Healthcare Reform out of Nowhere? Policy Reform and the Lack of Programmatic Commitment in Peru
Published online by Cambridge University Press: 31 August 2021
The reform approved in Peru in 2009 during a right-wing government deviates from similar attempts in the region to expand access to healthcare. Left-wing parties in Peru were extremely weak during the policy-making process and the political parties were non-programmatic. Based on original field research, this article demonstrates how parties that lacked core values uniting their leaders and had no commitment to the health reform did not care for the definition of specifications regarding funding and implementation. Instead, technocrats dominated the process of policy formation, which, accompanied by the lack of commitment from key political actors, led to poorly specified policy and deficient implementation.
La reforma aprobada en Perú en 2009 durante un gobierno de derecha se diferencia de otros intentos similares en la región para expandir el acceso a la salud. Los partidos de izquierda en Perú fueron extremadamente débiles durante la hechura de esta política pública y los partidos políticos no eran programáticos. Basado en trabajo de campo original, este artículo demuestra cómo los partidos que carecían de valores centrales uniendo a sus líderes y no tenían compromiso con la reforma de salud no se preocuparon por la definición de especificaciones relacionadas con el financiamiento e implementación de la misma. Más bien, los tecnócratas dominaron el proceso, lo que, junto a la falta de compromiso de parte de actores políticos claves, llevó a una política pública pobremente especificada y a una implementación deficiente.
A reforma aprovada no Peru em 2009 durante um governo de direita se desvia de tentativas semelhantes na região de expandir o acesso à saúde. Os partidos de esquerda no Peru foram extremamente fracos durante o processo de formulação de políticas públicas e os partidos políticos se comportavam de maneira não programática. Com base em pesquisa de campo original, este artigo demonstra como partidos que careciam de valores fundamentais para unir seus líderes e não tinham compromisso com a reforma de saúde não se importaram com a definição de especificações a respeito de financiamento e implementação. Em vez disso, os tecnocratas dominaram o processo de formação de políticas, o que, acompanhado pela falta de compromisso dos principais atores políticos, levou a uma política pública mal especificada e implementação deficiente.
- Research Article
- Copyright © The Author(s), 2021. Published by Cambridge University Press
1 Christina Ewig, Second-Wave Neoliberalism: Gender, Race, and Health Sector Reform in Peru (University Park, PA: Pennsylvania State University Press, 2010).
2 Candelaria Garay, Social Policy Expansion in Latin America (New York: Cambridge University Press, 2016); James W. McGuire, Wealth, Health, and Democracy in East Asia and Latin America (New York: Cambridge University Press, 2010); Jennifer Pribble, Welfare and Party Politics in Latin America (New York: Cambridge University Press, 2013).
3 Dan Collins, ‘Peru's Coronavirus Response was “Right on Time” – So Why Isn't It Working?’, The Guardian, 20 May 2020, available at www.theguardian.com/global-development/2020/may/20/peru-coronavirus-lockdown-new-cases, last access 21 May 2021.
5 Evelyne Huber and John Stephens, ‘Successful Social Policy Regimes? Political Economy, Politics, and the Structure of Social Policy in Argentina, Chile, Uruguay, and Costa Rica’, in Scott Mainwaring and Timothy R. Scully (eds.), Democratic Governance in Latin America (Stanford, CA: Stanford University Press, 2009), pp. 155–209; Jennifer Pribble and Evelyne Huber, ‘Social Policy and Redistribution: Chile and Uruguay’, in Steven Levitsky and Kenneth M. Roberts (eds.), The Resurgence of the Latin American Left (Baltimore, MD: Johns Hopkins University Press, 2011), pp. 117–38.
