Paper short abstract:

Our paper analyses existing individual case studies that focus on the politics of health financing reforms in LMICs. The analysis uses the 3-Is framework, enabling us to provide a more nuanced and fine-grained explanation of why health financing reform succeeds in some countries and fails in others.

Paper long abstract:

There is growing interest in the politics and political economy of health financing reform, as universal health coverage (UHC) has risen to the top of the global development agenda. While there is vast research discussing common political economy factors that impact health systems reforms across high-income countries, less research is available on the interplay of political factors affecting national health systems reform processes across low- and middle-income countries. Research that seeks to unpack political economy dynamics in health system reform processes tends to focus on the concept of 'political will'. This broad conclusion offers a limited explanation of why certain countries like Thailand, Mexico, Ghana, and Rwanda have successfully adopted health financing reforms to advance UHC, while other countries' reform processes have not yielded tangible improvements in healthcare access.

This paper presents the findings of a systematic review investigating political factors and dynamics impacting national governments' success or failure in implementing UHC financing reforms. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we reviewed data from six databases, then extracted and applied the '3-i' framework to understand how ideas/ideologies, interests, and institutions have influenced UHC reforms. Preliminary analysis shows that, rather than being the outcome of a generalised lack of political will, various actors within national healthcare systems hold different views and interests in adopting health financing mechanisms. Often, their views are influenced both by domestic and outside pressures, such as expectations from donors and international organisations and funding constraints as a consequence of globalised neoliberalism.

Paper short abstract:

This paper examines the Asian Development Bank’s COVID-19 response focusing on social sector support and health care in general and through a case study of the Bank’s pre- and post-COVID-19 lending to its major borrower, India.

Paper long abstract:

The Asian Development Bank’s (ADB) response to the COVID-19 pandemic was shaped by path dependency in both its development discourse and lending practices. In its first decades, the Bank was said to be a pragmatic lender, focused on infrastructure. By the first decade of the 2000s, the Bank’s mission changed to poverty reduction and gender equality, but its lending program continued to focus on infrastructure lending. However, this was no longer done primarily through sovereign lending to states but rather through lending for privatisation and public-private partnerships as well as direct private sector lending shaped by neoclassical economics discourse. This research investigates how the COVID-19 pandemic impacted ADB’s development thinking, in particular, its approach to its core supposed mission of poverty reduction and gender equity. We also examine the Bank’s COVID-19 response focusing on social sector support and health care in general and though a case study of the Bank’s pre- and post-COVID-19 lending to its major borrower, India. This political economy analysis highlights the extent to which neoclassical economic dogma continued to permeate every aspect and sector of Bank work, despite the new challenges arising from the pandemic.

Paper short abstract:

This paper investigates how a coupling of problem, policy and politics streams can lead to radical policy change in high school education financing in Africa. It argues that homegrown policy change is possible even in contexts of weak fiscal capacity and incompatible political ideology.

Paper long abstract:

In 2017 Ghana introduced a universal and comprehensively free senior high school (FSHS) programme to address financial barriers to post-basic education. A path-departing policy change supervised by a right-of-centre New Patriotic Party (NPP) government, the FSHS was adopted when “Ghana’s economy was in trouble hobbled by widening current account and budget deficits [and] rampant inflation” (IMF, 2019). The FSHS programme presents a paradox which we address through three interrelated questions: How did financial barriers to education rise to the status of a national problem in Ghana requiring a path-departing policy response? What factors facilitated the adoption of a comprehensively FSHS programme despite prevailing stable cost-sharing model and limited fiscal capacity of the state? Why did the NPP government adopt and implement a FSHS programme which is incompatible with its right of centre ideology? Drawing upon elite interviews including with government officials, members of parliament, donors, CSOs and extensive documentary reviews, such as parliamentary Hansards and media publications we challenge dominant policy diffusion and imposition theses which claim that path-departing policy change in LMICs is mainly actuated through exogenous factors. We argue that endogenous change is possible because political elites can fashion homegrown solutions when they are convinced that a policy problem exists and addressing it can enhance their electoral fortunes. Where political ideologies clash with electoral incentives, elites will jettison their ideologies in favour of pragmatic policies that may appease potential voters. Our findings have implications for how we think about social policy financing in the Global South.

Paper short abstract:

This paper conducts an international comparative analysis to understand the role of foreign aid in the evolution of social protection systems in the Global South and identifies key factors that have underpinned these dynamics.

