Blurring ‘social justice’ with ‘market justice’ in recent experiments with healthcare and social protection in the Global South

More than three decades after structural adjustment programmes were imposed on governments across the Global South, and amid growing recognition that development has largely failed to address poverty, experiments with expanding forms of welfare and social protection have gathered pace, focusing not only on workers and their families in formal-sector employment but also, in rhetoric at least, on ‘all citizens’. Cash transfer programmes, basic income grants, social pensions, and universal health coverage (UHC), have all gained currency in the 21st century. Reconfiguring relations between labour and welfare, these offer ‘new visions of social security in a world of precarious work’ (Kar, 2017: 12) and a recognition of the state’s responsibility (Ferguson, 2015) for those facing a ‘wageless life’, even while they draw them into financial infrastructures of global capitalism (Nilsen, 2021).

A large body of research focuses on cash transfer programmes and their ambitions to alleviate poverty, with heated arguments about their potential to generate new forms of citizenship or merely cement existing inequalities (e.g. Ferguson, 2015; Leisering, 2019; Nilsen, 2021). An arena of social policy generating similar disagreement concerns the expansion of ‘universal’ social protection in the field of health care. Universal Health Coverage (UHC), defined as ‘ensuring that all people can receive the quality health services they need without being exposed to financial hardship’ (WHO, 2010), has moved up the policy agenda as arguments for a more comprehensive approach – to invest in public health systems and ensure that the poor are included – have gained currency. Below, I discuss how UHC, like other attempts to introduce a ‘thin’ form of more universal welfare, remains squarely located within neoliberal social policy. I discuss the policy’s focus on expanding health insurance coverage to previously un-insured populations, particularly those who have no formal employment, drawing upon research conducted in Kenya and Tanzania.

Questions of financial risk protection are crucial to UHC: how to raise funds and pool risk so that the rich subsidize the poor and the healthy subsidize the sick, and how to protect people from ‘catastrophic healthcare costs’ (The Lancet, 2012). In Northern welfare states, national health insurance schemes or free healthcare provide (albeit ever more precariously) the kernel of the social contract between the state and its citizens and have been a cornerstone of citizens’ concepts of ‘the good society’ (Espen-Anderson, 1993). However, in most Lower-and-Middle-Income Countries (LMICs), financial protection from healthcare costs was until recently limited to (some) workers in the formal economy. Extending coverage thus raises question of how to include people who have no formal employment (often comprising the majority population), whose incomes and livelihoods are highly precarious. With World Bank support, many LMICs are seeking to extend financial protection to those without formal employment by experimenting with new forms, or expanding existing forms, of health insurance coverage.

Such experiments illuminate relations between changing forms of labour, citizenship, financial protection, and social welfare within neoliberal capitalism.

Universal health coverage: a new direction for social policy?

While the Washington Consensus sought to minimize state intervention, privatize many healthcare services, and place costs of healthcare onto individual users, UHC appears to imagine a different social contract. It draws on a language of solidarity, inclusion and equity, reinserts arguments of social justice into questions of healthcare access and provision, and recognizes the state’s responsibility for its citizens – pushing against the death of the social, so often decried in neoliberalism. Like Cash Transfer Schemes or Basic Income Grants then, UHC can be framed as a move towards social citizenship and expanded inclusion into social welfare, particularly in many postcolonial societies where systems of welfare and public healthcare have historically been limited (Ferguson, 2015; Prince 2017).

However, UHC is surrounded by many contradictions, as our ongoing research underlines. Foremost among these is that it represents moves to formalize social protection and for equity in access to health care at the same time as profitable markets for health care are expanding (Oxfam, 2023; Prince, 2023). Critics argue that UHC is the ‘trojan horse’ of neoliberal policies as it risks shifting the emphasis from public provision of services to merely expanding market access to health insurance policies (Qadeer, 2013). The demand for expanding coverage exists alongside a dominant ideology that healthcare should be provided through market mechanisms, healthcare users are ‘consumers’, and market participation will improve healthcare access. Although UHC policies appear to place responsibility onto the state, in practice a multitude of corporations and social enterprises are involved. Seeking markets for their products, these organizations seek to partner with state programmes as this ensures both longevity and the capacity to scale up (Prince 2020). The ways that market participation is embedded in such efforts to address ‘the social question’ calls for careful attention.

