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This book explores how political, social, economic and institutional factors in eight emerging economies have combined to generate diverse outcomes in their move towards universal health care. Structured in three parts, the book begins by framing social policy as an integral system in its own right. The following two parts go on to discuss the opportunities and challenges of achieving universal health care in Thailand, Brazil and China, and survey the obstacles facing India, Indonesia, Russia, South Africa and Venezuela in the reform of their health care systems. The evolution of social policy systems and the cases in this volume together demonstrate that universalism in health care is continuously redefined by the interactions between diverse political forces and through specific policy processes. At a time when international and national-level discourse around health systems has once again brought universalism to the fore, this edited collection offers a timely contribution to the field in its thorough analysis of health care reform in emerging economies.



1. Introduction: The Universalization of Health Care in Emerging Economies

Universal health coverage (UHC) is not a new topic in development discourse and practice. Since the late 1970s, neoliberalism has eroded solidaristic institutions and policies in health systems, shifting regulatory roles and functions in health service provision and care delivery from the public to the private sector. However, a recent shift in international and national health systems discourse has again brought universalism, particularly universal health coverage, to the fore. As many countries make significant strides towards universalism, this introductory chapter summarizes policy-relevant findings and lessons from the experience of eight emerging economies. Illustrating diverse forms of contestation and compromise over the contents of public policies and institutions affecting health outcomes, it highlights that moving towards universal health care is more about politics, institutions, and policies than financial resources.
Ilcheong Yi, Elizabeth Koechlein, Armando de Negri Filho

Analyzing Common Pressures and Diverse Social Policy Responses


2. The Continuing Enigmas of Social Policy

The welfare regime approach to social policy is shown to be past its use-by date, not least for imposing an ever-expanding set of ideal types that do not fit unyieldingly variegated outcomes across sectors and countries. Moreover, like many other approaches, it tends to derive its analytical framing from the Keynesian period as opposed to forging an understanding of neoliberalism and the increasing role of financialization as a direct and indirect influence upon social policy. Alternatives should be posed in terms of addressing both the transformational/developmental role of social policy and its sector-specific systems of provision.
Ben Fine

3. Universalism and Health: The Battle of Ideas

In this chapter, MacGregor contextualizes the issue of universal health coverage. She summarizes moves towards the adoption of universal health coverage as a goal of international policy. Arguments for universal health coverage are reviewed, noting references to human rights, social justice, security and social integration. Competing ideas are considered—universalism versus selectivism, welfare state versus neoliberalism and social investment. The chapter looks at the political mobilization of ideas in high-income and middle-income countries. Issues of implementation, variations in financing mechanisms and state capacity are noted. The conclusion is that politics matters—even more so as new challenges appear.
Susanne MacGregor

Moving Towards Universal Health Care: Opportunities and Challenges


4. The Politics of Health Care Reform in Thailand

The success of the universal health care programme in Thailand can be traced to two factors: a big bang approach to policy reform and prior institutional capacity in the form of reformist medical bureaucrats ensconced in the Ministry of Public Health. The big bang approach provided the requisite political power, while reformist bureaucrats provided evidence-based knowledge, past practical experience and institutional networks that were crucial for the forging of the universal health care programme. The combination of political power and bureaucratic capacity has thus led to a universal health care programme that has granted coverage to almost all Thai citizens.
Erik Martinez Kuhonta

5. The Impacts of Universalization: A Case Study on Thailand’s Social Protection and Universal Health Coverage

This chapter focuses on health care access in Thailand as well as on health financing reform and the path towards universal health coverage in the country. The chapter draws attention to the comprehensive outcomes of the Universal Coverage Scheme (UCS), also known as the 30 Baht health care programme, differentiating between the direct and indirect impacts of the scheme. It traces the historical development of UCS as part of the country’s social protection system. The chapter concludes by summarizing the key impacts of the health policy reform and implementation.
Prapaporn Tivayanond Mongkhonvanit, Piya Hanvoravongchai

6. Political and Institutional Drivers of Social Security Universalization in Brazil

Brazil’s experience in building a relatively successful universal health system was made possible by the combination of political incentives to serve poor constituencies, which made it politically sustainable; fiscal sustainability and the great extractive capacity of the Brazilian state; and the institutional capacity to run a complex decentralized system. This chapter argues that Brazil’s Unified Health System (SUS) has faced two important challenges: finding new financial resources for the sector and promoting efficiency gains. Finding new sources of funding has involved unprecedented political costs despite the increasing saliency of public health in the public agenda. Efficiency gains are also unlikely to occur in the near future due to the recent deterioration of public sector management since 2012 and other specific factors, including the judicialization of health care.
Marcus André Melo

7. Universalizing Health Care in Brazil: Opportunities and Challenges

This chapter explains the development of the Brazilian Unified Health System (SUS) within a hybrid development policy regime of neoliberal and new developmentalist policies. Focusing on three key dimensions for the development of health care in the Brazilian federative context— namely the regionalization of health care, stable and sufficient financing and public–private partnership—the chapter highlights the opportunities and challenges in moving towards universal health coverage in a context of great regional inequality, chronic underfunding and complicated relations between the public and private sectors. It argues that the creation and development of the SUS was a key driver towards the universalization of health coverage, and opened a window of opportunity to create a virtuous complementarity between health care expansion and other policies for overall development.
Ana Luiza d’Ávila Viana, Hudson Pacífico da Silva, Ilcheong Yi

