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Abstract
Democratic reform processes often go hand in hand with expectations of social welfare improvements. While the connection between the emergence of democracy and the development of welfare states in the West has been the object of several studies, however, there is a scant empirical literature on the effects of recent democratization processes on welfare policies in developing countries. This is particularly true for Africa. In a dramatically poor environment, Africans often anticipated that the democratic reforms many sub-Saharan states undertook during the early 1990s would deliver welfare dividends. This article investigates whether and how the advent of democracy affected social policies – focusing, in particular, on health policy – by examining one of the continent's most successful cases of recent democratization (Ghana) and comparing it with developments in a country of enduring authoritarian rule (Cameroon). Evidence shows that democracy can indeed be instrumental to the expansion and strengthening of social policies. In Ghana, new participatory and competitive pressures pushed the government towards devising and adopting an ambitious health reform. Despite façade elections, no similar pressures could be detected in undemocratic Cameroon and health policy remained almost entirely dictated by foreign donors.
Acknowledgements
This article is part of a ‘PRIN 2008’ research project cofunded by the Italian Ministry of Universities and Research and the Università degli Studi di Milano. A previous version was presented at the 52nd Annual Meeting of the African Studies Association (ASA), New Orleans, 19–22 November 2009. The author wishes to thank Fred Eboko, Armand Leka, Constantine Boussalis, Stefano Sacchi, Matteo Jessoula, Paolo De Renzio and two anonymous referees for helpful comments on issues the article deals with.
Notes
The classic argument about the redistributive properties of democratic politics is formalized in Meltzer and Richard, ‘A Rational Theory of the Size of Government’.
See, for example, Lake and Baum, ‘The Invisible Hand of Democracy’; Bueno de Mesquita et al., ‘Political Institutions, Policy Choice and the Survival of Leaders’; Gerring, Thacker, and Alfaro, Democracy and Human Development; Brown and Mobarak, ‘The Transforming Power of Democracy’.
Bollen and Jackman, ‘Political Democracy and the Size Distribution of Income’; Ross, ‘Is Democracy Good For the Poor?’, 861.
Cf. de Waal, ‘Democratic Political Processes and the Fight against Famine’, 13; Varshney, ‘Why Have Poor Democracies Not Eliminated Poverty?’, 729.
Lindberg, ‘“It's Our Time To «Chop»”’.
Lake and Baum, ‘The Invisible Hand of Democracy’, 588.
Carbone, ‘The Consequences of Democratization’.
Sen, ‘An Argument on the Primacy of Political Rights’; de Waal, ‘Democratic Political Processes and the Fight against Famine’.
Varshney, ‘Why Have Poor Democracies Not Eliminated Poverty?’.
Harms and Zink, ‘Limits to Redistribution in a Democracy’; Chong, ‘Inequality, Democracy, and Persistence’; Bollen and Jackman, ‘Political Democracy and the Size Distribution of Income’.
Brown, ‘Reading, Writing and Regime Types’; Brown and Hunter, ‘Democracy and Human Capital Formation’; Stasavage, ‘Democracy and Education Spending in Africa’.
Nelson, ‘Elections, Democracy and Social Services’; Ross, ‘Is Democracy Good For the Poor?’.
Bratton and Mattes, ‘Support for Democracy in Africa’.
Such works include Hickey, ‘Conceptualising the Politics of Social Protection in Africa’ and ‘The Politics of Staying Poor’; Stasavage, ‘Democracy and Education Spending in Africa’ and ‘The Role of Democracy in Uganda's Move to Universal Primary Education’; Nattrass and Seekings, ‘Democracy and Distribution in Highly Unequal Economies’; and Kosack, Do Democracies Serve the Poor?
See, for example, ‘Democracy in Africa. A Good Example’, The Economist, October 22, 2009; ‘Obama: Time to End Tyranny in Africa’, The Guardian, July 11, 2009; Freedom House, Freedom in the World 2011. The A uthoritarian C hallenge to D emocracy.
See, for example, Gros, ‘The Hard Lessons from Cameroon’, and van de Walle, ‘Africa's Range of Regimes’.
UNDP, Human Development Report 2010, 145.
Nelson, ‘Elections, Democracy and Social Services’, 80ff. Cf. Ross, ‘Is Democracy Good for the Poor?’.
SEND-Ghana, Balancing Access with Quality Health Care, 13.
Badasu, ‘Implementation of Ghana's Health User Fee Policy’, 290; Nyonator and Kutzin, ‘Health For Some?’, 330; Agyepong and Adjei, ‘Public Social Policy Development and Implementation’, 154.
