Using a creative juxtaposition of cases, Joseph Harris delves into one of the counter-intuitive aspects of democratization processes: namely, the tendency for reforms aimed at enfranchising a broad swathe of the population to instead reallocate power within and among elites. The argument is reminiscent of Jim Morone’s classic work in the American context The Democratic Wish, in which he showed among other things how the establishment of health care planning agencies aimed at lay and local input into the planning of health care facilities disrupted the established structures of control by the medical profession and allowed other elite interests to assert themselves at the profession’s expense. In Harris’s cases, in contrast, what we observe is the ascendence of reform “movements” within established professions: principally, medicine, law and pharmacy. These groups functioned as “movements” insofar as they maintained an informal association self-consciously dedicated to a common normative cause, but their defining features are their “in-between” status with bases in both professional communities and the state, and their dedication to a cause beyond the interests of the profession itself. These “professional movements” used their privileged access to the “infrastructure and resources” of the state and their professional expertise to act as social policy reformers with the goals of achieving universal coverage of health care and access to anti-retroviral medications.
Harris studies this phenomenon of state-embedded professionals in one principal national case – Thailand – and two cases chosen to cast the Thai case into comparative relief: Brazil and South Africa. The comparative range is extended by including the two lines of reform in each nation: toward ensuring universal health care coverage and toward making AIDS medication universally available. These cases appear to have been selected because they have in common the emergence of professional reform movements aimed at achieving changes in social policy during a period of democratization. In each case reforms were advanced by actors who left their bases in professional “practice” of some kind to take up positions within the state bureaucracy to function as agents of progressive reform. The cases also provide variation on one key dependent variable: the relative success of the reform movements. In the Thai and Brazilian cases, these efforts were largely successful; in the South African case they were not.
In the Thai case, through extensive interviews and documentary research, Harris first traces the role of a group of physicians, dubbing themselves the Rural Doctors Movement, to press forward legislation providing for universal health care coverage in the 1990s and early 2000s, as Thailand democratized after a lengthy period of military rule. Securing positions in the Ministry of Public Health and international organizations and working in concert with other groups in civil society and with one of the emerging political parties, members of the Rural Doctors Movement were able to advance an agenda of reform that extended the democratization process to the health care arena, through a framework of decentralization and citizen participation and to sweep universal coverage into that reform agenda. Though it is not possible to isolate the effect of this movement among the range of other forces in play within the state and civil society (and indeed one of the key state actors was a physician who was not a member of the professional movement though sympathetic to its aims), Harris draws from the Thai case the somewhat tempered claim that “[i]n the absence of the strategic actions of the Rural Doctors, there is little reason to believe that a number of critical things that enabled Thailand’s Universal Coverage Policy to come into being would ever have happened” (62).
In order to test this claim further, Harris turns to another case in which the emergence of a professional movement was associated with the adoption of universal health care coverage – the sanitaristas of Brazil in the 1980s through the 2000s – where he finds a “strikingly similar pattern.” Although the strategy was different and more state-centric, built around embedding principles in the new democratic constitution, crafting legislation and building the infrastructure of implementation rather than allying with a political party and civil society groups as in Thailand, the professionals who formed the Brazilian sanitarista movement operated from within the state at central and local levels to have an impact on the creation of universal access to health care similar to that of their Thai counterparts.
These two positive cases lend support to Harris’s claim regarding the importance of elite professional movements in achieving progressive ends in democratizing contexts, but they cannot demonstrate that such movements are sufficient to bring about such reforms. A case in which a professional movement failed in its progressive aims would open up a consideration of the contextual factors that make for success or failure. Harris finds such a case in South Africa, where despite the mobilization of a movement of reform-oriented medical professionals dating from the 1970s, some of whose members entered government after the dismantling of apartheid in the 1990s, universal access to health care was adopted “in name only”. The exploration of this case allows Harris to identify another factor, a necessary condition for the achievement of universal coverage that was present in each of the Thai and Brazilian cases but not in South Africa – namely, the existence of political incentives for politicians to adopt a health care reform agenda as a matter of partisan advantage. (It is worth noting here that in recent work in four established democracies I also found such partisan imperatives to be necessary conditions for the taking on the political risk of reforming health care.) In South Africa’s one-party democracy, such incentives were blunted. As Harris puts it, the hegemonic African National Congress “had the luxury of being able to opt for relatively easy and technically uncomplicated reforms that would pay political dividends and avoid larger and uncertain reforms that carried a great deal more political risk” (91). It is not clear from Harris’s account, however, why professional reformers were not able to exploit intra-party ideological contests within the ANC as a proxy for inter-party competition.
To further buttress his argument, Harris extends his purview to consider the role played by professional movements in his three national cases in the related area of access to anti-retroviral medications. Here the relevant members of the professional movements are related to but identifiably distinct from those concerned with universal health care coverage. In part this was because the AIDS medication crusade drew upon a somewhat different expertise set, requiring familiarity with the international web of legislation, regulation and legal cases governing pharmaceuticals. In these circumstances, the key professional actors were legally-trained, or at least “legally-minded” or “legally proficient” doctors and pharmacists. In Thailand, a sibling association of the Rural Doctors Movement laid the groundwork within the state for the adoption of compulsory licensing of AIDS medication in 2006 and 2007. In Brazil, the sanitaristas’ strategy comprised the constitutionalization of rights to health care as a ground for compelling state action, the securing of funding from international bodies and the adoption of legal frameworks governing pharmaceutical firms. And once again in South Africa, reformers’ attempts foundered in the face of the dominance of the ANC – which in this case was not merely indifferent but actively hostile to the reformers’ aims.
Harris concludes from this review that the ability of professional movements to achieve their progressive ends in democratizing regimes depends upon the nature of political competition in those regimes – in other words, the extent to which these movements operate in a context in which at least some politicians have a competitive partisan incentive to take up the reform agenda and its implementation. The single negative case of South Africa is a rather slender reed on which to build this case, especially given that there is relatively little in the book about party competition itself in the positive cases of Thailand and Brazil. Nonetheless, the book offers an illuminating insight into the role of these professional movements and a plausible set of hypotheses for further research.
This is a lucidly and persuasively written book that will be of interest in a number of fields: the sociology of professions, the politics of the welfare state and the comparative dynamics of democratization. Its identification of the role of professional reform movements seems likely to inspire further investigations of this phenomenon in other cases and contexts, and may well stand as a germinal contribution.
