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Contribution short abstract:

This paper examines the political determinants of universal healthcare reform in contrasting the role of government partisanship and electoral competition and their interaction with interest-based politics for determining the type of reform pursued in countries of the Global South.

Contribution long abstract:

Despite a global policy consensus towards the achievement of universal health coverage, national implementation varies widely across the world – emphasising that processes of healthcare reform remain inherently political rather than technocratic. 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 to achieving truly universal healthcare institutions in the Global South.

This paper examines the political determinants of universal healthcare reform by investigating two prominent drivers of policy expansion – government partisanship and electoral competition – and their interaction with two mediating factors of interest-based politics: labour unions and international development assistance. The paper codes the timing of major healthcare reforms across a sample of 95 countries in the Global South between 1995 and 2023, classifying them as either universal or segmenting. Drawing on data from the Varieties of Democracy and Development Assistance for Health databases, the analysis employs an event study to investigate the factors associated with each type of reform.

The findings demonstrate that politics plays a critical role in healthcare reform, even outweighing socio-economic factors. However, neither of the main explanatory factors – party ideology or electoral competition – is systematically associated with policy reform in the Global South. Instead, the study provides a more nuanced perspective on the complexities of political processes, showing that it is the combination of several factors – such as left-wing governments facing weak trade unions– that significantly increases the likelihood of universal reform.