Abstract
Background
Policy advocacy (PA) in European healthcare has a strong tradition promoting evidence-based policies. Key organisations, including the European Observatory on Health Systems and Policies, the WHO’s Evidence-Informed Policy Network, and the OECD play pivotal roles in integrating research into policymaking.
Objectives
To assess the involvement of European Family Medicine (FM) Associations in PA, identify key issues, and explore interactions with governmental and institutional bodies related to Primary Health Care (PHC)—defined as first-contact, continuous, comprehensive, and coordinated care provided by general practitioners/family doctors (GPs), in line with the WHO Alma-Ata and Astana declarations—and perceived challenges in PHC advocacy.
Methods
An exploratory descriptive, cross-sectional study was conducted among WONCA Europe Member Organisations and GPs involved in PA. Data collected between November 2023 and February 2024. Content analysis was performed to identify themes related to advocacy priorities.
Results
Responses were received from 12 member organisations across 12 countries and 37 participants from 17 countries. Key concerns included workforce shortages, high workloads, inadequate infrastructure, and insufficient financial compensation. Public visibility, gender equality, and the integration of FM into university curricula were also highlighted. Eleven respondents reported active engagement with national governments in policy discussions.
Conclusion
Respondents highlighted the need for a more unified strategy to address common PHC challenges across Europe. WONCA Europe’s Working Party on PA supports national efforts through exchange of best practices, research support, and promoting FM at national and European levels. Continued research and advocacy were viewed as essential for sustaining effective and equitable PHC in Europe.
Keywords: Policy advocacy, primary health care, family medicine, evidence-based policymaking, European healthcare systems
KEY MESSAGES
A coordinated strategy for policy advocacy across Europe is essential to align Family Medicine Organisations with European institutions.
Improving Primary Health Care infrastructure, particularly in technology and resource allocation, is essential for high-quality, patient-centered care.
Tackling gender inequality and reducing workloads in Family Medicine are key to achieving equitable and sustainable healthcare systems.
Introduction
Evidence-informed health policies in Europe
Policy Advocacy in Europe has a longstanding tradition of promoting evidence-informed policies, particularly concerning European health systems.
Established in 1998, the European Observatory on Health Systems and Policies provides Europe’s health policymakers with the evidence necessary to design and implement effective policies, bridging the gap between academia and practice [1].
In 2012, the World Health Organisation (WHO) European Region launched EVIPNet (Evidence-informed Policy Network), a worldwide WHO initiative promoting the integration of health research into policymaking. Operating globally, EVIPNet supports country-level teams of policy-makers, researchers, and civil society members to develop and implement evidence-based policies. The network enhances countries’ ability to create policy briefs and frameworks for effective policy decisions [2].
Since 1961, the Organisation for Economic Co-operation and Development (OECD) has influenced policies across 38 countries, promoting prosperity, equality, opportunity, and well-being. Collaborating with governments, policymakers, and citizens, it establishes evidence-based international standards and addresses social, health systems, economic, and environmental challenges [3].
When it comes to family doctors, the European Union of General Practitioners (UEMO), founded in 1967, also plays a crucial role. It represents European general practitioners advocating for high standards, professional development, and their critical role in Primary Health Care (PHC) [4].
PHC in this study refers to the foundation of the health system, encompassing accessible, continuous, person-centred, and coordinated care, as defined by the WHO (Alma-Ata and Astana Declarations) [5].
The current landscape of policy advocacy for PHC in Europe is dynamic, with increasing recognition of its pivotal role within the broader healthcare system [6]. However, the prominence and implementation of PHC advocacy vary significantly among European nations and at the national level. Diverse stakeholders are actively working to enhance PHC services’ effectiveness, accessibility, and quality [7]. This multifaceted approach includes efforts to strengthen PHC systems, ensure equity, and integrate PHC with other healthcare levels [8]. Figure 1 illustrates how several key trends and initiatives shape this landscape [6,8–13].
Figure 1.
Key trends and initiatives in Primary Health Care across Europe.
PHC: Primary Health Care.
WONCA Europe
WONCA Europe (WE), the regional branch of the World Organisation of Family Doctors, is the academic and scientific society for family medicine (FM) in Europe. It represents 47 member organisations (MOs) and over 90,000 family doctors across Europe [14,15].
Renowned for its collaboration with national Health Ministries and European Union (EU) institutions, WE works to improve health systems and PHC efficiency. Recognising the pivotal role of FM in PHC systems, their efforts focus on disease prevention, managing non-communicable diseases, and providing inclusive healthcare—particularly to refugees and migrants—. They also emphasise chronic illnesses care, mental health, and healthy ageing. By aligning with EU’s health policies WE aims to enhance healthcare quality and accessibility throughout Europe, highlighting PHC’S vital role in community health outcomes [14].
