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

Analysis of the enablers of capacities to produce primary health care-based reforms in Latin... 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. Key words. Health care quality, access, and evaluation, health care reform, leadership, organizational innovation, politics, primary health care. fostered a transformation from health care models that are hospital- Introduction centred, curative, medical and specialized to models that focus on Primary health care (PHC)-based reforms have been used to pro- more comprehensive, family- and community-oriented care, with mote changes in health systems and services. These initiatives have © The Author 2016. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Downloaded from https://academic.oup.com/fampra/article/33/3/207/1749908 by DeepDyve user on 13 July 2022 208 Family Practice, 2016, Vol. 33, No. 3 PHC as a strategy to coordinate health care across levels and provid- and analysis, the design of the data collection procedures and tools ers (1). and the data collection in the Argentinean settings. A Bolivian team In Latin America, these change processes emerged in the 1980s based in Cochabamba collected and analysed the local data. with the rise of democratic governments that empowered the partici- pation of new social actors committed to the improvement of social Units of analysis determinants of health and health equity. The advances engendered Our units of analysis were the reforms implemented between 1990 by these processes to change from one health care model to another and 2008 in the municipalities of Cochabamba (Department of were uneven (2–6). While some countries moved towards a com- Cochabamba, Bolivia); Vicente López (Province of Buenos Aires, prehensive PHC approach accompanied by radical institutional and Argentina); and Rosario (Province of Santa Fe, Argentina). We organizational changes that resulted in significant health improve - selected reforms that took place at the municipal level since the ments, other countries were able to develop only the primary level of decentralization processes during the 1980s and 1990s in Latin care or introduce programmes to improve maternal and child health America positioned the municipal level at the core of the imple- and control infectious diseases. Although these latter processes mentation of these reforms (5,6). Table  1 provides basic informa- favoured significant health improvements in specific populations tion about each municipality’s socio-economic and health services and/or diseases, they were unable to produce the institutional and characteristics. organizational changes required to reform and improve the health system as a whole (1–3). Sampling rationale The institutional process plays a fundamental role as a driver of To better understand the differences in the collective action capaci- organizational change through the introduction of regulatory mech- ties that led to different degrees of institutional change, we used anisms, structures, conceptions and values (7,8). The question that a purposeful sampling strategy, to selected Latin American cases continues to be the subject of an unresolved policy and academic showing a maximum variation with regard to the PHC approaches debate is how to produce institutional change (8,9). According to achieved by the reforms (2–4). While in Europe and other wealthy Hodgson (10), the triggers of institutional change depend on the developed countries PHC has primarily been viewed as the first capacities for collective action, in other words, the group of stake- level of health services for the entire population, in Latin America holders who are advocating for institutional change. coexist a number of PHC conceptions and models. These models Two approaches have analysed the enablers of collective action fall broadly into three main organizational approaches: (i) Selective capacities to produce institutional change processes. One approach PHC: focused in a limited number of high-impact services to tar- emphasizes the configuration of the collective action as the main get the most prevalent causes of child mortality and some infectious enabler of capacities to manage institutional change processes diseases. Although originally considered an interim strategy, this (10). The other approach assumes that collective action capacities approach has become the dominant mode of PHC for many coun- are modelled by new structures created during the trajectory of the tries. (ii) Primary care: refers to the entry point into the health system institutional restructuring process (8). We hypothesize that collec- and the place for continuing health care for most people, most of the tive action capacities consist of the dynamics between actors and time. (iii) Comprehensive PHC: a strategy for organizing health care structures, known as structuring, which underlie institutional change systems and society to promote health. This approach is based on the processes (11). Alma Ata Declaration. It has been implemented in few countries and Our research question is how did structuring processes influence in several small-scale experiences, although is mentioned as the goal the achievement of different levels of advances towards developing a for most of the PHC-based reforms (2). comprehensive PHC approach in three reform processes? More spe- cifically, our objective is to analyse how structuring processes during Case selection process three Latin American reforms aimed at the implementation of a com- Cochabamba was selected as an exemplary of a selective PHC prehensive PHC approach enabled or hindered the collective action approach, Vicente López as an example of a primary care approach capacities needed to implement the changes envisioned. and Rosario as an example of the comprehensive PHC approach (2,3). Methods Study design Data collection processes and analysis techniques We conducted a multicentre, longitudinal, retrospective multiple The research included primary and secondary data source analyses case study (12) between 2007 and 2010. The research was coordi- and multiple data collection techniques such as documental and offi - nated by an Argentinean team in charge of the overall coordination cial record reviews, semi-structured interviews and organizational Table 1. Sociodemographic and health services indicators for the municipalities under study Municipality Cochabamba Vicente López Rosario Number of residents 517 024 274 082 909 397 Percentage of structurally poor population according to the unmet basic needs index 33.8% 4.8% 13.5% Percentage of population without health coverage 75.1% 27.2% 39.1% a,b Ratio of public primary level of care centres per 10 000 population without coverage 0.7 2.6 2.3 a,b Ratio of primary level of care providers per 1000 population without coverage 0.3 1.2 1.4 Number of public hospitals 5 6 14 Source: Argentina: National Population, Households, and Dwellings Census (13), 2001; Bolivia: National Population and Housing Census, 2001 (14). The list of health centres and hospitals provided by the Health Secretaries. Downloaded from https://academic.oup.com/fampra/article/33/3/207/1749908 by DeepDyve user on 13 July 2022 Conditions to implement effective primary health care reforms in Latin America 209 and household surveys (Table  2). We used the same data collec- (10,15,16). The third dimension, the reform achievements, was char- tion procedures and tools in each case, with minor adaptations as acterized by five categories: (i) changes in the physical structure and required. Some techniques were combined sequentially and others human resources of the primary level of care; (ii) access to the pri- complementary. mary level of care; (iii) continuity of care, in terms of the affiliation First, we conducted a document review of norms, policy docu- of the population to the primary level of care; (iv) coordination of ments and scientific literature to define reform periods by identify - services, in terms of the capacity of the primary level of care to man- ing new institutional structures. The document review was validated age access to specialized practices or visits with hospitals; and (v) by and used to inform interviews with different actors. Second, to scope of the changes in the entire health system (17). Given the lack characterize the institutional process and the collective action during of information about the characteristics of the structure and perfor- each period, we conducted semi-structured interviews with policy- mance of services during the entire process, it was only possible to makers and with primary level and hospital managers and provid- reconstruct the characteristics of the structure at the beginning and ers. Overall, we conducted 156 semi-structured interviews, including end of the study period and to determine the performance of the 18 with policymakers (e.g. health secretaries, PHC managers) and services at the end of the study period, as shown in Table 4. 138 with hospital and PHC centre managers and health care pro- viders. Interviews were recorded, transcribed verbatim. A  directed Analytic strategy content analysis approach was used in documents and interviews. Temporal bracketing was applied as a sense-making strategy (18). This approach consists in using a theory as guidance for coding. The concept of temporal bracketing is derived from Anthony We draw our coding based on dimensions and categories of analysis Giddens’ structuration theory (19), which states that actors’ actions relevant to the structuring process (described in the next section). are constrained by social structures and that actions simultaneously To strengthen reliability, two researchers independently conducted reconstitute those structures over time. Because mutual influences are the analysis and then contrasted and discussed the differences in difficult to capture simultaneously and because changes in structures their findings. Third, we conducted an organizational survey of all follow diachronically from action, temporal bracketing proposes to PHC centres in each municipality to gather data on the structure analyse these interacting dimensions by temporarily ‘bracketing’ one and organizational practices at the primary level. The questionnaire, of them. Thus, we defined periods by identifying the introduction of administered by a researcher, included questions about the date the new institutional structures. In each period, we analysed the insti- health centre was created and its current resources and organiza- tutional process, the collective action and when possible, the health tional practices. We reviewed official records about the structure care and organizational changes occurred in system of health ser- of the services to complete missing data when necessary. We used vices as a result of the reform. the survey results to categorize the health centres into three groups according to their structure and functioning and then selected two health centres per category in each municipality in consultation with Results policymakers. Fourth, we conducted a household survey to deter- In this section, we describe the implementation of the processes in mine the PHC achievements in each municipality. We applied the each case under study. We begin with an overall description of the survey to age- and sex-stratified sample of 450 caregivers of children institutional structures created, their main objectives, the characteris- under 11 years of age living in the area of influence of the health cen - tics of each collective action, the scope of the achievements (Table 3) tres. We used descriptive statistical analysis to analyse both surveys. and the changes in the primary level structure and health care per- Finally, to validate and enrich our analysis, we organized workshops formance at the end of the study period (Tables 1 and 4). Then, we with policymakers and managers to present and discuss our findings. provide a detailed description of the health care and organizational practices promoted by the new institutional structures introduced during each period and the changes in the composition of the collec- Study analytical categories by dimension tive action, including internal and external relationships and politi- This study comprises three dimensions of analysis: the institutional cal and technical capacities (Table 3). process, the collective action and the reform achievements. Each dimension was approached with using a set of analytical categories Cochabamba or subdimensions. Table 2 shows each dimension in the first column and its analytical categories in the second column. In the third col- In Cochabamba, we identified three stages in the national reforms umn, we provide the categories’ conceptual or operational defini - in order to transfer resources to the municipalities; create new local tions. The next columns indicate the data sources (the data collection structures and economic incentives to promote popular participa- technique/s are described in the