Neoliberalism Redux: The Global Health Policy Agenda and The Politics of Cooptation in Latin America and Beyond

Debate
Neoliberalism Redux: The Global Health Policy

Agenda and the Politics of Cooptation in Latin America
and Beyond
Anne-Emanuelle Birn, Laura Nervi and Eduardo Siqueira
ABSTRACT
This article explores the neoliberal cooptation of social justice-oriented

global health policies over the last three decades, from primary health care and
‘health for all’ to various contemporary so-called ‘health equity’ initiatives,
such as Universal Health Coverage and ‘health convergence’. The authors
illustrate and contextualize the different periods and approaches with exam-
ples from a range of Latin American countries, drawing on diverse political
experiences and social struggles in the health arena. The analysis concludes
with reflections about the region’s experiences of resisting and challenging
the neoliberal health agenda, in spite of domestic and global environments
that have constrained these efforts, past and present. In this sense, the strug-
gle for bona fide equity in health and health policy remains an important and
ongoing priority.
INTRODUCTION
In the space of just a few years, the goal of Universal Health Coverage
(UHC) has risen to the top of the global health agenda, even becoming one
of the pillars of the UN’s new Sustainable Development Goals (SDGs). On
one level this appears to represent the successful fruition of decades-long
struggles by progressive forces around the world for public, universal health
systems in the context of health and development equity. Yet on another
level, as witnessed across the Americas, the rise of UHC as a global prior-
ity does not portend the creation of comprehensive, unified and single-tier
health systems, but rather a cooptation of such approaches by privatized or
semi-privatized, segmented and fragmented, ‘pluralistic’, profiteering, and
Our thanks go to Mariajosé Aguilera, Esperanza Krementsova, Ramya Kumar, Devaki Nambiar,
the anonymous reviewers and the editors of Development and Change.
Development and Change 00(0): 1–26. DOI: 10.1111/dech.12247

C 2016 International Institute of Social Studies.
2 Anne-Emanuelle Birn, Laura Nervi and Eduardo Siqueira
ultimately inequitable arrangements for universalizing partial and insuffi-

cient health insurance coverage.
While perhaps seeming to outsiders an arcane or semantic debate relevant
solely to global health specialists, the UHC cooptation story is illustrative of
the fate of many progressive international and global health policy efforts in
the context of neoliberal globalization over the past three decades. Further,
given that the health sector (or the medical industrial complex) constitutes
around 10 per cent of world GDP or US$ 6.5 trillion, including both public
and private spending (WHO, 2012; World Bank, 2016), what happens in the
massive health arena has enormous repercussions for society writ large.
Cooptation, a word coined in the seventeenth century to refer to the self-
selection of new members by an existing committee or group, came to
mean ‘the process of absorbing new elements into the leadership or policy-
determining structure of an organization as a means of averting threats to its
stability or existence’ (Selznick, 1949/1966: 13) in the mid-twentieth cen-
tury. More recently, the concept has been taken to connote the assimilation
of political movements and/or their ideas and leaders into dominant agendas
that contradict the project or mission of these movements or organizations.
Here we refer to cooptation as the process of decontextualized and selec-
tive appropriation of the progressive health justice agenda and discourse by
re-emergent neoliberal ideologies and actors.
This article examines the cooptation of social justice-oriented global health
policies over the last three decades, from primary health care and ‘health
for all’ to various so-called ‘health equity’ initiatives, drawing from a range
of Latin American examples. Our analysis concludes with reflections about
the region’s experiences of resisting and challenging the neoliberal health
agenda, in spite of domestic and global environments that have constrained
these efforts, past and present. In this sense, the struggle for bona fide equity
in health and health policy remains an important and ongoing priority, even as
proponents of highly visible initiatives (such as the SDGs) claim that equity,
universality and other health justice concerns are being amply addressed
through mainstream approaches.
THE DEEP ROOTS OF LATIN AMERICAN STRUGGLES FOR HEALTH

JUSTICE
Latin America is a particularly useful vantage point from which to analyse

health and social justice efforts and their cooptation, due to the century-long
experience of popular mobilization for improved working and living con-
ditions — including health services — as well as the perennial quashing
of these movements and the sometime appropriation of their aims. More-
over, as we shall see, Latin America has served as a key experimental
venue for several waves of neoliberal reforms in recent decades (Robinson,
2014).
Debate: The Cooptation of Global Health in Latin America 3
Although most of the region attained independence in the nineteenth cen-

tury (Cuba and Puerto Rico being notable exceptions), it was long charac-
terized by weak and unstable states, US/European economic dominance and
political interference, marginalization of indigenous and rural populations,
late industrialization, and concentration of land in the hands of elites. Yet
once countries in the region embarked upon concerted state-building efforts
in the late nineteenth and early twentieth centuries, these were accompa-
nied by a range of (initially mostly urban) highly vocal labour and social
movements. Building on burgeoning friendly societies of workers, these
movements incorporated demands for health care into struggles for better
working and living conditions, which at times were parlayed into concrete
victories (Garcı́a, 1981–2).
An early hallmark was Chile’s 1924 passage of statutory social insurance
for industrial workers, among the first outside of Europe, enabled by intense
working class and socialist struggles for a more just and equitable society.
After the leftist Popular Front coalition won the 1938 national elections, the
health minister at the time, Salvador Allende, a socialist physician, set the
wheels in motion for Chile’s Servicio Nacional de Salud (SNS), which was
ultimately enacted into law in 1952 under a more centrist administration
seeking to court the support of unions/militant labourites. Comparable to
the UK’s National Health Service launched in 1948, the SNS was one
of the world’s most comprehensive health care policies with significantly
expanded access to care for workers, dependants and the indigent; it was the
culmination of decades of mobilization by unions, social movements and
progressive health professionals, working with and through leftist political
parties (Illanes, 1993; Waitzkin, 2011).
Unlike other Latin American health care legislation at the time, Chile’s
SNS sought to integrate financing and provision of health services into an
umbrella public system that unified and centralized a variety of welfare insti-
tutions and medical insurance for industrial workers, although, like Britain,
Chile was not able to abolish private practice. On the cusp of Allende’s
election as President in 1970, the project to unify the health system under a
single, public payer met such fierce opposition among powerful physician
groups and private sector elites that it was not explicitly included in his
Popular Unity party’s platform of nationalization and redistribution. Then,
following the 1973 CIA-backed military coup that deposed Allende, Chile’s
landmark SNS achievement was brusquely overturned, just twenty-one years
after it was launched. The privatization reforms that followed under Au-
gusto Pinochet’s military dictatorship are considered by many to have been
an incubator for neoliberal policies in the health and social security sectors
(De Vos and Van der Stuyft, 2015).
Chile’s experience, though more dramatic –– in both the SNS’s early and
far-reaching coverage and its abrupt toppling –– was consistent with efforts
elsewhere. Through the mid-twentieth century, urban (and parts of agrarian)
Latin America became heavily unionized, with workers actively pressing
for a range of social benefits. There were major advances towards health
justice in Argentina in the late 1940s and early 1950s, Mexico in the 1930s
and 1940s, and various other countries, particularly those in the first wave
to establish social security for industrial workers (including Brazil, Costa
Rica, Cuba and Uruguay) (Mesa-Lago, 2012). However, as with Argentina’s
labour movement, among the pioneering and most militant on the continent,
unions were at times divided, and governments coopted some unions, played
favourites to dissipate power, and subjected organized labour to severe re-
pression during periods of authoritarianism. Despite these obstacles, many
workers’ organizations and social movements continued demanding access
to health care services and other social policies for all (Birn and Nervi, 2015).
In addition to domestic political and social dynamics, an important factor
in understanding the impulse for universal and equitable health and social
welfare systems in Latin America is the role of international exemplars,
including Bismarck’s compulsory social insurance scheme (part of his carrot
and stick policy of tempering working class unrest), based on regional,
sector- and occupation-specific ‘sickness funds’ launched in Germany in
1883, and the Soviet Union’s nationalized health system deriving from the
citizen right to health care, developed in the 1920s under Health Commissar
Nikolai Semashko. In Latin America just one country, Cuba, ultimately
adopted a fully publicly funded and delivered health system that transcended
the inequities of fragmentation and segmentation, though it differed from
the Soviet model. As we shall see, it remains the only country and health
system that has not been penetrated by neoliberalism and that has avoided
the cooptation of its health reforms.
FROM THE COLD WAR TO THE RISE OF NEOLIBERALISM:

