The Global Fragmentation of Public Health Systems

Photograph Source: Aeronautica Militare – CC BY 2.0

In many countries, what should have been a serious problem—COVID-19—quickly escalated into a crisis. Tracking and tracing capabilities were impaired or absent, central coordination was lacking, decisive actions were not taken, and lower-level staff were tasked with making life-or-death choices. This is a reflection of the US-British-led neoliberal form of capitalism that has infected the thinking of many world leaders and economists for the last 40+ years.


Successive governments’ own documents, such as US President Bill Clinton’s National Security Strategy (NSS) 1999 and the UK’s New Labour government under Prime Minister Gordon Brown, with its NSS 2008, warned that a pandemic was coming. Written from a selfish, US elite perspective, Clinton’s NSS 1999 said:

“History has shown that international epidemics, such as polio, tuberculosis and AIDS, can destroy human life on a scale as great as any war or terrorist act we have seen, and the resulting burden on health systems can undermine hard-won advances in economic and social development … [E]pidemics, including some that can spread through environmental damage, threaten to overwhelm the health facilities of developing countries, disrupt societies and economic growth, and spread disease to other parts of the world.”

Likewise, the equally UK elite-centric British NSS 2008 said: “the highest risk” to UK national security:

“…is an influenza-type pandemic, like the outbreak in 1918 which killed 228,000 people in the United Kingdom and an estimated 20–40 million worldwide. Experts agree that there is a high probability of a pandemic occurring – and that, as the SARS (severe acute respiratory syndrome) outbreak showed, the speed at which it could spread has increased with globalisation. We estimate that a pandemic could cause fatalities in the United Kingdom in the range 50,000 to 750,000, although both the timing and the impact are impossible to predict exactly.”

Things were done in response, namely the further undermining of public health by British and American governments domestically, as well as by governments around the world under the banner of market efficiency.

H5N1 & H1N1

Before Britain relinquished its colonial possession Hong Kong (HK) in 1997 at the end of a long-term lease, the UK’s Thatcher government made China sign an agreement which essentially kept many of the UK-type neoliberal economic structures in place. Ever since, China has sought to impose its own state-capitalist ideologies on Hong Kong. Commentators note the link between markets and the H5N1 (Avian Flu), which and appeared to worsen as a result of HK slums, agribusiness, fast food, and the priorities of Big Pharma. Switching to research on so-called emerging diseases was slowed by corporations’ internal decisions to reshape their research agendas.

Just as Britain wanted to maintain a neoliberal Hong Kong, the US worked with Mexican elites in the late-1980s to restructure their economy in preparation for the North American Free Trade Agreement in 1994. President Clinton even used emergency powers so that he could lend Mexico US dollars. When H5N1 hit Mexico, some argued that the 1980-90s’ restructuring of the economy, following financial crises in the country, led to failures to tackle the transmission of the disease. Mexico’s public health services was fragmented, privatized, and opened to foreign markets. The central government did not, therefore, have the control over the system necessary to track the spread of the virus.

Argentina is also a model of healthcare fragmentation and resultant inability to track and contain epidemics. Researchers Stern et al. trace Argentina’s poor response to the H1N1 (Swine Flu) outbreak in 2009 to the gradual dismantlement of its public healthcare system. Due in part to the top-down culture that considered healthcare to be the privilege of the few and not the right of the many, efforts made in the 1950s and 1980s to centralize the nation’s healthcare system were undermined by Western-backed coups and pressure from neoliberal advocates. As unemployment rose and privatization increased, growing numbers of Argentines lost access to healthcare. Similar to Canada’s situation (below), Argentine provinces and municipalities developed their own, localized services. Health experts agree that this form of privatized municipalism limited healthcare quality. The authors conclude that “[t]hese structural limitations were exacerbated by lethargy on the executive level, which ultimately stymied a comprehensive pandemic response in Argentina.”


In response to the severe acute respiratory syndrome (SARS) outbreak in 2003, Health Canada published a stern criticism of attempts to marketize the country’s healthcare system. The main point was that many frontline laboratory services had already been privatized, supposedly to reduce costs. But the report notes that private-sector labs are less likely to perform labor-intensive, low-profit tests for products relating to infectious diseases than they are to focus on more immediate and profitable research. As in the case of Mexico, the UK, and elsewhere, “[p]rivatization may also make it more difficult to perform certain kinds of surveillance” necessary to track an outbreak. Just like in the UK, where the Health and Social Care Act 2012 gave greater autonomy to regional hospitals and clinics, the Canadian system via judicial decisions placed healthcare further from government control and under provincial jurisdiction. Provinces became responsible for legislating for the tracking and spread of diseases, as well as for sanitation. “Moreover, the courts have granted provinces jurisdiction over a variety of related areas: drug addiction (including legislation for involuntary treatment), mental health (including legislation for involuntary committal), the medical profession (including the practice of medicine), workplace health and safety, the regulation of foods for health reasons, the safety and security of patients, and hospitals.”


The science journalist Sonia Shah argues that governments are ultimately responsible for implementing preventative technologies. Cholera, for instance, is a simple disease to contain via water sanitation. But private interests jeopardize containment. In 1799, the New York City hired a private company to build its waterworks. The company used substandard materials and the water quality suffered as a result. Shah notes that health systems around the world are subject to the same fate, concluding that the Ebola spread in 2013-14 was a result of poor standards caused by privatization.

During a roundtable discussion on Ebola, Oxford’s Dr. Robtel Neajai Pailey noted that the three most affected countries were Liberia and Sierra Leone, which had been devastated by civil wars, and Guinea. Pailey implicitly likens the effect of Guinea’s so-called market reforms to war. In addition to conflict, “[a]ll three have been subjected to neoliberal interventions by the IMF and the World Bank.” Liberia’s post-war reconstruction efforts were underpinned by privatization, deregulation, and reduced public spending on health and education. Post-conflict reconstruction emphasized privatization. To mitigate the effects of Ebola, “what was required was more state intervention, as neoliberal structures from international actors led to a state in which the healthcare systems in these three countries could not function properly.”


After a decade of financial crisis-induced austerity for the public (a political choice, not a necessity), populations in many countries questioned the apparent wisdom, rationality, and legitimacy of public-private enterprises and so-called markets. Arguments in favor of public-sector services strengthened. Healthcare and other professionals constituted the 150 organizations which sent a Manifesto to the World Bank and IMF, calling for a stronger public sector in healthcare.

At the very least, the global coronavirus crisis might give further credence to the left-wing factions of political parties hitherto ridiculed, ignored, and sabotaged by the so-called centrist elements.


T. J. Coles is director of the Plymouth Institute for Peace Research and the author of several books, including Voices for Peace (with Noam Chomsky and others) and  Fire and Fury: How the US Isolates North Korea, Encircles China and Risks Nuclear War in Asia (both Clairview Books).