(Updated) 2015

STRUGGLING WITH THE STATE: RIGHTS-BASED GOVERNANCE OF REPRODUCTIVE HEALTH SERVICES IN PUNO, PERU by Jean Monica Samuel A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy Dalla Lana School of Public Health University of Toronto © Copyright by Jean Monica Samuel 2015 Struggling with the State: Rights-Based Governance of Reproductive Health Services in Puno, Peru Jeannie Samuel Doctor of Philosophy Dalla Lana School of Public Health University of Toronto 2015 Abstract This dissertation explores the complex process of how socially excluded women carry out rights- based governance in state-operated health facilities. It addresses a central tension: how can marginalized actors exercise a governance influence over institutions that have systemically excluded them? The study examines the efforts of a group of Quechua-speaking indigenous women in the southern Peruvian Andes who act as citizen monitors of their reproductive health services. In a country where profound inequalities are embedded in the health care system, the monitors (aided by a network of strategic allies) seek to combat abuse and strengthen health service provision. Key to their governance strategy is the use of a human rights-based approach to health, intended to influence monitors’ power by repositioning them as rights holders. Theoretically, the dissertation draws on feminist political economy to examine the emergence of reproductive health care as a site of struggle between civil society and the state in Puno, Peru since the 1990s. It examines the monitoring initiative in Puno as an example of ongoing struggles with the state for the provision of quality reproductive health care. Methodologically, it ii uses institutional ethnography to link the work of citizen monitors with broader social, political and economic forces that shape their governance efforts. The study’s findings suggest that human rights-based approaches can help monitors to exercise power in governance struggles. Citizen monitoring in Puno has produced some important gains, including curbing everyday injustices such as discriminatory treatment and illegal fees in health facilities. Monitors have been less effective at influencing other types of systemic problems, such as understaffing. The initiative has created opportunities for hands-on learning and the creation of new kinds of alliances. More broadly, the study suggests that rights-based governance can contribute to the democratization of reproductive health service delivery and the promotion of inclusive citizenship. iii Acknowledgments I am indebted to the many people who made this research project possible. First and foremost, I would like to express my sincere gratitude to all of the citizen monitors in Ayaviri and Azángaro who graciously agreed to share their stories with me, as well as all of the key informants in Ayaviri, Azángaro, the city of Puno, and Lima. Equally, I would like to thank CARE Peru, especially Ariel Frisancho in Lima, and Luz Estrada and Milagro in Puno for their generosity, and their willingness to facilitate entry into the project. I am also grateful to the many Peruvian scholars in Lima and Puno, including Jeanine Anderson, Carmen Yon, Ruth Iguiñiz, Rosa Mujica, Luperio Onofre, Meliton Lopez Paz, and Fermín Laqui Ramos, who took time to meet with me and discuss early ideas about this project. I was fortunate to have the guidance and support of an exceptional team of scholars at the Dalla Lana School of Public Health. Anne-Emanuelle Birn and Ted Myers, my co-supervisors, and my committee member, Lisa Forman, played a huge part in moving this project from a loose idea to completion. Anne-Emanuelle’s incredible breadth of knowledge, close attention to detail and encouragement to consider the big ideas helped me develop this project far beyond what I originally envisioned. Ted Myers’ willingness to share his deep research knowledge and experience together with his unflagging support helped me keep moving through the program when I was not always sure I still had the energy. Lisa Forman’s kind invitation to attend a research workshop she had co-organized in Lima with Ariel Frisancho while I happened to be the city in 2009 was the original catalyst for this research project. Her close reading of my work and her engaged guidance, especially related to health and human rights, played an important role in this work. I am grateful to all three of you. Doctoral studies are a long and sometimes arduous process. It would have been extremely isolating without the good friends I made along the way at the DLSPH. A huge thanks to Amrita Daftary, Krista Maxwell, Kimberly Gray, Franziska Satzinger, Tess Sheldon, Wendy McGuire, Laurie Corna, Sarah Steele, Catherine Maule, and Emma Richardson. Outside of DLSPH, thank you