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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,
2
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
3
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.
4
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,
5
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.
7
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.
8
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
13
“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”.
15
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
16
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
17
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
18
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