Resisting the Effects of Neoliberalism on Public Policy
Comment on “Implementing Universal and Targeted Policies for Health Equity: Lessons
From Australia”
Dennis Raphael
1*
ID
, Toba Bryant
2
ID
Abstract
Fisher and colleagues carefully review the extent to which health equity goals of availability, affordability, and
acceptability have been achieved in the areas of national broadband network policy and land-use policy, in addition to
the more traditional areas of primary healthcare and Indigenous health in Australia. They consider the effectiveness
of policies identified as either universal, proportionate-universal, targeted or residualist in these areas. In this
commentary we suggest future areas of inquiry that can help inform the findings of their excellent study. These include
the impacts of Australia being a liberal welfare state and how acceptance of neoliberal approaches to governance makes
the achieving of health equity in these four policy areas difficult.
Keywords: Neoliberalism, Liberal Welfare States, Health Equity, Social Determinants, Australia
Copyright: © 2022 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access article
distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/
by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
Citation: Raphael D, Bryant T. Resisting the effects of neoliberalism on public policy: Comment on “Implementing
universal and targeted policies for health equity: lessons from Australia.” Int J Health Policy Manag. 2022;11(12):3148–
3150. doi:10.34172/ijhpm.2022.7354
*Correspondence to:
Dennis Raphael
Email: draphael@yorku.ca
Article History:
Received: 26 April 2022
Accepted: 13 June 2022
ePublished: 22 June 2022
Commentary
Full list of authors’ affiliations is available at the end of the article.
2022, 11(12), 3148–3150
doi
Introduction
Fisher and colleagues are to be commended for providing
us with a state-of-the-art analysis of the ins and outs of
implementing universal and targeted policies for health equity
in Australia.
1
One innovative aspect of this study was their
examination of the implementation of national broadband
network policy and land-use policy, in addition to the more
traditional areas of primary healthcare and Indigenous health.
They carefully review the extent to which these policies
have been able to achieve health equity goals of availability,
affordability, and acceptability through implementation
of policies identified as either universal, proportionate-
universal, targeted or residualist.
Overall, they conclude that performance on the three
dimensions of health equity in health of availability,
affordability, and acceptability was only partially successful in
the primary healthcare, broadband access, and land-use policy
areas. They were somewhat more successful in the Indigenous
health domain. Their Closing the Gap case study, for example,
showed that equity of service access for Aboriginal and
Torres Strait Islander communities warrants both forms of
targeting to ensure cultural safety of universal services and
to strengthen stand-alone community-led services, programs
and strategies. They conclude that residualist policies do
not promote equity of access to resources and see value in
universal and proportionate-universal approaches that are
tailored to specific health policy contexts.
The article is very rich in concepts and findings and
provides a good introduction to many key issues in the
health policy and equity realm. These concepts include the
idea of health equity, different forms of public policy action
to achieve health equity, and concrete examples of how these
processes play out in these four areas of health-related public
policy activity in Australia. The methodology also provides
a state-of-the-art model for both new and experienced
researchers employing qualitative case studies involving the
mapping of policy structures, engaging with grey literatures
to track policy debate and change, and carrying out in-depth
interviews with key informants from government and non-
government agencies and independent experts.
Fisher et al also identify a dimension with real implications
for understanding how public policy can promote health
equity: centralized versus devolved governance structures.
They suggest that devolved structures would be more
effective for implementing equity but do not provide much
detail as to why governmental authorities are reluctant to
implement such processes. They also suggest that funding
tends to be targeted project funding rather than agency
funding, a feature also related to governance structures. Also
noteworthy is that their focus on primary care and Indigenous
health services is primarily reactive, saying little about the
economic and political forces that drive the healthcare related
needs of vulnerable social groups. Readers are urged to read
their article which offers many insights into problematic
approaches to promoting health equity through health policy.
Our comments are provided primarily to suggest future areas
of inquiry that can help inform the findings of their excellent
study.
Raphael and Bryant
International Journal of Health Policy and Management, 2022, 11(12), 3148–3150
3149
Welfare States, Neoliberalism, and Redistribution
The authors mention how recent ideological trends have
shaped public policy development and implementation:
“Since the 1980s, the rise of neoliberal politics favouring
reduced state intervention in capitalist markets has seen some
retreat from universalism and revival of selective, targeted
approaches” (p. 2). Key aspects of adopting neoliberal
approaches to governance involve limiting social spending
and coverage by the public healthcare system.
2
Australia ranks
26th of 28 among Organization for Economic Cooperation
and Development (OECD) nations in social spending and
24th of 36 OECD nations in managing income inequality.
3,4
Only 68% of healthcare spending is public spending with 20%
of spending being out of pocket, amongst the highest figures
among OECD nations.
5
But, the authors do not detail nor explain how this neoliberal
trend has shaped the funding and accountability mechanisms
governments have implemented for health and social services
organization and delivery. And it is important to note that
while these developments have been apparent across all forms
of the welfare state they have been especially noticeable in
liberal welfare states of which Australia is a good example.
