Primary health care-oriented reforms: the political economy dynamics underlying health-system shifts across nine countries.

Using evidence from nine countries (Democratic Republic of Congo, Dominica, Egypt, Kazakhstan, Kenya, New Zealand, Thailand, Tunisia, and Uruguay), we analyze the political economy dynamics that emerged during implementation of primary health care (PHC)-oriented reforms. Across these cases, we identify 10 recurring health-system "shifts" toward stronger PHC orientation, which serve as a descriptive framework for examining the political economy challenges reformers faced and the strategies they used to navigate them. Primary data were collected from 356 participants through key informant interviews, focus groups, and expert consultations and were triangulated with document review. Using deductive mapping and inductive thematic analysis, we identify 10 PHC-focused health-system shifts present in some or all of the cases. These entailed shifts from: (i) short-term initiatives with limited scope to long-term, system-wide transformations; (ii) centralized control to devolved multilevel governance; (iii) hospital-centric resource allocation to strategic reallocations favoring primary care; (iv) physician-dominated care to multidisciplinary teams including non-physician providers; (v) siloed disease-focused services to integrated models of comprehensive care; (vi) peripheral, minimally regulated private sectors to their integration and actively state-stewarded participation; (vii) passive input-based budget allocations and provider payments to strategic purchasing; (viii) perceiving citizens as passive recipients of care to building active community engagement; (ix) ad hoc data collection to embedded learning and accountability; and (x) externally driven changes to local ownership for reforms. Reforms routinely triggered political economy dynamics-opposition from physicians, hospitals, specialists, and central bureaucracies; citizen skepticism; and capacity and patronage challenges under devolution. Strategies to address these included: high-level endorsement and passage of legislation; use of political and economic windows of opportunity; local capacity-building; decentralized autonomy; formal engagement with physician associations; regulated private sector participation; strategic purchasing to incentivize a PHC approach; strong data systems and assessments; community engagement; and locally grounded design with domestic capacity and financing. The paper underscores the value of anticipating political economy dynamics for designing and implementing PHC-oriented reforms.