6 Important exceptions, which analyse efforts to expand social benefits led by right-wing parties, are Ewig, Christina, ‘Reform and Electoral Competition: Convergence Toward Equity in Latin American Health Sectors’, Comparative Political Studies, 49: 2 (2016), pp. 184−218CrossRefGoogle Scholar; Garay, Social Policy Expansion; Fairfield, Tasha and Garay, Candelaria, ‘Redistribution under the Right in Latin America: Electoral Competition and Organized Actors in Policymaking’, Comparative Political Studies, 50: 14 (2017), pp. 1871–906CrossRefGoogle Scholar. See also Altman, David and Castiglioni, Rossana, ‘Determinants of Equitable Social Policy in Latin America (1990–2013)’, Journal of Social Policy, 49: 4 (2020), pp. 763–84CrossRefGoogle Scholar; Niedzwiecki, Sara and Pribble, Jennifer, ‘Social Policies and Center-Right Governments in Argentina and Chile’, Latin American Politics and Society, 59: 3 (2017), pp. 72–97CrossRefGoogle Scholar.
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9 I subject this theory to a further test elsewhere through a comparative study of a case where programmatic commitment is absent (AUS in Peru), a case where it is present (AUGE in Chile) and a mixed case (Seguro Popular in Mexico). See Zoila Ponce de Leon, ‘Political Parties and Policy Reform: Expansion of Healthcare in Latin America’, PhD diss., University of North Carolina at Chapel Hill, 2018.
10 Levitsky and Cameron, ‘Democracy without Parties?’; Mainwaring (ed.), Party Systems in Latin America; Scott Mainwaring and Timothy R. Scully, Building Democratic Institutions: Party Systems in Latin America (Stanford, CA: Stanford University Press, 1995).
11 Levitsky and Cameron, ‘Democracy without Parties?’; Levitsky, ‘Peru: The Institutionalization of Politics without Parties’.
12 Eduardo Dargent, Technocracy and Democracy in Latin America (Cambridge, UK: Cambridge University Press, 2015).
14 53.1 per cent in Latin America and the Caribbean in 2016. See International Labour Organization (ILO), Women and Men in the Informal Economy: A Statistical Picture, third edition (Geneva: ILO, 2018).
15 Juliana Martínez Franzoni and Diego Sánchez-Ancochea, The Quest for Universal Social Policy in the South: Actors, Ideas and Architectures (Cambridge: Cambridge University Press, 2016).
17 Gøsta Esping-Andersen, The Three Worlds of Welfare Capitalism (Princeton, NJ: Princeton University Press, 1990); Evelyne Huber and John Stephens, Development and Crisis of the Welfare State: Parties and Policies in Global Markets (Chicago, IL: University of Chicago Press, 2010); María Victoria Murillo, ‘Partisanship amidst Convergence: The Politics of Labor Reform in Latin America’, Comparative Politics, 37: 4 (2005), pp. 441–58; Pribble and Huber, ‘Social Policy and Redistribution’.
18 André Blais, Donald E. Blake and Stéphane Dion, ‘Do Parties Make a Difference? A Reappraisal’, American Journal of Political Science, 40: 2 (1996), pp. 514–20; Francis Geoffrey Castles, The Impact of Parties: Politics and Policies in Democratic Capitalist States (Beverly Hills, CA: Sage, 1982); Evelyne Huber and John Stephens, Democracy and the Left: Social Policy and Inequality in Latin America (Chicago, IL: University of Chicago Press, 2012).
19 Kitschelt et al., Latin American Party Systems; Mainwaring (ed.), Party Systems in Latin America.
21 Pribble, Welfare and Party Politics.
23 Ernesto Stein and Mariano Tommasi, ‘The Institutional Determinants of State Capabilities in Latin America’, in François Bourguignon and Boris Pleskovic (eds.), Annual World Bank Conference on Development Economics Regional 2007: Beyond Transition (Washington, DC: World Bank 2007), pp. 193–225.
24 Alex Segura-Ubiergo, The Political Economy of the Welfare State in Latin America (Cambridge: Cambridge University Press, 2007).
