On the 19th May, the Universitat Pompeu Fabra (UPF) hosted the 2023 Presentation of the International Journal of Social Determinants of Health and Health Services (IJSDOHS). The event brought together experts in the social determinants of health (SDOH) from across the world to explore and discuss the major questions and future pathways for research, policy and action regarding the SDOH and health services. 

The following article summarises the key issues and discussions that proceeded in Session 3 of the event.

Session 3, entitled “The neoliberal transformation and financialization of healthcare”, included presentations by Chee-Khoon Chan (Citizens' Health Initiative / Independent Researcher, Malaysia), Allyson Pollock (Newcastle University Institute of Population Health Sciences, UK) and Steffie Woolhandler (CUNY, New York, and Harvard University, US; Associate Editor, IJSDOHS). The session was moderated by David Himmelstein (CUNY, New York, and Harvard University, US; Associate Editor, IJSDOHS). He opened by presenting the gravity of the current reality of healthcare in countries across the world, and its relevance in discussions regarding the SDOH: “Over the past hundred years, and particularly over the last 3 decades or so, medicine itself has become a major capitalist industry and influencer, not through its medical practice only, but through its social and economic influence.”

In the first presentation, Chan focused on the Malaysian case, starting with some context of the country’s healthcare system both historically and at present. Unlike some of its neighbours, Malaysia has been relatively insulated from International Monetary Fund (IMF) policy dictates. Nevertheless, healthcare is currently provided by both the federal government and private entities, with the country’s total national healthcare spending at 4.7% GDP — lower than the average of middle-income countries (6.6%) — and the public sector share of this spending (2.6% GDP) below the amount recommended by the WHO. Chan stressed globalisation and privatisation as key drivers of the neoliberal transformation and financialisation of the Malaysian healthcare sector. He also highlighted the importance of understanding the multiple roles of the state regarding healthcare: the state acts as provider and regulator of public healthcare, but also as an investor in for-profit healthcare. These multiple interests lead to a two-tier healthcare system whereby those who can afford private health insurance have good quality, priority care, and those who can’t are left with a substandard and underfunded public health service. He finished by noting that there are currently competing visions for the future of Malaysia’s pluralistic healthcare system and its financing.

Pollock’s presentation followed, which demonstrated how, during the last 3 decades, incremental legislation has been implemented that has facilitated the dismantling and marketisation of the UK's National Health Service (NHS). She gave various examples of these legislations and their impacts on public health and health inequalities, such as laws that promote the financialization of public hospitals or the privatisation of certain medical procedures. Pollock claimed that the original 1948 vision of the NHS — as a service that is cradle to grave, offers a full range of services, is free at the point of delivery, is publicly owned and publicly funded through taxation, and has public accountability — is no longer a reality in today’s NHS: “What holds the NHS together now is actually the belief of the public... the politicians have long ago — and I’m afraid it's both the Conservatives on the right, and the left, in Labour — have totally given up on the NHS”. She noted how the privatisation of healthcare services and institutions has many knock-on effects, inasmuch as that certain services being shifted to the private sector means that there is less work in the NHS, and as a result, there has been a decrease in the training of junior doctors in the public sector. Moreover, there is no longer area-based planning and local provision of certain services, such as mental health services, meaning that people have to travel long distances to receive care. Pollock highlighted the 2022 Health and Care Act as a major step towards further privatisation and dismantling of the NHS, as it gives private healthcare providers complete discretion over which services they will provide, where, how and to whom. This is creating further inequalities in terms of access to services and quality of care, reflecting evermore the US model of healthcare. 

The final presentation by Woolhandler elaborated on the US healthcare model, in which 60% of medical care is private, yet public spending per capita for health exceeds the total spending on health per capita in other nations. She analysed issues such as medical debt and insurance in terms of the SDOH: “Medical debts in the US are huge, and often exceed the value of all non-medical debts together...this has serious consequences in the SDOH.” For example, medical debts often cause food and housing insecurity, and the co-payments of unpaid medical services regularly cause US citizens to become bankrupt. This is a major issue for North Americans: around 30 million people are uninsured, and many more are underinsured (their insurance doesn’t cover all of the necessary services), leaving them vulnerable to extremely large medical debts. This situation has clear health consequences: Woolhandler showed that in 2021, US life expectancy (76.1 years) lagged 6.3 years behind that of peer nations. She emphasised that inefficiency and bureaucracy are also major problems in a privatised healthcare system such as that of the US, where "About 25% of every dollar spent on healthcare in the US goes to paperwork and management". Woolhandler elaborated on the dangers to health equity and justice that the prioritisation of profit over care entails, concluding that “we have to address the issue of for-profit ownership of care, because… for-profit ownership is not compatible with top-quality healthcare.” Ending on a positive note, Woolhandler noted that this trajectory of financialisation of healthcare in the US has led to a large increase in the unionisation of healthcare workers and mobilisation of the population.

The Q&A session included a discussion on the dangers of private-public systems that mix personal health insurance schemes with public healthcare provision. All speakers were against this strategy due to the fact that it impoverishes public health systems and leaves them more vulnerable to cuts, exploitation and neglect. As one of the members of the audience (Carme Borrell, Agència de Salut Pública de Barcelona) quoted, “a system for the poor will be a poor system. We need a system for all.”