Abstract
Achieving Access: Professional Movements and the Politics of Health Universalism is a book that will be of considerable interest to sociologists of health and medicine, comparative-historical sociologists, political sociologists, and global and transnational sociologists of development (among others). Through a comparative case-study analysis of contemporary change in two health policy sectors within three theoretically relevant countries of the global South, author Joseph Harris asks what “explains the difference between the laggard response to expanding access to health care and HIV/AIDS medicine in South Africa and the pioneering responses of Thailand and Brazil” (p. 6).
For Harris and a growing group of like-minded social scientists, explaining such differences matters because contemporary public health policies of these kinds have likely saved millions of lives globally. Further, such improvements in access to health care and life-saving HIV/AIDS medications occurred “in countries that experts had generally deemed too poor and resource-constrained to support such programs” and in an era of widespread neoliberal policy adoption during which “health care costs were exploding and medical expertise was scarce” (p. 2). The book’s project of explaining how and why Thailand and Brazil overcame such adverse circumstance to forge more inclusive public health policies—while South Africa did not—also aims to deliver an important theoretical payoff. Namely, it seeks to address how democracy interfaces with a poorly understood set of politically engaged civil society actors, who may well exert policymaking influence beyond just the public health sectors of these countries.
Clearly articulated in its introduction and thoughtfully expanded upon in the conclusion, the book traces variation in access to public health care and life-saving anti-retroviral drugs (ARVs) across its three country cases to “the role that heightened political competition in the wake of democratic transition plays in providing openings for well-organized professional movements to influence the policymaking process” (p. 8). Echoing widespread agreements among many sociologists and political scientists, one piece of this argument holds that competition between political parties rendered their eventual leaders in national government more receptive to policy innovations in the health care and HIV/AIDS sectors of Thailand and Brazil. Conversely, the relative absence of such competition made the embrace of such reforms far less likely in South Africa by generating far fewer political opportunities for those advocating such shifts.
The book’s central argument thus reflects conventional wisdom that newly competitive political environments in Brazil and Thailand during the 1980s forced multiple parties to struggle with one another for control of the highest national political offices, all in ways that made them more receptive to certain segments of civil society seeking health sector reform. An anti-competitive pattern of one-party dominance by South Africa’s African National Congress (ANC) left its political leaders less receptive to such actors and their health policy-making overtures, yielding far narrower access to health care and ARVs.
More thoroughly embedded in a sociology of civil society and democracy than recent explorations of social policy expansion globally, the book’s argument also holds that competitive electoral environments hardly ensured the rise of innovative health care and HIV/AIDS policies in Thailand and Brazil. Rather, political competition allowed for a more surprising set of political dynamics to occur, the most important of which was the policy-making influence of what he and other scholars have termed “professional movements” in recent years. In Harris’s particular formulation, this refers to “a category of collective action that occupies an in-between space among the broader categories of the professions and social movements, referring to social movements that operate within and sometimes against broader professions” (p. 25).
Chapter One conceptualizes these actors in greater detail and juxtaposes them against mere technical experts and professionals, while also differentiating them from more commonly theorized protagonists of democratization and the welfare state such as ruling left parties and labor unions. Not to be confused with professionally run social movements, professional movements differ from epistemic communities of scientists whose prime motivations for policy advocacy flow from scientifically verified knowledge. Such movements are instead “comprised of medical and legal experts who advocate for health care rights on behalf of the poor and disenfranchised in the face of well-established professional and corporate interests” (p. 20).
The book relies heavily on this conceptualization to account for several counterintuitive assertions, including that “democratization empowers elites; that those responsible for advancing major social policies are frequently those least in need; and that professional movements achieve reform by virtue of privileged positions in the state, knowledge, and networks that are largely inaccessible to the common man” (p. 9). No doubt constrained by space and its laudable effort to engage audiences beyond sociology, the book’s conceptualization of professional movements stops short of engaging still other theorized protagonists of more inclusive social policy-making such as elected women representatives. It also differs sharply from an alternative conceptualization of Brazilian public health activists as a “pragmatist public,” whose odd mixture of ideological fervor and incrementalism is argued to have fueled their political efficacy (Gibson 2019). Still, the book’s way of thinking about such actors is provocative and—especially given the considerable explanatory tasks that the book assigns to this concept—more than merits the considerable space this notion absorbs in the introduction and conclusion.