Paper long abstract:

This study conducts an international comparative analysis of the recent evolution of social protection systems in the Global South, paying particular attention to the role of foreign aid in these dynamics. It asks: Has foreign aid contributed to the development of social protection systems? If so, what actors have driven this process? Taking an international comparative perspective is key to understanding the heterogeneous political and economic conditions and dynamics that are shaping social protection systems in the Global South.

Overall, we find that aid has contributed to the expansion of social protection systems in the Global South: an increase in social protection aid by one percentage point is estimated to lead to an increase in the share of countries’ population covered by social protection by approximately 0.25 per cent, which is not negligible. The analysis also identifies key factors that have underpinned the recent expansion of social protection systems, including the economic dynamism of aid-recipient countries, their redistributive fiscal capacity, their insertion into the global economy, and their level of income inequality. Donors’ influence and policy diffusion, the political ideology of incumbent regimes, and previous aggregate shocks also appear to have contributed to the expansion of social protection systems in some regions, particularly Latin America and Asia-Pacific, but not in sub-Saharan Africa. The paper provides a discussion of plausible reasons underpinning these differences.

Paper short abstract:

By investigating the impact of social protection on children’s healthcare access we highlight their needs and vulnerabilities as distinct from, but related to the household’s. Focusing on children is also important in proactively addressing life cycle and intergenerational poverty and vulnerability.

Paper long abstract:

In 2003 Ghana abolished its cash-and-carry health care financing policy and replaced it with a National Health Insurance Scheme (NHIS) which aspires to universal coverage. To enhance enrolment in the scheme, the NHIS law has embedded a social assistance component which exempts some categories of people including indigents, the elderly over 70+ years, social security contributors and children from paying premiums. Membership of the country’s flagship cash transfer programme, the Livelihood Empowerment Against Poverty (LEAP) also exempts beneficiaries from paying premiums for NHIS services. Despite recent improvements in health care access in Ghana through the NHIS, about 60% of Ghanaian residents are uninsured, 40% of children are being left behind in health care access and there is uneven geographical coverage. This study investigates the impact and different outcomes of LEAP on children’s health care access along three main dimensions, namely enrolment on NHIS, skilled birth attendance (ante-natal, delivery and post-natal) and immunization. We draw primary data from in-depth qualitative interviews and focus group discussions with caregivers, non-subscribers, service providers, NHIS and Ghana Health Service officials in two implementation districts with differing poverty levels and access to social services. We complement this with an analysis of statistical data from the Multiple Indicators Cluster and Ghana Living Standards Surveys and extensive reviews of programme documents, NGO and media reports. We find that linking cash transfers to health insurance may enhance health care access for children although other factors including distance, quality of service and state infrastructural power lead to uneven outcomes.

Paper short abstract:

The paper interrogates state and market intersections in planning, financing and delivering social policy initiatives. It draws on literature and interviews to discuss state-philanthropy relations and social policy delivery through a philanthropic mapping of the Tongu Districts of the Volta region.

Paper long abstract:

The Akosombo dam has for the past 62 years, been a bedrock of Ghana’s development agenda. The dam contributes immensely to the country’s power generation stock, upholds the commercial freshwater fishing industry and facilitates transportation among other things.

However, state authorities’ failure to keep up with the times, extreme weather conditions and poor early warning systems ensured that the devasting flood of 1963 repeated 60 years on. The so-called “controlled spillage” of excess water from the Akosombo Dam led to extensive flooding in the Lower Volta Basin affecting all the Tongu districts of the Volta Region and beyond. This resulted in the displacement of thousands of residents and the destruction of livelihoods. In line with the famous African proverb that ‘you do not fold your hands when your neighbour's house is on fire’, we observe multilayered interventions of state and non-state actors in addressing the ensuing humanitarian crisis in the Lower Volta Area (LVA) animating a complex state-philanthropy relations in humanitarian situations. This article focuses on interrogating state and market intersections in planning, financing and delivering social policy initiatives with the Lower Volta Basin in focus. It does a philanthropic mapping of Ghana, spotlighting the Tongu Districts of the Volta region, where the humanitarian quandary induced by the infamous Akosombo Dam spillage is expected to persist beyond 2024. It draws on extensive desk reviews, document analysis, and some in-depth qualitative interview data to discuss state-philanthropy relations and social policy delivery in Ghana using the state fragility theory as a framework.

Paper short abstract:

Foreign assistance in institutionalising and expanding social protection and intended and unintended consequences. This paper looks at the factors responsible for these consequences and the impacts they have had on social protection's role in poverty and vulnerability reduction in Nigeria.