THE BEGINNINGS OF COOPTATION IN INTERNATIONAL HEALTH
Although the struggles portrayed above unfolded in national contexts, Latin

American developments in health (as in other fields) were increasingly tied
to international actors and the now dominant capitalist order. The Americas
served as a testing ground for the possibilities of early international health
organizations, including the first multilateral health agency, the Washing-
ton DC-based Pan American Sanitary Bureau (founded in 1902; today the
Pan American Health Organization, WHO’s regional office), which was
initially focused on sanitary agreements to stave off epidemics that might
disrupt commerce. The Rockefeller Foundation, the influential private US
philanthropic organization that in the early twentieth century developed an
enduring model of international health based on technical disease campaigns
and asymmetrical agenda-setting, also pioneered its approaches in the region
(Birn, 2006; Palmer, 2010).
In the mid-twentieth century, health multilateralism secured a broader
institutional footing, one that would be shaped by a new set of priorities.
Following short-lived utopian aspirations for post-World War II health co-

operation to build on the League of Nations’ interrupted progressive efforts
to address the social and political context of health, international health
became swept up in Cold War concerns. International health — including
the flagship targeted campaigns of the World Health Organization against
yaws, malaria and smallpox, among other diseases (Cueto, 2007; Manela,
2014; Packard, 1998; Stepan, 2011), and US-led population control activ-
ities (Necochea López, 2014) — became a pawn in the Soviet–American
competition for power and influence.
The two major blocs were not always in control of the agenda, however. In
the 1970s, the WHO’s disease-focused, donor-driven approach began to be
challenged both by member countries — especially the non-aligned move-
ment and Group of 77 countries (G-77), which were advocating cooperative
efforts consistent with a New International Economic Order (NIEO), seeking
national sovereignty and fair terms of trade and aid (Benjamin, 2015) — and
from within its own headquarters, under the visionary leadership of its Dan-
ish Director-General Halfdan Mahler (first elected in 1973, and re-elected
until 1988). The primary health care (PHC) movement, enshrined in the sem-
inal 1978 WHO-UNICEF Conference and Declaration of Alma-Ata (WHO,
1978), in which over 130 governments were represented, held that health
should be addressed as a fundamental human right through integrated so-
cial and public health measures that recognized the economic, political and
social context of health, rather than through top-down, techno-biological
campaigns (Mahler, 1976). Entailing complex political negotiations at all
levels, this call for ‘urgent and effective national and international action
to develop and implement [PHC] throughout the world’ (WHO, 1978: 6) in
order to achieve ‘health for all . . . by the year 2000’ (ibid.: 5) represented
an explicit ideological (NIEO-framed) alternative to the existing disease-
control modus operandi.
The heart of the Alma-Ata strategy — a commitment to addressing
the roots of leading health problems, including inadequate nutrition, poor
sanitation, and social and economic inequality, from an intersectoral and
community-based PHC approach — generated enormous discursive cur-
rency and receptivity from numerous governments. But it was quickly
coopted. In the wake of Alma-Ata, the Rockefeller Foundation sponsored a
meeting and study promoting ‘selective primary health care’ (SPHC) — a
reductionist technical approach based on vaccines and vector control — to
replace the broad view of PHC, which it deemed ‘above reproach’ but overly
ambitious and insufficiently cost-effective (Walsh and Warren, 1979). Pres-
sure by the US government, especially, to adopt SPHC’s utilitarian promise
of visible results led UNICEF, the WHO and various bilateral agencies to
work for several decades on a far narrower agenda than that envisioned by
the Alma-Ata declaration (Cueto, 2004; Taylor and Jolly, 1988).
Meanwhile, ideological tensions over PHC and other WHO initiatives
and resolutions (including a formulary of generic essential medicines and
a code to prevent the unethical corporate marketing of breast-milk substi-