The book’s empirical case studies unfold in two parts. The three chapters of Part 1 (Chapters 2, 3, and 4) successively address changing “access to health care” in Thailand, Brazil, and South Africa, while another three chapters in Part 2 (Chapters 5, 6, and 7) neatly follow the same pattern in addressing shifts of “access to AIDS medicine” within each country. The book’s case-study analyses are most detailed and compelling in the discussions of Thailand in Chapters Two and Five. These chapters draw on original fieldwork to convincingly argue that neither health care nor pharmaceutical reforms would have been likely to unfold as they did in Thailand without the sustained mobilizations of domestic physicians in the Rural Doctors’ Society, a collective of legally knowledgeable pharmacists in the Drug Study Group, and other related organizations. Harnessing qualitative accounts of Thai doctors and state officials in the national Ministry of Public Health, Chapter Two convincingly shows that the country’s most important health care reforms were not traceable to a mass-based domestic health movement, which was nearly absent in Thailand. Rather, physicians in the country’s Rural Doctors’ Society leveraged their privileged positions within the ministry to establish a remarkably inclusive health care reform that both the country’s broader medical profession and conservative international organizations had resisted.
Documenting a parallel process at work in the Thai pharmaceutical sector, Chapter Five traces how a collective of legally trained pharmacists and doctors drew on their knowledge of intellectual property laws surrounding ARVs to work alongside global actors and the broader AIDS movement in making such drugs more publicly accessible. On the one hand, these accounts may stretch the “movement” half of the professional movement concept somewhat far for readers hoping to be shown that these professionals’ ideological motivations, meaning-making processes, and social movement identities mattered as much for their policy-making efficacy as their sheer expertise, career networks, and appointment to state positions. Yet, such limitations are less critical for validating the chapters’ persuasive claims about the roots of policy change in Thailand’s HIV/AIDS sector. In part, this is because the sector differs considerably from the public health service sector (see Chapters 2, 3, and 4), where nitty-gritty, decades-long processes of hiring and retaining the well-trained medical professionals needed to reliably and broadly deliver health services can severely test the motivation and commitment of even the most dedicated bureaucrats and politicians over time. By contrast to the primary health care sector, expanded access to AIDS medicines could be achieved swiftly and with relative ease through top-down policy-making decisions made in the national health ministry. The chapter’s extensive account of this process leaves little doubt that domestic physicians, pharmacists, and legal experts mattered at least as much or more than any other single factor for the most important HIV/AIDS-related pharmaceutical reforms in Thailand.
Though not based on the same kind of rich primary data used in the Thailand chapters, Chapters Three and Six use secondary sources to articulate how national-level health policy-making contributed to expanded care and ARV access in post-1985 Brazil. These chapters converge with previous research on these topics in showing that legally and politically savvy medical professionals, especially “sanitaristas” from the domestic Sanitarist Movement, seized new political opportunities after the 1985 departure of Brazil’s military regime from national power to advance meaningful policy reforms in both sectors. On the most basic level, Brazil’s newly competitive environment made national politicians from a variety of parties more receptive to the policy-making overtures of these activists, whose reform proposals became useful fodder for the cutthroat party politics of voter mobilization.
The case-study analysis in Chapter Three begins the book’s ambitious, cross-country sweep in earnest with a glimpse into contemporary Brazil’s national-level politics of public health care expansion. The chapter aims to tell what may be a more surprising story than other chapters’ account of how high-prestige Thai health professionals helped expand access to care in a more centralized polity amid repeated backslides into authoritarianism that permitted them a more sustained audience with political elites than mass health movements could muster. Though not unusual for a cross-national study, the chapter nevertheless minimizes clear differences in Brazil that mattered for the outcome of expanded access far more than its core argument about the knowledge, networks, and occupation of national positions by sanitaristas can fully accommodate. Efforts to expand access to health care in Brazil differed from those in Thailand in that Brazil’s sanitaristas had to contend with a comparatively massive population and geographic size and an increasingly decentralized public health state that precluded Thai-style centralized administration. An additional, quite salient difference that the chapter largely elides is how Brazil’s far deeper experience with democracy complicated ongoing policy-making influence for all actors, including sanitaristas, by generating an increasingly crowded state-society interface in both the local and national politics of public health policy-making.
