The Political Determinants of Health: Elective and Chiefly Authority in South Africa

Carol Mershon

Professor Department of Politics

Hugh S. and Winifred Cumming Chair in Politics University of Virginia

PO Box 400787 Charlottesville VA 22904 USA

mershon@virginia.edu September 2016 Acknowledgements. For research assistance, I thank Rachel Okrent, Paromita Sen, and Jennifer Simons. For helpful comments, I thank Michelle Dion, Daniel Gingerich, Elizabeth Kaknes, Jon Kropko, Phil Potter, Olga Shvetsova, Denise Walsh, and seminar participants at the Institutions in Context Workshop, University of Tampere, Finland, Collegio Carlo Alberto, Turin, Italy, and University of Virginia. I gratefully acknowledge financial support from the Center for Global Health, Center for International Studies, Office of the Vice President for Research, Research Support in the Arts, Humanities, and Social Sciences, and Sesquicentennial Research Fund, all of the University of Virginia, along with financial support from the University of Tampere, Finland, and the Collegio Carlo Alberto, Turin. Abstract. Under what conditions do local political elites in new democracies promote citizen wellbeing? Pursuing this inquiry for South Africa, I assess hypotheses on party competition, popular participation, and chiefly authority as sources of local variation in public goods provision. Empirical analyses use an augmented version of a comprehensive census mortality sample. The evidence disconfirms the hypothesis that incumbents respond to competitive incentives to supply public goods. Partial, nuanced support appears for the hypothesis that citizen participation enhances public goods provision. Where chiefs are strong, restricted party competition under the ANC lowers the probability of infant and under-five death in majority Black African households, the largest set of households by far; where chiefs are strong, as voter turnout rises, the probability of infant and under-five death in majority Black African households diminishes. The article makes integrated theoretical and empirical contributions to scholarship on public goods, chieftaincy, and the workings of democracy.

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The Political Determinants of Health: Elective and Chiefly Authority in South Africa

Under what conditions do local political elites in new democracies promote the wellbeing

of the people they rule? This question is especially urgent in sub-Saharan Africa. The 1990s

witnessed the introduction of democratic regimes across Africa, the region with the highest rates

of infant and under-five mortality in the world (World Health Organization (WHO), 2016a,

2016b). In many African democracies, including post-apartheid South Africa, sub-national

governments shoulder a range of responsibilities devolved by national government, and thus are

in charge of delivering such public goods as water, sanitation, and health care (e.g., S. G.

Banerjee & Morella, 2011; Riedl & Dickovick, 2014).

The determinants of decentralized public goods provision in South African democracy

hold particular interest. The 1996 Constitution declares the right to health care services.

Translating affirmations into policy, since 1997 no user fees apply in primary health care clinics;

even before that, since 1994, no user fees apply for maternal and child health care (e.g.,

Wilkinson, Gouws, Sach, & Karim, 2001). Now an upper-middle-income country, South Africa

is among the world’s most unequal societies. Economic inequality has increased since the 1994

advent of democracy (World Bank, 2015a). In this context, mean under-five 2007-2011 mortality

rates varied across South African municipal health districts from 24.9 per 1,000 (similar to the

Turkish national rate) to 152.1 (roughly the rate in Somalia, among the world’s highest; World

Bank (2015b, 2015c) cross-national data, Health Systems Trust (2014) South African data).

What explains such striking local-level variations? Two prominent answers in extant

political science research center, respectively, on competition among party elites and on

participatory pressures from citizens. In the first school, variations across localities in party

system competitiveness should drive variations in the strength of the largest party’s incentives to

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provide citizens with public goods (e.g., Keefer & Khemani, 2005). In the second, local

variations in popular participation should account for variations in the inducements to elected

incumbents to supply public goods (e.g., Cleary, 2007; Putnam, Leonardi, & Nanetti, 1993).

This article appraises not only those hypotheses but also two contending hypotheses from

the recent literature on chiefly authority. Across sub-Saharan Africa, party elites hold power in

tandem with chiefs (e.g., Acemoglu, Reed, & Robinson, 2014; Baldwin, 2013, 2014).1 For

instance, by one estimate, South African traditional leaders have authority over roughly 45

percent of the national population, above all in rural areas (Williams, 2004, p. 114). As discussed

below, the authority of South African chiefs in municipal decision-making is entrenched in law.

The prevailing wisdom in the new research on traditional leaders is that chiefs should diminish

the supply of public goods, given their capacity for control and coercion (cf. Koter, 2013; Mares

& Young, 2016). Yet some scholars argue instead that chiefs should enhance the delivery of

public goods (cf. Baldwin, 2013, 2016). What influence might both types of local elites—

elective and traditional—have on citizen wellbeing?

In pursuing its inquiry, the article makes multiple contributions. It advances research on

the determinants of public goods provision (e.g., Besley, Pande, & Rao, 2012; Halleröd,

Rothstein, Daoud, & Nandy, 2013; Touchton & Wampler, 2014). It tackles the fundamental

debate on the relative impact of contestation and participation under democracy, and expands

1 I use such generic terms as chiefs and traditional leaders interchangeably, and gloss over

distinctions within South African (and African) chiefly hierarchy, which separate kings from

senior traditional leaders, chiefs, and headmen and headwomen (cf. Baldwin, 2016; Williams,

2010). A minimalist definition identifies chiefs as unelected, typically hereditary local leaders

who belong to the communities they rule and who, once elevated, rule for life.

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understanding of political institutions and party systems in new democracies (e.g., Ferree, 2010;

Lupu & Riedl, 2012). And the paper enriches work on the persistence yet transformation of

chiefly institutions and their coexistence with elective authority (e.g., Acemoglu et al., 2014;

Baldwin, 2016).

The next section locates this study within relevant scholarship and develops hypotheses

on sources of local variation in public goods provision. The second part motivates the focus on

South Africa, and the third addresses research design. Fourth, I test hypotheses on an augmented

version of the ten percent mortality sample from the 2011 South African Census.2 The

conclusions discuss implications.

Elected and Unelected Elites’ Responsiveness to Citizen Needs under Democracy

I begin by treating the types of goods that local political elites can furnish those they

govern, and then take up the forces that might induce elites to deliver the goods.3 It is useful to

conceive of a continuum of goods that politicians, government bureaucrats, chiefs, and other

actors can provide to citizens, with one end anchored by phenomena that are close at hand to

what elites can affect. Label this the “proximal” end, as in Figure 1. At the other extreme, we

find “distal” outcomes, which are not within the direct control of elites or any other single

category of actor. At the proximal end, for example, could be a municipality’s per capita primary

health care spending. Not as directly in public servants’ hands as public spending, yet still clearly

within their realm of impact, are such phenomena as the percentage of children under one year

2 The dataset and replication materials will be available upon publication at Author's website and

the CPS website.

3 Like many political scientists, I use the term “local public goods” to denote those benefits

directed to a particular geographic area and affecting multiple community members.

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who are classified by the municipal health system as fully immunized and the share of

households in a municipality with piped water in the home or the yard. Granted, the applicability

of this statement would vary according to the institutions and policies in place; given the

responsibilities of South African municipal governments, it is appropriate for South Africa (e.g.,

Muller, 2008). As Figure 1 indicates, further away from the reach of political elites’ decisions,

though influenced by them, along with other factors and actors, are municipal-level infant and

under-five mortality rates (e.g., Kramon & Posner, 2013).