Paper long abstract:

The role of foreign aid in supporting the adoption and institutionalization of social protection in low- and middle-income countries is a topic of intense debates. The debates have centred around whether foreign aid has been effective in assisting countries in achieving their development goals, some argue that foreign aid has unintended consequences that have been largely ignored while others have voiced that these countries have become too dependent on aid that they are unwilling to undertake the development and expansion of social protection on their own. In Nigeria, for over a decade, the United Kingdom (UK) Foreign Commonwealth Development Office (FCDO) through the Child Development Grant Programme (CDGP) now Expanding Social Protection for Inclusive Development ESPID) has been assisting Nigeria in the adoption and institutionalisation of social protection, particularly social assistance since 2013. This assistance has rested on: policy, legislation, advocacy and engagement; capacity building and systems strengthening; and evidence generation and knowledge management and the expected impact is for Nigerian citizens, especially children and their caregivers, to experience reduction in multi-dimensional poverty. This paper is a research study aimed at better understanding the impacts that the FCDO support has had on the adoption, institutionalisation and expansion of social protection in Nigeria. Specifically, the intended and unintended consequences, the factors responsible for these intended and unintended consequences and how such assistance can be improved upon. Findings from the study is expected to assist international development partners in reforming the way they provide assistance, especially in the field of social protection.

Paper short abstract:

This paper seeks to explain, using political settlements analysis: i) why the Indonesian government has significantly increased education spending since the fall of the New Order and ii) why this has failed to translate into improved education quality and learning outcomes.

Paper long abstract:

Since the fall of the authoritarian New Order regime in 1998, the Indonesian government has significantly increased education spending in line with a constitutional requirement for it to spend at least 20 percent of its budget on education. Yet, while this increase appears to have contributed to improvements in access to education in subsequent years, it has not enhanced the quality of education or learning outcomes. The country has regularly placed towards the bottom in international standardised tests of student learning such as the OECD’s Programme for International Student Assessment (PISA). The most recent PISA, conducted in 2022, saw Indonesia’s scores in reading, mathematics and science fall sharply due to the impact of school closures during COVID-19, signalling a deepening learning crisis. This paper seeks to explain, firstly, why the Indonesian government has significantly increased education spending since the fall of the New Order and, secondly, why this has failed to translate into improved education quality and learning outcomes. It argues that both outcomes reflect the nature of the political settlement that has characterised the post-New Order period. Specifically, it reflects the fact that while the Asian economic crisis and the shift to a more democratic political regime empowered technocratic and progressive elements in Indonesian politics and society, predatory oligarchic elements nevertheless retained their dominance, enabling them to shape how increased education resources have been used.

Paper short abstract:

Ideologies underlying a country’s social and economic policies determine the different tasks assigned to a country’s social policies with implications on the transformation of economies and sustainably financing welfare expenditure. South Africa, Zambia and Mauritius will be used to argue the case.

Paper long abstract:

Social policy in the Global South has often been conflated with social protection with implications on the role and how to finance social policy. Yet the most redistributive regimes of North Europe have tended to be the most conscious of the productive role of social policy significantly reducing poverty, inequality and vulnerability. By embedding skills and training regimes in the much larger welfare policy concerns close to full employment make it to easier sustainably finance welfare expenditure. Using a transformative social policy framework and with reference to Mauritius, South Africa and Zambia which are part of the Anglophone Southern Africa Gender Equitable and Transformative Social Policy in post-COVID-19 Africa (GETSPA) project, the papers seek answers to the following pertinent questions: How has Mauritius, located in the Global South, sustainably maintained a universal welfare state characterised by universal entitlements to social and welfare benefits? What role and secret lies in Mauritius’s deployment of its social policy in the country’s rapid transitioning from a largely agrarian economy in the early 1970’s into manufacturing and subsequently service sector and welfare financing mechanisms? Why is South Africa’s Skills Development SETAs policy faltering as a welfare production regime strategy with 47 per cent of the population reliant on government provided social grants? What lesson can copper-reliant and donor-driven social protection Zambia draws from Mauritian and South Africa’s welfare production regimes and social policy financing? Emerging evidence suggests the importance of holding in tandem social and economic policy to sustainably finance welfare expenditure.

Paper short abstract:

The study estimates financing gaps for achieving Universal Health Coverage (UHC) in Africa and examines various sustainable financing schemes likely to close the UHC gap. Thus, it provides evidence-based policy discussion on financing UHC (SDG 3.8.1) gaps in African countries.