Such under-emphasized differences sit uneasily with Chapter Three’s ultimate explanations for change, particularly since the chapter emphasizes expansion in a subset of Brazil’s public health system—the primary public care sector—whose management became a legal responsibility of Brazil’s approximately 6,000 municipal governments early in the period examined. More highly decentralized than even the Brazilian HIV/AIDS sector addressed in Chapter Six, administration of the primary care sector has in fact relied predominantly on municipalities to finance, hire, and retain the public health professionals who actually deliver services; and this localized process has not always mapped neatly onto the national-level political dynamics featured in the chapter.
Alongside formidable capitalist interests in the private health care and insurance industries, and amid Brazil’s famously vibrant local democracy of myriad organized voices contending to influence the subnational formulation and implementation of health policies, such idiosyncrasies complicate the chapter’s effort to explain how and why sanitaristas achieved such remarkable influence at the crowded interface of state-society health politics. Indeed, the book’s emphasis on the elite pedigrees and technical knowledge of well-connected health professionals tells only one small part of their story and may leave some readers wondering how and why they—and not their equally connected and knowledgeable but better-funded counterparts in the medical profession who opposed expansion—gained access to relevant state positions and became influential in health policy-making at all. Its argument also diverges from other explanatory approaches that emphasize localized sources of change in primary public health care. Still, readers need not be shown these other dimensions of the Brazilian case to be convinced of the overall project’s less expansive claim that these actors mattered for nationwide health policy-making in ways that were unimaginable in South Africa.
Chapter Six argues that the knowledge, networks, and especially the legal expertise of Brazilian health activists also mattered greatly for broadening access to ARV medications in the country. More susceptible to pharmaceutical manufacturers based in the global North and an intellectual property rights regime that they largely engineered, Brazilian policy-making around ARVs bucked global trends during the 1990s by responding to the policy-making overtures of legally knowledgeable, domestic health activists. Though less nuanced than the notion of the “activist state” crystallized in João Biehl’s (2004) accounts of this process, the chapter describes how activists’ familiarity with the regime’s idiosyncrasies bred actionable strategies that elected leaders embraced in their politically motivated efforts to accommodate the special virtues of life-saving ARVs. The chapter argues that these activists’ ken in the global and domestic law of ARV regulation and production helped them devise and rally political support for breaking patents and other proactive, national moves. As such, it offers an instructive counterpoint to more conventional, political science explanations of Brazil’s HIV/AIDS reforms that typically assign far greater causal weight to ruling politicians for having improved access to ARVs. Though somewhat leaner in their empirical foundations, both Brazil chapters are well written and refreshingly accessible to non-experts.
While they face less daunting explanatory tasks than the book’s other empirical chapters, Chapters Four and Seven clearly validate the book’s overarching claim that a relative absence of political competition in South Africa largely precluded the crystallization of more effective health care and HIV/AIDS policies. They draw on both primary and secondary sources to convincingly show that the ANC’s dominance of national politics likely prevented its most important leaders from developing appetites for meaningful reform of public health care and HIV/AIDS policies.
Chapter Four tells the painful and instructive story of how the ANC, facing no credible political competitors for over two decades following its decisive electoral victory of 1994, instituted a National Health Insurance system that existed in little more than name only. Lacking in political incentives to undertake the difficult and unglamorous work of sufficiently staffing a considerable network of health facilities that its governments built through lucrative and often poorly administered construction contracts to private contractors, party leaders proved wholly unresponsive to the reformist overtures of both domestic and international health activists. Building on a deep, existing literature on South Africa’s notoriously ineffective HIV/AIDS policies, Chapter Seven similarly traces the ANC’s struggles in this sector to a lack of political competition and resulting unwillingness to engage activists with otherwise promising ARV-related policy proposals.
