Second-Wave Neoliberalism

The first wave of neoliberal reform that swept across Latin America in the early 1990s focused on economic policies favoring structural adjustment, such as currency devaluation, cuts in state-supplied social services, and removal of protection for domestic industry against global competition. This wave has been the subject of widespread debate and criticism for its negative impact on the most vulnerable strata of society. But the second wave of the mid-1990s, which saw the introduction of many social policy reforms, has not received nearly as much attention. Christina Ewig seeks to correct this imbalance in scholarly research by presenting a case study of the multifaceted efforts to reform the health sector in Peru under the Fujimori regime.

Second-Wave Neoliberalism combines top-down analysis of policy formation with bottom-up analysis of policy implementation using both qualitative and quantitative approaches—interviews and ethnographic observations along with formal surveys. Ewig’s findings lead her to conclude that neoliberal health reforms have brought greater social stratification and, in many ways, have increased gender, racial, and class inequity. But the story is complex, with real progress in some areas and surprising paradoxes in others, such as feminist involvement in family planning policy that resulted in a massive sterilization program targeting poor, indigenous women.

“Christina Ewig has written a first-rate book that makes contributions on several different levels. On the one hand, it integrates central political science concerns about the impact of welfare legacies and epistemic communities with a growing literature on gender equality and politics. At the same time, the book explores these issues through a compelling history of Peruvian health policy, focusing especially on the evolution of services shaped in response to the demands of male-dominated unions and then on efforts to restructure the system in the 1990s and early 2000s. Ewig’s analysis is all the more impressive because it is informed by extensive fieldwork that she conducted in Peru over the course of several years. Besides the obvious appeal this book will have for specialists in Peru, it should be of great interest to students of comparative social policy and of the complex politics of gender, intersectionality, and historical legacies.”—Robert Kaufman, Rutgers University

“Christina Ewig's book, with its focus on the social dimensions of social policy, is a most welcome contribution to the study of social policy in Latin America. Its examination of the gendered and racialized impacts of neoliberal reforms in social provision is richly illustrated by case studies from Ewig's many years of fieldwork in Peru. It leaves the reader in no doubt that deep social inequalities in provision persist largely unchallenged. Ewig convincingly shows that if women's rights organizations are to address these inequalities, they need to pay greater attention both to the power politics of policymaking processes and to the consequences of neoliberal reforms, such as decentralization and privatization, for disadvantaged populations. This book will be essential reading across a range of disciplines and will be valued especially for tackling previously under-researched issues in the social policy field.”—Maxine Molyneux, Institute for the Study of the Americas, School of Advanced Study, University of London

“In Second-Wave Neoliberalism, Christina Ewig offers careful and skilled intersectional analysis of the complex arena of policy reform—and this outstanding book is an example of such research at its best. Ewig's narrative emphasizes the centrality of gender, race, and class to the process of health sector reform and thus demonstrates the importance of looking at all three factors when assessing policy change. The book is a tremendous contribution to the gender and feminist studies literature.”—Lynne Haney, New York University

“Cristina Ewig skillfully shows us gendered inequality in access to basic services cannot be attributed solely to neoliberal reforms, especially in Peru. . . . Hopefully students of policy, health reform and Latin American politics will all see the benefit of this.”—Jelke Boesten, Journal of Latin American Studies

“Graduate students and professionals alike will find this extensive and constantly engaging research beneficial because it raises important questions and gives valuable insights for those in the field of gender and social policy.”—Constanza Tabbush, Bulletin of Latin American Research

Christina Ewig is Associate Professor of Gender and Women's Studies and Political Science at the University of Wisconsin–Madison.

