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Towards Universal Health Coverage in Ethiopia's ‘developmental state’? The political drivers of health insurance

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  • Lavers, Tom

Abstract

With Universal Health Coverage (UHC) now entrenched among the top global development priorities, questions arise as to the conditions under which politicians commit to UHC and why certain strategies for health financing and access are favoured over others. The Ethiopian government has been piloting and scaling-up Community-Based Health Insurance (CBHI) for the informal sector since 2010 and is establishing Social Health Insurance for formal sector workers as a means of achieving UHC. CBHI covers 11 million people making it one of the largest health insurance schemes in Africa. This paper employs a process tracing methodology to examine the political drivers of the adoption and evolution of state health insurance based on 28 key informant interviews conducted between 2015 and 2018 with politicians, policymakers and donor officials. The paper highlights the inadequacy of existing theories—focusing on interest group mobilisation, electoral competition and bureaucratic actors—for explaining the Ethiopian case. Instead the paper proposes an ‘Adapted Political Settlements’ framework that explains the state's push to expand CBHI and stalled progress on SHI. This framework highlights the interests and ideas of the ruling coalition as important drivers of reform. In a context of ruling party dominance and minimal threat from electoral competition, the ruling coalition has sought to build political legitimacy through the delivery of socioeconomic progress, including health services. The policy idea of health insurance, meanwhile, has secured elite commitment due to its fit with deeply held ideas within the ruling coalition concerning the importance of self-reliance and resource mobilisation for development. Finally, the centralisation of power within the ruling coalition prior to 2012 enabled the emergence of a long-term developmental vision and the marginalisation of opposition to health insurance, while fragmentation of the ruling coalition since 2012 has led SHI to stall.

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  • Lavers, Tom, 2019. "Towards Universal Health Coverage in Ethiopia's ‘developmental state’? The political drivers of health insurance," Social Science & Medicine, Elsevier, vol. 228(C), pages 60-67.
    • Handle: RePEc:eee:socmed:v:228:y:2019:i:c:p:60-67
    DOI: 10.1016/j.socscimed.2019.03.007
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    References listed on IDEAS

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    1. Samia Laokri & Olivier Weil & Koiné Maxime Drabo & Sary Mathurin Dembelé & Benoît Kafando & Bruno Dujardin, 2013. "Removal of user fees no guarantee of universal health coverage: observations from Burkina Faso," ULB Institutional Repository 2013/153197, ULB -- Universite Libre de Bruxelles.
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    3. Chemouni, Benjamin, 2018. "The political path to universal health coverage: Power, ideas and community-based health insurance in Rwanda," World Development, Elsevier, vol. 106(C), pages 87-98.
    4. Shigute, Zemzem & Mebratie, Anagaw D. & Sparrow, Robert & Yilma, Zelalem & Alemu, Getnet & Bedi, Arjun S., 2017. "Uptake of health insurance and the productive safety net program in rural Ethiopia," Social Science & Medicine, Elsevier, vol. 176(C), pages 133-141.
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    Cited by:

    1. Bukenya, Badru & Golooba-Mutebi, Frederick, 2020. "What explains sub-national variation in maternal mortality rates within developing countries? A political economy explanation," Social Science & Medicine, Elsevier, vol. 256(C).
    2. Koloma, Yaya, 2021. "Impact of Mutual Health Insurance on Urban Households Health Expenses and Vulnerability in Burkina Faso," EconStor Preprints 234465, ZBW - Leibniz Information Centre for Economics.
    3. Lavers, Tom, 2021. "Aiming for Universal Health Coverage through insurance in Ethiopia: State infrastructural power and the challenge of enrolment," Social Science & Medicine, Elsevier, vol. 282(C).

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