Mental health care is an important part of any society. Yet, its salience is not always reflected in how various institutions, societies, and countries respond to it. This often results in persons with mental health issues being underserved. Disparities in the treatment of these persons are linked to many factors, some of which remain unexplored. In most modern democracies, advocacy remains the primary vehicle by which many groups in society are able to access goods, services, and even governance benefits. However, persons with mental health issues often lack the agency to mount this advocacy on their own behalf. Against this backdrop, Perera asks a very potent question—why would the state supply services to those who are unable to demand them? And precedingly, what explains the cross-national variations in mental health care services?
In response to these questions, Perera uses seven chapters to argue that welfare workers—described as workers employed by the welfare state—are viable sources of relief for those living with mental health issues. Perera makes a very convincing case that these welfare workers have a stake in advocating for the interests of those living with mental health issues. The author draws on historical data from the United States, France, and other Scandinavian countries to show how variations in deinstitutionalizing mental healthcare often result in both positive and negative effects on welfare workers, not just mental health patients. This feedback then triggers a response from these workers who lobby policymakers in order to save their jobs or to acquire more resources to do their jobs. When such lobbying is successful, mental health patients benefit as a kind of positive externality. When such lobbying is unsuccessful, there is an expected negative feedback of reduced wages, layoffs, fewer public services, and less support for labor rights, which in turn negatively affects the services supplied to mental health patients. Still, Perera argues that such negative feedback may motivate welfare workers to increase their advocacy until positive outcomes are achieved.
Perera’s framework makes sense. It is a practical explanation of what often occurs, but less often explored empirically. The author is therefore to be credited not only for proffering a useful framework, but also for the empiricism with which the exploration was conducted. Importantly, Perera discusses the caveats and limitations of the proposed framework. One such caveat is that the success of the advocacy mounted by welfare workers is highly dependent on whether these street-level workers enjoy strong coalitions with their managerial bosses. There are two noteworthy critiques here—though neither critique diminishes the quality of the framework. Firstly, the principal-agent issues that play out at coalition-building between street-level bureaucrats and their bosses are much more complex than Perera explores in this book, and therefore warrants further explorations. Secondly, Perera’s discussion at times seems to suggest that when welfare workers are successful in their advocacy for themselves, there is an automatic trickle down to their patients. Though a plausible explanation, in reality, this is not always the case, and such nuances deserve more detailed unpacking than was provided.
Another noteworthy point in this book is that the author underscores the crucial role of public administrators in the process of healing some implicit defects of democracy and citizen participation. While Perera uses the terms “welfare workers” and “public employees,” these are actually bureaucrats whose actions bring relief to constituents who are unable to demand that relief on their own. While current scholarship on issues such as representative bureaucracy explores how innate and personalistic factors shape helping behavior among bureaucrats and elected officials, Perera takes us down a different path to explore how administrative and political arrangements also trigger similar outcomes. By doing this, she uncovers a largely unexplored dimension of public administration literature on mental health care.
As previously indicated, the author also pursues a cross-national analysis. Perera devoted some time to justify studying the comparative political economy of mental health. While Perera makes a strong argument for an exploration around political economy, the justification of a cross-national comparison is less developed. In Paul Light’s The Tide of Reform (1997), he outlines four tides of bureaucratic arrangements. By comparing how mental health services are delivered under two “tides,”—Scientific Management and Liberation Management—one could almost replicate the cross‑national contrast (e.g., U.S. versus France) entirely within U.S. bureaucratic evolution, by showing how shifting from rigid, expert‑driven systems (Scientific Management) to flexible, client‑centered ones (Liberation Management) produces many of the same differences that Perera attributes to national culture or policy.
I am therefore left asking, given that Perera’s focus is on how bureaucrats behave, whether these differences are based on the nature of the countries or the nature of the bureaucracies. If the latter, then a cross-national comparison becomes less relevant to the substantive discussion—the role of bureaucrats in shaping healthcare-related outcomes. A temporal comparison of different political administrations in a single country may yield the same explorative value and even more detailed explanations. If the former, then Perera’s account becomes even more consequential for the field in understanding the political economy of healthcare delivery. This distinction is crucial as it helps to shape how future research is oriented—focused on countries, or on how bureaucracies are arranged.
Perera makes two notable delimitations in this volume that are crucial for how the findings and framework are to be interpreted and applied. First, Perera delimits the current work only to “affluent democracies.” While a comparison between the Global North and the Global South would perhaps also provide more variations that would bolster external validity, Perera’s work remains instructive and insightful. Still, the findings are only best applied to a Global North context. This body of work therefore ignites the urgency of exploring this same issue in a South context where disparities in mental health care are even more prevalent. The second delimitation is done in relation to Perera’s definition of “welfare workers,” whereby only those working for the state in public organizations are included. Yet, we know that a more diverse set of stakeholders are engaged in welfare work. Of note, persons who work for civil society, non-profit groups, and even private sector organizations are often actively engaged in welfare work to the same degree as public servants. Perera’s work is therefore a seminal exploration into the true impact of how “welfare workers”, as a broader and more complex group, shape the health care experiences of constituents who lack the agency to demand services for themselves.