6
There have also been macro-level effects that influence
the health and well-being of equity-seeking groups. Garret
7
identifies six dimensions of macro-level neoliberal governance
which clearly have relevance for the issues discussed by Fisher
and colleagues: (1) overturning embedded liberalism which
regulated entrepreneurial and corporate activities at the end
of World War II until the mid-1970s; (2) the re-configuration
of the state to better serve the interests of capital; (3) patterns
of income and wealth distribution which benefit the rich at
the expense of most others; (4) increasing insecurity and
precariousness; (5) a rise in mass incarceration resulting
from increases in crime related to growing income inequality
and precariousness; and (6) a strategic pragmatism by which
governing authorities are willing to stray from the tenets of
neoliberalism when faced with natural or economic crises.
Potential responses to these are presented in the following
sections.
Neoliberalism and Transformations in the Provision of
Health and Social Services
There are aspects of neoliberal ideology which directly affect
the organization and delivery of health and social services
similar to issues raised by Fisher and colleagues. Baines
8
argues that neoliberalism’s valorizing of “the private market,
economic rationalism, and individual, rather than collective,
responsibility for social and individual ills” (p. 12) has
affected the non-profit sector in which healthcare and social
services are delivered. Such processes would explain much
of the centralized top-down, targeted funding favored by
Australian authorities which Fisher and colleagues decry as
reducing the capacity of service providers to meet the needs
of particular populations by limiting the flexibility required
to address their diverse needs, thereby limiting the quality of
service provision:
“In the nonprofit workplace, the neoliberal drift saturates
managerial models such as new public management and
other forms of performance and outcome management.
These approaches purportedly coach employees in “best
practices” and increase professional competencies, but in the
name of increasing efficiencies and removing waste and error,
these processes standardize work practices, reduce or remove
employee discretion, and increase the pace and volume of
work as well as the risk of staff burnout, demoralization, and
workplace illness and injury”
7
(p. 12).
Baines
8,9
documents the effects of these transformations
of social services in Canada. There has been a shift from
secure to project funding which require service agencies
to justify funding through the use of concrete and narrow
metrics drawn from business models such as New Public
Management. New Public Management has led to service
standardization, excessive concern with metrics, and a decline
in advocacy and community mobilization efforts. All of these
trends were mentioned in Fisher and colleagues’ article and
make achieving the goal of devolving governance processes
for promoting equity more difficult.
The Way Forward
Fisher and colleagues suggest that reporting research evidence
can convince authorities to devolve decision-making to local
authorities and agencies, thereby promoting health equity:
“Similarly, our CTG case study indicates that devolved
governance at a regional or local scale can play a role in
effective implementation of targeted policies, again by
flexibly tailoring actions to meet local communities’ needs
and goals. A systemic shift to use of such structures could
overcome some of the aforementioned weaknesses of targeted
funding practices such as short-termism, duplication and
excessive regulatory demands” (p. 9).
But if these funding practices are driven by the forces
we have mentioned above, additional actions are required.
Interestingly, the most developed literature on forms of
resistance to these trends comes from the social services
rather than the healthcare literature.
10
In regard to social
services practice, Weinberg and Banks
11
identify three
forms of resistance available to the social work profession
which may be relevant to those working in a variety of
public policy areas: political, social, and ethical. Political
resistance involves opposing problematic public policies that
inequitably distribute resources and create vulnerability. It
also includes resisting broader phenomena such as economic
globalization, unfettered capitalism, or even capitalism itself.
Social resistance can involve opposing discriminatory norms
and practices by joining social movements such as Black
Lives Matter, the labour movement, or other human rights
organizations. Ethical resistance is focused on individual
actions, and in the context of social work practice, would
be about resisting institutional practices that undermine the
organization and delivery of social services.
A commitment to equity is an ethical stance. For the most
part we would expect healthcare workers, advocates for
broadband internet access, and equitable land use planning
would subscribe to ethical principles of social justice, equity,
and human rights. If economic and political forces such as
acceptance of neoliberal approaches to governance around
Raphael and Bryant
International Journal of Health Policy and Management, 2022, 11(12), 3148–31503150
the making of public policy are driving the findings reported
in this study, then these forces must be resisted. While argued
in relation to social service organization and delivery in the
Nordic nations, Kamali and Jonsson’s
12
compelling statement
of how these forces can be resisted may very well be relevant
to promoting health equity across a range of public policy
domains in Australia and elsewhere:
“In this, critical social work should encourage cooperation
with a number of agents: people in need of social work
interventions; political parties defending the revitalisation of
the welfare state; trade unions of social workers committed
to the global ethics and values of social work; civil society
solidary organisations; and NGOs engaged in improving the
living conditions of people and in counteracting increasing
inequalities, marginalisation, racism and exclusion. This
is the only way in which critical social work can remain
committed to its core values, to social justice, to solidarity
and to its emancipatory mission and potential” (p. 267).
Ethical issues
Not applicable.
Competing interests
Authors declare that they have no competing interests.
Authors’ contributions
Both authors contributed equally to this work.
Authors’ affiliations
1
School of Health Policy and Management, York University, Toronto, ON,
Canada.
2
Faculty of Health Sciences, Ontario Tech University, Oshawa, ON,
Canada.
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