tutes) led WHO’s largest donor, the USA, to withdraw considerable support.
Formally, the excuse was that the WHO was inefficient, autocratic and
poorly managed (an accusation that might be levelled at many bureaucra-
cies). In reality, the opposite was true, at least in regards to PHC. PHC’s
call for the public provision of primary care, together with social and eco-
nomic measures, was efficient, redistributive and participatory; however,
it threatened the emerging, soon-to-be dominant ideological paradigm of
neoliberalism.
By 1980, amidst right-wing power-mongering and Cold War fears that
Cuba’s revolutionary turn would sweep through the continent, many Latin
American countries were ruled by US-backed military dictatorships and
other authoritarian governments. These regimes repressed opposition move-
ments (including but not exclusively those that called for socialism, ethical
governance and radical economic redistribution) and also facilitated the re-
turn of earlier neoclassical economic models (Veblen, 1900) emphasizing
individual rational actors and de-emphasizing state protections. Most Latin
American governments rejected, or in some cases coopted, the Alma-Ata
approach, instead favouring SPHC, which fitted the ascendant strategies of
targeted short-term programmes in the absence of rights, fragmentation of
social policy, and increased community responsibility for health services
delivery — fallaciously dubbed participation, again appropriating PHC’s
ideal of local decision making (Nervi, 2008; Testa, 1985; Ugalde, 1985).
One short-lived exception was Nicaragua, which made impressive strides
for PHC for several years following the 1979 Sandinista revolution (Garfield
and Williams, 1992) — an effort ultimately aborted when the Frente Sandin-
ista lost the elections in 1990 after a US-backed destabilization war involving
mercenary fighters.
The turn to neoliberal capitalism up-ended public sector investment prior-
ities, instead promoting policies aimed at reducing social spending, privatiz-
ing state-led industries and activities, and reorienting regulations to favour
business at the expense of protecting the public. The Soviet Union, facing
its own political and economic crises, no longer provided a counterbalance
to this ‘Washington Consensus’. By the mid-1980s, the WHO’s role as an
intergovernmental entity at the fulcrum of international health agenda setting
and activities had fundamentally changed. Its dues from member countries
plummeted, and it was displaced by agencies not subject to democratic
policy-making processes — UNICEF in the area of SPHC implementa-
tion, then the World Bank in health financing and reform, and, eventually,
UNAIDS in HIV control. A wholesale shift occurred, with a plethora of
alliances, partnerships and initiatives seeking to exercise private influence
over the WHO agenda and activities. Since then, these entities have shrewdly
drawn on the WHO for legitimacy, while maintaining a stranglehold over
its decision-making capacity; many are controlled by actors who cannot be
regarded as appropriate or ethical global health authorities and who have
no public accountability (Adams and Martens, 2015; Birn, 2014; Nambiar

et al., 2013; Richter, 2012).
PHASES OF NEOLIBERAL GLOBALIZATION AND HEALTH IN LATIN

AMERICA: CONTEXTUALIZING COOPTATION
While the debates over primary health care and the NIEO were unfolding,
the global political economy was undergoing turbulent change, caused by
a combination of the breakdown of the currency stability system forged in
Bretton Woods in 1944 and spikes in oil prices linked to turmoil in the Middle
East. While all but oil-exporting countries faced inflation and economic
stagnation, low- and middle-income countries (LMICs) were particularly
hard hit by rising oil prices and soaring interest rates.
By the early 1980s, a full-blown ‘debt crisis’ had materialized. Total
LMIC debt increased from US$ 70.2 billion in 1970 to US$ 579.6 billion
in 1980. Hastened by a 1979 rise in US interest rates to combat inflation,
Latin America’s debt, alone, more than doubled to US$ 327 billion in three
years.1 This led a band of countries across the continent to default on private
loans in rapid succession, beginning with Mexico in 1982. Mexico’s default
spread a financial shockwave across the continent (ECLAC, 1996; Prashad,
2012). As of October 1983, 27 LMICs, many in the Americas, had defaulted
on their loans or were in the process of rescheduling debts.
The International Monetary Fund (IMF) and World Bank began to furnish
loans to debtor countries to relieve balance-of-payments deficits and the
burden of servicing debt — as well as to bail out the private banking sector
in high-income countries. But the strings attached to these loans (condition-
alities) came at a high price: the implementation of structural adjustment
programmes (SAPs). SAPs, and subsequent loan programmes, compelled
major economic reforms designed to open domestic markets to foreign pen-
etration and stimulate low-cost exports. Reforms included: drastic cuts to
government spending (particularly in health and other social sectors) and
agricultural subsidies; removal of restrictions on foreign investments in in-
dustry and financial services; currency devaluation; and privatization of state
enterprises. While policies aiming to dismantle the welfare state and priv-
ilege and globalize the interests of capital first took hold in the Britain of
Margaret Thatcher and the USA of Ronald Reagan, the debt crisis provoked
an even more rapid transformation in Third World economies, with Latin
America as a laboratory. The economic crisis and reforms led to annual
inflation rates of up to 1500 per cent, poverty levels close to 50 per cent,
and large-scale capital flight from Latin America, all resulting in worsening
social indicators, such as infant mortality and school attendance (Musgrove,
1987). The 1980s became known as ‘The Lost Decade’, but since Latin
1. See: https://www.fdic.gov/bank/historical/history/191_210.pdf
America’s poverty rates did not come back down to 1970s levels until 2004,
it might be better to refer to the ‘lost quarter century’ (Ocampo, 2013).
While the debt crisis was the immediate impetus for interference by the
international financial sector, the termination of Latin America’s post-war
economic model — based on internal economic development and import
substitution policies — was an accompanying rationale. Political protests
against the concentration of power and wealth and demands for greater
redistribution provoked a brutal reaction from elite interests and conservative
sectors (backed by military forces and the USA) in a wave of dictatorships
from the mid-1950s to the 1980s; however, efforts to privatize the economy
and reduce the welfare state were incompletely realized (Pinochet’s Chile
serving as the ‘successful’ exception to this). The debt crisis thus offered
the opportunity for the neoliberal paradigm to penetrate deeply into Latin
America.
With huge cuts in public spending starting in the neoliberal onslaught of
the 1980s, compounded by existing fragmentation and extreme inequities,
huge swathes of the population had little or no access to healthcare. By
1990, most Latin American countries had embarked on extensive health sec-
tor reforms, many of which entailed privatization of both health and social
security systems, as advised by the World Bank and other financial agencies
(Armada et al., 2001). Specifically, these measures have included: increasing
penetration of financial capital in the health sector through growing private
health insurance coverage for those who can afford it, namely the healthy
and wealthy (exclusion of ‘high-risk’ individuals is a long-standing pri-
vate insurance practice throughout the Americas); and increasing the market
share of Big Pharma, as opposed to generic and public drug manufactur-
ers and distributors. Privatization within public health systems has taken
on different forms: the contracting of private hospitals and providers using
public funds; outsourcing of public system management; subcontracting of
the most profitable aspects of service delivery (for example, laboratories
and pharmacies); subcontracting of support services such as cleaning, food
services and patient transportation; outsourcing of public sector human re-
sources recruitment and management (including payroll); and other forms
of publicly subsidizing private providers and managers. In addition to the
private sector’s growing share of health insurance coverage, most policy
makers and administrators in Latin America agreed to charge user fees for
services provided by state-funded health institutions in order to increase rev-
enues and decrease demand. The proponents of these measures touted their
efficiency and transparency, even as they have produced opposite effects:
waste, unnecessary expenses, growing inequities and corruption.
In Latin America, with a larger middle class than many other LMIC
settings, another feature of neoliberalism flourished: the foreign penetration
of domestic insurance and pension markets that served formal sector workers
covered by social security systems. In the 1990s, US private pension and
health insurance investment soared in Latin America (Iriart et al., 2001);
in Colombia in 1994, a regulated health insurance market reform involving

both domestic and US insurance companies increased obstacles to access
and exacerbated inequities (Vargas et al., 2010); this famed, ‘exemplary’
(according to the World Bank) competition-oriented reform resulted in a
virtual collapse of the social security-based health system (Franco, 2013).
By the 2000s, the global implementation of neoliberal policies was lead-
ing to widespread resistance, in particular across a significant number of
Central and South American countries (as well as Mexico City), where so-
cial democratic or ‘pink’ governments invested in a series of initiatives to
expand health coverage, and in a number of policies to improve living and
working conditions, among other determinants of health, through publicly-
funded programmes under the principle of the right to health (ISAGS, 2012)
(discussed below). Yet many of the gains stemming from the redistributive
policies implemented within this counter-offensive are once again under at-
tack: neoliberal policies have clawed back ground, especially following the
Great Recession starting in 2008, which has ongoing (economic, political
and ideological) consequences (Borges et al., 2012).
INVESTING AND CONVERGING: EXAMINING COOPTATION

