Anthropology of Health Policy

by

Jessica Mulligan, Ingrid Brugnoli-Ensin

• LAST REVIEWED: 27 March 2019
• LAST MODIFIED: 27 March 2019
• DOI: 10.1093/obo/9780199766567-0210

Introduction

Given its holistic orientation, most medical anthropology touches upon politics: how power organizes systems of healing; how social suffering—usually political in origin—manifests in bodily symptoms; how some bodies are valued and optimized while others are controlled; and how dominant systems of meaning make legitimate some illness experiences and render others unknowable and invalid. The major theoretical traditions of the field—structural functionalism; phenomenology; Foucauldian biopolitics; critical medical anthropology; feminist epistemologies; and science and technology studies—have long grappled with power and politics. Fewer medical anthropologists, however, have studied policy directly. Policy is usually taken to mean guidelines for action. Policies can be official as of a government or more informal and practical. The organization of health systems and the provision of care is guided by policy decisions and non-decisions. Some of the works collected here take the more indirect approach to studying policy by exploring how politics impact health systems and the experiences of patients and healers. But the majority of the works study policy directly, either as a process that anthropology can help to better apprehend or as a domain of action that would benefit from anthropological insights. Anthropologists have productively studied all phases of the policy process from agenda setting, to policy formation, implementation, and assessment. Since all policies are health policies in the sense that they have potential health impacts, the possibilities for studying health policies anthropologically are practically endless. However, we have narrowed the field by concentrating on the major themes and trends in the literature: health reform and the marketization of care; immigration policy and health; race, indigeneity, and decolonizing health; pharmaceutical policy; governance and global health; reproduction and women’s health; and public health policy. We have opted for a thematic rather than a theoretical organization, so readers will find a variety of theoretical orientations including applied approaches in each of the sections.

General Overviews

Policy was an early concern of medical anthropologists, but it did not assume a central role in the field until more recently. As Eisenburg 2011 describes, a focus on culture and health system planning in the 1970s shifted to a more critical assessment of power in medical anthropology in the 1980s. Gruenbaum 1981 argued forcefully for an approach to policy that incorporated the state, colonialism, and class conflict into understanding the structural forces that produce health and illness. In the mid-1980s, applied anthropologists such as Carole Hill (Hill 1986) advocated for approaches to policy that were attentive to cultural difference, especially in the design and implementation of health programs. By the end of the 20th century, the impact of turning away from Primary Care for All policies and the embrace of structural adjustment was clear. Kim, et al. 2000 argued that economic progress was not reaching the poorest, whose health status had actually gotten worse. Growth did not inevitably lead to improved living conditions for all; instead, corporate-led growth led to growing inequality. Foreshadowing the current concern with metrics in global health, Kim and colleagues stressed the importance of not assessing the success of global health by looking only at aggregate indicators since these can mask inequality across and between regions. Castro and Singer 2004 analyzed the ways in which health policies actually contributed to worsening health outcomes, rather than to lessening inequality and strengthening health systems. Rylko Bauer and Farmer 2002, an influential call to study the marketization of medicine, has now largely been heeded with a rich body of medical anthropology looking at structural adjustment, insurance, the commodification of health care, and market ideologies. Pfeiffer and Chapman 2010 offers a compelling synthesis of the evidence against structural adjustment policies. Failures of international projects to improve the human condition through humanitarian efforts, economic development, and science, prompted anthropologists to critically assess humanitarian projects and policies as seen in the edited volume Feldman and Ticktin 2010. More recent works in the anthropology of health policy build on earlier approaches to investigate how national health programs rooted in insurance play out in the lives of providers and patients. Mulligan and Castañeda 2018 illuminates how the Affordable Care Act has had contradictory effects in the United States, increasing some forms of inequality and exclusion even while 20 million people gained access to insurance coverage. Around the world, insurance schemes are being implemented and imagined as a new solution to the old problem of health system strengthening and expanding access to biomedical care as seen in work by Dao and Nichter 2015.

• Castro, Arachu, and Merrill Singer. 2004. Unhealthy health policy: A critical anthropological examination. Lanham, MD: AltaMira Press.

  This expansive edited volume contains multiple case studies of health policy. The authors attribute the failure of health policies to generate positive outcomes to the “trilogy of fear, ideology, and geopolitics” (p. xv) that often displace concern with well-being. The book’s three sections discuss how international organizations create and implement health policies; national health policies re-inscribe social exclusions; and policies shape biomedicine.

• Dao, Amy, and Mark Nichter. 2015. The social life of health insurance in low- to middle-income countries: An anthropological research agenda. Medical Anthropology Quarterly 30.1: 122–143.

