Social Health Insurance in Albania: examining the World Bank’s role in health care financing reforms (1990-2022). Activities and strategies

This cumulative dissertation investigates how the World Bank (WB), as a transnational policy actor, influenced health care financing (HCF) reforms in Albania, a post-communist country in Central and Eastern Europe (CEE), from 1990 to 2022. While existing literature has examined the WB’s role in pension reform in CEE, its approach to HCF reforms remains controversial. Furthermore, scholars on welfare reforms (social and health care) in transitioning and low-income countries (LICs) primarily describe the WB as a coercive actor relying on loan conditionalities. This thesis offers a different perspective by examining how the WB combined material resources, technical assistance (TA), and knowledge-based strategies to influence Albania’s shift toward Social Health Insurance (SHI) and broader HCF reforms. The research draws on Orenstein’s (2008) model of transnational actor influence, integrating concepts from the political economy of international organisations and policy transfer studies. It conceptualises the WB not only as a policy “proposal actor” but also as a “problem broker,” a strategic player that frames reform challenges through evidence-based analysis and normative discourse. Using a qualitative methodological approach, the analysis in five interlinked papers is based on archival research, WB documentation, parliamentary records, and expert interviews. The findings reveal that Albania, unique in the CEE region for its lack of historical experience with an SHI model, initially resisted WB recommendations, opting instead for a domestically driven policy shift in the early 1990s. Over time, however, the WB adapted its approach by employing TA and lending instruments to shape the implementation of SHI and subsequent financing reforms. While the WB’s approach was non-coercive, it proved influential, especially through its long-term engagement, technical expertise, and framing of policy problems within macroeconomic and equity-focused narratives. Empirically, the dissertation provides the first longitudinal study of the WB’s role in Albanian health sector reforms, covering more than three decades. It illustrates how WB influence evolved from cautious opposition to adaptive engagement, ultimately shaping policy through knowledge production, learning processes, and discursive strategies. Theoretically, it refines our understanding of how transnational actors operate beyond coercion, particularly in low- and middle-income countries with fragile institutions. Overall, the dissertation contributes to debates on international influence in social policy by showing that the WB’s role in HCF reform is best understood not as imposing conditionality, but as a complex form of ideational and strategic engagement. In doing so, this dissertation offers new insights into the WB’s role in HCF reforms in post-communist CEE, illustrates transnational actor influence beyond the traditional focus on pension reform, and opens new avenues for research on non-coercive forms of policy transfer.