25 High-income: Esping-Andersen, The Three Worlds; Huber and Stephens, Democracy and the Left. Low-income: Huber and Stephens, Development and Crisis of the Welfare State; Fernando Filgueira, ‘Latin American Social States: Critical Junctures and Critical Choices’, in Yusuf Bangura (ed.), Democracy and Social Policy (London: Palgrave Macmillan, 2007).
26 Garay, Social Policy Expansion.
27 McGuire, Wealth, Health, and Democracy.
28 Adam Przeworski, Democracy and Development: Political Institutions and Wellbeing in the World 1950–1990 (Cambridge: Cambridge University Press, 2000); Amartya Sen, Development as Freedom (New York: Random House, 1999).
29 Stephan Haggard and Robert R. Kaufman, Development, Democracy, and Welfare States: Latin America, East Asia, and Eastern Europe (Princeton, NJ: Princeton University Press, 2008); Filgueira, ‘Latin American Social States’; McGuire, Wealth, Health, and Democracy.
30 Garay, Social Policy Expansion.
31 Natasha Borges Sugiyama, Diffusion of Good Government: Social Sector Reforms in Brazil (Notre Dame, IN: University of Notre Dame Press, 2013); Kurt Weyland, Bounded Rationality and Policy Diffusion: Social Sector Reform in Latin America (Princeton, NJ: Princeton University Press, 2006).
32 Dargent, Technocracy and Democracy; Ewig, Second-Wave Neoliberalism.
33 Weyland, Bounded Rationality.
34 Ewig, Second-Wave Neoliberalism.
35 John H. Aldrich, Why Parties?: The Origin and Transformation of Political Parties in America (Chicago, IL: University of Chicago Press, 1995); Mainwaring (ed.), Party Systems in Latin America; Mainwaring and Scully, Building Democratic Institutions; Giovanni Sartori, Parties and Party Systems: A Framework for Analysis (New York: Cambridge University Press, 1976).
36 Scartascini et al., ‘Political Institutions’.
37 Stein and Tommasi, ‘The Institutional Determinants’.
39 Bryan D. Jones and Frank R. Baumgartner, The Politics of Attention: How Government Prioritizes Problems (Chicago, IL: University of Chicago Press, 2005); John W. Kingdon, Agendas, Alternatives, and Public Policies (New York: Longman, 2003).
40 Fairfield and Garay, ‘Redistribution under the Right’; Garay, Social Policy Expansion; Christopher L. Gibson, Movement-Driven Development: The Politics of Health and Democracy in Brazil (Stanford, CA: Stanford University Press, 2019).
41 Martínez Franzoni and Sánchez-Ancochea, The Quest for Universal Social Policy.
42 Wendy Hunter and David S. Brown, ‘Democracy and Social Spending in Latin America, 1980–1992’, American Political Science Review, 93: 4 (1998), pp. 779−90; Evelyne Huber, Thomas Mustillo and John D. Stephens, ‘Politics and Social Spending in Latin America’, Journal of Politics, 70: 2 (2008), pp. 420–36; Robert R. Kaufman and Alex Segura-Ubiergo, ‘Globalization, Domestic Politics, and Social Spending in Latin America: A Time-Series Cross-Section Analysis 1973–97’, World Politics, 53: 4 (2001), pp. 553–87; Nita Rudra, Globalization and the Race to the Bottom in Developing Countries (Cambridge: Cambridge University, 2008); Alex Segura-Ubiergo, The Political Economy of the Welfare State.
43 Martínez Franzoni and Sánchez-Ancochea, The Quest for Universal Social Policy.
44 Levitsky and Roberts (eds.), The Resurgence of the Latin American Left, p. 5.
45 The UPP−PNP coalition was formed to support the presidential candidacy of Ollanta Humala, who lost the election to García in 2006. Unidad Nacional formed before the 2001 presidential election and presented Lourdes Flores as its candidate; the Partido Popular Cristiano (Christian Popular Party), Partido Solidaridad Nacional (National Solidarity) and Renovación Nacional (National Renewal) composed it.