Contents

List of Tables and Figures

Preface and Acknowledgments

List of Acronyms

1. Intersecting Legacies of Inequality

2. Colonization and Co-optation: Historical Legacies of Inequality in the State Health System

3. Global Currents: Neoliberal and “Rights-Based” Development Paradigms

4. Gendered Divisions: The National Politics of Health Reform

5. Mimicking Markets: Gender Equity and Public Health System Reforms

6. Controlling Poor Women’s Bodies: Intersections of Race, Gender, and Family Planning Policy

7. Insuring Gender Equity? Public and Private Insurance Schemes

Conclusion

Methodological Appendix

References

Index

Preface and Acknowledgments

When I conceived of this project in the late 1990s, I wanted to make a difference with my research. I had studied Latin American women’s movements previously, and this time wanted to contribute to a movement in some way through my research. After feminists had criticized the negative effects on women of structural adjustment in the 1980s and early 1990s, it seemed that a focus on the gendered effects of the “second wave” of neoliberalism—the market-oriented restructuring of state social policies such as health, education, and pensions—was the next logical step. What impact did this latest wave of reforms have on gender equity? How did race and class interact with gender to mediate the effects of these new policies on women and men of different social strata? What were feminist activists in the region doing to address this new wave of reforms? Did gender play into the political process of social policy reform, and if so, how? Answering these questions seemed like a productive way to contribute to already established interests of feminist activists and scholars alike in gender and political economy. Latin American feminists have a long-term interest in reproductive health. In addition, health policy has historically been one of the foundational pillars of Latin American social policy systems. Therefore, I chose to focus on health policy and to do so in the racially and socioeconomically diverse country of Peru.

I began my research by tracing the formulation of Peru’s health reforms, interviewing representatives of all possible interested political players, from labor unions to doctor’s associations and health ministers. While Peruvian feminists, as I had expected, were keyed into debates over national reproductive health care policy, to my surprise, there was little attention paid by feminists or policy makers to the gendered effects of “mainstream” health reforms—things like privatization or decentralization of health services. This lack of attention was surprising given the rhetoric of “gender mainstreaming” at the time emanating from global forums like the United Nations Fourth World Conference on Women—forums that Peruvian feminists were actively involved in. Thus, one puzzle that this book sets out to solve is why feminists failed to intervene in the formulation of “second-wave” social policy reforms, in spite of their flurry of activity related to economic adjustment and given their strong global activism. The absence of feminists’ participation in the mainstream health reform process is also one piece in understanding how the second-wave policy reform process itself was gendered.

As I researched the contemporary process of health reform, history began to draw more and more of my attention. Previous policy patterns and interest groups that had formed in response to these earlier policies clearly played a role in shaping the politics of the contemporary reform process—and they did so in ways that appeared to reinforce or even create new gender, class, and racial hierarchies. I had begun to discern the importance of “policy legacies,” a theoretical concept that refers to previous policy decisions that serve to shape the politics of future reform processes in important ways. Yet my research also led me to further refine the concept by demonstrating how such legacies may entrench the gender, class, and race inequalities upon which they arose. Moreover, my comparison of multiple health reforms in one country allowed me to begin to explain how and why some policy legacies were overcome in Peru’s health reform process, while others remained in place. On this count, I found that transnational “epistemic communities” played an important part in determining the survival or defeat of particular policy legacies in the reform period, and also helped to shape feminists’ interest in gender mainstreaming in the health sector.

But were these neoliberal reforms good or bad for women? Were they better or worse for some groups of women more than others? My second major task was to follow each of the major health reforms from formulation to implementation. I utilized mixed qualitative and quantitative methods to measure the impact of these reforms on gender equity. Market-oriented health policies tend to shift the costs of both biological and social reproduction from states and markets onto women and families—effects that are largely unanticipated in the policy-formulation stage. However, how these policies promote this shift and the extent to which they do so vary substantially according to the specific policy in question. Moreover, the same reform may have a dramatically different impact on different groups of women or men, dependent on race, class, or geographic location.

I hope that this book helps to illuminate for scholars, activists, and policy practitioners how seemingly neutral policies can have highly gendered and racialized consequences. I also hope that it provides some clues as to the political tools necessary to work toward a more equitable future.

While this book concentrates on the post–debt crisis period in Latin America, like many Latin American countries, I find myself greatly indebted today. This book entailed over fifteen months of initial research in Peru, followed by numerous follow-up trips. Many colleagues and friends in Peru were crucial in making this research fruitful. In particular, I thank Marcos Cueto, Ricardo Díaz, Ariel Frisancho, Narda Henríquez, Felipe Portocarrero, Cynthia Sanborn, and Victor Zamora for their ongoing support and assistance. For my major research stint in Peru, the Instituto de Estudios Peruanos (IEP) provided an intellectual home, with crucial library assistance at the IEP provided by Virginia García and Diana Balcazar. For their friendship and support while in Peru, I thank Cecilia Gianella, Farid Kahhat, Rocío Malpica, Caroline Mullen, and Eliana Villar.

