One way in which political leaders gain support in democratic systems is by distributing goods to citizens. Theories of accountability suggest that when political authorities provide these goods to citizens, they will be rewarded. Yet, incumbents have at their disposal multiple mechanisms through which they can distribute goods to citizens. Generally, goods are either distributed through programmatic or non-programmatic means. This dissertation evaluates how the mechanism through which goods are distributed influences the ways in which citizens evaluate goods performance and political leaders. I address this question by focusing on the distribution of healthcare in the West African country of Ghana. I propose a theory to explain the process by which individuals reward or punish incumbent leaders for healthcare provision distributed via a national health insurance scheme (programmatic distribution) and targeted monetary transfers (non-programmatic distribution). The central insight proposed by the theory is that the characteristics of healthcare distribution via a national insurance scheme lead individuals to evaluate incumbent leaders based on the quality of goods they receive, while the nature of healthcare distribution through targeted transfers leads individuals to evaluate incumbents based not on the quality of goods they acquire, but on their receipt of a transfer. Interview and survey research accord with these propositions. I find that individuals are more likely to sanction incumbents for poor performance when low-quality healthcare goods are distributed through a national insurance scheme. When these same low-quality goods are acquired via monetary handouts, individuals are less likely to sanction incumbents for the quality of said goods. In the latter case, poor performance is not associated with the quality of healthcare goods acquired by citizens, but whether or not the necessary resources for the acquisition of these goods were dispensed by incumbents. I contribute to the literature on goods distribution and accountability and provide novel theory and evidence on the impact of programmatic distribution and incumbent support.
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