With the recent ratification of Sustainable Development Goal Target 3.8, universal health coverage (UHC) has consolidated its position atop the global public health agenda. However, as a growing body of technical and political analysis reveals, uncertainties remain over the ability of all countries to achieve UHC, and the pathways they should take to get there.

This paper reviews some of the existing political economy analysis (PEA) of UHC, before presenting political settlements analysis (PSA) as an alternative, yet complementary, approach. It outlines a model that links political settlement type to UHC progress via political commitment, policy pathways, funding and governance arrangements, and provides some hypotheses about how fast progress to UHC will be under different political settlement types.

It also argues that UHC champions should adapt their ways of working to fit the political settlement, distinguishing between ‘government-supporting’, ‘government-substituting’ and ‘government-connecting’ strategies. It then presents case study evidence from six low- and lower-middle-income countries to help assess these claims. It concludes that, while the evidence of a relationship between political settlement and UHC progress is quite strong, the hypothesis about political settlement type and ways of working requires further research.