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Transnational Diffusion of Health Policy Ideas in Uruguay in the Early Twentieth Century

Published online by Cambridge University Press:  06 September 2021

CECILIA ROSSEL
Affiliation:
Universidad Católica del Uruguay
FELIPE MONESTIER
Affiliation:
Universidad de la República, Uruguay

Abstract

This article analyzes how policy ideas already adopted in Europe, particularly in France, were taken into consideration for the design of Uruguay’s National Public Assistance (NPA) policy. Established in 1910, the NPA was a pioneering government social policy for the time and for the region.

Some have argued that the design of the NPA law followed the secular and republican model instituted in France at the end of the nineteenth century when France established the Assistance Publique, particularly regarding the extent of public assistance to the poor, the role of the state in the provision of health care (as opposed to charity-based provision) and the centralization of health-care services (as opposed to a decentralized health-care system).

We analyze how these revolutionary ideas were discussed by the technicians and politicians who participated in the process that culminated in the approval of the law in Uruguay discussed these revolutionary ideas. We explore the factors that motivated the creation of the commission that developed the law. We also review available documentation on the drafting of the bill and the parliamentary debate that culminated in its approval. We find that the design of the NPA included many ideas diffused mainly from France. The French model was not simply emulated, however. Rather, the authors of the NPA thoroughly analyzed and considered the features and main consequences of the Assistance Publique, suggesting that diffusion in this case was more a process of learning than of simple mimicry.

Type
Article
Copyright
© Cambridge University Press 2021

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References

Notes

1. Mesa-Lago, C., Social Security in Latin America: Pressure Groups, Stratification, and Inequality, for example, explores the creation of social security systems in the region.Google Scholar

2. R. Castiglioni, “Building and Sustaining Social Protection: Cross-Class Coalitions, Elite Responses, and Party Politics in Chile and Uruguay (1900–1973)”; F. Filgueira, “Modelos de Desarrollo, Matriz Del Estado Social y Herramientas de Las Políticas Sociales Latinoamericanas”; S. Haggard and R. Kaufman, “Development, Democracy, and Welfare States”; J. Pribble, Welfare and Party Politics in Latin America.

3. See, for example, for Uruguay, F. Filgueira and C. Filgueira, El Largo Adiós al País Modelo. Políticas Sociales y Pobreza En Uruguay (Montevideo, 1994); R. Castiglioni, “Welfare State Reform in Chile and Uruguay: Cross-Class Coalitions, Elite Ideology, and Veto Players.” See also Alexandra Stern, “Responsible Mothers and Normal Children.” For Mexico, I. Rizzini, “The Child-Saving Movement in Brazil: Ideology in the Late Nineteenth and Early Twentieth Centuries.” For Brazil, see J. Martinez Franzoni and D. Sánchez-Ancochea, The Quest for Universal Social Policy in the South Actors, Ideas and Architectures (New York, 2016); for Costa Rica, Christopher Abel, “External Philanthropy and Domestic Change in Colombian Health Care: The Role of the Rockefeller Foundation, ca. 1920–1950,” Hispanic American Historical Review 75, no. (1995): 339. https://doi.org/10.2307/2517226. For Colombia, Karen Mead, “Beneficient Maternalism.”

4. Law 3.724.

5. Martinez Franzoni and Sánchez-Ancochea, The Quest for Universal Social Policy in the South Actors, Ideas and Architectures, 86.

6. See F. Filgueira, “Century of Social Welfare in Uruguay: Growth to the Limit of the Batllista Social State”; M. Setaro, “Vigilar y Cuidar El Bien Común: El Rol de Rectoría Del Sistema de Salud Desde Una Perspectiva Comparativa,” and Christine Ehrick, “Affectionate Mothers and the Colossal Machine.”

7. F. Filgueira and C. Filgueira, El Largo Adiós al País Modelo. Políticas Sociales y Pobreza En Uruguay; A. E. Birn, “The National-International Nexus in Public Health: Uruguay and the Circulation of Child Health and Welfare Policies, 1890–1940.” Birn also affirms that French legislation served as a reference point in the late nineteenth century regarding maternity leave, welfare provisions, mandatory breastfeeding for abandoned infants, milk hygiene, and other childcare measures (Birn, 2006, 37).

8. A. E. Birn, “The National-International Nexus in Public Health: Uruguay and the Circulation of Child Health and Welfare Policies, 1890–1940,” 44.

