Table 2.

Primary healthcare systems

Primary healthcare systems (1) Governance, (2) finance and (3) provision
NHS systems	Denmark	1. Participatory governance (multi-level), strongly decentralised and community-centred (municipalities), with public corporatism, and inclusion of different HCWs and major professional interest groups. The National Board of Health is responsible for physicians and nurses, while the Ministry of Children and Schools takes on the responsibility for social and healthcare assistants. Professional associations have the status of a trade union and negotiate salaries. There is strong transsectoral coordination because of the regional health agreements and the sub-regional networks that offer a framework for coordinating PHC across GP offices, municipalities and hospitals 2. Financed through national and local-level taxes and capitation is the main reimbursement model defined by framework contracts at regional level 3. Provision flows through a regional/municipal health system with UHC free at point of care. PHC includes: general practices (independent private businesses contracted by regions) and municipalities (local governments). GPs have a gate-keeping role. They offer: general medical diagnosis and treatment, and prevention services for all groups (including basic gynaecology/maternity care); however, dental care is excluded. Municipalities offer a broad range of services, including: health promotion, rehabilitation, school nursing and health visitor services, community-based mental health services, intermediate care, and elderly care services
	Portugal	1. Hierarchical governance with multi-level structures, co-existence of public and professional corporatism, partly decentralised. Decentralisation has been strengthened and new efforts are underway to reinforce governing capacities of municipalities, yet coherent transsectoral coordination is lacking. The state ensures financial governance and regulates the labour market, the salaries of HCWs as public servants, and graduate education, even in private universities. Physicians’ and Nurses’ Associations (Orden) are strong corporatist actors with self-governing powers. The state regulation of HCW salaries allows for some operational flexibility through combining different payment modes according to the type and need of the organisational setting 2. Financed via national taxes with different financing mechanisms according to the types of units providing PHC. Family Health Units: payment systems for staff varies according to the development model of the Family Health Units, with collective and individual incentives and customised health units; a combination of variable and performance-based remuneration can be used to motivate retention 3. Provision through the NHS with UHC and access free at point of care. PHC is provided by mainly multi-professional teams in Health Center Clusters each of them enrolling between 50,000 and 200,000 people; GPs have a strong gate-keeping role; HCWs are public sector employees. A new policy aims to merge Health Center Clusters and hospitals. PHC includes: medical diagnosis and treatment for all age groups (including maternal care and some basic dental care), health promotion/illness prevention, and some public health tasks
	UK/ England	1. Hierarchical governance with weak corporatism. The contract between NHS England (main regulatory body) and GPs forms the pillar of PHC, while the Clinical Commissioning Groups regulate the local level provision. Workforce governance is overseen by NHS England, while Health Education England is accountable for education, and NHS Employers and the Department of Health and Social Care take care of contractual regulations. Professional bodies (General Medical Council, Nursing and Midwifery Council) have self-regulatory professional rights, but are overseen by the NHS. Comprehensive coherent coordination mechanisms are missing 2. Financed via national taxes with small shares of private funding. GPs are reimbursed based on a capitation system with some entrepreneurial and pay-for-performance elements 3. Provision with UHC and access free at point of care, based on framework agreements and a strong gatekeeping role of GPs. Organisational settings and the substance of service provision vary significantly due to devolution politics. The NHS England establishes large Primary Care Networks, covering populations of around 50,000. GPs are mostly NHS employees, but new contracts open the door for private practice and entrepreneurship. PHC includes: general practice (including basic gynaecology and maternity care), community pharmacy and some basic dental and optometry services for all age groups. Primary Care Networks offer: preventative and health promotion services, vaccinations, prescriptions, and referrals to other specialised and social services
