Universal health coverage and public-private arrangements within Sri Lanka's mixed health system: Perspectives from women seeking healthcare.

Universal health coverage (UHC), a target of the United Nations' third Sustainable Development Goal on health, refers to people having access to essential healthcare services without suffering financial hardship. The World Bank and other leading global health actors champion mixed health systems-in which government and privately-financed market delivery coexist-as a sustainable model for UHC. Yet, little is known about what these public-private arrangements mean for women, a crucial partaker of UHC in low- and middle-income countries (LMICs). Using a critical feminist approach, this study explores how women negotiate access to public and private healthcare services within Sri Lanka's state-dominant mixed health system. Data were generated through focus group discussions and interviews with women residents of an urban division in Kandy, a city seeing rapid private healthcare expansion in central Sri Lanka. Notwithstanding policies of universality guiding public sector delivery, out-of-pocket payments burden socially and economically disadvantaged women. They use private services to fill gaps in the public system, and consult dual practitioners privately, to pave way for better (public) care. By contrast, wealthier women opt for private outpatient care, but capitalize on the dual practitioners to obtain priority access to oversubscribed services at public hospitals. Most women, regardless of social location, combine public with private, albeit to varying degrees, to save on household expenses. Relying on women's invisible care work, these public-private "hybrid" routes of access within Sri Lanka's poorly regulated mixed health system, reinforce social inequalities and individualize the responsibility for healthcare. The article throws light on the messiness of access within mixed systems and demands closer scrutiny of calls for private sector engagement in the quest for UHC in LMICs.

What matters in health (care) universes: delusions, dilutions, and ways towards universal health justice.

The presumed global consensus on achieving Universal Health Coverage (UHC) masks crucial issues regarding the principles and politics of what constitutes "universality" and what matters, past and present, in the struggle for health (care) justice. This article focuses on three dimensions of the problematic: 1) we unpack the rhetoric of UHC in terms of each of its three components: universal, health, and coverage; 2) paying special attention to Latin America, we revisit the neoliberal coup d'état against past and contemporary struggles for health justice, and we consider how the current neoliberal phase of capitalism has sought to arrest these struggles, co-opt their language, and narrow their vision; and 3) we re-imagine the contemporary challenges/dilemmas concerning health justice, transcending the false technocratic consensus around UHC and re-infusing the profoundly political nature of this struggle. In sum, as with the universe writ large, a range of matters matter: socio-political contexts at national and international levels, agenda-setting power, the battle over language, real policy effects, conceptual narratives, and people's struggles for justice.

Is there a social justice variant of South-South health cooperation?: a scoping and critical literature review.

Background: In recent decades, global health scholars and policymakers have highlighted the burgeoning role of South-South cooperation (SSC) in health, claiming it constitutes a more just and even-handed approach to health cooperation. But the assertion that SSC inherently challenges power asymmetries and pursues egalitarian agendas and forms of interaction merits interrogation. Here we explore a transformative, counter-hegemonic, solidarity-oriented form of SSC - social justice-oriented South-South cooperation (SJSSC) - as differentiated from other types of health aid. Objective: The objectives of this scoping review are: 1) to determine what is known and discussed through peer-reviewed and grey literature about SJSSC in health; and 2) to identify the different features and principles of SJSSC. This review seeks to inform research agendas and identify implications for policy and practice around SJSSC. Methods: We conducted a search for relevant peer-reviewed and grey literature in eight languages and screened abstracts that met inclusion criteria. We carried out a full-text review and data extraction on included pieces and conducted a thematic analysis identifying a set of repeated themes related to the features and principles of SJSSC. Results: We identified 188 publications meeting our criteria. Through an iterative process, we developed two overarching categories: values and strategies. Each comprises four themes that allowed us to map the ideas and practices of SJSSC depicted in the literature. The values mapped are: an anti-hegemonic world view; equity-oriented and redistributive political values; egalitarian terms of cooperation; and reciprocity. The strategies encompass: solidarity-building; health justice approaches; mutual exchange and collective justice; and challenging interests of dominant classes in the health arena. Conclusion: This review rectifies ungrounded claims about SSC by identifying and mapping the research literature on SJSSC and has relevance for the conceptualization, policy development, and practice of equitable health cooperation.

Latin American social medicine across borders: South-South cooperation and the making of health solidarity.

