Arne Ruckert

The global financial crisis and health equity: toward a conceptual framework

In this article, we identify pathways that link the global financial crisis to health equity. We distinguish between direct and indirect channels of influence, and develop a conceptual model that builds on the literature analyzing the impacts of globalization on social determinants of health. The most pertinent direct pathways discussed are economic contraction, health budget cutbacks, rise in unemployment, and qualitative transformations of health systems. We also outline how other indirect channels of influence are likely to affect health equity, including cutbacks to welfare programs, labor market transformations, the emergence of an ideological climate conducive to austerity politics, and reductions in official development assistance. We conclude by suggesting that the current intensification of neoliberal policy implementation is likely to undermine health equity, and that a different path toward economic recovery is required to ensure equitable access to health care.

The Trans-Pacific Partnership: Is it Everything We Feared for Health?

BACKGROUND Negotiations surrounding the Trans-Pacific Partnership (TPP) trade and investment agreement have recently concluded. Although trade and investment agreements, part of a broader shift to global economic integration, have been argued to be vital to improved economic growth, health, and general welfare, these agreements have increasingly come under scrutiny for their direct and indirect health impacts. METHODS We conducted a prospective health impact analysis to identify and assess a selected array of potential health risks of the TPP. We adapted the standard protocol for Health impact assessments (HIAs) (screening, scoping, and appraisal) to our aim of assessing potential health risks of trade and investment policy, and selected a health impact review methodology. This methodology is used to create a summary estimation of the most significant impacts on health of a broad policy or cluster of policies, such as a comprehensive trade and investment agreement. RESULTS Our analysis shows that there are a number of potentially serious health risks associated with the TPP, and details a range of policy implications for the health sector. Of particular focus are the potential implications of changes to intellectual property rights (IPRs), sanitary and phytosanitary measures (SPS), technical barriers to trade (TBT), investor-state dispute settlement (ISDS), and regulatory coherence provisions on a range of issues, including access to medicines and health services, tobacco and alcohol control, diet-related health, and domestic health policy-making. CONCLUSION We provide a list of policy recommendations to mitigate potential health risks associated with the TPP, and suggest that broad public consultations, including on the health risks of trade and investment agreements, should be part of all trade negotiations.

The global financial crisis and health equity: Early experiences from Canada

BackgroundIt is widely acknowledged that austerity measures in the wake of the global financial crisis are starting to undermine population health results. Yet, few research studies have focused on the ways in which the financial crisis and the ensuing ‘Great Recession’ have affected health equity, especially through their impact on social determinants of health; neither has much attention been given to the health consequences of the fiscal austerity regime that quickly followed a brief period of counter-cyclical government spending for bank bailouts and economic stimulus. Canada has not remained insulated from these developments, despite its relative success in maneuvering the global financial crisis.MethodsThe study draws on three sources of evidence: A series of semi-structured interviews in Ottawa and Toronto, with key informants selected on the basis of their expertise (n = 12); an analysis of recent (2012) Canadian and Ontario budgetary impacts on social determinants of health; and documentation of trend data on key social health determinants pre- and post the financial crisis.ResultsThe findings suggest that health equity is primarily impacted through two main pathways related to the global financial crisis: austerity budgets and associated program cutbacks in areas crucial to addressing the inequitable distribution of social determinants of health, including social assistance, housing, and education; and the qualitative transformation of labor markets, with precarious forms of employment expanding rapidly in the aftermath of the global financial crisis. Preliminary evidence suggests that these tendencies will lead to a further deepening of existing health inequities, unless counter-acted through a change in policy direction.ConclusionsThis article documents some of the effects of financial crisis and severe economic decline on health equity in Canada. However, more research is necessary to study policy choices that could mitigate this effect. Since the policy response to a similar set of economic shocks has globally varied and led to differential health and health equity outcomes, comparative studies are now possible to assess the successes and failures of specific policy responses. This raises the question of what types of public policy can mitigate against the negative health equity effects of severe economic recessions.

