National and Transnational Organizing Around Women’s Health
Issues:
Reinforcing or Challenging Neoliberalism?
Jana Everett
Department of Political Science
University of Colorado Denver
Sue Ellen M. Charlton
Department of Political Science
Colorado State University
Paper prepared for the Western Political Science Association annual meeting, Portland,
Oregon, March 2010.
1
National and Transnational Organizing Around Women’s Health Issues:
Reinforcing or Challenging Neoliberalism?
In this paper we examine the emergence and development of feminist organizing around
women’s health issues from the 1960s to the present. We argue that neoliberal globalization, the
form that global capitalism has taken since the 1980s, has overall negatively affected the well
being of women, especially women also subordinated by class, race/ethnicity, and other forms of
hierarchy. We make a preliminary assessment of the ways in which women’s movements related
to health, shaped by the global context, have reinforced and/or challenged neoliberalism.
This paper draws from our book project on gender, globalization, and development. In it
we conceptualize the feminist theories underlying feminist organizing efforts in terms of three
sets of tensions. The first set of tensions we characterize as equality versus difference. This set of
tensions is typified by the debate between liberal feminists who argue for equal rights between
men and women, and difference feminists who argue for recognizing the differences between
men and women, promoting women’s values and perspectives, and crafting policies that address
the specific needs of women.
The second tension in feminist theory reflects the debate over the degree to which gender
is the only important factor in understanding the subordination of women. We contrast a genderexclusive focus and a gender-plus focus. Both liberal and difference feminism share an
exclusive focus on gender in understanding the subordination of women. A gender-plus focus is
found in “diversity feminism”, in which feminists theorize “how the social construction of race,
2
class, and sexuality profoundly alter the status of gender,” and call for a politics of location that
“pluralize[s] and particularize[s] the meaning of women.”1
The third set of tensions is found in those who argue for “articulating women’s voices” as
opposed to those who emphasize “deconstructing gender.”2 Deconstruction feminists argue that
it is necessary to deconstruct the categories of “male” and “female” in order to undermine the
power structures inherent in the discourse of gender. The deconstruction approach is found
primarily among academic feminists. By definition, those feminists who work in an institutional
context have chosen to articulate women’s voices by exercising both individual and collective
agency.
SEEKING A FEMINIST APPROACH
Abortion, contraception, rape, gender-based violence, and sexuality are all topics in the
feminist development discourse and can be seen as components of women’s health, broadly
conceptualized. This broad characterization of health fits the 1946 definition of health made by
the World Health Organization (WHO): “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity.”3
Women face many threats to their well-being in the areas of reproduction, sexuality, and
violence and have organized to address these threats. Their personal experiences of the
reproductive body, violated body, caring body, and sexualized body became the bases of feminist
political movements in North America and Western Europe beginning in the late 1960s,
spreading to many other countries over the 1970s, and subsequently becoming prominent issues
in gender and development policies and debates in the 1980s and 1990s.4
This section emphasizes the ways in which the female body figures in contemporary
debates about health policies and development. The female body is clearly central to traditional
3
understandings of threats to women’s health, such as disease and maternal mortality and
morbidity. However, the “Second Wave” of feminism in the 1960s and 1970s focused greater
attention on the notion that “the personal is political.” Feminists argued that topics formerly
confined to the private sphere properly belong in the public sphere. Put differently, “personal”
issues such as reproduction, sexual autonomy, and violence—customarily hidden in families and
considered private matters—should be addressed in public and be subjected to legal and political
debates.
Body Politics in American Feminism
The history of the way in which personal issues became part of the political arena in the
United States, although unique in many ways, is important in the larger international context.
This history also illustrates some important differences that emerged within the feminist
movement, differences that continued into the 21st century. In the United States, feminists in the
1960s and 1970s sought to reassert control over their bodies, which they viewed as having been
taken away by the medical profession.5 They emphasized self-help and produced their own
resources, such as Our Bodies, Ourselves, first put out in pamphlet form by the Boston Women’s
Health Book Collective in 1969 and then published in nine editions between 1971 and 2011 and
translated into several other languages.6
Feminist publications offered women access to reliable information about their own
bodies. They charged that some contraceptives, such as Depa-Provera and IUDs, were
dangerous, having been released after only limited testing.7 Abortion was illegal, and feminists
assisted women in finding safe abortions and in some cases performing first-trimester abortions
themselves.8 They created women’s crisis centers and “hot lines” to support victims of rape and
domestic violence.
4
Reproductive rights and anti-violence work shaped a feminist ideology of radical
feminism based on women’s embodied experiences, what we have called difference feminism.
Radical feminists were critical of the power of professionals and of the capitalist system, and
they created alternative institutions, which they hoped would operate on an egalitarian basis.
Liberal feminists, in contrast, focused most of their attention on changing laws, for example laws
restricting contraception and prohibiting abortion.
In contrast to the mainstream movements, where both radical and liberal feminist
organizational efforts were dominated by middle-class, white women, American women of color
expressed frustration that the movements did not address their needs. Whereas radical feminists
concentrated on body politics and liberal feminists on legislative reform, women of color raised
issues of race and class, articulating a version of diversity feminism. They saw the structural
violence of racism and social class as forms of violence against women. Black women, in
particular, argued that sterilization abuse, lack of affordable treatment for sexually transmitted
diseases (STDs), and high rates of infant mortality were important components of reproductive
freedom.9 Disproportionate numbers of Black, Latina, and Native American women had
experienced sterilization abuse; for example, studies revealed that half of the women sterilized
though federally funded programs each year were Black.10 Black women were also critical of
what they saw as the “racialization of rape,” reminding white feminists that charges of rape had
historically been used to control black men.11
Internationalizing the Movement
All of these variations of the American feminist health movement were internationalized
through the formation of networks and the dissemination of feminist writing. In 1977 European
feminists held what became the first International Women’s Health Meeting (IWHM) in Rome.12
5
The first meetings, held every few years, focused on self-help and legalizing abortion. The focus
broadened with the addition of participants from Asia, Africa, and Latin America, who brought
up issues of racism and imperialism in population control programs. In a manner similar to
women of color in the US, women from the Global South emphasized diversity feminism in the
international feminist health movement. For example, they criticized the neo- Malthusian
assumptions that shaped population planning in the 1970s, which they interpreted as blaming
underdevelopment on poor people.13 In contrast, the IWHM perspective was that reproductive
rights required material conditions of social justice in order to have any real meaning.
