Gender, Globalization, and Health in a Latin American Context

J. Gideon

• Publisher: Palgrave Macmillan
• Year: 2014
• Print ISBN: 9781349287895, 9780230103559
• eBook ISBN: 9781137120274
• Topic: Politics & International Relations
• Subtopic: American Government
• Index: Politics & International Relations

Using a political economy of health, Gender, Globalization, and Health in a Latin American Context demonstrates how the development of health systems in Latin America was closely linked to men's participation in formal labor. This established an inherent male bias that continues to shape health services today. While economic liberalization has created new jobs that have been taken up mainly by women, these jobs fail to offer the same health entitlements. Author Jasmine Gideon explores the resultant tensions and gender inequalities, which have been further exacerbated in the context of health care commercialization.

Chapter 1

Latin American Social Policy: Challenging Gender Inequalities?

The “New” Social Policy in Latin America

Latin America is currently experiencing an era of innovation and change in the area of social policy (Barrientos et al., 2008; Barrientos and Lloyd-Sherlock, 2009; Martínez Franzoni et al., 2009; Martínez Franzoni and Voorend, 2011). In the past two decades, important shifts have occurred, which commentators suggest can be traced back to the economic crisis of the 1980s. It was at this point that the structural adjustment policies, implemented as a response to the crisis, demonstrated the limitations of social policy institutions in addressing the needs of those in poverty (Barrientos et al., 2008: 760). Neoliberal reform policies advocated under the guise of the Washington Consensus lacked any explicit inclusion of equity concerns. By the late 1990s, the negative impacts of these reforms on poverty levels and inequality were clear across the region, leading to widespread feelings of insecurity and a sense that the region’s societies were fundamentally unjust (Birdsall et al., 2008: 17). Global development discourse advocated the importance of policies oriented toward poverty reduction, and there was a widespread recognition that this required more than just economic growth. Within Latin America, governments responded with the introduction of new social policies that addressed questions of both poverty reduction and overcoming vulnerability (Ancochea and Mattei, 2011; Barrientos, 2013; Barrientos and Santibañez, 2009; Daguerre, 2011; Lloyd-Sherlock, 2009). Two of the first and most widely known programs were Bolsa Escola, which was first initiated in Brazil in 1994, and Progresa, initiated in Mexico in 1997. Both programs are examples of an approach that combined more efficient targeting of human development, using cash transfers as conditionalities to improve children’s access to health and education (Barrientos et al., 2008). Subsequently these conditional cash transfer (CCTs) programs were developed and replicated across much of the region, with the support of the World Bank and Inter-American Development Bank (Hall, 2012). Brazil and Mexico continue to have the largest programs, although Bolsa Escola was further refined and relaunched as Bolsa Familia in 2003 by President Lula and Progresa in Mexico was relaunched as Oportunidades in 2002.

For the recipients, cash transfers provide a useful income supplement, which for the poorest can be highly significant, even critical, in terms of livelihood support (Hall, 2012: 2). CCT programs offer important potential benefits for the health and well-being of children and have contributed to reducing poverty levels across the region (Leisering and Barrientos, 2013). Between 1999 and 2011 poverty in the region fell by 149 percent (CEPAL, 2012: 19). In Brazil, Bolsa Familia now reaches around 13 million households (25 percent of the total number of households). At the same time, social pension schemes have pushed pension coverage of people aged 65 and above to just over 86 percent, among the highest in the region. These social assistance programs have been widely credited as important contributory factors in the reduction of poverty and inequality in recent times (Barrientos, 2013: 887–888). In Mexico, Oportunidades has resulted in significantly better outcomes in many aspects of the child: physical, cognitive, and language development (Fernald et al., 2008).

From a more theoretical perspective, one of the most significant aspects of these programs is that they embody a shift away from the neoliberal, market-oriented models of social policy. In particular, the theoretical underpinnings of CCT programs draw on ideas of social investment (ECLAC, 2007; Jenson, 2009; Márquez, 2010). Social investment is primarily about tackling the intergenerational transfer of poverty and preparing the population for the social risks of the twenty-first century, including less job security and more precarious forms of work. Social investment advocates the importance of investing in human capital and lifelong learning, which in turn promotes economic participation, poverty reduction, and international competitiveness (Staab, 2010: 607). One significant feature of the social investment paradigm is its emphasis on the future—children now are already creating the future. As Jenson comments, “Policy communities now assert that economic dynamism depends on modernizing social models. Nowadays, the idea is to be proactive rather than compensatory. One result of this shift in ideas is that the definition of the best policy mix often targets children and youth” (2008: 2).