THROUGH TWO REPORTS, A GENERATION APART
While the contours of health reforms were set by financial directives, main-
stream development actors did not wish to leave the exact form of neolib-
eralization of LMIC health sector policies to chance. In the case of Latin
American countries returning to democracy, this meant circumscribing gov-
ernment responses to domestic constituencies which had pent-up, legitimate
claims on the state, for instance by re-infusing public financing into drained
public health systems. In 1993 the World Bank coopted the demand for
health sector investment by issuing its first health-oriented World Develop-
ment Report (WDR), entitled Investing in Health. Ironically and tragically,
the deterioration of health systems and the dire need for health investment
were products of the very loan conditionalities imposed by the International
Financial Institutions (IFIs) (Waitzkin et al., 2007). Moreover, the report
twisted popular demands for public investment in health into a policy pre-
scription encouraging private investment.
The WDR 1993 recommended that LMICs adopt a ‘basket’ of cost-
effective interventions — valued at US$ 12 per capita per year for the
lowest-income and US$ 21.50 for middle-income countries — as a top pub-
lic health priority. The basic basket theoretically covered immunization,
sick-child care, family planning, prenatal care and childbirth, treatment for
TB and sexually transmitted infections, and HIV prevention. Not included in
the recommended basket were treatments for chronic needs, such as diabetes
and mental illness, emergency treatment for many injuries, or broader public
health measures such as sanitation, many of which, the report argued, ought
to be provided by the private sector. The report based its recommendations

on the unsubstantiated assertion that in LMICs, private practitioners and
service providers for sanitation, housing and garbage collection are ‘often
more technically efficient than the public sector and offer a service that
is perceived to be of higher quality’ and more accountable (World Bank,
1993: 4).
Almost immediately, activists, advocates and many policy makers de-
nounced the prescriptions in the WDR 1993 for their narrow assessment
of health and health interventions, based almost exclusively on in-house
studies; for defining health care as a private good; for failing to recognize
the ongoing deleterious effects of SAPs on health care systems; and for dis-
regarding government responsibility for protecting health as a human right
(Laurell and López Arellano, 1996; Pfeiffer and Chapman, 2010). These
critiques, perhaps most forcefully from Latin American quarters, proved
prescient.
Although the report claimed ‘The main problem with universal govern-
ment financing is that it subsidizes the wealthy, who could afford to pay
for their own services, and thus leaves fewer government resources for the
poor’ (World Bank, 1993: 11), the reverse has been shown to be true, as
society-wide financing via progressive taxation helps ensure adequate re-
sources and broad public support for universal public systems (Hoddie and
Hartzell, 2014). Indeed, the 1990s privatization reforms drastically weak-
ened health systems, contributing to increasing gender, class and other so-
cial inequities. In spite of overwhelming evidence that private health ser-
vice delivery reduces access to care, especially among the marginalized
(Jasso-Aguilar and Waitzkin, 2015), the World Bank has actively encouraged
and promoted private health insurance marketplaces (Preker et al., 2010), as
per a key publication, Establishing Private Health Care Facilities in Devel-
oping Countries: A Guide for Medical Entrepreneurs (World Bank, 2007).
As previously noted, IFI-recommended user fees provided another mode
of promoting private financing for health, which the WHO and many health
ministers were gradually compelled to accept. Having been introduced with
particular intensity in Africa in the late 1980s as a cost-recovery/cost-sharing
mechanism for health systems jeopardized by SAPs, user fees became
widespread across LMICs. World Bank economists argued that market-
level user fees would generate health system revenues, improving access,
efficiency and quality of care. In addition, resources would shift from ex-
pensive in-patient treatment to more affordable primary health care services.
In sum, if patients paid for services, according to this sophistry, they would
use health resources more rationally.
It turned out that the Bank’s recommendations were based on ideology
rather than evidence, even though abundant research from Canada and other
settings had by then demonstrated that user fees reduced both access to
and utilization of care (e.g. Beck, 1974). Underscoring this, the World
Bank’s own in-house and external reviews have shown that fees resulted in
significant barriers to care (Lagarde and Palmer, 2011; Russell and Gilson,
1997), harming the very people they aimed to support — poor, rural popu-
lations. For example, when El Salvador eliminated user fees for the services
provided by the Ministry of Health through its network, both utilization
and equity improved markedly (MSPAS, 2009–2010). For years, numerous
governments, NGOs and advocacy groups called for abolition of user fees
in LMICs (PHM et al., 2005; Robert and Ridde, 2013). Only after more than
two decades has the World Bank finally recanted its position on user fees
(Rowden, 2013).
We now fast forward to 2013, when the world’s leading medical journal,
The Lancet, published ‘Global Health 2035: A World Converging within a
Generation’, produced by a Commission chaired by economists Lawrence
Summers and Dean Jamison, both intimately involved in the WDR 1993
and invited to build on its legacy (Jamison et al., 2013). The Commission’s
objective was to re-examine the case for investing in health and to develop a
global roadmap towards a ‘grand convergence’ in health: reducing the world-
wide burden of infectious diseases and reproductive, maternal, newborn and
child health disorders down to the current rates of Chile, China, Costa Rica
and Cuba, the lowest among LMICs (and lower than some HICs). Despite
presenting a potentially unifying rallying cry (and taking up the progressive
agenda’s concerns around mounting inequality along the way), the Commis-
sion’s report is devoid of any understanding of how the historical trajectory
or political economy and social justice struggles of these countries shaped
their health systems and health outcomes. Indeed, three of four highlighted
countries were part of the first era of welfare state building in Latin America
in the early to mid-twentieth century, and Cuba and Costa Rica have long
enjoyed publicly financed and delivered health care, with full and largely
equitable access — not to mention strong social investments in education,
housing and employment — and both have been at least partially effective
at staving off neoliberalism. Even Chile, which saw its efforts at building an
egalitarian welfare state torn asunder four decades ago, had by then among
the best indicators in the Third World.
Global Health 2035 proposes three goals to be achieved within two
decades: under-5 mortality of less than 16/1,000 live births; AIDS deaths
of below 8/100,000 population; and TB deaths of below 4/100,000 popula-
tion. It also advocates UHC under ‘progressive universalism’. This means
providing the poor with an essential package of services, graduating later to
a ‘larger benefit package’. These prescriptions are uncannily similar to the
failed IFI approaches of the 1980s and 1990s, and raise the same problems
regarding equity (which population-wide goals overlook): who decides what
is essential, and why there should be separate, scaled-down policies for the
poor instead of equal and comprehensive services for all based on the right
to health.
Similar to other such reports, Global Health 2035 ignores or underplays
a number of critical issues, including the role of intellectual property and
the patent regime in access to medicines and other goods (Dionisio, 2014).
Broader determinants of health are only broached in terms of taxing tobacco,
alcohol and sugar (regressive measures against the poor). The report also as-
sumes that technology-oriented medical interventions alone will address the
health consequences of poverty, unemployment, poor housing, environmen-
tal degradation, social and domestic violence, land grabs and displacement,
weak states and inequitable development and social policies, among other
determinants.
Crucially, recognizing the existence of inequality, and understanding its
roots and particularly its remedies, are very different things. Even as or-
thodox economists are touting a ‘grand convergence’ of mortality rates
across the world, with infant mortality halved in the last quarter century
and the differences in life expectancy between HICs and some LMICs less-
ening (Jamison et al., 2013), it is convergence of another sort that should
be decried rather than celebrated. First, the ‘grand convergence in health’
overlooks continued divergences in health and mortality within countries.
Second, the grandest convergences are in economic and social inequality
(Schrecker and Bambra, 2015) and precarious work (Benach et al., 2014),
both of which now characterize all societies, even if many LMICs have fared
the worst. This trend derives in large part from how most LMICs fit into the
capitalist world order and the cumulative effects of neoliberalism since the
1980s, in turn built on mostly incomplete or weak social welfare states. In
sum, Global Health 2035 pays lip service to inequality, essentially coopting
the aim of equity. Like the Millennium Development Goals that also aimed
to reduce mortality without discussing how this would be achieved, ‘con-
vergence’ has broad appeal because it appears to transcend the problem of
inequality without addressing its causes or effects at all.
UNIVERSAL HEALTH COVERAGE: THE PINNACLE OF COOPTATION

