Progressive Versus Competitive Democracy: Examining the Political Determinants of Universal Healthcare Reform in the Global South

The achievement of universal health coverage (UHC) for all stands at the centre of the international development agenda, championed by both national governments and transnational organisations. Despite this global consensus, 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 systems.

This paper examines the political determinants of universal healthcare reform by contrasting two prominent theories for explaining social policy reform in the Global South: party ideology and electoral competition. Informed by diverse country case studies and the regional literature on social policy reform, the analysis further explores the role of two potential mediating variables: insider-outsider politics and international development assistance. To do so, 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 residual. Drawing further on data from the Varieties of Democracy (V-Dem) 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, right-wing governments receiving development assistance, or high electoral pressures supported by organised labour – that significantly increases the likelihood of universal reform.