“Gender Equity and the Politics of Health Sector Reform ...impact gender and other forms of...
Transcript of “Gender Equity and the Politics of Health Sector Reform ...impact gender and other forms of...
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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
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.
Bibliography
Brooks,SarahMarie(2009),SocialProtectionandtheMarketinLatinAmerica:TheTransformationofSocialSecurityInstitutions,Cambridge,UKandNewYork,NY,USA:CambridgeUniversityPress.Contreras,Carlos(2004),ElAprendizajeDelCapitalismo:EstudiosdeLaHistoriaEconómicaYSocialDelPerúRepublicano,Lima,Peru:InstitutodeEstudiosPeruanos.
27
Cross,Mai’aK.Davis(2013),‘RethinkingEpistemicCommunitiesTwentyYearsLater’,ReviewofInternationalStudies,39(01),137–60.delaCadena,Marisol(2000),IndigenousMestizos:ThePoliticsofRaceandCultureinCuzco,1919-1991,Durham,NC,USA:DukeUniversityPress.Dion,MichelleL.(2010)WorkersandWelfare:ComparativeInstitutionalChangeinTwentieth-CenturyMexico,PittLatinAmericanSeries.Pittsburgh,PA,USA:UniversityofPittsburghPress.Doyal,Lesley(2000),‘GenderEquityinHealth:DebatesandDilemmas’,SocialScienceandMedicine,51:931–39.Evers,Barbara,andMercedesJuárez(2002),‘UnderstandingtheLinks:Globalization,HealthSectorReform,GenderandReproductiveHealth’,InFordFoundation(ed.),Globalization,HealthSectorReform,GenderandReproductiveHealth,NewYork,NY,USA:FordFoundation,pp.5-52.___(2010),Second-WaveNeoliberalism:Gender,RaceandHealthSectorReforminPeru,UniversityPark,PA,USA:PennsylvaniaStateUniversityPress.___(2008),‘Reproduction,Re-reformandtheReconfiguredState:FeministsandNeoliberalHealthReformsinChile.’In:IsabellaBakkerandRachelSilvey(eds.),BeyondStatesandMarkets:TheChallengesofSocialReproduction.NewYork,NY,USA:RoutledgePress,pp.143-158.___(2006),‘GlobalProcesses,LocalConsequences:GenderEquityandHealthSectorReforminPeru’,SocialPolitics:InternationalStudiesinGender,State&Society,13(3):427–55.___(2006b),‘HijackingGlobalFeminism:Feminists,theCatholicChurch,andtheFamilyPlanningDebacleinPeru’,FeministStudies,32(3):633–659.Ewig,Christina,andAmparoHernándezBello,(2009),‘GenderEquityandHealthSectorReforminColombia:MixedState-MarketModelYieldsMixedResults’,SocialScience&Medicine,68(6):1145–52.Ewig,ChristinaandGastónA.Palmucci(2012),‘InequalityandthePoliticsofSocialPolicyImplementation:Gender,AgeandChile’s2004HealthReforms’,WorldDevelopment,40(12):2490–2504.Falleti,TuliaG.(2010),‘InfiltratingtheState:TheEvolutionofHealthCareReformsinBrazil,1964-1988.’InJamesMahoneyandKathleenThelen(eds.),Explaining
28
InstitutionalChange:Ambiguity,AgencyandPower,NewYork,NY,USA:CambridgeUniversityPress,pp.38-62.Freundt-Thurne,Jaime(1998),FormerMinisterofHealthofPeru,InterviewbyChristinaEwig,April15,Lima,Peru.Gideon,Jasmine(2006),‘IntegratingGenderInterestsintoHealthPolicy’,DevelopmentandChange,37(2):329–52.____(2007),‘AGenderedAnalysisofLabourMarketInformalizationandAccesstoHealthinChile’,GlobalSocialPolicy,7(1):75–94.____(2008),‘CountingtheCostofPrivatisedProvision:Women,RightsandNeoliberalHealthReformsinChile’,IDSBulletin,39(6):75–82.Ginther,DonnaandShulamitKahn(2014),‘AcademicWomen’sCareersintheSocialSciences’,InAlessandroLanteriandJackVromen(eds.),TheEconomicsofEconomists:InstitutionalSetting,IndividualIncentivesandFutureProspects,CambridgeUKandNewYork,NY,USA:CambridgeUniversityPress,pp.285-315.GómezGómez,Elsa(2002),‘Género,EquidadyAccesoaLosServiciosdeSalud:UnaAproximaciónEmpírica’,RevistaPanamericanadeSaludPública,11(5):327–34.Haas,PeterM.(1992),‘Introduction:EpistemicCommunitiesandInternationalPolicyCoordination.’InternationalOrganization,46(1):1–35.Hacker,JacobS.(2004),‘PrivatizingRiskwithoutPrivatizingtheWelfareState:TheHiddenPoliticsofSocialPolicyRetrenchmentintheUnitedStates.’AmericanPoliticalScienceReview2:243–60.______(2002),TheDividedWelfareState:TheBattleoverPublicandPrivateSocialBenefitsintheUnitedStates,NewYork,NY,USA:CambridgeUniversityPress.Haggard,Stephan,andRobertR.Kaufman(2008)Development,Democracy,andWelfareStates:LatinAmerica,EastAsia,andEasternEurope,Princeton:PrincetonUniversityPress.