9. D. E. Ashford, “In Search of the Etat Providence.”

10. Kurt Weyland, Bounded Rationality and Policy Diffusion: Social Sector Reform in Latin America.

11. N. B. Sugiyama, “The Diffusion of Conditional Cash Transfer Programs in the Americas.”

12. Cecilia Osorio Gonnet, “A Comparative Analysis of the Adoption of Conditional Cash Transfers Programs in Latin America.”

13. Kurt Weyland, Bounded Rationality and Policy Diffusion; N. B. Sugiyama, “The Diffusion of Conditional Cash Transfer Programs in the Americas”; Sarah M. Brooks, “Social Protection for the Poorest”; Borges, “Neoliberalism with a Human Face?”

14. F. Filgueira and C. Filgueira, El Largo Adiós al País Modelo. Políticas Sociales y Pobreza En Uruguay; Christopher Abel, “External Philanthropy and Domestic Change in Colombian Health Care”; I. Rizzini, “The Child-Saving Movement in Brazil: Ideology in the Late Nineteenth and Early Twentieth Centuries”; Alexandra Stern, “Responsible Mothers and Normal Children”; Karen Mead, “Beneficient Maternalism”; R. Castiglioni, “Welfare State Reform in Chile and Uruguay: Cross-Class Coalitions, Elite Ideology, and Veto Players”; E. Brearley, “A History of Social Protection in Latin America: From Conquest to Conditional Cash Transfers.”

15. J. Martinez Franzoni and D. Sánchez-Ancochea, The Quest for Universal Social Policy in the South Actors, Ideas and Architectures.

16. Ibid., 110.

17. Ibid., 111–12.

18. Gilardi argues that, although it is usually referred to as convergence, these terms are not equivalent, because “convergence characterizes the outcome of the process, but not the nature of the process itself” (F. Gilardi, "in Transitional Diffusion" [2012], 3).

19. B. Simmons, F. Dobbin, and G. Garrett, The Global Diffusion of Markets and Democracy; Dabid Marsh and J. C. Sharman, “Policy Diffusion and Policy Transfer.”

20. F. Gilardi, “Transnational Diffusion: Norms, Ideas, and Policies”; Graham, Shipan, and Volden, “The Diffusion of Policy Diffusion Research in Political Science.”

21. There is also a debate concerning the concept of policy transfer and the extent to which it can be considered distinct from policy diffusion (David P. Dolowitz and David Marsh, 2000; J. C. Sharman, “Policy Diffusion and Policy Transfer.” For an application of these terms to the analysis of the history of a particular policy, see Shaun Goldfinch and Philippa Mein Smith, “Compulsory Arbitration and the Australasian Model of State Development.” In this article we adhere to the idea of policy transfer as a subtype of policy diffusion: Erin R. Graham, Charles R. Shipan, and Craig Volden, “The Diffusion of Policy Diffusion Research in Political Science”; Maggetti and Gilardi, “Problems (and Solutions) in the Measurement of Policy Diffusion Mechanisms.” See also F. Gilardi, “Transnational Diffusion: Norms, Ideas, and Policies.”

22. The literature also describes competition as a diffusion mechanism that occurs ‘”when units react to or anticipate one another in the attempt to attract or retain resources: F. Gilardi, “Four Ways We Can Improve Policy Diffusion Research,” 10. This category usually applies to understanding diffusion in contexts of tax competition, capital account and exchange policy, bilateral investment treaties, and infrastructure reforms. For a review of both notions, see F. Gilardi, “Transnational Diffusion: Norms, Ideas, and Policies”; F. Gilardi, “Four Ways We Can Improve Policy Diffusion Research.” Coercion is also frequently mentioned in the literature as another form of diffusion, i.e., “the use of force, threats, or incentives by one government to affect the policy decisions of another”: Charles R. Shipan and Craig Volden, “Policy Diffusion.” Neither of these forms of diffusion is considered in this article because neither competition nor coercion existed between Uruguay and France at the time the NPA law was approved.

23. Charles F. Shipan and Craig Volden, “Policy Diffusion.”

24. F. Gilardi, “Four Ways We Can Improve Policy Diffusion Research,” 10.

25. See Charles R. Shipan and Craig Volden, “Policy Diffusion”; Covadonga Meseguer, “Rational Learning and Bounded Learning in the Diffusion of Policy Innovations”; and Kurt Weyland, Bounded Rationality and Policy Diffusion: Social Sector Reform in Latin America.