previous subheading) used to study tion; decentralize the management of health services to the munici- each category. palities; and expand coverage and access to health services. The first The first dimension, the institutional process, was studied through two stages envisioned an improvement in coverage and access to ser- three categories: (i) identification of the institutional structures intro - vices for the maternal–child population and the final stage focused duced by the reforms; (ii) PHC approach envisioned by the institu- on the development of a comprehensive PHC approach based on a tional structures; and (iii) health care and organizational changes multicultural model. In this case, collective action was composed of promoted by the institutional structures. The second dimension, the social movements (which had a leadership role) and municipal and collective action, was characterized in terms of seven categories: (i) departmental (provincial) health managers, who were engaged in a collective action composition; (ii) internal relationships between competitive relationship with each other and with health providers their participants; (iii) actor that exerted the leadership role (11); from the primary level of care. The reform achieved the development (iv) stakeholders external to the collective action; (v) relationship of a structure for the primary level of care with the creation of 22 between the collective action and outside stakeholders; (vi) collec- new health centres that offer health services, mainly preventive and tive action’s technical capacities; and (vii) collective action’s politi- maternal–child care, provided during limited operating hours and cal capacities to implement and manage new institutional structures without the capacity to coordinate their patients’ care processes with Downloaded from https://academic.oup.com/fampra/article/33/3/207/1749908 by DeepDyve user on 13 July 2022 210 Family Practice, 2016, Vol. 33, No. 3 Table 2. Analytical categories by dimension, definition and data source Dimension Category Category’s conceptual or operational Data source definition Document review Interviews with Interviews with primary level Secondary sources Organizational Household policymakers and hospital managers and review survey survey providers Institutional Institutional structures Regulatory structures formally or factually X X process introduced by the reform to act upon the system of health services, such as policies, programmes and management structures PHC approach envisioned The PHC approach is characterized as selec- X X X tive PHC, primary care or comprehensive PHC Changes promoted Health care and organizational changes X X X promoted by the institutional structures Collective Composition Key actors, taking action to realize the X X action changes promoted by the reforms Relationship The relationship between the actors X X comprising the collective action is characterized as competitive, collaborative or neutral Leadership Actor who leads the collective action X X decision-making processes Outsider actors Identification of the key actors who are X X outsiders to the collective action Relationship with outsiders The relationship between the collective action X X and key actor outsiders is characterized as conflictive, collaborative or neutral Technical capacities Ability of the collective action to create or X X manage regulatory mechanisms that emerge from the new institutional structures (9,13) Political capacities Ability to achieve the social and professional X X legitimacy required to create and carry out new institutional structures (9,13) Reform Physical structure and Changes in the number of primary level X X X achievements human resources health centres, team composition and office hours’ coverage Access to primary health Annual average of medical visits to a primary X care services health care centre among children under age Continuity of care/affiliation Percentage of children under age 11 that have X to the primary level of care a regular source of care in a primary health care centre Downloaded from https://academic.oup.com/fampra/article/33/3/207/1749908 by DeepDyve user on 13 July 2022 Conditions to implement effective primary health care reforms in Latin America 211 hospitals (Tables 1 and 4). This development enabled the channel- ling of 44.7% of the total visits with children under age 11 to the primary level of care. However, the annual rate of visits in this age group was lower than the two recommended annual visits (mainly well-child check-ups) and only a reduced percentage of children had a regular source of care at the primary level of care (Table 4), due to the low ratio between health centres and physicians per inhabitants without coverage (Table 1). This stage is described below. During the first stage, the reform creates the Grassroots Territorial Organizations (Organizaciones territoriales de base—OTB) and the Local Health Directorates (Directorios Locales de Salud—DILOS). The Local Health Directorates were tripartite structures comprised the Grassroots Territorial Organizations (head of the Local Health Directorates), the municipal and the departmental health authorities. The Local Health Directorate of Cochabamba is left in charge of the primary health care centres. Previously, the primary health care level was dependent on the hospitals and the departmental authorities, and in each health centre, the managerial functions relied on the main physician. The Local Health Directorate embodies the collective action. Its actions served as the foundation for both expanding the structure of the primary level of care with the creation of seven new health centres and improving the coverage of preventive services for the maternal–child population. However, these actions took place in a framework of internal conflict-filled relationships between physi - cians, who perceived that their power over services and their profes- sional autonomy was threatened. The strength of collective action resided in the political capacities derived from the social legitimacy that emerged from the support of social movements (which provided physical spaces for expanding the primary level of care). Its weak- nesses were the lack of professional legitimacy and technical capac- ity to manage health services. The second stage was defined by the creation of the Universal Mother and Child Insurance (Seguro Universal Materno Infantil— SUMI), which sought to expand free health services for the mater- nal–child population and integrate new norms of health services management and care provision. At the local level, the Municipal Health Directorate (Directorio Municipal de Salud—DIMUSA) was created and put under the charge of the local management of health services. Here, nine health centres were inaugurated. The composi- tion, relationships and capacities of the collective action continued unchanged with respect to the previous stage. The third stage was structured around the creation of the national-level Family, Community and Intercultural Health Strategy (Salud Familiar Comunitaria Intercultural—SAFCI), which sought to expand the coverage of health insurances beyond the maternal and child population and promote a comprehensive PHC approach with a focus on multiculturality. During this stage, six new health centres were added to the primary level of care. Although the con- flicts within the collective action decreased here, the relevant changes in the composition, relationships and capacities of collective action did not take place. Vicente López The reform process in Vicente López was developed in three stages that created formal and informal institutional structures aimed at consolidating a primary level of care with the capacity to provide comprehensive, high-quality health care. Collective action here was led by the managers of the PHC Department in collaboration with primary level of care professionals and social movements. These social movements gradually subsided during the second and third stages. Table 2. Continued Dimension Category Category’s conceptual or operational Data source definition Document review Interviews with Interviews with primary level Secondary sources Organizational Household policymakers and hospital managers and review survey survey providers Coordination of services Percentage of health centres managing patient X between health care levels referrals to hospitals and support services X X Scope of institutional change Influence of the changes on the entire health system characterized as peripheral (introduction of new practices and/or programmes limited to a primary level that is subordinate to and/or isolated from the rest of the system); intermediate (strengthening of primary health care with significant changes in the health care and organizational models that question the system status quo); or strategic (introduction of changes in the system’s health care and organizational models that locates the primary health care level at the core of the system) Downloaded from https://academic.oup.com/fampra/article/33/3/207/1749908 by DeepDyve user on 13 July 2022 212 Family Practice, 2016, Vol. 33, No. 3 Table 3. Description of the institutional process, the collective action and the scope of the institutional change, by case and periods Cochabamba Dimensions Categories Periods: 1993–96 1996–2003 2003–08 Institutional process Institutional structures Popular Participation Universal Mother and Family, Community and Law Child Insurance Intercultural Health Grassroots Territorial Creation of Municipal Strategy Organizations Health Directorates in Local Health charge of managing Directorates municipal primary health services PHC approach Shift from a curative Selective PHC Comprehensive PHC envisioned and hospital-centric model to a selective PHC approach Changes promoted Basic package of Expansion of the Integration of services with emphasis maternal and child indigenous and popular on prevention targeting service package medicine maternal and child Popular participation Expansion of the service populations Introduction of health package beyond Popular participation services management maternal and child Economic incentives and norms services and resource transfers Popular participation from national level to municipalities Collective action Composition Grassroots Grassroots Territorial Grassroots Territorial Territorial Organizations and Organizations and Organizations and municipal and municipal and municipal and departmental health departmental health departmental health managers managers managers Relationship Competitive Competitive Competitive Outsider actors Primary level and Primary level and Primary level and hospital practitioners hospital practitioners hospital practitioners Relationship with Conflict-filled. Disputes Conflict-filled. Conflicts with western- outsiders around who should Disputes around the minded professionals manage the PHC definition of and physicians against services and the professional physicians the Family, Community regulation of practices and Intercultural Health physicians’ working Strategy conceptions hours Leadership Grassroots Territorial Grassroots Territorial Grassroots Territorial Organizations Organizations Organizations Technical capacities Technical difficulties Difficulties Weak capacities for implementing the managing the introducing the Family, measures promoted by purchase and Community and the national reform management of Intercultural Health medicines and medical Strategy into health supplies services Political capacities Strong social Strong social Strong social legitimation supported legitimation supported legitimation supported by population and by population and by population and social social movements social movements movements advocating advocating for advocating for for improved health improved health improved health access and respect for access access and recognition of indigenous culture Lack of professional Lack of professional Lack of professional legitimation; legitimation; physicians legitimation; physicians physicians opposed to opposed to the reform opposed to the reform the reform Reform Scope of the Peripheral Peripheral Peripheral achievements institutional change Downloaded from https://academic.oup.com/fampra/article/33/3/207/1749908 by DeepDyve user on 13 July 2022 Conditions to implement effective primary health care reforms in Latin America 213 Table 3. Continued Vicente López Dimensions Categories Periods: 1993–96 1996–2003 2003–08 Institutional Institutional PHC municipal Strengthening of the Spaces of informal process structures department and institutional structures coordination across programmes targeted emerged in the previous health care levels at the maternal– period child population with support from the provincial Ministry of Health and the Pan American Health Organization PHC approach Shift from a curative Primary care Comprehensive PHC envisioned and hospital-centric model to a selective PHC approach Changes promoted Community