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“Gender Equity and the Politics of Health Sector Reform: Overcoming Policy Legacies and Forming Epistemic Communities.” In: Jasmine Gideon, ed. Gender and Health Handbook. London: Edward Elgar, 2016, pp. 283-97.

GenderEquityandthePoliticsofHealthSectorReform:OvercomingPolicyLegacies,FormingEpistemicCommunities

ChristinaEwigProfessor

DepartmentsofGenderandWomen’sStudiesandPoliticalScienceUniversityofWisconsin–Madison

cewig@wisc.edu

Abstract:

Healthcarereformpresentsanopportunitytoamelioratelong-standinginequitiesin

existinghealthsystems–orinequitable“policylegacies”.Conversely,reformsmay

introducenewinequities.Thischapterarguesthatpolicylegaciesaregenderedin

crucialways,andthatreformismostlikelytotakeplaceinmomentsofperceived

“crisis”inwhichepistemiccommunitiesplayaninfluentialrole.Inthiscontext,thekeys

togenderequitablehealthreformaretheabilitytoovercomeprevious,gender-

inequitablepolicylegaciesandepistemiccommunitiesthatholdprinciplescompatible

withgenderequityandwhichareintegratedwithmemberswhoareconsciousofhow

healthsystemscanshapegenderequity.Thesalienceofthesetwinelementsis

illustratedthroughacasestudyofPeru’shealthreformsofthe1990sandearly2000s.

…………..

Whenhealthinsurancecoverageislefttoprivateinsurerstodecidewhatshall

becovered,moreoftenthannot,women’shealthcareneeds–frombirthcontrol,

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cervicalcancercaretochildbirthcoverage–areconsidered“additionalneeds”that

requireextrafeesiftheyareofferedatall(e.g.Pollack2002,EwigandHernández2009,

EwigandPalmucci2012).Whenhealthsystemsinpoorcommunitiesarere-structured

toprovideincentivesforfamiliestobringchildreninforwell-babycareincluding

nutritionalassessmentsandvaccines,moreoftenthannot,theseincentivesrelyon

mothersorotherfemalecaregiverstotakeresponsibilityforthiscarework(Ewig2006,

Gideon2008,Molyneux2006).Whenfeesforbasichealthservicesareintroduced,

theseserveasabarrierforwomentoaccesshealthcare,moresothanformen,

becausewomen’sreproductivehealthrequiresmoreroutinevisitsthanmen’s,and

thesecostscanbecomeespeciallyproblematicifwithinthefamilythemaleisthe

primarycash-earneranddisapprovesofhiswifeorfemalepartnerseekingcare(Ewig

2006;GómezGómez2002,Nanda2002).Insomecontexts,suchasPeruorGuatemala

whereindigenouswomenarelesslikelytospeakthelanguageofhealthcareworkers,

economicsandgendermayintersectwithracial/ethnicbarriers.Forexample,when

incentivesforgreaterproductivitywereintroducedintoPeruvianstatehealthworker

contracts,thisresultedinatoxicmixwherepersonnelusedracismandlinguisticbarriers

tojustifyhealthcareinterventionswithoutproperconsentinordertoachievehealth

care“productivity”goals(Ewig2006b).Forallofthesereasons,thewaysinwhichhealth

caresystemsarestructured–insurancesystems,fees,therangeofservicesoffered,

patienthealthcareincentivesandworkstructuresandregulations–matterforgender

equity.Thesematterforthequalityofcareprovided;fortheeconomic,geographicand

culturalaccesstotheservicesthemselves;andfortheadditionalfamilycarework

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burdenthatwomenlargelyshoulder.Ultimately,thesestructuresmatterfundamentally

forwomen’sdignityandwell-being.1Whilethesearethespecificwaysthathealth

structuresmayshapegenderequity,onecanalsoidentifyrace,classoragebased

inequitiesperpetuatedbyspecifichealthsystemstructures,manyofwhichalso

intersectwitheachotherandwithgenderequity.

Whilewehavesignificantandgrowingevidenceofhowhealthcaresystemsmay

impactgenderandotherformsofequity,fewerscholarshaveconsideredthegendered

politicsofhealthreformprocesses.2Whenhealthcarereformsareundertaken,these

presentbothanopportunityandariskinrelationtogenderandotherformsofequity.

Reformsmaybeanopportunitytoaddressandamelioratelong-standinginequitiesin

existinghealthsystems–orinequitable“policylegacies”.Conversely,reformsmay

(wittinglyorunwittingly)introducenewinequities.Keytoareformprocessthat

successfullyaddressesgenderinequitiesiscarefulattentiontothedesignofpolicies

withgenderequityinmind.Thus,asIhavearguedelsewhere,oncehealthsectorreform

isonthepoliticalagenda,twoelementsareessentialforsuccessful,gender-equitable

policies:theabilitytoovercomeprevious,gender-inequitablepolicylegaciesandthe

integrationofthepolicyreformitselfwithaconsciousnessofhowhealthcarecanbe

structuredtobestpreventinequities(Ewig2010).Thisis,however,moreeasilysaid

thandone.Policylegacies,bydefinition,aredifficulttochange,whilegender-equitable

designrequiresnotjusttheintegrationoftraditionallyinsulatedandtechnocratic

reformteamswithmembersthatadvocateforgenderequity,butalsoover-arching

policyprinciplesthatarecompatiblewithgenderequity.

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Thischapterfocusesongenderandthepoliticsofhealthsectorreformwiththe

objectiveofoutliningboththebarriersandkeystogenderequitablehealthsector

reformoncereformisonthepoliticalagenda.Opportunitiesforgenderequitable

reformsarisewhentheopportunityforreformitselfarises,andwhenepistemic

communitiesengagedinthereformprocessholdprinciplescompatiblewithgender

equityandareintegratedwithteammemberswhoareconsciousofhowhealthsystems

canshapegenderequity.Ibeginbydefiningpolicylegacies,outliningthebarriersthat

thesemayposetoreform,andhowpolicylegaciesthemselvescanbegendered.

