| This study examines a major health system reform initiated in Panama during the 1970s, the integration of health services provided by the country's Social Security Fund (CSS) and Health Ministry (MS). Secondarily, the study also analyzes the adoption of a primary health care (PHC) approach to health care delivery within the "integrated" service system. The analysis focuses on three "integrated" regions.;Integration sought to extend coverage, reduce stratified access, and increase efficiency of CSS and MS health services. PHC was seen as a means of extending preventive and basic curative services to underserved rural areas. Assessing Integration and PHC's performance in meeting these goals is a major objective of this study. To explain performance and the "how" and "why" of implementation, the investigation centers on the changing politico-administrative, economic, and professional-medical context. The study interlaces the macro-level context with regional and micro-level operations and decision making. Two distinct time periods are identified. Favorable conditions during the 1970s fostered a generally successful implementation phase. The strong political support provided by country's military "strongman," Omar Torrijos, was key to the Integration's implementation and early success. However, by the 1980s, economic crisis, political polarization, and institutional conflict threatened progress toward greater coverage and access. By the mid-1980s, the future of integrated service delivery was in jeopardy. Moreover, although successful in extending coverage and reducing stratified access, the "integrated" regions fell short of the mark in terms of institutionalizing the PHC strategy and increasing efficiency. Here, professional-medical concerns were found to influence performance.;The study also tests a decision-making model for the analysis of policy implementation in public bureaucracies. The model examines the effect of policy content and context variables on decision making by regional officials. Two decision-making configurations emerge: a clientelist network of "personal contacts" that responded to the stable conditions of the 1979s, and (2) an anarchic and dispersed configuration in the 1980s that responded to political strife and economic crisis during that period. |