OF PROGRESSIVE GLOBAL EFFORTS
The most remarkable contemporary cooptation of the global health equity

agenda involves UHC. On the surface, this latest global health policy trend
seems unobjectionable (Reich et al., 2015), albeit, as evidenced in Latin
America, not substantiated by solid evidence (González-Guzmán and Cortes
Hernández, 2015; Laurell, 2015a). Who could oppose the attractive goal of
extending health coverage to entire populations? But the very ambiguity of
the term ‘coverage’ (deriving from language used in the private insurance
sector) and the imprecision of the definition mask an approach that departs
from public universal health care or health care for all. Indeed, the Rocke-
feller Foundation, a key backer of the UHC goal, has recommended ‘models
that harness the private health sector in the financing and provision of health
services for poor people’ (Rockefeller Foundation, 2009: 2; Rodin and de
Ferranti, 2012).
WHO has also offered a ringing endorsement of UHC even though its con-
current support for a renewed and equitable PHC has been muted. WHO’s
backing of universalism in health care without equity began with a 2005
World Health Assembly resolution regarding prepaid pooling of resources
to prevent catastrophic health expenditures and impoverishment (PHM et al.,
2014; Sengupta, 2013). This was itself an outcome of the report of the 2000–
01 WHO Commission on Macroeconomics and Health (see WHO, 2001),
which revived the WDR 1993’s discredited formula that poverty is chiefly
a result of ill health rather than the other way around (Waitzkin, 2003).
By 2010, after the onset of the Great Recession, with health care costs
continuing to rise and many LMIC health systems in disarray following
decades of neglect and downsizing, the WHO’s World Health Report con-
veyed its full commitment to UHC, defined as ensuring that ‘all people have
access to services and do not suffer financial hardship paying for them’
(WHO, 2010: 7). The World Bank has clarified UHC to mean: ‘access to the
health care they need’ (World Bank, 2014) — that is, health services that
are ‘essential’ or ‘vital’ rather than comprehensive — and featuring equity
in access, good quality services, and financial risk protection (see WHO,
2014b). WHO Director-General Dr Margaret Chan has amplified this grand
claim by arguing that:
Universal health coverage is one of the most powerful social equalizers among all policy
options. It is the ultimate expression of fairness. If public health has something that can
help our troubled, out-of-balance world, it is this: growing evidence that well-functioning
and inclusive health systems contribute to social cohesion, equity, and stability. They hold
societies together and help reduce social tensions. (Chan, 2015)
In making governments responsible for ‘ensur[ing] that all providers,

public and private, operate appropriately and attend to patients’ needs cost
effectively and efficiently’ (WHO, 2010: xviii), UHC portends a departure
from PHC’s call for public, unified, comprehensive financing and delivery
of care.
Many UHC efforts, such as reforms in the USA and Mexico, involve
multifaceted financing reforms that add coverage to previously uninsured
populations for some services (‘packages of benefits’), but not necessarily
for all needed services (even as well-insured populations retain comprehen-
sive coverage). In UHC plans, the public sector either withdraws from the
provision of care altogether, to become a manager and purveyor of funds,
or enters into a competitive relationship with an expanded, often for-profit
private sector, leading to further fragmentation. Through UHC, insurance
corporations gain access to public revenue streams (social security contri-
butions and taxes) that finance contracts to provide a set of services to the
previously uninsured (Sengupta, 2015). For their part, the newly insured,
who are overwhelmingly economically precarious, are required by law in
some settings to contribute taxes, premiums and user fees for their own
coverage; at the same time the most vulnerable — who are employed in the
informal sector — may be excluded from ‘universality’ (Oxfam Interna-

