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PUBLIC MANAGEMENT REFORMS BETWEEN
AUSTERITY AND DEMOCRACY

PUBLIC ACCOUNTABILITY AND

HEALTH CARE GOVERNANCE

EDITED BY PAOLA MATTEI

Public Accountability and Health Care Governance
 Paola Mattei
Editor

Public Accountability
and Health Care
Governance
Public Management Reforms Between
Austerity and Democracy
Editor
Paola Mattei
St Antony’s College
University of Oxford
Oxford, UK

ISBN 978-1-137-47298-4 ISBN 978-1-137-47299-1 (eBook)

DOI 10.1057/978-1-137-47299-1

Library of Congress Control Number: 2016937365

© The Editor(s) (if applicable) and The Author(s) 2016

The author(s) has/have asserted their right(s) to be identified as the author(s) of this work
in accordance with the Copyright, Design and Patents Act 1988.
This work is subject to copyright. All rights are solely and exclusively licensed by the
Publisher, whether the whole or part of the material is concerned, specifically the rights of
translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on
microfilms or in any other physical way, and transmission or information storage and retrieval,
electronic adaptation, computer software, or by similar or dissimilar methodology now
known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information
in this book are believed to be true and accurate at the date of publication. Neither the
publisher nor the authors or the editors give a warranty, express or implied, with respect to
the material contained herein or for any errors or omissions that may have been made.

Cover image © CVI Textures/Alamy Stock Photo

Printed on acid-free paper

This Palgrave Macmillan imprint is published by Springer Nature

The registered company is Macmillan Publishers Ltd. London
 CONTENTS

Public Management Reforms and Their Impact on Democratic

Processes 1
Paola Mattei

German Healthcare in Transition: Global Pressures,

Governance and Public Wellbeing 13
Patricia Hogwood

Hospital Planning in a Competitive Arena:

Sustaining or Suspending Market Forces? 37
Tanja Klenk

Marketization and Accountability: Lessons from

the Reforming Norwegian Healthcare System 65
Simon Neby

From Demigods in White to Normal Employees:

Employment Relations and New Incentive
Structures in German Hospitals 91
Maximiliane Wilkesmann

v
vi CONTENTS

Accountability in Multilevel Health Care Services:

The Case of Norway 115
Haldor Byrkjeflot, Tom Christensen, and Per Lægreid

Organ Transplant Policies and Cultural Worldviews 147

Paola Mattei

From “Major Decisions” to “Everyday Life”:

Direct Accountability to Clients 165
Thomas Schillemans, Hester van de Bovenkamp,
and Margo Trappenburg

Accountability and Shared Measurement

in Health Care: Examples from Israel 193
Yehonatan Almog, Bruce Rosen, and Jack Habib

Index 217
 CONTRIBUTORS

Yehonatan Almog System-wide Impact and Measurement Unit, Myers-JDC-

Brookdale Institute, Jerusalem, Israel
Hester van de Bovenkamp Institute of Health Policy & Management, Erasmus
University, Rotterdam, The Netherlands
Haldor Byrkenflot Department of Sociology and Human Geography, University
of Oslo, Oslo, Norway
Tom Christensen Department of Political Science, University of Oslo, Oslo,
Norway
Jack Habib The Executive Director of the Myers-JDC-Brookdale Institute, Jerusalem,
Israel
Patricia Hogwood Department of Politics and International Relations, University
of Westminster, Westminster, UK
Tanja Klenk Department of Social Work and Social Welfare, University of Kassel,
Germany
Per Laegreid Department of Administration and Organization Theory, University
of Bergen, Bergen, Norway
Paola Mattei Associate Professor of Comparative Social Policy, St Antony’s College,
University of Oxford, Oxford, UK
Simon Neby Uni Research, Stein Rokkan Centre for Social Studies, Bergen, Norway

vii
viii CONTRIBUTORS

Bruce Rosen Smokler Center for Health Policy Research, Myers-JDC-Brookdale

Institute, Jerusalem, Israel
Thomas Schillemans Faculty of Law, Economics, and Governance, Utrecht
University School of Governance, Utrecht, The Netherlands
Margo Trappenburg Faculty of Law, Economics, and Governance, Utrecht
University School of Governance, Utrecht, The Netherlands
Maximiliane Wilkesmann Faculty of Business, Economics, and Social Sciences,
TU Dortmund University, Dortmund, Germany
 LIST OF FIGURES

Chapter 5
Figure 1 Total number of hospitals and hospitals’ ownership
structures over time (compiled by the author) 94
Figure 2 Total number of hospitals and hospitals’ ownership
structures over time (compiled by the author) 101
Figure 3 Trend in hip replacement surgery, selected OECD
countries, 2000–2011 (or nearest year). 104
Figure 4 Attitudes among different generations of chief physicians
(approval rating; 4 = agree and 5 = strongly agree) 106
Figure 5 Number of physicians in hospitals without direct
employment relationship. 109

Chapter 8
Figure 1 Relative contribution of nine external stakeholders
to public standing and image of the organization 179
Figure 2 Relative contribution of nine external stakeholders
to “improving the quality of services” 181

Chapter 9
Figure1 From common indicators to shared measurement 196

ix
 LIST OF TABLES

Chapter 2
Table 1 Selected reforms in German healthcare 1993–2011 22

Chapter 3
Table 1 Ideal types of hospital planning 50
Table 2 Truth table 58

Chapter 6
Table 1 Attention to accountability in legislative history
of the Coordination Reform 123
Table 2 Accountability dimensions by reform plans,
likely consequences and empirical observations 134

Chapter 8
Table 1 The Major Decisions Model and the Everyday
Life Model and how they relate to arguments
on participation and accountability 171
Table 2 Institutional design choices relating to direct
accountability to clients 186

Chapter 9
Table 1 Main goals of shared measurement by organization
category and population served 197

xi
 Public Management Reforms and Their
Impact on Democratic Processes

Paola Mattei

INTRODUCTION
Over recent decades, a religious-like reform fervour has dominated the
hospital sector in many European countries. Among them, Germany has
systematically enacted cost containment measures, as well as other
governance reforms designed to increase the efficiency of the hospital care
system. Many of these reforms aimed at promoting managerialism and
increasing managerial autonomy of hospitals in the hope of relieving
central governments from direct intervention in the operational strategies
of public hospitals. ‘Autonomy’ has become a golden value associated with
managerial reforms, an uncontested solution to the vicissitudes facing
public hospitals in Europe, under enormous pressures from demographic
changes, the recent financial crisis, rising patients’ demands and increasing
technological costs.
This edited book stems from the need to further our understanding of
the relationship between managerial solutions and public accountability
in hospitals in Germany. For many there appears to be a tension, indeed
the two concepts have been described as ‘opposite ends of a spectrum’

P. Mattei (*)
Associate Professor of Comparative Social Policy,
University of Oxford, Oxford, UK
e-mail: paola.mattei@sant.ox.ac.uk

