In the late 1980s, both Taiwan and the Netherlands sought for ways to reform their health system. In OECD countries at that time, fast increasing health expenditures in combination with fiscal constraints led to calls for restructuring the health system to control the costs of public spending. In Taiwan, rapid economic growth between 1950-1980 led to expectations for a higher quality of life among the public. With the emergence of political opposition to its authoritarian rule, the ruling Nationalist party proposed the introduction of a universal health system by the year 2000. But existing social health insurance schemes covered only 59% of the population at the time. Forty-one percent of the population remained uninsured, while the population in the Netherlands already enjoyed universal coverage. Faced with the challenging task of extending coverage to the entire population within a brief period, Taiwan considered the same question that was being discussed in the Netherlands: how to ensure quality and access of health care to all, while simultaneously controlling the costs of health spending?

Having closely observed lessons learned from the welfare crisis in OECD countries, Taiwan reformed its health system in 1995. It introduced a universal single-payer health insurance model, centrally administered by the government. The rationale was that a single-payer system would increase administrative simplicity and control the costs of health spending. In contrast, the Netherlands reformed its health system in 2006 by making private insurers responsible for the provision of universal health insurance. The logic of the reform was that regulated competition between private insurers would increase the efficiency of the health system by containing the costs, while ensuring quality.

This thesis compares the health reform experience in Taiwan and the Netherlands. Taiwan and the Netherlands had a shared global context and similar objectives, but they reformed their social health insurance systems in a different way. In Taiwan, the government administers social health insurance, while in the Netherlands private actors carry out the delivery of social health insurance. What factors explain the divergent outcomes of their social health insurance reform? This thesis examines the various actors, ideas and institutions that create these different outcomes. In doing so, it sheds light on the political economy of health reform. The discussion of how to control rising health expenditures is reinvigorated today in the face of the challenges of an aging population and costs of medical technology. This thesis contributes to this current discussion by understanding past reform experiences and the political economy that informs it.