- Conference 2019
- Contact us
Working paper 113
Badru Bukenya and Frederick Golooba-Mutebi
Technical questions, such as systems development and management; governance, the role of service users in financing and decision-making and resource availability, have long dominated research on healthcare provision in developing countries. The importance of the broader political context, specifically the way power is organised and exercised and the extent to which it meets the acceptance of a country’s ruling elites, or, more specifically, the prevailing political settlement, is usually disregarded (DFID, 2010:22). This ESID-commissioned research explored whether, and the extent to which, ‘the balance or distribution of power between contending social groups and classes, on which [the Ugandan] state is based’ (di John and Putzel, 2009:4) matters with regard to government capacity for delivering maternal health services. Findings indicate that within Uganda’s weak-dominant political settlement, sub-national level settlements exert a profound effect on the capacity and commitment of local government to deliver services. Since the mid-2000s, the health sector in Uganda has been governed for political ends, rather than geared towards higher levels of performance. This has undermined any system-wide efforts to improve service delivery. Case study material from two otherwise very similar districts, Ssembabule and Lyantonde, which record very different levels of progress in reducing maternal mortality, illuminates this argument. At the district level, good performance is driven by developmental coalitions of local politicians, bureaucrats, health sector professionals and civil society organisations with the capacity and commitment to devise and enforce innovative approaches to governing the sector.
Working paper 112
This paper explores the political economy drivers of Ghana’s flagship cash transfer programme, Livelihood Empowerment Against Poverty (LEAP). In contrast to existing accounts of the LEAP as a domestically driven cash transfer scheme, the evidence here shows that donor pressures, leveraged through financing, played a more prominent role than the paradigmatic ideas of domestic political elites in shaping the adoption of the LEAP. Despite the recent discovery of oil and the country’s subsequent ascension to middle-income status, donors remain important players in the Ghanaian political economy, given their dominance in the investment component of government’s budget and the resultant inability of political elites to generate the rents that are so badly needed for meeting various redistributive demands without donor financing. However, once the LEAP was adopted, domestic political calculations and the incentives generated by Ghana’s political settlement dynamics took centre stage in shaping the actual implementation of the programme, especially around questions of targeting and geographical coverage, and the prioritisation of reforms with more visible impact that could be leveraged upon to win competitive elections. These findings suggest that an adapted political settlements framework that goes beyond domestic political calculus, and which explicitly incorporates the influence of ideational and transnational factors, can greatly improve our understanding of the political economy drivers of social protection in Africa.
Working paper 111
Vasudha Chhotray, Anindita Adhikari and Vidushi Bahuguna
The idea of state responsibility for ensuring food security has gained ground, with strong popular mobilisations for the Right to Food around the world; but important variations prevail, both in the articulation of demands around food security interventions and in political responses to these. This paper takes a close look at India’s Public Distribution System, a programme with a long history and clear national-level, legislative backing, but considerable differences in prioritisation at the subnational level. Through an empirically rich and innovative comparison of Chhattisgarh with Jharkhand – both created at the same time, in 2000 – it asks why the opportunities afforded by statehood allowed Chhattisgarh to politically prioritise the PDS, but not Jharkhand. The paper finds that the explanation lies in the interrelated dimensions of political competition, the nature of pressures exerted by electorally significant societal groups, and political enablement of bureaucratic capacity. Finally, the analytical framework at the heart of the paper contributes to the emerging literature on the political conditions that allow the deployment of state capacity for the promotion of welfare.
Working paper 110
Rasmus Hundsbæk Pedersen and Thabit Jacob
This paper analyses the introduction and expansion of health insurance schemes in Tanzania. Health insurances were introduced around year 2000 as part of a more general health reform process aimed at improving access to health services. The paper argues that the health insurances were driven by a policy coalition of bureaucrats and transnational actors, who, inspired by international trends, framed reforms as a way for the ruling party to live up to one of its core priorities since independence, namely, improved and, eventually, universal access to health services. The introduction of insurances was expected to help mobilise funds and improve the working of the health care system for this purpose. However, judged by their modest design and slow implementation, the ruling political elite remained ambiguous about health insurances. Politically, a fast rollout was perceived to be risky. Similar political considerations may explain the reluctance to expand health insurance coverage through a mandatory scheme that bureaucrats and development partners have propagated recently. The rejection of the initial design for such a scheme came as a surprise to the policy coalition, which did not enjoy the same access to key decisionmakers as in the past. Concurrently, and driven by increased electoral competition, the ruling party has increasingly focused on improving access through the expansion of physical health infrastructure. This has the additional advantage of being highly visible among the rural majority of the population, who overwhelmingly vote Chama Cha Mapinduzi (CCM). This is our second paper on social protection in Tanzania.