Expansion of practices Coordination between participation and services covered health care services and Improvement health and strengthening of professional agreements care access affiliation to the between primary care Emphasis on health primary level and hospital physicians care promotion and Strengthening of the Strengthening of the preventive practices primary level of care’s primary level of care’s problem-solving problem-solving capacity and technical capacity and technical quality quality Increase in the propor- tion of multidisciplinary PHC teams Strengthening of the figures of health centres and programme coordinators Collective action Composition PHC Department, PHC Department, PHC Department and primary level primary level primary level practitioners and social practitioners and social practitioners movements movements Relationship Collaborative Competitive Collaborative Outsider actors Hospital physicians Hospital physicians Hospital physicians and and managers and managers managers Relationship with Neutral Competitive with Collaborative with outsiders hospital physicians hospital physicians and competitive with social movements Leadership PHC Department PHC Department PHC Department Technical capacities Teams with managerial Teams with managerial Teams with and professional and professional managerial and expertise and Pan expertise and Pan professional expertise American Health American Health Organization and Organization and Provincial Ministry Provincial Ministry support support Political capacities Social and professional Professional legitimation Professional legitimation legitimation supported thanks to the primary thanks to the primary by population and level practitioners’ level practitioners’ social movements support support and the advocating for strengthening of the improved access to management structure health services Downloaded from https://academic.oup.com/fampra/article/33/3/207/1749908 by DeepDyve user on 13 July 2022 214 Family Practice, 2016, Vol. 33, No. 3 Table 3. Continued Vicente López Dimensions Categories Periods: 1993–96 1996–2003 2003–08 Primary level Decreased support Decreased social practitioners who from population and legitimation and share the reform social movements population support principles and have becomes irrelevant been strengthening their professional role with the proposed changes Reform Scope of the Peripheral Peripheral– Intermediate achievements institutional change intermediate Rosario Dimensions Categories Periods: 1990–94 1995–2000 2001–04 2005–08 Institutional Institutional PHC Department. PHC districts Health districts Matrix- process structures Maternal and child management model programmes PHC approach Shift from a curative Primary care Comprehensive PHC Comprehensive PHC envisioned and hospital-centric model to a selective PHC approach Changes promoted Health care and Transfer of health Integration of levels of Articulation of organizational care practices to the care. professionals from regulations at the primary level Establishment of the different levels for the primary level Participatory primary level as a development of case management of the gateway and as the management primary level coordinator of the care agreements and care Geographic integration process guidelines of primary level Regulation of access to services under the specialized practices and PHC districts services Geographic assignment of the population to health centres PHC Department, PHC Department and PHC Department, Collective action Composition PHC Department, primary level health care system policymakers and health primary level practitioners and managers, primary care system managers, practitioners and social movements social movements level practitioners and primary level social movements practitioners and social movements Relationship Collaborative Collaborative Collaborative Collaborative Outsider actors Hospital specialist Hospital specialist Hospital specialist Hospital specialist physicians physicians physicians physicians Relationship with Neutral Competitive Collaborative Collaborative outsiders Leadership Primary level Primary level teams and Service managers Policymakers physicians managers Technical capacities Primary care managers Primary care Increased managerial Increased managerial with expertise in health physicians trained in and health care and health care expertise care management postgraduate general expertise medicine programmes Political capacities Social legitimation due Social legitimation due Professional Professional legitimation to social movement to social movement legitimation due to due to the firm rooting support support the integration of the primary level Professional Professional of the primary level teams and managers in legitimation due to legitimation due to teams and managers health system decision primary level primary level teams into health service maker positions physicians support support and academic managers’ positions and professional beyond the primary development level Downloaded from https://academic.oup.com/fampra/article/33/3/207/1749908 by DeepDyve user on 13 July 2022 Conditions to implement effective primary health care reforms in Latin America 215 Table 3. Continued Rosario Dimensions Categories Periods: 1990–94 1995–2000 2001–04 2005–08 Social legitimation Social legitimation due due to social to social movement movement support and support and recogni- recognition of the tion of the movement’s movement’s achievements by hospital achievements physicians by hospital physicians Reform Scope of the Peripheral Intermediate Strategic Strategic achievements institutional change Source: Own data collected based on primary sources (interviews and workshops) and secondary sources (document review) as part of this research. Given that hospital managers and professionals did not share the wanted to influence the health services functioning in their facilities. reform values, they remained distant and indifferent during the first There were also disputes with hospital specialists as the teams of stage. Nevertheless, during the second stage and with the attempt to the primary level services expanded their composition, practices and expand the practices envisioned for the primary level of care, a dispute competencies. emerged between health professionals from different levels of care. At The third stage created informal spaces for coordination between the beginning, the reform envisioned a selective PHC approach, which hospital heads of service, health centre directors and PHC pro- provided the foundation for the gradual creation of an autonomous, gramme coordinators. During this stage, the conflicts with hospi - relatively strong and comprehensive primary level of care. During the tals declined and three additional health centres were created. The reform, the number of primary level health professionals increased social movements were excluded from the collective action, despite and 13 new health centres were created. This led to a relatively high the contributions that they made by providing infrastructure support ratio of health centres and physicians per inhabitants without cov- for the creation of new health centres. erage at the end of the study period (Table  1). By 2008, more than half of the centres provided a wide range of health services during Rosario extended operating hours, but with limited capacities to coordinate their patients’ care processes with hospitals (Table 4). With this devel- In Rosario, there were four periods marked by new managerial opment, 46.2% of the total number of children under age 11 had a and decision-making structures created by the Municipal Secretary regular source of care in the primary level of care. This level of care of Public Health. These structures favoured the strengthening and represented 49.4% of total visits and achieved a rate of 3.9 annual empowerment of health services management through a PHC move- visits in this population (Table 4). Each stage of this change process is ment made up of workers from the primary level of care. Using these described below. structures, the PHC movement was able to achieve enhancements During the first stage, the Municipal PHC Department was cre - in the structure and organizational and health care practices of the ated with support from the provincial Ministry of Health and the primary level from the outset. The movement then gradually consoli- Pan American Health Organization/World Health Organization dated the primary level as a gateway and as the coordinator of the (PAHO/WHO). The Municipal PHC Department opened four new care process and enabled the principles and practices of the compre- health centres and developed different health promotion and pre- hensive PHC approach to permeate the other levels of the system. vention programmes, targeted mainly towards the maternal–child The collective action was led by a municipal movement of mostly population and infectious diseases. The political capacities of this made up of primary level professionals (practitioners and manag- Department were embedded in professional legitimations provided ers) who were embedded in service management structures, in part- by the primary level professionals who shared the reform principles nership with social movements. The reform achievements radically and benefitted from the reform and by the provincial Ministry of improved the structure and organization of the primary level of care Health and PAHO/WHO who supporting and strengthening the and introduced a PHC-based transformation into the entire health technical capacities provided. Additionally, the social movements system. During the reform, 29 new health centres were created, add- that advocated for improved health care access were well-channelled ing to the 49 centres that existed prior to the reform. This led to the and therefore provided both social legitimation for the reform and result of a relatively high ratio of health centres and physicians per physical spaces for expanding the structure of the primary level inhabitants without coverage (Tables 1 and 4). Approximately 75% of care. of these centres provided a wide range of services that were inte- During the second stage, the PHC Department strengthened the grated with hospitals and available during extended operating hours structure of the primary level of care with six new health centres (Table 4). With this development, the system achieved that 55.1% of and expanded the health programme beyond maternal–child health all children under age 11 had a regular source of care at the primary and infectious disease. The Department also promoted expanded level. This channelled 57.9% of the total number of visits and led health practices, improved technical quality and strengthened role to a rate of 4.4 visits per year in this population. Each stage of the for the primary level of care as both a regular provider of care and change process is described below. the coordinator of the population’s care processes. Within the col- During the first stage, the PHC Department was created. The lective action, there were disputes with the social movements who Department developed preventive programmes targeted at the Downloaded from https://academic.oup.com/fampra/article/33/3/207/1749908 by DeepDyve user on 13 July 2022 216 Family Practice, 2016, Vol. 33, No. 3 Table 4. Reform achievements in terms of changes in the structure and health care performance of the primary level of health care Changes in the structure of the primary level* Service performance of the primary level (2008) Number of primary % of primary health Primary health care centres’ office Access to primary health care Affiliation with the primary level Coordination of care health centres care centres with a hours per week (average) services** of care** services between multidisciplinary team health care levels* At start of each 2008 At start of each 2008 At start of each reform*** 2008 Annual average Annual average of % of children % of children % of health centres reform**** reform*** of medical visits medical visits to under age 11 that under age 11 managing patient among children a primary health have a regular that have a referrals to hospitals under age 11 care centre among source of care regular source and support services children under of care in a age 11 primary health care centre Cochabamba 6 28 0% 0% Reduced and unstable 35.3 3.8 1.7 20.2% 4.0% 0.0% Vicente López 7 20 0% 60.0% Reduced and unstable 46.9 7.9 3.9 65.1% 46.2% 30.0% Rosario 49 78 0% 73.8% Reduced and unstable 59.3 7.6 4.4 78.4% 55.1% 100% There are no available data prior to the change process for these variables. The composition of a team was considered to be multidisciplinary whenever the following elements were present, at a minimum: In Argentina: (i) a generalist or paediatrician, (ii) a clinician, a gynaecologist or ob-gyn, (iii) a nurse and (iv) a social worker or a psychologist. In Bolivia: (i) a GP, (ii) a dentist, (iii) a licensed nurse and (iv) an auxiliary