In this book, Professor Garay explores why, since the late 1980s, many governments in Latin America have redesigned social welfare policies to incorporate outsiders, defined as persons who lack social insurance. The social welfare policies on which the study focuses are income support, health care, and pensions. A distinctive feature of the newly redesigned social welfare policies is their nondiscretionary character. Unlike many previous social welfare policies in Latin America, recent reforms to health care, pension, and income support policies have been engineered in ways that make it harder for incumbents to grant or withhold benefits to serve their electoral or personal interests. One reason for this change involves transitions from authoritarian rule and the consolidation of democracy. As democracy in the region has widened and deepened, opposition parties and social movements have been able to exert more pressure for nondiscretionary policies. Incumbents, meanwhile, have become increasingly averse to being accused of clientelistic practices.
An introductory chapter on the political incorporation of outsiders is followed by a theoretical chapter on social welfare policymaking in Latin America; a descriptive-historical chapter introducing the four main case studies; one chapter each on the political determinants of social welfare policy expansion to outsiders in Brazil, Argentina, Mexico, and Chile; and a concluding chapter summarizing the argument and applying the findings of the previous chapters to the shadow cases of Peru, Venezuela, Uruguay, and South Africa.
In each of the four countries on which the analysis focuses, the study finds that electoral competition for outsiders encouraged the redesign of social welfare policies in favor of the previously excluded. Less universally present was the mobilization of social movement coalitions, which helps to explain why some governments provided “inclusive” social welfare policies whereas others supplied only “restrictive” reforms.
In Brazil (starting with Itamar Franco’s government in 1992) and Argentina (starting with Eduardo Duhalde’s government in 2002), governments provided inclusive social welfare policies featuring universal or near-universal coverage, generous benefits, and the participation of social organizations in policy implementation. These inclusive policies were designed and implemented in response to popular mobilization that threatened the incumbent government’s popularity or even its hold on power. In Mexico (starting with Vicente Fox’s government in 2000) and Chile (starting with Ricardo Lagos’s government in 2004), where social movement coalitions did not mobilize, governments had to negotiate social welfare policy reforms with conservative legislators, resulting in restrictive social welfare policies confined to more limited coverage, stingier benefits, and little participation of social organizations in policy implementation.
The study finds, in short, that social welfare policy is reformed in a pro-poor direction when presidents find themselves electorally vulnerable to challengers who seek or appear to seek the votes of outsiders. Social welfare policy that is reformed in a pro-poor direction, in turn, tends to become more inclusive when organizations representing the very poor mobilize for wider coverage, higher benefits, and popular participation in policy implementation. In the absence of such mobilization, advocates of pro-poor reforms in health care, pensions, and cash transfers have more difficulty overcoming resistance from entrenched interests, including conservatives in the national legislature, business organizations, subnational authorities, and labor union leaders with a stake in the existing system of social provision.
In each of the four country chapters, the exposition hews closely to the main argument about the impact of electoral competition and social mobilization on the degree of social welfare policy reform. Careful attention is devoted to tracing specific causal processes linking politics to policy. Each chapter has a similar structure, but treatment of individual governments within each chapter tends to highlight particular social welfare policies.
In Argentina, for example, the discussion of health care focuses mainly on the Plan Remediar (enacted by the Duhalde administration in 2002, providing free medications for those who utilize public health centers) and the Plan Nacer (enacted in 2005, expanding access to maternal and infant health care). In Brazil, by contrast, the discussion of health care focuses heavily on the implementation of the Unified Health System from 1993 on. The Programa (now Estratégia) Saúde da Família (enacted in 1994, delivering primary health services to about two-thirds of the population) is mentioned (143–44), but is analyzed less thoroughly than Argentina’s Plan Nacer.
Each country chapter also contrasts the book’s electoral competition and social mobilization explanation with three plausible alternative explanations for the degree of social welfare policy expansion to outsiders. These alternative explanations focus, respectively, on resource availability (the commodity boom of the early and mid- 2000s), international influences (learning from foreign models, pressure from international financial institutions), and partisanship (the “return of the left” in Latin America after an era of free market reform).
The book raises intriguing questions about the relationship between social welfare policy and well-being. Among the eight focus and shadow cases, Peru “stands out for the absence of meaningful social policy innovations” (316). Health care is cited as a partial exception to this generalization, but Fujimori’s Basic Health Care for All program (1994) is characterized as “minor,” and his maternal and infant health insurance scheme (1998) is regarded as having had “negligible” coverage and funding. Even Toledo’s Integrated Health Insurance program (2001), by the end of its first decade of operation, had reached only 40 to 50 percent of the outsider population.
On the whole, Professor Garay concludes, Peru was at best a case of “restrictive” social welfare policy reform (320), like Mexico or Chile, rather than like Argentina or Brazil. Despite these tepid health care reforms, infant mortality in Peru fell from 56 per 1,000 live births in 1990 to 13 per 1,000 in 2015. This 77 percent decline of infant mortality in Peru over the 25-year period was the steepest among the 20 countries of Latin America, steeper than the declines in the “inclusive” cases (Brazil 71 percent, Argentina 55 percent), in the other “restrictive” cases (Mexico 70 percent, Chile 56 percent), and in cases with higher initial levels of infant mortality (Bolivia, 64 percent; Guatemala, 59 percent; Haiti, 48 percent). More research is needed not only on how politics affects policies but also on how policies affect well-being. Such research would have to explore the causes and consequences of a wider range of social welfare policies (nutrition, education, family planning, housing, and the provision of safe water, sanitation, and electricity) and would have to tackle the “demand side” (the take-up of cash transfers and services by those who are formally eligible for them, which is often surprisingly low), as well as the “supply side” on which most analyses have concentrated.
Scope of coverage, generosity of benefits, and degree of participation of organizations representing the previously excluded are operationalized rigorously in useful appendixes. The analysis draws on qualitative comparisons, carefully selected descriptive statistics, government documents, high-quality secondary sources, and personal interviews with 245 informants. The writing is lucid and unpretentious, and the tables, charts, and diagrams are pertinent and well designed.
Social Policy Expansion in Latin America illuminates forces and conditions that shape and constrain social welfare reforms that benefit the previously excluded, helping to identify critical points at which policymakers can design and implement programs to promote decent standards of living, the acquisition of knowledge, and long and healthy lives. Scholars interested in the political determinants of social welfare policies will find the book rigorous and intriguing; graduate and advanced undergraduate students interested in Latin American policymaking will find it readable and thought-provoking; and policymakers in Latin America will find it helpful in understanding the opportunities and constraints that their predecessors have faced.
