Banking on Health: The World Bank and Health Sector Reform in Latin America

Banking on Health: The World Bank and Health Sector Reform in Latin America Within the social sciences, much of the common sense surrounding the behavior of international financial institutions (IFIs), such as the International Monetary Fund (IMF) and the World Bank (WB), follows a rather conventional line of thinking. It runs something like this: many governments across the world required international funding amid debt crises in the mid-to-late twentieth century. As a result, they requested help from the IMF and WB. In order to ensure that past and now future debts were repaid, these groups demanded cuts to public services, such as education, health, and state employment, in order to free up state funds for debt servicing. In the end, these cuts generated increased inequality and generally benefited only wealthy citizens and transnational corporations. There is, of course, much truth to this story. The IMF and WB did condition their loans based on austerity measures. States that received their assistance often did cut state employment and attempt to downsize state bureaucracies. Many countries did witness escalating rates of inequality throughout the mid-to-late twentieth century. When it comes to health care, however, this story fails to capture the empirical realities in many parts of Latin America. While some states did severely cut state funding for health and privatize their health systems, such as Chile under General Augusto Pinochet, other governments worked with these IFIs to pursue a much different health care path. In her excellent new book, Shiri Noy examines the role of the World Bank throughout Latin America during the most recent decades. At the general level, Noy first uses statistical techniques to demonstrate that WB efforts did not generate reductions in public health expenditures throughout Latin America. Her most important contribution, however, is to demonstrate how WB pursuits throughout many countries in Latin America have been contingent upon domestic institutions and domestic dynamics. Although the WB has, in fact, urged Latin American governments to utilize neoliberal measures, the WB has also generally pursued a goal of universal health care and has not uniformly promoted the wholesale privatization of the health care industry, as one might infer from the social scientific common sense surrounding IFIs. In addition to her statistical analysis, Noy provides three case studies in order to more carefully analyze WB efforts in Latin America—looking at Argentina, Peru, and Costa Rica. She illustrates how differences in respective countries’ health care models have shaped WB efforts in these locations. In Costa Rica, for instance, she points out that the government had already provided near universal coverage to its citizens. Nonetheless, the WB wanted to assist the Costa Rican government in pursuing more efficient reforms. To do so, the WB didn’t contravene goals of universal coverage for a privatized system, but rather the WB recommended neoliberal measures to enhance the existing system, such as the use of primary care and the separation of functions within the health care industry. By contrast, the Peruvian state maintained a relatively weak health care system in comparison with Costa Rica, characterized by lack of state capacity and state autonomy. As a result, the WB focused its efforts on, for example, targeting the health of children and their mothers. And in Argentina, while the WB focused on, for example, the introduction of increased market mechanisms into the health care industry, it didn’t encourage the complete privatization of Argentine care. In all three cases, then, the WB championed neoliberal means, but also worked toward coverage for all citizens, that is, through neoliberal measures. Throughout her new book, Noy neatly demonstrates the power of mixed-methods approaches within global comparative research. She not only uses intensive statistical modeling, but also weaves together interviews throughout Latin America with a multiplicity of actors involved in negotiations between the WB and respective Latin American governments. That is impressive. What is more, she challenges convention social scientific thinking on IFI activities and encourages us to rethink as well as hone our understanding of how IFIs work with governments across the world to pursue particular aims. While Noy remains focused on theoretical engagement with literature surrounding, for example, welfare state development and state capacity/autonomy, I think there is also an opportunity to critique state theory that has developed in the context of globalization. Both world-systems and other neo-Marxist scholars have advanced the idea that neoliberalism unfolds in an often top-down manner. They have often assumed that through IFIs, powerful states like the United States achieve their neoliberal will to privatize and deregulate economies. Within health care, though, we find a much different scenario. It thus remains important to consider how we might wish to revise some of these top-down-oriented theories and whether or not we should reconsider some of the ultimate aims of the US empire or “the core” or “the transnational state”—or any other conception of global power that pervades social scientific thought surrounding these dynamics. Noy’s work is an excellent installation into the world of comparative, global/transnational sociology. Her mixed-methods approach is inspirational, and her findings encourage us to always look beyond the conventional narratives that some scholars assume are uniformly true. Her work would be an excellent addition to courses on medical sociology, global/transnational sociology, comparative sociology, the welfare state, and Latin America. © The Author(s) 2018. Published by Oxford University Press on behalf of the University of North Carolina at Chapel Hill. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Social Forces Oxford University Press