[Figure 1 about here.]

Such a proximal-distal continuum, long common in the public health field, has recently

come in for criticism (e.g., Krieger, 2008). It highlights, however, that some prominent analysts

have lumped together what could well be viewed as distinct types of goods and outcomes (e.g.,

Franck and Rainer (2012) on educational attainment and infant mortality rates). The continuum

also points to the need to consider that “anti-poverty policies can affect infant mortality directly

or indirectly” (Díaz-Cayeros, Estévez, & Magaloni, 2016, p. 18). That is, outcomes at or near the

proximal end of the continuum, as relatively clear products of political decision-making, could

logically shape distal outcomes. Seeking to build on this and other contributions, I now take up

the circumstances that might motivate elected and unelected political elites to provide local

public goods.

A large body of scholarship in political science focuses on what might be termed the

electoral channel of representation in order to identify the incentives for elected politicians to

deliver public goods. Distinguished research in political science establishes elite contestation and

citizen participation as defining features of a democratic regime. Under democracy, elites

compete in recurring, free, and fair elections for voters’ support, and citizens are free to

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participate in politics in a host of ways other than voting for the representatives they prefer (e.g.,

Cheibub, Gandhi, & Vreeland, 2010; Dahl, 1971). Yet analysts of democracy differ in relative

emphasis on inter-party competition and popular participation. Some scholars underscore

electoral competition as the bedrock of democracy and the source of societally beneficial policy

outcomes (e.g., Lake & Baum, 2001; Powell, 2000). Others highlight civic engagement as

underpinning good governance and responsiveness under democracy (e.g., Cleary, 2010; Putnam

et al., 1993). This divide in the literature informs the first two hypotheses here.

The logic in the first hypothesis starts from the widespread assumption that elected

politicians engage in strategic calculations to maintain their power. In turn, party politicians

adopt strategies suited to the conditions they face. Relatively competitive local partisan

environments should thus spur the politicians of one party to expend relatively great effort at

differentiating themselves from those of other parties. In particular, to succeed in relatively stiff

partisan competition, a party should strive to convince voters of its capacity to enhance human

wellbeing (e.g., Arvate, 2013; Chhibber & Nooruddin, 2004; Gottlieb, 2015; Keefer & Khemani,

2005).

H1: The more competitive local elections are, the better public goods provision

should be.

The second hypothesis focuses not on party contestation but rather on citizen

participation as the primary source of local variations in the supply of goods and services. In this

reasoning, participatory pressures from below influence political incumbents, who then attend to

citizen concerns. Even more, the manifold forms of civic engagement boost the capacity of

ruling parties to make government work. Thus, when citizens actively voice their concerns,

whether through petitioning, protest, contacting public officials, or other modes, they both

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motivate and equip ruling parties to respond to their needs (e.g., Cleary, 2010; Putnam et al.,

1993; Schlozman, Verba, & Brady, 2012).

H2: The more citizens participate in local politics, the better public goods

provision should be.

The next two hypotheses are grounded in the recent literature on the power of traditional,

unelected elites in new democracies. The predominant perspective in this scholarship suggests

that chiefs serve as vote brokers for election-minded party politicians, and thus restrict the

provision of public goods (cf. Acemoglu et al., 2014; Koter, 2013; Mares & Young, 2016).

According to Koter (2013, p. 193), the relationship between voters and such local leaders as

chiefs “is complex, … based both on reciprocity and on some degree of exploitation.” Chiefs

influence, monitor, and (threaten to) sanction voters. Moreover, as Baldwin (2016) observes, this

research posits that chiefs, through either coercion or norms of reciprocity or deference, should

bring voters to cast votes without regard to candidates’ anticipated performance in office. With

chiefs as local brokers, clientelistic exchange between politicians and voters should drive

electoral politics. Chiefs should dampen any impact of competitive incentives or participatory

pressures on elective officials’ concern to meet citizen needs. Chiefs should throw their weight

behind their preferred party, whether those preferences arise, e.g., from shared ethnicity or from

favors performed by a party; and they should view a local party able to dole out favors as one

with a secure, not shaky, hold on elective office. Politicians, for their part, should cultivate

chiefs’ backing and rely on their capacity to suppress voter demands and direct votes to the party

they endorse. This logic culminates in the expectation that the stronger chiefs are, whether their

sway hinges on sanctions or norms, the worse the supply of public goods should be.

H3: Where traditional authorities exist, the stronger chiefs are, the worse public

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goods provision should be.

The fourth hypothesis envisions chiefs not as vote brokers but as “development brokers”

(Baldwin, 2016) who have the ability and the incentive to boost public goods provision in their

communities. Baldwin (2016, p. 21) characterizes chiefs as “socially and economically

embedded [local] leaders” at the same time that she contends that chiefs resemble the “stationary

bandits” depicted by Olson (1993, 2000). As stressed by Olson (1993, 2000), the stationary

bandit wields power due to coercive capacity. Even so, to the extent that contemporary African

chiefs approximate stationary bandits, their self-interest should lead them to serve the public

interest: chiefs should enhance the wellbeing of the members of their communities precisely

because they too belong to and live in the local communities they rule. What is more, chiefs’

time horizon exceeds that of elected politicians: they rule as chiefs for life. Their long tenure

strengthens their ability and incentive to facilitate the cooperation among citizens underpinning

the supply of public goods. Chiefs should thus mobilize action among citizens under their

jurisdiction to yield shared local benefits.4 Chiefs with citizens should, in a word, “co-produce”

public goods (Baldwin, 2016; cf. Ostrom, 1996). Elected politicians should then recognize that

chiefs can buttress their performance in office. Knowing that chiefs can sympathize more or less

openly with one party or another, politicians should court chiefs’ support as their party seeks and

wields power, and as they, with the chiefs’ aid, supply services to citizens. Politicians should

recognize as well that chiefs can increase flows of information between citizens and elites.

Traditional institutions can furnish additional arenas and points of access in which citizens

4 Imagine, for example, that chiefs use moral suasion and the specter of sanctions to assure

community participation in census enumeration and avoid undercounts. The public good of

accurate counts enables targeting of, e.g., water services. On the census scenario, see below.

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convey their preferences and obtain information so as to select candidates capable of meeting

their concerns (cf. Baldwin, 2013, 2016; Díaz-Cayeros, Magaloni, & Ruiz-Euler, 2014). Hence

the stronger chiefs are, the more public goods provision should be enhanced.

H4: Where traditional authorities exist, the stronger chiefs are, the better public

goods provision should be.

The logic in all hypotheses but the third depends on the assumption that (parties expect

that) voters have and use information about incumbent performance when making vote decisions

(e.g., A. Banerjee, Kumar, Pande, & Su, 2011). Survey evidence suggests that this assumption

applies in South Africa (e.g., Ferree, 2006) and elsewhere in Africa (e.g., Baldwin, 2013, 2016;

Mattes & Bratton, 2007; Weghorst & Lindberg, 2013). Yet the proof of the pudding in this paper

is in tests of hypotheses on variations in public goods. Discussion of the design for evaluating

hypotheses starts with country case selection.