Hall,PeterA.(1993),‘PolicyParadigms,SocialLearning,andtheState:TheCaseofEconomicPolicymakinginBritain’,ComparativePolitics,25(3):275–96.Haney,LynneA.(2002),InventingtheNeedy:GenderandthePoliticsofWelfareinHungary,Berkeley,CA,USA:UniversityofCaliforniaPress.
29
Haq,Mahbabul(2003),‘TheHumanDevelopmentParadigm’,InSakikoFukuda-ParrandA.K.ShivaKumar(eds.),ReadingsinHumanDevelopment:Concepts,MeasuresandPoliciesforaDevelopmentParadigm,NewYork,NY,USAandOxford,UK:OxfordUniversityPress,pp.17-37.Huber,Evelyne,andJohnD.Stephens(2001),DevelopmentandCrisisoftheWelfareState:PartiesandPoliciesinGlobalMarkets,Chicago,IL,USA:UniversityofChicagoPress.
InstitutoNacionaldeEstadísticaeInformática(INEI)(1999),Género,EquidadyDisparidades:UnaRevisiónenlaAntesaladelNuevoMilenio.Lima,Peru:InstitutoNacionaldeEstadísticaeInformática,MinisteriodelaPromocióndelaMujeryelDesarrollo,andFondodePoblacióndelasNacionesUnidas.Kickbusch,Ilona(2003),‘TheContributionoftheWorldHealthOrganizationtoaNewPublicHealthandHealthPromotion’,AmericanJournalofPublicHealth,93(3):383–88.Kuiper,EdithandDrucillaK.Barker(eds.)(2006),FeministEconomicsandtheWorldBank:History,TheoryandPolicy,NewYork,NY,USA:Routledge.Lee,KelleyandHilaryGoodman(2002),‘GlobalPolicyNetworks:thePropagationofHealthCareFinancingReformsinthe1980s.’InKelleyLee,KentBussandSuzanneFustukian(eds.),HealthPolicyinaGlobalizingWorld,CambridgeUKandNewYork,NY,USA:CambridgeUniversityPress,pp.97-119.Mackintosh,Maureen,andPaulaTibandebage(2006),‘GenderandHealthSectorReform:AnalyticalPerspectivesonAfricanExperience’,InShireenHassimandShahraRazavi(eds.)GenderandSocialPolicyinaGlobalContext:UncoveringtheGenderedStructureof“TheSocial”,BasingstokeUKandNewYork,NY,USA:PalgraveMacmillan,pp.237–57.
Mamudu,HadiiM.,MariaElenaGonzalez,andStantonGlantz(2011),‘TheNature,Scope,andDevelopmentoftheGlobalTobaccoControlEpistemicCommunity’,AmericanJournalofPublicHealth,101(11):2044–54.
Mannarelli,MaríaEmma(1999),LimpiasyModernas:Género,HigieneyCulturaEnLaLimaDelNovecientos,Lima,Peru:CentrodelaMujerPeruanaFloraTristán.Mesa-Lago,Carmelo(1989),AscenttoBankrupcy:FinancingSocialSecurityinLatinAmerica,Pittsburgh,PA,USA:UniversityofPittsburghPress.Mettler,Suzanne(1998),DividingCitizens:GenderandFederalisminNewDealPublicPolicy,Ithaca,NY,USA:CornellUniversityPress.