nurse. A regular source of care is considered to be available whenever there is a source of care or physician that regularly provides medical care to. Source: Authors’ interpretation based on: *Organizational survey: Rosario, 2007; Vicente López and Cochabamba, 2008. **Household survey: Rosario, 2008; Vicente López and Cochabamba, 2008/2009. ***Interviews with PHC policymakers and managers. ****Start of each reform: Cochabamba 1993; Vicente López 1993; Rosario 1990. Downloaded from https://academic.oup.com/fampra/article/33/3/207/1749908 by DeepDyve user on 13 July 2022 Conditions to implement effective primary health care reforms in Latin America 217 maternal–child population and introduced management norms to confrontation with the physicians in the system. This dynamic regulate operating hours, medical records and the use of supplies impeded the strengthening of the technical and political capacities in health centres. At this stage, 25 new health centres were created. needed to exploit new institutional structures, guarantee effective The participation of professionals with experience in service man- implementation of the reform and provide continuity for the change agement provided technical capacity for the collective action. The process. Although the reform was able to strengthen the primary political capacities emanated from the social legitimacy provided level of care and introduce organizational changes and improve- through support from social movements that sought to improve the ments in service performance, it produced a dynamic of ‘interrupted’ population’s access to health care and from the professional legiti- change limited to the development of a selective PHC approach. macy based on a participatory management model of professionals In Vicente López, the new institutional structures favoured the gen- with strong personal leadership skills. During this stage, hospital eration of a new collective action based on the participation of profes- managers and professionals were indifferent to what was happening sionals, managers and technical personnel from the primary level of in the primary level. care. This collective action was able to produce new institutional struc- The second stage created PHC districts and participatory man- tures that expanded their technical capacities, but under a dynamic of agement structures and decentralized the coordination of health path-dependency (20). This dynamic reproduced the development of centres. Health teams and social movements were invited to par- organizational capacities and changes centred on the primary level of ticipate in these initiatives. Health centres were assigned responsibil- care but with limited influence on the rest of the health service system. ity for a geographically defined population and their practices were In Rosario, the new institutional structures led to the generation expanded (e.g. health centres were given responsibility for prenatal of a broad-based, collaborative, collective action that in turn pro- check-ups, which were previously provided at hospitals). Nine new duced these new institutional structures. These structures favoured health centres were created, new professional profiles were inte - the consolidation of greater technical and political capacities that grated into health centres and the range of services offered at the pri- allowed the collective action to conquer key management spaces mary level was expanded. This advance in service delivery that was within the health service system (21). This dialectic relationship formerly the exclusive competency of specialists led to a dispute with between actors and institutional structures favoured the system’s hospitals. The PHC movement created a postgraduate programme ability to overcome technical and political challenges at each stage, in general medicine, which strengthened the technical capacity and enabling the consolidation of a comprehensive PHC approach. professional legitimacy of the collective action. Lessons learned from the evidence indicate that reform processes The third stage created health districts that generated spaces for aimed at producing health systems based on a PHC comprehensive articulation between the PHC districts and hospitals. During the eco- approach require collective action with a dynamic composition that nomic crisis that dominated this stage, several health centres oper- includes actors from different institutional fields with capacities to ating within community organizations closed. The need to manage confront technical and political challenges during the different stages limited resources more efficiently favoured the regulation of access of the change process (22). The new institutional structures should to the second level of care, in turn strengthening the figure of the be conceived as technical mechanisms of regulation for implement- primary level as a gateway and as the coordinator of the popula- ing new approaches of PHC among the actors involved in the health tion’s care processes and blurring the dispute with hospitals. This service system. These structures also represent a platform that facili- role strengthened the social and professional legitimacy of the collec- tates the emergence and/or consolidation of partnerships that foster tive action, supported by a process of accumulation of professional, a growing influence on the health service system. academic and political prestige. Although this study produced significant information and find - During the fourth stage, the PHC movement—which was embed- ings based on a broad set of data collection techniques and a com- ded in the management structures of the second level of care— prehensive analysis approach, it has important limitations. First, an implemented a matrix-management model. This model established analysis of the effectiveness of the studied reforms was outside of the processes for collaboration between professionals in the primary and scope of this study. Second, we did not analyse how the socio-eco- second levels of care in a determined geographic area with the goal nomic differences between settings influenced the actors’ capacities. of strengthening the comprehensiveness and technical quality of the Third, our observation and analysis centred on the actors involved primary level (through the joint development and implementation and the processes that took place at the local level and within the of care guidelines), the continuity of the care process, coordination boundaries of the public subsystem. Little or no attention was given between providers and access to specialized practices. The collective to the potential influence of political and institutional processes action established collaborative relationships with hospital profes- at higher government levels or in other health subsystems. Future sionals and their technical and political capacities continued improv- research could shed light on these issues. ing. The number of health centres recovered with the construction of municipal health centres. Conclusion The reform processes introduced new institutional structures that Discussion permitted the agglutination of different stakeholders who were In this section, we interpret our findings and attempt to identify the potential beneficiaries of the reform as a common force, although enablers of the collective action capacities to produce (or not pro- not necessarily with the same objectives. These processes achieved an duce) the results envisioned in each case under study. In doing so, evolution from selective to more comprehensive PHC approaches, we consider the collective action capacities to be the result of the strengthening managerial capacities and expanding and improving dynamic of the structuring processes between the institutional struc- the performance of the primary level of care. However, these changes tures and the collection action. were of differing scope depending on the capacity of the different In Cochabamba, the new structures produced at the national collective actions, which represent both the product and catalyst of level resulted in weak collective action, with internal conflicts and change in the new institutional structures. Downloaded from https://academic.oup.com/fampra/article/33/3/207/1749908 by DeepDyve user on 13 July 2022 218 Family Practice, 2016, Vol. 33, No. 3 4. Macinko J, Starfield B, Erinosho T. The impact of primary healthcare on In each case, the interaction between the characteristics of the insti- population health in low- and middle-income countries. J Ambul Care tutional structures and the collective action produced different struc- Manage 2009; 32: 150–71. turing dynamics that served as either facilitating or limiting factors 5. Acosta Ramírez N, Pollard Ruiz J, Vega Romero R, Labonté R. Compre- in the development of the technical and political capacities that are hensive primary health care in South America: contexts, achievements and needed to develop a comprehensive PHC approach. In Cochabamba, policy implications. Cad Saúde Pública 2011; 27: 1875–90. there was an ‘interrupted’ structuring process that achieved the estab- 6. Báscolo E, Yavich N. Governance and the effectiveness of the Buenos Aires lishment of a primary level with a selective PHC approach. In Vicente public health insurance implementation process. J Ambul Care Manage López, there was a ‘path-dependency’ structuring process that permit- 2009; 32: 91–102. ted the consolidation of a ‘primary care’ approach, but with limited 7. Greenwood R, Raynard M, Kodeih F, Micelotta ER, Lounsbury M. Insti- influence in hospitals. In Rosario, there was a ‘dialectic’ structuring tutional complexity and organizational responses. Acad Manag Ann 2011; 5: 317–71. process that favoured the development of the capacities that are 8. Lawrence T, Suddaby R, Leca B. Institutional work: refocusing institu- needed for the consolidation of a comprehensive PHC approach. tional studies of organization. J Manage Inq 2011; 20: 52–8. The path towards health service systems centred on PHC is nei- 9. Seo MG, Creed WD. Institutional contradictions, praxis, and institu- ther a linear nor a natural process. The analysis of ‘structuring’ pro- tional change: a dialectical perspective. Acad Manage Rev 2002; 27: cesses allows for the tracking (and potentially interventions in) of the 222–47. generation of capacities for collective action (19). 10. Hodgson RC, Levinson DJ, Zaleznik A. The Executive Role Constellation. Boston, MA: Harvard Business School Press, 1965. 11. Denis JL, Langley A, Rouleau L. The practice of leadership in the messy Acknowledgements world of organizations. Leadership 2010; 6: 67–88. We thank Edgar Valdez, director of the Institute for Human Development 12. Yin RK. Case Study Research: Design and Methods. 2nd edn. Thousand [Instituto para el Desarrollo Humano (IDH)] of Bolivia, for his continuous Oaks, London, New Delhi: Sage Publications, 1994. support and the IDH staff for their technical and human quality. We espe- 13. Instituto Nacional de Estadísticas y Censos. Censo Nacional de Población cially want to mention Liseth Arias, the Bolivian team coordinator, and Hogares y Vivienda. 2001 Resultados Generales. Variables Pre-codifi - the main members of her team: Carla Alcocer, Joaquín Salcedo, Fernando cadas. Total de País y Provincias. 2002. http://www.indec.gov.ar/micro_ Bustamante and Ana Cristy Ugarte. We acknowledge the invaluable inputs of sitios/webcenso/ (accessed on April 2010). the Argentinean and the Bolivian decision makers, managers and practitioners, 14. Instituto Nacional de Estadísticas. República de Bolivia. Censo de particularly Gabriela Castiglia, Leonardo Caruana and Horacio Crespo from Población y Vivienda. 2001. http://www.ine.gob.bo/cgi-bin/Redatam/ Argentina and Jaime Titisano and Franklin Antezana from Bolivia. We thank RG4WebEngine.exe/PortalAction?&MODE=MAIN&BASE=TallCreac& the editors and reviewers whose comments lead to an improved version of MAIN=WebServerMain.inl (accessed on April 2010). the original manuscript. Finally, we thank the institutions and persons whose 15. Lawrence T. Power, institutions and organizations. In: Greenwood R, Oli- human and financial support made this publication possible; within them we ver C, Suddaby R, Sahlin-Andersson K (eds). The Sage of Handbook of are especially grateful to Jeannie Haggerty. Organizational Institutionalism. Los Angeles, London, New Delhi, Singa- pore, Washington, DC: Sage Publications, 2008, pp. 170–97. 16. Deephouse D, Suchman M. Legitimacy in organizational institutionalism. Declaration In: Greenwood R, Oliver C, Suddaby R, Sahlin-Andersson K (eds). The Sage of Handbook of Organizational Institutionalism. Los Angeles, Lon- Funding: International Development Research Centre (IDRC). The analysis don, New Delhi, Singapore, Washington, DC: Sage Publications, 2008, pp. that led to this paper was conducted thanks to the support of the CONICET, 49–77. and the postdoctorate fellowships granted to Ernesto Báscolo by the National 17. Báscolo EP, Yavich N, Urquía ML. Capacidades locales de gestión como School of Public Administration (École Nationale d’Administration Publique) factor predictivo de la utilización y accesibilidad a los servicios de primer and the Department of Family Medicine at the McGill University. nivel para la obtención de cuidados prenatales. Rev Gerenc Polít Salud Ethical approval: International Development Research Centre (IDRC). 