Voluntary Associations, Collective Action and Health Aid Effectiveness

A growing number of researchers points to the coordination challenges and collective action problems that prevent both governments and civil society from co-operating as principals in development processes and lead to an under-supply of public goods (Booth and Cammack 2013). Specifically, development processes in thoroughly corrupt countries are characterized by a lack of collective action since actors' willingness to monitor officials' behavior, impose sanctions and enforce reforms rather depends on how many other individuals in the same society are expected to be corrupt (Persson, Rothstein, and Teorell 2013, 450). The weakness of formal oversight institutions in many aid recipient countries has led development practitioners to believe that citizens' involvement can improve the quality of public service delivery and reduce corruption in particular in countries that are subject to international development assistance. In particular, assuming that beneficiaries have the incentives to demand good quality services their participation in the monitoring of service providers is expected, among others, to reduce absentee rates among health professionals, increase access to priority drugs and basic medical equipment, as well as improve physical health infrastructure (Banerjee et al. 2010, 2). Political scientists have repeatedly pointed to the links between civic engagement and government responsiveness. In particular, citizens’ willingness and capacity to overcome collective action problems and to engage in processes of performance oversight ultimately reside in both effective formal and informal institutions of performance oversight. However, in the context of weak formal institutions, voluntary associations become an important source of trustworthiness among individuals, which enables communities’ to engage in collective endeavors and exercise demands on state actors. Specifically, voluntary associations provide effective information sharing and sanctioning mechanisms that increase the costs of opportunistic, non-cooperative behavior. Hence, norms and networks that restrain opportunism and resolve problems of collective action appear to be crucial to enable citizens to engage in issues of public service delivery. For this reason, donors have increased their efforts to strengthen citizen voice and accountability in order to promote increased demand for better governance. However, despite more than two decades of support in international development for greater citizen participation and failures of 'top-down' development approaches, the aid effectiveness literature has largely ignored the importance of civic engagement in voluntary associations and bottom-up processes of performance oversight. Therefore, this study attempts to close this gap and contribute to a better understanding of the role voluntary associations have in creating incentives and shaping accountability processes in aid recipient countries. Correspondingly, this work seeks to address the question whether civic engagement in voluntary associations contributes to make health aid work. Moreover, the study also explores the interaction of citizen demand for accountability and formal political institutions that create an enabling environment for civic engagement. The analysis is based on country-level data from a large number of aid recipient countries over the period 1990-2012 (five 5-year-average sub-periods). Dynamic panel estimation techniques are applied to account for endogeneity issues.