46 Maxwell A. Cameron, ‘The Left Turn that Wasn't’; Kitschelt et al., Latin American Party Systems; Steven Levitsky, ‘Peru: The Institutionalization of Politics without Parties’; Levitsky and Cameron, ‘Democracy without Parties?’; Tanaka, ‘Perú, 1980–2000’.
47 For a list of interviews, see online Appendix, available at doi.org/10.1017/S0022216X21000493 under the ‘Supplementary materials’ tab.
48 The Observatorio de Élites Parlamentarias de América Latina/ Parliamentary Elites in Latin America (PELA) data is available at https://oir.org.es/pela/, last access 16 June 2021.
49 The remaining 2 per cent was affiliated to the military and police health system. Ministerio de Salud (MINSA), Cuentas nacionales de salud, Perú 1995−2012 (Lima: MINSA, 2015).
50 Ewig, Second-Wave Neoliberalism.
51 Dargent, Technocracy and Democracy.
52 Miguel Jaramillo and Sandro Parodi, ‘El Seguro Escolar Gratuito y el Seguro Materno Infantil: Análisis de su incidencia e impacto sobre el acceso a los servicios de salud y sobre la equidad en el acceso’, Grupo de Análisis para el Desarrollo (GRADE) Working Paper No. 46, 2004.
53 Although they were called ‘insurance’, those who were affiliated did not have to pay a premium, it was completely free.
54 Author interviews with Ariel Frisancho (MINSA director 1995–2000, ForoSalud national coordinator 2011–13), Lima, 9 Dec. 2015; Juan Arroyo (ForoSalud national coordinator 2002–4, MINSA vice-minister 2017), Lima, 10 Feb. 2016; anonymous interviewee (former member of the USAID Health Office in Lima); Víctor Carrasco (Professor at Universidad Peruana Cayetano Heredia), Lima, 13 Nov. 2015.
55 See timeline in the online Appendix, available at doi.org/10.1017/S0022216X21000493 under the ‘Supplementary materials’ tab.
56 Table A.2.1 in the online Appendix, available at doi.org/10.1017/S0022216X21000493 under the ‘Supplementary materials’ tab, shows the positions of the parties for a further three policy issues (price controls, subsidised housing, free university education), on which the Peruvian parties are equally dispersed.
57 Author interviews with, among others, Oscar Ugarte (former PRAES consultant, health minister 2008–11), Lima, 27 Nov. 2015; Arturo Granados (PHRplus, PRAES, and PolSalud consultant 2003–12, MINSA director 2012–16), Lima, 28 Jan. 2016; anonymous interviewee; Jorge Ruiz (PPC advisor, CEO of the Stella Maris Clinic and board member of the Private Clinics’ Association of Peru 2002–12), Lima, 25 Jan. 2016; Ada Pastor (PHRplus and PRAES consultant 2003–8, MINSA director 2012), Lima, 22 Jan. 2016; David Tejada (PNP advisor 2006–11), Lima, 28 Jan. 2016; Luis Wilson (APRA congressman 2006–11), Lima, 13 Feb. 2016.
58 Author interview with David Tejada.
59 Author interview with Arturo Granados.
60 Political parties as well as individual legislators can send bills to Congress.
61 It was also the job of this second advisor to gather the signatures of all the coalition members on the bill before it was introduced.
62 Author interview with Oscar Ugarte.
63 Author interview with Midori de Habich (former health minister of Peru; former head of PHRplus, PRAES and PolSalud), Lima, 11 Dec. 2015.
64 For a graphical depiction of the connections between the different actors involved in the policy-making process of AUS, see Figure A.4.1 in the online Appendix, available at doi.org/10.1017/S0022216X21000493 under the ‘Supplementary materials’ tab.