Overcomingpolicylegaciesisnoteasy.Moreoftenthannotthisrequiressomekindof

“crisis”thatspurspolicy-makerstolookoutsidetheirtypicalpolicyrepertoirefor

alternativepolicysolutions.Ithenturntotheissueofreformprinciplesandthe

integrationofreformteamswithmembersconscientiousofgenderequity.Iarguethat,

inthisregard,epistemiccommunitiesmattersignificantly.Thesecommunitiesoften

obtaingreaterinfluenceintimesofcrisisorflux;thustheprinciplesofandparticipants

engagedinanepistemiccommunitymatterforwhetherornotgenderequitablepolicies

willbeconsideredatthetimeofreform.Iendbyillustratingmyargumentwithan

accountofhowthehealthreformprocessplayedoutinPeruinthe1990s.

GenderedPolicyLegaciesandHealthSectorReform

Pastpoliciescreateinterests,institutionsandnormsthataredifficulttochange.

Thus,policychangeisnotsimplytheactofintroducinganewpolicyontoapolitical

agendaandgarneringsupport;itisalsoaprocessofovercominginterestgroups,

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institutionsandnormsassociatedwithandsupportiveoftheoldpolicystructure.

Decades–sometimescenturies–ofpolicycontinuityarenoteasilyundone.Thisisthe

fundamentalcontributionofthosethathavedevelopedtheconceptof“policylegacies”;

previousprocessesofpolicydevelopmentservetocreateanentrenchedpolicycontext

that,moreoftenthannot,servesasanimportantbarriertochange.PaulPiersonwas

thefirsttoelaboratetheconceptofpolicylegacies,thedifferentpossibletypesof

legacies,andhowthesemightoperate(1994).Perhapsthemostimportanttypeof

policylegacyis“interestgrouplegacies”;societalgroupsthatbenefitfromaspecificset

ofpolicies.Thebenefitsmayrangefromthedirectlymaterialtoaccesstopower,and

thegroupwillseektodefendthesebenefitsinthefaceofreforms.Otherlegaciesmay

beintheformofinstitutions;stateorprivateinstitutionsthatbecomethescaffoldsofa

publicpolicyarenotinterestgroupsbutareinstitutionswithbudgets,personnel,

physicalspacesandinstitutionalidentitiesthathavevestedinterestsindefendingtheir

ownsurvival.Finally,therearewhatPiersonreferstoas“learninglegacies”and“lock-

in”effects;theseareessentiallynormsandexpectations,thefirstprimarilyapplicableto

policymakersandthelattertopublics,withregardtohowpoliciesaretraditionally

organizedanddelivered.FollowingPierson,ahostofauthorshaveusedtheconceptof

policylegacytohelpexplainresistancetosocialpolicyreforminarangeofcontexts

fromWesternEuropeandtheUnitedStates(Pierson1994,HuberandStephens2001,

Hacker2002)toLatinAmerica,AsiaandEasternEurope(Brooks2009,Dion2010,

HaggardandKaufman2008,Pribble2013).

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Whatmostauthorsthatworkwithinapolicylegaciesframeworkdonot

recognizeisthefactthatthesepolicylegaciesarenotsimplyupholdinganentrenched

setofpolicies,butthattheyalsoupholdanentrenchedsetofprivileges,privilegesthat

oftenreinforcegender,raceandclassdistinctions.AsIhavearguedelsewhere(Ewig

2010),policylegaciesarethemselvesgendered,racedandclassed.Thepolicystatusquo

oftengrantsmaterial,social,orpoliticalprivilegeunevenlyacrosskeyaxesofsocietal

power.Thus,policylegaciesoftenseektoprotectnotjustgenericmaterialbenefitsor

accesstopower,butgender,raceandclassprivilegesinparticular.

Adiscussionofthespecifickindsofpolicylegaciesthathealthsectorscan

generatehelpstoillustrate.Thehealthsectorispossiblythemostlikelypolicysectorto

developstrongpolicylegacies.Theverycomplexityofhealthservicesyieldsmultiple

layersofproviders,fromprimaryclinicstosophisticatedhospitals,withinsurers,

pharmaceuticalcompaniesandhealthsupplyandequipmentpurveyorsfurther

enmeshedintheoverallsystem.Healthsystemsalsoemploylargeworkforcesofhealth

careprofessionals,andservearangeofbeneficiaries.Eachofthesepossibleconstituent

groups:insurers,pharmaceuticalandsupplycompanies,healthprofessionalsandhealth

carebeneficiariesareallpotentialinterestgrouplegacies;eachmayhaveaninterestin

maintainingthestatusquo–frominsuranceratestobeneficiaries’desiresfora

particulargenreoftreatment.Withinthecontextofapoliticalprojectofreform,

reformsoftenprovoketheseconstituenciestoorganizeasinterestgroups–patient

groupadvocates,healthsectorunions,insurerlobbiesarejustafewpossibleexamples.

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Theseinterestgrouplegaciesareusuallythemostvocalandvisibleopponentsof

reforms.

Existinginstitutions,too,maybecomevocalopponentsofreform.Inhealth

systemswithlargelypublicprovision,statehealthinstitutions(MinistriesofHealth,

SocialSecurityHealthInstitutes,NationalHealthServices)havevestedinterestsin

maintainingastakeinthenationalhealthsystem,beitfromthevantagepointof

maintainingpoliticalinfluencewithinthestateitselforfromthevantagepointof

protectingtheirbudgetsandworkforce.Instatesthatgrantarolefortheprivatesector

inhealthprovision,thesetoogenerateinstitutions,aswellasinterests.Thesemaybe

networksofprovidersorinsurersthatseektomaintaininfluenceinpolicydiscussionsas

wellasdefendtheirownmaterialstakeinthesector.

Yet,othermoresubtlelegaciesalsomaycomeintoplay.Policymakersmay

displaypreferencesforparticularpolicyapproachesthatfitwithpastexperience.For

example,thehistoricmarket-orientationofUSsocialpolicymade,inthecaseofthe

UnitedStates,theideaofasingle-providerorasingle-payerhealthsystemoutofthe

questionwhenPresidentClintonandthenPresidentObamapursuedhealthsector

reforms.Suchpreferencesbuiltfrompastexperienceconstitutepolicy-learninglegacies,

andcanshapetherangeofchoicesthatareconsideredpoliticallytractable.Somewhat

differentare“lock-in”effects.Healthsectorsmight,forexample,offerin-homedoctors

visits,asiscommoninFrance,orindividualchoiceofdoctor,asiscommonintheUS.