Violence against women was an important issue at the IWHM meetings in the 1980s, and
as participants became more diverse, the definition of the scope of violence broadened to
encompass religious, militarist, and institutional violence as well as the original focus of
interpersonal violence. Women refugees from Latin American military dictatorships told stories
of the “disappeared.” South Asian Indian women began to talk about police rape and dowry
deaths in the late 1970s and in the 1980s added sex-determination tests leading to “female
feticide” to the many forms of violence experienced by Indian women. Women from South
Korea and the Philippines raised the issue of “comfort women”, forced by the Japanese military
to be prostitutes during World War II. By the 1980 UN Women’s Conference in Copenhagen,
the conference report called for legislation “to prevent domestic and sexual violence against
women” and violence against women figured even more prominently at the 1985 Nairobi
Conference.14
One of the most difficult issues confronting feminists around the world has been the role
of culture in defining “gender-based violence” (GBV) and how to address it. In the 1970s there
was a division between Northern and Southern activists over gender-based violence as Northern
6
women identified some cultural practices in Africa and Asia, notably genital cutting, as instances
of violence against women, and Southern activists angrily labeled these claims as “cultural
colonialism.” The anger reflected African women’s frustration that Northern feminists failed to
acknowledge the role of local women’s working to address these practices or the role of
Northern states in the underdevelopment of the South. By the 1980s movements against genderbased violence had emerged in a number of Southern states, and a shared understanding of the
wide range of forms that constituted violence had developed among Northern and Southern
feminists. These included genital-cutting, honor killings, sex-selective abortions, rape as a
weapon of war, as well as the issues first identified by European and American feminist
movements: rape and domestic violence.
During the 1980s some feminists who occupied leadership positions in NGOs helped to
reorient the approach of population planning organizations from numerical targets for
contraceptive acceptance to women’s empowerment and reproductive rights.15 This
reorientation took place in the context of several key shifts in national and international political
realities. In 1984, the United States government, in response to the policies of the Reagan
Administration, took a strong anti-abortion stance. This policy reduced family planning funding
in general and eliminated funding for programs run by foreign NGOs. The impact of these cuts
was exacerbated by the general reduction in government health programs resulting from
structural adjustment programs.
Population planning NGOs, such as the Population Council and the International Planned
Parenthood Foundation, were weakened by the attacks on family planning programs. Needing
new allies to help set an agenda that would be more effective in the challenging environment,
NGOs increasingly recruited liberal feminists who could development incremental, pragmatic,
7
and inclusionary approaches to population issues, broadly defined. For example, Adrienne
Germain, a feminist working for the Ford Foundation in Bangladesh, developed a reproductive
health program that was shaped in response to the demands of local women rather than foreign
governments or organizations. In 1984, she co-founded the International Women’s Health
Coalition, an advocacy group for women’s reproductive rights. NGOs that emphasized
population issues such as family planning began adopting the new orientation of reproductive
health:
As an alternative to narrowly focused population programs, a reproductive health
approach encompasses, among other things, family planning, prevention and
treatment of sexually transmitted disease and other reproductive tract infections,
and prevention and management of infertility. It recognizes unsafe abortion as a
major health problem and emphasizes the special needs of adolescents.16
Collective Agency and International Agenda-Setting
In the early 1990s, a group of feminists initiated a campaign to create a uniform feminist
stance on reproductive rights to influence the upcoming 1994 UN Conference on Population and
Development (ICPD) in Cairo.17 The resulting “Women’s Declaration on Population Policies,”
supported by women’s organizations around the world, called for the recommendations coming
out of the ICPD to take a reproductive health approach to population planning and to proclaim
that “reproductive rights are human rights.”18
The commitment to reproductive rights that emerged in the Cairo Program of Action was
an enormous achievement for the feminist organizing campaign prior to the 1994 conference, but
not all feminist groups agreed with the pragmatist approach that led to the commitment. The
feminist debates after Cairo exposed the fault lines between liberal and diversity approaches.
8
Diversity feminists argued, in particular, that the Cairo program did not address the international
economic environment created by the widespread dominance of neoliberal policy-making.
Radical groups, such as the Feminist International Network of Resistance to Reproductive and
Genetic Engineering (FINRAGE) and the Committee on Women, Population and the
Environment (CWPE) believed that the pragmatists had sold out to the “population
establishment” by emphasizing a pragmatic and inclusionary approach rather than a radical,
transformative one. Betsy Hartmann charged, “The document accepts the current population
paradigm as a given, offering no substantive critique of the “free market” economic model or its
impact on poor women.”19 Rosalind Petchesky, while supporting the ICPD Programme of
Action, pointed out an important shortcoming: “the ICPD’s failure to address macroeconomic
inequities and the inability of the prevailing neoliberal, market-oriented approaches to deliver
reproductive and sexual health for the vast majority.”20 One feminist NGO consistently
critiquing the neoliberal framework and calling for a comprehensive framework for development
was Development Alternatives for Women in a New Era (DAWN), with which Brazilian Sonia
Correa and Indian Gita Sen were associated.
