With the rise of international public health standards over the last century, many governments have embarked on health system reform to address inefficiencies in financing and provision of care. Yet even similar initiatives within geopolitical regions have produced significantly different healthcare system designs across countries. Despite sharing the historical legacy of the Soviet Union and similar health challenges, the post-Soviet states have followed a wide variety of reform trajectories. Countries as poor as Moldova and Kyrgyzstan and as wealthy as Russia have introduced insurance mechanisms and private provision of care. Countries as wealthy as Kazakhstan and as poor as Ukraine and Uzbekistan have maintained state-financed healthcare systems with state provision of care.

My dissertation tests several explanations for these patterns in the post-Soviet states since 1991. I demonstrate the importance of both timing and incentive for major structural reforms, arguing that the long-term trajectories observed in the post-Soviet healthcare systems can be traced back to a critical juncture for major healthcare system reforms in the 1990s. I contend that decisions made at that time led to the institutionalization of reform trajectories through the development of legal (de jure) and practical (de facto) state responsibility for financing and provision, contradictions between these two concepts of state responsibility, and resulting patterns of political rhetoric, public opinion, and outcomes surrounding reform efforts. Utilizing historical institutional analysis and process tracing methods, I show that the decisions in the 1990s were significantly shaped by the prioritization of long-term state-building efforts, and that, because of the dual nature of healthcare as a policy area -- connected both to the economic sphere and the human rights sphere -- threats to state stability were the most pressing concern for decision makers in considering reform designs. When national cleavages aligned with divisions of economic ideologies in regions, state leaders avoided introducing major reforms, instead preferring to maintain consistency in the state's role as they sought to build legitimacy for the system. These findings contribute to our understanding of institutional change in the post-Soviet states and of the politics surrounding healthcare reforms in middle- and lower-income countries.