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Cg 2011 by Stephen August Meserve. All Rights Reserved c 2011 by Stephen August Meserve. All rights reserved. THE POLITICAL ECONOMY OF HEALTH: DEATH, DISEASE AND DISTRIBUTION BY STEPHEN AUGUST MESERVE DISSERTATION Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Political Science in the Graduate College of the University of Illinois at Urbana-Champaign, 2011 Urbana, Illinois Doctoral Committee: Professor William T. Bernhard, Chair Professor Robert D. Pahre Associate Professor Jude C. Hays Associate Professor Brian J. Gaines Abstract Death and disease exact a heavy toll on citizens in democracies. In response, citizens expect elected politicians to alleviate their suffering by providing public health funding to afflicted areas. I argue that the funding of health policy in democracies is subject to distributional incentives similar to other government policies. Patterns of government control, partisan- ship, strategic importance and quality of legislative representation condition the provision of public health funding within countries. In turn, public health spending conditions district mortality outcomes. I examine evidence from turn of the century France, United States and modern India to test this theory. First, I consider qualitative evidence of the distri- bution of health funds. I then assemble administrative district level electoral, budgetary and health information and predict levels of health funding and resulting mortality rates. Political importance, not just need, plays a prominent role in determining who lives and dies in democracies. This has profound implications for the plight of modern democracies facing disease threats. ii To the friends and family who picked me back up. iii Acknowledgments This project went through numerous twists and turns before arriving where it is. I would like to thank my adviser William Bernhard, who created a supportive environment for me and gave me the time to find my own way with this project while reading draft after draft. Thanks also to my other committee members for their help, in particular to Robert Pahre for his big picture advice and Jude Hays for his methodological thoughts. Fellow graduate students also helped shape this project intellectually over the years, especially Neill Mohammad, Dan Pemstein and Carie Steele. I also give my thanks to current and past members of the University of Illinois political science department for their advice on various drafts and presentations of this work. Finally, many people gave me a lot of love during this project, especially when times were tough. Grateful thanks to my parents, Janet and Peter, my brother, Jeffrey, and my fianc´ee,Carie. My close friends also helped me get here with their patience and support. Thanks to Neil Baer, Todd Borrowman, Christina Head, Neill Mohammad, Shweta Moorthy and Dan Pemstein. iv Table of Contents Chapter 1 Deadly Politics . 1 Chapter 2 A Theory of Public Health Resource Distribution . 8 Chapter 3 Third Republic France 1910-1940 . 31 Chapter 4 The United States 1900-1950 . 82 Chapter 5 India 1971-1999 . 114 Chapter 6 Politics and Health in Democracies . 142 References . 145 v Chapter 1 Deadly Politics Distribution lies at the heart of democratic politics. Democratic institutions often strive to ensure that representatives are elected by an equal number of voters but cannot ensure that all voters are equally advantaged in the political process. While a simplistic understanding of democracy describes it as a form of majority rule, where parties currently in power make decisions benefiting the majority of the voters, this does not capture the incentives of parties and politicians for reelection. In practice, the realities of democratic politics may subvert the public good or majority will by making certain voters more politically important than others. Parties and politicians seeking reelection respond to this pattern of electoral importance by favoring some voters over others, creating winners and losers using government policy. The logic of political survival motivates politicians to distribute public policy not according to need or equity, but according to political importance. This project focuses on the hitherto undescribed role of domestic distribution in public health funding. Most scholars consider health funding an ethical or technical problem. Getting the type of treatments right, nailing down the science of medicine and then making sure that public health budgets are appropriately large is the focus of scholarly and policy discussions of public health. It may seem natural to assume that the goal of health policy for political decision makers is simple: the reduction of misery within their borders. After all, one of the first priorities of the state is to ensure all its inhabitants' basic physical security. The integrity of this assumption breaks down, however, when considering the constraints of scarce resources, especially in developing democracies. In the face of limited resources, democratic politicians cannot realistically satisfy their populations' health needs completely. 1 How, then, are health distribution decisions made? Will politicians distribute using a solely need based approach? I argue that political importance, not just citizen need, plays a prominent role in de- termining who receives health assistance in democracies. To explain health funding and mortality patterns, I treat public health as a political problem. Elected politicians dis- tribute public health funding to districts in order to meet their political needs, rather than medical necessity. They seek to maximize their own reelection chances rather than lives saved. As a consequence, politically influential constituencies will be more likely to receive public health assistance. I develop a theory explaining politician motivations to distribute health resources and identify the determinants of government health provision. In particular, I identify four sources of political importance: electoral support levels of parties currently holding power, strategically important electoral districts, patterns of health partisanship and representation by influential legislators. I contend that these constituencies will receive extra public health funding and have lower mortality rates. I test my hypotheses in a novel empirical environment. Policymakers and scholars largely confine discussion of political trade-offs in health and mortality to the modern developing world. Developing world politicians, however, play a complex political game with interna- tional organizations. The interests of exogenous international actors make valid analysis of the domestic politics of health in modern developing cases extremely difficult. I overcome this problem by instead analyzing early 20th century countries experiencing health crises of similar severity without aid from international actors. I test my distributional theory of health in the late French Third Republic (1910-1940) and turn of the century United States (1900-1950). Modeling health spending and mortality in this period isolates the domestic distribution of health and sidesteps the serious problem of causal contamination from in- ternational actors. Finally, an analysis of India (1971-1999), a modern case, rounds out the empirics in order to assess the salience of domestic health distribution in the presence of international interests. All of these countries experienced high mortality rates from a variety 2 of diseases such as influenza, malaria, tuberculosis and waterborne illness. Overall mortality rates in the early 20th century in Europe and North America were very similar to developing countries today. Politically motivated distribution of health funding has profound policy implications. My research suggests that more democracy is not, in itself, a panacea to health crises because democratic politicians distribute public health in order to secure elections. This runs counter to conventional wisdom advocated by many international organizations, who advance democracy promotion and increased transparency as solutions. Political competi- tion alters health patterns and therefore conditions who lives and dies within democracies. If politicians distribute health policy to accomplish domestic political goals, rather than eradicate health problems, even relatively well governed democratic countries may fail to adequately address citizen health needs. This jibes with cursory knowledge of current dis- ease patterns. Some of the most well governed, relatively democratic countries in Africa, for example, suffer the greatest in the struggle against HIV/AIDS. Democratic South African leaders famously did little to confront the scourge of HIV/AIDS (Butler 2005b, Willan 2004). Botswanan HIV/AIDs rates remain high. Poor health affects other developing democracies such as India as well. International health aid donors in particular must pay careful at- tention to patterns of distributional politics in order to help reduce disease and misery. This is especially important in the wake of recent international initiatives such as the 2005 Paris Declaration and 2008 Accra Agenda for Action that emphasize domestic ownership and control of international health programs. The trend towards more domestic control of international aid resources necessitates increased monitoring to ensure that funds are not used as distribution for domestically important, rather than highly vulnerable, populations. My work also contributes to the legislative studies and comparative political economy literatures on distributive politics by using an
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