Violence against women figured prominently in the 1985 UN Women’s Conference in
Nairobi and the recommendations made in the Forward Looking Strategies called on
governments to increase their assistance to victims and to “increase public awareness of violence
against women as a societal problem.”21 The next major push to have violence against women
addressed as a global health issue came in the early 1990s, in preparation for the 1993 UN World
Conference on Human Rights (WCHR) to be held in Vienna. Human rights were conventionally
thought of in terms of state harms inflicted on individuals. During the late 1980s feminist legal
scholars began to make the argument that women’s human rights rested not only on state action,
9
but also on the actions of (mainly men) community and family members, and that the state had a
responsibility to protect women from all these forms of violence.
Feminist leadership for the Vienna conference came from the Center for Women’s Global
Leadership (CWGL) and its director, Charlotte Bunch, a veteran feminist with a background in
civil rights, lesbian feminism, and human rights. The CWGL initiated a global campaign for the
incorporation of GBV into the Vienna Program for Action. CGWL held leadership institutes for
Southern feminists, launched a global petition drive, and developed a campaign, “16 Days of
Action Against Gender-Based Violence” to create a strong base of support for the idea that
“women’s rights are human rights” and that the elimination of GBV had to be a central plank in
the global feminist agenda. During the feminists staged an International Tribunal at which
women from 25 countries testified on various types of GBV, such as domestic violence, rape,
political persecution, and the structural violence that leads to illiteracy.22
Feminists were successful in getting GBV recognized as a human rights violation and a
crime at the international level. The Vienna Declaration and Program of Action issued by the
WCHR recognized women’s human rights and recommended that the UN General Assembly
“adopt the Declaration on the Elimination of All Forms of Violence Against Women” which
occurred on December 20, 1993.23 In 1994 the UN appointed a Special Rapporteur on Violence
Against Women to the UN Commission on Human Rights.
In retrospect, the Fourth World Conference on Women (FWCW) in Beijing in 1995
stands as the culmination of feminist organizing and formal international recognition of an
expanded definition of women’s health rights. The Beijing Platform for Action reinforced the
commitment to women’s reproductive rights and freedom from violence, identified rape as a war
crime, and the signatories of the Platform pledged to end genital cutting, prenatal sex selection,
10
and violence against women. The Beijing Platform also put forward supported women’s right to
control their sexuality, although several government delegations objected.24
Finally, the UN responded specifically to the gender-based violence that had emerged in
the context of the civil and international wars of the 1980s and 1990s. The International Criminal
Court, established in 1998, included many forms GBV as crimes in wartime, UN Security
Council Resolution 1325 in 2000 called for the inclusion of women in peace and security
deliberations and, the International Criminal Tribunal for the former Yugoslavia handed down a
conviction for rape and enslavement as crimes against humanity.25 As a result of these initiatives,
by the early 21st century, issues that three decades earlier had been unidentified or ignored,
including domestic violence and rape as a systematic war strategy, were part of the international
discourse on human rights.
Assessment
The conception of women’s human rights and the inclusionary agenda developed by
transnational and national feminists in the 1990s led to some important gains for women in the
form of revised norms and legislation. Nuket Kardem characterizes the results as “a global
gender equality regime” that led to the gendering governance institutions.26 The discourse of
women’s human rights provides the language of this gender equality regime. Women’s human
rights advocates have been successful in enlarging the conception of human rights to encompass
violence against women along with established conceptions of civil and political rights.
As it has developed in the past two decades, the discourse of women’s human rights includes
aspects of both liberal and difference feminism. The role of diversity feminism in developing and
expanding the concept of women’s human rights is less clear. Historically, definitions of human
rights emerged from the European experience and therefore have been linked to a bias toward
11
individualism and a liberal political economy. Issues of class, race, and ethnic diversity—
intersectionality in general—have been addressed only more recently and with less enthusiasm.
Revisions in human rights norms proceed slowly and are embedded in international covenants
that, in turn, reflect a growing level of international consensus. The changes take place in a linear
fashion and the diversity and complexity of most societies are hard to address in the negotiation
processes leading to formal statements and covenants about human rights. As a consequence,
diversity feminism has had its greatest impact intranationally rather than internationally. At the
local level diversity feminism can be seen in the commitment to change personal interactions in
daily life and in struggles “around the specificity of the lived body in a particular place.”27 For
example, a feminist NGO in Medellin, Colombia, sets out to change power relationships in the
lives of women through consciousness raising, popular education, participatory organizational
processes and art.
The dominant thrust of women’s movements since the 1990s has featured an inclusionary
agenda creating space for feminist action on within existing institutions.28 Women’s movements
have undergone what Sonia Alvarez calls “NGOization,” becoming organizations with small
professional staffs that depend on foundations and governments to fund their projects.29 These
projects have engaged gender policy advocacy, from domestic violence legislation to the
establishment of legislative quotas and the delivery of services off-loaded from the shrinking
state. Women’s NGOs also produce shadow reports that critically appraise their governments’
policies (or lack thereof) on implementation of the 1979 Convention on the Elimination of
Discrimination Against Women (CEDAW). Merrindahl Andrew has contrasted feminist “protest
activity against the state and against dominant norms” in the 1960s and 1970s with more recent
approaches which entail being “partially institutionalized in government and nongovernment
12
bodies, and in policies, practices, and social norms.”30 This inclusionary approach recalls the
strategies long used by liberal and difference feminists in their approach to changing norms and
laws on human rights. But the inclusionary approach also led to an important shortcoming of
feminist activities in the 1990s: the lack of a direct challenge to neoliberal globalization.
