{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,20]],"date-time":"2026-05-20T09:06:28Z","timestamp":1779267988769,"version":"3.51.4"},"reference-count":26,"publisher":"Oxford University Press (OUP)","issue":"5","license":[{"start":{"date-parts":[[2026,4,7]],"date-time":"2026-04-07T00:00:00Z","timestamp":1775520000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"funder":[{"DOI":"10.13039\/100004423","name":"World Health Organization","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100004423","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100007447","name":"Susan Thompson Buffett Foundation","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100007447","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,5,20]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>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 \u201cshifts\u201d 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\u2014opposition 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.<\/jats:p>","DOI":"10.1093\/heapol\/czag042","type":"journal-article","created":{"date-parts":[[2026,3,31]],"date-time":"2026-03-31T11:32:28Z","timestamp":1774956748000},"page":"831-848","source":"Crossref","is-referenced-by-count":0,"title":["Primary health care\u2013oriented reforms: the political economy dynamics underlying health-system shifts across nine countries"],"prefix":"10.1093","volume":"41","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9912-7471","authenticated-orcid":false,"given":"Anuska","family":"Kalita","sequence":"first","affiliation":[{"name":"Department of Global Health and Population, Harvard T. H. Chan School of Public Health , Boston ,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kevin","family":"Croke","sequence":"additional","affiliation":[{"name":"Department of Global Health and Population, Harvard T. H. Chan School of Public Health , Boston ,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Erica","family":"Barbazza","sequence":"additional","affiliation":[{"name":"World Health Organization , Geneva ,","place":["Switzerland"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Susan","family":"Sparkes","sequence":"additional","affiliation":[{"name":"World Health Organization , Geneva ,","place":["Switzerland"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Leonard","family":"Cosmas","sequence":"additional","affiliation":[{"name":"WHO Country Office in Kenya , Nairobi ,","place":["Kenya"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mohamed","family":"Hassany","sequence":"additional","affiliation":[{"name":"Ministry of Health and Population , Cairo ,","place":["Egypt"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Arnoldas","family":"Jurgutis","sequence":"additional","affiliation":[{"name":"World Health Organization , Astana ,","place":["Kazakhstan"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Don","family":"Matheson","sequence":"additional","affiliation":[{"name":"Centre for Public Health Research, Massey University , Turitea ,","place":["New Zealand"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Abdon Mukalay","family":"wa Mukalay","sequence":"additional","affiliation":[{"name":"University of Lubumbashi , Lubumbashi, Democratic Republic of Congo"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Vishwanath Andy","family":"Partapsingh","sequence":"additional","affiliation":[{"name":"Pan American Health Organization\/World Health Organization, Office for Barbados and the Eastern Caribbean Countries , Bridgetown ,","place":["Barbados"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Belgacem","family":"Sabri","sequence":"additional","affiliation":[{"name":"Tunisian Association for Defending the Right to Health\/People's Health Movement , Tunis ,","place":["Tunisia"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Marcela","family":"Schenck","sequence":"additional","affiliation":[{"name":"Universidad de la Rep\u00fablica , Montevideo ,","place":["Uruguay"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Shamsuzzoha","family":"Syed","sequence":"additional","affiliation":[{"name":"World Health Organization , Geneva ,","place":["Switzerland"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Viroj","family":"Tangcharoensathien","sequence":"additional","affiliation":[{"name":"International