Paper long abstract:

Health coverage is one of the four basic guarantees of social protection floors and monitored under SDG 3.8.1. It corresponds to the Universal Health Coverage (UHC) Index and captures coverage of essential health services. Most developed and few emerging countries have already achieved the minimum UHC Index target of 80 between 2015 and 2021. Out of the few emerging/developing countries that achieved the target, none included African countries. WHO global service coverage database 2024 shows persistent healthcare protection coverage gaps across all African countries since 2000, and the estimated gap from 2021 is 33. Somalia, Chad, and Central African Republic have a huge gap of 53, 51, and 48, respectively. Countries with the least gaps ranging from 5 to 10 include Seychelles (5), Algeria (6), Cabo Verde (9), South Africa (9), and Egypt (10). Clearly, time is running out for most African countries to achieve SDG 3.8 targets by 2030. Therefore, there is the need for radical but reliable and sustainable financing strategies likely to close the healthcare coverage gaps. The study seeks to provide evidence-based policy discussion on financing UHC gaps by estimating the financing gap for achieving healthcare protection coverage, and to examine various sustainable financing schemes likely to close the gap without financial hardship on households (SDG3.8.2). The study employs trend analysis of expenditure and financing sources to quantify the extent of the healthcare financing gap from 2000 to 2021. Data is obtained from WHO Global Health, IMF Government Finance Statistics, and IMF World Economic Outlook databases.

Paper short abstract:

This paper examines the political determinants of universal healthcare and explores the role of left-wing, progressive forces and electoral competition for determining universal health coverage and healthcare spending.

Paper long abstract:

The achievement of universal health coverage (UHC) for all stands at the centre of the international development agenda, for example as part of the UN Sustainable Development Goals. Still, processes of healthcare reform remain inherently political rather than technocratic and face a variety of political economy barriers. While the literature has consistently highlighted the central role of regime type and especially democratisation, it remains poorly understood which specific attributes of democracy are conducive for achieving truly universal healthcare systems.

This paper examines the political determinants of universal healthcare and explores the role of left-wing, progressive forces and electoral competition for determining universal health coverage and healthcare spending. In using healthcare as a case study for broader universal welfare reform in the Global South, this paper hypothesises that electoral competition, through the mechanism of mobilising cross-class political coalitions for social policy expansion, is the key democratic driving force for achieving comprehensive and universal policy reforms.

Drawing on the novel Healthcare Universalism Index (Schillings and Sánchez-Ancochea 2023) to measure varieties of universal healthcare provision across the world and the Varieties of Democracy (V-Dem) dataset, the theory is tested for a large panel of countries. As such, the paper finds evidence that democratisation or left-wing governments alone are often necessary but not sufficient conditions; instead, the existence of competing political forces appears crucial for advancing universal policy reform.

Paper short abstract:

This paper examines the durability of two social policies, input subsidies and social cash transfers, in Malawi and Zambia. Informed by path dependency concepts, it finds that they can endure despite deep fiscal/political challenges when driven by powerful policy coalitions or mobilised recipients.

Paper long abstract:

The politics of social policy in Sub-Saharan Africa has recently received considerable scholarly attention. Some argue that social protection policies are largely domestically driven as part of regime survival strategies (Hickey et al., 2020), while others emphasise the coercive role of donors (Fischer, 2018; Adesina, 2020). However, most of the recent research has focused on single policies during moments of significant expansion. This paper builds on existing research by examining what makes social policies endure in contexts of limited fiscal space, political volatility, and competing existing social policies.

The paper compares agricultural input subsidies (AIS) and social cash transfers (SCT) in Malawi and Zambia. AIS have long been a fundamental part of both countries’ political economies, especially since the advent of multi-party politics. SCTs were introduced by the international aid sector in the mid-2000s with varying degrees of government buy-in, relatively high in Zambia and low in Malawi. Using the theoretical lens of path dependency (Campbell 2012; Weible & Sabatier, 2018), this paper finds that the durability of policies depends on the mobilisation capacity of its recipients, which is low for SCTs and relatively high for AIS. Moreover, the financial/political power of policy coalitions is crucial yet fragile, illustrated by a recent shift in favor of the donor-driven SCTs driven by the countries’ growing debt crises.

This paper draws on four months of qualitative interviews conducted in Malawi and Zambia, complemented by extensive desk research. Participants included officials from relevant government ministries, foreign donor agencies, NGOs, parliamentarians, and independent researchers.