Advantages of Focusing on South Africa

Studying South Africa brings four major benefits. First, decentralization of public goods

provision makes the South African context well suited to appraising these hypotheses. As

democratization proceeded, political parties compromised on a multi-level constitutional design,

often deemed quasi- or semi-federalism, in which central government retains control of finances,

regulates lower levels of government, and decentralizes responsibilities for various services and

goods (Simeon & Murray, 2001; Tafel, 2011; cf. Filippov, Ordeshook, & Shvetsova, 2004). The

majority African National Congress (ANC) came to see decentralization as fundamental to the

post-apartheid democratic regime. Opposition parties supported decentralization in the belief that

they could establish local power bases as counterweights to ANC-dominated central government.

Below the nine South African provinces, then, three categories of municipalities are in charge of

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such services as water, sanitation, electricity, roads, and refuse removal (e.g., Steytler, 2003).

Whereas a category A municipality has exclusive jurisdiction in its area, a B municipality shares

jurisdiction with the C municipality of which it forms a part. The district health system in

category A and C municipalities delivers primary health care; the non-overlapping A and C

municipalities constitute South Africa’s 52 municipal health districts. Category B municipalities

focus on disease prevention and health promotion (e.g., Coovadia, Jewkes, Barron, Sanders, &

McIntyre, 2009; Mayosi, Lawn, van Niekerk, Bradshaw, Karim, & Coovadia, 2012).5

Second, municipal South African party systems display greater variation than might be

supposed. Granted, in 2006 the ANC won 85.9 percent of municipal councils elected across all

three categories of municipalities. Likewise, as Figure 2 indicates, the ANC won 86.3 percent of

the councils elected in the A and C municipal health districts that are the focus of this study.6

These local victories accord with the ANC’s dominance of the national-level party system.

Observe too in Figure 2, however, that in those municipal health districts where the ANC came

in first, its margin of victory in seats varied from 0 to 0.824, around a median of 0.589; in three

municipalities, the ANC tied in seats, with vote shares sealing its win. Two other measures tap

variation in the ANC’s municipal strength, as shown at the top of Figure 2: the largest party’s

percentage of seats, which for the ANC ranges from 0.400 to 0.900, around a median of 0.757;

and the effective number of parties in council seats (ENPS), which for the ANC ranges from

1.220, expressing obvious dominance of the local party system, to 2.941.7 As the bottom part of

5 South African municipalities are not in charge of education or social services.

6 Figures 2 portrays all category A and C municipalities, the municipal health districts. On the

South African party system as relatively strongly institutionalized, see, e.g., Riedl (2014).

7 The well-known ENPS weights the raw number of parties by party size as expressed in seats

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Figure 2 portrays, the Democratic Alliance (DA) and Inkatha Freedom Party (IFP) witnessed

clear variation in their margins of victory and the percentage of seats where they landed first in

the 2006 municipal elections. The ENPS evinced fairly pronounced variation across councils

won by the DA and IFP. Voter turnout varied above all for municipal health districts won by the

ANC, and less so among other districts.8 Such differences within the set of councils won by the

ANC and across those won by different parties help make South Africa an apt testing ground.9

[Figure 2 about here.]

Third, chiefs are empowered in South African municipal decision-making and electoral

processes. South African chiefs hold land and allocate it to those who live under their

jurisdiction. They oversee property inheritance, settle disputes, and maintain social order (e.g.,

Logan, 2009; Ntsebeza, 2005; Williams, 2004, 2010). Chiefly authority in municipal decision-

making is enshrined in law, so that, where chiefs exist, elected municipal councils must consult

with them, traditional councils must be established, and traditional councils must participate in

developing local policy and legislation (Municipal Systems Act 2000, Art. 17 [2]; Traditional

(e.g., Mershon & Shvetsova 2013; Taagepera & Shugart, 1989).

8 The Independent Electoral Commission of South Africa (IEC) (2014) calculates turnout as the

percentage of registered voters plus the number of those who voted without advance registration

but with (conditional on presentation of identity documents) official approval to vote.

9 I assume that the largest party in an election becomes the ruling party afterwards. This

assumption prevails in research on government formation, corresponds to a national-level

regularity among parliamentary democracies (e.g., Mershon 2002; Strøm, Müller, & Bergman,

2010), and is a municipal-level regularity with few exceptions in South Africa to date (e.g., EISA

2006a, 2006b; Jolobe, 2007).

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Leadership and Governance Framework Act 2004, Sects. 3B, 4; cf. Beall, Mkhize, & Vawda,

2005; Logan, 2009; Williams, 2009). Where chiefs exist, they may earn appointment to

municipal district health councils, designed as those councils are to promote, along with citizen

health, positive relationships between elective and traditional authorities (National Health Act

2003, Sect. 31, esp. [3a]). Moreover, in the South African countryside, the Independent Electoral

Commission typically turns to chiefs to boost voter registration and mobilization, and encourages

chiefs to help monitor voting stations on election day (e.g., de Kadt & Larreguy, 2014; Williams,

2004). Chiefs extend the reach of the South African state in other ways: shortly before the 2011

Census, Statistics South Africa publicized its “partnership” with chiefs in its effort to avoid the

2001 census undercount in rural areas, as it “called on all traditional leaders to inform their

constituents about the significance of taking part in a census” and observed that chiefs were

“well placed to assist Stats SA” (Statistics South Africa, 2011).

Driving home the interest of studying the coexistence of elective and chiefly authority in

South Africa, Figure 3 illustrates the marked differences in local party systems across municipal

health districts as distinguished by presence and strength of chiefs. (See below on the coding of

municipal health districts as under no, weak, or strong chiefs.) The DA garnered first place in the

2006 elections only in municipal health districts lacking chiefs; both districts led by the DA were

in the Western Cape province, center of British and Dutch colonization. In contrast, the IFP came

first only in districts with strong chiefs, all of which were in its stronghold of the province of

KwaZulu Natal. Every one of the municipal health districts with weak chiefs saw a victorious

ANC in 2006. The differences not only across but also within sets of municipal health districts

are crucial to this study. For instance, witness the variation in ENPS and voter turnout within

each group of districts in Figure 3. Such variation also makes South Africa well suited to

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evaluating these hypotheses.

[Figure 3 about here.]

Last, extant research on South Africa yields conflicting evidence on this paper's

hypotheses. Although some case studies suggest that electoral incentives motivate incumbents to

supply public goods (e.g., Beall, 2005, p. 16), in line with H1, there are grounds for serious

doubt on both H1 and H2. One vein of research emphasizes the inadequate institutional capacity

of local government and the recurrence of malpractice, nepotism, and corruption within it (e.g.,

Atkinson, 2007; Krämer, 2016). Survey data show that only 27 percent of South Africans

perceive municipal councilors as responsive (Bratton (2012) on Afrobarometer), and an

experiment with South African municipal councilors reveals that they "are not particularly

responsive to anyone" in handling constituents' queries about public goods (McClendon, 2016, p.

1). De Kadt and Lieberman (2015) find that South African voters do not reward the ANC for

receipt of water, sanitation, and refuse removal services. Yet this evidence does not speak

directly to how incumbents might or might not act to deliver public goods (cf. de Kadt &

Lieberman, 2015, p. 30).

