The political economy of universal healthcare: a global comparative perspective

Thesis

While universal healthcare stands at the centre of the global development agenda, its political and distributive foundations remain poorly understood. This thesis examines the political economy of healthcare through the lens of universalism in social policy: the principle that states should provide comprehensive and equitable access to high-quality services for all. Using a global comparative analysis, the thesis sheds light on three aspects of healthcare universalism: its measurement, social consequences, and political determinants.

The first paper introduces the Healthcare Universalism Index (HUI), a composite indicator capturing ‘varieties of universalism’ across 204 countries from 1995 to 2023. The analysis reveals moderate global convergence and persistent regional disparities in the HUI, alongside robust evidence that universalism is linked to higher redistribution outcomes – both cross-nationally in the Global North and dynamically in the Global South.

The second paper conceptualises universal social policies as relational 'spaces of equality' that contribute to generalised trust by fostering equitable welfare experiences and social connectedness. Multilevel models across 105 countries demonstrate significant associations between healthcare universalism and trust, with important heterogeneity: public spending plays a stronger role in the Global South, while privatisation erodes trust in the Global North. These effects are strongest among those most likely to opt out of public systems, supporting the idea that universalism fosters cross-class bonds.

The third paper investigates why governments in the Global South adopt universal versus segmented healthcare expansions, drawing on an original reform dataset across 90 countries between 1990 and 2023. Event history analysis finds that left-wing governments and electoral volatility are predictors of universal reforms, while right-wing governments, healthcare privatisation, and labour union strength increase the likelihood of segmented expansion.

In combining theoretical and empirical innovations with a global comparative lens, the thesis repositions healthcare universalism as a multidimensional, relational, and political foundation for understanding inclusive development trajectories.

Authors: Schillings, T

• DOI: 10.5287/ora-14em781kg
• Type of award: DPhil
• Level of award: Doctoral
• Awarding institution: University of Oxford
• Language: English
• Keywords: health systems; Global South; universal healthcare; inequality; universalism
• Subjects: Comparative Social Policy; Political Economy; Comparative Politics; Development Studies; Development Economics