences of one NP and two NP candidates, as they struggle to establish and deliver PHC services in areas of high need, rural, and Indigenous Māori communities in New Zealand. Using information gathered initially by interview, we develop an analysis of how the institutional and policy context is shaping their experiences and limiting opportunities for the informants to provide meaningful comprehensive PHC. Their work (time and effort), with various health organizations, was halted with little rationale, and seemingly contrary to New Zealand's strategic direction for PHC stipulated in the Primary Health Care Strategy 2001. The tension between the extant biomedical model, known as primary care, and the broader principles of PHC was evident. Our analysis explored how the perpetuation of the neoliberal health policy environment through a "hands-off" approach from central government and district health boards resulted in a highly fragmented and complex health sector. Ongoing policy and sector perseverance to support privately owned physician-led general practice; a competitive contractual environment; and significant structural health sector changes, all restricted the establishment of NP services. Instead, commitment across the health sector is needed to ensure implementation of the NP workforce as autonomous mainstream providers of comprehensive PHC services.

What Went Wrong: Corona and the Worldafter the Full Stop.

This article examines the global response to the Covid‐19 pandemic. It argues that we urgently need to look beyond the virus if we want to understand the real seriousness of what is happening today. How did we end up in a space of thinking, acting, and feeling that has normalized extremes and is based on the assumption that biological life is an absolute value separate from politics? The author suggests that today's fear is fueled by mathematical disease modeling, neoliberal health policies, nervous media reporting, and authoritarian longings.

The U.S. Health Care System on the Eve of the Covid-19 Epidemic: A Summary of Recent Evidence on Its Impaired Performance.

Four decades of neoliberal health policies have left the United States with a health care system that prioritizes the profits of large corporate actors, denies needed care to tens of millions, is extraordinarily fragmented and inefficient, and was ill prepared to address the COVID-19 pandemic. The payment system has long rewarded hospitals for providing elective surgical procedures to well-insured patients while penalizing those providing the most essential and urgent services, causing hospital revenues to plummet as elective procedures were cancelled during the pandemic. Before the recession caused by the pandemic, tens of millions of Americans were unable to afford care, compromising their physical and financial health; deep-pocketed corporate interests were increasingly dominating the hospital industry and taking over physicians’ practices; and insurers’ profits hit record levels. Meanwhile, yawning class-based and racial inequities in care and health outcomes remain and have even widened. Recent data highlight the failure of policy strategies based on market models and the need to shift to a nonprofit social insurance model.

Neoliberalismo, violencia política y salud mental en Perú (1990-2006)

Introducción: el presente artículo examina los factores que han ocasionado el precario estado de la salud mental en el Perú, donde casi el 90 % de pacientes con síntomas asociados con problemas mentales no reciben tratamiento. Desarrollo: se analiza el programa neoliberal de salud implementado durante el gobierno de Alberto Fujimori (1990-2000). Posteriormente, se estudia cómo esta política pública afectó al programa de salud mental y al estado de la salud de la población. Finalmente, se examinan diversos diagnósticos sobre la salud mental posterior al retorno a la democracia en el año 2000, desde una per- spectiva de los derechos humanos. Esta investigación finaliza el año 2006, momento en que el gobierno presentó un nuevo Plan Nacional de Salud Mental. Conclusiones: la falta de acceso a un tratamiento adecuado a nivel nacional ha sido consecuencia directa del reducido gasto del Estado en materia de sa- lud, en especial hacia las enfermedades no transmisibles y de salud mental. Las políticas neoliberales de salud implementadas durante el gobierno de Alberto Fujimori redujeron el rol del Estado como garante del acceso universal a los servicios de salud, y situaron a la salud mental en un lugar marginal dentro de la salud pública. El retorno a la democracia en el año 2000, el informe final de la Comisión de la Verdad y Reconciliación (2003) y el llamado de organismos internacionales, Iglesias Católicas y Evangélicas, junto con ong, presionaron al gobierno para situar a la salud mental como parte importante de la agenda de pública de salud.