Policiessuchasthesemaygiverisetopublicexpectationsforpolicycontinuity;reforms

thatattempttochangethesepoliciesmayfacegreaterresistance.

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Whilethisdistinctionamongtypesofpolicylegaciesisusefulforunderstanding

thevarietyofbarriersthesemayposetoreform,itisalsoworthconsideringhowthese

legaciesmayengenderparticularkindsofsocialprivilegealongtheaxisofgenderin

particular.3Thisisperhapsmosteasilyillustratedthroughinterestgrouplegacies,which

maynotonlyhavevestedinterestsindefendingexistingpolicieswhichmightprovide

themmaterialbenefitsoraccesstopower,butoftenhaveinterestsbasedontheir

predominantclass,genderorracialmake-up.Forexample,historicallylargelymale

unionsinmanycountrieshavedefendedthe“male-breadwinner”modelof

employment,arguingforhigherwagesinorderthattheirwivescouldstayoutofthe

workforce.Appliedtothehealthsector,incountrieswheresocialpolicieswerelargely

shapedbyuniondemands(asinthecorporatistpatterncommontoCentralEuropeor

theresidualemployer-basedmodeloftheUnitedStates,bothestablishedattheendof

the19thcentury)itfollowedthatearlyhealthbenefitswereenjoyedprimarilyby

workers,andwiveswerebeneficiariesonlybyvirtueofmarriage,creatingaclear

genderedhierarchyofprivilege.Thus,whenunionsbecomeinterestgrouppolicy

legacies,anddefendpoliciesthatpromotemalebreadwinnerprivilege,theymayalso

defendaparticulargenderedorder.

Butitisnotjusttheinterestgroupsthatresistreformandupholdgender

hierarchies;theinstitutionsthemselvesdoaswell.Alargebodyoffeministworkonthe

welfarestatehasdemonstratedhowwelfarestateinstitutionsnotonlystratifyalong

classlinesbutalsoalonggenderlines.4Thisalsoappliestohealthsectors,as

fundamentalpillarsofoverallnationalwelfaresystems.Whenhealthsectorsarenot

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unified,butinsteadarestratified,withdifferentpublicorprivatesystemsserving

differentclassesofworkers,aswithsystemsthatemergedoutofhistorically

‘Bismarkian’patternsofworkercooptation(suchasCentralEuropeandLatinAmerica),

andthosethatevolvedintomoreresidual,market-dependentmodels(liketheAntipode

countriesoftheUS,Australia,CanadaandNewZealand)theseareoftenstratifiedby

genderaswell.Becausewomenareeitheroutoftheworkforcealtogether,orclustered

inthelower-incomeearningandinformalsectorsofthelaborforce,theyarealsomore

likelytoberelegatedtopoorlyfinancedandlowerqualityportionsofstratifiedhealth

caresystems(Gideon2007,EwigandHernández2009).Forexample,wherehealth

systemsaredividedbetweenpublicallyfinancedandoftenmeans-testedpublicsystems

thattargetthepoorandpay-as-you-gostatesocialsecurityand/orprivatesystemsthat

areaworker’sbenefit,womenwillbeconcentratedinthepoorly-financedpublic

systemswhilemaleworkersaremorelikelytobeinthebetterqualitysocialsecurityor

privatesystems.Whenitcomestothepoliticsofreform,thegoverningbodiesofthe

socialsecuritysystems,suchassocialsecurityinstitutes,typicallyhavemorepolitical

clout.And,whentheseseektodefendthepolicystatusquo,theyoftenalsoholdupa

genderedhierarchyofhealthcareprivilege.

Similarly,policylearninglegaciesandlock-ineffects,althoughnotasclosely

associatedwithaparticulargroupofpeople,canhaveimportantimplicationsforgender

equity.Thepreviousexampleofpolicymakers’andthepublic’sresistanceintheUSto

single-payerhealthcareas“governmentintrusion”inthismarket-orientedpolitical

contextservestoillustrate.Bycategoricallyopposingasinglepayersystem,themost

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gender-equitablefinancingoptionofhealthcarewasleftoffthenegotiatingtable.

Becausewomenbearchildrenandlivelongerthanmen,insurersviewwomenasmore

costly.Routinereproductivehealthservices(birthcontrol,cervicalcancerscreenings,

mammograms)andespeciallychildbirthareviewedbyinsurersasanadditionalcost

burdenposeduniquelybywomen(evenifthesewomenplantobearnochildren–asto

insurersallwomenofreproductiveagepresentthe“risk”ofbearingchildren).One

solutiontothehigher“risks”posedbyhumanreproduction–asisthecasewithall

healthcareriskprofiles–istopoolresourcessothattheburdenissharedamonga

largergroup,andthusthecostsoftheserisks,whentheyarise,arespreadthinly,and

donotpresentamajorburdenforanyonegroup.Conversely,when“risks”become

perceivedasanonerouscost–amorelikelyscenarioinsmallpoolsorindividual

insurancemarkets–thisprovidesincentivestodenyparticulartypesofcoverage.Single-

payersystemsprovidethelargestpossibleriskpool,andthusarethemostlikelyto

ensureequityintherangeofservicesoffered,includinghealthcareservicesforwomen.

Singlepayersystemsmayinvolvegovernmentprovisionofhealthcareservices,asinthe

NationalHealthServiceoftheUnitedKingdom,orentirelyprivateprovision,asin

Canada.