© The Editor(s) (if applicable) and The Author(s) 2016 1

P. Mattei (ed.), Public Accountability and Health Care Governance,
DOI 10.1057/978-1-137-47299-1_1
2 P. MATTEI

(Mattei, 2009). The essays in this book hope to explore whether there is
a necessary trade-off that requires a challenge to democratic accountability,
as autonomy and New Public Management (NPM) are increasingly
associated with hospital reforms. In particular, can the accountability gap
be resolved through horizontal accountability? Before beginning a discus-
sion of accountability, it is important to rein in this ‘ever-expanding
concept’ (Mulgan, 2000), so that confusion between its manifold types
does not drive the analysis. Here, we will focus on the core meaning: on
the opportunity for calling somebody to account; to have them provide
information about and justification for their actions. Within this defini-
tion, external scrutiny, social interaction and potential sanctions for those
accountable are essential elements.
Yet, who is to call whom to account? In Mulgan’s (2000) description,
accountability is ‘vertical’ or hierarchical where those calling for account-
ability assert rights of superior authority upon those who are accountable.
This means elected politicians can keep in check public bureaucrats and
the legislator can scrutinize the actions of political executives. It also
means there is a relationship between citizens and the holders of public
office where, in principle, the electorate can control the sovereignty they
have delegated (Mair, 2005). For that, ‘there must be a line, no matter
how convoluted, running from any act of a public administrator to the
electorate’ (McGarvey, 2001a, 2001b, p. 26). In practice, for democratic
accountability to exist, citizens must also be capable of identifying the line
(Finer, 1941).
However, with new autonomization processes occurring within the
healthcare sector, traditional lines of accountability have been restruc-
tured and new types of accountability have been added (Page, 2006).
In particular, horizontal accountability has sometimes become a
supplement to other forms of accountability relationships. Horizontal
accountability differs from ‘traditional’ vertical forms in that there is no
superior agent demanding accountability, but the accountor and the
accountee are on equal levels of authority (Schillemans, 2011).
Horizontal accountability also involves a relationship to third parties
such as semiautonomous agencies, independent evaluators, boards of
stakeholders or interest groups (Schillemans, 2011). Additionally, it
has been associated with participatory mechanisms of decision-making.
The extent to which these changing accountability relationships are
effective as traditional forms are increasingly challenged and is under
investigation in the essays.
 PUBLIC MANAGEMENT REFORMS... 3

MOUNTING FINANCIAL PRESSURES ON PUBLIC HOSPITALS

In most European countries, public healthcare has occupied a large share
of government expenses. Partially due to changes in demography, these
costs have increased and are likely to increase further. Other pressures have
come through increasing public demand for better services and through
technological innovations to deal with disease and new health problems
more successfully. All these conditions come at a time when the supply of
financial resources is under enormous strain as European governments try
to balance public deficits. Poor economic growth, compounded with the
recent economic crisis, has meant that German and other public health-
care systems are under ‘considerable pressure to review and restructure’
(Saltman, Figueras and Sakellarides, 1998).
Demographic change has brought new challenges to various aspects of
social policy, including healthcare. Firstly, the dependency ratio in systems
has increased due to lower fertility and higher life expectancy rates (Hunter,
2008; Kanavos & McKee, 1998; Pierson, 1998). As the share of those who
can contribute to tax revenues and social security contributions supporting
health services has declined, there has been an increase in demand for health
services as the share of elderly people has risen. For example, the elderly are
more likely to suffer from diseases such as ‘heart disease, cerebrovascular
disease, cancer, dementia and bone fractures’ (Kanavos & Mckee, 1998,
p. 43), therefore requiring more medical treatment.
The development of new technology for hospitals and an increased
focus on patient satisfaction (Saltman, Fiegueras, & Sakellarides, 1998)
has pressurized hospitals to increase investments at further financial costs.
Technologies such as coronary artery bypass grafts and cardiac and natal
intensive care units require not only more capital but increases in mainte-
nance expenditure and labour as highly specialized staff are needed to look
after and be trained to use medical equipment (Bohenhelmer, 2005).
Given that healthcare is a labour-intensive industry where production
rates are low (Mossialos, Dixon, Figueras, & Kutzin, 2002), sustaining a
skilled work force with high wages could become problematic (Galor &
Moav, 2000). According to the World Health Organization (WHO), ris-
ing healthcare costs are primarily driven by technological change (account-
ing for 50–75 % of growth in costs) rather than other factors such as
ageing populations (WHO, 2011). As a result, technological improve-
ments often come at a much greater cost, ‘widening the gap between the
possible and the affordable’ (Kanavos & Mckee, 1998; Ranade, Renades,
1994, p. 42).
4 P. MATTEI

Slow economic growth and the global financial crisis of 2008 have also
brought pressures on macroeconomic policy and public budgets which
has affected healthcare spending. As fiscal deficits have risen, governments
have felt pressure to reduce this. While Stuckler et al. (2010) suggest that
there has been no evidence showing direct cuts in healthcare budgets as a
solution to deficits, some countries have not adjusted them according to
inflation, which in real terms has meant a high level of contraction. In the
UK, the government budget was already in deficit before the crisis and
although there seemed to be an increase in the National Health Service
(NHS) budget in cash terms, in real terms it was constrained (Ham,
2011). On the other hand, in Germany, the contribution rate to health
insurance was decreased in 2009 to ease the burden of employers and
employees and the gap would be compensated by transfers from the
federal budget.
As a result of the above-mentioned challenges, public hospitals have
been undergoing various reforms. In particular, they have faced pressures to
curtail public expenses and to increase efficiency as a part of the global shift
to NPM. NPM started in the 1980s to increase the cost-efficiency of public
sectors, especially through encouraging a market structure, while still main-
taining the objectives of the public sector (Levy, 2010). Such thinking can
be found to have influenced the reform processes in Germany and England
which we will consider in the following sections.

CONCEPTUAL FRAMEWORK
Traditional political accountability is built on a parliamentary chain in
which voters delegate their sovereignty to representatives in elected
bodies, who then delegate tasks to cabinet and the civil service. Political
accountability is a key feature in the chain of delegation. This is the first
kind of accountability the essays are investigating here. Social account-
ability is the second kind of accountability that the book focuses on.
Schillemans (2008) calls this public or direct accountability to citizens.
It presupposes an accountability relationship between the administra-
tion and stakeholders, which include the community at large, users’
organizations and (civil) interest groups, who exert a pressure on public
organizations, obliging them to account for the services they deliver.
This is done through, for example, the media, public reporting, public
panels or online information. Giving account to various stakeholders in
society usually occurs on a voluntary basis and has also been labelled
 PUBLIC MANAGEMENT REFORMS... 5