Established SHI systems	Germany	1. Participatory governance with strong corporatism, decentralisation, sectoral fragmentation, and organisational diversity. SHI Insurance Funds and SHI Physician Associations form the self-governing and self-administering bodies of the SHI system; they jointly negotiate contract frameworks, reimbursement schemes and budgets. Stronger marketisation and privatisation have opened the door for new forms of contract agreements, that weaken the governing powers of the key SHI stakeholders. Comprehensive coordination mechanisms are lacking. SHI Physician Associations have statutory rights, while other HCW groups are external policy players. Multi-level and transsectoral governance and coordination are weak 2. Financed through SHI-based mandatory insurance with some tax-funding and little out-of-pocket payments. Reimbursement is negotiated within the SHI joint self-regulatory bodies. SHI Insurance Funds and SHI Physicians agree on a joint budget for ambulatory care, which SHI Physician Associations subsequently allocate between PHC and specialist physicians. Reimbursement of PHC physicians is mainly based on fee-for-service with some mixed models and diversity 3. Provision through self-employed office-based physicians in single- or group practice based on UHC and free access at point of care with no mandatory gatekeeping. The dominant model of collective contracting between SHI funds and SHI Physicians is expanded towards selective contracting (between SHI funds and physicians) aiming to foster integrated care and organisational diversity, including large centres run by private business companies. Provision includes: general medical (family medicine) ambulatory diagnostic and treatment for all groups, some preventative services, some health promotion, GP home visits and coordination of care. Larger PHC Centres may provide a wider range of services. Dental care, eye care, gynaecology, and elder care/nursing are not part of PHC
	Netherlands	1. Participatory governance with national regulation, regulated competition and strong corporatism. The Dutch Health Care Authority is the main regulatory body of insurance companies and providers, controlling the coordination of services and financial arrangements of the workforce. Health insurances have legal responsibility to purchase high-quality care services. Efforts to strengthen community-centred governance and provision of PHC are underway but implementation is currently not clear. Some coordination mechanisms have been established. Corporatism is multi-professional including physicians, nurses, midwives, physiotherapists, pharmacists, and other HCW groups 2. Financed through mandatory SHI (private insurance with public regulation) with relevant market and out-of-pocket payment (for some services). Reimbursement of GPs is characterised by mixed models (fee-for-service, capitation, incentives) and diversity 3. Provision through self-employed office-based physicians with increasing organisational diversity, i.e. midwives play a dominant role in maternity care; single GP practices are replaced by group practices and PHC Centres including multi-professional provider models with midwives and physiotherapists are independent professional groups with direct patient access. Provision is based on UHC and mostly (some exceptions) free access and an increasingly strong gate-keeping role of GPs. Provision includes: ambulatory diagnostic and treatment for all groups, midwifery/maternity care, physiotherapy, (non-specialised) mental health care, some preventative services and health promotion, care at home/community-based care, and coordination of care. Larger PHC Centres may provide a wider range of services. Dental care, eye care, and elder care/nursing services are not part of PHC
	Switzerland	1. Participatory governance and strong corporatism, strongly decentralised with weak governance at the national level. Each of the 26 cantons is responsible for governing and securing healthcare provision for their populations, including financial issues, based on a joint regulatory framework. The accreditation of GPs is, however, regulated at the federal level. Key professional stakeholders include the Swiss Medical Association, Conference of Regional Health Directors, and cantonal/regional GP Associations with some (still weak) involvement of community authorities. Other important players are Health Maintenance Organisations (HMOs) that may set up direct contract agreements with providers and weaken existing governance frameworks. Coordination mechanisms are generally weak, except in the HMOs 2. Financed through mandatory SHI at Canton level. Highly diverse contract models with provider fee-for-service reimbursement schemes and a high share of out-of-pocket payments (approx. 66%) 3. Provision is strongly physician-centred and provided by GPs in self-employed single- and group practices supported by medical assistants. Provision is based on UHC with no mandatory gate-keeping, but HMO’s may establish integrated contracts with gatekeeping mechanisms. Provision includes: generalists ambulatory care diagnostic and treatment for all groups, vaccination and some preventative and health promotion services, home visits and coordination of care provided by other providers, and a few basic gynaecology services. Larger PHC Centres and HMOs may provide a wider range of services, making provision more diverse. Dental care and elder care/nursing services are not part of PHC
