Doctoral student Alissa Bernstein (University of California, Berkeley), with the supervision of Dr. Charles Briggs, will undertake research on the relationship between the making of public policy and its implementation. While the two processes generally are regarded as distinct phases, Bernstein will explore the possibility that they may be closely intertwined, informing each other as a circuit. This study will offer insights into how new policy ideas emerge and how they may alter entrenched practices and improve outcomes.
To investigate these questions, Bernstein will conduct a twelve-month study of the planning, making, revising, and implementing of major health reform policy in Bolivia, Salud Familiar Communitaria Intercultural (SAFCI). The researcher will examine how this policy is shaped and possibly changed as it circulates within different sectors of the Bolivian health care system. Data will be gathered at two public clinics and two worker health insurance clinics. The researcher will employ a variety of social science methodologies, including ethnographic interviews, participant observation, and epidemiological analysis. As an institutional ethnography, the research will be carried out in offices, meetings, conferences, workshops, and clinics where policies may be generated, debated, circulated, revised, and implemented.The overarching research questions are: (1) Can the reform policy-making process be truly collaborative? If so, who is involved and how does this approach impact the form of policy that emerges? (2) How does the context of a particular sector or community shape the ways that policy is interpreted, rewritten, and implemented for use? (3) What are some of the measurable outcomes of reform policy implementation and what areas are facing problems or resistance?
In addition to contributing to social science theory, findings from this research will have practical application, in the health field and beyond. This study is innovative in that it looks not just at policy outcomes, but also takes an original approach to understanding processes of policy formation. Though often marginalized in these debates about public policy, many observers argue that Latin America has recently generated some of the most creative ideas and undertaken significant pervasive transformations, which makes Bolivia an ideal site for pursuing these questions. Funding this research also supports the education of a graduate student.
While scholars in the anthropology of public policy have generally viewed the making and implementation of health policies as distinct phases, my research in Bolivia argued that these processes were closely intertwined in the form of a circuit. The goal of my twelve-month study was to examine the planning, designing, writing, revising, and implementing of the current major health reform policy in Bolivia, Salud Familiar Communitaria Intercultural (SAFCI). I also examined the ways this policy was reconfigured as it circulated in order to fit within different sectors of the Bolivian health care system and different areas of the country. I asked: (1) Was the health reform policy-making process collaborative and how was collaboration understood? If so, who is involved and how does this approach impact the form of policy that emerges? (2) How does the context of a particular sector or community shape the ways that policy is interpreted, reconfigured, and implemented? My research was divided into four phases. In Phase One I examined health reform as a national legal process, interviewing members of the policymaking team and others who participated in the process of designing the policy. I found that the policymaking process involved qualitative data from rural health programs around the country and a series of participative meetings in which the premises of the health policy were negotiated, drawing from data within Bolivia and larger models, such as Latin American Social Medicine. In Phase Two I conducted ethnographic research in both rural and urban health clinics in the public and social security sectors to examine the ways these clinics were understanding, incorporating, and circulating the new health policy. Phase Three involved research in rural areas of Bolivia that were either used as models for aspects of the health policy design, or that were involved in implementing and circulating the policy. Phase Four, data analysis, is currently in process. I found that policymakers, indigenous populations, NGOs, and social organizations came together to build national health policy, but that collaboration and participation were often understood differently by differently situated actors. I also looked downstream to see how policymaking approaches influenced how these policies were implemented, primarily at the municipal and local levels, and questioned whether they reached targeted populations. I also found that the Bolivian health officials engaged in qualitative data gathering to revise and continue to improve the national health policy. Health policy in Bolivia was flexible to the needs of particular groups, specifically those that were historically underserved and marginalized, and emphasized local and municipal needs. My research led me to conclude that in order to build lasting and effective public health policy, the process of policy-making must incorporate needs and perspectives from different scales of society. Local perspectives can work in conjunction with distinct theoretical approaches and epidemiological data about population health. The findings from this study have the potential to impact the disciplines of anthropology, public health and public policy. I argue that understanding both upstream policy-making processes and downstream approaches to policy-implementation are essential aspects in the process of building relevant and effective national health policies aimed towards underserved populations. These disciplines can be brought together to solve public health problems. For example, ethnographic data about policymaking and implementation can augment epidemiological data. It can also help explain how health indicators are created and defined and how they might be used in constructing health policies that take into account social and economic inequities. Finally, the Society for Medical Anthropology (2011) released a statement about the role that medical anthropologists can play in the shifting global health environment. My project responds to their suggestion, "By illuminating the social processes, power relations, development culture, and discourses that drive the global health enterprise, medical anthropologists can contribute in valuable ways to health diplomacy and advocacy efforts". A more concerted focus on the development of health policy is an important topic in medical anthropology. For medical anthropologists to contribute we need to know how policies are made, what gets left out in the process, and what makes them succeed or fail in implementation. During a time when deep problems have motivated health reform efforts in the United States and elsewhere, scholars and policymakers are searching for innovative, effective approaches. Though often marginalized in these debates, many observers argue that Latin America has recently generated some of the most creative ideas and undertaken significant pervasive transformations. Bolivia is a striking example of this broader phenomenon and an important case in which cultural differences are placed at the center in order to reduce health inequities. My study offers insights into how new ideas about health and care emerge and how they might transform entrenched practices and improve health outcomes. This study demonstrates that health reform in Latin America can offer important insights into transformations that are being undertaken around the world.
