Under neoliberalism citizens in Chile and beyond have seen a reshaping of social service delivery, particularly in the health sector.
The privatisation of many services undertaken as part of neoliberal reform programmes implemented in the 1980s and 1990s meant that health was no longer a right to which all citizens where entitled but instead a service to which access is determined according to ability to pay. At the same time citizens were encouraged to take responsibility for their own health and welfare – and that of their families. The gender dimensions of this have been the subject of much debate (Schild 2000 and 2007). The privatisation of healthcare services has resulted in many activities being transferred back into the household where the gender division of labour generally means that women have had to take responsibility for them. At the same time changes in production processes that have also been part of neoliberal reform programmes have led to a growing number of women moving into the paid workforce (Standing 1999). Many women are therefore subject to competing demands on their time.
Reconfiguring state–society relations has also been an integral part of neoliberal reform processes. In Chile the transition from authoritarian rule in 1990 facilitated this process. As Schild argues:
New ways of governing welfare were installed as a part of a necessary dismantling of pre-existing, and presumed undemocratic, structures. The reorganisation of power relations within state bureaucracy and between the state and society at large, along the lines of a new, market rationality, was thus accomplished … (Schild 2007: 185)
The key feature of this change has been the cooptation of civil society organisations to participate in the delivery of services and again this process has been the subject of much criticism by feminists (Schild 2000). One of the central concerns in Chile has been the way in which this co-optation of civil society has led to the ‘NGO-isation’ and subsequent depoliticisation of the women’s movement as a growing number of women’s organisations have reformed into non-governmental organisations (NGOs) in order to meet funding criteria and be able to develop projects (Alvarez 1999; Bradshaw 2006). While spaces have been created for women’s participation in the design of service delivery they have been limited and have little or no impact on key decision-making processes (Gideon 2005).
Another important feature of the modern state has been the emergence of rhetoric that attempts to address the question of gender inequality (Schild 2007). As other papers in this IDS Bulletin have illustrated (see, for example, Pereira) governments are particularly willing to address gender issues if they can do so instrumentally and be seen to be addressing other goals such as poverty reduction at the same time. By explicitly addressing gender inequities in the health sector the Chilean government is able to position itself as a forwardthinking ‘modern’ state. However, as feminist critics have pointed out, the government has not been so willing to address many of the essential concerns of the women’s movement such as domestic violence and the right to abortion which remains illegal in Chile (Blofield and Haas 2005).
This article will examine these issues in relation to changes in the health sector in Chile and will predominantly focus on the access to health services as defined by the right to health. The article will start with a brief discussion of how the right to health has historically been reshaped by successive regimes before focusing on the current situation and the design and implementation of the new Plan AUGE (el Acceso Universial con Garantias Explicitas en Salud) in the health sector that seeks to guarantee access to health for all citizens, regardless of their gender or income level. On the one hand, it is an important development in terms of addressing gender inequalities in access to health services which will play a central role in securing women’s equal right to health. Women’s groups were involved in the consultation process around the design of the reform package and over time some of their demands have been integrated into the Plan AUGE (OEGS 2006). On the other hand however, the Plan promotes a somewhat limited notion of women’s right to health and the whole issue of reproductive rights is not addressed by the Plan. Similarly while the Plan makes no claim to address broader gender inequalities in the health sector, critics have argued that it does serve to reinforce the gender division of labour in unpaid care by transferring more health related caring activities onto the household.
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This article comes from the IDS Bulletin 39.6 (2008) Counting the Cost of Privatised Provision: Women, Rights and Neoliberal Health Reforms in Chile
