Seeing Like a State: Strategic Social Policy Choices in Africa

Abstract

Why do states decide to provide better services for their citizens? When and how do normative requirement about service provision become concrete policy actions? What role do donors play in this process? The paper poses these questions in the context of health and education policy and seeks to address them by looking at one specific policy issue in one developing region: the abolition of user fees for primary health and education services in Sub Saharan Africa. Although basic health and education are both human rights of equivalent value, 18 African countries have responded to pressure to abolish fees in primary education, but some form of ‘cost sharing’ persist for health services in all but 5 countries, despite popular pressure and evidence that fees exclude the poor (Deininger & Mpuga 2004, Fafchamps & Minten 2004). The paper uses a multi-method approach combining quantitative analysis, a qualitative inter-sectoral case study of Tanzania and a ‘least likely’ case of healthcare reform in Lesotho, to untangle the causal processes at play. It argues that, when considering policy changes such as abolishing fees, developing states engage in rational cost-benefit analyses that consider the likely political returns for any change against the amount of material effort required. Although democracy has increased the returns for pro-poor policies with mass appeal, the material constraints on most African countries have remained high. As the qualitative cases reveal it has been by strategically focusing resources on tasks requiring less capacity (like education) and by opportunistically forging alliances with forces outside the state – such as donors and civil society – that capacity constraints have been overcome and free services introduced.

Keywords: Africa, health and education policy, state building