Neoliberalism: what it is, how it affects health and what to do about it.

Since the 1970s, neoliberalism has been the dominant economic and political philosophy among global institutions and some Western governments. Its three main strategies are: privatisation and competitive markets; reduced public expenditure on social services and infrastructure; and deregulation to enhance economic activity and ensure freedom of ‘choice’. Generally, these measures have negatively affected the health and wellbeing of communities.
In the 1980s and 1990s successive New Zealand (NZ) governments introduced extreme neoliberal reforms to the economy and public services, including healthcare. This led to widening income inequalities and an unequal distribution of the ‘determinants of health’, burdens borne disproportionately by children, the poor, and by Māori and Pacific people. Failure to regulate for the protection of citizens undermined health and safety systems, the security of work and collective approaches to health improvement. Health reform in the 1990s was touted as “a shining example” internationally of how to modernize public healthcare. We feel ashamed to have been part of this regrettable experiment. Limiting health expenditure widened inequalities in access to services, and managerialist restructuring subverted the service culture of the health system, with dire consequences.
There has been some retreat from neoliberalism in NZ in recent years but, despite this, it lingers covertly in our institutions and could be described as an ‘embedded norm’, with Covid-19 dramatically aggravating prior inequities. The need now is to move policy attention from equality of health inputs to equity of health outcomes. This will require: (i) redirection of resources and a focus on ‘upstream’ health initiatives; (ii) recognition that social investment returns benefits far in excess of costs; and (iii) adequate funding of services is needed to ensure social and cultural equity goals are achieved.
We see some hope with planned health policy changes for NZ. Amongst these changes, there will be health co-governance with the indigenous population, which will have a separate funding stream. However, there is still no explicit recognition of the utility of Public Health as an upstream approach to promoting health equity or the important principle of ‘proportionate universalism’ to provide a strategic way of balancing targeted and population approaches.