Working paper 109
Thabit Jacob and Rasmus Hundsbæk Pedersen
Social protection has become a more important part of social service delivery in Tanzania over the last couple of decades. This paper analyses the politics behind the making and implementation of the Productive Social Safety Nets (PSSN), a cash transfer scheme that became part of a broader, existing scheme aimed at poverty reduction and rural development, TASAF I-III. We trace the interrelationship between the domestic policy process and the shifting influence of transnational ideas. We argue that the introduction of TASAF and later PSSN was strongly influenced by international trends, driven by a policy coalition of bureaucrats and development partners, but that it was sanctioned by the country’s political elites, who at times used the programmes for electoral purposes. This happened for instance by influencing the scale and speed of PSSN’s implementation prior to the national elections in 2015, despite a tradition of scepticism towards cash transfers within the ruling CCM party. Recently, President John Magufuli’s more productivist ethos, emphasising the importance of work, poses a threat to the programmes’ continuation. This may also reduce the targeting of the poorest of the poor, which constitutes a major element of PSSN as we know it.
Working paper 108
Two parallel tracks of research on economic transformation in developing countries have operated at a distance from each other over the last two decades. A global track – global value chains/global production networks (GVC/GPNs) – has focused on the increasing interconnectedness of global trading networks and has overlooked the role of the state and the explanatory power of domestic political economy. Meanwhile, a domestic track – including literature on developmental states, industrial policy and political settlements – has tended to take a methodologically nationalist perspective to examine economic transformation in developing countries, with limited reflections on external economic and political pressures. This paper contributes to an emerging stream of literature that examines how the domestic and global scales influence how developing country governments and firms tackle the challenge of economic upgrading. By combining insights from the political settlements and GVC/GPNs literature, this paper examines the Rwandan government’s attempt at upgrading its coffee production to enter specialty coffee markets. It shows how the existing GVC/GPNs literature makes an important contribution to describing how multipolar governance influences the pathways for economic upgrading in Rwanda’s coffee sector, but that even where access is granted, benefits are captive to the demands of international buyers, and gains for some have not translated across the sector. Insights from the political settlements literature showcase how domestic politics influences who benefits from insertion to GVC/GPNs and how the unequal provision of opportunities affects political stability.
Working paper 107
Despite substantial improvements in access to health services in Ghana during the last two decades, there has been limited progress in improving maternal health, and the country as a whole was unable to meet the Millennium Development Goal (MDG 5) in relation to maternal mortality. However, some administrative regions have made significant progress, with the Upper East, one of Ghana’s most impoverished regions, surprisingly recording the most dramatic progress in the reduction of maternal mortality during the last decade. This paper explains Ghana’s limited progress in reducing maternal mortality as a product of the country’s ‘political settlement’, in which ruling elites are characterised by a perennial threat of losing power to other powerful excluded elites in tightly fought elections, incentivising those in power to direct public investments to policy measures that contribute to their short-term political survival. Competitive clientelist political pressures have contributed to greater elite commitment towards health sector investments with visual impact, while weakening elite incentives for dedicating sufficient public resources and providing consistent oversight over other essential, but less visible, interventions that are necessary for enhancing the quality of maternal health. In the absence of system-wide drivers of improved performance, sub-national variations in the quality of maternal health services are strongly shaped by the capacity and commitment of regional and district health authorities in enforcing human resource management norms within the Ghanaian health sector, thus ensuring the accountability of health workers. In the largely impoverished Upper East Region, incentives for health workers’ performance are particularly driven by a hybrid form of accountability that combines top-down pressures from the Regional Health Directorate with horizontal forms of accountability among various health facilities.
Working paper 106
Frederick Golooba-Mutebi with Yvonne Habiyonizeye
Studies examining the impact of different kinds of organisational and institutional reform on service delivery in the health sector in developing countries highlight and explain advances, strengths, weaknesses, shortcomings and failures in delivery. They rarely explore directly the role of the prevailing political arrangements in individual countries, specifically how politics is organised and practised, in influencing approaches to, and the nature and quality of, service delivery. This paper seeks to contribute towards filling the gap. It explores the extent to which the operation of Rwanda’s political system in the light of the prevailing political settlement shapes service delivery and outcomes in the health sector. A political settlement begets specific rules of the game and incentives, constraints, opportunities and risks in its own context. All things being equal, in Rwanda’s dominant party/dominant leader political settlement, the short- to medium-term prospects of the current government losing power to opposition rivals are slim. Consequently, there is no pressure on the government to deliver on popular expectations or suffer electoral defeat. In the face of marked achievements in recent times, therefore, the paper explores the possible influences on service delivery in post-genocide Rwanda. It argues that the nature of political organisation and how politics works are decisive.
Working paper 105
This paper explores the evolution of the business–government dimensions of South Africa’s democratic political settlement. It details how and why market-based reforms were embraced by both political and economic actors in the 1990s as part of a broader commitment to a rule-bound political settlement. It explores two aspects of the subsequent play of the game: the rise and decline of a ‘corporatist’ elite bargain; and the evolution of initiatives to foster black economic empowerment. Overall, rule-bound, disciplining reforms were embraced more readily than pro-active initiatives to build capability. The result has been that South Africa became mired in a combination of economic stagnation and the strengthening over time of forces antithetical to market-based reform.