30
Molyneux,Maxine(2006),‘MothersattheServiceoftheNewPovertyAgenda:Progresa/Oportunidades,Mexico’sConditionalTransferProgramme’,SocialPolicy&Administration40(4):425–49.Nanda,Priya(2002),‘GenderDimensionsofUserFees:ImplicationsforWomen’sUtilizationofHealthCare’,ReproductiveHealthMatters,10(20):127–34.Nelson,Barbara(1990),‘TheOriginsoftheTwo-ChannelWelfareState:Workmen’sCompensationandMother’sAid’InLindaGordon(ed.),Women,theStateandWelfare,Madison,WI,USA:UniversityofWisconsinPress,pp.123–51.O’Connor,JuliaS,AnnSholaOrloff,andSheilaShaver(1999),States,Markets,Families:Gender,Liberalism,andSocialPolicyinAustralia,Canada,GreatBritain,andtheUnitedStates,Cambridge,U.K.andNewYork,NY,USA:CambridgeUniversityPress.
Orenstein,MitchellA.(2008),PrivatizingPensionsTheTransnationalCampaignforSocialSecurityReform,Princeton,NJ,USA:PrincetonUniversityPress.Petchesky,RosilandP.(2003),GlobalPrescriptions:GenderingHealthandHumanRights.LondonUKandNewYork,NY,USA:ZedBooksandUNRISD.
Pierson,Paul(1994),DismantlingtheWelfareState?:Reagan,ThatcherandthePoliticsofRetrenchment.Cambridge,UKandNewYork,NY,USA:CambridgeUniversityPress.Pollack,MollyE.(2002),EquidaddeGéneroEnElSistemadeSaludChileno,Santiago:CEPAL/ECLAC.
Pribble,Jennifer(2013),WelfareandPartyPoliticsinLatinAmerica,CambridgeUKandNewYork,NY,USA:CambridgeUniversityPress.Roemer,MiltonIrwin(1964),LaAtenciónMédicaEnAméricaLatina,EstudiosyMonografias15.Washington:UniónPanamericana.Rosemblatt,KarinAlejandra(2000),GenderedCompromisesPoliticalCultures&theStateinChile,1920-1950,ChapelHill,NC,USA:UniversityofNorthCarolinaPress.Sen,Gita,AshaGeorge,andPiroskaÖstlin(eds.)(2002),EngenderingInternationalHealth:TheChallengeofEquity,Cambridge,MA,USA:MITPress. Skocpol,Theda(1995),ProtectingSoldiersandMothersthePoliticalOriginsofSocialPolicyintheUnitedStates,Cambridge,MA,USA:BelknapPressofHarvardUniversityPress.
31
Standing,Hilary(1999),FrameworksforUnderstandingGenderInequalitiesandHealthSectorReform:AnAnalysisandReviewofPolicyIssues,WorkingPaper99.06.Cambridge,MA,USA:HarvardCenterforPopulationandDevelopmentStudies._____(1997),‘GenderEquityandHealthSectorReformProgrammes:AReview’,HealthPolicyandPlanning,12(1):1–18.Stepan,Nancy(1991),“TheHourofEugenics”:Race,Gender,andNationinLatinAmerica,Ithaca,NY,USA:CornellUniversityPress.Weyland,Kurt(2006)BoundedRationalityandPolicyDiffusion:SocialSectorReforminLatinAmerica,Princeton,NJ,USA:PrincetonUniversityPress.____(2002),ThePoliticsofMarketReforminFragileDemocracies:Argentina,Brazil,Peru,andVenezuela.Princeton,NJ,USA:PrincetonUniversityPress.Zito,AnthonyR.(2001),‘EpistemicCommunities,CollectiveEntrepreneurshipandEuropeanIntegration’,JournalofEuropeanPublicPolicy,8(4):585–603.Zulawski,Ann(2007),UnequalCures:PublicHealthandPoliticalChangeinBolivia,1900-1950,Durham,NC,USA:DukeUniversityPress.
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