horizontal accountability (Schillemans, 2008). Unlike political, this

form of accountability does not place strong sanctions on those held to
account, but leaves citizens with the options of ‘exit’ or ‘voice’ (ibid.).
The introduction of choice in the delivery of public services has strength-
ened social accountability.
Whilst political accountability is rooted in a transfer of authority,
through the ‘chain of delegation’ attached to the parliamentary system,
citizen accountability is a useful scrutiny of the machinery of the state as
citizens raise their voices. According to this view, social accountability is a
beneficial addition to democratic accountability promising further democ-
ratization (Keane, 2008). Argued similarly, social accountability may
present a ‘re-balancing’ within an already increased ‘complex web of
accountabilities’, as public managers now have increased justificatory
duties to their clientele (Page, 2006).
In contrast, several studies have argued that NPM reforms in fact
undermine traditional forms of political accountability and lead to
increasingly hybrid organizations (e.g., Mattei, 2009). The concept of
‘accountability’ in itself can be conceptualized in at least two different
forms. In its ‘narrow’ sense it refers to its analytic and heuristic tool. In a
‘broader’ sense, it has a normative dimension linked to democratic and
constitutional theories of the state. Calling for a broader conception of
accountability, Dubnick (1996, 2003) opines that studying accountability
relationships requires conceptual clarity and the recognition of account-
ability as a social phenomenon, larger than simply the narrow mechanisms
for enforcing political control. In a recent paper (Dubnick, 2003), he
theorizes a third perspective associated with an ethical theory of account-
ability based on the second-personal stance (Darwall, 2013). He elaborates
on the concept of blame cultures and on being blameworthy before mak-
ing errors. Actors have moral obligations that determine their behaviour.
Decision-making is not merely a political act, but also an ethical one. For
this purpose, in this paper we concentrate on the German moral dimen-
sion of accountability in contrast to the British meaning context. The
significance of Dubnick’s theoretical model may be seen in the incarna-
tions of accountability in the German case of organ transplant policies
under investigation.
Although the literature on the ‘magic concept’ of accountability is expand-
ing, there is significant uncertainty about its meaning context and philosophi-
cal ideas associated with different meanings in different countries. In essence,
so far the consensus is that the concept consists of three parts: someone is
6 P. MATTEI

called to account by someone for something. For example, in Mulgan’s

minimal definition of ‘accountability’, ‘calling somebody to account’ means
to have them provide information about and justification for their actions
(Mulgan, 2000, p. 555). Hence, accountability involves the process of exter-
nal scrutiny, social interaction and the possibility of meting out sanctions to
those held accountable.
Accountability relationships can pertain to different actors (‘accountors’)
accounting to different ‘forums’ (‘accountees’) (Bovens, 2007, p. 182;
Schillemans, 2008, p. 177) by different standards and values. This is clearly
illustrated with the example of healthcare reforms, the organization of
which currently embodies a complex and frequently contested system of
relationships that are political, administrative, managerial, legal or profes-
sional in nature. In such a system, a variety of actors (politicians, bureaucrats,
managers and health professionals) are held to account on the basis of
different criteria such as political, economic or financial ones, standards of
healthcare quality or the quality of other service provision (Mattei, Mitra,
Vrangbæk, Neby, & Byrkjeflot, 2013). They must give an account to
patients, taxpayers, politicians, or external regulatory institutions. So from
the outset a plurality of different accountability relationships exist, which
may at times overlap or even compete.
At times, public and political accountability are used interchangeably
by various scholars and at times as distinct accountability mechanisms
(Bovens, 2007, p. 183; or Mattei, 2009, p. 37; Sinclair, 1995, pp. 225–226).
In this book, we understand political accountability to refer to those
processes in which the accountors are elected politicians who spend
public money, exercise public authority or oversee a public body under
public law. Account giving is ‘done in public, (…) open or at least acces-
sible to citizens’ (Bovens, 2007, p. 183). Political accountability, from
our understanding, refers more narrowly to the relationship between the
legislature and the executive, that is, between elected politicians, and
bureaucrats, or other appointed civil servants which ‘exercises authority
on behalf of [these] elected representatives’ (Day & Klein, 1987 cited in
Sinclair, 1995, p. 25). Here the account-giving institution in question is
indirectly held accountable by the public via the politician. The politi-
cian, in turn, is held directly accountable in elections and parliamentary
proceedings by the people he or she represents.
The most important function of public accountability, at least in
principle, is that of democratic control (Bovens, 2007, p. 192; Mair,
2005). Voters ‘make elected representatives answer for their actions’,
 PUBLIC MANAGEMENT REFORMS... 7

while politicians in turn can hold those accountable upon whom they
entrust certain powers (Mattei, 2009, p. 37). In addition, for democratic
control to function effectively, ‘there must be a line, no matter how
convoluted, running from any act of a public administrator to the electorate’
(McGarvey, 2001a, 2001b, p. 26). It is crucial that citizens are able to
identify and monitor the line and direction of this accountability relationship
(Finer, 1941).
As healthcare governance is delegated from politicians towards autono-
mous agencies, the latter become ‘uncoupled from official representative
bodies towards more professional actors’ (Papadopoulos, 2010, p. 1034).
At the same time ‘politicians displace public accountability to senior civil
servants’. But these are then assessed on the basis of ‘achievement of
performance targets, rather than by the quality of the democratic process’
(Mattei, 2009, p. 25). However, for a welfare system to be democratic, it
is necessary for public accountability to function.

RESEARCH QUESTION AND APPROACH

Like many welfare institutions, healthcare governance across Europe is
changing radically. In an era of rising political uncertainty and budgetary
pressures, national leaders have been forced to balance the financial viability
of public health structures with democratic imperatives to maintain socially
just outcomes. Over the past three decades, states have increasingly turned
to NPM-style reforms to attempt to strike this compromise. In the hope of
lightening balance sheets while enhancing the efficiency and quality of
service delivery, governments have shifted identities from principal care
providers to contractual monitors, setting targets increasingly directed
towards third-party managers in quasi-markets and the private sector.
Consciously or not, states have thus progressively lifted managerial and
market accountability above democratic answerability.
Over the past decade, German healthcare has undergone considerable
NPM-inspired transformations alongside gradual hospital privatization:
managerial accountability is on the rise as the state retreats to a role of
defining and evaluating performance goals, Chief Executive Officers
(CEOs) assume growing control over hospital direction at the expense of
medical staff, and physicians grapple with disappearing autonomy and the
need to cater to unforgiving market objectives.
As a growing body of political science, public administration and public
policy literature show, NPM-style reforms are often accompanied by
8 P. MATTEI

hidden and unintended consequences with a detrimental impact on

democracy: by decoupling policy inputs from the production of public
services, such changes fundamentally alter administrative forms and values
in ways that risk diminishing the power of democratic oversight and
exposing health services to conflicting managerial and professional logics.
The speed with which many restructuring efforts have been enacted in
Germany and the rest of Europe has thus far hampered a thorough review
of the often unexpected policy outputs and outcomes they engender. Yet,
understanding how political change, restructured governance and care
results interrelate is critical to evaluating health systems. In addition to build-
ing upon wider theoretical debates regarding the unexpected and potentially
adverse effects that accompany NPM-style reforms, this book hence begins
to fill this critical empirical void by drawing upon extensive data presented at
an international conference on Accountability under Market Pressures in
February 2014, convened by Professor Paola Mattei with the assistance of
Dr Therese Feiler and Jeremy Pilaar at St Antony’s College.
As public governance and accountability reforms extend from the
uppermost reaches of national governments to the care experiences of
individual patients, this collection of essays investigates the interaction
between both macro and micro-units of analysis from multiple disciplinary
perspectives, including political science, public administration, history,
sociology and law. Insights regarding the case in Germany are also consis-
tently placed alongside similar changes happening within other nations in
order to contextualize emerging lessons within broader European and
global settings. First, the book explores the ways in which NPM-style
accountability reforms have taken root and evolved in Germany in the past
several decades; second, the book examines changing employment relations
in the healthcare sector following these reforms and their unexpected
consequences; third and finally, the book explores how shifting lines of
accountability to citizens have unintendedly altered not only healthcare
institutions, but patient experiences and the outcomes they produce.
While this edited collection will be of primary interest to healthcare
scholars, the wider implications its chapters raise regarding the potentially
perverse and often unseen effects of governance reforms that shift account-
ability away from democratically elected representatives will appeal to
policymakers across Europe as they attempt to grapple with the continued
need to alter and monitor healthcare systems in an age of budgetary austerity.
Though the governance landscape in European health sectors remains
in constant flux, NPM- and post NPM-inspired reforms have proven
 PUBLIC MANAGEMENT REFORMS... 9

