Uncertain Faith: Pathways of primary care reforms in mature welfare States.

Primary care (PC) systems are considered critical elements in the performance of health systems. Health systems of mature welfare States have been characterized as being, for the most part, hospital-centric, medico-centric, and focused on curative rather t
han preventive care. These systems face growing challenges related to demographic and epidemiologic evolutions, including social exclusion, precarity, and marginalization of segments of the population. In this context, universal access to basic health services and social care appears to be a priority. Reforms are conceived as temporal trajectories characterized by dynamic processes with uncertain outcomes despite, in some cases,
clarity of initial purpose.  Based on a comparative policy analysis, this article compares PC reforms in three jurisdictions: France, Quebec and Wallonia. The laboratory of these reforms offers a privileged window of opportunity to look at different pathways
of reforms and factors that shape their destiny. Drawing on diverse reform trajectories, the paper examines the interplay between predominant logics and the institutional legacy of health care systems, and how this shapes the ambition and content of primary care reforms. More precisely, the nature of policy context and ideas, the configuration of interests, the mix of policy instruments and actors that gravitate within and around
PC reforms are considered drivers of changes. The study of the case of PC reform within
each jurisdiction is based on scholarly and grey literature relating to these reforms and on
research projects that we have conducted or currently conducting. Periods of observation considered for this comparative analysis consist of cycles of PC reforms between 1990 and 2026. Analysis consists in the development of socio-historical narrative of PC reforms in each jurisdiction and cross-case comparison to identify constellations of ideas and interests, levers and actors and their impact and relative weight on transformative capacities and policy trajectories. This study reveals the crucial role of micro discontinuities in the production of changes within a predominant incrementalist mode associated with PC reforms.