2007; 6: 112–25. Conflict of interest: none. 18. Langley A. Temporal bracketing. In: Mills A, Durepos G, Wiebe E (eds). Sage Encyclopaedia of Case Study Research, Vol. 2. Thousand Oaks, CA: References Sage Publications, 2009, pp. 919–21. 1. World Health Organization. The World Health Report 2008. Primary 19. Giddens A. The Constitution of Society. Berkeley, CA: University of Cali- Health Care. Now More Than Ever. Geneva, Switzerland: World Health fornia Press, 1984. Organization, 2008. 20. Pierson P. Increasing returns, path dependence, and the study of politics. 2. Macinko J, Montenegro H, Nebot C. Renewing Primary Health Care in Am Polit Sci Rev 2000; 94: 251–67. the Americas: A Position Paper of the Pan American Health Organization/ 21. Hargrave T, Van de Ven H. Institutional work as the creative embrace of World Health Organization (PAHO/WHO). Washington, DC: Pan Ameri- contradiction outside traditional boundaries. In: Lawrence TB, Suddaby can Health Organization, 2007. R, Leca B (eds). Institutional Work: Actors and Agency in Institutional 3. Haggerty JL, Yavich N, Báscolo EP; Grupo de Consenso sobre un Marco Studies of Organizations. Cambridge: Cambridge University Press, 2009, de Evaluación de la Atención Primaria en América Latina. [A framework pp. 120–40. for evaluating primary health care in Latin America]. Rev Panam Salud 22. Báscolo E. [Governance and political economy of PHC policies in Latin Publica 2009; 26: 377–84. America]. Cien Saude Colet 2011; 16: 2763–72. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Family Practice Oxford University Press

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

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10.1093/fampra/cmw038
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Abstract

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. Key words. Health care quality, access, and evaluation, health care reform, leadership, organizational innovation, politics, primary health care. fostered a transformation from health care models that are hospital- Introduction centred, curative, medical and specialized to models that focus on Primary health care (PHC)-based reforms have been used to pro- more comprehensive, family- and community-oriented care, with mote changes in health systems and services. These initiatives have © The Author 2016. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Downloaded from https://academic.oup.com/fampra/article/33/3/207/1749908 by DeepDyve user on 13 July 2022 208 Family Practice, 2016, Vol. 33, No. 3 PHC as a strategy to coordinate health care across levels and provid- and analysis, the design of the data collection procedures and tools ers (1). and the data collection in the Argentinean settings. A Bolivian team In Latin America, these change processes emerged in the 1980s based in Cochabamba collected and analysed the local data. with the rise of democratic governments that empowered the partici- pation of new social actors committed to the improvement of social Units of analysis determinants of health and health equity. The advances engendered Our units of analysis were the reforms implemented between 1990 by these processes to change from one health care model to another and 2008 in the municipalities of Cochabamba (Department of were uneven (2–6). While some countries moved towards a com- Cochabamba, Bolivia); Vicente López (Province of Buenos Aires, prehensive PHC approach accompanied by radical institutional and Argentina); and Rosario (Province of Santa Fe, Argentina). We organizational changes that resulted in significant health improve - selected reforms that took place at the municipal level since the ments, other countries were able to develop only the primary level of decentralization processes during the 1980s and 1990s in Latin care or introduce programmes to improve maternal and child health America positioned the municipal level at the core of the imple- and control infectious diseases. Although these latter processes mentation of these reforms (5,6). Table  1 provides basic informa- favoured significant health improvements in specific populations tion about each municipality’s socio-economic and health services and/or diseases, they were unable to produce the institutional and characteristics. organizational changes required to reform and improve the health system as a whole (1–3). Sampling rationale The institutional process plays a fundamental role as a driver of To better understand the differences in the collective action capaci- organizational change through the introduction of regulatory mech- ties that led to different degrees of institutional change, we used anisms, structures, conceptions and values (7,8). The question that a purposeful sampling strategy, to selected Latin American cases continues to be the subject of an unresolved policy and academic showing a maximum variation with regard to the PHC approaches debate is how to produce institutional change (8,9). According to achieved by the reforms (2–4). While in Europe and other wealthy Hodgson (10), the triggers of institutional change depend on the developed countries PHC has primarily been viewed as the first capacities for collective action, in other words, the group of stake- level of health services for the entire population, in Latin America holders who are advocating for institutional change. coexist a number of PHC conceptions and models. These models Two approaches have analysed the enablers of collective action fall broadly into three main organizational approaches: (i) Selective capacities to produce institutional change processes. One approach PHC: focused in a limited number of high-impact services to tar- emphasizes the configuration of the collective action as the main get the most prevalent causes of child mortality and some infectious enabler of capacities to manage institutional change processes diseases. Although originally considered an interim strategy, this (10). The other approach assumes that collective action capacities approach has become the dominant mode of PHC for many coun- are modelled by new structures created during the trajectory of the tries. (ii) Primary care: refers to the entry point into the health system institutional restructuring process (8). We hypothesize that collec- and the place for continuing health care for most people, most of the tive action capacities consist of the dynamics between actors and time. (iii) Comprehensive PHC: a strategy for organizing health care structures, known as structuring, which underlie institutional change systems and society to promote health. This approach is based on the processes (11). Alma Ata Declaration. It has been implemented in few countries and Our research question is how did structuring processes influence in several small-scale experiences, although is mentioned as the goal the achievement of different levels of advances towards developing a for most of the PHC-based reforms (2). comprehensive PHC approach in three reform processes? More spe- cifically, our objective is to analyse how structuring processes during Case selection process three Latin American reforms aimed at the implementation of a com- Cochabamba was selected as an exemplary of a selective PHC prehensive PHC approach enabled or hindered the collective action approach, Vicente López as an example of a primary care approach capacities needed to implement the changes envisioned. and Rosario as an example of the comprehensive PHC approach (2,3). Methods Study design Data collection processes and analysis techniques We conducted a multicentre, longitudinal, retrospective multiple The research included primary and secondary data source analyses case study (12) between 2007 and 2010. The research was coordi- and multiple data collection techniques such as documental and offi - nated by an Argentinean team in charge of the overall coordination cial record reviews, semi-structured interviews and organizational Table 1. Sociodemographic and health services indicators for the municipalities under study Municipality Cochabamba Vicente López Rosario Number of residents 517 024 274 082 909 397 Percentage of structurally poor population according to the unmet basic needs index 33.8% 4.8% 13.5% Percentage of population without health coverage 75.1% 27.2% 39.1% a,b Ratio of public primary level of care centres per 10 000 population without coverage 0.7 2.6 2.3 a,b Ratio of primary level of care providers per 1000 population without coverage 0.3 1.2 1.4 Number of public hospitals 5 6 14 Source: Argentina: National Population, Households, and Dwellings Census (13), 2001; Bolivia: National Population and Housing Census, 2001 (14). The list of health centres and hospitals provided by the Health Secretaries. Downloaded from https://academic.oup.com/fampra/article/33/3/207/1749908 by DeepDyve user on 13 July 2022 Conditions to implement effective primary health care reforms in Latin America 209 and household surveys (Table  2). We used the same data collec- (10,15,16). The third dimension, the reform achievements, was char- tion procedures and tools in each case, with minor adaptations as acterized by five categories: (i) changes in the physical structure and required. Some techniques were combined sequentially and others human resources of the primary level of care; (ii) access to the pri- complementary. mary level of care; (iii) continuity of care, in terms of the affiliation First, we conducted a document review of norms, policy docu- of the population to the primary level of care; (iv) coordination of ments and scientific literature to define reform periods by identify - services, in terms of the capacity of the primary level of care to man- ing new institutional structures. The document review was validated age access to specialized practices or visits with hospitals; and (v) by and used to inform interviews with different actors. Second, to scope of the changes in the entire health system (17). Given the lack characterize the institutional process and the collective action during of information about the characteristics of the structure and perfor- each period, we conducted semi-structured interviews with policy- mance of services during the entire process, it was only possible to makers and with primary level and hospital managers and provid- reconstruct the characteristics of the structure at the beginning and ers. Overall, we conducted 156 semi-structured interviews, including end of the study period and to determine the performance of the 18 with policymakers (e.g. health secretaries, PHC managers) and services at the end of the study period, as shown in Table 4. 138 with hospital and PHC centre managers and health care pro- viders. Interviews were recorded, transcribed verbatim. A  directed Analytic strategy content analysis approach was used in documents and interviews. Temporal bracketing was applied as a sense-making strategy (18). This approach consists in using a theory as guidance for coding. The concept of temporal bracketing is derived from Anthony We draw our coding based on dimensions and categories of analysis Giddens’ structuration theory (19), which states that actors’ actions relevant to the structuring process (described in the next section). are constrained by social structures and that actions simultaneously To strengthen reliability, two researchers independently conducted reconstitute those structures over time. Because mutual influences are the analysis and then contrasted and discussed the differences in difficult to capture simultaneously and because changes in structures their findings. Third, we conducted an organizational survey of all follow diachronically from action, temporal bracketing proposes to PHC centres in each municipality to gather data on the structure analyse these interacting dimensions by temporarily ‘bracketing’ one and organizational practices at the primary level. The questionnaire, of them. Thus, we defined periods by identifying the introduction of administered by a researcher, included questions about the date the new institutional structures. In each period, we analysed the insti- health centre was created and its current resources and organiza- tutional process, the collective action and when possible, the health tional practices. We reviewed official records about the structure care and organizational changes occurred in system of health ser- of the services to complete missing data when necessary. We used vices as a result of the reform. the survey results to categorize the health centres into three groups according to their structure and functioning and then selected two