exceptionally durable, taking root in the 1980s and growing in complex-

ity since. While states have attempted to re-regulate and re-centralize
the governance of healthcare to some degree in the past several years,
these efforts have generally further entrenched managerial accountabil-
ity structures by sharpening state system objectives and penalties for
poor performance rather than re-introducing direct democratic account-
ability mechanisms. Public administration and political science litera-
tures have also consistently demonstrated that national welfare
institutions are sticky constructs that are not quickly modified or dis-
placed. As such, the reform trends analysed in this volume will likely
remain of critical importance to governments’ steering of healthcare in
Europe for decades to come.
I would like to thank the Norwegian Research Council and St Antony’s
College for funding the workshop organized at St Antony’s College,
University of Oxford, in February 2014. All the papers included in this book
were presented and discussed there. Special thanks go to all the workshop
participants and discussants for their detailed feedback. I am particularly
indebted to the research assistant Jeremy Pilaar, for his intellectual and rich
contribution to the workshop and for his involvement in the initial stages of
this book project. I am grateful to Taylor and Francis for permission to repro-
duce sections of ‘Moral values and responsible administration: live organs
transplant system in the United States and Germany’ in International Journal
of Public Administration (2015). I am also grateful to the following individu-
als for shaping my thinking on accountability: Jeremy Waldron, Christopher
Hood, Tom Christensen and Peter Mair.

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 German Healthcare in Transition: Global
Pressures, Governance and Public Wellbeing

Patricia Hogwood

GERMAN HEALTHCARE IN TRANSITION:

A ‘PARADIGM SHIFT’?
In common with other European countries, Germany is undergoing a
shift from its traditional welfare state model to that of a regulatory state
model. A central question in this process is, what becomes of the welfare
provision to citizens that was the defining feature of northern European
post-war governance? In West Germany, as in comparable northern
European states, a post-war consensus emerged around social justice as a
normative aspiration for governance. The traditional principles behind
Germany’s ‘conservative continental’ approach to welfare and social
service provision (Esping-Andersen, 1990, 1999; Hemerijck, 2002;
Hemerijck, Keune, & Rhodes, 2006) were designed to uphold social
justice as a central governance value. In adapting its welfare system, the
German government faces a twin challenge: to bring in new modes of
service provision that are financially sustainable, but yet maintain high
levels of social solidarity attributed to the traditional welfare governance
model. This chapter finds that successive German governments have

P. Hogwood (*)
Department of Politics and International Relations,
University of Westminster, Westminster, UK
e-mail: P.Hogwood@westminster.ac.uk

© The Editor(s) (if applicable) and The Author(s) 2016 13

P. Mattei (ed.), Public Accountability and Health Care Governance,
DOI 10.1057/978-1-137-47299-1_2
14 P. HOGWOOD

prioritised the aim of financial sustainability over the promotion of social

solidarity. Whereas financial sustainability has been targeted through a
series of governmental measures, governmental engagement with social
solidarity has been confined largely to the level of discourse, through
debates on ‘wellbeing’ and ‘social justice’. Attempts to reform the health
sector have taken place under conditions of growing economic and social
polarisation. Such conditions have increased the salience of a debate on
public accountability. With the erosion of the principle of social equity in
favour of one of neoliberal competition, the principle of public account-
ability is being offered as a substitute ‘contract’ between state and society;
as the basis for a new consensus on the appropriate role of government in
the provision of healthcare.
The transition in healthcare that has taken place in Germany and in com-
parable European countries over the past three decades has been described
as nothing short of a ‘paradigm shift’. Peter Hall (1993) situates a para-
digm shift in public policy in the overarching consensus and values that
determine policy goals. The catalyst for the shift comes from an accumulation
of changes that challenge the existing paradigm until it is finally stretched
so thinly that it can no longer retain its credibility. The process may be
informed by expert opinion, but ultimately it is a sociological process; most
likely politically driven (Hall, 1993, pp. 278–281). Under normal circum-
stances, the instruments used to attain policy goals and the techniques
deployed to calibrate those policy instruments would typically serve to
uphold broad continuities in policy. However, under a paradigm shift, a
new consensus will inform the development of new policy parameters and
the partisan competition that takes place within them. For Hall, this ‘third
order’ change is a disjunctive process associated with policy discontinuity.
New policy tools will be devised or existing ones recalibrated to implement
the new objectives. This chapter takes up two themes from Hall’s analysis.
Firstly, a paradigm shift rests not only on objective changes, but more sig-
nificantly on perceptions of change. It finds that shared new perceptions—
whether objectively accurate or not—are a key driver of change in German
healthcare provision. These include a perceived need to increase global eco-
nomic competitiveness; and a perception that the costs of social care in
general and healthcare in particular are spiralling out of control. Together
with other factors, such perceptions are reflected in a shift in the focus of
the discourse on healthcare provision from ‘services’ to ‘markets’. Secondly,
healthcare provision, as welfare provision more generally, continues to be
highly controversial and politicised. Technocratic language and processes
 GERMAN HEALTHCARE IN TRANSITION 15

may characterise the policy tools used to implement health policy, but the
broad aims and objectives are firmly grounded in a changing set of over-
arching and deeply political values.
This chapter reviews some of the external and internal pressures that
have stretched traditional modes of welfare provision—and, by extension,
healthcare provision—to breaking point. It demonstrates that a paradigm
shift incorporating a new set of policy instruments under an overarching
neoliberal framework has been effected over two decades of healthcare
sector reform in Germany, launched by a Christian Democrat-Liberal
government in 1993 but subsequently pursued to completion by govern-
ments of all colours. The chapter then evaluates the impact of the neoliberal
paradigm shift on social cohesion and health service governance legiti-
macy. Successive policy measures have imbued the German health service
with market principles and have led to an increase in private service provi-
sion and competition amongst service providers. They have also raised the
profile of the federal government as a health governance actor. While such
measures have resulted in a greater choice in health provision (at least for
those who can afford to pay supplementary costs), claims of increased
efficiency and accountability are more questionable. Tensions have arisen
between the German public, which remains wedded to the ideal of social
solidarity in healthcare provision as in the welfare system more generally,
and a political elite keen to progressively distance the state from upholding
full, unqualified access to healthcare services. As a ‘system of stratification’
(Esping-Andersen, 1990, p. 23), the new-paradigm health service in
Germany is helping to define an increasingly polarised society, reflected in
a growing ‘poverty-’ and ‘health gap’ in Germany. Finally, the chapter
discusses the substitution of the principle of public accountability for that
of social solidarity and questions its capacity to act as a basis for legitimising
contemporary health service governance.

