Struggling with the State: Rights-based Governance of Reproductive Health Services in Puno, Peru

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 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.Ph.D