Moreover, there is also the idea that successful individuals enrich our common future, and ensuring success in the present is beneficial for the community as a whole, now and in the future (Jenson, 2008: 3). This emphasis on investing in children now informs a wide array of policy instruments in Latin America besides CCTs. In particular, a number of countries including Chile, Mexico, and Uruguay have focused on the promotion of parenting skills and the expansion of early childhood education and care (ECEC) services (Schady, 2006; Staab and Gerhard, 2011).

Other important theoretical advances evident in Latin American social policy include the shift away from traditional “male breadwinner” models of provision, in line with wider global debates that acknowledge changing household arrangements and the “adult worker” model (Lewis, 2001). Policy makers across the region have taken a new interest in the household and family as the target unit of social policies, most evident in CCT programs. Human rights discourses have also played an important role in poverty reduction debates (Cecchini and Martínez, 2011). Rights-based approaches have informed policy designs and link to the notion of social guarantees that underpins programs such as Chile’s Plan AUGE (Regime of Explicit Guarantees in Health/Regimen de Garantías Explícitas en Salud) in the health sector, where users are guaranteed access to a specific number of health services, regardless of their income levels (Barrientos et al., 2008; Dannreuther and Gideon, 2008; Pribble, 2013). Similarly the Plan for Social Equity (PE—Plan de Equidad) in Uruguay¹ has drawn on the idea of social guarantees to develop a new model of social protection combining cash transfers with other social benefits (Filgueira et al., 2009; Pribble, 2013). These programs also draw on notions of “basic universalism”—defined as a system of social protection that guarantees coverage for all citizens for a group of essential services and transfers (Filgueira et al., 2006).

The continued expansion of these new approaches to social policy has been further facilitated in the twenty-first century by the election of left-wing governments across the region.² The promotion of social equity has always been a core goal of the left, and governments have faced the challenge of promoting social progress within the context of market reforms and economic globalization (Weyland, 2010). Given this reality, none of the left-wing governments have attempted direct redistribution through social policy; instead policies have focused on poverty reduction, strengthening social protection, and investing in human capital. Filgueira and colleagues (2011) suggest that institutional inertia is also an important factor in explaining the lack of overall structural change in social policy. It is clearly more straightforward—and more economically viable—to maintain and amend the existing mechanisms already in place rather than introduce entirely new programs that can be politically controversial and challenge the overarching neoliberal economic model. Indeed, policy instruments such as CCTs have been very popular with governments because they offer them the opportunity to pursue the noncontroversial goal of poverty alleviation and human capital formation (Hall, 2012; Madrid et al., 2010).

Health Reform in a Latin American Context

Developments within the health sector need to be considered more specifically within this broader social policy landscape. By the mid-1990s, nearly all the countries in the region had implemented some type of reform within the health sector, although the variety of reform makes it hard to generalize (Mesa-Lago, 2006). Indeed Molyneux (2008) has questioned how far it is possible to characterize Latin American social policy as “neoliberal,” given the diversity that exists across the region. She argues that

Neoliberalism may be too broad a descriptor, and that this has been a much more sequenced, variable, fragmented and political process than is often implied. There is a need for a more finely grained approach to understanding the “neoliberal turn,” and for greater analytic refinement to capture the different “moments” in its policy evolution, its variant regional modalities and its co-existence with earlier policies and institutional forms (2008: 776).

Molyneux’s point is reinforced by Mesa-Lago’s findings that there are in fact ten distinct models of reform that have been implemented to varying degrees and with diverse results across Latin America. However, these reforms typically emphasized the marketization of health provision and introduced programs of privatization and liberalization and the targeting of services in order to increase efficiency and improve equity in health outcomes.

