Studies on the development of welfare states have largely relied on theories focusing on the role of partisan politics, institutions, and, more recently, varieties of capitalism in order to explain the experiences of advanced industrial democracies. However, existing theories on welfare state development do not comfortably apply to developing economies or emerging democracies wherein leftist parties or labor organizations are weak or under strong state control. How did these ‘Third Wave democracies’ succeed in implementing progressive welfare policies, despite the absence of an institutionalized left?
Democratizing Health Care, by Illan Nam, addresses this question by introducing alternative actors who spearheaded the welfare reform in Thailand and South Korea: solidarity coalitions. Tracing the different development trajectories of health care in Thailand and South Korea, Nam argues that solidarity coalitions − those who forged alliances among societal and/or state actors − played a decisive role in the development of health care in the two countries. Solidarity actors were able to acquire the political resources (mobilizing know-how, networks, knowledge, and beliefs) necessary to push for health care reform from their experiences as democracy activists during the 1970s and 1980s.
Strategies for containing such democracy movements by each regime, ranging from repression to co-optation, explain the variation in health regimes in the two countries. In Korea, the authoritarian regime primarily used tactics of repression to contain democracy movements, which led to the formation of horizontal alliances among societal groups such as citizens’ organizations and labor. The use of repression intensified the coalition's mistrust and antagonism against the state, which in turn limited the coalition's ability to effectively communicate with experts in creating a sustainable solution to the systemic problems underlying health care. The post health care reform in Korea is thus characterized as fragmented and compartmentalized in which, despite expanded coverage, efforts to reduce households’ high levels of private spending were largely ineffective.
On the other hand, the Thai regime relied upon co-optation in addition to repression, which had the effect of creating a conducive environment for the rise of vertical alliances between reform-minded bureaucrats and activists. Through the bureaucrats’ expertise and knowledge of the health system, the Thai reform was able to introduce a more sustainable and comprehensive health care program. Nam evaluates post-reform Thai system as being more effective in reducing regressive health spending, especially with the ‘30-baht copayment’ that delivered universally accessible health benefits at a low fixed payment to the public.
Although Nam's research based on qualitative process-tracing of the two countries provides a compelling argument, some questions do arise. First, the lack of justification behind the selection of her case studies leads to issues of generalizability. Would her argument be able to explain other cases lacking an institutionalized left, or is her theory restricted to newly emerging democracies? The critical role of democratic transition on creating opportunities for solidarity coalitions may also pose limitations on the explanatory power of her argument. Labor unions or leftist parties are also weak or not institutionalized in non-democracies, as is the case in China. Nonetheless, such authoritarian regimes are not free from resistance via student-led movements, as can be seen in the Tiananmen Square protests of 1989. According to Nam's causal mechanism, such democracy movements and subsequent regime response would have created similar opportunities for societal groups to acquire the political resources necessary for welfare reform.
However, in such cases of failed attempts at democratization, can solidarity coalitions still become effective alternative actors for welfare development? In other words, is the solidarity coalitions’ ability to make use of their political resources to achieve redistributive reform dependent on a political environment that is conducive to political participation? The need for ‘new rules of the game’ in order for the solidarity coalitions to be able to use their political resources raises the question of whether the success of health care reform can be attributed to regime change, rather than solidarity coalitions.
Second, the impact of democratization on solidarity coalitions become obscure in cases where solidarity actors include state actors. According to Nam, the solidarity coalition's ability to garner the power resources necessary to initiate policy change is heavily dependent on the processes of democratization. Democracy activists were able to attain their political resources during their resistance against the authoritarian state; the transition to democratization then provided a political opportunity for them to pursue their agenda on redistributive issues.
As is the case, democracy activists such as NGOs, civic organizations, and labor unions accumulated political skills through their interaction with the state. Yet, how did state response against grassroots democracy movements affect state actors, namely the progressive bureaucrats? Whether state actors were on the responding or receiving end of state containment of democracy activism needs to be clarified. The study moreover does not fully explain how these state actors were able to acquire and polish their political resources before and after democratization. The political resource of progressive bureaucrats, ‘expert knowledge’, seems to remain constant and insulated from the effects of democratization that otherwise enabled societal groups to acquire their skills. Democracy movements seem to have only affected the political skills of societal actors; how state actors in Thailand were able to acquire expertise during the democracy movement and how their political resource was conditioned by regime response are issues that need be addressed.
Though there are details that warrant further elaboration, this book is insightful and provocative, providing a novel approach to understanding welfare expansion in developing democracies through identifying new welfare actors. Through the introduction of alternative actors pursuing health care reform, the author demonstrates that even when labor-based parties are largely absent, leftist and progressive forces in the form of solidarity coalitions may still have considerable influence on the direction of health care policy.
Nam's analytical framework incorporating solidarity coalitions, democratization, and political resources provides insights into the role of less organized and informal actors in understanding the political mechanism behind welfare development in an under-institutionalized setting. Though the author focuses specifically on health care reform, her findings have broader implications for studies on welfare state development, democratization, and state−society relations in new democracies and developing economies. In short, with its thorough qualitative analysis and novel framework, this book is highly recommended to scholars studying the politics of redistribution as well as comparative welfare states.