A CHANGING DISCOURSE AND THE CRISIS

OF THE WELFARE STATE

Since the mid-1970s onwards, in common with other European coun-

tries, Germany has faced a combination of exogenous and endogenous
structural pressures prompting a substantial reappraisal of the role of
welfare services in contemporary governance. Whereas to date Germany
has sailed through the crisis in the Eurozone (2008–) relatively unscathed,
the problem of an ageing population has imposed significant pressures on
16 P. HOGWOOD

pensions, healthcare and end-of-life care. Unique to Germany have been

the unprecedented costs arising from the unification of the two post-war
German states, the Federal Republic of Germany (FRG) and the former
German Democratic Republic (GDR) in 1989–1990. However familiar
these developments may be, it is worth tracing their interactions and
impact on the changing values surrounding German welfare and health
provision in a wider European context.
The 1970s recessions saw rising unemployment in Germany and west-
ern Europe alike. Austerity politics linked labour market issues with
welfare. For the first time, governments were forced to confront the fiscal
and financial implications of a uniform welfare provision that aimed to
achieve social equity (Rothgang, Schmid, & Wendt, 2010, p. 121). Could
social equity continue to be represented as a fundamental right, or was it
now a luxury that governments could ill afford? Germany, with its ‘conser-
vative continental’ welfare model (Hemerijck et al., 2006) was particularly
vulnerable. Assuming a nuclear family with a single breadwinner,
Germany’s model set replacement incomes in proportion to prior occupa-
tional or earning status. Within this proportionality principle, replacement
incomes were also generous and of a relatively long duration.
A further structural factor concerned demographic change. Better
lifelong medical care and a decline in the birth rate have led to the ageing
of European populations. As the average age of the population increased,
the adverse change in the ‘dependency ratio’ of tax contributors to welfare
recipients drove up the total cost of pensions, medical care, support services
and institutional care for the elderly. In Germany, this development was
compounded by the prevalence of early retirement during the boom years.
Continuing advances in medical science and the ageing population are
currently considered to be the two greatest pressures on the health service
in Germany. In themselves, these two factors alone would guarantee rising
costs in the health sector (DeStatis, 2013, p. 249).
Globalisation has been credited not only with the spread of neoliberal
values and new governance practices, but with changing views of welfare.
The logic of globalisation suggests that if a state’s welfare benefits are
too generous in comparison with those of its neighbours, that state will
be less competitive in the international market.1 This suggests limits

1
France’s drift towards austerity, for example, seems to confirm this prediction. R. Janssen
(Jensen, 2014) ‘Why austerity is contagious’ Social Europe Journal http://www.social-europe.
eu/2014/10/austerity-is-contagious/28/10/2014 11:41:12.
 GERMAN HEALTHCARE IN TRANSITION 17

on welfare state expansion and possible retrenchment of existing welfare

provision (see e.g. Pierson, 1998; Genschel, 2004). Despite contestation
of these assumptions, a narrative of competitive vulnerability under
globalisation has deeply permeated welfare policy development in
Europe. Further, globalisation highlights links between labour and wel-
fare developments. A wave of deregulatory pressures originating from
changes in the US political economy from the late 1970s and early 1980s
has in turn led to a marked erosion of protected employment in European
countries (Schwarz, 2001, pp. 43–44). The spread of liberal work prac-
tices has meant that fewer workers experience the stability of traditional
working patterns throughout their lives. Instead, greater use is made of
short-term, flexible and zero-hours contracts; redundancy as a form of
workforce control; career breaks; early retirement, and so on. One con-
sequence of workforce liberalisation is a more unpredictable tax base for
the funding of welfare systems.
As globalisation gathered momentum, the platform for political
conflicts around the welfare state shifted from the calibration of policy
tools—originally, economic policy—to more fundamental conflicts over
welfare governance. By the late 1990s, such conflicts no longer concen-
trated solely on aggregate spending levels but took in institutional changes
that effectively brought markets into the welfare state (Schwarz, 2001,
p. 36). Perceptions of a need to increase global economic competitiveness,
together with the spiralling costs of social care were reflected in a shift in
the focus of the discourse on welfare provision from ‘services’ to ‘markets’.
Principles of competition and state regulation were widely reflected in
efforts to kick-start a welfare state retrenchment.
Towards the beginning of the new millennium, a new paradigm in
public policy began to consolidate in the form of the ‘regulatory state’.
This brought far-reaching changes in the agenda and focus of welfare
policy in north-western Europe. The main characteristic of welfare under
the regulatory state is that, rather than providing welfare services itself as
a means of minimising social inequalities, the state seeks to provide more
cost-effective services by contracting out to private agencies. Significantly,
with this contracting out, the post-war understanding of the welfare
contract between government and the governed was breached. The
government could no longer be held directly accountable to the public for
the services provided. In place of the principle of electoral accountability
for welfare services, a substitute principle of public accountability was
offered and secured through the greater regulation and monitoring of
18 P. HOGWOOD

service provision. This shift reflected changing values around welfare

provision. It symbolised a derogation of what had been widely understood
as a fundamental right to a concession contingent on affordability.
Consistent with this shift, European governments began to try to persuade
citizens to think about the cost of the non-productive stages or contingen-
cies in life (childcare, illness, old age, etc.) in terms of individual responsi-
bility rather than relying on the state.
European government responses to the 2008 crisis in the Eurozone
suggest that, by this time, the paradigm shift in welfare had become
firmly entrenched (Farnsworth & Irving, 2011). Rather than setting
fresh aims and devising new policy tools to respond specifically to the
crisis, government actions have instead followed the paths of institu-
tional change laid down since the emergence of the regulatory state
model and the market-oriented discourse. These have promoted a
reinforcement of labour market segmentation, a further restriction of
access to unemployment and other benefits, and further cuts to public
expenditure in healthcare, pensions and education. Moreover, the trend
towards marketisation is reflected in the exclusion of traditional industrial
lobbies from government consultations in favour of business interests
(de la Porte & Pochet, 2014, p. 2).

GERMAN HEALTHCARE GOVERNANCE: POLITICAL

CONTESTATION AND THE EMERGENCE OF A NEOLIBERAL
PARADIGM
The Myth of ‘Spiralling Costs’
Drawing on Hall’s characterisation of paradigm shift, it can be anticipated
that German welfare provision will remain highly controversial and politi-
cised. At the values level, it is commonly agreed that the values surrounding
the construction of the post-war consensus on welfare had entrenched the
values of the social democratic left as the standard from which other
approaches are held to ‘deviate’ (Pierson, 1994; Jensen, 2014). This means
that, in order for the new neoliberal agenda to become the dominant para-
digm, it would have to justify its values and aims explicitly and effectively,
ultimately changing the consensus to reflect these.
Another random document with
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way and to put in a handkerchief on your head under your helmet.
With plenty of ice you may perhaps escape without getting fever or
being suffocated.”

RAILWAY BUFFET AT TIVIWANE.

The trip by this line, which no European would care to take for
pleasure, is really to the negroes a treat, who go by the train as an
amusement. The directors did not count upon receipts from the
blacks when they started the line, especially after a train which ran
off the metals smashed up a whole carriage full of natives against a
huge baobab tree. Of course, when that happened no one thought
the negroes would patronize the railway again. But it turned out quite
the contrary. From that day they came in crowds, but they had
provided themselves with talismans!
The marabouts, who do a brisk business in charms, had simply
added a new string to their bow, for they sold gris-gris against the
dangers of the iron road!
 THE QUAY AT ST. LOUIS.