RETHINKING FEMINIST STRATEGIES IN THE NEW CENTURY
In spite of the continued UN attention to gender-based violence, the implementation of
recommendations from the Cairo, Vienna, and Beijing conferences disappointed feminists of
nearly every persuasion. The first decade of the 21st century was marked by growing religious
fundamentalism hostile to feminist definitions of women’s rights, a conservative U.S.
presidential administration under George W. Bush that once again opposed family planning
funding for NGOs, and renewed neoliberal policies that pushed for privatized health services in
the United States and elsewhere. The UN’s institutional clout weakened, while the G8, World
Bank, IMF, and WTO gained in influence. Although women’s groups did bring up
macroeconomic issues at a variety of UN-sponsored meetings, the official documents issued
after these meetings ignored these concerns. The election of Barack Obama restored family
planning funding, but subsequent attacks within the U.S. on funding for contraception and
abortion raised doubts about the future of the administration’s policy. Moreover, the global
economic crisis beginning in 2008 exacerbated unemployment and underemployment around the
world and governments everywhere were pressured to reduce public debt by trimming public
services.
The primary approach to economic development in the new millennium was the
Millennium Development Goals (MDGs), announced by world leaders in 2000. The MDGs were
defined “top-down” without any input from civil society groups.31 World leaders pledged work
13
toward eight goals by 2015, including ending extreme poverty, achieving universal primary
education, achieving gender equality, controlling HIV/AIDS, reducing child mortality, and
improving maternal health.32 Some feminist groups were angered that issues of political and
economic empowerment were not addressed in the gender equality goal, which was
operationalized as eliminating gender disparities in education. They argued that education,
however important, was an unnecessarily and inappropriately narrow approach to gender
equality.
Feminists and other civil society leaders criticizing the MDGs have been divided on
whether to lobby for greater inclusiveness in the MDGs or to support grassroots efforts outside
of the MDG framework.33 Peggy Antrobus of DAWN labeled the MDGs, “A Major Distraction
Gimmick,” and went on to criticize
their inadequate targets and indicators; their restriction to indicators that are
quantifiable, when much of what is most important—such as Women’s Equality
and Empowerment—is not easily quantifiable; their omission of important Goals
and Targets, such as Violence against Women and Sexual and Reproductive
Rights; their silence on the context and institutional environment in which they
are to be met.34
Other feminist organizations emphasized strengthening the gender perspective of the
Millennium Development Goals. Feminist researchers joined the Millennium Project Task Force
to incorporate a gender perspective into the MDGs, and women’s groups formed a coalition to
incorporate HIV/AIDS into reproductive health services.35 An example of what feminists were
able to accomplish can be seen in Millennium Development Goal number 5. The original
formulation of “MDG 5 Improve Maternal Health” included no discussion of reproductive
14
health. After lobbying by NGOs, “Achieve universal access to reproductive health,” was added
in 2005 to “Reduce by three-quarters the maternal mortality rate,” as targets for MDG 5.36
Feminist groups have attempted to strengthen this commitment to reproductive health; for
example, in 2011 a coalition of feminist, development, and family planning organizations
submitted a statement to the UN Commission on the Status of Women, calling for prioritization
of funding for female condoms.37
During this same period, feminist groups and movements against HIV/AIDS became
more aligned. There was an absence of a gender analysis in the movement for essential
medicines in 2000-01, but after 2001, the South African Treatment Action Campaign began to
promote women’s empowerment with many of its leaders and the majority of members, who
were women. Global networks emerged to combine efforts against HIV/AIDS and for gender
equality. “Strategies from the South”, a coalition of 39 international and regional networks
formed in 2006 “dedicated to improving the HIV/AIDS response by international and regional
joint advocacy and by putting power, gender and sexuality issues back on the table within the
broader framework of human rights”.38 Strategies from the South illustrate an effort to link
together feminist activists with activists on HIV/AIDS. In 2010-2011, this South-South network
conducted a series of national workshops on holding national governments accountable for
progress in realizing the targets for MDGs 3, 5, and 6 (on gender equality, maternal mortality,
and HIV/AIDS). At the India meeting in 2011, feminist leaders illustrated the malaise of many
feminists in their critique of the MDGs. One woman stated, “Women’s movement and feminist
movement [sic] has not accepted the MDG framework as it was more welfare oriented and less
transformative in the way it was framed.”39 Another pointed out, “VAW [violence against
women] is a missing target and it has to be integrated into HIV and maternal health.”40
15
In retrospect, the debate over the Millennium Development Goals illustrates the longstanding tensions in feminist strategies toward social, economic, and political change. What can
be accomplished through the kinds of inclusionary strategies advocated by both liberal and
difference feminists, especially in circumstances requiring mobilization of a variety of social
groups? The efforts to mitigate the devastating effects of HIV/AIDs suggest that coalitionbuilding across social groups and nation-states can yield progress. Similarly, strategies of elite
access to institutional decision-making resulted in the modification of MDG 5 to include
reproductive health—a long-standing, shared feminist objective. None of these efforts, however,
resulted in any changes in the structures of globalization, particularly those sustaining the
neoliberal political economy. Although diversity feminists were quick to point out the defects in
government policies and international initiatives such as the MDGs, they lacked the resources to
transform those structures.
We assume, therefore, that feminist organizing is unlikely to alter the fundamental power
of contemporary neoliberalism. Consequently, we look for those arenas where feminists may use
a combination of inclusive and resistance strategies to “work” the existing structures—both those
of individual nation-states and those of international systems. Thus we see agency as contingent
on time, place, and political institutions. The two case studies that follow illustrate the variety of
circumstances in which collective agency may make a difference in people’s lives, even while
falling short of transformation.
Since the beginning of the twenty-first century, there have been several examples of
feminist engagement with the state in order to expand women’s access to health services and to
address issues of reproductive rights and gender-based violence (GBV). The first case depicts the
16
involvement of feminists in health sector reform in Chile. The second case illustrates feminist
organizing at the regional level in Africa.
Women and Health Sector Reform: Chile
Among states in the Global South, Chile was an early adopter of neoliberal reforms in
their system of health care.41 From the 1930s to the 1970s, for the mainly male formal sector
workforce, both white collar and blue collar, health care was a right they enjoyed that the state
provided. Most women gained access to health care as female dependents of male workers.