health centres per category in each municipality in consultation with Results policymakers. Fourth, we conducted a household survey to deter- In this section, we describe the implementation of the processes in mine the PHC achievements in each municipality. We applied the each case under study. We begin with an overall description of the survey to age- and sex-stratified sample of 450 caregivers of children institutional structures created, their main objectives, the characteris- under 11 years of age living in the area of influence of the health cen - tics of each collective action, the scope of the achievements (Table 3) tres. We used descriptive statistical analysis to analyse both surveys. and the changes in the primary level structure and health care per- Finally, to validate and enrich our analysis, we organized workshops formance at the end of the study period (Tables 1 and 4). Then, we with policymakers and managers to present and discuss our findings. provide a detailed description of the health care and organizational practices promoted by the new institutional structures introduced during each period and the changes in the composition of the collec- Study analytical categories by dimension tive action, including internal and external relationships and politi- This study comprises three dimensions of analysis: the institutional cal and technical capacities (Table 3). process, the collective action and the reform achievements. Each dimension was approached with using a set of analytical categories Cochabamba or subdimensions. Table 2 shows each dimension in the first column and its analytical categories in the second column. In the third col- In Cochabamba, we identified three stages in the national reforms umn, we provide the categories’ conceptual or operational defini - in order to transfer resources to the municipalities; create new local tions. The next columns indicate the data sources (the data collection structures and economic incentives to promote popular participa- technique/s are described in the previous subheading) used to study tion; decentralize the management of health services to the munici- each category. palities; and expand coverage and access to health services. The first The first dimension, the institutional process, was studied through two stages envisioned an improvement in coverage and access to ser- three categories: (i) identification of the institutional structures intro - vices for the maternal–child population and the final stage focused duced by the reforms; (ii) PHC approach envisioned by the institu- on the development of a comprehensive PHC approach based on a tional structures; and (iii) health care and organizational changes multicultural model. In this case, collective action was composed of promoted by the institutional structures. The second dimension, the social movements (which had a leadership role) and municipal and collective action, was characterized in terms of seven categories: (i) departmental (provincial) health managers, who were engaged in a collective action composition; (ii) internal relationships between competitive relationship with each other and with health providers their participants; (iii) actor that exerted the leadership role (11); from the primary level of care. The reform achieved the development (iv) stakeholders external to the collective action; (v) relationship of a structure for the primary level of care with the creation of 22 between the collective action and outside stakeholders; (vi) collec- new health centres that offer health services, mainly preventive and tive action’s technical capacities; and (vii) collective action’s politi- maternal–child care, provided during limited operating hours and cal capacities to implement and manage new institutional structures without the capacity to coordinate their patients’ care processes with Downloaded from https://academic.oup.com/fampra/article/33/3/207/1749908 by DeepDyve user on 13 July 2022 210 Family Practice, 2016, Vol. 33, No. 3 Table 2. Analytical categories by dimension, definition and data source Dimension Category Category’s conceptual or operational Data source definition Document review Interviews with Interviews with primary level Secondary sources Organizational Household policymakers and hospital managers and review survey survey providers Institutional Institutional structures Regulatory structures formally or factually X X process introduced by the reform to act upon the system of health services, such as policies, programmes and management structures PHC approach envisioned The PHC approach is characterized as selec- X X X tive PHC, primary care or comprehensive PHC Changes promoted Health care and organizational changes X X X promoted by the institutional structures Collective Composition Key actors, taking action to realize the X X action changes promoted by the reforms Relationship The relationship between the actors X X comprising the collective action is characterized as competitive, collaborative or neutral Leadership Actor who leads the collective action X X decision-making processes Outsider actors Identification of the key actors who are X X outsiders to the collective action Relationship with outsiders The relationship between the collective action X X and key actor outsiders is characterized as conflictive, collaborative or neutral Technical capacities Ability of the collective action to create or X X manage regulatory mechanisms that emerge from the new institutional structures (9,13) Political capacities Ability to achieve the social and professional X X legitimacy required to create and carry out new institutional structures (9,13) Reform Physical structure and Changes in the number of primary level X X X achievements human resources health centres, team composition and office hours’ coverage Access to primary health Annual average of medical visits to a primary X care services health care centre among children under age Continuity of care/affiliation Percentage of children under age 11 that have X to the primary level of care a regular source of care in a primary health care centre Downloaded from https://academic.oup.com/fampra/article/33/3/207/1749908 by DeepDyve user on 13 July 2022 Conditions to implement effective primary health care reforms in Latin America 211 hospitals (Tables 1 and 4). This development enabled the channel- ling of 44.7% of the total visits with children under age 11 to the primary level of care. However, the annual rate of visits in this age group was lower than the two recommended annual visits (mainly well-child check-ups) and only a reduced percentage of children had a regular source of care at the primary level of care (Table 4), due to the low ratio between health centres and physicians per inhabitants without coverage (Table 1). This stage is described below. During the first stage, the reform creates the Grassroots Territorial Organizations (Organizaciones territoriales de base—OTB) and the Local Health Directorates (Directorios Locales de Salud—DILOS). The Local Health Directorates were tripartite structures comprised the Grassroots Territorial Organizations (head of the Local Health Directorates), the municipal and the departmental health authorities. The Local Health Directorate of Cochabamba is left in charge of the primary health care centres. Previously, the primary health care level was dependent on the hospitals and the departmental authorities, and in each health centre, the managerial functions relied on the main physician. The Local Health Directorate embodies the collective action. Its actions served as the foundation for both expanding the structure of the primary level of care with the creation of seven new health centres and improving the coverage of preventive services for the maternal–child population. However, these actions took place in a framework of internal conflict-filled relationships between physi - cians, who perceived that their power over services and their profes- sional autonomy was threatened. The strength of collective action resided in the political capacities derived from the social legitimacy that emerged from the support of social movements (which provided physical spaces for expanding the primary level of care). Its weak- nesses were the lack of professional legitimacy and technical capac- ity to manage health services. The second stage was defined by the creation of the Universal Mother and Child Insurance (Seguro Universal Materno Infantil— SUMI), which sought to expand free health services for the mater- nal–child population and integrate new norms of health services management and care provision. At the local level, the Municipal Health Directorate (Directorio Municipal de Salud—DIMUSA) was created and put under the charge of the local management of health services. Here, nine health centres were inaugurated. The composi- tion, relationships and capacities of the collective action continued unchanged with respect to the previous stage. The third stage was structured around the creation of the national-level Family, Community and Intercultural Health Strategy (Salud Familiar Comunitaria Intercultural—SAFCI), which sought to expand the coverage of health insurances beyond the maternal and child population and promote a comprehensive PHC approach with a focus on multiculturality. During this stage, six new health centres were added to the primary level of care. Although the con- flicts within the collective action decreased here, the relevant changes in the composition, relationships and capacities of collective action did not take place. Vicente López The reform process in Vicente López was developed in three stages that created formal and informal institutional structures aimed at consolidating a primary level of care with the capacity to provide comprehensive, high-quality health care. Collective action here was led by the managers of the PHC Department in collaboration with primary level of care professionals and social movements. These social movements gradually subsided during the second and third stages. Table 2. Continued Dimension Category Category’s conceptual or operational Data source definition Document review Interviews with Interviews with primary level Secondary sources Organizational Household policymakers and hospital managers and review survey survey providers Coordination of services Percentage of health centres managing patient X between health care levels referrals to hospitals and support services X X Scope of institutional change Influence of the changes on the entire health system characterized as peripheral (introduction of new practices and/or programmes limited to a primary level that is subordinate to and/or isolated from the rest of the system); intermediate (strengthening of primary health care with significant changes in the health care and organizational models that question the system status quo); or strategic (introduction of changes in the system’s health care and organizational models that locates the primary health care level at the core of the system) Downloaded from https://academic.oup.com/fampra/article/33/3/207/1749908 by DeepDyve user on 13 July 2022 212 Family Practice, 2016, Vol. 33, No. 3 Table 3. Description of the institutional process, the collective action and the scope of the institutional change, by case and periods Cochabamba Dimensions Categories Periods: 1993–96 1996–2003 2003–08 Institutional process Institutional structures Popular Participation Universal Mother and Family, Community and Law Child Insurance Intercultural Health Grassroots Territorial Creation of Municipal Strategy Organizations Health Directorates in Local Health charge of managing Directorates municipal primary health services PHC approach Shift from a curative Selective PHC Comprehensive PHC envisioned and hospital-centric model to a selective PHC approach Changes promoted Basic package of Expansion of the Integration of services with emphasis maternal and child indigenous and popular on prevention targeting service package medicine maternal and child Popular participation Expansion of the service populations Introduction of health package beyond Popular participation services management maternal and child Economic incentives and norms services and resource transfers Popular participation from national level to municipalities Collective action Composition Grassroots Grassroots Territorial Grassroots Territorial Territorial Organizations and Organizations and Organizations and municipal and municipal and municipal and departmental health departmental health departmental health managers managers managers Relationship Competitive Competitive Competitive Outsider actors Primary level and Primary level and Primary level and hospital practitioners hospital practitioners hospital practitioners Relationship with Conflict-filled. Disputes Conflict-filled. Conflicts with western- outsiders around who should Disputes around the minded professionals manage the PHC definition of and physicians against services and the