Political drivers of fragmentation in health financing in low- and middle-income countries: a conceptual framework and narrative review.

Fragmentation in health financing remains a persistent obstacle to equity, efficiency and financial protection in many low- and middle-income countries (LMICs). This paper develops a conceptual framework to explain how political and administrative arrangements shape fragmentation across the core financing functions of revenue raising, pooling, purchasing and benefit design. We conducted a narrative and conceptual review of literature on political economy analysis, political settlements, decentralisation, decision-space and health financing reforms, complemented by illustrative reviews of reforms in Mexico and India. The framework distinguishes two proximate domains - political organisation and administrative organisation - and examines how they interact with political settlements to produce, maintain or reduce fragmentation. We define fragmentation as the division of financing functions across schemes, actors or levels of government without sufficient coordination to secure cross-subsidy, equity, efficiency and financial protection. The framework also clarifies that political drivers do not affect all financing functions in the same way: electoral incentives often shape visible benefit expansion, interest groups are especially important for purchasing and payment rules, and federal or decentralised arrangements strongly influence revenue allocation, pooling and implementation discretion. The Mexico and India illustrations show how reforms can expand coverage while leaving important forms of fragmentation in place. The paper provides a practical roadmap for applying political economy analysis to health-financing fragmentation and for identifying politically feasible reforms in pursuit of universal health coverage.