Reflections from South Africa on the Value and Application of a Political Economy Lens for Health Financing Reform

Reflections from South Africa on the Value and Application of a Political Economy Lens for Health Financing Reform

Health Systems and Reform

Commentary Reflections from South Africa on the Value and Application of a Political Economy Lens for Health Financing Reform

INTRODUCTION

In the mid nineteen nineties Michael Reich and Gill Walt, drawing on independent lines of work, called for an injection of political economy thinking into health policy analysis in low- and middle-income countries. Reich noted that "policy reform is inevitably political because it seeks to change who gets valued goods in society" and Walt, that health policy is "concerned with who influences whom in the making of policy, and how that happens." Both concluded that neither primarily technical work, such as economic analysis, nor a well-designed policy are themselves enough to bring about policy change. Rather, deliberate and specific analysis of the wider political forces, the actors, processes and power, influencing such change is necessary to understand its political feasibility and to consider how to support the process of change.

As we approach twenty twenty, the call for Universal Health Coverage has ensured that health financing reform is on policy agendas around the world. Such large-scale health financing and system reform is quintessentially political given that interests compete, there is much to gain and lose, and the current institutional status quo is inevitably challenged. It is no surprise that health financing reform is being contested and debated in parliaments as well as publicly from the highest to lowest income countries.

Yet, there remains barely any political economy analysis of health financing reform in low- and middle-income countries. Although there is no current mapping of literature in the field, only thirteen out of one hundred exemplar papers included in the twenty eighteen Low- and Middle-Income Country Health Policy Analysis Reader had an explicit focus on financing policy. Earlier mapping reviews have demonstrated the small and fragmented nature of the overall field, and its limited consideration of health financing issues. In an overall field review for nineteen ninety-four to two thousand seven, only fifteen out of one hundred sixty-four empirical papers addressed such issues and over a slightly longer period (nineteen ninety-four to two thousand nine), only six out of eighty-six empirical papers specifically addressed financing policy implementation (that is, the experience of putting policy into practice within the health system).

This special issue of Health Systems and Reform on the Political Economy of Health Financing Reform is important, then, in bringing attention to the importance of applying a political economy lens both in understanding the challenges of health financing reform in the Universal Health Coverage era and, critically, in thinking through strategies to support its implementation. The articles in this issue present a political economy framework for analyzing policy experience, as well as various examples of its application.

In this commentary, the framework is briefly applied to understand the twenty-five-year history of debate and contestation around large-scale health financing reform in South Africa. At the time of the first democratic elections in nineteen ninety-four, it was widely recognized that significant restructuring of the fragmented, inequitable and inefficient health system inherited from the apartheid era was needed. Twenty-five years later it has, however, not yet been possible to secure sufficient political and popular support for any set of related proposals.

This commentary first uses the framework to explore what forms of contestation around financing reform in South Africa explain the failure to achieve policy change. Second, it presents four general reflections about the use of the framework by government strategy teams tasked with supporting health financing reform.