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 coalition to expand UHC, national implementation varies widely across countries – with widening gaps between countries of the Global North and the Global South. Most recently, the widespread protests against the introduction of a fully universal healthcare system in South Africa highlight that processes of welfare reform remain inherently political rather than technocratic in nature. This paper contributes to the growing literature on the political determinants of healthcare reform by examining why some countries in the Global South achieve universal coverage while others remain trapped in residual systems. 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. The paper contrasts two prominent theories for explaining social policy reform in the Global South: government partisanship and electoral competition. In doing so, it highlights the importance of two mediating variables that have received limited attention in previous research. First, insider-outsider politics, which determine whose interests dominate the policy agenda, play a critical role in shaping reform trajectories. Second, international development assistance often acts as both an enabler and a constraint, influencing the scope and direction of reforms through funding, conditionalities, and agenda-setting. The analysis builds on an original dataset coding the timing and nature of major healthcare reforms across 95 countries in the Global South between 1995 and 2023, classifying reforms as either universal or residual. Leveraging data from the Varieties of Democracy (V-Dem) and Development Assistance for Health databases, the study employs an event study framework 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 – government partisanship 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. This paper underscores the need to bring politics explicitly into the study of healthcare reform. By focusing on the dynamic and contested nature of reform processes, it provides a more nuanced understanding of why some countries achieve universal healthcare while others fall short. The findings have important implications for both theory and practice, suggesting that strategies to promote UHC must engage with the political realities of coalition-building, interest mediation, and external pressures that shape healthcare reform in the Global South.