However the evidence fits with H3 or H4, controversy attends debates on roles played by

chiefs under South African democracy, for under apartheid the state manipulated the chieftaincy

in seeking control over the homelands (e.g., Ntsebeza, 2005). Subscribing to the vote broker

view of chiefs, De Kadt and Larreguy (2014) document that South African chiefs transfer blocs

of popular support to the party they favor. Nonetheless, they do not examine evidence on public

goods; and, as Baldwin (2016) contends, chiefs can both affect voting behavior and enhance

public goods provision. Case studies disclose that in some municipalities elected officials and

chiefs do not work together to foster local development (e.g., Beall, 2006, p. 466; Beall &

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Ngonyama, 2009, pp. 22-23; Oomen, 2005; Turner, 2014), but in others such cooperation does

unfold. For instance, one municipal councilor affirmed that “we [councilors] have to work with

the traditional leaders and give them respect. Also they control the land. Any development

project that involves land must get approval from the traditional leaders” (Beall, 2006, p. 465;

Beall & Ngonyama, 2009, pp. 20-21; Krämer, 2016; Oomen, 2005; Turner, 2014). In

Afrobarometer surveys, South African respondents evince less favorable views of traditional

leaders than do respondents elsewhere in sub-Saharan Africa, but South African respondents

hold even more negative attitudes toward elected officials (Logan, 2009; cf. Logan, 2013). Case

studies suggest that chiefs enjoy loyalty (Beall, 2005; cf. Beall, Parnell, & Albertyn, 2015) and

legitimacy in the communities they rule (Williams, 2010; cf. Oomen, 2005), in part stemming

from their ability to enhance local development. In sum, although the relevant current research is

rich, it not only reaches discordant findings but also lacks comprehensive, direct appraisal of all

four hypotheses here.

Measures and Methods

Tests of these hypotheses proceed with a household-level dataset from the 2011 South

African Census, which offers an unparalleled view of the distal public good of infant and under-

five mortality. The 2011 South African Census tracked deaths that occurred within households

during the preceding year (November 2010-October 2011, given the enumeration phase). In

2014, an edited, anonymized, subsetted ten percent 2011 Census sample on mortality became

available online through DataFirst (2015). These cross-sectional data have both advantages and

limitations. They offer roughly 40,000 observations and a place code that permits pinpointing

whether a given household reporting a death is located within a zone under chiefly jurisdiction.

Yet the Census mortality datafile contains only a dozen variables and is silent on the household’s

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access to services of any kind.10

To study the distal public good of citizen health, I first augment the ten percent 2011

Census mortality datafile by creating two dummy dependent variables. I recode the age of the

deceased in a given household to capture the event of an infant death in the last year (with 1

denoting occurrence, 0 absence) and the event of an under-five death in the household (1

occurrence, 0 absence). Turning to independent variables at the individual level, I track the

gender of the deceased infant (or child; 1=female; 0=male). At the household level, I recode the

majority racial group in the household to create a set of dummy variables denoting White (with 1

denoting the majority in a given household identified in the Census as White, 0 else), Black

African (1, 0 else), Coloured (1, 0 else), and Asian/Indian and other (1, 0 else); the last becomes

the reference category.11 Moreover, I recode one of the datafile’s place variables to designate the

household’s location in an area identified by the 2011 Census as a traditional enumeration area

(EA; 1=household within EA under chiefly jurisdiction, 0 else).12

Whereas the independent variables discussed so far are based on items contained within

10 Conversely, the ten percent 2011 Census sample on household services registers the event of

death within a household yet is silent on the deceased’s age. For good reason, infant and under-

five mortality rates are routinely regarded as better indicators of population health than, e.g.,

adult mortality rates. I thus do not use the household services datafile to examine citizen health.

11 I borrow the official population group classifications used in the South African Census.

12 The 2011 Census recorded data for more than 100,000 EAs, which were demarcated to

produce homogenous areas and coded to enable aggregation up to the municipal level. The

Census identified three types of EAs, urban, commercial farming, and traditional, with the last

under chiefly jurisdiction.

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the mortality sample, I also incorporate information from other datasets. The first independent

variable at the municipal health district level is a dummy tapping the household’s location in a

health district where party system competitiveness is relatively restricted (with 1 denoting those

municipal councils elected in 2006 for which the ENPS fell below 1.75, 0 else; IEC 2014).13 One

part of the analysis incorporates a dummy variable denoting whether the household was found in

a health district in which the ANC landed in first place in the 2006 municipal elections, along

with an interactive dummy to isolate those districts with both limited competition and the ANC

as the largest party in 2006. Another contextual variable captures popular participation in the

form of voter turnout in the 2006 elections in a given municipal health district (IEC 2014). Note

that all election-related independent variables pertain to the 2006 municipal elections, on the

assumption that, if local-level contestation and/or participation were to affect health outcomes in

late 2010-late 2011, they would be most likely to do so for the 2006-2011 electoral cycle.

Moreover, I track both 2010 district health service spending per capita and 2010 primary

health care spending per capita in the municipal health district in which a given household is

13 The use of dummies on ENPS aligns with common practice in scholarship on party

competition. In a separate original dataset on electoral outcomes across all municipal health

districts, the Pearson correlation between near-unipartism, on the one hand, and, on the other,

ENPS, the largest party’s margin, and the largest party’s seat share is, respectively, -0.854,

0.828, and 0.849 (p < 0.001 for all correlations). I rely on the dummy denoting near-unipartism

because it clearly taps the concept of restricted competition, of one party sitting astride the local

party system. As added advantages, the near-unipartism measure sorts the municipal health

districts into two roughly equal groups, and facilitates use of the interactive variable denoting the

ANC as the largest party.

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located (both in deciles; District Health Barometer (DHB) (2014)). I rely on two indicators of the

delivery of health care in the municipal health district in which a given household is found: the

2010 percentage of children under 1 year of age who are fully immunized; and the 2010

percentage of children aged 12 to 59 months who received Vitamin A (both in deciles; DHB

(2014)). The DHB also draws on 2011 Census data to report, for the municipal health district in

which a given household is located, the percentage of people lacking piped water within their

dwelling or within 200 meters of it, and the percentage of adults aged 18 to 65 lacking secondary

schooling (both in deciles; DHB (2014)). In view of research on the impact of ethnic diversity on

public goods provision (e.g., Alesina, Devleeschauwer, Easterly, Kurlat, & Wacziarg, 2003;

Kramon & Posner, 2013; Lieberman & McClendon, 2012; McDonnell, 2016), I control for

linguistic fractionalization in the municipal health district in which a given household is found

(in deciles; data from Statistics South Africa (2014).14 Table SI-1 in the online Supplementary

14 Values on the widely-used fractionalization indexes approach 1 as diversity rises and 0 as it

declines. For several reasons, I exclude a control for deciles on racial fractionalization at the

municipal health district level. This variable is highly correlated with deciles on the districts’

degree of linguistic fractionalization and share of households lacking piped water (Pearson

correlation = -0.7304 and -0.849, respectively, p < 0.001 for both). Moreover, in democratic

South Africa, municipal health districts are relatively racially diverse when the shares of White

and mixed race (Coloured) individuals are relatively high, and correspondingly, the share of

Black Africans is relatively low. (Shares of Asians/Indians vary less and tend to be low

throughout.) Thus, the theoretical proposition that diversity impedes public goods provision

clashes with the fact that racial diversity at the district level covaries with the presence of the

privileged group. The degree of racial fractionalization at the district level, then, does not

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Information provides descriptive statistics on the dependent and independent variables.