Echoing broader debates within the field of social policy, discussion within health policy has also shifted toward a focus on universalism in health. Indeed many critics would argue that public health advocates have consistently maintained the need to adhere to the principles established in the late 1970s via the Alma Ata Declaration, where there was a virtual consensus that Universal Health Care Coverage (UHC) should be a fundamental goal (Stuckler et al., 2010). This commitment was reiterated in the 2008 World Health Organization’s (WHO) report, Primary Health Care: Now More than Ever, that advocated the need to recognize health as a human right and push for universal health care coverage. This report acknowledged the challenges of doing so in an era of globalization and the privatization of health services (WHO, 2008a).

Within Latin American health systems there has been progress toward implementing universal coverage in health, most notably in Brazil, Chile, Mexico, and Uruguay. Indeed, the Pan American Health Organization expressed its commitment to universalism in its 2007 report, Renewing Primary Health Care in the Americas. Yet as commentators have argued, it is important to recognise the important distinction between universal coverage and universal access (Frenz and Vega, 2010; Stuckler et al., 2010). As Ravindran (2012: 1) explains, “Universal access is a concept that includes but goes beyond universal coverage . . . Universal access calls for making health systems functional and remove supply-side barriers, and for removing demand side barriers such as social exclusion and discrimination, lack of information and lack of decision-making power to seek health care.”

As she notes, structural inequalities by caste, race, ethnicity, and gender further reinforce barriers to access and must be taken into account in any discussion of universalism. Indeed Mesa-Lago (2010: 65) has suggested that in the context of the current world economic crisis, poor women’s access to public health care services is likely to be more negatively affected than men’s. He argues that since the incidence of poverty is greater among women than men and they use basic health services more frequently than men, they stand to lose out the most. Yet, gender differences in access to and use of services are not sufficiently factored into debates around universalism (WHO, 2010c). However, other commentators have suggested that such a broad notion of universalism that considers access alongside coverage is rooted in the experience of advanced industrialized democracies. This idea cannot be equally applied to the Latin American case since the consolidation of a welfare system in which all citizens have access to high quality social services and receive generous income transfers is untenable (Pribble, 2013: 8). Nevertheless, while acknowledging the reality of this statement, it is still possible to determine what measures Latin American governments have sought to implement in order to remove some of these barriers to access alongside the shift toward more universal coverage of services.

Many of the issues raised here will be explored in more depth in subsequent chapters in the book. The analysis will predominantly focus on the case of Chile, the only country in the region that has fully implemented a large-scale reform. This makes the Chilean case an excellent choice for a case study analysis and enables us to consider the broader lessons that can be drawn out of its experience. In order to contextualize the Chilean case and consider the extent to which its experience really is unique, comparative material is drawn from the rest of the region.

Social Policy and Inequalities

Despite notable progress toward poverty reduction across the region, levels of inequality have remained relatively consistent over the past few decades. While there is some variation between countries, compared with the rest of the world, the Gini index has remained high across Latin America and income remains highly concentrated among a very small elite (Blofield, 2011). Moreover, according to the Economic Commission for Latin America (CEPAL, to use its Spanish acronym), patterns of poverty have remained relatively unchanged since the late 1990s. “The breakdown of poor groups by sex is similar to the one seen in 1999, but a major shift has occurred in the percentage of persons living in female-headed households —from 18% of all indigent households in 1999 to 28 percent in 2011. In poor households, the change has been from 19 percent to 28 percent” (CEPAL, 2012: 19).