Latin American social medicine efforts are typically understood as national endeavours, involving health workers, policymakers, academics, social movements, unions, and left-wing political parties, among other domestic actors. But Latin America's social medicine trajectory has also encompassed considerable between-country solidarity, building on early twentieth century interchanges among a range of players who shared approaches for improving living and working conditions and instituting protective social policies. Since the 1960s, Cuba's country-to-country solidarity has stood out, comprising medic exchanges, training, and other forms of support for the health and social struggles of oppressed peoples throughout Latin America and around the world, recently via Misión Barrio Adentro in Venezuela. These efforts strive for social justice-oriented health cooperation based on horizontal power relations, shared political values, a commitment to social and economic redistribution, bona fide equity, and an understanding of the societal determination of health that includes, but goes well beyond, public health and medical care. With Latin America's left-wing surge now receding, this article traces the provenance, dynamics, impact, challenges, and legacy of health solidarity across Latin American borders and its prospects for continuity.

'Socialising' primary care? The Soviet Union, WHO and the 1978 Alma-Ata Conference.

In September 1978, the WHO convened a momentous International Conference on Primary Health Care in Alma-Ata, capital of the Soviet republic of Kazakhstan. This unprecedented gathering signalled a break with WHO's long-standing technically oriented disease eradication campaigns. Instead, Alma-Ata emphasised a community-based, social justice-oriented approach to health. Existing historical accounts of the conference, largely based on WHO sources, have characterised it as a Soviet triumph. Such reasoning, embedded in Cold War logic, contradicts both the decision-making processes in Geneva and Moscow that led the conference to be held in the Union of Soviet Socialist Republics (USSR) and the reality that the highest Soviet authorities did not consider it a significant ideological or political opportunity. To redress the omissions and assumptions of prior accounts, this article examines the Alma-Ata conference in the context of Soviet political and health developments, drawing from Soviet archival and published sources as well as WHO materials and interviews with several key Soviet protagonists. We begin by outlining the USSR's complicated relationship to WHO and the international health sphere. Next, we trace the genesis of the proposal for-and realisation and repercussions of-the primary healthcare (PHC) meeting, framed by Soviet, Kazakh, WHO and Cold War politics. Finally, we explore misjudgements and competing meanings of PHC from both Soviet and WHO perspectives, in particular focusing on the role of physicians, community participation and socialist approaches to PHC.

How extractive industries affect health: Political economy underpinnings and pathways.

A systematic and theoretically informed analysis of how extractive industries affect health outcomes and health inequities is overdue. Informed by the work of Saskia Sassen on "logics of extraction," we adopt an expansive definition of extractive industries to include (for example) large-scale foreign acquisitions of agricultural land for export production. To ground our analysis in concrete place-based evidence, we begin with a brief review of four case examples of major extractive activities. We then analyze the political economy of extractivism, focusing on the societal structures, processes, and relationships of power that drive and enable extraction. Next, we examine how this global order shapes and interacts with politics, institutions, and policies at the state/national level contextualizing extractive activity. Having provided necessary context, we posit a set of pathways that link the global political economy and national politics and institutional practices surrounding extraction to health outcomes and their distribution. These pathways involve both direct health effects, such as toxic work and environmental exposures and assassination of activists, and indirect effects, including sustained impoverishment, water insecurity, and stress-related ailments. We conclude with some reflections on the need for future research on the health and health equity implications of the global extractive order.

South-South cooperation in health: bringing in theory, politics, history, and social justice.

Since the mid-2000s, the practice of South-South cooperation in health (SSC) has attracted growing attention among policymakers, health and foreign affairs ministries, global health agencies, and scholars from a range of fields. But the South-South label elucidates little about the actual content of the cooperation and conflates the "where" with the "who, what, how, and why". While there have been some attempts to theorize global health diplomacy and South-South cooperation generally, these efforts do not sufficiently distinguish among the different kinds of practices and political values that fall under the South-South rubric, ranging from economic and geopolitical interests to social justice forms of solidarity. In the spirit of deepening theoretical, historical, and social justice analyses of SSC, this article: (1) critically revisits international relations theories that seek to explain SSC, exploring Marxian and other heterodox theories ignored in the mainstream literature; (2) traces the historical provenance of a variety of forms of SSC; and (3) introduces the concept of social justice-oriented South-South.

South-South cooperation in health: bringing in theory, politics, history, and social justice / A cooperação Sul-Sul em saúde: trazendo perspectivas teóricas, políticas, históricas e de justiça social / Cooperación Sur-Sur en salud: aportando perspectivas teóricas, políticas, históricas y de justicia social

Abstract: Since the mid-2000s, the practice of South-South cooperation in health (SSC) has attracted growing attention among policymakers, health and foreign affairs ministries, global health agencies, and scholars from a range of fields. But the South-South label elucidates little about the actual content of the cooperation and conflates the "where" with the "who, what, how, and why". While there have been some attempts to theorize global health diplomacy and South-South cooperation generally, these efforts do not sufficiently distinguish among the different kinds of practices and political values that fall under the South-South rubric, ranging from economic and geopolitical interests to social justice forms of solidarity. In the spirit of deepening theoretical, historical, and social justice analyses of SSC, this article: (1) critically revisits international relations theories that seek to explain SSC, exploring Marxian and other heterodox theories ignored in the mainstream literature; (2) traces the historical provenance of a variety of forms of SSC; and (3) introduces the concept of social justice-oriented South-South.