Given the binary dependent variables and the hierarchical structure of the data, the

appropriate model specification is multilevel mixed effects logistic regression. The estimations

take the following form:

Infant (U5) death in HHij = k + β1 Electoral competitivenessj + β2 Popular participationj

+ β3 Infant (U5) Gender + β4 HH Controlsi + β5 MHD Controlsj + εi j

The models weigh five classes of influences on the probability that the death of an infant

(child) occurs in household i within municipal health district j: a contextual dummy variable

tapping party competition in j, a contextual variable capturing citizen participation in j, the

gender of the infant (child) as the sole individual-level variable, a set of controls at the household

level, and another set of controls at the level of the municipal health district. At one stage of the

analysis, I conduct estimations for three sets of municipal health districts, according to presence

and strength of chiefly authority.15 All models use importance weights (on sampling for the

mortality ten percent datafile, DataFirst, 2015; personal communications with Statistics South

Africa personnel, July 10, 13, 14, 2015).

Empirical Analysis

The baseline model for infant mortality, identified as Model 1 in Table 1, looks at the

household’s majority racial group and the infant’s gender as influences on the occurrence of

infant death, along with the household’s location within a particular municipal health district. As

generate a theoretical prediction for the household-level likelihood of infant and child death.

Estimations including this variable are available from the author.

15 The online Tables SI-2A through SI-2C provide descriptive statistics on dependent and

independent variables for the three sets of municipal health districts.

18

the leftmost column of the table displays, babies in majority Black African and Coloured

households are relatively likely to die before their first birthday. Majority White households, on

the other hand, face a relatively low probability of experiencing the loss of an infant; the

coefficient on this dummy variable attains a marginal level of statistical significance. Female

babies in South Africa are less likely to die than are males, a finding aligning with extant public

health studies (e.g., Kahn, Garenne, Collinson, & Tollman, 2007).

[Table 1 about here.]

Model 2 incorporates a range of attributes that characterize municipal health districts. As

exhibited in the second column of Table 1, Model 2 leaves intact the impact of race and gender

on infant death. Moreover, the evidence from Model 2 overturns the expectation distilled in H1.

Specifically, the coefficient on the dummy variable tapping near-unipartism (as based on ENPS)

at the 2006 municipal election has a negative sign and is statistically significant: in municipal

health districts where one party dominates party competition, the likelihood that households

experience the loss of an infant is low relative to households in districts where multiple parties

engage in stiffer competition for council seats. In contrast, these data corroborate the

participatory hypothesis, H2: the greater the voter turnout in a municipal health district at the

2006 election, the lower the likelihood that a given household sustains the death of an infant.16

Looking at public goods, the greater a municipal health district’s share of adults lacking

16 As a robustness test, I conduct estimations in which deciles on the largest party’s margin of

victory replace the near-unipartism dummy as the proxy tapping inter-party competition (cf. note

12; details in Table SI-3). Similar results on H1 and H2 emerge. The numbers of observations

and groups decline in these estimations because there are missing data on 2006 electoral results

for one municipal health district, given boundary changes.

19

secondary education, the higher the probability that a household in the district suffers the death

of an infant. Two indicators of the municipal district’s delivery of goods typically presumed to

affect wellbeing—Vitamin A coverage and per capita primary health care spending—operate as

expected to significantly lower the probability of infant death in a given household. Remarkably,

the more widespread the immunization of infants in a municipal health district, the higher, not

the lower, the likelihood that a household in the district endures a baby’s death. Noteworthy, too,

is that overall district health care spending exerts little influence on infant mortality.

Model 3, the baseline model for the event of under-five death, reveals that children in

majority Black African and Coloured households are relatively likely to die before reaching the

age of five. Female children are relatively likely to survive beyond their fifth birthday. Majority

White households are relatively unlikely to undergo the tragedy of child death, but the

coefficient on this dummy lacks statistical significance.

The findings arrayed in the rightmost column of Table 1, on under-five death, resemble

those from Model 2, on infant death as determined by an array of attributes of municipal health

districts. One difference in Model 4 as compared to Model 2 is that the dummy for majority

White households lacks statistical significance. In Model 4, the result conflicting with H1, on

party competition, remains; support for H2, on citizen participation, persists. In line with Model

2, as scarcity of schooling rises, so too does the probability of child death. A surprise on infant

immunization recurs, now elevating the likelihood of under-five death. Vitamin A coverage and

per capita primary health care spending significantly reduce the probability of child mortality.17

17 As another robustness test, I replace the measures of deprivation in water and schooling with

the composite South African Index of Multiple Deprivation, which is based on 2011 Census data

and considers the material, employment, educational, and living environment domains (cf.

20

I use Models 2 and 4 as the basis for plots of the marginal effects of race and gender on

the probability of infant and child death, as differing across distinct municipal-level contexts of

partisan competition. As Figure 4 illustrates, the probability of infant death in majority Black

African households, as opposed to all other South African households, stands at 8.10 percent in

municipalities with relatively competitive party systems; it decreases to 7.07 percent where one

party dominates competition. Similarly, the probability of child death in Black African

households, as opposed to all other South African households, falls from 10.11 percent to 8.93

percent as the electoral arena shifts from competitive to one-party dominant. The marginal

effects of gender on the probability that households witness the death of babies and children, as

varying across distinct competitive contexts, are more limited; the advantage that female babies

and children have in survival lessens slightly where one party dominates the municipal party

system. Although the confidence intervals for these point estimates overlap, examining contrasts

of marginal effects reveals that these differences are statistically significant. (Details in Table SI-

4.)

[Figure 4 about here.]

I now evaluate hypotheses on chiefly authority by estimating variants of Models 2 and 4

while sorting the sample of households into three groups of municipal health districts: those

lacking chiefs altogether; those districts where chiefs are weak, that is, where the sampled

percentage of households in enumeration areas under chiefly jurisdiction lies above zero but

below the mean; and those districts where chiefs are strong, where the sampled percentage of

Noble, et al., 2013). The findings disconfirming H1 remain, while support for H2 disappears

(details in Table SI-3). Voter turnout and the SAIMD are relatively highly correlated (Pearson

correlation = -0.6327, p < 0.001).

21

households in enumeration areas under chiefly jurisdiction lies at or above the mean.

