The political economy of national health insurance schemes: evidence from Zambia.

Governments in low and middle-income countries (LMICs) are increasingly considering the introduction of national health insurance scheme (NHIS) as a strategy to achieve universal health coverage (UHC) targets. The literature has widely documented the technical challenges associated with implementing UHC policies in LMICs but much less is known about the political process necessary to pass UHC legislation. In this article, we document the political economy issues surrounding the establishment of the Zambia NHIS in 2018. We adapted a political economy framework incorporating, semi-structured interviews with diverse stakeholders and document analysis of policies, operational reports and legislatures from 1991 and 2018. Our findings show the 26-year journey towards the establishment of the NHIS in Zambia involved a long sequence of policy dialogue, technical review and stakeholder engagement. Our interviews with key stakeholders suggest that the act was eventually passed due to strong political will and dominant leadership of the Ministry of Health. Passing the law required trade-offs between choices influenced by stakeholder pressures and recommendations from research and actuarial studies. Another equally critical factor was the high public support and legacies of past policies, such as the removal of user fees that had created quality gaps and inequities in the health system. Furthermore, global ideas about UHC and initiatives implemented by other countries also generated support for Zambia's NHIS. Overall, this study highlights the complex set of political economy factors that need to align in order for governments to be able to adopt health insurance in low-income settings. We show that political leadership and commitment to getting reforms passed is crucial. We also highlight how certain narratives about countries in the global health sphere can shape policies in other countries.