This is the negro all over. If he has but confidence in his gris-gris,
he will brave a thousand dangers. If he has but confidence in his
chief, he will follow him without hesitation, and without faltering to the
end of the world. Inspire him then with that confidence, and you will
be able to do anything with him.
Baudry had come to meet me on the line, and with him was a
negro wrapped up in a tampasendbé, or native shawl. This man was
Mandao, the interpreter I had asked for. He had decided to go with
us without a moment’s hesitation. This was yet another trump card
for us, and all would now go well.
We reached St. Louis at six o’clock in the evening on January 17.
An officer on the Staff of the Governor was waiting for me. M. de
Lamothe, who was, by the way, an old friend of mine, received me
most graciously, and was ready to do everything in his power to help
me.
The Brière de l’Isle of the Deves and Chaumet company was to
start on the 19th for the upper river. She was, however, already
overloaded. What should we do? Time
was pressing!
On
the
mornin
g of the
18th I
engage
d the
A STREET IN ST. LOUIS.
coolies
who
BOUBAKAR-SINGO. were to follow us. Most of them were
Sarracolais, whose tribe lives on the
Senegal between Bakel and Kayes.
From amongst a hundred candidates Baudry had already picked out
twelve, and to these had been added a second master pilot
belonging to the local station. All these were experienced
campaigners, who had long been in the French service; they were
sturdy, well-built fellows, eager for adventure. I had but to eliminate
three, and to confirm Baudry’s choice of the others, for we were
limited to eight men, including their leader. After all, however, the
coolies were dismissed by order of Governor Grodet before we
actually started, so there is no need to introduce them more
particularly. Boubakar-Singo, the second leader, who became pilot of
the Davoust, alone deserves special mention. He was a splendid-
looking Sarracolais, a first-rate sailor, who, when a storm came on,
would jump into the water stark naked intoning all the prayers in his
repertory.
 THE COOLIES ENGAGED AT ST. LOUIS.

Our coolies engaged, we had not only to equip, but to dress them.
We set them to work at once, for we had already solved the difficulty
of how best to transport our stores. The governor lent us a thirty-five
ton iron lighter, into which we stowed away everything, and the
Brière de l’Isle took her in tow.
It was not, however, without considerable trouble that we
managed the stowing away of all our goods, but we succeeded
somehow in being ready in good time. On the evening of the 19th
the Brière weighed anchor, and we started for the upper river; our
friends at St. Louis, the Government officials, the sailors, the
tradespeople waving their hats and handkerchiefs in farewell, and
shouting out “Good luck.”
What a Noah’s ark was this thirty-five ton barge of ours, and what
a mixed cargo she carried, with our bales and her sails, not to speak
of the passengers! coolies, stately Moors, sheep and women. With
the sails of the Davoust we rigged up a kind of shed in the stern to
protect all these people, who, with nothing to do all day, crept about
on the sloping roof sunning themselves like lizards. We turned the
two days during which we were towed along to account by going
over our numerous bales yet once more. Strange to say, almost
incredible indeed, nothing was missing. It was worth something to
see Bilali Cumba, a herculean coolie, pick up the instruments,
weighing in their galvanized case more than 240 lbs., as easily as a
little milliner would lift a cardboard box.
It was Bilali who made me the following sensible answer the other
day, when we had given out wooden spoons to the men for their own
use. Of course, like all negroes, they ate with their fingers, making
their porridge up into a ball, and rolling it till it was quite hard before
putting it into their mouths. I was laughing at Bilali about this when
he said, “Friend, tell me what is the good of your spoon?” then
spreading out the palms of his toil-worn hands he added, “What is
good to work with is good to eat with.”
As Joan of Arc with her flag, he dedicated his hands to toil and
honour too.
Our trip did not pass off without certain little accidents; the
constant splashing of the water loosened the joints of the barge, and
we had to stick them together as best we could. However, we arrived
on the 23rd at Walaldé, then the highest navigable point of the river.
Probably it would be possible to go much further up, as far as
Kaheide, in fact, at all times of the year, but it would have to be in
boats with a different kind of keel to that now in use, and we have
not got to that yet.
The Brière de l’Isle now left us to descend the river again.
Henceforth we were to fly with our own wings. Painfully and slowly
we made our way in our thirty-five ton barge, towed along by a rope
from the bank, the river gradually widening out as we passed
Kaheide, Matam, Saldé.
Then, alas! we got one piece of bad news after another.
At Saldé we heard of the death of Aube; at Bakel of the massacre
of Colonel Bonnier and his column.
Too much fuss has been made about these glorious deaths, say
many foolish critics. Over the ashes of soldiers killed in battle, there
 has been too much heated
discussion. Well, at least, hyænas
only do their terrible work at night!
As for me, I lost a chief whom I
loved, and many old comrades with
whom I had been under fire or in
garrison. Hastily we pushed on for
Bakel and Kayes, eager for further
news, not only plunged in the deepest
grief, but somewhat anxious about
what was in store for ourselves.
THE ‘BRIÈRE DE L’ISLE.’
On February 13 we arrived at
Kayes. I went at once with Baudry and
Mandao to the Governor, M. Grodet, who told me that he had
received despatches authorizing him to suspend my expedition, and
to employ us as he liked! Our party was at once broken up. Baudry
was sent to make forced marches to the Niger to escort some
convoys of provisions on their way to re-victual Timbuktu. I should be
disposed of later, and, as a matter of fact, I was eventually sent to
take command of the Niger flotilla.
THE MARKET-PLACE AT ST. LOUIS.

THE MARKET-PLACE AT ST. LOUIS.

