Poor medicine for poor people? Assessing the impact of neoliberal reform on health care equity in a post-socialist context

Abstract

Driven in part by a resurgent interest in social inequality and health, and in part by increasing scrutiny of the social and health consequences of neoliberal economic reform, principles of health equity and social justice, the centerpieces of the Health for All strategy drafted at Alma Ata in 1978, are once again at center stage in global public health debates. Whether and how equity in access to health care can be maintained in a context of market-based health sector reform has not been systematically addressed, particularly from the perspective of local communities. This paper will explore how health reform affects health care in post-socialist Mongolia. Through a mixed-methods household-based study of low-to-middle income communities in urban and rural Mongolia we find that despite explicit and concerted efforts to reduce inequities, the reform system is unable to provide equitable health care either vertically or horizontally. Emphasis on privatization of the secondary and tertiary sectors of the system, coupled with deployment of universally-accessible, but from a clinical standpoint, limited, version of essential primary care, produces a fragmented system. Particularly for the vulnerable poor, access to services beyond the primary care system is compromised by financial, opportunity, and informational cost barriers. This research suggests that new models of health reform are needed that will effectively bridge the growing gaps between public and private resources, primary and secondary and/or tertiary care, and clinical and public health services.

Hospitalization in Tajikistan: determinants of admission, length of stay, and out‐of‐pocket expenditures. Results of a national survey

“…This finding can be illustrated through the observation of repeated hospitalization events for the chronically ill and the disabled, as well as through expenditures on repeated consultations, diagnostics, laboratory testing, and the cost of pharmaceuticals (Janes et al, 2006). Similarly, (having undergone surgery) and intensive care are strongly associated with an increase in out-of-pocket payments for hospitalization.…”

Health dispossessions and the moralization of disease: the case of diarrhea in the Mekong Delta, Vietnam

“…These tendencies are also observable in posttransitional (Springer 2010) and (post)socialist contexts (Bohle and Greskovits 2007). They produce a "cacophony of socialist and neoliberal governmentality" (Bui 2015), strongly felt in the field of health (Janes et al 2006). Lincoln (2014) has shown how "healthism" and the individualization of health responsibilities played out during a 2007/2009 cholera epidemic (severe form of diarrhea) in Northern Vietnam, illustrating how "officials, media, and citizens not only identified scapegoats and proposed solutions, but also endorsed particular visions of moral conduct, social order, and public health" (Ibid.…”

Herders and hazards: covariate dzud risk and the cost of risk management strategies in a Mongolian subdistrict

“…Agricultural sector 1 3 reform plans were not suited to the dire situation of the country at the time (Nixson et al 2000), and many were forced into a subsistence mode of production with households bearing all the risks of pastoralist production. Immediate outcomes of the privatization process combined with economic crisis were significant problems with distribution and an increase in poverty and wealth inequality (Janes and Chuluundorj 2004;Janes et al 2006;Nixson and Walters 2006;Rak and Janes 2004).…”

“…Similarly, Janes and Chuluundorj's (2015) nationwide survey from 2001 to 2003 concluded that the difference between dzud as a climate hazard and dzud as a disaster lies in socio-economic factors and forms of governance. These authors illustrate that herders are not only managing highly variable natural environments, but also produce in fluctuating economic conditions which increase vulnerability to natural hazards.…”

“…These authors illustrate that herders are not only managing highly variable natural environments, but also produce in fluctuating economic conditions which increase vulnerability to natural hazards. Thus, this article builds upon the critique developed by Janes and Chuluundorj (2015) regarding lack of investment in the pastoral sector for covariate risk mitigation, "While hazards may not be modifiable by human agency, vulnerability is: disaster prevention hinges on the mitigation of those processes that produce it". In their view, vulnerability to natural hazards is a social phenomenon and can be addressed through human action at a variety of scales.…”