Saúde mental em Portugal, constrangimentos e desafios para o Serviço Social

Social Work in mental health implies an articulation of health with the social aspects and people’s and communities’ lives, in the dimensions of interaction and sociability. That is why the concept of Social Determinants of Mental Health contributes to base intervention. The concept of Multidimensional Social Work encompasses multiple aspects, and the issue of the identity of Social Work in technological society brings to light two tendencies, the positivist and the humanist. Social Work falls into the field of Human Rights, both civil, social and economic rights, redistribution and social justice, as well as cultural rights, identity and recognition, central to people with mental health problems. The role of social workers in mental health is part of the context of government policies, in which the intervention of Social Work will be analyzed, as well as the constraints that neoliberal health policies pose to the profession.

‘We need poverty reduction; not medicine’: Health, Wealth and Poverty in Developing Countries

Poor health and disease and the nature of interventions to ameliorate them typically generate opportunities and costs. What diseases are prevalent, which interventions are favoured and what factors fuel the nature of health interventions are recurrent concerns for political economic analysis. This paper juxtaposes the primary neoliberal health policy which emphasises a well-funded healthcare system with a health system underpinned by principles of social justice, namely, equity poverty and development. The evidence from across the Developing World suggests an urgent need to reconsider the ‘big money, more medicine’ policy framework.

It Gets Better If You Do? Measuring Quality Care in Puerto Rico

Quantifying quality is supposed to unite health policy, health plans, and health care consumers in a circuit of constant improvement. In practice, significant gulfs separate how policymakers, health plan administrators, and consumers write and talk about quality. Drawing on policy literature, ethnography inside a managed care organization, and interviews with health plan members, this article examines a quality improvement program at a health plan in Puerto Rico. The findings challenge the assumption underwriting neoliberal health policy that quality measurement leads to quality improvement.

The Cancer on Your Coffee Table

Women's magazines are a significant resource for information about women's health, but there are important variations in how they address health issues. A discourse analysis of 148 health articles and coverlines that appeared in nine top-circulating US women's magazines reveals how the magazines configure health problems of all types and how these messages engage with various feminist discourses. By looking at how agency, autonomy, and subjectivity are constructed, and identifying whether health problems and solutions are cast as individual or collective, the paper found reflections of postfeminist, liberal-feminist, and radical-feminist discourses. Findings indicate that health emerges as a metaphor for life in control through individual-oriented postfeminist wellness mandates, which dominate health coverage. Health as a decontextualized individual issue is especially suitable within the contexts of a consumerist reading environment and of the broader US neoliberal health policy. Alternately, women who suffer from disease confound the “will to health” and thus are allowed liberal-feminist agentic subjectivity and can question the system from a radical-feminist perspective. There are also a few examples of articles that deal with political health issues, reflecting radical-feminism. Text that engages with liberal- and radical-feminist discourses is much less prevalent than text that espouses postfeminist hyperindividualism.

Disintegrated care: the Achilles heel of international health policies in low and middle-income countries

To review the evidence basis of international aid and health policy. Current international aid policy is largely neoliberal in its promotion of commoditization and privatisation. We review this policy's responsibility for the lack of effectiveness in disease control and poor access to care in low and middle-income countries. National policies, international programmes and pilot experiments are examined in both scientific and grey literature. We document how health care privatisation has led to the pool of patients being cut off from public disease control interventions--causing health care disintegration--which in turn resulted in substandard performance of disease control. Privatisation of health care also resulted in poor access. Our analysis consists of three steps. Pilot local contracting-out experiments are scrutinized; national health care records of Colombia and Chile, two countries having adopted contracting-out as a basis for health care delivery, are critically examined against Costa Rica; and specific failure mechanisms of the policy in low and middle-income countries are explored. We conclude by arguing that the negative impact of neoliberal health policy on disease control and health care in low and middle-income countries justifies an alternative aid policy to improve both disease control and health care.