Producing Neoliberal Hegemony? A Neo-Gramscian Analysis of the Poverty Reduction Strategy Paper (PRSP) in Nicaragua

Arne Ruckert, in his article “Producing Neoliberal Hegemony? A Neo-Gramscian Analysis of the Poverty Reduction Strategy Paper (PRSP) in Nicaragua,” examines the hegemonic aspects of poverty reduction strategies in the post Washington consensus. In his critical reading of the PRSP, Ruckert considers the extent to which this latest global “development” initiative differs from earlier structural adjustment programs. Taking Nicaragua as his case study, Ruckert argues that the PRSP can be seen as an attempt by international financial institutions to rebuild hegemony, but this is not the only result. Ruckert explores not only the ways in which counterhegemonic ideas can be drawn into the service of neoliberalism, but also how those ideas can have positive, perhaps unintended, effects.Introduction Over the last two decades, the World Bank and the International Monetary Fund (IMF) have played an increasingly important role in structuring developing country societies and economies. By linking concessional lending to structural conditionalities, in many cases these international financial institutions (IFIs) have exerted enormous influence over the ways in which developing countries have integrated themselves into the world economy. Moreover, through structural adjustment programs (SAPs), the IFIs have been partly successful at amending the social and economic fabric of developing countries. However, SAPs have recently come under heavy criticism for their disappointing development results, the inherent social costs associated with them, and the lack of country ownership of adjustment policies.1 In recent years, the IFIs themselves have acknowledged shortcomings of the SAP development approach,2 and have expressed their intention to move away from the Washington Consensus towards a new lending paradigm based on a new Post-Washington Consensus (PWC).3 This move found expression in the introduction of the Comprehensive Development Framework (CDF), which represents the overarching policy design of the PWC and was first articulated in 1997 by former World Bank president James Wolfensohn and the Poverty Reduction Strategy Paper (PRSP), the most visible policy tool of the PWC, which was introduced to the development community in 1999 at the G8 summit in Cologne. According to

Post-Neoliberalism in the Americas: An Introduction

Future historians may well look back upon the beginning of the twenty-first century as a major turning point in the social and economic history of the Americas. In quick succession, left-wing political parties were elected to office in the majority of Latin American countries, and close to 60 percent of Latin America’s total population is currently governed by leaders who consider themselves to be on the left of the political spectrum (Arnson 2007b: 3). This shift to the left started when, in Venezuela, Hugo Chavez ascended to power in a landslide victory in 1998 with a strong commitment to progressive social policy and the promise of developing a “new socialism for the 21st century.” This was followed by the election of Ricardo Lagos, leader of the Socialist Party of Chile in 2000, and the electoral victory of Lula da Silva’s Worker’s Party in Brazil in 2002, both promising to address the dismal situation of their countries’ poor and to modify prevailing neoliberal policies. In South America, Argentina and Bolivia followed suit, with Nestor Kirchner ascending to power in Argentina in 2003 and Evo Morales, leader of the first indigenous socialist movement in Bolivia —El Movimiento al Socialismo (MAS)—entering office on an anti-neoliberal platform in 2005.

Public-private partnerships (ppps) in global health: the good, the bad and the ugly

Global Health Partnerships (ghps) have become ubiquitous within global health governance (ghg). Even before the onset of the global financial crisis public–private partnerships (ppps) were an omnipresent policy tool in global health and in the current austerity climate ppps have been heralded as an effective way to address a growing resource gap in ghg. Despite their omnipresence, ghps have not received adequate attention from critical scholars; few efforts have been made conceptually and theoretically to grasp how ppps are transforming the logic of ghg. We argue that ghps have contributed to the emergence of a complex global health governance architecture in which private solutions (market mechanism) are generally privileged over public approaches. Drawing on Gramscian conceptualisations of public/private, we suggest that the reshaping of the private and public realm inherent to ppps represents a further deepening of the neoliberal management of individuals and populations, allowing private interest to become more embedded within the public sphere and to influence global and national health policy making. This undermines the attempt to improve global health results as the inequitable distribution of social determinants of health, especially poverty and social exclusion, remain the main barriers to achieving health for all.

