Christina Ewig

Gender equity and health sector reform in Colombia: Mixed state-market model yields mixed results

In 1993, Colombia carried out a sweeping health reform that sought to dramatically increase health insurance coverage and reduce state involvement in health provision by creating a unitary state-supervised health system in which private entities are the main insurers and health service providers. Using a quantitative comparison of household survey data and an analysis of the content of the reforms, we evaluate the effects of Colombias health reforms on gender equity. We find that several aspects of these reforms hold promise for greater gender equity, such as the resulting increase in womens health insurance coverage. However, the reforms have not achieved gender equity due to the persistence of fees which discriminate against women and the introduction of a two-tier health system in which women heads of household and the poor are concentrated in a lower quality health system.

Reform and Electoral Competition Convergence Toward Equity in Latin American Health Sectors

Scholars of Latin America disagree about the effects on equity of social policy reforms of the 1980s and 1990s. Those who see negative or no effects blame reforms, while those who believe welfare regimes have become more equitable attribute the change not to reform but to democracy and left governance. I resolve this disagreement by first developing a more holistic measure of equity. With this measure, I establish a convergence toward equity in the health sectors of Brazil, Colombia, and Chile. I then process-trace to determine the causal factors behind this convergence. Paradoxically, I find that the reform period was crucial because it gave rise to an alliance between technocrats and politicians facing electoral competition who together succeeded in overturning preexisting policy legacies, paving the way for equity. Left governance was not a significant factor behind this convergence, while democracy was important but has been underspecified.

New Political Legacies and the Politics of Health and Pension Re-reforms in Chile

Chile was a pioneer in introducing market competition into its largely public-dominated health and pension systems. Numerous countries followed Chile’s lead in privatizing pension provision; US President George W. Bush looked to Chile’s pension reform as a model for the United States to follow. Chile’s health reforms were also pioneering in that it was the first Latin American country to introduce private health providers and insurers into a largely public health care system, inspiring similar market-based reforms across the Latin American region. Yet, despite international and regional leadership in health and pension reforms, Chileans themselves have been less than satisfied with the new market-based systems. This discontent has manifested in recent “re-reforms” of both health and pension policies in Chile during the 2000s. The democratically elected center-left governments of Ricardo Lagos and Michele Bachelet attempted to pass reforms in which the state would increase its oversight over these social policy areas and would compensate to a greater degree for market failures.

Running the obstacle course to sexual and reproductive health: lessons from Latin America

Running the obstacle course to sexual and reproductive health is targeted at policy, donor and activist audiences. The book provides a thorough account of the political issues at stake and the obstacles to major change in the realm of reproductive health policy in Latin America. The author, Bonnie Shepard, takes a no-nonsense approach to laying out the issues and identifying the best strategies to advocate for more comprehensive reproductive health policies in the region, ones that would both respect the 1994 International Conference on Population and Development (ICPD) accords and go beyond them by making abortion legal, safe and accessible. Shepard worked in the 1980s for Pathfinder International, promoting reproductive healthcare in the Latin American region, and then as a Ford Foundation officer in Chile in the 1990s, through which she developed close ties with regional feminist activists working on health-related projects. The content of the book is based on this experience combined with research that she carried out in Chile, Colombia and Peru from 1998 to 2000. While the lessons drawn from the book can be applied to the broader Latin American region, these three countries form the empirical basis of the book. The five chapters of the book each address separate issues related to sexual and reproductive health. The first four chapters could stand alone, while the fifth concluding chapter brings the previous four chapters into broader conversation. The introduction provides a basic background to international reproductive rights trends, including an overview of the 1994 ICPD conference and accords. Unlike most accounts of recent challenges to the ICPD accords – which generally focus on international organized resistance from the Catholic Church and other fundamentalist opponents – Shepard’s focus is on local resistance to the implementation of these accords. This is a refreshing and important perspective because, as she points out, the local obstacles are numerous. Yet, some links between local resistance and international networks of conservative forces might have been useful. Chapter one centres on the issue of divorce in Chile and abortion in Chile and Colombia. The thesis of the chapter is that in religiously controversial policy areas such as these, there is often a ‘double discourse’, which Shepard describes as a ‘political and cultural system’, in which the public and policy-makers openly refuse to challenge Catholic prohibitions on divorce and abortion, while more liberal attitudes towards these issues are taken in practice through informal or illegal means. One consequence is that those with lesser economic means often do not have access to divorce (as was the case in Chile up until 2004) or safe abortion, while the wealthy find ways to access these services in spite of formal policy prohibitions. Chapter two analyzes national feminist reproductive health non-governmental organization (NGO) advocacy networks in all three countries and a handful of regional networks, such as the Latin American Women’s Health Network and Culture, Health & Sexuality Vol. 11, No. 3, April 2009, 349–351