tional, 2013) by virtue of being outside social security protections. Addi-
tionally, most UHC approaches do not call for funding via higher and more
equitable taxes — through which the rich would be contributing to risk pools
directly or indirectly — but rather rely on cross-subsidies among uninsured
populations and requirements that providers offer charity or ‘free care’ for
‘community benefit’ (Birn et al., forthcoming 2016).
To be sure, universality is a key principle of health systems, important to
ensuring equity, social inclusion and efficiency. It was certainly central to
the Alma-Ata declaration, which called for ‘health care based on practical,
scientifically sound and socially acceptable methods and technology made
universally accessible’ (WHO, 1978: 3). The Canada Health Act of 1984, for
example, codified that country’s national health insurance system by defin-
ing universality as coverage to all residents and a single level of care for
all. Universality has also been at the heart of most European health systems.
But WHO’s focus on universal coverage, without the guarantee of a unified,
solidarity-oriented, single-tiered and comprehensive set of services as the
heart of its return to PHC, is highly disconcerting. Stated differently, ‘if
everyone has access to some health care benefits, but only a few have their
cancer treatment covered, there is no universalism to speak of’ (Martı́nez
Franzoni and Sánchez-Ancochea, forthcoming 2016). Nor can a health sys-
tem be considered universal when some people enjoy higher quality care
or more resources than others, or where co-payments impede access. Any
policy that fragments more than it unifies or results in segmented financing
or pools of beneficiaries inherently goes against universalism, even if it is
called universal.
If implemented based on unifying principles — having the state play a
‘central role’ in assuring funding for and access to a unified set of health
care services and regulating quality — UHC could be helpful (Cotlear et al.,
2015). There remains a possibility that ‘progressive governments can try to
privilege public systems’ and equity (PHM et al., 2014: 81), but the thrust of
UHC, adding new patient demand and a new revenue stream to profiteering
insurance companies in a context of further fragmentation, makes such a
possibility remote. A 2014 Lancet series on UHC in Latin America reiter-
ates such understandings of technocratic exigencies driving reforms without
considering their political basis (Waitzkin, 2015).
Another deficiency is that UHC does not adequately incorporate a so-
cial determinants of health perspective (Clark, 2015; Marmot, 2013). For
WHO’s Director-General to assert that: ‘universal coverage is the single
most powerful concept that public health has to offer’ (Chan, 2013) belies
WHO’s articulated commitment to the societal determinants of health and
ignores WHO’s own ample evidence that social injustice, that is, political,
economic and other societal inequities (among which lack of access to health
care is but one aspect), ‘is killing people on a grand scale’ (WHO, 2008: 26;
see also Navarro, 2009).
In sum, aspirational language notwithstanding, decontextualized UHC

is a misguided approach, justified by certain legitimate concerns around
catastrophic health spending, but offering the likelihood of large-scale, ra-
pacious health system penetration by, and channelling of resources to, private
interests that entrench health system inequity and income-based stratifica-
tion. Unified and integrated national health systems, which are based on
health as a right rather than as a commodity, pool resources across entire
populations, and prevent impoverishment due to catastrophic illness, offer
the best hope for equity and efficiency, even as quality has been threatened
by resource starvation and privatization in recent decades (Chiriboga, 2014;
Heredia et al., 2015). Why such systems are not at the heart of WHO’s push
for universality is puzzling indeed.
One answer comes from Mexico, whose troubled health system has be-
come the ironic poster child for UHC, bolstered by a concerted advocacy
campaign by its proponents. While touted as the culmination of three stages
of advances in health care organization and access (Frenk et al., 2003), Mex-
ico’s situation might be better understood as the result of a regression of once
promising efforts towards health policy equity. The vicissitudes of Mexico’s
century-long effort to meet the demands of its 1910–20 revolution and its
1917 Constitution include the creation of mandatory rural service for gradu-
ating doctors, nurses and other health personnel, as well as a system of health
services for agrarian cooperatives established by the 1930s government of
President Lázaro Cárdenas. Unable to meet citizen social welfare claims on
the state in a unitary or equitable fashion, due to the power of domestic
elites and foreign investors, the Cárdenas administration responded to the
enormous mobilization of both agrarian and industrial unions with universal
education and increased health care access (Carrillo, 2005). However, health
insurance and social security measures for various segments of the formal
labour force were piecemeal, exclusionary and fragmented. A solid social
security system for industrial workers (IMSS, realized in 1943), and for civil
servants (ISSSTE, initiated in 1959), were on their way to extending the
same level of coverage to agricultural workers and the informal sector when
neoliberal reforms started tearing the system apart (Laurell, 2015b).
As such, Mexico’s 2004 Seguro Popular (SP) marks more of a failure
than a success in the country’s quest for health equity justice. Exacerbat-
ing Mexico’s infamously fragmented system, the SP was established not to
universalize existing programmes (themselves under assault), but to cover
the country’s 50 million uninsured individuals (almost half of its 2004 pop-
ulation of 105 million people) through voluntary health insurance coverage
for a defined package of interventions (Laurell, 2007). Instead of merging
coverage for the uninsured population with the social security system, as
Brazil did (discussed below), Mexico’s legislation — so-called structured
pluralism — created a new separate system, financed by premiums from the
state and federal governments and participating families (with exemptions
for the poorest 20 per cent) and contracting with public and private providers.
In 2012, the Ministry of Health and its allies claimed that UHC had
been reached through incorporation of the 50 million previously uninsured
(Knaul et al., 2012), but census and national survey data contradict this
claim, indicating that between 25 and 30 million people remain uninsured,
including over one-third of the poorest income quintile (PHM et al., 2014).
Not only has private expenditure on health remained near its pre-reform
level (48 per cent of the total, according to WHO, 2014a) but SP affili-
ates continue to pay proportionately more out-of-pocket than those covered
by social security (Knaul et al., 2012), with out-of-pocket expenditures
for the poorest groups barely declining (Laurell, 2015a). Meanwhile, SP’s
benefits are less comprehensive than the social security scheme. SP’s de-
fined set of interventions (not diseases) exclude common causes of mor-
tality and morbidity, such as complications related to diabetes (Mexico’s
leading cause of death), cerebrovascular diseases, many types of cancer,
and trauma or burns due to accidents. Moreover, because SP expansion
has not been supplemented by concomitant investments in infrastructure
and human resources, many of the previous barriers to quality and access
persist, especially in rural areas. Regional disparities and inequitable and
fragmented financing and coverage remain entrenched, and the populations
who have historically benefited from, or been disadvantaged by, a segmented
system remain the same as before the reform (Laurell, 2015a). As Profes-
sor Cristina Laurell, a perspicacious analyst of health care privatization in
Mexico and other Latin American countries, has cogently argued, UHC —
euphemized as structured pluralism — is regressive rather than progressive,
retaining the vast inequalities of fragmented systems (unequal pluralism,
structured or otherwise, enables this) and opening the door to ever further
privatization, contradicting the very aims of universal and equitable health
systems.2
LATIN AMERICAN COUNTER-EXAMPLES TO GLOBAL HEALTH

COOPTATION
Notwithstanding the troubling tales of UHC in some Latin American coun-

tries, struggles for health justice in resistance to neoliberal hegemony have
enjoyed a revival of sorts in recent years (González-Guzmán and Cortes
Hernández, 2015), albeit with caveats. Virtually all Latin American coun-
tries have tried to tackle healthcare inequities — Uruguay moved towards
an integrated national health system in 2008, Bolivia has increased access
with a paradigm of multiculturalism and the elimination of user fees — but
the challenges of confronting problems produced by costly private systems
and fragmented public ones loom large.
2. See Cristina Laurell’s website: http://asacristinalaurell.com.mx