TheRoleofEpistemicCommunitiesinOvercomingLegaciesandDesigningEquity

Giventherangeofpossibleinterests,institutionsandnormsthatconstitute

policylegaciesandwhichmaydefendexistingpolicyarrangements,majorsocialpolicy,

includinghealth,reformsarerare.Asaresultoftheobstaclesposedbylegacies,radical

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reformsthateliminateoldpolicysystemsmayinfactbeimpossible,andpolicymakers

resorttolayeringnewpolicyprogramsnexttoexistingsystems,apatternseeninBrazil

(Faletti2010)andtheUnitedStatesbetween1965and2010(Hacker2004).More

radicalreformsthateliminatepolicylegaciesmostoftentakeplaceincontextsofa

perceivedcrisis.Itisatmomentsofcrisisthatepistemiccommunitiesbecomemost

influential.Thus,forgenderequitablehealthreformtooccur,theprinciplesofthe

engagedepistemiccommunitymustbecompatiblewithgenderequityandthe

communitymustbeintegratedbymembersversedingenderequity–includingwhatit

isandhowtoachieveit.

Severalauthorshavearguedthatradicalsocialpolicyreformprocessesrequire

someformofcrisisinordertospurreforminthefirstplace(Weyland2002,2006,277;

HaggardandKaufman2008,chapters5and7;Orenstein2008,61;Ewig2010).Inthe

caseofhealthsectors,theexistinghealthsystemmustbeviewedasfailinginsomeway;

perhapsitisviewedasfiscallyunsustainable,orwoefullyinadequateinitsreach.

“Crisis,”especiallyinthesocialpolicyrealm,isnotnecessarilyanempiricallymeasurable

phenomenonbutismoreoftenamatterofperceptionandpoliticalcontext.For

example,thefactthatColombia’shealthcaresystemhistoricallyreachedlessthan15

percentofthepopulationformuchofitsexistencewasacrisisinempiricalterms,but

onethatenduredforyearsbecausekeypoliticalactorsdidnotperceiveitasaproblem.

Lackofaccesstohealthcarebecamea“crisis”thatinducedpoliticalchangeonlyonce

Colombiansocialmovementssucceededinframingsocialinequalities–includinglackof

accesstohealthcare–astherootofColombia’slong-standinginternalconflict.Ifthe

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crisisisperceivedasgraveenough,orifexistinginstitutionsorstructuresareperceived

tobepartoftheunderlyingproblemcausingthecrisis,thenpolicymakersmayact

againstpolicylegaciesandmovetowardaradicalreformagenda,ratherthanrelyingon

pastpolicy-learninglegaciesandsimplymakingadjustments,butnotsignificantly

restructuringexistingsystems.Ofcourse,reformersmaynotsucceedintheirobjectives

duetopolicylegacies,buttheremustbeanimpetustoprovokeareformeffortinthe

firstplace.

Oncepoliticiansarewillingtolookbeyondtheirownnational,historicalpolicy

contextforsolutionstoacrisis,whatreformwilltheychoose?Giventheconditionsof

uncertaintyprovokedbycrisis,politiciansincrisiscontextsaremorelikelytoseekadvice

andinformationfromepistemiccommunities(Haas1992,p.15;Hall1993;Zito2001).

DefinedbyPeterHaas,an“epistemiccommunityisanetworkofprofessionalswith

recognizedexpertiseandcompetenceinaparticulardomainandauthoritativeclaimto

policy-relevantknowledgewithinthatdomainorissuearea”(1992,p.3).5The

professionalsthatmakeupanepistemiccommunityareusuallyembeddedinboth

internationalandstatebureaucraciesandinteractwithoneanotheraspartofa

transnationalnetworkcenteredonaparticularpolicydomain.Theseprofessionals

share:asetofnormativeandprincipledbeliefs;asetofcausalbeliefs;specificnotions

ofvalidityandacommonpolicyenterprise,usuallytoaddressaparticularproblem

(Haas1992,p.3).Theirrelianceonexpertknowledgeiswhatmakestheseprofessionals,

andtheirnetworks,distinctfromothertransnationalnetworks(Cross2013,p.143).6

Epistemiccommunitiescanbehighlyinfluentialbyoutliningforpolicymakersthe

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“salientdimensions”ofapolicyproblemandthe“chainofevents”,orcauseandeffect,

likelytoproceedfromaparticularpolicyoption.Theyareparticularlyinfluentialin

complexpolicyareaswhereinformationismoredifficulttosortandweigh(Haas1992).

Finally,forepistemiccommunitiestohaveinfluence,theyalsomust“havereadyaccess

todecision-makers”andlittlecompetitionfromothercompetingactorsorepistemic

communities(Cross2013,p.145).

Thecomplexityofthehealthsector,coupledwithitsdensenationaland

internationalbureaucracies(thevarietyofnationalbureaucraciesthatmayregulateor

providehealthcare,coupledwithinternationalinstitutionsliketheWorldHealth

Organization(WHO),theWorldBankandothers)makeitapolicydomainwhere

epistemiccommunitiestendtoberooted,andwheretheiradviceisoftensoughtoutby

policymakers.7Yet,inhealthsectorsandotherpolicyareas,thereareoftencompeting

epistemiccommunities,withdifferingsetsofnormative,principledbeliefs,andwith

differingdegreesofinfluenceatanyonemoment(Cross2013;Orenstein2008).

Theprinciplesofanepistemiccommunitymaysetconstraintsorprovide

opportunitiesforgenderequitablepolicychange.Thisisbecauseproblemsbecome

definedinwaysreflectiveoftheprinciplesoftheepistemiccommunity,with

prescriptivesolutionsthatfollow-onthesedefinitions.Forexample,ifanepistemic

communitycommittedtomarket-basedprinciplesisreliedupontoprovideexpertisein

agivensetting,themarketitselfislikelytobeviewedaspartofanysolution.Givenits

emphasisonmarkets,andlessonsocialorpoliticalfactors,genderequityislesslikelyto

berecognizedasanissueexceptthroughthelensofcost-benefit.Forexample,“costly”

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reproductivehealthcareislesslikelytobecovered.And,womeninfamiliesaremore

likelytobeseenaspotential“free”laborforensuringgreaterbenefitsatreducedcosts.

Withoutanexplicitlyfeministcritiquewithinthisepistemiccommunitythatpointsto

thelong-termcostsofnotcoveringreproductivehealthcare(forexample,excess

morbidity)oranaccountingofthetimelosstowomen’sproductivityofadditional

carework,genderinequitablereformsaremorelikelytoprevail.Yet,morethanneeding

agenderlenstosortthroughcostsandbenefitsmorebroadlyconceived,acost-benefit

approachissimplylessopentounderstandingthesocial,culturalandpoliticalnatureof

genderequity.Forexample,itislesslikelytorecognizethepowerinequalitieswithin

familiesthatarereinforcedbyupholdingtraditionalgenderroles.