  Argues that anthropologists should pay more attention to insurance and health care financing in low- and middle-income countries, especially since insurance is now the primary vehicle for expanding access to health services. Reviews experiences in Thailand, Vietnam, and Rwanda. Finds that insurance does not always ameliorate inequality; individuals left with significant financial exposure; and issues remain around sustainability and the strength of institutions. The authors suggest areas for future research.

• Eisenburg, Merrill. 2011. Medical anthropology and public policy. In A companion to medical anthropology. Edited by Merrill Singer and Pamela I. Erickson, 93–116. Malden, MA: John Wiley & Sons.

  Drawing from policy studies and public health, creates a framework for applied medical anthropology involvement in policy processes, especially at local and state levels. Provides a history of policy focused work in medical anthropology (begins in 1976 with an article by George Foster) and offers advice to anthropologists who would like to impact policy processes. Argues against an approach to policy that is confined to studying policymaking processes.

• Feldman, I., and M. Ticktin, eds. 2010. In the name of humanity: The government of threat and care. Durham, NC: Duke Univ. Press.

  This volume explores the effects of carrying out governance in the name of humanity. Through case studies of humanitarian interventions, biomedical research, pharmaceutical policy, and environmental regulation, the authors show that intervening for the benefit of humanity has contradictory effects. Biomedical health research and humanitarian programs can exploit the health care naive; leave out those who appear insufficiently motivated to pursue treatment; and foreground scientific success over patient experience.

• Gruenbaum, Ellen. 1981. Medical anthropology, health policy and the state: A case study of Sudan. Policy Studies Review 1.1: 47–65.

  Urged anthropologists to focus more on economics and policy (rather than just culture). Sociocultural emphasis and micro-level studies fail to apprehend the production of health through broader social formations. To effectively contribute to policy, anthropologists need a robust theory of the state that incorporates class conflict. Attributed poor health indicators in Sudan to colonial intervention, export-based economic development, and class conflict within the colonial and postcolonial state.

• Hill, Carole E., ed. 1986. Current health policy issues and alternatives: An applied social science perspective. Southern Anthropological Society Proceedings (Book 19). Athens, GA: Univ. of Georgia Press.

  Hill and colleagues address health policy from an anthropological, or what the authors refer to as an “applied social science,” perspective. Each article in the volume offers concrete recommendations for addressing policy issues. Topics include the cultural context of policy, how policy is made, and the role of anthropologists in creating more culturally appropriate health policy. Examples discussed from the United States, Costa Rico, Mexico, China, and Micronesia.

• Kim, Jim Yong, Joyce V. Millen, Alec Irwin, and John Gershman. 2000. Dying for growth: Global inequality and the health of the poor. Monroe, ME: Common Courage Press.

  Interdisciplinary work (clinicians, economists, anthropologists, philosophers, political scientists, and historians). Expansive overview of the problems of economic growth leading to immiseration and falling health indicators for the world’s one billion people without access to clean water or sufficient food. Case studies from Peru, Guatemala, Cuba, and the United States demonstrate that focusing on macroeconomic indicators like growth can obscure the suffering and inequality experienced by the poor.

• Mulligan, Jessica, and Heide Castañeda. 2018. Unequal coverage: The experience of health care reform in the United States. New York: New York Univ. Press.

  Edited volume that explores the experiences of individuals in the United States who sought insurance coverage in the wake of the implementation of the Affordable Care Act of 2010. Found that access to the law’s benefits were highly stratified by place of residence, income, and immigration status. Collects the work of multiple ethnographers studying the implementation of a health policy.

• Pfeiffer, J., and R. Chapman. 2010. Anthropological perspectives on structural adjustment and public health. Annual Review of Anthropology 39:149–165.

  Structural adjustment policies promulgated by the World Bank and the International Monetary Fund required the downsizing of state bureaucracies including ministries of health, controls on inflation, deregulation, and opening up to foreign capital. This review article synthesizes thirty years of anthropological research into the impacts of structural adjustment on low income countries and finds that the results have been catastrophic for the health outcomes of the poor.

• Rylko Bauer, Barbara, and Paul Farmer. 2002. Managed care or managed inequality? A call for critiques of market-based medicine. Medical Anthropology Quarterly 16.4: 476–502.

  An impassioned critique of the role of profit and costs in guiding the organization and distribution of medical care in the United States, and increasingly abroad. Calls on anthropologists to study marketization more closely as an ideology and also in practice and especially to be attentive to the ways in which managed care and other market-based approaches to health policy reinforce inequalities of race, class, and gender.