Overcoming these inequalities remains a major challenge for Latin America. Whilst social policy offers one potential means of redistributing incomes, this path has not been taken by governments in the region. As argued earlier, attempting this type of resource redistribution is seen as too politically challenging. Indeed, while President Lagos did attempt to introduce a more redistributive element of the Plan AUGE in the Chilean health reforms, this was rejected during the parliamentary debate.³ Other factors have also contributed to the lack of progress in addressing the high levels of inequality. One issue relates to the ways in which questions of poverty and inequality are framed in national level political discourse and how far elites support the need for change. Drawing on the case of Brazil, Elisa Reis (2011) argues that while elites are concerned with questions of inequality, they do not see redistribution as the solution. Rather they believe that education is the answer and this offers individuals a means of bettering themselves. Nevertheless, elites unanimously reject the idea of paying higher taxes to improve education but, at the same time, do believe it is the state’s responsibility to ensure better education is provided. The need for tax reform in Latin America is widely acknowledged (Ter-Minassian, 2012). Yet there has also been reluctance across the region, even from more left-wing governments, to introduce more progressive forms of taxation (Filgueira et al., 2011; Mahon, 2011). This also raises important questions about the financial feasibility of a far-reaching shift to universal provision of health and education services in the region (Filgueira et al., 2011). In Uruguay a tax reform was introduced in 2006. While this did move toward a greater progressivity of direct taxation, critics argued that it did not touch inheritance or business profits (Filgueira et al., 2011: 269). In the Chilean case, critics have argued that the taxation system is particularly inequitable because it forces the middle- and low-income groups to shoulder most of the tax burden while allowing the super-rich to get away with paying one of the lowest tax rates among middle-income and advanced countries. Indeed, Michelle Bachelet pledged her commitment to reforming the tax system if elected for a second presidential term in the November 2013 elections. The majority of indirect taxes in Chile are regressive—reaching more than 66 percent of all tax revenues—the highest among middle-income and OECD (Organisation for Economic Co-operation and Development) countries. Moreover, significant tax loopholes exist, which impact the equity of the system.

Tax expenditures or loopholes—which in Chile also happen to be extremely regressive—at 4% of GDP are much higher than in most middle income countries in Latin America with the exception of Mexico. In addition, while the evasion rate of the value-added tax (VAT) is among the lowest in the world, the income tax evasion rate, estimated at about 50%, is very high given Chile’s level of development. Finally, natural resource rents—which in a country as dependent on the extraction of natural resources as Chile comprise a very large share of GDP—are mostly untaxed (López and Figueroa, 2011: 4).

In sum, the pro-poor discourse that is evident in social policy is clearly not reflected in fiscal policy in the region. It has also been suggested that public expenditure has been overly focused on social assistance programs, thus diverting valuable resources, either directly or indirectly, from social investment in social services including health, education, and basic sanitation, which provide essential inputs that are required to enable people overcome poverty (Barrientos, 2013a; Hall, 2008, 2012; Staab, 2010). Critics have also expressed concern that the “quick fix” appeal of CCTs in terms of both a cheap means of reducing absolute poverty and high political payoffs means that governments have become increasingly reliant on them as a cornerstone of social policy. Other elements of social policy, such as much needed structural reforms, are more costly to implement and have less visible results. Though CCTs were only ever intended as a temporary relief measure, there is a concern that they will come to be viewed increasingly as mainstream, long-term policy, occupying center stage (Hall, 2012).

Poverty and Inequality and Health

Looking more closely at health policy and the health sector, concerns around the failure of new policies to address health inequalities also arise. Since the mid-1990s, public expenditure on health in Latin America has been relatively high, especially compared to other regions, yet this has failed to overcome the deeply entrenched health inequalities. Increased public spending alone does not guarantee that the quality of services will improve or that social services will be more equitable (Nelson, 2007: 80). Critics have argued that the distribution of spending has served to reinforce inequalities, with resources predominantly oriented toward expensive curative services rather than primary health care services, which may be more relevant to the poor (Laurell, 2007; Lloyd-Sherlock, 2006). Privatization also exacerbates and embeds inequalities, as health care itself is restructured wherein internal hierarchies are reworked and the pattern of those treated and excluded is reshaped (Mackintosh, 2003: 6). Moreover, others have warned that notionally universal entitlements have been progressively undermined by the introduction of user fees (Lloyd-Sherlock, 2009: 355). Here too new vested interests from the private sector are introduced into the health system that can later serve to block reform because care practitioners benefit from direct paym...

Table of contents

• Cover
• Title
• Chapter 1 Latin American Social Policy: Challenging Gender Inequalities?
• Chapter 2 A Gendered Political Economy of Health
• Chapter 3 The Development of Gendered Health Systems
• Chapter 4 Engendering Governance in Health?
• Chapter 5 Gender, the Changing Nature of Work and Health
• Chapter 6 Gender, Migrant Labor, and Health
• Chapter 7 Concluding Comments
• Notes
• Bibliography
• Index