Resumo: Desde meados da primeira década do século XXI, a cooperação Sul-Sul em saúde (CSS) vem atraindo cada vez mais atenção entre gestores, ministérios da saúde e das relações exteriores, agências de saúde global, e pesquisadores de diversas disciplinas. Não obstante, o uso do termo "Sul-Sul" para caracterizar essa prática explica pouco sobre o conteúdo da cooperação, além de misturar o "onde?" com o "quem, quê, como e por quê?". Já houve algumas tentativas de teorizar a diplomacia da saúde global e a cooperação Sul-Sul geralmente, mas esses esforços têm sido insuficientes no sentido de distinguir as diversas práticas e valores políticos sob a rubrica Sul- Sul, desde os intereses econômicos e geopolíticos até a solidariedade e a justiça social. No espírito de aprofundar as análises políticas, teóricas, históricas, e de justiça social nas discussões sobre a CSS, o artigo: (1) revisita criticamente as teorias de relações internacionais que podem explicar a CSS, explorando teorias en la tradição Marxista e heterodoxas ignoradas na literatura convencional; (2) identifica as origens históricas das diferentes formas dessa cooperação; e (3) introduz o conceito da cooperação Sul-Sul orientada a la justiça social.

Resumen: Desde mediados de los años 2000, la práctica de la cooperación Sur-Sur en salud (CSS) ha recibido una creciente atención entre formuladores de políticas, ministerios de salud y de asuntos exteriores, organismos internacionales de salud y académicos provenientes de un gran abanico de campos científicos. Sin embargo, la denominación cooperación Sur-Sur poco dilucida acerca del contenido real de la cooperación y mezcla el "dónde" con el "quién, qué, cómo, y el por qué". A pesar de que han habido algunos intentos de teorizar sobre la diplomacia en la salud global y la cooperación Sur-Sur en general, estos esfuerzos no han identificado de manera suficiente los distintos tipos de prácticas y los diferentes valores políticos que caen en la rúbrica de CSS, y que incluyen desde los intereses económicos y geopolíticos hasta las formas de solidaridad fieles a la justicia social. Con el ánimo de ahondar en los análisis políticos, teóricos, históricos y de justicia social de la CSS, este artículo: (1) vuelve a examinar críticamente las teorías sobre las relaciones internacionales que intentan explicar la CSS, explorando teorías en la tradición Marxista y otras teorías heterodoxas, que han sido ignoradas en la literatura convencional; (2) rastrea los orígenes históricos de distintas formas de CSS; y (3) presenta el concepto de cooperación Sur-Sur orientada por la justicia social.

Synergy for health equity: integrating health promotion and social determinants of health approaches in and beyond the Americas / Sinergia para la equidad en salud: integración de los enfoques de la promoción de la salud y de los determinantes sociales de la salud dentro y fuera de la región de las Américas

Health promotion and social determinants of health approaches, when integrated, can better contribute to understanding and addressing health inequities. Yet, they have typically been pursued as two solitudes. This paper presents the key elements, principles, actions, and potential synergies of these complementary frameworks for addressing health equity. The value-added of integrating these two approaches is illustrated by three examples drawn from the authors' experiences in the Americas: at the community level, through a community-based coalition for reducing chronic disease disparities among minorities in an urban center in the United States; at the national level, through healthy-settings interventions in Canada; and at the Regional level, through health cooperation based on social justice values in Latin America. Challenges to integrating health promotion and social determinants of health approaches in the Americas are also discussed.

Los enfoques de la promoción de la salud y de los determinantes sociales de la salud, cuando se integran, pueden contribuir mejor a la comprensión y el abordaje de las inequidades en salud. No obstante, normalmente se han aplicado como dos cuestiones separadas. En este artículo se presentan los elementos clave, los principios, las acciones y las posibles sinergias de estos marcos complementarios para abordar la equidad en salud. El valor añadido de la integración de estos dos enfoques se ilustra mediante tres ejemplos extraídos de las experiencias de los autores en la Región de las Américas: a nivel de la comunidad, mediante una coalición comunitaria dirigida a reducir las disparidades en relación con las enfermedades crónicas entre las minorías de un centro urbano de los Estados Unidos; a escala nacional, mediante las intervenciones de promoción de entornos saludables en Canadá; y a nivel regional, mediante la cooperación en salud basada en los valores de la justicia social en América Latina. También se analizan las dificultades que entraña integrar los enfoques de la promoción de la salud y de los determinantes sociales de la salud en la Región de las Américas.

