Analysis of the enablers of capacities to produce primary health care-based reforms in Latin America: a multiple case study

BACKGROUND Primary health care (PHC)-based reforms have had different results in Latin America. Little attention has been paid to the enablers of collective action capacities required to produce a comprehensive PHC approach. OBJECTIVE To analyse the enablers of collective action capacities to transform health systems towards a comprehensive PHC approach in Latin American PHC-based reforms. METHODS We conducted a longitudinal, retrospective case study of three municipal PHC-based reforms in Bolivia and Argentina. We used multiple data sources and methodologies: document review; interviews with policymakers, managers and practitioners; and household and services surveys. We used temporal bracketing to analyse how the dynamic of interaction between the institutional reform process and the collective action characteristics enabled or hindered the enablers of collective action capacities required to produce the envisioned changes. RESULTS The institutional structuring dynamics and collective action capacities were different in each case. In Cochabamba, there was an 'interrupted' structuring process that achieved the establishment of a primary level with a selective PHC approach. In Vicente López, there was a 'path-dependency' structuring process that permitted the consolidation of a 'primary care' approach, but with limited influence in hospitals. In Rosario, there was a 'dialectic' structuring process that favoured the development of the capacities needed to consolidate a comprehensive PHC approach that permeates the entire system. CONCLUSION The institutional change processes achieved the development of a primary health care level with different degrees of consolidation and system-wide influence given how the characteristics of each collective action enabled or hindered the 'structuring' processes.