General Agusto Pinochet, coming to power in through a military coup in 1973, enacted health
reforms beginning in 1979, which introduced market principles, eliminated employer
contributions, and shifted some of the costs of health care to the individual. Formal sector
workers could purchase health insurance from newly created private providers or rely on state
services, which were decentralized to municipalities and regions. There was a 7 per cent
mandatory health insurance contribution on earnings. Low-income individuals could receive free
care in the state system, but were eligible for a limited range of services. The majority of the
population relied on state services, and both systems required client co-payments.
In addition to being partially privatized and decentralized, this two-tiered system was also
gendered, with women representing 34.4 percent of private insurance beneficiaries in 2001 and
rates for coverage 3.2 times higher than rates for men’s.42 Women could purchase slightly less
expensive plans (still twice the cost of men’s plans) that excluded childbirth (“no-uterus
plans”).43 The influence of the Catholic Church could be seen in the exclusion from coverage of
services involving sterilization or treatment for abortion complications. (In Chile and most other
Latin American countries, abortion was illegal and also relatively common.)
17
Chile underwent a democratic transition in 1990, and the coalition government
established a government agency for women’s issues, the National Women’s Service
(SERNAM). Chilean feminists were divided over the issue of working with the new government:
some did, others took a stance of complete autonomy, and still others recommended “conditional
collaboration from an independent base.”44 In 2000, then-President Lagos initiated a process of
health sector “re-reform,” and set up working groups and a technical commission to design a new
health care system.45
In the broad area of health, most Chilean feminists concentrated on reproductive rights
and gender-based violence. There were some feminists, who, along with organizations of nurses
and midwives, participated in the working group, “Citizenship and Health” and a special
commission on gender issues in health sector reform set up by the Health Minister, Michelle
Bachelet. The special commission issued a report in January 2001, addressing not only
reproductive rights and gender-based violence, but also the principles of “financing on the ability
to pay rather than risk, and shared responsibility for the costs of social reproduction.”46 The
participatory process of working groups was ended when Bachelet left the health ministry in
early 2002, and a technocratic interministerial commission drafted the new legislation without
considering the women’s proposals.
A new opportunity to engage with state officials opened for feminists in 2002, when the
Pan American Health Organization (PAHO) initiated a “Gender, Equity and Health Reform
Project” in Chile.47 PAHO is an international public health agency and the regional office for the
World Health Organization.48 In Chile, the project resulted in feminist organizations holding four
“Parliaments of Women for Health Reform” between 2002 and 2005, demanding greater
involvement of civil society in the health reform process, and the commissioning of research on
18
gender and health. The PAHO project included a “mapping exercise,” identifying for women’s
health advocates key entry points for civil-society groups engaging with the state and educating
state officials on the unpaid work women contributed in health care.
The “re-reform,” entitled the Plan for Universal Access with Explicit Guarantees or “Plan
AUGE,” was passed by the Chilean legislature in 2004 and came into force in 2005. Plan AUGE
provided a universal package of health services for Chilean citizens. Childbirth services were
included, ending the “no-uterus” plans.49 During the implementation phase of Plan AUGE,
feminists were able to create allies in the health ministry and SERNAM. An earlier SERNAM
minister had chosen not to get involved in the reform process, but a newly appointed minister
worked with feminists during the implementation process. Subsequently Plan AUGE began
covering mental health services and the effects of GBV. Through a gender mainstreaming
program, SERNAM was given the authority to evaluate the extent to which government agencies
had integrated gender into their policies. In 2004 SERNAM found that the health ministry did
not meet the standards of gender integration. The threat of budget cuts led to greater gender
responsiveness on the part of the ministry. Gender sensitivity training in the health ministry was
carried out through funding from PAHO.
The African Union (AU) Protocol to the African Charter on Human and Peoples’ Rights on
the Rights of Women in Africa
In addition to transnational and national level organizing, women’s networks at the
regional level have played an important role in placing women’s rights on the political agenda. In
Africa a regional advocacy network composed of regional and national women’s organizations
formulated a women’s rights protocol that addresses gender-based violence (GBV) and
reproductive rights, as well as economic and political rights, such as the right to inherit land. The
1981 African Charter on Human and Peoples’ Rights adopted by the Organization of African
19
Unity (OAU) did not address women’s rights in a substantial manner, and in 1995 a seminar
jointly sponsored by the African Commission on Human and People’s Rights and Women in
Law and Development in Africa (WiLDAF) discussed “the need to make the African Charter
‘more responsive’ to women’s rights”.50 They pointed out that the respect for traditional values
endorsed by the Charter could be used to justify certain forms of violence against women, such
as genital cutting. Over the next eight years, a regional advocacy network of women’s
organizations developed a draft protocol and lobbied national governments and the OAU/AU.51
The Women’s Rights Protocol was formally approved by the African heads of state in July 2003
and came into force in November 2005. In 2004 the women’s network set up the coalition,
Solidarity for African Women’s Human Rights (SOAWR) to direct the campaign for ratification
and implementation of the Women’s Protocol.
The Women’s Protocol prohibits all forms of violence against women, obliges states to
adopt necessary legislation for violence prevention and the punishment of perpetrators, and
commits governments to provide the resources necessary to implement these provisions.
Specifically prohibited and condemned are harmful practices such as genital cutting, forced
marriage, and victimizing women identified as “witches.”52 Reproductive rights are guaranteed
by the protocol, including contraception, protection against sexually transmitted diseases, such as
HIV/AIDS, and abortion in cases of sexual assault, incest and under conditions where the
pregnancy endangers mental or physical health. The Protocol is legally binding, but lacks
enforcement provisions. The coalition of women’s organizations was unable to gain support
from governments for a provision setting restrictions on polygamy but gained acceptance for a
statement that “monogamy is the preferred form of marriage.”53 The Protocol requires states to
include information on implementation in their biennial reports to the African Commission.