Giventhepotentialinfluenceofepistemiccommunitiesoverthedirectionof

healthreforms,integrationofthesecommunitieswithmembersthatincorporatean

understandingofgenderequityinhealthsystemsintotheirrepertoireofexpertiseisan

essentialprerequisiteforgenderequitablereforms.But,again,thisiseasiersaidthan

done.Bytheirverynature,epistemiccommunitiestendtobeclosednetworks.Specific,

oftenunspoken,credentialsarerequired.Haasspeaksofepistemiccommunitiesas

networksof“scientists”or“socialscientists”(1992).Inthehealthdomain,thisusually

translatesintoaminimumofamedicaldegreeorpublichealthprofessionaldegree.

Sometimesdemographersorhealtheconomistswithhigherdegreesmayalso

participate.Moreover,anindividualmustachieveaparticularstaturewithintheir

bureaucraticentitybeforetheywillbeperceivedasarelevant“expert”.

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Credentialscoupledwithprofessionalpositioncanserveasimportantbarriersto

entry,foranyindividual,andtothosewithaninterestingenderequityinparticular.

Nurses,forexample,arepredominantlywomenandoftenwitnessandexperience

genderinequitiesonthejob.Yetrarelyaretheirnursingcredentialsviewedassufficient

expertiseinhealthepistemiccommunities.Atthesametime,aswithallprofessional

organizations,womenoftenfacediscriminatoryobstaclestoreachinguppertier

professionalpositions.Thisisnottoimplythatexpertiseingenderequityisoroughtto

beanexclusivedomainofwomen,butlifeexperienceoftendoesmakegenderequity

moresalienttowomen,andthusaninformationdomainofgreaterinterest.Yet,

womenarelessnumerousinthosetopbureaucraticpositionsandtheircredentialsless

recognized.

Theprinciplesoftheepistemiccommunitymayalsoattractparticularkindsof

participants.Thosethatarecenteredoneconomicsolutions,forexample,willtendto

bedominatedbyeconomiststhathavehistoricallyeschewedgenderasanimportant

domainandwhichisaprofessiondominatedbymen.8Moreover,thelikely

bureaucracieswithinwhichanepistemiccommunitybasedontheseprincipleswouldbe

housed(MinistriesofFinance,theWorldBankortherelevantregionaldevelopment

banks)tendtobestaffedbymenandhavehistoricallybeenresistanttospecificcallsfor

genderequity(KuiperandBarker2006).Bycontrast,thoseepistemiccommunitiesthat

arerootedinpublichealth,orrights-basedprincipleswillhavedifferentmemberand

institutionalprofiles.Whilestillmale-dominated,thehealthprofessionshavebecome

moregender-integratedthaneconomics,ashavehealthministriesandinternational

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healthorganizations,likeWHO.Rights-basedprinciples,too,tendtoinvitebroader

domainsofexpertiseandmayberootedinnotjustnationalhealthministriesbut

potentiallyotherbureaucraticdomains,likewomen’sministries.Moreover,

internationalinstitutionsliketheUnitedNations(UN)arethelocusofrights-based

ideals.UNentitiesincludeWHO,butalsothevarietyofUNofficessuchasUNWomen

(anditspredecessors)andtheUN’svarietyofspecialrapporteurs.

GenderandHealthSectorReforminPeru9

Peru’shealthreformprocessofthe1990sisillustrativeoftheimportanceof

bothpolicylegaciesandepistemiccommunitiesinshapinggenderequity.Peruhad,like

mostnations,verydurablepolicylegaciesfromitslonghistoryofhealthpolicy

formation,andtheselegacieshadcreatedtheirowngenderedinequities.Thedual

economicandpoliticalcrisesoftheearly1990sservedasatriggertoinitiatereformsof

thehealthsystem.Aswithreformprocessesineconomicandsocialpolicysectorsacross

theLatinAmericanregion,thepoliticalprocessitselfwashighlyinsulatedwithin

governmentbureaucracies,withlittleroomforinfluencebyactorsinbroadercivil

society.Yet,thosethatdesiredreform–thePresidentandhiscloseadvisors–didnot

havearoadmap;oldpolicypatternsseemedtohavecontributedtothecrisis,sothey

searchedfornewsolutions.Itisinthiscontextthattwoepistemiccommunities

competedforinfluenceoverthereformprocess:theneoliberalandtherights-based

approachestosocialpolicyreform.Ofthetwo,theneoliberalapproachclearly

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dominated,buttherights-basedoneunsuccessfullyattemptedtoinfluencereformsto

thegovernment’sfamilyplanningprogram.

Peru’shealthsystemdatestothelate19thcenturywhencoastal,whitepolitical

leadersworkedtoestablishabasicpublichealthinfrastructureservingprimarilythe

poor,indigenouspopulationandtargetingwomeninparticular.Theseeliteswere

influencedbytheLamarkianviewofeugenicspredominantinLatinAmericaatthetime

thatsoughtimprovementoftheracenotthroughbiologicalmeans,butthroughsocial

changethattheybelievedcouldleadtoracialbetterment(Stepan1991).In1908,

PeruvianintellectualFranciscoGrañacoinedthetermautogenia,aPeruvianversionof

eugenicsthatsoughttoimprovethe“race”internallythroughraisinghealthand

nutritionalstandards(delaCadena2000,p.17).Women,duetotheirbiologicaland

socialreproductiveroles,weretheprimaryfocusoftheseearlyhealthinitiatives,given

thattheywereseenasthevehiclesthroughwhichhereditaryoracquiredcharacteristics

couldbecultivated(Stepan1991,chapter4;Zulawski2007,chapter4).Publichealth

expansionwasalsomotivatedbydesirestoincreaseeconomicdevelopment;expanding

miningandagriculturesectorsrequiredalargerandhealthierlaborforce(Mannarelli

1999,Contreras2004).Healthfacilitiesinisolatedregions,suchastheAmazon,also

servedathirdobjectiveof“civilizing”indigenouspopulations.Theresultingloose

networkofgovernmentandcharityhealthposts,clinicsandhospitalswerebasicin

nature.Thus,Peru’spublichealthsystemwasestablishedonhighlygenderedand

racializedprinciples–nationalimprovementandeconomicgrowthwoulddependon

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increasedpopulation,andaraciallytransformedpopulation.Bothobjectivesdepended

intimatelyonwomen’sreproductivecapacities.

