By Eduardo J. Gómez

In recent years, several emerging economies, such as India, China, Russia, and Indonesia, have introduced national health insurance programs targeting the poor, safeguarding them from increased out-of-pocket and catastrophic expenses. With the exception of Indonesia, increased government spending for these programs has not helped to safeguard the poor from these expenses. This article introduces an analytical framework combining the importance of constitutional design, decentralization, and social health movements to account for these differences in policy outcomes. The author’s proposed analytical framework differs from those studies emphasizing financial constraints, the effective targeting of funds to the poor, and administrative capacity, suggesting instead that the design of political institutions and the incentives that they create for policy implementation and regulation may provide greater insight into why these targeted health insurance programs are not achieving their goals.