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

What explains divergent reform trajectories in the expansion of healthcare across the Global South? While the achievement of universal health coverage stands at the centre of the international development agenda, national implementation remains highly uneven – raising fundamental concerns about the political constraints that shape healthcare expansion. While some governments pursue comprehensive reforms to establish unified, equitable healthcare systems, others adopt segmented approaches to expand access while maintaining socio-economic hierarchies in service provision. This paper adopts a political economy framework to examine the conditions under which governments adopt universal versus segmented healthcare reforms. Drawing on the literature on social policy expansion in the Global South, I theorise two main drivers of healthcare reform in emerging democracies and their interaction with vested interests: government ideology and electoral competition. I argue that left-wing governments are more likely to pursue universal reforms due to their ideological alignment with a newly enfranchised electorate, while increasing electoral competition reduces the incentives for clientelism and increases the appeal of high-visibility policies that signal a commitment towards 'delivering development’ for broad-based constituencies. However, these electoral dynamics are conditioned by the power of vested interests, with private healthcare providers and organised labour resisting broad-based expansion in favour of protecting their own benefits. Empirically, I introduce a novel dataset of health system reforms that expanded access or benefits to new population groups across 90 countries in the Global South between 1990 and 2023. Reforms are classified as either universal or segmented, based on their impact on equity in healthcare provision. Using event history analysis, I explore the electoral and interest-based factors associated with each type of reform. The results provide strong support for the role of politics in healthcare expansion trajectories: left-wing governments are significantly more likely to adopt universal reform but are constrained by the strength of organised labour, while right-wing governments are more likely to pursue segmented reforms and conditioned by the level of healthcare privatisation. On the other hand, political competition emerges as a highly significant predictor of universal reforms, with further analysis supporting the suggested mechanism of decreasing incentives for clientelist policy under conditions of high electoral volatility. This paper makes three key contributions to the growing literature on the political economy of social policy in the Global South: (1) it introduces a new global dataset of healthcare system reform that conceptually distinguishes between universal and segmented expansion; (2) it develops a theory of electoral visibility and constrained clientelism as a driver of universal healthcare reform; and (3) it tests how vested interests shape the political logic of reform adoption. Overall, the findings challenge technocratic models of healthcare reform and highlight the central role of electoral incentives, ideological preferences, and vested interests in shaping how governments expand access to healthcare.