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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

What explains divergent reform trajectories in the expansion of healthcare across the Global South? While achieving universal health coverage is central to the international development agenda, national implementation remains uneven - raising concerns about the political constraints shaping healthcare reform. Some governments pursue comprehensive reforms to establish unified, equitable systems, while others adopt segmented approaches that expand access but maintain socio-economic hierarchies.

This paper develops a political economy framework to examine the conditions under which governments adopt universal versus segmented healthcare reforms. I theorise two main drivers ofsocial policy expansion,: government ideology and electoral volatility, and how they interact with vested interests. I argue that left-wing governments are more likely to pursue universal reforms aligned with newly enfranchised electorates, while high electoral volatility reduces incentives for clientelism and increases the appeal of visible policies demonstrating broad-based development. However, these dynamics are conditioned by vested interests, with private providers and organised labour often resisting broad expansion to protect their own benefits.

Empirically, I introduce a novel dataset of health system reforms across 90 countries in the Global South (1990–2023), classifying reforms as universal or segmented based on their impact on equity. Using event history analysis, I show that left-wing governments are significantly more likely to adopt universal reforms but are constrained by organised labour, while right-wing governments favour segmented reforms, shaped by the degree of healthcare privatisation. Overall, the findings challenge technocratic models and highlight the central role of electoral incentives, ideology, and vested interests in shaping healthcare expansion.