Political Context and Health Financing Reform

The articles in this special issue make two particularly valuable contributions to understanding health financing reform. First, through historical case studies, they provide rich empirical evidence showing that reform is more than a technical matter: it is also a heavily political undertaking. Second, they provide guidance to reformers on political management, illustrating the utility of a framework that identifies groups of actors who facilitate and obstruct change, including interest groups and political leaders. A focus on political management highlights the role of human agency in health financing reform. Reform is shaped not only by agency but also by political context—enduring political and social arrangements not easily altered by the actions of individuals. For instance, the adoption and smooth implementation of reform may be more likely in a country with a government that has a unitary political structure that limits the ability of anti-reform groups to block change. Several scholars warn against excessive analytical focus on the actions of individuals, as doing so may mask the role of structural forces and long-term social processes in explaining political and social outcomes, including social welfare policy adoption and implementation. The articles in this special issue attend to political context but highlight individual agency. In this commentary, I do the reverse. I do so with a view to calling attention to some of the larger and more enduring factors—pertaining to nature of the political system and party rule, features of civil society, and the global political environment—that alongside human agency may explain why major health financing reforms advance in some national settings but not others.