Grievance Politics and Technocracy in a Developmental State: Healthcare Policy Reforms in Singapore

This article uses a process-tracing approach to understand changes in Singapore's health sector from the start of self-rule in 1959 to the end of the COVID-19 pandemic in 2022. Singapore is a developmental state recognized for its effective management of healthcare costs and its lack of political freedom. In both respects, the ‘Singapore model’ is of interest to other cities and nations. The standard narrative is one of technocratic proficiency in a context in which civic freedoms are heavily constrained, but this article identifies the surprisingly important role of social voices at key moments. It finds episodes in which effective changes to social policies are not the product of a state embedded in an organized society, but rather are influenced by the independent organizational capacity of certain social groups providing inputs to state elites on social grievances and policy needs. Effective policy changes require a responsive state elite that — even if it is technocratically dominated, as is the case in Singapore — can listen to social claims and provide answers that are not repressive. The article conceptualizes these dynamics as ‘grievance politics’ and shows their role in explaining health reforms. It contributes to understanding global health systems and policy making in developmental states by a fruitful cross-fertilization with social movement studies.