Morethan30yearslater,betweenthe1930sand1950s,unionactivismby

workersandco-optationoftheirmovementsbygovernmentleadersleadtoalayering

ofmuchmoreextensiveandhigherqualityhealthsystemsnexttotheexisting,public

healthstructureestablishedinthe19thcentury.Industrialization,migration,and

urbanizationledtotheemergenceoftwonewclassesofworkers−urbanfactory

workersandmiddle-classprofessionals.Thedominantpoor/eliteclassdivisionofthe

19thcenturyhadbeguntoloosenasanewclasscategory,theurbanworker,emerged.

Theseurbanindustrialworkersandmiddle-classprofessionalsrepresentedasmallnew

groupofelitesandanewracialgroup:manyweremestizo,ormixedwhiteand

indigenousdescent.Organizedinseparatewhiteandblue-collarunions,overthecourse

ofthreedecades,theseworkersandprofessionalspressuredPeruvianpoliticalleaders

tocreateseparate,higherqualityhealthsystems.Inaco-optivepatternreminiscentof

theOttoVanBismark’sGermany,successiveauthoritarianleaderscreatedfirsta

Workers’SocialSecurity(SSO,SeguroSocialdelObrero)systemin1936,andin1946a

separatewhite-collarhealthandpensionsystem,theEmployees’SocialSecuritySystem

(SSE,SeguroSocialdelEmpleado).Eachhadseparatehospitalsandinsurancesystems,

withtheEmployeehospitalrivalingthequalityofeliteprivatehospitals.Bothfar

surpassedthequalityofthepublichealthsystemrunbytheMinistryofHealth.

Eventually,in1979,Peru’smilitarygovernmentcombinedtheblueandwhite-collar

systems.Butevenaslateas1995,thecombinedsocialsecurityhealthsystemserved

19

only26percentofthepopulationwhilethepublicsystemserved52percentandafull

20percenthadnoaccesstohealthcareatall(Ewig2010,p.53).

Itiscrucialtonotethegenderedandracializednatureoftheseparatehealth

systemsthatevolvedinPeru.Whilethepublicsystemspecificallytargetedwomenand

indigenouspeoplesmoregenerally,thebetterqualitysocialsecuritysystemswere

developedexplicitlyformestizomenintheformalworkforce.Thiswasprimarilydueto

thefactthatwomencomposedjust21.7percentoftheeconomicallyactivepopulation

in1961,and25.1percentby1981(INEI1999).Buteveniftheywereeconomically

active,mostwomenworkedintheinformalsectororasdomesticworkers,andtheSSE

andSSOinitiallydidnotcovereitherofthesecategoriesofworkers.Thegendered

divisionofcoveragewasnominallyimprovedinthe1970swhenthemilitary

governmentincorporateddomesticworkersintothesocialsecuritysystem(Mesa-Lago

1989,p.178).However,reformwasmitigatedbydomesticemployers’evasionsof

payments,greaterthanthealreadyhighratebyemployersingeneral.Dependentwives

comprisedjust7percentofthoseinsuredbysocialsecurityin1961,but23percentby

1981.10Thetotalnumberofadultwomencoveredbysocialsecuritywasprobably

higher,butnotdramaticallyso,duetotheemploymenttrendsdiscussedpreviously.

Forwivesandcommon-lawpartnerswhowereinsuredasdependents,the

coverageSSEandSSOprovidedwasextremelylimited.11Originally,wivesofinsured

maleworkerswereonlycoveredformaternityhealthcare–allotherhealthcarefor

wiveswaseitherthroughthepublichealthsystemorpaidoutofpocketintheprivate

sector.In1975,childrenunderoneyearofagewereaddedasdependents(Mesa-Lago

20

1989,p.181;Roemer1964).OnlyinMarch1979didtheoutgoingmilitarygovernment,

aspartofconsolidatingtheSSEandSSOsystems,expanddependentcoveragetocover

aworker’sspouseandchildrenunderageeighteen.12However,womenworkerswere

notabletocarryaspouseordependentontheirsocialinsurancepolicyuntil1992,

furtherdemarcatingthesocialsecuritysystemashighlymasculine.Together,thedual

publicandsocialsecurityhealthsystemsreinforcedgender,raceandclassstratification

alreadyevidentinPeruviansociety.

WhenPresidentAlbertoFujimoriurgedmembersofhiscabinettopursuea

reformofthehealthsectorintheearly1990s,severalkeypolicylegaciesstoodinthe

way.First,unionizedworkerssoughttopreservethebenefitstheygainedfroma

separate,higherqualityhealthsystem.Morepotentyetwereunionizeddoctorsthat

fearedchangesinsalaryandjobsecurity,withdoctorsinthesocialsecurityhealth

systemreapinghigherbenefitsthanthoseinthepublicsectorandboastingastronger

union.TheSocialSecurityInstitute(atthetimecalledtheInstitutoPeruanode

SeguridadSocial)fearedlosinginstitutionalpowerinrelationtotheMinistryofHealth,

shouldthereformimplyaunificationofhealthsystems.And,onanormativelevel,

whilebeneficiariesofthesocialsecuritysystemshadalwaysbeenviewedasimportant

protagoniststhathadtobenegotiatedwith,policymakers’viewofbeneficiariesofthe

publichealthcontinuedtobepatronizing.

Bytheearly1990s,acombinationofeconomiccrisisandcivilwarhadledtoa

nearcollapseofthePeruvianhealthsystems,andthisinturnpredisposedPresident

AlbertoFujimoritosupportdramaticstepstorectifyproblems.But,heleftthecourseof

21

actionuptothepolicyexpertsinthePeruvianbureaucracy,manyofwhomwere

engagedintheneoliberalepistemiccommunity.AhealthministerinFujimori’searly

administrationrecalledthatinreactiontothecrisisthepresidentinsisted“thattherebe

healthcare,”butlefttheministertoworryaboutthe“details”(Freundt-Thurne1998).

