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

In the mid-1990s Michael Reich and Gill Walt, drawing on independent lines of work, called for an injection of political economy thinking into health policy analysis in lowand middle-income countries (LMICs). 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 technicalwork, such as economic analysis, nor awelldesigned 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 2020, the call for Universal Health Coverage (UHC) 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 LMICs. Although there is no current mapping of literature in the field, only 13 out of 100 exemplar papers included in the 2018 LMIC 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 1994–2007, only 15 out of 164 empirical papers addressed such issues and over