26. Charles R. Shipan and Craig Volden, “Policy Diffusion.”

27. Kurt Weyland, Bounded Rationality and Policy Diffusion: Social Sector Reform in Latin America.

28. F. Gilardi, “Four Ways We Can Improve Policy Diffusion Research,” 8.

29. F. Filgueira, “Century of Social Welfare in Uruguay: Growth to the Limit of the Batllista Social State.”

30. J. P. Barrán and B. Nahum, Batlle, Los Estancieros y El Imperio Británico; F. Filgueira and C. Filgueira, El Largo Adiós al País Modelo; S. Haggard and R. Kaufman, “Development, Democracy, and Welfare States”; G. Caetano, Historia Mínima Del Uruguay.

31. A. E. Birn, “The National-International Nexus in Public Health: Uruguay and the Circulation of Child Health and Welfare Policies, 1890–1940.”

32. A. E. Birn (2006) mentions that “From the 1890s, Uruguayans participated in virtually every international congress related to public health and social welfare; they published their own presentations either in Uruguayan or international journals and typically issued analytic summaries of the conference discussions in Uruguay’s Boletín del Consejo Nacional de Higiene. The few meetings to which professional emissaries were not sent were attended by Uruguayan diplomatic envoys. Carlos Nery, the Uruguayan consul general to Great Britain, for example, spent considerable effort researching social welfare institutions in Europe. He represented Uruguay at the International Conference on Public and Private Welfare held in Milano in 1906… . Most countries sent one representative to the 1900 Paris conference at which the International Classification of Diseases was first revised; Uruguay sent two (Bertillon, 1900). Similarly, the seven-person delegation Uruguay sent to the XVth International Congress on Hygiene and Demography held in Washington in 1912 was larger than that of all but a handful of countries” (Birn, 42).

33. G. Fuentes, “La Creación Del Sistema Nacional Integrado de Salud En Uruguay (2005–12): Impulso Reformista Con Freno Desde Los Puntos y Actores de Veto.”

34. It also established the conditions that would qualify a person as “indigent” and thus eligible to receive free assistance: M. Setaro, “Vigilar y Cuidar El Bien Común: El Rol de Rectoría Del Sistema de Salud Desde Una Perspectiva Comparativa.” A “poor certificate” was issued by the justices of the peace. To be considered poor or indigent in Montevideo, a person had to show that he received income of less than $50 [per month] without dependent children or $80 with dependent children. The corresponding amounts were $30 and $50 if he lived in other regions of the country. Those with incomes above these amounts but lacking sufficient resources to pay a fee for services provided by the mutual organizations could receive medical care in public hospitals by paying a fee. In theory, the rich could not use public services.

35. In the second half of the nineteenth century, a growing number of civil society organizations emerged in Uruguay. Many of them were focused on providing health care to different groups of European immigrants who were arriving in large numbers to the country. These organizations—called “asociaciones mutuales” or “mutualistas” and based on the principles of Charity and Philanthropy—established cooperative arrangements to provide health care to their members and became, in the first decades of the twentieth century, one of the main pillars of the country’s health-care system. The first “mutualista,” the Asociación Española de Socorros Mutuos, was created in 1853, and was followed by a large number of similar institutions linked to European immigrants Portillo, “Historia de La Medicina Estatal En Uruguay (1724–1930).” These institutions were excluded from the regulation imposed by the NPA and were not absorbed by the state.

36. J. P. Barrán, Medicina y Sociedad En El Uruguay Del Novecientos. El Poder de Curar.

37. Ibid.

38. F. Herrera and R. Gorlero, “Médicos Uruguayos Ejemplares. Tomo I. José Scosería (1861–1946).”

39. See J. P. Birn, “The National-International Nexus in Public Health: Uruguay and the Circulation of Child Health and Welfare Policies, 1890–1940,” 46. He “was elected a member of the Academies of Medicine of Paris, Buenos Aires and Rio de Janeiro, and in 1931 Morquio was named an officer of France’s famed Légion d’Honneur” (Birn, 46). The other members of the commission were Dr. Alfredo Vidal y Fuentes, chairman of the Board National Public Hygiene; Dr. Gabriel Honoré, director of Public Health in Montevideo; Dr. Benjamín Fernández y Medina; Dr. José Ramasso and Dr. Juan J. De Amézaga, a young lawyer who was also a member of Congress.

40. For example, the mortality rate for children under five years of age was around 200 deaths per 1,000 live births Ferrari, “A 100 Años de La Ley de Asistencia Pública Nacional (1910–2010).” Also at the time, the country was emerging from a long century of wars, revolutions, and riots. See J. M. Ferrari, “A 100 Años de La Ley de Asistencia Pública Nacional (1910–2010).”

