From Neoliberalism to Universalism: Explaining the Emergence of Universal Health Coverage As a Global Norm

How do new ideas displace hegemonic ones? The neoliberal logic that gained ascendancy in the 1980s emphasized privatization of government services, the weakening of social entitlements, and the liberalization of government regulation. The institution of neoliberalism in the developing world was driven by the Reagan-Thatcher revolution and supported by structural adjustment programs. This normative shift, aided by coercive institutions, led to the dismantling of state-run healthcare systems, the institution of user fees in hospitals and clinics, and the promotion of private health insurance – all of which had pernicious effects on access to healthcare. And yet, despite the fact that austerity and structural adjustment continue to play an important role in world affairs today, the turn of the millennium has witnessed a wave of commitments to universal healthcare in the developing world in countries ranging from Turkey to Thailand to Mexico and Ghana. Recently, this process has accelerated, and universal coverage has received major new attention at the international level, culminating in a UN resolution in support of universal coverage. This paper explores the emergence of a new norm around universal health coverage at the global level and advances an explanation that emphasizes the importance of negative evidence for weakening dominant norms and the importance of positive evidence for making alternative norms appear viable. The diffusion of new norms and displacement of old ones, however, depends on the strategic actions of norm entrepreneurs. This account illustrates the significance of interactions between the national and global levels and suggests that institutions with coercive powers that play key roles in the persistence of hegemonic norms can themselves be transformed to support markedly different new normative projects.