The political dimension of health reform: the case of Mexico and Colombia

This thesis analyses the state's capacity to pursue health reform. It argues that the feasibility of health reforms, as well as their final content, are in great part determined by their political context, and the political strategies reformers resort to when pursuing their policy agenda. The analysis is framed in the political context in which a reform initiative evolves, the political dynamics of and around the health reform process, and the characteristics and strategies of the teams in charge of leading policy change (change teams). The research aims to contribute to existing knowledge in the health policy field by furthering the analysis and explanation of the political feasibility of health reforms. A two case study comparative analysis is used based on primary and secondary sources and in-country interviewing. Colombia and Mexico, challenged by the need to attain universal coverage, and faced with large inefficiencies, set about to transform their health systems in the 1990's. While Colombia was successful in passing legislation and initiating implementation, Mexico made a series of similar attempts, but its reform was brought to a near halt. The analysis of these contrasting outcomes given the similar choice of political strategies in comparable political contexts, allows for a greater understanding of the factors at play. Key findings demonstrate the relevance of the political context in determining the potential of interested actors within and outside the state, to influence health reforms. The study also reveals the remarkable resemblance between the political strategies used by health reform teams, and those used by economic adjustment teams in the 1980's. While these strategies enabled the latter to introduce major policy change, they helped health reform teams only partially. As a result, health reformers were successful in enabling the creation of new private health financing and provider organisations, but the transformation of the old public health service institutions remains a challenge.