65 Author interviews with, among others, José del Carmen (health vice-minister 2005–6 and 2012–14), Lima, 17 Feb. 2016; César Chanamé (EsSalud manager 2006–11, health vice-minister 2015), Lima, 10 Feb. 2016; Melitón Arce (chief MINSA advisor 2006–7, health vice-minister 2007–10), Lima, 6 Feb. 2016; Arturo Granados; anonymous interviewee; Paulina Giusti (health vice-minister 2014–15, MINSA advisor 2005–7), Lima, 10 Dec. 2015.
66 Author interview with Carlos Ponce (APRA/Wilson advisor 2006–11, MINSA advisor 2015), Lima, 18 Dec. 2015.
67 Author interview with Víctor García (former advisor to UPP Congressman Francisco Escudero, former MINSA advisor), Lima, 15 Dec. 2015.
68 Author interview with Carlos Ponce.
69 García's choice to appoint Oscar Ugarte, a USAID consultant but also a known member of a regional left-wing party, can also be seen as linked to this intention.
70 Author interview with Víctor Carrasco.
71 Author interview with Augusto Portocarrero (former director of the Planning and Budget Division at MINSA), Lima, 8 Jan. 2016.
73 Author interviews with, among others, Oscar Ugarte; Walter Menchola (Unidad Nacional congressman 2006–11), Lima, 28 Jan. 2016; Carlos Ponce; Alberto Valenzuela (Unidad Nacional advisor, technical director of the Private Clinics’ Association of Peru 2008–10, MINSA advisor 2015–16), Lima, 18 Nov. 2015.
74 Dr Leoncio Díaz (president of the Asociación Nacional de Médicos del MINSA), speaking at the Health Committee meeting, Lima, 10 Sept. 2008.
75 For instance, including some psychiatric services was a concern, as neither private clinics nor public hospitals could provide the required services.
76 Author interview with Luis Wilson. President García started referring to AUS in public as one of the main promises of his government.
77 PNP remained firm in its position that AUS was only going to benefit the private sector and voted against it.
78 Author interview with Oscar Ugarte.
79 Author interviews with Víctor García (UPP/Escudero advisor 2006–10, MINSA advisor 2010–11), Lima, 15 Dec. 2015; and Carlos Ponce.
80 Author interview with Walter Menchola.
81 Author interview with Carlos Ponce.
82 Author interview with Midori de Habich.
83 Author interview with Carlos Ponce.
84 The 2007 statistic comes from Instituto Nacional de Estadística e Informática (INEI), Informe técnico: condiciones de vida en el Perú (Lima: INEI, 2015). The 2019 statistic comes from INEI, Informe técnico: condiciones de vida en el Perú (Lima: INEI, 2020).
85 Author interview with Alfredo Sobrevilla (PolSalud team leader 2012–15, PHRplus and PRAES consultant), Lima, 19 Nov. 2015.
86 Author interview with Melitón Arce.
87 According to former Health Minister Ugarte and other interviewees, de Habich convinced First Lady Nadine Heredia of the importance of continuing with AUS. Heredia was a powerful actor during Humala's government.
88 Alejandro Arrieta, ‘Serie sobre hospitalizaciones evitables y fortalecimiento de la atención primaria en salud: El caso de Perú’, Inter-American Development Bank Discussion Paper 275, 2012.
89 Author interview with Midori de Habich.
90 Members of both MINSA and MEF noted that de Habich was able to convince the minister of economy and his team due to the fact that she was an economist herself. She had studied in the same university as most MEF members and had previously worked for the Banco Central de Reserva del Perú (Peruvian Central Reserve Bank).
91 The USAID-funded project PolSalud (a continuation of PRAES) was in charge of providing technical assistance for this revision. Author interview with Alfredo Sobrevilla.
92 Author interview with Midori de Habich.
95 So far, they have two offices (Lima and Chiclayo). The projection is to open one in each region.
96 This is hard because there is a lot of ‘filtration’ in the system (people who do not qualify are included). SIS calculates this is between 10 per cent and 30 per cent of affiliates. If the budget were to be assigned based on a premium, SIS would be forced to verify its pool of affiliates.
97 Author interview with José del Carmen.