20
The Women’s Protocol has been an important resource for women’s rights in African
countries. It was referenced in a civil suit brought over a rape of a 13-year-old girl by her teacher
in Zambia. The judge quoted Article 4 of the Women’s Protocol that stated that “shall take
appropriate and effective measures to enact and enforce laws that prohibit all forms of violence
women including unwanted and forced sex,” awarded damages to the girl, and called on the
authorities to prosecute the teacher. In several countries provisions of the Women’s Protocol
have been translated into songs as an educational tool for women’s rights.54
Writing in November 2010, Mary Wandia, one of the co-founders of SOAWR and a
member of the African Feminist Forum Working Group, notes that there is much work yet to do
in putting into place national legislation to enforce the Women’s Protocol provisions. She
recommends that feminists form strategic partnerships with professional organizations of lawyers
and judges to increase understanding of the Protocol and litigation using it. To that end, SOAWR
created “A Guide to Using the Protocol on the Rights of Women in Africa for legal action.”55
WHAT DO THESE CASES TELL US?
At the national level, in the case of health sector reform in Chile, and at the regional
level, in the coalition of African women’s groups, formalized in SOAWR in 2004, feminists
have pursued women’s rights’ goals through inclusionary strategies of policy advocacy. In Chile
the result was improved health care coverage for women and in Africa the result was a formal
commitment by African leaders to take action against GBV. In both cases, the policies adopted
reflected greater support for feminist values on gender-based violence than on abortion. The
African Women’s Protocol allowed abortion under limited conditions, and Plan AUGE in Chile
did not address abortion, which remained illegal.
21
The two cases highlight the importance of cooperation between regional and national
levels for feminist policy advocacy. In Latin America PAHO’s Gender Equality and Health
Reform Project was an important resource for Chilean women activists. In Africa the regional
Women’s Protocol was used to enforce women’s rights in a Zambian court. In both cases
institutional transitions provided a favorable political opportunity structure for women’s rights
reforms. In Africa the transition from the OAU to the AU allowed for policy change and greater
input for civil society organizations. In Chile, President Lagos’s decision reform the health sector
provided an opportunity for women to lobby for policies meeting women’s needs.
The inclusionary strategies pursued in these two cases emphasized relationships between
feminist leaders and political elites and de-emphasized relationships between feminist leaders
and any kind of mass base of women. Adams and Kang note that alliances with government
leaders were crucial for the success of African women activists. For example, ties between
Michelle Bachelet and feminists, and relationships between feminists and health ministry
officials were important in Chile. In Chile the Women’s Parliaments strongly endorsed
reproductive rights and identified unpaid care work as a central gender issue, but those demands
went nowhere. There is a potential in Chile for women (and men) to claim their rights and file
judicial claims against health care providers who do not provide the health services guaranteed
by Plan AUGE, but studies show very few people know this.56 There is a similar potential for the
Women’s Protocol in Africa. Feminist educational campaigns at grassroots levels, if they
involved two-way communication, could make both Plan AUGE and the Women’s Protocol
more relevant to urban working class and rural women. In the end, however, this would require a
strategy of collective agency.
22
In the academic feminist literature on gender and health in Latin America, there are two
contending perspectives on how to make sense of the agency of women’s groups participating in
health sector reform since 2000 in Chile. One perspective is advanced by Christina Ewig, who
argues that the reconfigured neoliberal state offers both limits and opportunities to women’s
rights groups advocating gender equality in health.57 She notes that “organized feminists and
their allies in the state” were able to “socialize the costs of reproduction, in particular, biological
reproduction.”58 A second perspective is put forward by Jasmine Gideon, who characterizes the
participation of women’s groups with the neoliberal state as co-optation, as she argues that the
participation processes promote neoliberal values and have little impact on state decision making
on health care.59
The two perspectives are not mutually exclusive; rather they emphasize lighter and darker
shades of gray in assessing the implications of feminist inclusionary strategies with the
neoliberal state. We think that it is useful to take a “both-and” approach to the perspectives of
Ewig and Gideon. We appreciate that inclusionary strategies of participation with and in the
neoliberal state, on the one hand, have the potential to strengthen women’s voices and improve
outcomes for women in society by engaging with state institutions. On the other hand,
inclusionary strategies have the potential to weaken women’s voices and worsen outcomes for
women in society because most women are not organized or mobilized at the grassroots level.
Without this mobilization, there is no guarantee that gender-sensitive laws and policies will be
implemented. Additionally, without a mass base of women holding decision makers accountable,
a change in political players at the regional or national level may reverse these laws and policies.
The achievements of SOAWR in Africa can be assessed along similar lines. On the one
hand, the record on implementing and enforcing the Women’s Protocol by the 31 states that have
23
ratified it is mixed at best. On the other hand, the existence of the Women’s Protocol is a
resource that feminists in Africa can use in their campaigns for women’s rights and
empowerment. African governments, through the Women’s Protocol, have gone on the record in
support of women’s rights, and this has some effect on their actions. For example, in June 2011
African Heads of State called on the UN to adopt a resolution banning genital cutting worldwide.
For this resolution to be meaningful, however, local collective action campaigns are necessary.
Our position may thus be identified one of “strategic inclusion,” even as we heed the
voices of resistance. We recognize the dilemma summarized by Faranak Miraftab:
The global neoliberal policies of privatization and cost recovery in providing basic
services launch simultaneous and contradictory processes of selective inclusion and
exclusion… the promotion of local governments have [sic] brought large proportions of
women and disadvantaged people into the arena of formal politics through local councils.
