Having worked in the global health field, it has always concerned me that the emphasis of many in the field (and in the EA) community seems to be solely focused on second order interventions that bypass the state. Often it seems that the removal of particularly incompetent/abusive dictators would do much more in the long-run to improve healthcare outcomes than even the most well-suited targeted interventions. While the obvious pushback may be that regime change is difficult and there is no universal blueprint (nor guarantee that the next regime will be better), there does appear to be low hanging fruit on this front. For example, eSwatini's monarch has systematically hindered economic growth while receiving millions in healthcare aid despite rates of HIV and other communicable diseases remaining as high as anywhere in the region. Recent protests suggest that well-targeted aid could facilitate a democratic transition, but this doesn't seem to fit into any existing models of impact. Can anyone point me in the direction of any related work? Thanks in advance. 

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First off, remove democracy from your lexicon. It's too complicated and confusing word, it means different things to different people. Usually if you bring democracy into this debate you get a circular answer by accidentally assuming many institutions at once.

A good starting question here is to think about the service recipients. What is the theory of change for how they compel the state to provide services under each system? What assumptions are needed for it to work?

Citizens have to coordinate to punish a leader that does not provide services if they want more services than the leader prefers to provide. So steps are:

  1. Citizens must want services.
  2. Citizens must find out if services are provided and if better provision is possible.
  3. Citizens they must communicate to eachother both the information and their awareness.
  4. Citizens they must coordinate to punish simultaneously because individually attack leaders is ineffective and punishable.
  5. If they want to prevent leaders from counter punishing (repression), citizens must punish repression (see above steps).
  6. Citizens must choose public goods over selling their votes.

Elections make the later steps easier by coordinating simultaneous punishments (election day). Experienced oppositions make 2 and 3 easier. If 1 or 6 are violated, you won't get any benefit though. Also if the middle class solves this and the poor do not, guess who gets service...

The short answer is that many countries democratize but see little benefit for public service because this is a really long chain that can break down easily.

I may come back and find the studies for this stuff.

These are all good points and I think there is substantial evidence to support the majority of them. Quick tangent: I'm not so sure about your dismissal of the link between voters selling votes and a lack of service provision as there are several places in which selling votes often occurs as an inadequate form of exchange and/or a way of reallocating finances to allow for the purchase of goods. 

Regardless of that minor detail, I'm more or less in agreement with this framework. It gets a bit more complicated when you introduce alternative systems of co... (read more)

Yes there is a lot of work on this area. AFAIK not on health outcomes but on similar areas. If there's interest I could do a blog post on it. https://github.com/tliptrot/Academic/raw/d4f44f249235afddbe16c67a3e6849038be22526/One Bullet Propert Rights Liptrot and Srivastava.pdf

Personally I'd be very interested in such a blog post

Above is my recent article on property rights and sudden deaths of autocrats, which is not really your question. When I find time!

1geoffrey5mo
Quick clarifying questions about your abstract if you have time. I'm confused about the term "weakly constrained" Does "weakly constrained" mean (a) the leader is weak because elite supporters make the leader weak, (b) the elite supporters are weak and can't limit the leader much, (c) a jargon-loaded academic definition that I shouldn't worry too much about because it's too hard to explain, or (d) something else? Also, does personalist always mean anything about constrained-ness in theory? (Like I get in reality, it may correlate a certain way, but I'm wondering about the definition)
3Timothy_Liptrot5mo
Good question. Perhaps I should clarify this in the abstract. Weakly constrained means elite supporters cannot limite the leader much. Personalist means weakly constrained by elite supporters. The idea is that one person has lots of power, hence personalist.

We also know a lot about what types of regimes are more susceptible to democratization. A democratization effort in Vietnam is much more likely to succeed because Vietnam is a party state, has some elections, has a strongish economy, etc. I can say more about that too.