This research depended upon the openness of policy makers, members of civil society, local community members, and health professionals in Peru who agreed to be interviewed. Those who wanted to be named are listed in the bibliography, and I thank all of those interviewed for generously sharing their time and thoughts. For help in facilitating my community studies, I thank Dr. Danilo Fernández and Antonio Moreno. I also thank my survey research assistants, Claudia Gianella, Rocío Malpica, and Madeleine Pariona Oncebay.

I am grateful to a number of institutions for their generous financial support. My major stint of fieldwork from January 1998 through April of 1999 was funded by grants from the Fulbright Foundation; from the Ford Foundation–funded exchange between the Red Para el Desarrollo de Ciencias Sociales en el Perú and the Duke/UNC Program in Latin American Studies; and from the Institute for the Study of World Politics. A Woodrow Wilson–Johnson and Johnson Dissertation Grant in Women’s Health funded my expenses for interviews with representatives of international institutions in Washington, D.C. I also benefitted from a Paul Hardin Dissertation Writing Fellowship from the Royster Society of Fellows at the University of North Carolina at Chapel Hill.

This project began while I was a graduate student at the University of North Carolina at Chapel Hill. For early advice and encouragement as well as ongoing support to this day, I thank especially Evelyne Huber and Jonathan Hartlyn. Others who provided early support include John D. Stephens, Catharine Newbury, and Carol Wise. For guidance in my survey analysis I am grateful to José Sandoval. Friends and colleagues who commented on early portions of what would eventually become this book include Merike Blofield, Jenni Brier, Ethel Brooks, Sarah Brooks, Anne Marie Choup, Anne Eckman, Maxine Eichner, Jessica Fields, Claudio Fuentes, Robin Greeley, Shuchi Kapila, Michelle Mouton, Waranee Pokapanichwong, and Carisa Showden.

The University of Wisconsin–Madison provided a stimulating and supportive environment for revising and completing the final book manuscript. I especially appreciate the generous colleagues at UW–Madison and elsewhere who read and commented on the final versions of this manuscript. Jane Collins, Joseph Harris, Yoshiko Herrera, and Rosalind Petchesky read the entire manuscript and provided detailed comments. Many others provided useful comments on one or more chapters or inspiring conversations, including Marcos Cueto, Wendy Chavkin, Paul Gootenberg, Alice Kang, Robert Kaufman, Florencia Mallon, Joan Nelson, Tricia Olsen, Joe Soss, Natasha Borges Sugiyama, Aili Tripp, and Kurt Weyland. Myra Marx Ferree helped me to get the framing right. Kerry Ratigan provided expert research assistance on the final manuscript.

Publication of early versions of some chapters allowed me to test out arguments made in this book. An early version of chapter 5 was published as “Global Processes, Local Consequences: Gender Equity and Health Sector Reform in Peru,” in Social Politics 13, no. 3 (Fall 2006). The story of family planning that appears in parts of chapters 3, 4, and 6 was published as “Hijacking Global Feminism: Feminists, the Catholic Church, and the Family Planning Debacle in Peru,” in Feminist Studies 32, no. 3 (Fall 2006). Some of the empirical material from chapter 4 appeared previously in “Piecemeal but Innovative: Health Sector Reform in Peru,” in Crucial Needs, Weak Incentives: Social Sector Reform, Democratization, and Globalization in Latin America, edited by Robert R. Kaufman and Joan M. Nelson (Baltimore: Woodrow Wilson Center and Johns Hopkins University Press, 2004).

I am especially grateful to Sandy Thatcher of Penn State Press, who agreed to take on this project and has provided helpful suggestions throughout the process. I am also grateful to Lynne Haney and another anonymous reader who reviewed the manuscript and provided constructive and useful comments, resulting in a much stronger manuscript.

My mother and father, Marianne and William Ewig, have been sources of support throughout this long process. My son, Gabriel, has been the best distraction, reminding me each day of the many beautiful things the world has to offer (beyond writing books!). Most importantly, I thank my partner, Will Jones. In addition to the critical commentary he provided on multiple versions of this book manuscript, his dedication to sharing in the tasks of social reproduction in our household, his willingness to allow me to travel for research for long periods while he cared for our family and home, as well as his unflagging intellectual and emotional support have made this book possible.

History

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Latin American Studies

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Political Science

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