But policies have, simultaneously, evicted a large proportion of poor households from
their shelters and have disconnected them from basic services…This selective opening of
some spaces and closing of others raises troubling discordances for feminists and
others…who support the participatory discourse of liberation and emancipation.60
In sharing the reality of “discordance,” we question whether the dilemma for feminist agency is
unique to the neoliberal world. Feminists have always had to challenge “the system”—whatever
system was in place. This was true for 19th and 20th century feminists in the United States and as
well for the lonely voices elsewhere and earlier.
In summary, we assume that neoliberal globalization is here to stay for the foreseeable
future, and that the preponderance of research suggests its negative implications for women,
notably in the arena of health. We also note, however, that other dimensions of globalization,
such as the transformation of communication technologies and the multiplication of transnational
organizations (both inter-governmental and non-governmental) offer tools and spaces for women
to assert collective agency. Likewise, it is clear—particularly in the Chilean case—that it does
make a difference who is in power, even in a neoliberal world. Perhaps this is a useful
24
observation, as elections unfurl in the United States, France, Myanmar, and elsewhere around the
world.
NOTES
1
Mary Dietz identifies difference, diversity, and deconstruction as three divergent perspectives in contemporary
feminist theory: “Current Controversies in Feminist Theory,” Annual Review of Political Science 6 (2003), p. 408.
2
Kathy Ferguson, “Interpretation and Genealogy in Feminism,” Signs: Journal of Women in Culture and Society 16
(1991), p. 322.
3
WHO, Preamble to the Constitution of the World Health Organization as adopted by the International Health
Conference, New York, 19 June - 22 July 1946; signed on 22 July 1946 by the representatives of 61 States (Official
Records of the World Health Organization, no. 2, p. 100); www.who.int/suggestions/faq/en/index.html
4
See Wendy Harcourt, Body Politics in Development: Critical Debates in Gender and Development (London: Zed
Books, 2009).
5
Estelle Freedman, No Turning Back: The History of Feminism and the Future of Women (New York: Ballantine
Books, 2002), p. 216.
6
New York: Simon and Shuster. See “Celebrate Forty Years of Activism,”
www.ourbodiesourselves.org/40thanniversary.asp.
7
Sheryl Burt Ruzek, The Women’s Health Movement: Feminist Alternatives to Medical Control (New York:
Praeger, 1978), p. 42.
8
Sara Evans, Tidal Wave: How Women Changed America at Century’s End (New York: Free Press, 2003), p. 47.
9
Jennifer Nelson, “All This that Happened to me Shouldn’t Happen to Nobody Else: Loretta Ross and the Women
of Color Reproductive Freedom Movement of the 1980s,” Journal of Women’s History 22: 3, (2010), p. 140.
10
Ibid., p. 141.
11
Kristin Bumiller, In an Abusive State: How Neoliberalism Appropriated the Feminist Movement Against Sexual
Violence( Durham, NC: Duke University Press, 2008), p. 10.
12
Sylvia Estada-Claudio, “The International Women and Health Meetings: Deploying Multiple Identities for
Political Sustainability,” in Solidarities beyond Borders: Transnationalizing Women’s Movements, ed. Pascale
Dufour, Dominique Masson and Dominique Caoutte (Vancouver: UBC Press, 2010), pp. 108-126.
13
Malthus was a 19th century English scholar who believed that population would rise faster than the food supply.
Neo-Malthusians identified overpopulation as the biggest threat to development. In contrast, feminists and many
Southern theorists believed that economic development was necessary to lower fertility and population control in
poor countries was being pushed the governments of rich nations instead of development. See Sonia Correa in
collaboration with Rebecca Reichman, Population and Reproductive Rights: Feminist Perspectives From the South
(New Delhi: Kali for Women, 1994), p. 1.
14
Report of the World Conference of the United Nations Decade for Women: Equality, Development and Peace,
held in Copenhagen from 14 to 30 July 1980, A/CONF.94/35:
www.5wwc.org/conference_background/1980_WCW.html; Report of the World Conference to Review and
25
Appraise the Achievements of the United Nations Decade for Women: Equality, Development and Peace, Nairobi,
15-26 July 1985, www.5wwc.org/downloads/Report_of_WCW-1985.pdf.
15
Mathieu Caulier, The population revolution: from population policies to reproductive health and women's rights
politics,” International Review of Sociology 20: 2 (2010), pp. 347-376.
16
Dr. Mahmoud Fatthala, an IWHC Board Member, quoted in ibid., p. 367.
17
Martha Chen, “Engendering World Conferences: The International Women's Movement and the United Nations,”
Third World Quarterly 16:3 (1995), pp. 477-493.
18
Excerpted in Correa, Population and Reproductive Rights, p. 66.
19
Betsy Hartman, Reproductive Rights & Wrongs: The Global Politics of Population Control, Revised edition.
(Boston: South End Press, 1999), p. 153.
20
Rosalind Petchesky, Global Prescriptions: Gendering Health and Human Rights (London: Zed Books, 2003), p.
36.
21
Cited in Jutta Joachim, Agenda Setting, the UN, and NGOs: Gender Violence and Reproductive Rights
(Washington, DC: Georgetown University Press, 2007), p. 116.
22
Ibid., p. 127
23
Ibid., p. 130.
24
Conservative delegations forced the deletion of any reference to sexual orientation, but feminists viewed the
wording that was adopted in Paragraph 96 as offering a foundation for future efforts to gain explicit recognition for
lesbian rights. See Shelagh Day, “Women’s Sexual Autonomy: Universality, Sexual Rights and Sexual Orientation
at the Beijing Conference,” Canadian Women’s Studies 16: 3 (1996).
25
Liz Kelly, “”Inside Outsiders:’ Mainstreaming Violence Against Women into Human Rights Discourse and
Practice,” International Feminist Journal of Politics 7:4 (2006), p. 484.
26
Nuket Kardam, “the Emerging Global Gender Equality Regime from Neoliberal and Constructivist Perspectives
in International Relations,” International Feminist Journal of Politics 6:4 (2004), p. 86.