Synergy for health equity: integrating health promotion and social determinants of health approaches in and beyond the Americas.

Health promotion and social determinants of health approaches, when integrated, can better contribute to understanding and addressing health inequities. Yet, they have typically been pursued as two solitudes. This paper presents the key elements, principles, actions, and potential synergies of these complementary frameworks for addressing health equity. The value-added of integrating these two approaches is illustrated by three examples drawn from the authors' experiences in the Americas: at the community level, through a community-based coalition for reducing chronic disease disparities among minorities in an urban center in the United States; at the national level, through healthy-settings interventions in Canada; and at the Regional level, through health cooperation based on social justice values in Latin America. Challenges to integrating health promotion and social determinants of health approaches in the Americas are also discussed.

Sexual and reproductive health and rights in Latin America: an analysis of trends, commitments and achievements.

The Programme of Action of the International Conference on Population and Development (ICPD) in 1994 defined strategies and goals for advancing reproductive health and rights that are still far from being reached in Latin America. This paper will use elements of a framework developed by Gruskin et al(1) that analyses the interconnected factors affecting the sexual and reproductive health of people living with HIV. We use and adapt some of these elements to examine the extent to which sexual and reproductive rights have been realized in Latin America since 1994. Specifically, we consider the rights, needs and aspirations of people; the socioeconomic context; national and international law and policy; health systems, services and programmes; the opposition; the perceived high costs of political support; the role of civil society, NGO networks and coalitions; and development aid, donor policy and government funding. There are a growing number of progressive regional and national bodies, organizations, groups and individuals with a commitment to sexual and reproductive health and rights in the region, and many gains have been made in the realization of these rights. However, these gains are only partial, given the acute inequality across ethnic, socioeconomic and geographic lines, and there is evidence of widening gaps. Given the breadth of the subject and the number of countries involved, this paper can cite only a few of the enormous number of examples from the literature. We hope the paper will stimulate further in-depth, critical reviews of these issues at the country and regional level.

Grand Challenges Canada: inappropriate emphasis and missed opportunities in global health research?

In May 2010, Grand Challenges Canada (GCC) was launched with the mandate to identify global challenges in health that could be supported through the Government of Canada's Development Innovations Fund (DIF: $225 million over five years). The GCC offers a potentially excellent mechanism for taking Canada's participation in global health challenges "to a higher level". Recent GCC announcements raise new questions about the emphasis being placed on technological discovery or "catalytic" research. Missing so far are opportunities that the Fund could offer in order to support innovative research addressing i) health systems strengthening, ii) more effective delivery of existing interventions, and iii) policies and programs that address broader social determinants of health. The Canadian Grand Challenges announced to date risk pushing to the sidelines good translational and implementation science and early career-stage scientists addressing important social, environmental and political conditions that affect disease prevalence, progress and treatment; and the many unresolved challenges faced in bringing to scale proven interventions within resource-constrained health systems. We wish to register our concern at the apparent prioritization of biotechnical innovation research and the subordination of the social, environmental, economic and political context in which human health is either protected or eroded.

Canada's health care system: A relevant approach for South Africa?

BACKGROUND: While countries such as the USA, South Africa and China debate health reforms to improve access to care while rationalising costs, Canada's health care system has emerged as a notable option. In the USA, meaningful discussion of the advantages and disadvantages of the Canadian system has been thwarted by ideological mudslinging on the part of large insurance companies seeking to preserve their ultra-profitable turf and backed by conservative political forces stirring up old fears of 'socialised medicine'. These distractions have relegated the possibility of a 'public option' to the legislative dustbin, leaving tens of millions of people to face uninsurance, under-insurance, bankruptcy and unnecessary death and suffering, even after passage of the Obama health plan. While South Africa appears to experience similar legislative paralysis, there remains room for reasoned health reform debate to address issues of equity, access, and financing. OBJECTIVE: Our aim is to contribute to the debate from a Canadian perspective, setting out the basic principles of Medicare (Canada's health care system), reviewing its advantages and challenges, clarifying misunderstandings, and exploring its relevance to South Africa. We periodically refer to the USA because of the similarities to the South African situation, including its health care system, which mirrors South Africa's current position if left unchanged. CONCLUSION: While Medicare is neither flawless nor a model worthy of wholesale imitation, we contend that open discussion of Canada's experience is a useful component in South Africa's current policy and political efforts.