Towards Universal Health Coverage in Ethiopia's 'developmental state'? The political drivers of health insurance.

With Universal Health Coverage (UHC) now entrenched among the top global development priorities, questions arise as to the conditions under which politicians commit to UHC and why certain strategies for health financing and access are favoured over others. The Ethiopian government has been piloting and scaling-up Community-Based Health Insurance (CBHI) for the informal sector since 2010 and is establishing Social Health Insurance for formal sector workers as a means of achieving UHC. CBHI covers 11 million people making it one of the largest health insurance schemes in Africa. This paper employs a process tracing methodology to examine the political drivers of the adoption and evolution of state health insurance based on 28 key informant interviews conducted between 2015 and 2018 with politicians, policymakers and donor officials. The paper highlights the inadequacy of existing theories-focusing on interest group mobilisation, electoral competition and bureaucratic actors-for explaining the Ethiopian case. Instead the paper proposes an 'Adapted Political Settlements' framework that explains the state's push to expand CBHI and stalled progress on SHI. This framework highlights the interests and ideas of the ruling coalition as important drivers of reform. In a context of ruling party dominance and minimal threat from electoral competition, the ruling coalition has sought to build political legitimacy through the delivery of socioeconomic progress, including health services. The policy idea of health insurance, meanwhile, has secured elite commitment due to its fit with deeply held ideas within the ruling coalition concerning the importance of self-reliance and resource mobilisation for development. Finally, the centralisation of power within the ruling coalition prior to 2012 enabled the emergence of a long-term developmental vision and the marginalisation of opposition to health insurance, while fragmentation of the ruling coalition since 2012 has led SHI to stall.