Alongside its many strengths, Achieving Access mirrors all books in exhibiting shortcomings. Understandable for a project with cross-national ambitions, the contextual blinders it applies when examining individual countries may nevertheless leave some readers questioning the internal validity of key findings on which the book’s most sweeping theoretical claims rest. The uneven depth of the book’s analysis—with only one positive country case of expanded access (Thailand) drawing on fieldwork and primary data—could precipitate criticisms that the scope of its argument is more constrained to the Thai case than it claims. By drawing heavily on a slice of the nationally focused, secondary source literature about public health politics in Brazil (its only other positive case of a country with meaningful policy change), the book commits the same oversight as the existing accounts it draws on: namely, it foregoes serious consideration of subnational politics in the world’s fourth largest democracy.
In addressing a country where high decentralization of the primary health sector lends subnational politics an outsized influence, inferential obstacles arise when relying on blunt instruments such as the reconsidering of work from a secondary literature on Brazil that has generally overlooked whether, how, and when local governments can matter for changing public health policies and their implementation. The book correspondingly misses how Brazil’s nationwide transformation in access to primary health care owed much to subnational factors, especially a curious fusion of ideological motivation and pragmatism that fueled locally mobilized sanitaristas in their efforts to create and wield new municipal democratic offices in the public health sector. Lacking the sorts of primary sources that are better equipped for unpacking such actors’ motivations and considering the potential salience of their social movement lineages, a key part of the book thus stands upon an empirical foundation that some may find too shaky for shedding new light on sources of historic change in Brazilian public health policy.
These and other limitations may also complicate prospects for the book’s intended theoretical interventions. Perhaps by pressing to differentiate its approach from others that examine identity movements within the professions, the book’s actual analysis of professional movements most highlights their expertise, social networks, and occupation of state positions. The resulting de-emphasis on how ideology and meaning-making—defining features of all social movements—operate for such actors may ultimately disappoint readers hoping for more robust explorations of how and why “the moral foundations that motivate participants in professional movements” (pp. 26–27) can matter for their policy-making influence. Indeed, the book’s limited exploration of how ideology and identity mattered for the many discrete interventions of the Thai doctors—and its lack of the primary data needed to more fully assess such dynamics for Brazil’s sanitaristas—may inadvertently revive a question it hopes to dispel regarding what, if anything, such actors have to do with social movements.
To be sure, readers who bracket such limitations in the movement half of the “professional movements” concept and embrace the book’s resulting analytic focus on specialized knowledge can still be convinced of the more modest claim that meaningful collaborations between health professionals and ruling politicians occurred amid democratization and mattered greatly for national public health policies in both countries. But such arguments begin to approximate those of James McGuire (2010) and other political scientists like Tulia Falleti (2010) and Candelaria Garay (2016) perhaps more than is beneficial for the book’s intended conceptual contribution. As a result, the theoretical bridge that it aims to construct between the professions and social movements may run the risk of not quite spanning the divide for some readers.
In sum, Achieving Access is an ambitious book whose limitations are largely a product of its many strengths. It is especially notable for its broad scope in addressing the social roots of continuity and historic change in two health policy sectors across three different countries in as many different continents. Thoughtfully extending this outward gaze, the book’s conclusion usefully explores the prospects and durability of professional movements in these countries and beyond. Here, it strikes a refreshingly optimistic tone regarding their prospects for efficacy around the world, while noting the scarcity of other global examples beyond the health and pharmaceutical sectors. Along the way, it also helpfully contrasts its stories of health policy transformation in Thailand and Brazil with the experience of the United States, where organized collectives of health professionals long militated against similar expansions in access to public health care. As a comparative case-study project of broad cross-national scope, the overall project skillfully integrates comparisons and contrasts of national-level politics in countries whose distinct colonial and modern histories may well have discouraged less courageous analysts. As such, the book offers engaging and thoughtful insights that will be of interest not just to sociologists but also to scholars and students of the professions, public health and social policy-making more generally.