Thus,thereformscenariowasonetypicalofthatforeseenbyscholarsofepistemic

communities;perceivedcrisisleadstoasearchforpolicyalternatives,andarelianceon

expertslargelyworkingwithinstateandinternationalbureaucraciesforsolutions.

TwocompetingepistemiccommunitiesshapedthecontextforPeru’shealth

reformprocessofthe1990s:neoliberaldevelopmentandtherights-based,human

developmentcommunity,withthelatterrisinginexpressoppositiontotheneoliberal

model.Theprinciplesoftheneoliberalepistemiccommunitywerebasedonclassic

economictheory,whichprioritizedmarketoverstatesolutionstoeconomicaswellas

socialproblems.Thisepistemiccommunitywascomposedofanetworkofpolicymakers

thatspannedbothnationalandinternationalinstitutions.Internationally,this

communitywasembeddedmostintheBrettonWoodsinstitutions,suchasthe

InternationalMonetaryFundandtheWorldBank,butotherinternationalorganizations

aswellasregionalactorsalsoplayedsignificantroles(Orenstein2008,chapter2).The

WorldBankandtheInter-AmericanDevelopmentBank(IADB)weretheinstitutions

mostcloselytiedtoPeru’shealthreforms,throughaseriesofreformloans.The

bilateralUSAIDwasalsoengagedtoalesserextent.Nationally,adherentstoneoliberal

principlesandmembersofthiscommunitywereembeddedinkeyreforminstitutions,

22

suchasthePrimeMinister’soffice,theMinistryofEconomicsandFinance,andthe

MinistryofHealth.

Bycontrast,theUnitedNationsprioritizedhumanrightsthroughitshuman

developmentparadigm,whichemphasizesnotjusteconomicbutalsosocial,cultural,

andpoliticaldimensionsofwell-being(Haq2003).Aspartofthisfocus,theUNalso

supportedmeasuresaimedatincreasinggenderequityandwomen’srights,from

conventionsonwomen’srightstotheGender-RelatedDevelopmentIndex,which

measuresgenderequitydisparitiesacrosscountries.Thisepistemiccommunityarosein

responsetotheneoliberalone,offeringanalternativerights-basedvisionthat

prioritizedhumanandsocialdimensionsoverthemarket.Yet,thenatureofits

internationalinstitutionalbase,UNorganizations,meantthatthisepistemiccommunity

lackedthekindsofdirectconnections–suchasloansandadvisors–toPeru’sreforms

thattheWorldBank,IADBandUSAIDhad.WhiletheWorldHealthOrganizationandits

regionalsubunit,thePanAmericanHealthOrganization,areUNentities,inthemid-

1990sthesesufferedfrompoorleadershipandtheirprincipleshaddriftedmoreclosely

totheneoliberalepistemiccommunity.InPeru,therights-basedepistemiccommunity

hadconnectedmoststronglywithlocalfeministNGOsasaresultoftheUNsponsored

WorldWomen’sConferences,likethe1995FourthWorldConferenceonWomenin

Beijing,China.ButitfoundfewinroadsintothePeruvianstatebureaucracy;itwasnot

asestablishedasan“expert”communityembeddedinnationalbureaucraciestothe

sameextentthattheneoliberalcommunitywas.

Turningtotheissueofthegenderednatureoftheseepistemiccommunities,

23

veryfewofthemembersoftheneoliberalepistemiccommunitywerewomen.When

womenwereengaged,theytendedtobecontractedthroughtheinternationalsideof

theneoliberalepistemiccommunity.ThemainIADBcontactinrelationtoPeru’shealth

reformwasaUSwoman,andthemainPeruvian-basedrepresentativeforUSAID

workingonhealthreformwasaPeruvianwoman.TheprimaryWorldBankcontactin

WashingtonD.C.wasaPeruvianman.TheleadPeruvianreformershowever,located

bothintheMinistryofHealthandtheMinistryofEconomicsandFinanceweremen.

OnewomanactivelyparticipatedaspartofoneofthereformteamswithintheMinistry;

butotherwisetheteamswerecomposedalmostentirelyofmen.Butmoreimportant

thanthegendercompositionofthecommunityitselfiswhetherornotthepromotion

genderequitywasonthereformagenda;myinterviewswithkeyreformersindicated

thatitwasnotsomethingthatwascontemplatedaspartofthereformeffort.Nordid

themajorpoliciesshowanyspecificattentiontogenderequity.

Bycontrast,therewereeffortsbytherights-basedepistemiccommunityto

promotegenderequityinPeru’shealthreformprocess.AverysmallteamatthePan

AmericanHealthOrganizationinWashingtonD.C.was,atthetime,promotingand

supportingresearchthatwouldbetterunderstandthegendereffectsofhealthreforms

intheLatinAmericanregion.Thisoffice,composedofwomenhealthprofessionalswith

averylimitedbudgetandinfluence,did–eventually–succeedinconvincingPeru’s

MinistryofHealthtoestablishapositionintheMinistrychargedwithintegratinga

concernforgenderequityintoMinistryhealthprogramming.Whilethepositionwas

promising,itwasestablishedwellafterthemajorreforms,andhadlittleinfluenceinthe

24

Ministryduetomajorunderfundingandlackofprestige.Feministactivistsengagedwith

thisrights-basedepistemiccommunityhadgreatersuccessininfluencingthereform

process,butonlyintheareaoffamilyplanning.AsaresultofPeru’sratificationofthe

1994CairoDeclarationonPopulationandDevelopment,feministshadconvincedthe

Fujimorigovernmenttoestablishatripartitecommissionrepresentingthestate,

internationalinstitutions,andcivilsocietytochartPeru’scourseforimplementingthe

CairoProgrammeofActionwhichaffirmedwomen’srightstoreproductivehealthand

well-being.13Thisinternationalprogramofaction,directlylinkedtotherights-based

epistemiccommunitygroundedinUNcircles,offeredamechanismforfeministsto

engagethestateinthepara-bureaucraticspaceofthetripartitecommission.Inthis

space,theydidpromoteaholisticapproachtowomen’sreproductiverights.