8. What Kind of Welfare State Is Emerging in China?

Through a survey of current social policy arrangements and historical trajectories, the emerging Chinese welfare state is positioned in relation to the main models in the literature on welfare state typologies. It is found that the emerging welfare state in China is developing in response to economic necessity rather than political-ideological drivers, a process which is not original, not socialist, and not developmental. China’s emerging welfare state can be best classified as a fragmented liberal-conservative hybrid model which is limited and defensive in terms of both ambition and practice.
Stein Ringen, Kinglun Ngok

9. China’s Universal Health Care Coverage

Despite being a developing country with approximately 1.4 billion people, China has managed to extend a basic health care safety net to more than 95 percent of its population over the past decade. What forces converged to make this achievement possible? Guided by the political economy theory on agenda setting developed by John Kingdon (1984), this chapter illustrates that achieving universal health coverage (UHC) in China has required the convergence of the following factors: heightened problem recognition, ideas/ideology for policy formulation, political institution willingness and available fiscal space. We also demonstrate, however, that official universal health insurance coverage in contemporary China has not yet equated to fully comprehensive and effective coverage in practice, as not every citizen has equal access to the same quality of health care. The success of China’s UHC was built on the simultaneous investment in, and development of, preventive and basic health services and the provision of insurance coverage for all. Still, stark health disparities between urban and rural residents remain, along with high health expenditures and inflation of health care costs caused by inefficiency and waste. Nevertheless, China’s policy journey still provides a valuable example to inform other nations as to what is needed to enable major health system reforms.
William Hsiao, Mingqiang Li, Shufang Zhang

Obstacles to Moving Towards Universal Health Care


10. Constraints on Universal Health Care in the Russian Federation: Inequality, Informality and the Failures of Mandatory Health Insurance Reforms

Cook provides a comprehensive overview of Russia’s post-communist health care system, including the health crisis of the 1990s, and the recovery of health care financing and health indicators for the population from 2000. The chapter recognizes the broad coverage of Russia’s health care system and focuses on obstacles to universal and effective coverage, including socioeconomic and regional inequalities as well as informal payments for health services. Cook assesses the system’s accomplishments and limitations, as well as the multiple efforts at health care reform since 1990.
Linda J. Cook

11. The Fragmented Social Protection System in India: Five Key Rights but Two Missing

India is one the world’s fastest-growing economies, but it struggles with high levels of poverty, malnutrition, and infant and maternal mortality rates. While the country has made strides in providing for a rights-based approach towards food, work and education, with much visible impacts on their developmental outcomes, two key fundamental rights—social insurance and health—have not received adequate policy attention. This chapter discusses the role of civil society mobilization and political support in ensuring entitlements with respect to work (albeit in rural areas), education and food and argues for a similar approach for ensuring universal health coverage, welcoming the Draft National Health Policy 2015, which advocates for health as a fundamental right. The chapter suggests immediate policy interventions, including the very critical aspect of sanitation, to address key health sector issues, particularly in India’s rural areas.
Santosh Mehrotra, Neha Kumra, Ankita Gandhi

12. The Drivers of Universal Health Care in South Africa: The Role of Ideas, Actors and Institutions

This chapter examines the opportunities and challenges entailed by the recently proposed National Health Insurance (NHI) reforms in South Africa. It discusses what NHI is trying to achieve within the context of the country’s current two-tiered health system and how it hopes to address existing problems, before examining the political, institutional and implementation challenges the reforms will face. While most attention has been thus far devoted to the structural requirements and fiscal affordability of universal coverage, this chapter highlights attention on wider challenges—in particular the important role played by key stakeholders tasked with implementing the reforms.
Rebecca Surender

13. Social Policy in Venezuela: Bucking Neoliberalism or Unsustainable Clientelism?

Following an overview of social protection policies in Latin America, this chapter considers the specific case of Venezuela with a focus on the presidency of Hugo Chávez (1998–2013). After analysing the ideological, political and economic drivers of the social protection system introduced by the government, the chapter highlights continuity with a domestic tradition of financing social protection with volatile oil export revenues. Through detailed reference to health policy, it is argued that the achievements were significant, particularly given the national crisis inherited by Chávez, but that welfare initiatives were unsustainable without major institutional and economic policy change.
Julia Buxton

14. Expanding Social Security in Indonesia: The Current Processes and Challenges

This chapter reviews social security development in Indonesia, which has evolved from providing very little in its early years, to a system that benefited only formal sector workers, to universal coverage. There are two important milestones in this development. First, starting in the mid-1960s, the New Order government gradually developed various social security schemes, albeit limited to the formal sector. Second, after the Asian financial crisis towards the end of the 1990s, a stronger social security system was established by adopting legislation for universal coverage. The challenges for implementing it, however, remain formidable due to Indonesia’s vast geography, large population and diversity in availability and quality of infrastructure.
Asep Suryahadi, Vita Febriany, Athia Yumna


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