A new study, led by DrPH student Natalia Houghton, with co-authors GLC Director Wolfgang Munar, Nino Paichadze, Ernesto Bascolo, and Michael Hariman, offers one of the most comprehensive syntheses to date of primary health care governance (PHC) evidence in Latin America and the Caribbean. After screening more than 9,600 papers, published over the past 25 years, only 66 papers directly examine PHC governance in the region. This limited body of work points to a research landscape that is both limited and uneven, particularly for such a large and diverse set of countries.
- Evidence is concentrated in Brazil. Of the 66 studies, 46 focused on Brazil, leaving the Caribbean and other LAC nations largely unexamined. This concentration limits what we can learn about governance across the region's diverse political and institutional contexts.
Most studies describe reforms without assessing effectiveness. Existing research documents laws, policies and organization structure but rarely evaluates whether these arrangements are effective, why some reforms persist or why others fail.
No studies examine PHC governance over time. The review found no longitudinal studies assessing how reforms evolve or become institutionalized, leaving a critical gap in our understanding of sustainability.
Informal norms, despite their influence on PHC governance, remain understudied. Actors, incentives, and political context — the factors that most directly shape how systems function — are seldom the focus of research. Informal power structures, organizational culture, and political competition are frequently visible in the background of studies but rarely examined directly.
These gaps matter. PHC governance challenges in the region are not simply technical — they are political and institutional. Formal mandates frequently collide with informal power structures, resource constraints, and shifting political priorities. So, understanding why reforms succeed or fail requires evidence that goes deeper than documenting what policies exist on paper.
Where does the field need to go next?
The authors call for a new generation of research that goes beyond documenting formal structures:Theory-driven research that examines power, incentives, and institutional dynamics
Comparative, multi-country studies to enable cross-national learning
Longitudinal research to understand how reforms evolve over time
Mixed methods that connect governance processes to PHC outcomes
This study maps what we know — and makes visible what we don't. Closing this gap is essential for how reforms are designed and sustained.
Funded by the Gill-Lebovic Center for Community Health in the Caribbean and Latin America, this study forms part of Natalia Houghton's doctoral dissertation at the Milken Institute School of Public Health at George Washington University. It is the first systematic scoping review of PHC governance evidence for the region, and it is central to the GLC's mission: building the kind of evidence needed to understand how primary health care reforms actually function — and how they can be sustained across diverse contexts in Latin America and the Caribbean. Research commissioners, international organizations advancing Universal Health Coverage, and the Primary Health Care Alliance can draw on this work to shape more targeted investments, policy dialogue, and technical support programs across the region.