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Accepted Paper:
Progressive versus Competitive Democracy: Examining the Political Determinants of Universal Healthcare
Tobias Schillings
(University of Oxford)
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.