Emergent SHI systems in Central Eastern/ Eastern Europe	Kazakhstan	1. Hierarchical centralised governance with the Ministry of Health as key regulatory body, operationalised regionally through 17 Oblast Health Departments, including accountability for adequate staffing levels, education, and social support plans in rural areas. Operational governance is more diverse, including budget autonomy of most state-based organisations. Corporatism is very weak. Some transformations are underway (multi-professional and community approaches) and coordination has improved, but implementation is highly diverse and information is lacking. Corporatism is weak but increased. However, but key associations (Association of Family Physicians, Associations of Nurses, National Association on Primary Health Care, and Social Worker Alliance) are not part of the governing bodies 2. Financed via SHI with a mix of taxes (about 2/3) and high out-of-pocket/co-payments (about 1/3). PHC providers are salaried Oblast employees; self-employed providers/private business are marginal. Remuneration is mainly based on capitation, universal for the whole country, and some additional pay-for-performance to incentivise referrals to specialists 3. Provision is based on a large and diverse network of PHC facilities that strongly vary between rural and urban regions. A gatekeeping system co-exists with some payment models that incentivise specialised care. Organisational settings are highly diverse and dependent on geographical conditions; in urban areas PHC is provided in multi-speciality and specialised policlinics; in more rural areas by smaller teams, including physician assistants (Feldshers) and midwives as the smallest organisational unit in rural areas; remote areas may be supported by mobile solutions including equipped PHC buses and two trains. PHC comprises of a very wide range of services, including: medical diagnosis and treatment for all groups, some psychological and social support services, coordination with the communities. The share of services provided by specialised physicians is high in PHC
	Romania	1. Hierarchical centralised governance with some participatory governance with Insurance Funds and some corporatism. The Ministry of Health, through its General Directorate for Healthcare and the National Health Insurance House, is legally responsible for PHC, operationalised at the local level through district public health authorities and district health insurance houses. However, the framework contract for PHC provision is negotiated between the College of Physicians and the National Health Insurance House. The College of Physician and the Order of Generalist Nurses, Midwives, and Nurses are the main professional stakeholders, responsible for overseeing professional issues and collaborating with government authorities. Coordination mechanisms are generally weak 2. Financing is primarily based on a mandatory SHI system with some state and local budgets and relevant out-of-pocket payments. Remuneration is based on fee-for-service and per capita payments; salaries are market-based 3. Provision is based on a nationwide network of self-employed office-based GPs working in single- and group-practices with nurses and administrative staff and having a gatekeeping role. Provision is based on UHC and regulated through a Framework Contract between the National Health Insurance House and private office-based physicians, including a basic benefit package for the insured and a minimum package for the uninsured. Major services include: medical non-urgent diagnostic and treatment services for all groups, a broad range of preventive services and health promotion (including vaccination), some basic gynaecology services and maternity care, and coordination with community health workers or health mediators. Dental care is not part of PHC, but efforts have been increased to include preventive services
	Serbia	1. Hierarchical centralised governance with the Ministry of Health as the key regulatory body, based on a Network Plan of State Health Institutions that coordinates the different stakeholders and providers (PHC Centres, Institutes, pharmacies, etc.) with some corporatism, e.g. SHI Funds are responsible for negotiating salaries and remuneration. Professional corporatism is weak and limited to the associations of physicians, dentists, and pharmacists. A small private segment exists that is market-based and operates outside SHI governance and state control. Coordination is weak, however, this is more advanced in the PHC Network 2. Financing is based on a mandatory SHI system with a small portion being taxed-based and high out-of-pocket payments. Salaries and remuneration of medical PHC providers are negotiated annually with SHI funds, based on a mixed system of performance-based payment and capitation 3. PHC is mainly provided by a network of physicians in large state-owned Centres (mostly PHC Centres, some included in hospitals), some institutes, and several pharmacies. A PHC Centre can be established for at least 10,000 residents at the municipality/city level. Providers in the Network are mostly state employees; pharmacists may be self-employed; a small share of private PHC provision is fully office-based and no public data is available. Provision is based on UHC with limited financial protection/high co-payments and mandatory gatekeeping through GPs and some specialist physicians (occupational medicine, paediatrics, gynaecology, dentistry). Major services include: medical diagnosis and treatment for all groups of the population, prevention and health promotion services, prehospital emergency care, geriatrics/palliative care, dental care, pharmacy services, some maternity care, emergency in-patient care if a hospital is too far away, some transportation services, and epidemiology/public health services

Source: authors’ own table; references, see supplementary material 1