Blurring ‘social justice’ with ‘market justice’

UHC is presented by its proponents as a policy that pursues social justice (WHO, 2010). However, it is not clear what form of justice is being pursued. Global health offers a key ideological battleground for competing political understandings of what is a ‘just’, ‘legitimate’ or ‘fair’ outcome, distinctions that Reid-Henry (2016) summarizes as ‘market justice’ versus ‘social justice’ approaches. The market justice approach, dominant globally since the early 1980s, prioritizes an economistic rationale, presenting intervention in terms of cost/benefits in relation to healthy productive global citizens (or lives saved); it harnesses what are often termed the ‘energies’ of the private sector, and it minimizes politics. The social justice approach considers investments primarily in the public sector as necessarily to pursue the public good, which is considered to lie outside the realm of market and profits. A close examination of the reforms and interventions included under the UHC agenda underlines the dominance of market-based approaches, often clothed in a language of social justice or more frequently, a ‘social good’, where the pursuit of profit is presented as compatible with the expansion of social protection. How, then, does the rhetoric of social justice sit with the dominance of the market as a means of pursuing more universalist visions of healthcare access?

Social justice is not necessarily about radical socio-economic change, but (in social democratic terms) about more ‘just’ societies. In his plea to make UHC attainable, Amartya Sen (2015) argues that the ethics of UHC (reducing inequities in access to health care, ensuring financial protection for all) ‘have to be distinguished from the value of eliminating inequalities in general, which would demand much more radical and social changes than UHC requires’. This indicates the (lack of) political ambitions surrounding UHC. Although presented as a return to the ambitions of the 1978 Alma Ata Declaration for ‘Health for All by the year 2000’, UHC is conceived in much narrower terms (Kehr, Muinde and Prince 2023) with its narrow focus on financial coverage and technical reforms.

This can be illustrated by a brief foray into our research on attempts in east Africa to expand health insurance to the previously un-insured. In 2018, the Kenyan government promised to ensure that ‘all citizens can access affordable healthcare’ and announced its ambition of achieving UHC by 2023, with financial and technical support from the World Bank and WHO. The government encouraged non-governmental organizations (NGOs), social enterprises and fintech companies to move into the field of UHC, where they promised to expand access to ‘affordable healthcare’ alongside financial protection. In this context, we explored Kenya’s attempts to expand membership of its national health insurer, the National Hospital Insurance Fund (NHIF), to include those outside formal employment, as well as micro-insurance schemes and digital health designs in Kenya and Tanzania (Ameso and Prince, 2022; Muinde, 2020; Muinde and Prince, 2023; Neumark and Prince, 2021).

In Kenya, the national health insurer covers mainly the formally employed, and only 20% of the Kenyan population. Most people therefore live without financial protection for healthcare costs. The NHIF is not designed for an economy where informal labour is predominant, and its design remains deeply regressive, offering a tiered system that benefits the formally employed and the most privileged. Despite efforts to persuade those outside formal employment to pay NHIF premiums, households without regular incomes find the monthly fee of US$5 too costly and often drop out, becoming ‘defaulters’. Policies aimed at those outside formal employment emphasize the responsibility of the individual for maintaining premium payments, effectively tasking individuals to take responsibility for their own financial protection. Precarity is also embedded in formal employment, as insurance coverage ceases if one loses the job.

Alongside attempts to reform national health insurance, Kenya has experimented with micro-insurance schemes. Their products are embedded in infrastructures of financial capitalism, fintech and digital technologies offered by Safaricom, Kenya’s mobile phone giant, and M-PESA, its mobile money platform (Donovan and Park, 2022). Here, they piggyback on the financial inclusion agenda, which offers an attractive model for investors, with the expansion of health insurance markets through digital platforms recognized as an emerging frontier in Kenya (Neumark and Prince 2021). Kenya’s financial and communication technologies thus enable micro-insurance companies to sell policies to the poor, tapping into ‘markets’ at the bottom-of-the-pyramid (see Bähre, 2020). These schemes target users as consumers rather than as citizens, aiming to shape their capacities to participate in insurance markets through seeking to instil particular orientations, such as to save and insure for healthcare, effectively displacing arguments that embed rights to healthcare within the social contract and social citizenship. Typical of social enterprise solutions, they seek to combine a ‘social good’ – enabling and expanding access to financial protection for health among the poor – with the pursuit of profit (Erikson, 2015; Hunter and Murray, 2019).

Conclusion: future pathways for research

Like other experiments with ‘thin’ social protection, the UHC agenda offers what the guest editors call ‘a thin universalism’, which does not seek to ensure meaningful social protection for all and provides only very basic protections. This situation describes a form of austerity welfare, where social welfare ‘is no longer a simple transfer from the state to its citizens’ but rather generates new financial products; ‘having poor people invest directly in social security through financial products while sustaining new forms of capitalist accumulation’ (Kar, 2017: 12). How market participation has come to stand in for the public good, the forms it takes at different scales of social policy implementation, and the ways it shape conceptions of citizenship among policy-makers, government planners, social enterprise managers, and ‘beneficiaries’, are questions for ongoing research (e.g. Bärnreuther, 2023). As the ideology of market justice becomes ever more deeply ingrained in social policy worldwide, critically assessing what other pathways could, with renewed imagination, be opened up, remain our urgent tasks.