Political Economy of Primary Health Care: A Comparison of Health System Reforms

Abstract

This doctoral thesis examines the political economy of primary health care (PHC) reforms across nine countries—the Democratic Republic of Congo, Dominica, Egypt, Kazakhstan, Kenya, New Zealand, Thailand, Tunisia, and Uruguay—which represent diverse political, economic, and health system contexts. Addressing a gap in the literature where the political economy of PHC remains underexplored, the study investigates: (1) How have political economy factors driven PHC reforms? and (2) What are the distinct political economy factors of PHC reforms, and how do they differ across different types of PHC reforms—those focusing on financing versus organization? Employing historical institutionalism alongside the Control Knob Framework, this thesis analyzes how political economy factors interact to shape reform trajectories. The research draws on primary qualitative data from 324 respondents via interviews, focus groups, and expert consultations across the sampled countries, complemented by an extensive review of literature and policy documents. Using the Framework Method, both deductive analysis for theory application and inductive approaches for theory building were applied. Process tracing provides an in-depth analyses of each reform, while the Comparative Sequential Method examines reform trajectories across health systems. The findings reveal that political economy dynamics operate at multiple interrelated levels. Temporality is critical—historical legacies and path dependencies can constrain and enable reforms, while political upheavals or economic crises create windows for transformative change. Institutional contexts—political systems, electoral rules, constitutional provisions, and bureaucracies—significantly influence reform outcomes. Interest groups such as physicians, civil society, donors, and citizens actively shape reforms, while the politics of ideas affect public support and sustainability. This research identifies six distinct domains of political economy tensions in PHC reforms: (1) public versus private sector, (2) hospital versus primary care, (3) physicians versus non-physicians, (4) centralized versus decentralized administration, (5) expanding versus limiting citizens’ choice, and (6) selective versus comprehensive changes. Moreover, the chosen reform entry point—whether financing or organization—shapes how these tensions unfold. Understanding these dynamics can help policy actors anticipate resistance and devise strategies to navigate reforms. To build resilient health systems, countries must strengthen local capacities for political economy analysis and engage diverse stakeholders.