professional physicians the Family, Community regulation of practices and Intercultural Health physicians’ working Strategy conceptions hours Leadership Grassroots Territorial Grassroots Territorial Grassroots Territorial Organizations Organizations Organizations Technical capacities Technical difficulties Difficulties Weak capacities for implementing the managing the introducing the Family, measures promoted by purchase and Community and the national reform management of Intercultural Health medicines and medical Strategy into health supplies services Political capacities Strong social Strong social Strong social legitimation supported legitimation supported legitimation supported by population and by population and by population and social social movements social movements movements advocating advocating for advocating for for improved health improved health improved health access and respect for access access and recognition of indigenous culture Lack of professional Lack of professional Lack of professional legitimation; legitimation; physicians legitimation; physicians physicians opposed to opposed to the reform opposed to the reform the reform Reform Scope of the Peripheral Peripheral Peripheral achievements institutional change Downloaded from https://academic.oup.com/fampra/article/33/3/207/1749908 by DeepDyve user on 13 July 2022 Conditions to implement effective primary health care reforms in Latin America 213 Table 3. Continued Vicente López Dimensions Categories Periods: 1993–96 1996–2003 2003–08 Institutional Institutional PHC municipal Strengthening of the Spaces of informal process structures department and institutional structures coordination across programmes targeted emerged in the previous health care levels at the maternal– period child population with support from the provincial Ministry of Health and the Pan American Health Organization PHC approach Shift from a curative Primary care Comprehensive PHC envisioned and hospital-centric model to a selective PHC approach Changes promoted Community Expansion of practices Coordination between participation and services covered health care services and Improvement health and strengthening of professional agreements care access affiliation to the between primary care Emphasis on health primary level and hospital physicians care promotion and Strengthening of the Strengthening of the preventive practices primary level of care’s primary level of care’s problem-solving problem-solving capacity and technical capacity and technical quality quality Increase in the propor- tion of multidisciplinary PHC teams Strengthening of the figures of health centres and programme coordinators Collective action Composition PHC Department, PHC Department, PHC Department and primary level primary level primary level practitioners and social practitioners and social practitioners movements movements Relationship Collaborative Competitive Collaborative Outsider actors Hospital physicians Hospital physicians Hospital physicians and and managers and managers managers Relationship with Neutral Competitive with Collaborative with outsiders hospital physicians hospital physicians and competitive with social movements Leadership PHC Department PHC Department PHC Department Technical capacities Teams with managerial Teams with managerial Teams with and professional and professional managerial and expertise and Pan expertise and Pan professional expertise American Health American Health Organization and Organization and Provincial Ministry Provincial Ministry support support Political capacities Social and professional Professional legitimation Professional legitimation legitimation supported thanks to the primary thanks to the primary by population and level practitioners’ level practitioners’ social movements support support and the advocating for strengthening of the improved access to management structure health services Downloaded from https://academic.oup.com/fampra/article/33/3/207/1749908 by DeepDyve user on 13 July 2022 214 Family Practice, 2016, Vol. 33, No. 3 Table 3. Continued Vicente López Dimensions Categories Periods: 1993–96 1996–2003 2003–08 Primary level Decreased support Decreased social practitioners who from population and legitimation and share the reform social movements population support principles and have becomes irrelevant been strengthening their professional role with the proposed changes Reform Scope of the Peripheral Peripheral– Intermediate achievements institutional change intermediate Rosario Dimensions Categories Periods: 1990–94 1995–2000 2001–04 2005–08 Institutional Institutional PHC Department. PHC districts Health districts Matrix- process structures Maternal and child management model programmes PHC approach Shift from a curative Primary care Comprehensive PHC Comprehensive PHC envisioned and hospital-centric model to a selective PHC approach Changes promoted Health care and Transfer of health Integration of levels of Articulation of organizational care practices to the care. professionals from regulations at the primary level Establishment of the different levels for the primary level Participatory primary level as a development of case management of the gateway and as the management primary level coordinator of the care agreements and care Geographic integration process guidelines of primary level Regulation of access to services under the specialized practices and PHC districts services Geographic assignment of the population to health centres PHC Department, PHC Department and PHC Department, Collective action Composition PHC Department, primary level health care system policymakers and health primary level practitioners and managers, primary care system managers, practitioners and social movements social movements level practitioners and primary level social movements practitioners and social movements Relationship Collaborative Collaborative Collaborative Collaborative Outsider actors Hospital specialist Hospital specialist Hospital specialist Hospital specialist physicians physicians physicians physicians Relationship with Neutral Competitive Collaborative Collaborative outsiders Leadership Primary level Primary level teams and Service managers Policymakers physicians managers Technical capacities Primary care managers Primary care Increased managerial Increased managerial with expertise in health physicians trained in and health care and health care expertise care management postgraduate general expertise medicine programmes Political capacities Social legitimation due Social legitimation due Professional Professional legitimation to social movement to social movement legitimation due to due to the firm rooting support support the integration of the primary level Professional Professional of the primary level teams and managers in legitimation due to legitimation due to teams and managers health system decision primary level primary level teams into health service maker positions physicians support support and academic managers’ positions and professional beyond the primary development level Downloaded from https://academic.oup.com/fampra/article/33/3/207/1749908 by DeepDyve user on 13 July 2022 Conditions to implement effective primary health care reforms in Latin America 215 Table 3. Continued Rosario Dimensions Categories Periods: 1990–94 1995–2000 2001–04 2005–08 Social legitimation Social legitimation due due to social to social movement movement support and support and recogni- recognition of the tion of the movement’s movement’s achievements by hospital achievements physicians by hospital physicians Reform Scope of the Peripheral Intermediate Strategic Strategic achievements institutional change Source: Own data collected based on primary sources (interviews and workshops) and secondary sources (document review) as part of this research. Given that hospital managers and professionals did not share the wanted to influence the health services functioning in their facilities. reform values, they remained distant and indifferent during the first There were also disputes with hospital specialists as the teams of stage. Nevertheless, during the second stage and with the attempt to the primary level services expanded their composition, practices and expand the practices envisioned for the primary level of care, a dispute competencies. emerged between health professionals from different levels of care. At The third stage created informal spaces for coordination between the beginning, the reform envisioned a selective PHC approach, which hospital heads of service, health centre directors and PHC pro- provided the foundation for the gradual creation of an autonomous, gramme coordinators. During this stage, the conflicts with hospi - relatively strong and comprehensive primary level of care. During the tals declined and three additional health centres were created. The reform, the number of primary level health professionals increased social movements were excluded from the collective action, despite and 13 new health centres were created. This led to a relatively high the contributions that they made by providing infrastructure support ratio of health centres and physicians per inhabitants without cov- for the creation of new health centres. erage at the end of the study period (Table  1). By 2008, more than half of the centres provided a wide range of health services during Rosario extended operating hours, but with limited capacities to coordinate their patients’ care processes with hospitals (Table 4). With this devel- In Rosario, there were four periods marked by new managerial opment, 46.2% of the total number of children under age 11 had a and decision-making structures created by the Municipal Secretary regular source of care in the primary level of care. This level of care of Public Health. These structures favoured the strengthening and represented 49.4% of total visits and achieved a rate of 3.9 annual empowerment of health services management through a PHC move- visits in this population (Table 4). Each stage of this change process is ment made up of workers from the primary level of care. Using these described below. structures, the PHC movement was able to achieve enhancements During the first stage, the Municipal PHC Department was cre - in the structure and organizational and health care practices of the ated with support from the provincial Ministry of Health and the primary level from the outset. The movement then gradually consoli- Pan American Health Organization/World Health Organization dated the primary level as a gateway and as the coordinator of the (PAHO/WHO). The Municipal PHC Department opened four new care process and enabled the principles and practices of the compre- health centres and developed different health promotion and pre- hensive PHC approach to permeate the other levels of the system. vention programmes, targeted mainly towards the maternal–child The collective action was led by a municipal movement of mostly population and infectious diseases. The political capacities of this made up of primary level professionals (practitioners and manag- Department were embedded in professional legitimations provided ers) who were embedded in service management structures, in part- by the primary level professionals who shared the reform principles nership with social movements. The reform achievements radically and benefitted from the reform and by the provincial Ministry of improved the structure and organization of the primary level of care Health and PAHO/WHO who supporting and strengthening the and introduced a PHC-based transformation into the entire health technical capacities provided. Additionally, the social movements system. During the reform, 29 new health centres were created, add- that advocated for improved health care access were well-channelled ing to the 49 centres that existed prior to the reform. This led to the and therefore provided both social legitimation for the reform and result of a relatively high ratio of health centres and physicians per physical spaces for expanding the structure of the primary level inhabitants without coverage (Tables 1 and 4). Approximately 75% of care. of these centres provided a wide range of services that were inte- During the second stage, the PHC Department strengthened the grated with hospitals and available during extended operating hours structure of the primary level of care with six new health centres (Table 4). With this development, the system achieved that 55.1% of and expanded the health programme beyond maternal–child health all children under age 11 had a regular source of care at the primary and infectious disease. The Department also promoted expanded level. This channelled 57.9% of the total number of visits and led health practices, improved technical quality and strengthened role to a rate of 4.4 visits per year in this population. Each stage of the for the primary level of care as both a regular provider of care and change process is described below. the coordinator of the population’s