Insider–Outsider Politics and Support for Universal Health Coverage in Low- and Middle-Income Countries

Abstract

When and why does the public support redistributive policies that seek to provide social risk protection through universal health financing? One central political dilemma in establishing systems of universal health coverage (UHC) in low- and middle-income countries is the small tax base available to contribute to pooled financing of healthcare. Middle-class workers in the formal sector (labor market insiders) may already get health coverage through the state or private insurers, leaving them little incentive to contribute to UHC that will primarily benefit indigent workers in the informal sector (labor market outsiders). Applying the insider–outsider politics framework, we explore attitudes toward UHC using recent data from Afrobarometer surveys in 36 countries in Sub-Saharan and North Africa. We find that, in spite of growing attention to universal coverage among policymakers, support from the average citizen is low, though variable, across countries. Further, in contrast with expectation, economically secure labor market insiders are more willing than labor market outsiders to pay more in taxes to finance health coverage. However, support for more tax financing of health services was dependent on trust in government and perceptions of government efficacy. Trust in the government’s capacity to use tax financing effectively may be a more important determinant of support for UHC than rational self-interest.