Table 2 reports the results of these estimations. The overarching message is that

influences on infant and under-five death vary across districts as distinguished by strength of

chiefly authority. Drilling deeper, Model 5 looks at the event of infant death among households

located in municipal health districts where chiefs are absent. As displayed at the far left of Table

2, the burden of infant mortality borne by majority Black African households reappears in this

class of districts. A significantly lower probability of infant death arises again in majority White

households located in districts without any chiefs. Here, for the first time, majority Coloured

households do not face a significantly greater likelihood of experiencing infant death than do

other households. Another first in the findings here is that female babies are not significantly less

likely to die than are male babies. Among households located in districts lacking chiefs, where

inter-party competition in the 2006 municipal election was relatively restricted (as tapped by the

near-unipartism dummy), the probability that a household suffers the loss of an infant is

relatively low; the coefficient attains marginal levels of statistical significance. Voter turnout in

the 2006 election no longer exerts a discernible impact on infant death. Thus, both H1 and H2

fall flat for households in this group of districts. As for public goods, the larger a district’s share

of people without piped water in or near their home, the greater the likelihood that a household in

the district suffers the death of an infant. Whereas infant immunization, Vitamin A coverage, and

per capita primary health care spending do not affect infant mortality, per capita total district

health spending reduces the probability that a household sustains the death of an infant.

[Table 2 about here.]

When we move to households located in districts where chiefs are weak, we discover that

only two factors exert a statistically significant impact on infant death: a baby’s birth in a

22

majority Black African household and in a municipal health district with a relatively high share

of adults lacking secondary schooling. As exhibited in the second column of Table 2, on Model

7, two other variables carry weight at marginal levels of significance: a baby’s birth in a majority

Coloured household and its gender. In these districts, as in those where chiefs are absent, the

evidence corroborates neither H1 nor H2.

Our attention shifts to households located in districts where chiefs are strong. As

registered in the third column of Table 2, devoted to Model 7, the probability of infant death is

significantly higher in majority Black African and majority Coloured households than in other

households in these districts. Alongside these factors, three other statistically significant

influences on infant death emerge in districts where chiefs are strong. Vitamin A coverage and

per capita primary health care spending diminish the likelihood that a given household will

experience the death of an infant. Educational deprivation raises that likelihood.

Look now at the right side of Table 2, on the event of under-five death, against the

backdrop of the findings arrayed on the table’s left side. Proceed step by step, from one set of

districts to another. Hence begin by comparing the results from Model 8 (fourth column), on

under-five death in households where chiefs are absent, and from Model 5, on infant death where

chiefs are absent. Major similarities emerge. Most important, the evidence runs counter to H1

and disconfirms H2. Next compare the findings from Model 9 (fifth column), on under-five

death where chiefs are weak, and from Model 6 on infant death in the same set of districts.

Despite some differences, similarities link the two groups of findings. In particular, support for

neither H1 nor H2 arises in these two estimations.

Now compare the findings from Model 10 (rightmost column), on under-five death where

chiefs are strong, and from Model 7, on infant death in such districts. For these settings, majority

23

Black African and majority Coloured households have a relatively high probability of facing the

tragedy of both under-five and infant death. Echoing the earlier findings, the interventions of

Vitamin A coverage and per capita primary health care spending lower the probability of child

death, whereas failures in the delivery of education increase the probability of child death. Most

pertinent to the argument, two differences separate the findings on infant and child death where

chiefs are strong: relatively restricted inter-party competition in the municipal heath district in

which a given household is located significantly reduces the probability of child death, which

flies in the face of the contestation hypothesis, H1; and relatively great voter turnout in a

household's health district reduces the probability of child death, supporting the participatory

hypothesis, H2. The coefficient on the latter variable attains marginal levels of statistical

significance.

It merits notice that in municipal health districts where chiefs are strong, compared to

other districts, relatively many people live without piped water and relatively many adults lack

secondary education. (See Tables SI-1, SI-2A through SI-2C). Even amid relative deprivation,

the proximal public goods of Vitamin A coverage and per capita primary health care spending

affect the distal public good of interest here: they work to lower the likelihood of infant and child

death. In this light, H4 is upheld. Where chiefs are strong, the contestation hypothesis, H1, fails

for both infant and under-five death, whereas the participatory hypothesis, H2, finds support only

for under-five death.

To better grasp the repeated failure of H1, I ask: does the identity of just which party

might or might not dominate municipal elections matter? I thus conduct estimations that

incorporate two additional dummy variables measured at the municipal health district level: one

marks those districts where the ANC came in first in the 2006 municipal elections; and the other

24

is an interactive dummy isolating those districts with both limited competition and the ANC as

the largest party in 2006. (For detailed results, see Table SI-5.)

I use such estimations as the basis for plots of the marginal effects of race and gender on

the probability of infant and child death, as differing across districts where the ANC does and

does not dominate partisan competition and looking only at districts where chiefs are strong.18 As

Figure 5 depicts, where chiefs are strong, the probability of infant death in majority Black

African households, as opposed to all other South African households, is 14.92 percent in

municipalities with relatively competitive local party systems or with the IFP as the leading party

(recall Figure 3). That probability declines to 7.71 percent where the ANC is dominant.

Likewise, where chiefs are strong, the likelihood that households suffer the loss of a child

decreases from 17.08 percent in districts with local party systems not dominated by the ANC, to

9.76 percent where the ANC sits astride the party system. The differences in survival just

discussed translate to seventy-two babies and seventy-three children in two similar

municipalities with strong chiefs for which the only difference would be whether or not the ANC

dominates the local party system. The marginal effects of gender on the probability that

households experience the death of babies and children, as varying by the fact of ANC

dominance where chiefs are strong, are more restricted; the advantage that female babies and

under-fives have in survival narrows slightly where strong chiefs and ANC dominance coincide.

Examining contrasts of marginal effects shows that the racial differences are statistically

significant, and those for gender are not. (For details, see Table SI-6.)

18 The plots focus only on districts where chiefs are strong because, due to collinearity, such

estimations for districts lacking chiefs and with weak chiefs omit one or both of the two

additional dummy variables used to isolate ANC dominance. See Table SI-5.

25

[Figure 5 about here.]

Still focusing on districts where chiefs are strong, I probe H2 further by calculating the

marginal effects of race and gender on the probability of infant and child death, as differing

across representative values of voter turnout. As Figure 6 illustrates, among districts with strong

chiefs, as voter turnout rises, the probability of infant and child death in Black African

households diminishes, whereas the probability that female babies and children die varies less.

Inspecting contrasts of marginal effects discloses that the racial differences are statistically

significant for both infant and under-five death. The differences for gender are not significant.

(See Table SI-7 for details.)

[Figure 6 about here.]

Conclusion

This article addresses a question of fundamental importance: what influence might local

political elites have on citizen wellbeing? It weighs answers emerging from scholarship on

contestation and participation as essential pillars of democracy and on the role of chiefly

institutions under democracy. The empirical analysis focuses on South Africa, a compelling site

for multiple reasons. Taking advantage of a comprehensive dataset on the distal public good of

infant and under-five mortality, I test hypotheses about the impact of interparty competition,

participatory pressures, and chieftaincy on health outcomes.

Since the end of apartheid, South African democracy has witnessed growth sufficient to

transform it into an upper middle-income economy. Yet one of the most striking findings here,

recurring throughout, is that majority Black African households are relatively likely to face the

tragedy of the death of an infant and a child under five. Racial inequities are a matter of life and

death for South African babies, children, and their families even now, after apartheid.

26

The ANC has dominated national-level South African politics since 1994. The ANC in

national government has championed and secured legislation that requires elected representatives

in local assemblies to pull chiefs into policy making. At no stage in this analysis do households

located in municipal health districts with relatively great party competition see a relatively low

likelihood of infant and child death. What is more, at multiple points the evidence directly

contradicts H1: relatively limited competition significantly reduces the probability of infant and

child death. Alongside the thoroughgoing failure of H1 stands partial, nuanced support for H2.

