There is growing evidence that political economy factors are central to whether or not proposed health financing reforms are adopted, but there is little consensus about which political and institutional factors determine the fate of reform proposals. One set of scholars see the relative strength of interest groups in favour of and opposed to reform as the determining factor. An alternative literature identifies aspects of a country’s political institutions–specifically the number and strength of formal ‘veto gates’ in the political decision-making process—as a key predictor of reform’s prospects. A third group of scholars highlight path dependence and ‘policy feedback’ effects, stressing that the sequence in which health policies are implemented determines the set of feasible reform paths, since successive policy regimes bring into existence patterns of public opinion and interest group mobilization which can lock in the status quo. We examine these theories in the context of Malaysia, a successful health system which has experienced several instances of proposed, but ultimately blocked, health financing reforms. We argue that policy feedback effects on public opinion were the most important factor inhibiting changes to Malaysia’s health financing system. Interest group opposition was a closely related factor; this opposition was particularly powerful because political leaders perceived that it had strong public support. Institutional veto gates, by contrast, played a minimal role in preventing health financing reform in Malaysia. Malaysia’s dramatic early success at achieving near-universal access to public sector healthcare at low cost created public opinion resistant to any change which could threaten the status quo. We conclude by analysing the implications of these dynamics for future attempts at health financing reform in Malaysia.
Sickle Cell Trait (SCT) has been shown to be protective against malaria. A growing literature suggests that malaria exposure can reduce educational attainment. This study assessed the relationship and interactions between malaria, SCT and educational attainment in north-eastern Tanzania.
Seven hundred sixty seven children were selected from a list of individuals screened for SCT. Febrile illness and malaria incidence were monitored from January 2006 to December 2013 by community health workers. Education outcomes were extracted from the Korogwe Health and Demographic Surveillance system in 2015. The primary independent variables were malaria and SCT. The association between SCT and the number of fever and malaria episodes from 2006 to 2013 was analyzed. Main outcomes of interest were school enrolment and educational attainment in 2015.
SCT was not associated with school enrolment (adjusted OR 1.42, 95% CI [0.593,3.412]) or highest grade attained (adjusted grade difference 0.0597, 95% CI [−0.567, 0.686]). SCT was associated with a 29% reduction in malaria incidence (adjusted IRR 0.71, 95% CI [0.526, 0.959]) but not with fever incidence (adjusted IRR 0.905, 95% CI [0.709-1.154]). In subgroup analysis of individuals with SCT, malaria exposure was associated with reduced school enrollment (adjusted OR 0.431, 95% CI [0.212, 0.877]).
SCT appears to reduce incidence of malaria. Overall, children with SCT do not appear to attend more years of school; however children who get malaria despite SCT appear to have lower levels of enrolment in education than their peers.
Political systems dominated by a single party are common in the developing world, including in countries that hold regular elections. Yet we lack knowledge about the strategies by which these regimes maintain political dominance. This article presents evidence from Tanzania, a paradigmatic dominant party regime, to demonstrate how party institutions are used instrumentally to ensure the regime's sustained control. First, I show that the ruling party maintains a large infrastructure of neighbourhood representatives, and that in the presence of these agents, citizens self-censor about their political views. Second, I provide estimates of the frequency with which politicians give goods to voters around elections, demonstrating that such gifts are more common in Tanzania than previous surveys suggest. Third, I use a survey experiment to test respondents’ reaction to information about corruption. Few voters change their preferences upon receipt of this information. Taken together, this article provides a detailed picture of ruling party activities at the micro-level in Tanzania. Citizens conceal opposition sympathies from ten cell leaders, either because they fear punishment or seek benefits. These party agents can monitor citizens’ political views, facilitating clientelist exchange. Finally, citizens’ relative insensitivity to clientelism helps explain why politicians are not punished for these strategies.
A large literature examining advanced and consolidating democracies suggests that education increases political participation. However, in electoral authoritarian regimes, educated voters may instead deliberately disengage. If education increases critical capacities, political awareness, and support for democracy, educated citizens may believe that participation is futile or legitimizes autocrats. We test this argument in Zimbabwe—a paradigmatic electoral authoritarian regime—by exploiting cross-cohort variation in access to education following a major educational reform. We find that education decreases political participation, substantially reducing the likelihood that better-educated citizens vote, contact politicians, or attend community meetings. Consistent with deliberate disengagement, education’s negative effect on participation dissipated following 2008’s more competitive election, which (temporarily) initiated unprecedented power sharing. Supporting the mechanisms underpinning our hypothesis, educated citizens experience better economic outcomes, are more interested in politics, and are more supportive of democracy, but are also more likely to criticize the government and support opposition parties.
Studies have found links between organizational structure and performance of public organizations. Considering the wide variation in uptake of malaria interventions and outcomes across Nigeria, this exploratory study examined how differences in administrative location (a dimension of organizational structure), the effectiveness of administrative processes (earmarking and financial control, and communication), leadership (use of data in decision making, state ownership, political will, and resourcefulness), and external influences (donor influence) might explain variations in performance of state malaria programs in Nigeria. We hypothesized that states with malaria program administrative structures closer to state governors will have greater access to resources, greater political support, and greater administrative flexibility and will therefore perform better. To assess these relationships, we conducted semistructured interviews across three states with different program administrative locations: Akwa-Ibom, Cross River, and Niger. Sixty-five participants were identified through a snowballing approach. Data were analyzed using a thematic framework. State program performance was assessed across three malaria service delivery domains (prevention, diagnosis, and treatment) using indicators from Nigeria Demographic and Health Surveys conducted in 2008 and 2013. Cross River State was best performing based on 2013 prevention data (usage of insecticide-treated bednets), and Niger State ranked highest in diagnosis and treatment and showed the greatest improvement between 2008 and 2013. We found that organizational structure (administrative location) did not appear to be determinative of performance but rather that the effectiveness of administrative processes (earmarking and financial control), strong leadership (assertion of state ownership and resourcefulness of leaders in overcoming bottlenecks), and donor influences differed across the three assessed states and may explain the observed varying outcomes.
As mobile phone ownership rates have risen in Africa, there is increased interest in using mobile telephony as a data collection platform. This paper draws on two pilot projects that use mobile phone interviews for data collection in Tanzania and South Sudan. In both cases, high frequency panel data have been collected on a wide range of topics in a manner that is cost effective, flexible and rapid. Attrition has been problematic in both surveys, but can be explained by the resource and organisational constraints that both surveys faced. We analyse the drivers of attrition to generate ideas for how to improve performance in future mobile phone surveys.
This article identifies political economy factors that help explain dramatic differences in the pace of child mortality reduction between Tanzania and Uganda from 1995 to 2007. The existing literature largely explains divergence in basic health outcomes with reference to economic variables such as GDP per capita. However, these factors cannot explain recent divergence across African countries with similar levels of GDP per capita, rates of economic growth, and levels of health funding. I argue that institutional and governance divergences between Tanzania and Uganda can be linked directly to differing coverage levels of key child health interventions (especially related to malaria control), and thus to differing child health outcomes. These institutional differences can be explained in part by historical factors, but more relevant causes can be found in recent political events. In Tanzania, there was an unusually effective project of institution building in the health sector, while in Uganda, by contrast, there was a negative political shock to the health system. This was driven by the repatrimonialization of the Ugandan state after President Yoweri Museveni’s decision to eliminate term limits in the 2001–2006 period. This repatrimonialization process reversed previous health sector institutional gains and had particularly negative effects on child health service delivery in Uganda over the period in question.