also to my dear friends who supported me through the project, especially Judith Pyke and Kelly Gallagher-Mackay. I’d also like to express my gratitude to two excellent scholars, Kathryn Church and in memory of Roxana Ng, both of who were pivotal in setting me on my academic journey and who were so supportive over the years. iv I thank my mother, Evelyn Samuel for her love and encouragement over the years, and my aunt, Jean Johnson, for the same. You are both wonderful role models. My gratitude also to the rest of my B.C. family and Toronto family. Finally, there are no fitting words to thank my partner, David Szablowski, and my sons, Kai Samuel-Szablowski and Nikko Szablowski. I am so lucky to share my life with the three of you. This project would not have been possible without the generous financial support from the Canadian Graduate Scholarship program of the Social Sciences and Humanities Research Council and from the University of Toronto’s Open Fellowship and the Hastings Memorial Fellowship. v Table of Contents Introduction: Addressing Reproductive Health Inequality in Andean Peru ……… 1 1.1 Conceptual Underpinnings: Inequality, Exclusion and Intersectionality in Peru…………………………….…………………………...…7 1.2 Inequality and Exclusion in the Peruvian Health System ……………………… 13 1.3 Challenging Inequalities in Reproductive Health Care: The Citizen Monitoring Initiative in Puno………………………………………...………… 21 1.4 Roadmap of the Thesis…………………………………………………..…… 32 Chapter 2: Theoretical Approach………..………………………………….……… 36 2.1 Introduction ………………………………………………….……………….… 36 2.2 Social Struggles over State Involvement in Social Reproduction …………..… 37 2.3 Governance and Power Relations in Struggles Over Women’s Reproductive Health Care …………………………………………………… 45 2.4 Conclusion ……………………………………………………………........ 53 Chapter 3: Research Methodology and Methods ……………………………… 54 3.1 Introduction ……………………………………………………………………. 54 3.2 Methodological Orientation: Institutional Ethnography………………….…… 56 3.3 Research Methods ……………………………..………………………..……… 61 3.4 Ethics Procedures ……………………………………………………………… 77 3.5 Limitations of the Study …………………………………………………..…… 80 Chapter 4: Intersecting Currents: Participation and Reproductive Health Care in Puno, 1990-2005……………………………………….…………… 83 4.1 Introduction ………………………………………………………………….… 83 4.2 Reproductive Health Care in Puno 1990-1993: A Quiet but Profound Crisis ……………………………….…………………. 87 4.3 A New Focus on Reproductive Health Care, 1994-2000 …………………….… 98 4.4 Participatory Engagement with the State, 2000-2005 ………………………… 115 4.5 Conclusion …………………………………………………………………..… 124 Chapter 5: Rights-Based Governance in Practice: Citizen Monitoring of Reproductive Health Services………………………………………..………………..… 129 5.1 Introduction ………………………………………………………….……..… 129 5.2 Development of the Citizen Monitoring Initiative …………………….……… 132 5.3 Framework for Organizing the Presentation of Findings ………………..…… 138 5.4 Dimensions of Governance: Ideas …………………………………………… 139 5.5 Dimensions of Governance: Daily Practices …………………………….…… 149 vi 5.6 Dimensions of Governance: Institutions …………………………………….… 175 5.7 Conclusion: Citizen Monitoring and the Global Crisis of Social Reproduction 187 Chapter 6: Addressing Everyday Injustices: the Potential and Limits of Citizen Monitoring ……………………………………………………………..….. 188 6.1 Introduction …..…………………………………………………..…………… 188 6.2 Struggling with the State through Rights-Based Governance: Emerging Themes …………………………………………………..………… 189 6.3 Citizen Monitoring in Puno and the Global Crisis of Social Reproduction …..……………………………………………………..… 204 6.4 Citizen Monitoring of Health Care in Puno: The Politics of Scaling Up ……………………………………..…………….. 212 6.5 Conclusion ………..……………………………………………………..…… 218 Chapter 7: Conclusion: Lessons Learned and Further Research......................... 220 7.1 Social Exclusion and Reproductive Health Care Delivery .………………….. 220 7.2 Addressing Embedded Inequalities: Insights from the Citizen Monitoring Initiative …..…………………………………………………....… 224 7.3 Democratizing Reproductive Health Care…………………………………….. 226 7.4 Areas for Further Research …………………………….…………………...… 228 7.5 Closing Reflections …………………………………………………………… 230 vii List of Appendices Appendix A: Interview Guide - Participant Interviews (English Version) Appendix B: Interview Guide - Participant Interviews (Spanish Version) Appendix C: Interview Guide – Key Informant Interviews (English Version) Appendix D: Interview Guide – Key Informant Interviews (Spanish Version) Appendix E: Informed Consent Letter - Participant Interviews Appendix F: Informed Consent Letter – Key Informant Interviews Appendix G: Informed Consent Letter – Key Informant Interviews (Spanish Version) Appendix H: Informed Consent Letter – Participant

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