Banking on Health: The World Bank and Health Sector Reform in Latin America

Social Forces , Volume Advance Article (4) – Apr 19, 2018

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Publisher
Oxford University Press
Copyright
© The Author(s) 2018. Published by Oxford University Press on behalf of the University of North Carolina at Chapel Hill. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
ISSN
0037-7732
eISSN
1534-7605
D.O.I.
10.1093/sf/soy032
Publisher site
See Article on Publisher Site

Abstract

Within the social sciences, much of the common sense surrounding the behavior of international financial institutions (IFIs), such as the International Monetary Fund (IMF) and the World Bank (WB), follows a rather conventional line of thinking. It runs something like this: many governments across the world required international funding amid debt crises in the mid-to-late twentieth century. As a result, they requested help from the IMF and WB. In order to ensure that past and now future debts were repaid, these groups demanded cuts to public services, such as education, health, and state employment, in order to free up state funds for debt servicing. In the end, these cuts generated increased inequality and generally benefited only wealthy citizens and transnational corporations. There is, of course, much truth to this story. The IMF and WB did condition their loans based on austerity measures. States that received their assistance often did cut state employment and attempt to downsize state bureaucracies. Many countries did witness escalating rates of inequality throughout the mid-to-late twentieth century. When it comes to health care, however, this story fails to capture the empirical realities in many parts of Latin America. While some states did severely cut state funding for health and privatize their health systems, such as Chile under General Augusto Pinochet, other governments worked with these IFIs to pursue a much different health care path. In her excellent new book, Shiri Noy examines the role of the World Bank throughout Latin America during the most recent decades. At the general level, Noy first uses statistical techniques to demonstrate that WB efforts did not generate reductions in public health expenditures throughout Latin America. Her most important contribution, however, is to demonstrate how WB pursuits throughout many countries in Latin America have been contingent upon domestic institutions and domestic dynamics. Although the WB has, in fact, urged Latin American governments to utilize neoliberal measures, the WB has also generally pursued a goal of universal health care and has not uniformly promoted the wholesale privatization of the health care industry, as one might infer from the social scientific common sense surrounding IFIs. In addition to her statistical analysis, Noy provides three case studies in order to more carefully analyze WB efforts in Latin America—looking at Argentina, Peru, and Costa Rica. She illustrates how differences in respective countries’ health care models have shaped WB efforts in these locations. In Costa Rica, for instance, she points out that the government had already provided near universal coverage to its citizens. Nonetheless, the WB wanted to assist the Costa Rican government in pursuing more efficient reforms. To do so, the WB didn’t contravene goals of universal coverage for a privatized system, but rather the WB recommended neoliberal measures to enhance the existing system, such as the use of primary care and the separation of functions within the health care industry. By contrast, the Peruvian state maintained a relatively weak health care system in comparison with Costa Rica, characterized by lack of state capacity and state autonomy. As a result, the WB focused its efforts on, for example, targeting the health of children and their mothers. And in Argentina, while the WB focused on, for example, the introduction of increased market mechanisms into the health care industry, it didn’t encourage the complete privatization of Argentine care. In all three cases, then, the WB championed neoliberal means, but also worked toward coverage for all citizens, that is, through neoliberal measures. Throughout her new book, Noy neatly demonstrates the power of mixed-methods approaches within global comparative research. She not only uses intensive statistical modeling, but also weaves together interviews throughout Latin America with a multiplicity of actors involved in negotiations between the WB and respective Latin American governments. That is impressive. What is more, she challenges convention social scientific thinking on IFI activities and encourages us to rethink as well as hone our understanding of how IFIs work with governments across the world to pursue particular aims. While Noy remains focused on theoretical engagement with literature surrounding, for example, welfare state development and state capacity/autonomy, I think there is also an opportunity to critique state theory that has developed in the context of globalization. Both world-systems and other neo-Marxist scholars have advanced the idea that neoliberalism unfolds in an often top-down manner. They have often assumed that through IFIs, powerful states like the United States achieve their neoliberal will to privatize and deregulate economies. Within health care, though, we find a much different scenario. It thus remains important to consider how we might wish to revise some of these top-down-oriented theories and whether or not we should reconsider some of the ultimate aims of the US empire or “the core” or “the transnational state”—or any other conception of global power that pervades social scientific thought surrounding these dynamics. Noy’s work is an excellent installation into the world of comparative, global/transnational sociology. Her mixed-methods approach is inspirational, and her findings encourage us to always look beyond the conventional narratives that some scholars assume are uniformly true. Her work would be an excellent addition to courses on medical sociology, global/transnational sociology, comparative sociology, the welfare state, and Latin America. © The Author(s) 2018. Published by Oxford University Press on behalf of the University of North Carolina at Chapel Hill. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

Social ForcesOxford University Press

Published: Apr 19, 2018

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