Madagascar is one of the poorest countries in the world today, with gross domestic product (GDP) per capita of less than 400 dollars in 2016 and a colossal rate of monetary poverty (over 90% on the international poverty line). Yet nothing appears to have ever marked the country out for such a terrible fate. Far from it, in fact. Although the latest political crisis that started in early 2009 and found an electoral conclusion in late 2013 has played a role, it is a mere blip on the historical radar. Madagascar’s long-term economic trajectory is a real mystery, which raises farther-reaching questions as to what is behind the divergent development processes observed in the world today. Not only has per capita GDP been trending downward since 1960, but also every time the country has set out on a growth path, it has been stopped in its tracks by a socio-political crisis that has shattered the hopes it raised.

This chapter discusses the country’s key structural assets: control of violence; formal institutional capacities as shown by the dual economic and political transition as well as bureaucratic accomplishments; and expression of the population’s democratic aspirations.Episodes of violence are flare-ups rather than deliberate political strategies. In the light of the country’s long history, no non-state organisation appears to have any real power to whip up violence. Although violence exists in Malagasy society, it is largely repressed and, when it does surface, it tends to take the form of infrapolitical eruptions expressing a discontent that does not clearly pinpoint its causes or directly designate those responsible.Depending on the period, Madagascar posts capacities and achievements that could place it at an advanced stage of natural state in all three economic, bureaucratic and political arenas. Three examples illustrate this: the success of the export processing zones, significant results in the fight against bureaucratic corruption and the process of democratic transition.Last but not least, population matters. Changes of government have often been driven by large-scale movements. Escalating economic and unfulfilled democratic governance aspirations are a major source of popular frustration and potential mobilisation.

A spectacular thirty-meter-high viaduct spans the Ouseburn river as it makes its way through Newcastle-upon-Tyne, in the northeast corner of England. Modern, bright-yellow and black tram cars ply the viaduct, bringing passengers from working-class Byker to more affluent South Gosforth station in a journey that takes roughly ten minutes. But while the Byker viaduct allows riders to traverse the physical chasm carved out by the Ouseburn with ease, the social differences that separate residents of Byker from their better-off neighbors are much harder to bridge. Twice as many children in Byker (two in five) live in poverty as in Gosforth. And while a fifty-five-year-old man from Gosforth can expect to live another seventeen years in good health, the average fifty-five-year-old in Byker has only another nine years of healthy life expectancy ahead of him (Bambra 2016, 92).

In 1964, a nationwide survey of health and health care utilization in the Finnish population revealed striking inequalities. Finnish citizens living in rural areas, where access to medical services was limited, had higher mortality, and poorer people in Finland were more frequently ill than their higher-socioeconomic status (SES) neighbors, yet less likely to see a doctor. In response, an innovative program, organized at the municipal level, was rolled out in 1972. It provided integrated public health, prevention, and primary health care and services free of charge, and focused on the poorest areas first. A review of health policy by the tripartite Economic Council that same year articulated the joint goals of improving population health and ensuring a more equal distribution of health, a dual formulation that would later be repeated in the WHO’s Health For All agenda (interview FI5). The North Karelia project, Finland’s internationally renowned, multisectoral effort to reduce regional inequalities in cardiovascular mortality, was also launched in 1972.

Solving the puzzle of resilient inequality requires coming to grips with how higher-than-desirable levels of inequality have come to be reproduced in so many of the rich democracies simultaneously. In Chapter 1, I showed that the normal explanations for this phenomenon offered by political science and economic theories fall short, and took the first steps toward laying out an alternative argument. In this chapter, I make a more comprehensive case for my claim that political solutions to the problem of inequality are shaped both by legacies of the past and by the way politicians talk about the problem of inequality in the present. As the central institutions for containing the growth of inequality in the welfare regimes of the postwar period collided, beginning in the 1980s, with a rising neoliberal economic policy paradigm, politicians on the center-left responded by changing how they framed the issue of inequality. This shift in framing had unanticipated consequences, however: instead of making the problem of inequality more politically tractable, as politicians hoped, the new framing of inequality as a matter of health made it more technically intractable by prompting policy-makers to eschew the simplest, most effective policy remedies. Before laying out my argument in full, I must clarify how I understand three core concepts – health inequalities, welfare regimes, and neoliberalism – that are necessary background for the argument, but that may have different resonances for different audiences.

In the preceding three chapters, we saw how politicians and policy-makers in England, France, and Finland reframed the issue of inequality in the 1990s and 2000s. In each country, public discourse about the problem of inequality – how the problem was defined, what caused it, who was responsible for solving it, and how best to do that – underwent important changes during this period. Reframing inequality in this way was facilitated by the availability of an international consensus on health inequality at the European level, whose development was described in Chapter 3. The reframing of inequality resulted in large part from the efforts of politicians who wanted to maintain their credibility as defenders of societal equity, but who were increasingly unwilling to advocate classical welfare policies like redistributive taxation, substantial public spending on services, or intervention in product markets.

In Chapter 4 we saw that, when the postwar welfare order in Britain came into contact with a rising neoliberal current, center-left politicians reframed the problem of social inequality in terms of health. In order to avoid violating a self-imposed taboo against discussing redistribution, Labour leaders took up the issue of health inequality, which appeared to allow the party to maintain its long-standing commitment to a more equitable society without raising the specter of taxing high incomes. Health inequality has played an analogous discursive role in French politics, allowing French center-left leaders to avoid discussing a sensitive topic made salient by the collision between France’s conservative-corporatist postwar welfare order and the neoliberal paradigm that came to dominate Europe in the 1980s.