Health Policy Program Foundation , Nonthaburi ,","place":["Thailand"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Zhamin","family":"Yelgezekova","sequence":"additional","affiliation":[{"name":"World Health Organization , Astana ,","place":["Kazakhstan"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Suraya","family":"Dalil","sequence":"additional","affiliation":[{"name":"World Health Organization , Geneva ,","place":["Switzerland"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3225-6230","authenticated-orcid":false,"given":"Faraz","family":"Khalid","sequence":"additional","affiliation":[{"name":"World Health Organization , Geneva ,","place":["Switzerland"]}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"286","published-online":{"date-parts":[[2026,4,7]]},"reference":[{"key":"2026052004164521900_czag042-B1","volume-title":"Political Economy Analysis of Primary Health Care\u2013Oriented Reforms: A Case Study of Primary Care Networks in Kenya","author":"Ashubwe","year":"2024"},{"key":"2026052004164521900_czag042-B2","doi-asserted-by":"publisher","first-page":"1230","DOI":"10.1016\/S0140-6736(14)61646-9","article-title":"Health-system reform and universal health coverage in Latin America","volume":"385","author":"Atun","year":"2015","journal-title":"Lancet"},{"key":"2026052004164521900_czag042-B3","doi-asserted-by":"publisher","first-page":"693","DOI":"10.1016\/0277-9536(84)90298-3","article-title":"The political and administrative context of primary health care in the Third World","volume":"18","author":"Bossert","year":"1984","journal-title":"Soc Sci Med 1982"},{"key":"2026052004164521900_czag042-B4","doi-asserted-by":"publisher","first-page":"224","DOI":"10.1080\/23288604.2019.1625251","article-title":"Political analysis for health policy implementation","volume":"5","author":"Campos","year":"2019","journal-title":"Health Syst Reform"},{"key":"2026052004164521900_czag042-B5","doi-asserted-by":"publisher","first-page":"1318","DOI":"10.1093\/heapol\/czaa095","article-title":"The origins of Ethiopia\u2019s primary health care expansion: the politics of state building and health system strengthening","volume":"35","author":"Croke","year":"2021","journal-title":"Health Policy Plan"},{"key":"2026052004164521900_czag042-B6","doi-asserted-by":"publisher","first-page":"22","DOI":"10.1093\/heapol\/czad107","article-title":"Health reform in Nigeria: the politics of primary health care and universal health coverage","volume":"39","author":"Croke","year":"2024","journal-title":"Health Policy Plan"},{"key":"2026052004164521900_czag042-B7","doi-asserted-by":"publisher","first-page":"1864","DOI":"10.2105\/ajph.94.11.1864","article-title":"The ORIGINS of primary health care and SELECTIVE primary health care","volume":"94","author":"Cueto","year":"2004","journal-title":"Am J Public Health"},{"key":"2026052004164521900_czag042-B8","doi-asserted-by":"publisher","first-page":"117","DOI":"10.1186\/1471-2288-13-117","article-title":"Using the framework method for the analysis of qualitative data in multi-disciplinary health research","volume":"13","author":"Gale","year":"2013","journal-title":"BMC Med Res Methodol"},{"key":"2026052004164521900_czag042-B9","volume-title":"Political Economy Analysis of Primary Health Care\u2013Oriented Reforms: A Case Study on Introducing Multidisciplinary Teams in Kazakhstan","author":"Jurgutis","year":"2024"},{"key":"2026052004164521900_czag042-B10","volume-title":"Political Economy Analysis of Primary Health Care\u2013Oriented Reforms: A Case Study on New Zealand","author":"Matheson","year":"2024"},{"key":"2026052004164521900_czag042-B11","doi-asserted-by":"publisher","first-page":"100945","DOI":"10.1016\/j.lanepe.2024.100945","article-title":"Political economy dichotomy in primary health care: bridging the gap between reality and necessity","volume":"42","author":"Rajan","year":"2024","journal-title":"Lancet Reg Health Eur"},{"key":"2026052004164521900_czag042-B12","volume-title":"Getting Health Reform Right: A Guide to Improving Performance and Equity","author":"Roberts","year":"2004"},{"key":"2026052004164521900_czag042-B13","volume-title":"Political Economy Analysis of Primary Health