The forgotten dimension of social reproduction: the World Bank and the poverty reduction strategy paradigm

ABSTRACT This article invokes Gramscian theory in an effort to better grasp the reorganization of social reproduction under neoliberal globalization. It argues that recent transformations in the world development order warrant a rethinking of the concept of social reproduction, towards acknowledging the increasingly apparent role of transnational governance institutions in organizing social reproduction processes, particularly in peripheral countries. To substantiate this argument, the article interrogates the Poverty Reduction Strategy Paper development approach, the most visible policy tool of the post-Washington Consensus. In the Poverty Reduction Strategy Paper process, the World Bank has started to link debt relief administered through the Enhanced Heavily Indebted Poor Country (HIPC II) initiative to the delivery of basic social services to the poor, and directly finances human capital investments through conditional cash transfer programs. While conditionalities attached to Bank funding continue to promote the privatization of various state functions associated with social reproduction, especially in the areas of health care and education, the Bank, at the same time, funds ‘social inclusion’ programs that directly absorb some of these functions. This signals the emergence of a new social reproduction regime of ‘conditional inclusion’ under World Bank leadership.

The financial crisis and global health: the International Monetary Fund's (IMF) policy response

In this article, we interrogate the policy response of the International Monetary Fund (IMF) to the global financial crisis, and discuss the likely global health implications, especially in low-income countries. In doing so, we ask if the IMF has meaningfully loosened its fiscal deficit targets in light of the economic challenges posed by the financial crisis and adjusted its macro-economic policy advice to this new reality; or has the rhetoric of counter-cyclical spending failed to translate into additional fiscal space for IMF loan-recipient countries, with negative health consequences? To answer these questions, we assess several post-crisis IMF lending agreements with countries requiring financial assistance, and draw upon recent academic studies and civil society reports examining policy conditionalities still being prescribed by the IMF. We also reference recent studies examining the health impacts of these conditionalities. We demonstrate that while the IMF has been somewhat more flexible in its crisis response than in previous episodes of financial upheaval, there has been no meaningful rethinking in the application of dominant neoliberal macro-economic policies. After showing some flexibility in the initial crisis response, the IMF is pushing for excessive contraction in most low and middle-income countries. We conclude that there remains a wide gap between the rhetoric and the reality of the IMFs policy and programming advice, with negative implications for global health.

Policy coherence, health and the sustainable development goals: a health impact assessment of the Trans-Pacific Partnership

Abstract The international community, comprised of national governments, multilateral agencies and civil society organisations, has recently negotiated a set of 17 sustainable development goals (SDGs) and 169 targets to replace the Millennium Development Goals, which expired in 2015. For progress in implementing the SDGs, ensuring policy coherence for sustainable development will be essential. We conducted a health impact assessment to identify potential incoherences between contemporary regional trade agreements (RTAs) and nutrition and health-related SDGs. Our findings suggest that obligations in RTAs may conflict with several of the SDGs. Areas of policy incoherence include the spread of unhealthy commodities, threats to equitable access to essential health services, medicines and vaccines, and reduced government regulatory flexibility. Scenarios for future incoherence are identified, with recommendations for how these can be avoided or mitigated. While recognising that governments have multiple policy objectives that may not always be coherent, we contend that states implementing the SDGs must give greater attention to ensure that binding trade agreements do not undermine the achievement of SDG targets.

Globalization and the rise of precarious employment: the new frontier for workplace health promotion:

Global market integration over the past three decades has led to labour market restructuring in most countries around the world. Employment flexibility has been emphasized as a way for employers to restructure their organizations to remain globally competitive. This flexibility has resulted in the growth of precarious employment, which has been exacerbated by the global financial crisis and resulting recession in 2007/2008, and the ongoing economic uncertainty throughout much of the world. Precarious employment may result in short and long-term health consequences for many workers. This presents a deeper and more structural determinant of health than what health promoters have traditionally considered. It calls for a different understanding of workplace health promotion research and intervention that goes beyond enabling healthier lifestyle choices or advocating safer workplace conditions to ensuring adequate social protection floors that provide people with sufficient resources to lead healthy lives, and for advocacy for taxation justice to finance such protection.