Trade unions, civil society organisations and health reforms.

Public healthcare systems have become increasingly commodified in the past fifteen years, with the drivers for this commodification coming from several directions. National governments in high-income countries with aging populations are concerned about the increasing demand for healthcare services, particularly for high-technology treatments. Low taxation policies preclude the raising of more revenue for improved public healthcare services, and these have been reinforced by policies such as the European Union's Maastricht Treaty entry criteria, which set limits for public-sector spending.

National public healthcare systems have developed according to their own specific histories, and these often influence the effects of commodification and the nature of resistance to these changes. In low-income countries, the international financial institutions have imposed funding conditions that have forced government to introduce reforms of the public healthcare sector (Verheul & Rowson, 2001; Lister, 2006). Trade treaties have contributed to this process by encouraging policies of liberalisation, which have opened up public services to global multinational service companies (Lipson, 2002).

The private sector has entered public healthcare systems through several mechanisms. As a way of preparing the public healthcare sector for competition and marketisation, one of the initial stages of reform is for public hospitals to become 'corporatised'--a process by which they have to operate according to business principles. This contributes to the commodification of healthcare, even if full privatisation does not take place (Sen, 2005; Leys, 2001). Services may be gradually contracted out to the private sector, often starting with catering, cleaning and facilities management before moving on to clinical services; and the development of public-private partnerships to build and manage new hospitals has presented many governments with an apparent solution to short-term funding, though in the long term, governments will be paying the private sector for inflexible long-term contracts (Pollock, 2004).

Thus there is a growing presence of private-sector companies operating in public healthcare systems, as well as significant changes taking place in the role of government in public healthcare systems (Lethbridge, 2005). The impact of these changes on healthcare workers and on healthcare users has been felt in a variety of ways. For healthcare workers, their socioeconomic security has been undermined by either the introduction of corporatisation to public-sector hospitals, or the contracting out of services to the private sector. Changes in wage levels and terms and conditions are the immediate results of the commodification of public healthcare, leading to increasingly precarious employment (Afford, 2003). The lack of investment in public healthcare combined with deteriorating working conditions has resulted in depleted public health services (Laurell, 2001), and it has also led to the migration of skilled health workers from many low-income countries to higher-income countries. For healthcare users, the effect has often been to limit access and worsen the quality of the services delivered (Gilson, 1995; Bloom & Lucas, 1999; Bloom & Standing, 2001; Hilary, 2001). It also creates a feeling of insecurity about the future of healthcare provision. The introduction of user fees has often had a devastating effect, restricting access to healthcare even when there are exemptions for disadvantaged groups (Gilson, 1995; Nyonator & Kutsin, 1999; Jeppsson, 2001).

The nature of healthcare has an important influence on the kinds of resistance to changes that can be seen in public healthcare services. Access to healthcare which is free at the point of access is an important factor in preventing loss of income due to illness, which contributes to the reduction of income inequalities. People use healthcare services throughout their lives, and though the nature of their relationship with healthcare is different to the relationships people have with other public utilities because other factors influence health besides access to treatment, people often have close ties with local healthcare facilities. When these facilities are threatened, people respond with strong campaigns. The relationships between healthcare users and healthcare workers may be strengthened by their campaigning together (Lethbridge, 2004).

Much research into trade union resistance to globalisation has concentrated on the manufacturing sector, and although there has been some specific research into campaigns against the privatisation of public services, models of resistance are dominated by the manufacturing perspective. Healthcare trade unions have been active in campaigns to protect public healthcare services throughout the world, and this article aims to contribute a specific sectoral analysis to resistance to neoliberalism, as seen in the experience of public healthcare services.

This study will explore four examples of resistance to healthcare commodification by trade unions alongside community organisations and social movements. A case study approach was chosen as a way of analysing the patterns of resistance. The four dimensions of commodification considered here are hospital privatisation, hospital corporatisation, a post-privatisation campaign against low pay, and a campaign for access to HIV/AIDS treatment.