Care\u2013Oriented Reforms: A Case Study on the Reorientation of the Health System in Uruguay","author":"Schenck","year":"2024"},{"key":"2026052004164521900_czag042-B14","doi-asserted-by":"publisher","first-page":"183","DOI":"10.1080\/23288604.2019.1633874","article-title":"Political economy analysis for health financing reform","volume":"5","author":"Sparkes","year":"2019","journal-title":"Health Syst Reform"},{"key":"2026052004164521900_czag042-B15","doi-asserted-by":"publisher","first-page":"20","DOI":"10.1016\/j.gaceta.2011.10.009","article-title":"Primary care: an increasingly important contributor to effectiveness, equity, and efficiency of health services. SESPAS report 2012","volume":"26","author":"Starfield","year":"2012","journal-title":"Gac Sanit"},{"key":"2026052004164521900_czag042-B16","doi-asserted-by":"publisher","first-page":"457","DOI":"10.1111\/j.1468-0009.2005.00409.x","article-title":"Contribution of primary care to health systems and health","volume":"83","author":"Starfield","year":"2005","journal-title":"Milbank Q"},{"key":"2026052004164521900_czag042-B17","volume-title":"Political Economy Analysis of Primary Health Care\u2013Oriented Reforms: A Case Study on Contracting District Health Systems for Primary Care Services in Thailand","author":"Tangcharoensathien","year":"2024"},{"key":"2026052004164521900_czag042-B18","doi-asserted-by":"publisher","first-page":"369","DOI":"10.1146\/annurev.polisci.2.1.369","article-title":"Historical institutionalism in comparative politics","volume":"2","author":"Thelen","year":"1999","journal-title":"Annu Rev Polit Sci"},{"key":"2026052004164521900_czag042-B19","doi-asserted-by":"publisher","volume-title":"Advances in Comparative-Historical Analysis","author":"Thelen","DOI":"10.1017\/CBO9781316273104.002"},{"key":"2026052004164521900_czag042-B20","volume-title":"Implementing the Primary Health Care Approach: A Primer","author":"WHO"},{"key":"2026052004164521900_czag042-B21","volume-title":"Operational Framework for Primary Health Care: Transforming Vision into Action","author":"WHO, UNICEF","year":"2020"},{"key":"2026052004164521900_czag042-B24","volume-title":"A Vision for Primary Health Care in the 21st Century: Towards Universal Health Coverage and the Sustainable Development Goals","author":"WHO, UNICEF"},{"key":"2026052004164521900_czag042-B22","volume-title":"Declaration of Astana: The Global Conference on Primary Health Care","author":"WHO, UNICEF","year":"2018"},{"key":"2026052004164521900_czag042-B23","volume-title":"Report of the International Conference on Primary Health Care, Alma-Ata, USSR, 6\u201312 September 1978","author":"WHO, UNICEF"},{"key":"2026052004164521900_czag042-B25","volume-title":"Primary Health Care Implementation Solutions Initiative","author":"World Health Organization","year":"2025"},{"key":"2026052004164521900_czag042-B26","doi-asserted-by":"publisher","first-page":"e1035","DOI":"10.1016\/S2468-2667(23)00255-4","article-title":"Universal health coverage in China part 2: addressing challenges and recommendations","volume":"8","author":"Yip","year":"2023","journal-title":"Lancet Public Health"}],"container-title":["Health Policy and Planning"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/heapol\/advance-article-pdf\/doi\/10.1093\/heapol\/czag042\/67933980\/czag042.pdf","content-type":"application\/pdf","content-version":"am","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/heapol\/article-pdf\/41\/5\/831\/67933980\/czag042.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/heapol\/article-pdf\/41\/5\/831\/67933980\/czag042.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,20]],"date-time":"2026-05-20T08:17:03Z","timestamp":1779265023000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/heapol\/article\/41\/5\/831\/8626274"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,7]]},"references-count":26,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2026,4,7]]},"published-print":{"date-parts":[[2026,5,20]]}},"URL":"https:\/\/doi.org\/10.1093\/heapol\/czag042","relation":{},"ISSN":["0268-1080","1460-2237"],"issn-type":[{"value":"0268-1080","type":"print"},{"value":"1460-2237","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2026,5]]},"published":{"date-parts":[[2026,4,7]]}}}