Integrated care: a fresh perspective for international health policies in low and middle-income countries

To propose a social-and-democrat health policy alternative to the current neoliberal one. The general failure of neoliberal health policies in low and middle-income countries justifies the design of an alternative to bring disease control and health care back in step with ethical principles and desired outcomes. National policies, international programmes and pilot experiments--including those led by the authors--are examined in both scientific and grey literature. We call for the promotion of a publicly-oriented health sector as a cornerstone of such alternative policy. We define 'publicly-oriented' as opposed to 'private-for-profit' in terms of objectives and commitment, not of ownership. We classify development strategies for such a sector according to an organisation-based typology of health systems defined by Mintzberg. As such, strategies are adapted to three types of health systems: machine bureaucracies, professional bureaucracies and divisionalized forms. We describe avenues for family and community health and for hospital care. We stress social control at the peripheral level to increase accountability and responsiveness. Community-based, national and international sources are required to provide viable financing. Our proposed social-and-democrat health policy calls for networking, lobbying and training as a joint effort in which committed health professionals can lead the way.

If they get sick, they are in trouble: health care restructuring, user charges, and equity in Vietnam.

The transition from a centrally planned economy in the 1980s and the implementation of a series of neoliberal health policy reform measures in 1989 affected the delivery and financing of Vietnam's health care services. More specifically, legalization of private medical practice, liberalization of the pharmaceutical industry, and introduction of user charges at public health facilities have effectively transformed Vietnam's near universal, publicly funded and provided health services into a highly unregulated private-public mix system, with serious consequences for Vietnam's health system. Using Vietnam's most recent household survey data and published facility-based data, this article examines some of the problems faced by Vietnam's health sector, with particular reference to efficiency, access, and equity. The data reveal four important findings: self-treatment is the dominant mode of treatment for both the poor and nonpoor; there is little or no regulation to protect patients from financial abuse by private medical providers, pharmacies, and drug vendors; in the face of a dwindling share of the state health budget in public hospital revenues and low salaries, hospitals increasingly rely on user charges and insurance premiums to finance services, including generous staff bonuses; and health care costs, especially hospital costs, are substantial for many low- and middle-income households.

“Managing” the poor: Neoliberalism, medicaid HMOs and the triumph of consumerism among the poor

In order to explore the contradictions of neoliberal health policy, this article examines Medicaid managed care in Philadelphia. At the federal and state levels, government is increasingly promoting private‐sector market‐based strategies over policies formerly associated with the welfare state, arguing that the former are the most effective means of achieving economic growth and guaranteeing social welfare. A prime example of this shift, Medicaid managed care is a policy by which states contract with private‐sector health maintenance organizations to provide health coverage to the poor. Drawing on ethnographic and historical data, this paper shows how Pennsylvania's Medicaid managed care program has created access barriers for poor Philadelphians. It also illustrates how ideologies that justify this policy shift serve to mask its detrimental effects on the poor. By contrasting the state's consumerist model with one group's protest efforts, this article calls into question the neoliberal ideology that undergirds health and welfare “reform.”

Crisis, Neoliberal Health Policy, and Political Processes in Mexico

The Mexican case represents an orthodox neoliberal health policy in the context of the structural adjustment adopted by the Mexican government in 1983. The social costs of this strategy are very high, including an increase in unemployment, wage depression, regressive redistribution of wealth, and profound changes in social policies. These transformations are reflected in the health sector, where the four main axes of neoliberal policy--expenditure restrictions, targeting, decentralization, and privatization--have been implemented. This represents a change in social policy from a model based on citizens' social rights and the state's obligation to guarantee them, to a model characterized by selective public charity. This strategy has been imposed on society as a result of the Mexican corporative political regime based on a state party system. Since 1985, however, there has been a growing process of independent organization of civil society. This led in the presidential elections of 1988 to the defeat of the candidate of the governing party by the candidate of a popular-democratic opposition front. Although the government party imposed its candidate through electoral fraud, social mobilization against neoliberal policies continues in the midst of an important political crisis that can only be resolved by profound democratization of Mexican society.