The transnational politics of healthcare reform: International Organisations and healthcare financing in Central and Eastern Europe

Healthcare policy is a core component of welfare state systems. However, welfare state research is often “bounded to methodological nationalism” (Zürn, 2005), focusing primarily on national actors while overlooking the influence of transnational actors (TNAs) (Stone, 2004). TNAs, particularly IOs, are crucial in transferring their ideas and knowledge to national policy arenas (Weyland, 2006; Bazbauers, 2018). Lacking direct institutional power within national arenas, TNAs rely on the ideational influence of their policy advice and recommendations as the primary influential means in national policymaking processes, particularly in LMICs (Beland & Orenstein, 2009). This dynamic was especially evident in the post-communist transformation of CEE (Deacon & Stubbs, 2007). Many TNas became involved in the region’s transition to the extent that the transnational dimension of transition was recognised as a fourth component alongside the political, economic, and social transitions (Orenstein et al., 2008). CEE countries became testing grounds for reform, with IOs such as the WB and the IMF shaping economic and social policies (Deacon, 1998). The engagement of these two IOs was initially driven by the severe economic crises accompanying the transition, marked by hyperinflation, budget deficits, and stagnating economies, which necessitated external financial and technical support. The WB, leveraging its development lending mandate, became a prominent actor in social sector reforms. While its role in pension reforms has been extensively studied (e.g., Orenstein, 2008), its influence on healthcare reforms remains contested and less understood. Similarly, the IMF provided macroeconomic expertise and assistance to the CEE countries during the transition and the economic crises in 2009. However, its role in healthcare reforms remains underexplored. In this context, this study investigates the healthcare financing (HCF) policy prescriptions of the WB and IMF in 17 countries (Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Czech Republic, Estonia, Hungary, Kosovo, Latvia, Lithuania, Montenegro, North Macedonia, Poland, Romania, Serbia, Slovakia, Slovenia) from 1989 to 2019. Drawing on 96 key documents (80 from the WB, 16 from the IMF) and their qualitative content analysis via MAXQDA, the analysis first outlines the prescriptions provided by each IO on HCF sub-policies: revenue-raising, pooling, purchasing, and benefit entitlement, coverage (WHO, 2000). Findings reveal substantial variation in the prescriptions of both IOs across sub-policies and countries, highlighting a context-specific approach to HCF reforms tailored to local political, economic, and social realities. This challenges the ‘one-size-fits-all’ approach often attributed to IFIs. Second, the analysis employs both an economic lens (focused on efficiency) and a normative lens (emphasising equity in access, coverage, and financial protection) to identify which perspective predominates in each IO’s policy prescriptions. Third, the relationship between the state, market, and HCF reforms is examined through the prescriptions provided by the IOs. This study contributes to developing a political science of health and healthcare by fostering interdisciplinary collaboration. It demonstrates how IR studies and ideational scholarship can enrich research on healthcare policy. By adopting a transnational perspective, the study also seeks to overcome the blind spot of methodological nationalism and thus offer a more comprehensive understanding of the actors shaping healthcare policy.