Title : Understanding reform capability evolution in universal health coverage: A multiple streams analysis of Portuguese primary care (1974- 2024)
Abstract:
Understanding Reform Capability Evolution in Universal Health Coverage: A Multiple Streams Analysis of Portuguese Primary Care (1974-2024). Despite growing research on Universal Health Coverage (UHC) implementation, less attention has been paid to how high-income countries develop and maintain reform capabilities essential for UHC sustainability. This study addresses this gap by analyzing Portugal's five-decade journey in primary care reform through Kingdon's Multiple Streams Framework, introducing a novel theoretical model for understanding reform capability evolution. Through comprehensive analysis of policy documents, health system performance data, and recent OECD indicators, we examine how Portugal's capacity for implementing effective reforms has evolved from basic post-revolution changes to sophisticated system transformation. Our findings reveal distinct patterns of reform capability maturation, from simple policy window utilization to complex stakeholder engagement and evidence-based implementation. Regions with mature reform capabilities demonstrate significantly better outcomes, achieving 30% lower rates of avoidable hospitalizations and 20% better chronic disease management despite lower per capita spending than EU averages. Based on these findings, we propose the Reform Capability Maturation Framework (RCMF), which identifies three levels of capability development - basic, intermediate, and advanced - each characterized by distinct patterns of stream interaction and implementation sophistication. The framework demonstrates how reform capabilities evolve from simple international model adaptation to sophisticated domestic innovation, providing new insights into UHC sustainability in high-income countries. This study makes several significant contributions: it extends Multiple Streams Theory to explain reform capability evolution, provides empirical evidence linking capability maturation to health system performance, and offers practical insights for policymakers maintaining universal coverage under demographic and economic pressures. The findings are particularly relevant as healthcare systems globally face increasing pressure to maintain universal access while adapting to aging populations and resource constraints.