Wendy Harcourt, “The Body Politic in Global Development Discourse,” in Women and the Politics of
Place (Bloomfield, CT: Kumarian Press, 2005); eds. Wendy Harcourt and Arturo Escobar, p. 45; Donna
F. Murdock, When women have Wings: Feminism & Development in Medellin, Colombia (Ann Arbor,
MI: University of Michigan Press, 2008), p. 35.
27
28
Amanda Gouws, “Changing Women’s Exclusion from Politics: Examples from Southern Africa,” African and
Asian Studies 7 (2008), pp. 537-563; Shireen Hassim, “Terms of Engagement: South African Challenges]” Feminist
Africa 4 (2005), www.feministafrica.org/index.php/terms-of-engagement.
29
Alvarez, Sonia E. (1999) ‘Advocating Feminism: The Latin American feminist NGO ‘‘boom’’’, International
Feminist Journal of Politics 1(2):181-209.
30
Andrew Merrindahl, “Women’s Movement Institutionalization: The Need for New Approaches,” Politics &
Gender 6: 4 (2010), p. 609.
31
Petchesky, Global Prescriptions, pp. 68-69.
26
32
UN, "We can end poverty by 2015 Millennium Development Goals www.un.org/millenniumgoals/index.shtml.
33
Patrick Bond, “Global Governance Campaigning and MDGs: from top-down to bottom-up anti-poverty work,”
Third World Quarterly 27:2 (2006), pp 339 – 354.
34
Ibid., p. 340.
35
Carol Barton, “Integrating Feminist Agendas: Gender Justice and Economic Justice,” Development 48:4, (2005),
pp. 75-84; Adrienne Germain, “Women’s Groups and Professional Organizations in Advocacy for Sexual and
Reproductive Health and Rights,” International Journal of Gynecology and Obstetrics 106 (2009), pp. 185-187.
36
K. S. Mohindra and Beatrice Nikiema, “Women’s Health in Developing Countries: Beyond an Investment,”
International Journal of Health Services 40:3 (2010), p. 559-560.
37
Statement Submitted by ActionAid et al to the Commission on the Status of Women, Fifty-fifth session, 22
February-4 March 2011,
http://daccess-ddsny.un.org/doc/UNDOC/GEN/N10/682/55/PDF/N1068255.pdf?OpenElement
38
Strategies from the South,
http://www.strategiesfromthesouth.org/whoweare.html?%3C%3Fphp%0D%0Aphpinfo%28%29%3B%0D%0A%3F
%3E=
39
Strategies from the South, Civil Society Meeting on MDGs 3, 5 and 6 & Cross Dialogue on MDGs 3, 5 and 6,
Feb. 14-15, 2011, pp. 10. http://strategiesfromthesouth.org/pdf/India-Final-Report.pdf.
40
Ibid., p. 14.
41
This section of the paper is based on the following sources: Christina Ewig, “Reproduction, Re-reform and the
Reconfigured State. Feminists and Neoliberal Health Reforms in Chile,” in Beyond States and Markets. The
Challenges of Social Reproduction, eds. Isabella Bakker and Rachel Silvery (London: Routledge, 2008), pp. 143158; Jasmine Gideon, “Integrating Gender Interests into Health Policy,” Development and Change 37: 2, (2006), pp.
329-352; Charles Dannreuther and Jasmine Gideon, “Entitled to Health? Social Protection in Chile’s Plan AUGE,
Development and Change 39: 5 (2008), pp. 845-864; Jasmine Gideon, “Consultation or Co-option? A Case Study
from the Chilean Health Sector,” Progress in Development Studies 5:3(2005), pp. 169-181.
42
Ewig, “Reproduction, Re-reform and the Reconfigured State,” pp. 148-149.
43
Ibid., p. 149.
44
Gideon, “Integrating Gender Interests,” p. 343.
45
“Re-reform” is the term used by Ewig.
46
Ewig, “Reproduction, Re-reform and the Reconfigured State,” p. 151.
47
Ibid., p. 152.
48
PAHO http://new.paho.org/hq/index.php?option=com_content&task=view&id=91&Itemid=220
49
Dannreuther and Gideon, “Entitled to Health,” p. 857.
50
Melinda Adams and Alice Kang “Regional Advocacy Networks and the Protocol on the Rights of Women in
Africa” Politics & Gender 3 (2007), p. 460.
51
In 2002 the African Union (AU) was formed as a successor organization to the Organization of African Unity.
27
52
Rose Gawaya and Rosemary Semafumu Mukasa, “The African Women’s Protocol: A New Dimension for
Women’s Rights in Africa,” Gender and Development 13:3, (2005), pp. 42-50. The Women’s Protocol is available
at www.achpr.org/english/women/protocolwomen.pdf.
53
Adams and Kang, “Regional Advocacy Networks,” p. 464.
54
Messain d”Almeida, “African Women’s Organizing for the Ratification and Implementation of the Maputo
Protocol,” AWID Friday File, November 11, 2011. http://awid.org/News-Analysis/Friday-Files/African-Women-sOrganizing-for-the-Ratification-and-Implementation-of-the-Maputo-Protocol
55
Equality Now, “A Guide to Using the Protocol on the Rights of Women in Africa for legal action.” 2011
www.soawr.org/resources/Manual_on_Protocol_on_Women_Rights_in_Africa.pdf.
56
Dannreuther and Gideon, “Entitled to Health?” p. 858.
57
Ewig, “Reproduction, Re-reform and the Reconfigured State”.
58
Ibid., p. 156.
59
Gideon, “Consultation or Co-option,” p. 169.
Faranak Miraftab, Wagadu, “Invited and Invented Spaces of Participation: Neoliberal Citizenship and
Feminists’ Expanded Notion of Politics.” 1: Spring 2004, at
http://appweb.cortland.edu/ojs/index.php/Wagadu/article/viewFile/378/719.
60
28