 I must quote the actual words of
this despatch, so fatal to us, for not
long since M. Grodet was defending
himself from the charge of having
been somehow the cause of the delay
to our expedition of two whole years.
The despatch was addressed
—“Colonies à Gouverneur, Sudan,”
and ran thus—“Autorise surseoir
GOVERNMENT HOUSE, Mission Hourst, et disposer de cet
KAYES. officier.”[2]
As will be observed, the Governor
of the Sudan was authorized, that is to say, he could do as
suggested or not, to suspend, that is to say, to stop us, for the limited
time which seemed desirable to him. But any further disputing about
it would do no good now.
One remark, however, I must make: we were stationary for two
years on the banks of the Niger above Timbuktu, doing no particular
service to our country. Decœur, Baud, and others were marching on
Say from Dahomey. Can one fail to see what immediate political and
diplomatic advantages would have accrued to France from a junction
which would have united the hinterlands of the two colonies?
It is true that Decœur and Baud were not starting from the Sudan,
but from Dahomey, where Governor Ballot was sending out exploring
expeditions, not stopping them.
But I have done. It is worse than useless to dwell on the endless
petty mortifications, annoyances, and disappointments we had to
endure. Useless indeed to recall all our own bitter experiences,
which could but damp the enthusiasm of future explorers as eager to
advance as we were. We succeeded in spite of everything in making
ourselves useful. Even whilst re-victualling Timbuktu, which was
threatened with famine—here again the responsibility rested with
very highly placed officials—I was able to survey the whole of the
system of lakes extending on the west of the town.
 The most important of these lakes, Faguibine, is a regular inland
sea, with its islets, its promontories, and its storms. It is a vast basin
nearly 68 miles long by 12 broad, with a depth, which we sounded,
exceeding here and there 160 feet. It is fed by the Niger when that
river is in flood. We made a peaceful raid on this fine sheet of water
in the Aube, a boat I shall introduce to you later, whilst the terrible
Ngouna chief of the hostile Kel Antassar tribe retreated from us
along its banks. Here for the first time I came into actual contact with
the Tuaregs.
Baudry meanwhile explored the Issa-Ber (already visited by
Caron) in his barge, and proved the navigability of the river at high
tide.
I feel full of respectful gratitude to the military authorities of
Timbuktu, especially Colonels Joffre and Ebener, for the almost
affectionate consideration with which they treated me, and for being
willing to employ us, for giving us something definite to do to relieve
the monotony and ennui of our detention. This was really an
immense consolation to us, the best that any officer can hope for.
In May 1895 I received orders to return to France. Baudry, who, I
am happy to say, was worn out mentally rather than physically, had
preceded me by two months. As already stated, our coolies had
been disbanded—from motives of economy, said the order. Our
stores, too, were dispersed. Our boat was still at Bafulabé, and, mon
Dieu, in what a state! One might have sworn that its sections had
been intentionally twisted out of shape with blows from a hammer.
Our chronometers—little torpedo-boat watches, regular
masterpieces of precise time-keeping, made by that true artist M.
Thomas—were being used at Badumbé in the telegraph office. Our
bales, of the charge of which I had never been relieved, had been
sent to Mopti for the Destenave expedition, which had been allowed
to start. My friends in France, to whom I had addressed despairing
appeals, remained silent; even Baudry gave not a sign of life.
Everything seemed finally lost. My expedition had not been
superseded, it had been dissolved, destroyed.
 I confess that when I embarked once more in the winter to make
my way, by slow stages, back to France, I did for the first time
despair of my unlucky schemes, and as I dwelt upon them, I believed
that they were at an end for ever.
I had at least the consolation, as Davoust had had before me, of
having struggled to the last.
On July 20, when I was halting at Bafulabé, and gazing with
inward rage though outward calm at the dented sections of my
Davoust, a telegram was handed to me. It was from Colonel De
Trentinian, who had—at last!—succeeded M. Grodet as Governor of
the French Sudan.
It said, “The Colonial Minister resumes the original project of your
expedition.”
I have had a few minutes of wild joy and happiness in my life. But
not even on the day when, after I had been struggling nearly a month
against fearful odds in the revolted district of Diena, I saw the column
of succour approaching; nor again, last December, when, as we
embarked at Marseilles, I thought all our difficulties were surmounted
and all our dangers were left behind, did I experience such an
immense sense of relief and delight as now. I could keep my oath
after all! and by successful action put to confusion those who, either
because they were badly advised or unscrupulous, had thrown
obstacles in our way.
This is what had happened.
In France they say the absent are always in the wrong, and our
story goes to prove it. Of all those who, when I left, had protested
their devotion, had congratulated me in advance, who had even
warmly embraced me, scarcely any—I had almost said not one—had
taken our part or pleaded for us. In France, scientific societies,
geographical and others, spring up like mushrooms, and form little
cliques, hating each other like poison, and losing no opportunities of
abusing each other in their speeches and declamations at their
various banquets. Without running any risk themselves, or making
any special exertion, their big-wigs—I was nearly saying their
shareholders—get a lot of notoriety and patting on the back, through
the work of a few members who are toiling far away from home.
If you ask their help in your difficulties, or even their moral
support, they take absolutely no notice of you; but later, when you
return, and have extricated yourself from your troubles by your own
unaided efforts, and if you are also very docile, they will make no
end of noisy fuss over you.
I have often thought of these scientific swells when I have
watched negro chiefs marching along followed by their satellites.
They strut about, playing on the flute or the fiddle, beating their
drums and shouting out compliments in a deafening manner. Every
epithet seems suitable to their chief; he is their sun, their moon, and
all the rest of it. “Thou art my father, thou art my mother, I am thy
captive!” they shout.
But when adversity overtakes this flattered chief of theirs, when
he is in trouble of any kind, gets the worst of it in some skirmish, for
instance, what becomes of all the toad-eating satellites? They melt
away, to go and offer their incense of flute and violin playing and
bell-ringing to some more fortunate favourite of the hour.
Oh, these self-interested sycophants, how well I know them!
I have, however, a grateful pleasure in adding that there are
exceptions to the rule. I will mention but one here. My dear and
venerated friend, M. Gauthiot, chief secretary of the Société de
Géographie Commerciale, was always ready to cheer us in our
hours of discouragement, to aid us in our hopeful days; putting at our
disposal all his influence, all his persuasive power, and exercising on
our behalf the undoubted authority he possessed in all things
geographical and colonial.
Directly he reached Paris Baudry went to seek him, not of course
without some arrière pensée. “Well, how goes the mission?” he
asked at once. “Done for, unless you can save us,” was the reply. “I’ll
see about it,” said M. Gauthiot at once.
Then he went to my old friend Marchand, who was expected to do
such great things on the Congo. “And Hourst and the descent of the
Niger?” “You see what has come of that,” was the answer. “Well,
perhaps something may yet be done.”
Both did their utmost for us, but it was M. Gauthiot who took the
last redoubt. The money question appeared to be the greatest
difficulty, for they were trying to cut down the expenditure budget as
much as possible. “Monsieur le Ministre,” said my friend, “I have
come with my hands full!” And five thousand francs were in fact
voted for my exploring expedition by the Comité de l’Afrique
Française.
In a word, the efforts of our new allies turned the scale in our
favour.
At that time M. Chautemps was, fortunately for us, Colonial
Minister, whilst M. Chaudie was Governor-General of French West
Africa, and Colonel (now General) Archinard Director of Colonial
Defence, and it was on these three that the final order depended. I
need only add, that they, with M. Gauthiot, became the four sponsors
of the re-organized expedition, and we are full of respectful gratitude
to them all.
“All I had to do in the matter,” said Baudry to me, “was simply to
put in an appearance.”
I alluded above to the question of funds. Well, the whole thing was
re-arranged on a fresh footing, otherwise the conditions were less
favourable than they had been two years before. Nothing had
changed with regard to the Tuaregs, but news had come by way of
the Sudan that Amadu Cheiku, the dethroned Sultan of Sego, was
trying to re-establish an empire on the banks of the Niger. Then the
Toutée expedition was already on its way; no news had been
received from it, and it is often more difficult to be second than first in
traversing a new district.
Colonel Archinard, therefore, wished to increase the strength of
our expedition considerably. To begin with, we were to have three
barges instead of one, and that meant twenty coolies instead of
eight. Then Lieutenant Bluzet, who, though still of low rank in the
service, was quite an old and experienced officer of the French
Sudan, was to take charge of the military training of our men. “Take a
doctor too,” said the Colonel, “he will make one more gun at least;”
and I choose Dr. Taburet, who had been my medical adviser with the
Niger flotilla, engaging his services by telegram.
All this of course added to the expense, and it was no easy matter
to balance the accounts of so big an expedition with so very small a
budget. However, we managed to do it somehow: Bluzet and Baudry
made advances from their pay, and Bolard went on campaign once
more with all his usual zeal and energy.
“You start four,” said Marchand to Baudry, when he saw him off at
the Orleans station, “only one will return!”
Thank God, however, we all came back!
Directly I received the telegram from Colonel de Trentinian I set to
work without losing a moment. I had to collect all our scattered
stores again at Bafulabé from here, there, and everywhere. The
Davoust had to be got into working order, and the only way to do that
was to put her together and launch her, there would then be no
unnecessary delay when the time for starting came. I was aided in
this by a quarter-master with a turn for mechanics, a man named
Sauzereau, who had already rendered me great service when I had
charge of the Niger flotilla. It was hard work, but we succeeded, and
it was a happy day when we baptized our boat by her already
chosen name of Davoust at the little station of Bafulabé. It was the
first time she had been afloat since we tried her near the Pont Royal
in Paris. A missionary from Dinguira had come over at considerable
inconvenience on purpose to pronounce a benediction over her.
Colonel de Trentinian was good enough to travel from Kayes to be
present, and I can tell you my Davoust presented a very fine
appearance on the Bakhoy. I would rather see her there than on the
Seine. Digui, who had been second master pilot on the Niger flotilla,
and whom I had chosen as Captain in place of Bubakar, dismissed,
was delighted with his boat.
When all was counted over, there were many missing loads.
Fortunately Captain Destenaves had only brought a few of the
valuable bales to Mossi, the rest were at Sego, but of the tins of
preserves and other provisions nothing was left but one case of fine
Cognac, which, taken in very small doses, was our greatest luxury.
There was still a little left a year later when we were at Fort
Archinard. See how temperate we were! Baudry’s bicycle, which we
had baptized Suzanne, I don’t know why, was in a pitiable state
when we found her again. But Sauzereau was a specialist in such
cases, and she was soon rolling along the Badumbé road, to the
great astonishment of the blacks.
I had now nothing more to do but to wait for Baudry at Kayes. I
went down there, and one fine morning he flung himself into my
arms with Bluzet and twenty coolies behind him. Of course with
regard to the coolies I speak figuratively. With a view to economy
these coolies had not been rigged out, and they really looked like a
band of brigands. Still they impressed me very favourably. I knew
several of them, who had already served under me. They were not, it
is true, quite equal to those I had engaged at first, and been obliged
to disband by order of the Governor, but they were not bad fellows,
and they would get into good working order by the way.
All had gone well with Baudry and Bluzet; they had even found
time on board the boat, which had brought them up from St. Louis, to
make up some rhymes, and in the evening, after copious libations—I
mean copious for Africa—we had the honour of listening to a sonnet
of which they were the joint authors. Here it is:
 NIGHT ON THE RIVER.