41. Sherry Zaks, “Relationships Among Rivals (RAR).”

42. F. Gilardi, “Four Ways We Can Improve Policy Diffusion Research.”

43. David P. Dolowitz and David Marsh, “Learning from Abroad.”

44. Legislative Power Uruguay, “Parliamentary Sessions, July 6th.,” 320.

45. D. E. Ashford, “In Search of the Etat Providence.” “His tireless struggle to eradicate the idea of charity and the religious character of local public assistance offices is the French equivalent of the struggle to get the no less militant evangelical Protestants out of the Poor Law administration in England. Monod became the leader of social reform. In what could well be the first relevant debate on the territorial distribution of resources, Monod argued (with the ‘wild applause’ of the Chamber of Deputies) that the richest departments had an obligation to assist the poorest areas to build local insurance funds. The debate of ideas and policy options was more intense in France than in the rest of the democracies of the time because the Bureaux de Beneficencia was seen as an intrusion of the Church into local social policy, and, consequently, as an obstacle to the application of republican standards in the provision of public assistance” (Ashford, 1991, 155).

46. Legislative Power Uruguay, “Parliamentary Sessions, July 6th.,” 320.

47. A. E. Birn, “The National-International Nexus in Public Health: Uruguay and the Circulation of Child Health and Welfare Policies, 1890–1940.” In 1898, for example, he participated in Madrid in the IXth Congress of Hygiene and Demography.

48. Legislative Power Uruguay, “Parliamentary Sessions, July 6th.” Joaquin de Salterain, 82.

49. Legislative Power Uruguay. Joaquin de Salterain, 82. Note that references to the parliamentary debate indicate the date of publication of the session minutes, which usually occur around one week after the day the debate took place in Congress.

50. Legislative Power Uruguay, “Records from Parliamentary Sessions, July 20th.” Ponce de León, 189.

51. Legislative Power Uruguay, “Records from Parliamentary Sessions, August 11th.” De Salterain, 239.

52. References to Italy were made in: 08/7/1910 (82). De Salterain; 12/7/1910 (119). López; 11/8/1910. (239) De Salterain; 11/8/1910 (239). De Salterain; 20/8/1910 (270). Ponce de León. Reference to Belgium were made in 20/8/1910 by both Ponce De León and De Salterain (270–71).

53. 14/6/1910 (342). De Salterain; 15/6/1910 (377). Brito; 08/7/1910 (82). De Salterain; 25/8/1910 (n.d.) De Salterain.

54. 14/6/1910 (341). De Salterain. There were a few mentions of other countries in Latin America. Argentina is mentioned by opponents of the bill, both to justify the need for the director of public assistance to be a doctor and to refer to the way private institutions of public assistance provide care to the homeless in the city of Buenos Aires. Also, the experiences of private institutions funded with state subsidies are mentioned (among them the Drop of Milk, the Tuberculosis Asylum and the Children’s Board, which is described as a “fourth state power”). Regarding Brazil, Rio de Janeiro is referred to as one of the many cities that have night shelters for poor people who do not need permanent hospitalization. Chile is also mentioned among the countries that have night shelters dependent on public assistance to give refuge to poor people who do not need permanent hospitalization. This omission is criticized by the drafters of the project when the international trend was to create these kinds of services and have them provided by government agencies.

55. Legislative Power Uruguay, “Records from Parliamentary Sessions, August 11th.” Ponce de León, 242.

56. De Salterain, 241.

57. Legislative Power Uruguay, “Records from Parliamentary Sessions, June 14th,” 14. De Salterain, 341.

58. Legislative Power Uruguay, “Records from Parliamentary Sessions, August 11th.”, Ponce de León, 241.

59. Legislative Power Uruguay, “Records from Parliamentary Sessions, June 14th,” 14. De Salterain, 341.

60. Legislative Power Uruguay, “Records from Parliamentary Sessions, July 20th,” 17. Roxlo, 254.

61. Legislative Power Uruguay, “Records from Parliamentary Sessions, July 20th,” 17. Roxlo, 254.

62. In fact, between June and August 1910, France was mentioned twenty-four times in the debates that took place in Congress.

63. Regarding this last point, promoters and opponents avoided framing the debate in terms of a confrontation between the State and the Catholic Church. The project enshrined state control over an activity in which the Catholic Church played a prominent role.

64. Fabrizio Gilardi, Katharina Füglister, and Stéphane Luyet, “Learning From Others”; Covadonga Meseguer, “Rational Learning and Bounded Learning in the Diffusion of Policy Innovations”; David P. Dolowitz and David Marsh, “Learning from Abroad.”