This article examines health sector reforms in Latin America and the Caribbean to discuss the ideological, theoretical, and conceptual elements that inform the reform agenda and the models put forward for attaining greater equity in the region’s countries. Its starting assumption is that the relevant literature generally neglects the economic, social, and political aspects underlying the processes of change, reinforcing the idea that these are purely technical processes and to be settled technically. It presents a brief review of political science literature on the issue of the State, its relative autonomy and its relationship to society, emphasising moments of crisis and reform. It analyses the contemporary health sector reform agenda, the leading role of international organisations – especially the World Bank – and some results of its implementation. It concludes that politics must be restored as essential to the reform process, given that the tendency is to discredit politics and spread the belief that important technical changes can be made to health system structures without contemplating the various contending projects and the resistance from actors opposed to change. It is therefore fundamental to think in depth about the role of the State and its ability to formulate and implement policies, and to analyse national options in the light of the constraints and proposals formulated/induced by outside forces, but also of national contexts, a perspective that has been largely overlooked in health sector studies.