The example of Cuba, of course, long pre-dates the rise of neoliberal-

ism. Even before the 1959 Cuban Revolution, the main political parties
supported certain public health services as a lure for voters. But its trans-
formation into Latin America’s sole equitable, fully public, universal health
care system took place in the context of a socialist state forged through
decades of political struggle. In the thick of the Cold War, the revolution
spurred nationalization of productive assets and universal provision of so-
cial services — sanitation, housing, education, and so on. Starting with rural
health services in the country’s most remote and underserved areas, within a
decade Cuba’s health services were integrated into a regionalized network of
polyclinics at the primary level with corresponding secondary and tertiary
care facilities, together comprising free, high quality, participatory health
care reaching the entire population. Although half the physicians fled the
country after the revolution, a large-scale medical training effort ensured
sufficient staff by the 1970s; the subsequent development of a respected
biotech/pharmaceutical sector enabled near self-sufficiency (Farber, 2011;
Feinsilver, 1993). Despite the major economic belt-tightening that accom-
panied the breakup of the USSR and the end of Soviet subsidies, the Cuban
health care system has not only persisted but thrived. It is also significant
that, more than any other country, Cuba has, since the revolution, addressed
the larger societal forces influencing health through policies of committed
egalitarianism in education, housing, transport and other areas (Pagliccia
and Álvarez Pérez, 2012).
Costa Rica’s experience also represents a long struggle for the right to
health. As a fruit- and coffee-exporting ‘banana republic’ coming out of
a divisive civil war, in the 1940s it launched the foundations of what in
just three decades would become a comprehensive welfare state (partially
financed by the abolition of the military). In 2012 the country had the highest
scope of universal protections and government services of the region, outside
of Cuba (Martı́nez Franzoni and Sánchez-Ancochea, 2013). Although the
crisis of the 1980s led to severe recession, the government continued to
invest in social services, including public health, thus maintaining gains
in infant mortality and overall health status (Mesa-Lago, 1985; Morgan,
1987). Today, Costa Ricans enjoy the second-longest life expectancy in the
Americas, after Canadians.
To what can one ascribe these health gains? First, Costa Rica’s manda-
tory social insurance system, launched in 1941, began with the lowest paid
blue-collar workers, over time incorporating higher paid workers until uni-
versality was reached from the bottom up. A single fund was created so
that, unlike in other countries, there was no segmentation by industry. The
expansion of coverage thus enjoyed wide public support. By the 1970s,
when the wealthy were mandated to contribute payroll taxes into social in-
surance, a unified set of high-quality benefits covered the entire population,
although since doctors were not prohibited from practising privately, elites
paid for privileged medical access without going through the social security
system (Martı́nez Franzoni and Sánchez-Ancochea, 2013). At the level of

organization of health services, several features of the system stand out:
publicly provided services (rather than services contracted out to the private
sector); a single public insurer; no purchaser–provider split or autonomy for
hospital managers; integration into a single system; and user involvement in
the management of services (Unger et al., 2007).
Other factors are also key. In the 1970s, a special fund was created for the
poorest populations previously excluded from social policies. Wide backing
for social entitlements helped Costa Rica to partially resist neoliberal reforms
when its economy faltered (i.e., fending off privatization of social service
provision), although the quality and funding for some services deteriorated
markedly at this time (Seligson and Martı́nez Franzoni, 2009). Emphasis on
principles of collectivism and worker solidarity, and the state’s prioritization
of human development (with high levels of literacy, employment genera-
tion and women’s insertion into the paid labour force) — all part of Costa
Rica’s long tradition of social protection — helped cushion it against the
worst hardships of recent economic crises (Martı́nez Franzoni and Sánchez-
Ancochea, 2013). Still, since the 1990s the health and education systems
have faced a deterioration of both quality and equity, with creeping pri-
vatization and out-of-pocket spending and the entry of for-profit insurance
corporations.
Neoliberalism in the 1980s and 1990s also failed to stop Brazil’s re-
democratization movement from trying to build universal social policies and
a universal, public and unified health system, as opposed to UHC (Cohn,
2008). Drawing from the post-dictatorship 1988 Constitution’s enshrining
of health care as a universal right under the principles of universality, equal-
ity and community participation, Brazil’s reform has attempted to rectify
inequities in health care access and financing, based on a publicly funded,
integrated universal system (D’Avila Viana et al., 2015; Lima et al., 2005).
It operates a tax-funded Unified Health System (SUS), free at the point
of service for the entire population (Paim et al., 2011). The decentralized
system, involving federal, state and municipal governments in both manage-
ment and financing, has sought to improve equity in part by creating local
decision-making councils and regional management roles to align health
system planning with needs (Fleury, 2011). Today PHC is delivered across
most of the country through over 32,000 community-based family health
teams, each consisting of a doctor, nurse, nurse technicians and up to a
dozen full-time community health workers, serving over 120 million people
across the country. Yet even with SUS, problems and inequities persist. Pro-
vision of most tertiary care is contracted out to an increasingly expensive,
although substantially not-for-profit, private sector. Private insurance covers
25 per cent of the population, but represents over half of health expendi-
tures. The shortage of primary care doctors in the poorest and most rural
areas recently obligated the Brazilian government to contract almost 15,000
doctors, mostly from Cuba, through the Mais Médicos programme, stirring
controversy and garnering welcome support among the almost one quarter
of the population lacking physicians (Kirk et al., 2015).
Despite the significant increase in public coverage, recent privatization
trends undermine SUS and undergird a two-tiered health care system: a pub-
lic SUS for the poor, and subsidized private health insurance for those who
can afford it — and yet who often return to SUS coverage for catastrophic
expenses, depleting its resources, even as they resist paying higher taxes
(de Almeida Rodrigues, 2014). In sum, the main problems impeding SUS
from fulfilling its mandate of universality, quality and equality are federal un-
derfunding, increased public financing for private sector insurance, rigidity
of the bureaucratic-administrative structure of the state, and privatization of
SUS management (dos Santos, 2013). These problems have persisted if not
grown, even under three successive progressive (in the social policy arena)
Workers’ Party administrations: the SUS has seen defunding and a greater
role for and power of the private sector, despite a strong resistance movement
that has increasingly denounced its denationalization (ABRASCO, 2015).
The arrival of the new millennium brought further efforts to build universal
and public health systems in several other countries of the region. Among
these, the case of Venezuela stands out: in the space of less than a decade,
through the Barrio Adentro programme (‘Inside the Neighborhood’, founded
in 2003) and thanks to the work of some 14,000 Cuban doctors, Venezuela
doubled access to primary health care (reaching near universality), with
3,200 health clinics built in the country’s poorest neighbourhoods — places
that had never before enjoyed such local infrastructure or attention to human
need (Muntaner et al., 2013). This initiative drew on Venezuela’s 1999
Constitution that declared health to be a human right guaranteed by the state,
coupled with ‘bottom-up’ political demands for health and social services,
nutrition, housing, education and improved employment (Walker, 2015).
Undoubtedly the considerable resources invested in this effort (including
the exchange of Venezuelan oil for the services of thousands of Cuban
doctors, organized between Fidel Castro and Hugo Chávez) go beyond what
some other countries might manage, but re-orienting existing health care
spending would go a long way in any setting. The enormously popular Barrio
Adentro programme has also improved health care infrastructure, and in 2010
Venezuela’s Bolivarian government began an ambitious programme to train
its own community physicians and reduce dependence on foreign doctors.
By March 2015, almost 19,000 Venezuelan physicians had graduated with
degrees in Integral Community Medicine and had begun working with Barrio
Adentro (MPPS, 2015). A remaining challenge is to fully integrate Barrio
Adentro with the existing state public health system, since they currently
operate in parallel.
The lack of interest on the part of most mainstream development ac-
tors (whose ideological agendas reject these kinds of redistributive mea-
sures) in supporting, highlighting or even considering Venezuela’s integrated
approaches as a legitimate and effective (though not flawless) route to global
health equity speaks volumes (although non-interference by the USA and