Analyzing all municipal health districts together, I find that households in districts with relatively

high voter turnout have a relatively low probability of experiencing the death of an infant or

child. Subdividing districts by strength of chiefly authority, it first appears that, only where

chiefs are strong, H2 holds for the event of child death; in all sets of districts the evidence on

infant death disconfirms that hypothesis. Scrutiny of marginal effects buttresses the finding that

limited competition enhances infant and child survival in Black African households and also

reveals that, where chiefs are strong, relatively restricted party competition under the ANC

lowers the probability of infant and under-five death in majority Black African households, the

most numerous category of households by far. Moreover, where ANC dominance and strong

chiefs coincide, as voter turnout rises, the likelihood of Black African infant and child death

dwindles. This evidence disconfirms H3 and supports H4 while thwarting H1 again and shoring

up H2.

This analysis of South African health outcomes is the first of its kind, given its theoretical

and empirical reach. Thus, along with novel evidence bearing on the research question, the paper

identifies avenues for further research on South Africa. First, it points to the interest of

investigating the determinants of such proximal public goods as safe water, along with the distal

27

public good of citizen wellbeing (e.g., on within-nation variation in Mexico, Díaz-Cayeros et al.

(2016)). Nonetheless, such a study lies outside the scope of this paper. Díaz-Cayeros et al. (2016)

examine both proximal and distal public goods, not by chance, in a book.19 Second, the findings

here guide enriched statistical analyses of the distal public goods of infant and child mortality in

South Africa. More finely grained data on electoral outcomes, chiefly authority, linguistic

fractionalization, and delivery of services relevant to health outcomes—not only water but also

sanitation, for instance—are available. Such measures could be used as more refined independent

variables, for the Census mortality datafile permits closer pinpointing of a given household’s

location.20

Third, the paper breaks new ground in its systematic empirical appraisal of the

hypotheses advanced, but does not uncover the mechanisms beneath its findings. Whether South

African chiefs co-produce with community members the distal public good of citizen health—or

other public goods—remains an open question. As noted, case study evidence from South Africa

suggests varying answers, with co-production present in some localities, absent in others, and

diverse patterns in localities without co-production (e.g., Oomen, 2005; Turner, 2014; Williams,

2010). Of particular interest, in some local cases chiefs cultivate networks with elected officials

to secure funds for local public goods, rather than mobilizing community cooperation to generate

19 Kramon and Posner (2013) show that relatively few studies look at both proximal and distal

public goods, engage in such an examination themselves, and do not assess hypotheses on the

impact of both elective and chiefly authority. On the last point, see below.

20 The publicly available data from the South African District Health Barometer on proximal

public goods do not allow for disaggregation: the DHB's measures of immunization, vitamin

coverage, and health spending pertain to the fifty-two health districts.

28

local public goods (Williams, 2010, esp. Chs. 6, 8). Additional research is needed to discern the

conditions accounting for any variation in co-production. For instance, public goods in two types

of chiefdoms could be compared: those experiencing the death of a chief and then, after an

interval, leadership under an inexperienced chief; and all other chiefdoms (cf. Baldwin, 2016, pp.

115-120). The data on South African chieftaincy permitting such a comparison are not publicly

available, however.

Another mechanism beneath the findings here might be that the ANC has used its

longstanding dominance at the national level to restrict resources available to, and public goods

provision within, municipalities controlled by opposition parties. Case-study evidence current as

of 2012 indicates that this has not occurred (Cameron, 2014; Resnick, 2014). Yet comparative

statics, based on a scenario that has only quite recently materialized, would offer the best

assessment of this possibility. The 2014 national elections handed the ANC its smallest seat

share in the National Assembly to date, 62.3 percent. Not only has national-level ANC

dominance eroded but also, crucially, local-level opposition parties have gained new strength:

the municipal elections of early August 2016 gave the ANC only 59.3 of the vote nationwide and

returned a number of municipal councils without a seat majority (de Vos, 2016; McMurry,

Martin, Lieberman, & de Kadt, 2016; Phillip, 2016). At the time of writing, the most variegated

set of municipal councils in the history of South African democracy has barely started work on

public goods provision. Future analysis of public goods under these governments is obviously

appealing.

This inquiry holds lessons for research beyond South Africa. Existing research highlights

the role of traditional leaders across sub-Saharan Africa, and pioneering studies examine how

chiefs in concert with both elective officials and community members co-produce proximal

29

public goods in Africa (e.g., Baldwin, 2016). Outside Africa, traditional leaders have local

political powers and at least the potential to affect public goods (e.g., Beath, Christia, &

Enikolopov, 2013; Cornell & Kalt, 2000; Díaz-Cayeros et al., 2014; Van Cott, 2010). To my

knowledge, however, no project other than this one appraises the impact of both elective and

traditional authority on the distal—literally vital—public goods of infant and under-five survival.

This article indicates how such work could proceed.

Most broadly, this study demonstrates that political scientists need to revisit the wisdom

on “elections as instruments of democracy” (Powell, 2000). Rich and diverse research schools in

the discipline analyze parties, party systems, and elections as essential links in the chain of

democratic representation and responsiveness. Yet where traditional leaders wield local power,

understanding the extent to which democracy serves citizen needs calls for investigation into

both elected and unelected authority. This article thus makes integrated theoretical and empirical

contributions to scholarship on public goods, chieftaincy, and the workings of democracy.

30

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Figure 1. Proximal-Distal Continuum of Public Goods: Some Examples. PROXIMAL DISTAL | | | per capita primary health spdg immunization, Vitamin A coverage IMR, U5MR per capita district health spdg pct HH with piped water Note: See text for discussion of examples.

37

Figure 2. South African Municipal Party Systems, by Party Winning Most Seats in 2006 Municipal Elections.

0 .5 1 1.5 2 2.5 3

IFP (n=5)

DA (n=2)

ANC (n=44)

Largest Party's Margin Largest Party's Pct SeatsENPS Pct Voter Turnout

38

Figure 3. South African Municipal Party Systems, by Party Winning Most Seats in 2006 Municipal Elections and Chiefly Strength (No, Weak, and Strong Chiefs).

0 .5 1 1.5 2 2.5 3

stro

ngw

eak

none

IFP (n=5)

DA (0)

ANC (n=18)

IFP (0)

DA (0)

ANC (n=9)

IFP (0)

DA (n=2)

ANC (n=17)

Largest Party's Margin Largest Party's Pct SeatsENPS Pct Voter Turnout

Note: The horizontal axis shows values on the largest party’s margin of victory in seats, the largest party’s percentage of seats, the municipal councils’ effective number of parties in seats (ENPS), and percentage voter turnout in the 2006 municipal elections. Key to abbreviations: ANC=African National Congress; DA=Democratic Alliance; ENPS=Effective number of parties in seats; IFP=Inkatha Freedom Party.

39

Figure 4. Marginal Effects of Race and Gender on Probability of Infant and Under-Five Death, by Degree of Party Competition in Household's Municipal Health District.