See, for example, Nugent, Big Men, Small Boys and Politics in Ghana.
Waddington and Enyimayew, ‘A Price to Pay’; and Waddington and Enyimayew, ‘A Price to Pay, Part 2’; Aryeetey and Goldstein, ‘Ghana. Social Policy Reform in Africa’.
Sulzbach, Garshong, and Owusu-Banahene, Evaluating the Effects of the National Health Insurance Act in Ghana, 3.
Ministry of Health, Pulling Together, Achieving More.
van der Geest, ‘The Efficiency of Inefficiency’, 2148.
Essomba, Bryant, and Bodart, ‘The Reorientation of Primary Health care in Cameroon’, 233.
Ibid., 235.
Litvack and Bodart, ‘User Fees Plus Quality Equals Improved Access to Health Care’, 374; Essomba, Bryant, and Bodart, ‘The Reorientation of Primary Health Care in Cameroon’.
Cf. Médard, ‘Décentralization du système de santé publique et resources humaines au Cameroun’, 1–2.
Reporters Without Borders, Ghana Report, 2010.
Freedom House, Freedom of the Press. Ghana Country Report, 2009.
Cf. Sen, ‘An Argument on the Primacy of Political Rights’.
National Democratic Congress, Manifesto 2004, 49.
Interview, Isaac Adams, Director of Research, Information and Statistics, Ministry of Health, Accra, November 25, 2008.
Interview, Sam Adjei, former deputy Director of Ghana Health Service, interview, Accra, November 25, 2008.
Aryeetey and Goldstein, ‘Ghana. Social Policy Reform in Africa’.
National Democratic Congress, Manifesto 1996.
National Democratic Congress, Manifesto 2000.
National Democratic Congress, Manifesto 2004 and Manifesto 2008.
New Patriotic Party, Manifesto 1996.
New Patriotic Party, Manifesto 2000.
Cf. Rajkotia, The Political Development of the Ghanaian National Health Insurance System, 8–10; Agyepong and Adjei, ‘Public Social Policy Development and Implementation’, 155.
Ibid., 155–6.
Cf. Rajkotia, The Political Development of the Ghanaian National Health Insurance System; Agyepong and Adjei, ‘Public Social Policy Development and Implementation’, 155–6.
UN, Integrated Regional Information Network.
Freedom House, Freedom of the Press. Cameroon Country Report.
Reporters Without Borders, Cameroon Report.
See Freedom House, Freedom of the Press. Cameroon Country Report; Committee to Protect Journalists, ‘Attacks on the Press 2009: Africa Developments’ (February 16, 2010), ‘CPJ Alarmed by Harassment of Journalists in Cameroon’ (March 9, 2010) and ‘Cameroon Must Investigate Jailed Editor's Death’ (April 25, 2010). In its 2009 appraisal of media freedom, Reporters Without Borders ranked Ghana 27th out of 175 nations, with Cameroon in 109th place. Out of a slightly more numerous total number of states (195), Freedom House similarly positions Ghana in 53rd place and Cameroon in 143rd. For the complete rankings, see http://www.rsf.org and http://www.freedomhouse.org.
Social Democratic Front, SDF Manifesto 1990.
Social Democratic Front, SDF Election Platform 1997.
See, for example, Konings, ‘Opposition and Social-democratic Change in Africa’, 308; ‘Cameroun: fin de partie pour John Fru Ndi’, Jeune Afrique, October 27, 2009.
Basile Kollo, Directeur des Ressources Humaines, Ministère de la Santé Publique, Interview, Yaoundé, February 29, 2008.
For World Bank data on ‘control of corruption’, see Kaufmann, Kraay, and Mastruzzi, ‘Governance Matters VIII’, 6.
See http://www.transparency.org for data by Transparency International.
See ‘Just'où ira Paul Biya?’, Jeune Afrique, May 5, 2008, and ‘Paul Biya accuse d'instrumentaliser “Epervier”’, Jeune Afrique, January 25, 2010.
Gruénais, ‘L’État à la conquête de son territoire national’, 2.
Cf. Hsiao and Shaw, ‘Introduction, Context and Theory’, 11–14. In Rwanda, the principle of compulsory health insurance for universal coverage was only established by Law no. 62/2007 of December 2007, a law that was implemented from 2008. Previously, since 1999 Kigali had introduced and promoted a system of community-based insurance schemes (besides other schemes covering the formal sector), but so-called mutuelles had remained voluntary schemes.