IFIs may have also been protective).3
THE STRUGGLES AND NEED FOR A NEW GLOBAL HEALTH

(INTERNATIONAL ECONOMIC) ORDER
The preceding analysis shows the extent to which the global health agenda
of the last three decades has been captured by neoliberal exigencies via two
avenues. The first is a concerted effort at privatization of health services
(including in settings where there has been historical progress at addressing
equity issues) and global health activities, through pro-privatization policy-
making channels in major multilateral, bilateral and philanthropic agencies.
The other avenue comprises indirect efforts by these same actors, together
with domestic counterparts, to appropriate the agendas, values and activi-
ties of social movements, unions, advocacy groups, grassroots NGOs, and
other solidarity efforts that represent bona fide social justice and equity-
oriented public health approaches. This cooptation has sought to reframe
key categories and principles elaborated and long employed by progressive
sectors into the lexicon and policies of public and private players engaged
in health policy making at national and international levels. The latter form
of cooptation is especially nefarious because appropriated language around
universality, convergence and shared agendas can be deceptive — eliciting
support from many audiences who are unaware that progressive agendas
might have been taken over and distorted (Armada et al., 2001).
Alongside the task of unmasking and debunking the modus operandi of two
generations of a dominant neoliberal agenda in health, it is also important to
recognize the experiences of resistance to this onslaught. Such experiences
demonstrate that there are viable progressive and dynamic alternatives to
the hegemonic model that go well beyond the labour base of yore. They
also reveal the weaknesses and fragility of these alternatives, reinforcing the
need for ongoing struggle towards the building of a new global health order.
While Latin America is by no means the only region in which alternative
models have emerged, perhaps no other part of the world has undergone
such long-term and dramatic struggles in the health and political arenas,
at times yielding extraordinary moves towards social justice, and at times
seeing these overturned — a poignant reminder that without continuous
mobilization, even the most profound health and social justice achievements
may be reversible.
In an era in which the WHO itself is being coopted by private and philan-
throcapitalist interests (Velásquez, 2015), vigilance and broad participation
by scholars, activists and the (critical) development community at large will
3. It is extraordinary, for example, that global health philanthropic efforts pay no attention to
these promising, if Sisyphean, developments.
be essential in staving off the neoliberal cooptation of progressive global

health equity policies and in helping to build a counter-cooptation move-
ment for genuine health justice.
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Anne-Emanuelle Birn (corresponding author; e-mail: ae.birn@utoronto.ca)

is Professor of Critical Development Studies at the University of Toronto,
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policies, global health and national systems reforms in Latin America, and
health and trade agreements in the Americas.
Eduardo Siqueira (e-mail: carlos.siqueira@umb.edu) is an Associate Pro-
fessor at the College of Public and Community Service and Coordinator
of the Brazilian Transnational Project at the University of Massachusetts,
Boston, USA. He has written articles on work environment policy, environ-
mental justice for Brazilian immigrants, Brazilian health policy, and health
and safety disparities at work.

Neoliberalism Redux: The Global Health Policy Agenda and The Politics of Cooptation in Latin America and Beyond

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Neoliberalism Redux: The Global Health Policy Agenda and The Politics of Cooptation in Latin America and Beyond

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Neoliberalism Redux: The Global Health Policy

Anne-Emanuelle Birn, Laura Nervi and Eduardo Siqueira

This article explores the neoliberal cooptation of social justice-oriented

Development and Change 00(0): 1–26. DOI: 10.1111/dech.12247

ultimately inequitable arrangements for universalizing partial and insuffi-

THE DEEP ROOTS OF LATIN AMERICAN STRUGGLES FOR HEALTH

Latin America is a particularly useful vantage point from which to analyse

Although most of the region attained independence in the nineteenth cen-

FROM THE COLD WAR TO THE RISE OF NEOLIBERALISM:

Although the struggles portrayed above unfolded in national contexts, Latin

Following short-lived utopian aspirations for post-World War II health co-

a code to prevent the unethical corporate marketing of breast-milk substi-

no public accountability (Adams and Martens, 2015; Birn, 2014; Nambiar

PHASES OF NEOLIBERAL GLOBALIZATION AND HEALTH IN LATIN

in Colombia in 1994, a regulated health insurance market reform involving

INVESTING AND CONVERGING: EXAMINING COOPTATION

to be provided by the private sector. The report based its recommendations

UNIVERSAL HEALTH COVERAGE: THE PINNACLE OF COOPTATION

The most remarkable contemporary cooptation of the global health equity

In making governments responsible for ‘ensur[ing] that all providers,

informal sector — may be excluded from ‘universality’ (Oxfam Interna-

In sum, aspirational language notwithstanding, decontextualized UHC

LATIN AMERICAN COUNTER-EXAMPLES TO GLOBAL HEALTH

Notwithstanding the troubling tales of UHC in some Latin American coun-

2. See Cristina Laurell’s website: http://asacristinalaurell.com.mx

The example of Cuba, of course, long pre-dates the rise of neoliberal-

system (Martı́nez Franzoni and Sánchez-Ancochea, 2013). At the level of

health equity speaks volumes (although non-interference by the USA and

THE STRUGGLES AND NEED FOR A NEW GLOBAL HEALTH

be essential in staving off the neoliberal cooptation of progressive global

ABRASCO (2015) ‘Dilma, preserve os interesses públicos na saúde! Saúde é Polı́tica de

WHO (1978) ‘Declaration of Alma-Ata. International Conference on Primary Health Care,

Anne-Emanuelle Birn (corresponding author; e-mail: ae.birn@utoronto.ca)

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