care processes. Within the col- During the first stage, the PHC Department was created. The lective action, there were disputes with the social movements who Department developed preventive programmes targeted at the Downloaded from https://academic.oup.com/fampra/article/33/3/207/1749908 by DeepDyve user on 13 July 2022 216 Family Practice, 2016, Vol. 33, No. 3 Table 4. Reform achievements in terms of changes in the structure and health care performance of the primary level of health care Changes in the structure of the primary level* Service performance of the primary level (2008) Number of primary % of primary health Primary health care centres’ office Access to primary health care Affiliation with the primary level Coordination of care health centres care centres with a hours per week (average) services** of care** services between multidisciplinary team health care levels* At start of each 2008 At start of each 2008 At start of each reform*** 2008 Annual average Annual average of % of children % of children % of health centres reform**** reform*** of medical visits medical visits to under age 11 that under age 11 managing patient among children a primary health have a regular that have a referrals to hospitals under age 11 care centre among source of care regular source and support services children under of care in a age 11 primary health care centre Cochabamba 6 28 0% 0% Reduced and unstable 35.3 3.8 1.7 20.2% 4.0% 0.0% Vicente López 7 20 0% 60.0% Reduced and unstable 46.9 7.9 3.9 65.1% 46.2% 30.0% Rosario 49 78 0% 73.8% Reduced and unstable 59.3 7.6 4.4 78.4% 55.1% 100% There are no available data prior to the change process for these variables. The composition of a team was considered to be multidisciplinary whenever the following elements were present, at a minimum: In Argentina: (i) a generalist or paediatrician, (ii) a clinician, a gynaecologist or ob-gyn, (iii) a nurse and (iv) a social worker or a psychologist. In Bolivia: (i) a GP, (ii) a dentist, (iii) a licensed nurse and (iv) an auxiliary nurse. A regular source of care is considered to be available whenever there is a source of care or physician that regularly provides medical care to. Source: Authors’ interpretation based on: *Organizational survey: Rosario, 2007; Vicente López and Cochabamba, 2008. **Household survey: Rosario, 2008; Vicente López and Cochabamba, 2008/2009. ***Interviews with PHC policymakers and managers. ****Start of each reform: Cochabamba 1993; Vicente López 1993; Rosario 1990. Downloaded from https://academic.oup.com/fampra/article/33/3/207/1749908 by DeepDyve user on 13 July 2022 Conditions to implement effective primary health care reforms in Latin America 217 maternal–child population and introduced management norms to confrontation with the physicians in the system. This dynamic regulate operating hours, medical records and the use of supplies impeded the strengthening of the technical and political capacities in health centres. At this stage, 25 new health centres were created. needed to exploit new institutional structures, guarantee effective The participation of professionals with experience in service man- implementation of the reform and provide continuity for the change agement provided technical capacity for the collective action. The process. Although the reform was able to strengthen the primary political capacities emanated from the social legitimacy provided level of care and introduce organizational changes and improve- through support from social movements that sought to improve the ments in service performance, it produced a dynamic of ‘interrupted’ population’s access to health care and from the professional legiti- change limited to the development of a selective PHC approach. macy based on a participatory management model of professionals In Vicente López, the new institutional structures favoured the gen- with strong personal leadership skills. During this stage, hospital eration of a new collective action based on the participation of profes- managers and professionals were indifferent to what was happening sionals, managers and technical personnel from the primary level of in the primary level. care. This collective action was able to produce new institutional struc- The second stage created PHC districts and participatory man- tures that expanded their technical capacities, but under a dynamic of agement structures and decentralized the coordination of health path-dependency (20). This dynamic reproduced the development of centres. Health teams and social movements were invited to par- organizational capacities and changes centred on the primary level of ticipate in these initiatives. Health centres were assigned responsibil- care but with limited influence on the rest of the health service system. ity for a geographically defined population and their practices were In Rosario, the new institutional structures led to the generation expanded (e.g. health centres were given responsibility for prenatal of a broad-based, collaborative, collective action that in turn pro- check-ups, which were previously provided at hospitals). Nine new duced these new institutional structures. These structures favoured health centres were created, new professional profiles were inte - the consolidation of greater technical and political capacities that grated into health centres and the range of services offered at the pri- allowed the collective action to conquer key management spaces mary level was expanded. This advance in service delivery that was within the health service system (21). This dialectic relationship formerly the exclusive competency of specialists led to a dispute with between actors and institutional structures favoured the system’s hospitals. The PHC movement created a postgraduate programme ability to overcome technical and political challenges at each stage, in general medicine, which strengthened the technical capacity and enabling the consolidation of a comprehensive PHC approach. professional legitimacy of the collective action. Lessons learned from the evidence indicate that reform processes The third stage created health districts that generated spaces for aimed at producing health systems based on a PHC comprehensive articulation between the PHC districts and hospitals. During the eco- approach require collective action with a dynamic composition that nomic crisis that dominated this stage, several health centres oper- includes actors from different institutional fields with capacities to ating within community organizations closed. The need to manage confront technical and political challenges during the different stages limited resources more efficiently favoured the regulation of access of the change process (22). The new institutional structures should to the second level of care, in turn strengthening the figure of the be conceived as technical mechanisms of regulation for implement- primary level as a gateway and as the coordinator of the popula- ing new approaches of PHC among the actors involved in the health tion’s care processes and blurring the dispute with hospitals. This service system. These structures also represent a platform that facili- role strengthened the social and professional legitimacy of the collec- tates the emergence and/or consolidation of partnerships that foster tive action, supported by a process of accumulation of professional, a growing influence on the health service system. academic and political prestige. Although this study produced significant information and find - During the fourth stage, the PHC movement—which was embed- ings based on a broad set of data collection techniques and a com- ded in the management structures of the second level of care— prehensive analysis approach, it has important limitations. First, an implemented a matrix-management model. This model established analysis of the effectiveness of the studied reforms was outside of the processes for collaboration between professionals in the primary and scope of this study. Second, we did not analyse how the socio-eco- second levels of care in a determined geographic area with the goal nomic differences between settings influenced the actors’ capacities. of strengthening the comprehensiveness and technical quality of the Third, our observation and analysis centred on the actors involved primary level (through the joint development and implementation and the processes that took place at the local level and within the of care guidelines), the continuity of the care process, coordination boundaries of the public subsystem. Little or no attention was given between providers and access to specialized practices. The collective to the potential influence of political and institutional processes action established collaborative relationships with hospital profes- at higher government levels or in other health subsystems. Future sionals and their technical and political capacities continued improv- research could shed light on these issues. ing. The number of health centres recovered with the construction of municipal health centres. Conclusion The reform processes introduced new institutional structures that Discussion permitted the agglutination of different stakeholders who were In this section, we interpret our findings and attempt to identify the potential beneficiaries of the reform as a common force, although enablers of the collective action capacities to produce (or not pro- not necessarily with the same objectives. These processes achieved an duce) the results envisioned in each case under study. In doing so, evolution from selective to more comprehensive PHC approaches, we consider the collective action capacities to be the result of the strengthening managerial capacities and expanding and improving dynamic of the structuring processes between the institutional struc- the performance of the primary level of care. However, these changes tures and the collection action. were of differing scope depending on the capacity of the different In Cochabamba, the new structures produced at the national collective actions, which represent both the product and catalyst of level resulted in weak collective action, with internal conflicts and change in the new institutional structures. Downloaded from https://academic.oup.com/fampra/article/33/3/207/1749908 by DeepDyve user on 13 July 2022 218 Family Practice, 2016, Vol. 33, No. 3 4. Macinko J, Starfield B, Erinosho T. The impact of primary healthcare on In each case, the interaction between the characteristics of the insti- population health in low- and middle-income countries. J Ambul Care tutional structures and the collective action produced different struc- Manage 2009; 32: 150–71. turing dynamics that served as either facilitating or limiting factors 5. Acosta Ramírez N, Pollard Ruiz J, Vega Romero R, Labonté R. Compre- in the development of the technical and political capacities that are hensive primary health care in South America: contexts, achievements and needed to develop a comprehensive PHC approach. In Cochabamba, policy implications. Cad Saúde Pública 2011; 27: 1875–90. there was an ‘interrupted’ structuring process that achieved the estab- 6. Báscolo E, Yavich N. Governance and the effectiveness of the Buenos Aires lishment of a primary level with a selective PHC approach. In Vicente public health insurance implementation process. J Ambul Care Manage López, there was a ‘path-dependency’ structuring process that permit- 2009; 32: 91–102. ted the consolidation of a ‘primary care’ approach, but with limited 7. Greenwood R, Raynard M, Kodeih F, Micelotta ER, Lounsbury M. Insti- influence in hospitals. In Rosario, there was a ‘dialectic’ structuring tutional complexity and organizational responses. 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Censo de particularly Gabriela Castiglia, Leonardo Caruana and Horacio Crespo from Población y Vivienda. 2001. http://www.ine.gob.bo/cgi-bin/Redatam/ Argentina and Jaime Titisano and Franklin Antezana from Bolivia. We thank RG4WebEngine.exe/PortalAction?&MODE=MAIN&BASE=TallCreac& the editors and reviewers whose comments lead to an improved version of MAIN=WebServerMain.inl (accessed on April 2010). the original manuscript. Finally, we thank the institutions and persons whose 15. Lawrence T. Power, institutions and organizations. In: Greenwood R, Oli- human and financial support made this publication possible; within them we ver C, Suddaby R, Sahlin-Andersson K (eds). The Sage of Handbook of are especially grateful to Jeannie Haggerty. Organizational Institutionalism. Los Angeles, London, New Delhi, Singa- pore, Washington, DC: Sage Publications, 2008, pp. 170–97. 16. Deephouse D, Suchman M. Legitimacy in organizational institutionalism. 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Journal

Family Practice – Oxford University Press

Published: Jun 1, 2016

Keywords: latin america; dialectics; health care reform; organizational innovation; politics; quality of care; child

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