Health insurance had been part of the World Bank's broad health reform agenda for developing countries since the late 1980s and early 1990s, but it never quite developed into a central theme in debates and reform practice at that time. Moreover, insurance schemes were neither meant to be arranged directly by the government, nor to be universal, nor comprehensive (World Bank, Financing Health Services in Developing Countries): universal coverage was considered a feasible strategy for ‘only a few middle-income countries’ (World Bank, World Development Report. Investing in Health, 161). It was only in 2005 that the World Bank explicitly put some distance between itself and the adoption of user fees for the ‘basic health services for poor people’ (Yates, International Experiences in Removing User Fees for Health Services, 14).
Wagstaff, ‘Social Health Insurance Reexamined’; Hsiao and Shaw, ‘Introduction, Context and Theory’.
World Health Organization, World Health Report 2008, 25–7.
Cf. Rajkotia, The Political Development of the Ghanaian National Health Insurance System, 7.
Sam Adjei, former deputy Director of Ghana Health Service, interview, Accra, 25 November 2008.
Interviews with top-level officials involved in the reform process confirmed the primary role of domestic politics and the relative marginalization of external inputs – including, in particular, the World Bank – in making key decisions about the direction of reform (Sam Adjei, quoted above; Isaac Adams, Director of Research, Information and Statistics at Ministry of Health, interview, 25 November 2008). The same point is found in Rajkotia (The Political Development of the Ghanaian National Health Insurance System, 7, 10), who refers to donors as ‘neutral/opponents’ with respect to the NHI Act. By 2009, a few other countries had abolished or limited user fees as a result of domestically-driven processes in which donors such as the WB, ECHO, WHO, DFID, DANIDA and several NGOs essentially followed suit, rather than taking a leading role (Morestin and Ridde, The Abolition of User Fees for Health Services in Africa, 1). Whether reform processes in these countries were also spurred by democratic change is beyond the scope of this study.
World Bank, World Development Indicators 2009.
As a policy ‘input’, health insurance may be regarded as little relevant to voters that normally judge governments on the basis of outputs. Yet insurance had a very direct impact on output, that is on the provision of and access to health services, since it addressed the problem of exclusion caused by the cash and carry system. For many Ghanaians, the difference was between access to health services (through insurance) and no access to health services (because of barriers created by the cash and carry). This is what made insurance something voters could associate very tangible prospective effects to. More specifically, the common view among Ghanaian politicians as well as voters was that insurance would be more favourable to the average Ghanaian poor than the cash and carry system. Whether this assumption turned out to be true is not of direct relevance to this article. Yet what little evidence is available on the implementation phases seems to show that the NHIS was relatively effective and the country's vulnerable groups benefited from the reform. The scheme proved quite successful in enrolling a growing part of the population, in removing financial barriers for households to access health care, and thus in increasing utilization of services as well as users’ satisfaction (SEND-Ghana, Balancing Access with Quality Health Care, 6; Witter and Garshong, ‘Something Old or Something New?, 7, 13–14; Rajkotia, The Political Development of the Ghanaian National Health Insurance System; Asante and Aikins, Does the NHIS Cover the Poor?, 4; Durairaj, D'Almeida, and Kirigia, Obstacles in the Process of Establishing Sustainable National Health Insurance Scheme, 2). The structure of insurance premiums did go some way towards the establishment of a more equitable access by (1) differentiating between core poor, very poor, poor, middle income, rich and very rich, and (2) by exempting the extreme poor. All the same, obstacles to accessing the health system for the most vulnerable groups remain, particularly with regard to the urban-rural divide (Durairaj, D'Almeida, and Kirigia, Obstacles in the Process of Establishing Sustainable National Health Insurance Scheme, 2).
As implementation only started in 2005, health indicators will likely take some time to show the expected improvements (if ever). This is likely true also for Human Development Index trends, for which one may predict stronger improvements in democratic Ghana rather than in nondemocratic Cameroon. As shows, while Cameroon achieved better progress and overtook Ghana in HDI scores and rankings during the 1980s – that is, prior to the multiparty reforms – Ghana was back ahead by the mid-1990s, and has been ever since. To the extent that the index measures social progress, HDI trends would thus be consistent with the notion that a democratic regime (that is, Ghana since the 1990s) is better than a nondemocratic regime at improving social conditions. Moreover, as pointed out, one may expect HDI progress to be further strengthened as the NHIS reform gradually produces its effects. The HDI, however, is not necessarily a valid indicator because, besides its education-based and health-based components, it is also based on GDP per capita data. Economic growth per se, in other words, could be enough to change – for good or for worse – the HDI trend of a country regardless of social policies and outcomes.
Yates, International Experiences in Removing User Fees for Health Services.
Nelson, ‘Elections, Democracy and Social Services’, 82[0].