Slow through the reaches of the oily stream,

Unshapely, huge, and heap’d with cumbrous freight,
The steamer drags along its ponderous weight,
And panting, breathes a cloud of eddying steam;

Upon the deck the wearied negroes dream,

In sleep’s fine thraldom—humble, candid, great,—
While overhead the moon in regal state
Trails robes of gauze enmesh’d with astral gleam.

The misty night exhales a poisonous balm

From vague-spread margins, where the shadows lie,
Of softly-tufted bush and tropic palm;

Then from the silence, echoless, on high

Mounts through the torpor of the deadly calm,
To ethereal plains the siren’s piercing cry.

ON THE SENEGAL.
EN ROUTE.
 CHAPTER II

FROM KAYES TO TIMBUKTU

On October 10, 1895, we finally left Kayes. Our packages had

been piled up the evening before in three railway wagons, and our
party now took their places in the carriages. Baudry, Bluzet, and
Sauzereau our engineer, who were to go up in the Davoust,
remained, and the rest of my staff were the following: the second
master pilot, Samba Amadi, generally called Digui, a man of colossal
height and herculean strength, but more remarkable still for his zeal,
his fidelity, and his nautical skill; the native interpreter Suleyman
Gundiamu, who had been to Timbuktu with Caron as one of his
coolies; the Arabic translator, Abdulaye Dem, a cunning and
intelligent little Toucouleur, more cultivated than most of the negro
marabouts; and twenty coolies, or native sailors.
We reached Bafolabé in the evening without incident. A ferry-boat
took us across the Bafing, one of the two rivers which unite to form
the Senegal. A road some two feet wide starts from the right bank of
the Bafing, and follows the course of the other affluent, the Bakhoy,
to the village of Djubeba, where we camped on the evening of the
13th.
Thus far our journey had been effected by the aid of very civilized
means of transport. On leaving Djubeba, however, our difficulties
were to begin.
 LEFEBVRE CARTS UNHARNESSED.

The carriage, or rather cart, which is used in the French Sudan for
taking down provisions and other necessaries to our different
stations on the Niger is of the kind known as the Lefebvre, about
which there was so much talk during the Madagascar expedition. It
consists of a big case of sheet iron mounted on a crank axle, and
provided with two wheels. It is drawn by a mule.
Is it an ideal equipage? or is it as bad as it is painted? I do not
venture to decide the question. The truth, perhaps, lies between the
two extremes. On the one hand, these carts were always able to
follow our troops in the Sudan; but on the other, their intrinsic weight
might very well be lessened. The chief advantage of metal rather
than of wooden carts, is that they are watertight, and that when
unloaded they can be floated across streams or rivers, but as I have
never seen a Lefebvre cart execute this manœuvre, I feel a little
sceptical about it still.
 LOADING OUR CONVOY.

When the packages to be carried are small, compact, and about

the same size and shape, it is easy enough to stow them away, but
this was by no means the case with ours, and our large packages
would be fearfully difficult to arrange and balance in the heavy metal
carts.
On the 14th the mules arrived, some of which were to be
harnessed to the carts, whilst others were to carry pack-saddles. The
whole of that day and the next were occupied in the arranging and
loading.
The sections of the Davoust could not, of course, have been
carried in carts in any case. I had asked for seventy porters to take
charge of them, and these porters arrived in the evening. There was
nothing now to prevent our starting.
The route from the French Sudan, so often traversed to re-victual
our stations, has been too many times described for me to pause to
speak of the stages by which the traveller passes from the banks of
the Senegal to those of the Niger. For us, the usual difficulties were
increased by the variety of our means of transport, including as they
did carts, mules with pack-saddles, and porters. Moreover, ours was
the first convoy which had passed over the route since the winter,
and the road had not yet been mended all the way. The first few
days were very tiring, and men and animals were all alike done up
when we reached our first halting-place a little after noon. But every
one did his best, and became more skilful at managing, so that in
three days after the start our black fellows were as well up to their
work as we were ourselves.
This was our general mode of dividing the day. At two o’clock in
the morning the blowing of a horn roused everybody; the drivers
gave the animals their nose-bags containing a few handfuls of millet
to keep up their strength on the road; Bluzet, to whose special care I
had confided the porters, collected his people, whilst our cook
quickly warmed for each of us a cup of coffee which had been
prepared overnight. An hour later we were off, the porters leading
the way, our path lighted by torches of twisted straw, the fitful gleam
of which made our negroes look like a troop of devils come to hold
their sabbat in Central Africa.
Bluzet rides at the head of the caravan, looking back every now
and then, whilst two or three coolies run in the rear or on the flanks
of our little column, like sheep dogs keeping a flock together. About a
hundred yards behind the carts come jolting along on their rumbling
iron wheels, whilst the pack animals bring up the rear.