This is the semi-final DRAFT of the final chapter of Kaufman and Nelson, eds., Crucial Needs, Weak Incentives: The Politics of Health and Education Reform in Latin America, Wilson Center Press and Johns Hopkins University Press, forthcoming autumn 2004. The book includes twelve case studies of major sector reforms, and comparative essays examining the politics of reform in each of the two sectors.
In Chapters 3 and 9, we focused on the actors and institutions that shaped cross-national patterns of reform of health and education services. One point to emerge from these chapters was the difficulty that reformers faced in maneuvering around strong opposition from a variety of stakeholders within the existing systems – including teachers and health workers' unions, patronage politicians, and in the case of the health sector, private insurers and providers. Indeed, the cases provided considerable evidence to support the conventional wisdom that there is an asymmetry of power between well-organized groups who stand to lose from the reform process, and prospective “winners” who face serious collective action problems.
At the same time, however, it was also clear that changes were occurring in many countries, and that some of these involved quite substantial reorganizations of financing and lines of accountability within the social sectors. In part, not surprisingly, these reforms tended to be most extensive in countries where stakeholder groups -- particularly, the providers' unions -- were relatively weak. But this dimension of interest group politics tells only part of the story in any of the countries we have examined. Reforms were shaped as well by the broader international context, by links between social service reforms and broader goals and issues, and by political contingencies and strategies that sometimes opened new windows of opportunity for policy changes.
In this concluding chapter, we take a step back from the specificities of the health and education sectors and examine the processes through which reforms have been shaped and implemented. Reform in any aspect of public policy is never just a single event, and social service reforms tend to be particularly long-drawn-out processes, played out in multiple arenas and involving different challenges at each stage. We distinguish analytically between four phases. In the first phase, reforms become