-.05

0.0

5.1

.15

Effe

cts

on P

r(Inf

ant D

eath

) and

Pr(U

nder

-5 D

eath

)

0 1Limited Party Competition in 2006 Election in HH's District (0 = no, 1 = yes)

Majority Black African HH, Infant Death Female Infant DeathMajority Black African HH, Child Death Female Child Death

Average Marginal Effects with 95% CIs

40

Figure 5. Marginal Effects of Race and Gender on Probability of Infant and Under-Five Death, by Fact of ANC Dominance in Household's Municipality and Only Under Strong Chiefs.

0.0

5.1

.15

.2.2

5Ef

fect

s on

Pr(i

nfan

t Dea

th) a

nd P

r(Und

er-5

Dea

th)

0 1ANC Dominant in 2006 Municipal Election (0= no, 1 = yes)

Majority Black African HH, Infant Death Female Infant DeathMajority Black African HH, Child Death Female Child Death

Average Marginal Effects with 95% CIs

41

Figure 6. Marginal Effects of Race and Gender on Probability of Infant and Under-Five Death, at Representative Values of Voter Turnout in Household's Municipality and Only Under Strong Chiefs.

0.0

5.1

.15

.2Ef

fect

s on

Pr(I

nfan

t Dea

th) a

nd P

r(Und

er-5

Dea

th)

.40 .45 .50 .55 .60Voter Turnout in 2006 Election in HH's District

Majority Black African HH, Infant Death Female Infant DeathMajoity Black African HH, Child Death Female Child Death

Average Marginal Effects with 95% CIs

42

Table 1. Explaining the event of infant and under-five deaths in households; multilevel mixed effects logistic regression.

Infant Death in HH Under-Five Death in HH 1 2 3 4 Black African

1.438*** (0.265)

1.424*** (0.265)

1.330*** (0.216)

1.315*** (0.216)

Coloured 1.049*** (0.280)

1.086*** (0.281)

0.849*** (0.231)

0.879*** (0.232)

White -0.611† (0.333)

-0.600† (0.332)

-0.356 (0.260)

-0.348 (0.260)

Female

-0.089* (0.036)

-0.091* (0.036)

-0.065* (0.031)

-0.067* (0.031)

MHD near-unipartism 2006 election

-- -0.160* (0.070)

-- -0.153* (0.063)

MHD voter turnout 2006 election

-- -2.118* (0.972)

-- -2.413** (0.868)

MHD pct no piped water home/200m 2011

-- 0.021 (0.020)

-- 0.019 (0.018)

MHD pct adults no secondary school 2011

-- 0.067** (0.020)

-- 0.077*** (0.017)

MHD linguistic fractionalization 2011

-- -0.019 (0.016)

-- -0.018 (0.015)

MHD < 1 year fully immunized 2010

-- 0.022† (0.012)

-- 0.021† (0.011)

MHD 1-5 yrs Vitamin A coverage 2010

-- -0.031** (0.011)

-- -0.029** (0.010)

MHD per cap primary health care spending 2010

-- -0.033** (0.012)

-- -0.030** (0.011)

MHD per cap district health spending 2010

-- -0.012 (0.015)

-- -0.016 (0.013)

Municipal health district: identity

0.242 (0.034)

0.142 (0.027)

0.235 (0.031)

0.128 (0.023)

Wald χ2 148.23 201.95 194.72 269.22 Prob > χ2 0.0000 0.0000 0.0000 0.0000 Log likelihood -11649.00 -11461.498 -14213.22 -13982.263 N obs 39,122 38,631 39,122 38,631 N groups 52 51 52 51 † p < 0.10; * p < 0.05; ** p < 0.01; *** p < 0.001. Notes: Reference category on HH majority racial group: Asian/Indian and other. Each model includes a constant, not reported. The numbers of observations and groups decline in Models 2 and 4 because there are missing data on 2006 electoral results for one municipal health district, given boundary changes.

43

Table 2. Explaining the event of infant and under-five deaths in households; multilevel mixed effects regression, by strength of chiefly authority. Infant death in HH Under-five death in HH Chiefly strength in HH’s district Chiefly strength in HH’s district Absent Weak Strong Absent Weak Strong

Model 5 6 7 8 9 10 Black African

1.133* (0.510)

1.452*** (0.327)

2.035* (1.009)

1.020* (0.420)

1.371*** (0.269)

1.693* (0.720)

Coloured 0.753 (0.519)

0.825† (0.465)

2.085* (1.055)

0.531 (0.429)

0.859* (0.384)

1.654* (0.772)

White -1.573* (0.620)

-0.101 (0.457)

0.806 (1.080)

-1.118* (0.478)

0.073 (0.361)

0.669 (0.779)

Female -0.105 (0.071)

-0.141† (0.077)

-0.064 (0.049)

-0.061 (0.062)

-0.153* (0.068)

-0.036 (0.043)

MHD near- unipartism 2006

-0.265† (0.149)

0.374 (1.180)

-0.133 (0.088)

-0.225† (0.128)

0.193 (0.993)

-0.199* (0.082)

MHD voter turnout 2006

-2.611 (2.398)

-18.001 (26.848)

-1.671 (1.519)

-1.092 (2.083)

-13.312 (22.604)

-2.243† (1.432)

MHD pct no piped water 2011

0.176** (0.062)

0.269 (0.306)

0.053 (0.036)

0.116* (0.054)

0.214 (0.259)

0.055 (0.034)

MHD pct adults no 2ndary school '11

-0.007 (0.048)

0.210** (0.062)

0.075* (0.029)

0.055 (0.040)

0.185** (0.054)

0.071* (0.028)

MHD linguistic fractional’n 2011

-0.085 (0.056)

0.043 (0.034)

-0.016 (0.022)

-0.045 (0.047)

0.034 (0.030)

-0.022 (0.021)

MHD < 1 year immunized 2010

-0.063 (0.042)

-0.032 (0.037)

0.002 (0.021)

-0.021 (0.035)

-0.016 (0.031)

-0.016 (0.020)

MHD age 1-5 Vitamin A 2010

-0.004 (0.019)

0.022 (0.047)

-0.108*** (0.018)

-0.000 (0.017)

0.023 (0.040)

-0.102*** (0.017)

MHD per cap PHC spdg 2010

0.033 (0.039)

0.084 (0.205)

-0.051*** (0.014)

0.010 (0.035)

0.042 (0.173)

-0.041** (0.013)

MHD per capita health spdg 2010

-0.085** (0.031)

0 (omitted)

0.020 (0.019)

-0.087** (0.028)

0 (omitted)

0.025 (0.018)

MHD: identity

1.33e-09 (0.072)

1.66e-00 (0.039)

0.086 (0.036)

4.36e-06 (0.045)

2.94e-07 (0.034)

0.092 (0.030)

Wald χ2 106.26 79.34 74.70 9.24 98.74 77.47 Prob > χ2 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 Log likelihood -3038.329 -2493.239 -5901.847 -3703.453 -3048.900 -7200.632 N obs 11,661 8,855 18,115 11,661 8,855 18,115 N groups 19 9 23 19 9 23 † p < 0.10; * p < 0.05; ** p < 0.01; *** p < 0.001. Notes: Reference category on HH majority racial group: Asian/Indian and other. In districts where chiefs are weak, one variable is omitted due to collinearity.