Unfortunately,asIdetailelsewhere(Ewig2010,Ewig2006b),whiletheletterofPeru’s

resultingfamilypoliciesappearedtofollowthespiritoftheCairoProgrammeofAction–

forexampleadvancingaccesstocontraceptionandautonomyinreproductivehealth

decision-making–inpractice,poorandindigenouswomen’srightstomake

autonomousdecisionsabouttheirreproductiveliveswereunderminedbyamassive

sterilizationcampaign,covertlycarriedoutbytheFujimorigovernmentandwhichfor

themostpartdidnotobtaininformedconsentfromthewomensubjectedto

sterilization.Therewasadivorce,inotherwords,betweenthecoursechartedbythe

tripartitecommissionandtherealpolicydecisionsmadelargelyinisolationbythe

President,VicePresidentandheadoftheFamilyPlanningprogramintheMinistryof

Health.

25

Thus,whilethemoregender-consciousrights-basedepistemiccommunitydid

attempttoinfluencePeru’sreforms,itlackedastronganchorwithinthebureaucracy,

andtiestokeydecision-makers,tomakearealdifferenceinpolicyoutcomes.

Moreover,whileitisadmirablethatfeminists–asactivistsratherthanbureaucratsasis

typicalofepistemiccommunities–wereabletotie-intothereformprocess,theydidso

onlyinthedomainofreproductiverights.Theirengagementwithreproductiverights

wasanaturalproductoftheirlonghistoryofactivisminrelationtoreproductiverights

inPeru.However,mostoftheseactivistswerenothealthsystemorpublichealth

experts,andtheideaofintegratinggenderequityintothebroaderhealthreform

agendawasnotpartoftheiragenda.

Ultimately,theneoliberalreformsappliedtoPeru’shealthsectordidhavesome

unintended,genderedeffectsonexistingpolicylegacies,somepositiveandothers

negative.Forexample,theneoliberalreformteamssoughttoovercometheresistance

toreformoforganizedlabor–workersanddoctors–andtheylargelysucceeded.

Overcomingtheseinterestlegacies,paradoxically,openedthewayforreformsthat

mighthaveeasedsegmentationbetweenthesocialsecuritysystemthathistorically

servedmaleworkersandthepoorerqualitypublichealthsystemhistoricallyserving

womenandindigenouspeoples.Increasedfundsinsupportofthepublichealthsystem

andinnovativeparticipatoryprogrammingfurtheredthisobjectiveandwerematerially

importantforthepoorandwomenconcentratedinthepublichealthsystem.Atthe

sametimehowever,thereforms’promotionofaparallelprivatehealthinsuranceand

providermarketcausedincreasedstratificationbyclassandgenderandwhilethe

26

applicationofmarketmechanismstothepublicsector–suchastheintroductionofuser

fees–posednewbarriersthatreducedaccesstohealthcareforthemostmarginalized.

Finally,thesterilizationcampaignsdemonstratedapersistenceofbroaderpolicy

legaciesthattreatedpublichealthclientsinapatronizingmanner,andwhichcontinued

toutilizepoorwomen’sbodiesasameanstoachievenationaleconomicand

demographicobjectives.

Conclusion

Healthreformrepresentsbothanopportunitytoaddressgenderinequitiesin

healthcaresystems,andariskthattheseinequitiesmightbeexacerbatedornew

inequitiesintroduced.Thechallengeofgender-equitablehealthreformistwo-fold:to

overcomingpastpolicylegaciesthatcreateandperpetuategenderinequitiesandto

integratehealthreformteams–inparticulartheepistemiccommunitiesthatmay

informtheirdecision-making–withgender-knowledgeableexpertscommittedto

addressinggenderinequity.Thisdualchallengeisnoteasytoachieve,asthePeruvian

casemakesabundantlyclear,butstakingouttheparametersofthechallengemay

enlightenfutureeffortsatreform.

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1Forusefuloverviewsofgenderequityimplicationsofhealthsystemsandhealthsector

reformsseeDoyal2000;EversandJuárez2002;MackintoshandTibandebage2006;

Sen,GeorgeandOstlin2002;Standing1997,1999.

2ExceptionsincludeEwig2008;Ewig2010;Gideon2006;Petchesky2003.

3ThroughoutthischapterIemphasizegender,inkeepingwiththefocusofthevolume.

However,policylegaciesmayalsoberootedinrace,class,rural/urbanoragedivisions,

amongotheraxesofinequality.

4Seeforexample:Haney2002;Mettler1998;Nelson1990;Skocpol1995;O’Connor,

Orloff,Shaver1999;Rosemblatt2000.

5SeeCross2013forafullgenealogyoftheconcept.Seethespecialissueof

32

InternationalOrganization(46:1,1992)foraseriesofcasestudiesofepistemic

communities.

6Theconceptofepistemiccommunityhasbeenstretchedbyseveralauthors,equating

thesewithtransnationaladvocacycoalitionsorwithmoreactivist-orientednetworks.

Forconceptualclarity,however,epistemiccommunitiesaredistinctfromtheseother

formsbecausetheyarespecificallyboundbyexpertknowledge.

7Seeforexample:Mamudu,GonzalesandGlantz2011;LeeandGoodman2002;

Kickbush2003.

8GintherandKahn(2014,287)notethatamongsocialscienceprofessions,economics

hasbeenthemostresistanttogenderequality,withapersistent20%gapbetween

womenandmeninobtainingPhDsandsubsequentbarrierstoadvancementfacedby

women.

9ThefollowingisacondensedsummaryofthePeru’shealthreformprocessfromEwig

2010.

10CalculatedfromfiguresinMesa-Lago1989,p.183.

11Mesa-Lago1989pointsoutthatPeruwasparticularlyrestrictiveinsocialsecurity

dependentcoverageamongLatinAmericancountries.

12DecretoLeyNo.22482,March27,1979.

13ReadtheProgrammeofActionandfollow-upagreementshere:

http://www.unfpa.org/publications/international-conference-population-and-

development-programme-action