WONCA Europe working party on policy advocacy
On July 7, 2023, the WONCA Europe Executive Board and Council approved the creation of the WONCA Europe Working Party on Policy Advocacy (WEWPPA) with the aim to empower policy advocacy, strengthen collaborative ties, and influence European policymakers on PHC [16]. The WEWPPA seeks to promote collaboration among the EU, WHO, and PHC organisations to strengthen policy advocacy for FM across Europe. This initiative follows the EURODATA [17] and PRICOV [18] projects, funded by WE during the COVID-19 pandemic, which highlighted PHC’s critical role. Subsequent online webinars transformed research findings into actionable insights for policymakers, leading to the formation of WEWPPA to boost impact on European policy-making.
Objective
This paper aims to describe the current situation and challenges that Member Organisations (MOs) of Family Doctors and GP′s involved in WEWPPA activities encounter in advocating for PHC and FM policy across Europe. Additionally, it seeks to identify key advocacy topics in each country.
The study aimed to answer: (1) What are the key PHC advocacy challenges across European MOs? (2) How do MOs engage policymakers in PHC advocacy?
Methods
Study design
An exploratory descriptive, cross-sectional study was adopted to gather insights from WE MOs, WEWPA members, and GP′s interested in Policy Advocacy was implemented through an online survey. The study was exploratory in nature, aiming to identify trends and perspectives rather than draw country-level generalisations. The survey sought to understand their engagement in policy advocacy and interaction with governmental and institutional bodies regarding PHC in Europe.
The ad hoc online survey was developed and validated by the WEWPPA executive board to support the development of the Working Party’s action plan and to address challenges facing family doctors in European PHC systems, such as resource constraints and workforce shortages.
Validation
The survey instrument underwent face and content validation by the WEWPPA executive board and two external experts in health policy. Feedback from this process was used to refine question wording, structure, and clarity before dissemination.
Participants
Representatives from MOs, WEWPPA members, and interested GPs participated voluntarily. Respondents identified whether they answered in an individual or organisational capacity. Organisational respondents were typically board members or policy leads authorised to provide official perspectives.
In countries with multiple respondents (e.g. Spain, Belgium, Turkey), responses were compared, and common themes were synthesised through consensus review by two researchers to ensure consistency.
Data collection instrument
The survey assessed communication between national family doctor associations and governments or relevant institutions regarding healthcare recommendations. Additionally, it explored connections with Members of the European Parliament focused on healthcare issues. The survey sought examples of family doctors’ engagement in the media, social networks, patient associations, or community activities that highlight PHC’s role. Furthermore, it examined advocacy priorities, modes of public communication, and expectations from WEWPPA in supporting policy engagement.
The survey consisted of 20 questions: 15 closed-ended (multiple choice) and 5 open-ended questions addressing advocacy themes and examples.
Questions aimed to pinpoint critical policy advocacy issues in each country and gather suggestions for how the WEWPPA could support PHC promotion. Finally, respondents were encouraged to provide additional comments or suggestions (Annex I. Supplementary material).
Procedure
The survey was electronically distributed to WE MOs representatives and 70 readers of the WEWPPA newsletter, with an invitation to participate. Two reminder emails were sent at two-week intervals to maximise response rates. Confidentiality was ensured, and respondents were asked to complete the survey within a specified timeframe.
Data collection occurred from November 2023 to February 2024, with content analysis completed by March 2024. Two researchers from the core team reviewed the data for quality before performing descriptive analysis.
Positionality statement
The authors are active participants in WONCA Europe’s policy advocacy activities. This insider perspective provided access to relevant networks and contextual understanding; however, efforts were made to ensure objectivity through independent review of data and transparent reporting.
Results
We received contributions from 12 MOs representing 12 out of 47 WE MOs (Table 1), along with responses from 37 individual GPs across 17 countries. Of the 12 MOs that completed the survey, 10 were from the European Union.
Table 1.
Origin of the participants and member organizations.
| Country | Total number of participants | Member organisations |
|---|---|---|
| Austria | 1 | Austrian Association of Family Medicine |
| Belgium | 2 | Domus Medica |
| Bulgaria | 2 | BGPSREa |
| Croatia | 1 | |
| Czech republic | 1 | |
| Denmark | 1 | Dansk Selskab for Almen Medicin |
| France | 1 | Collège de la Médecine Générale |
| Germany | 3 | German College of General Practitioners and Family Medicine Physicians (DEGAM) |
| Greece | 3 | |
| Ireland | 3 | Irish College of General Practitioners |
| Italy | 2 | |
| Kazakhstan | 1 | Kazakhstan Association of Family Physicians |
| Norway | 1 | |
| Portugal | 2 | |
| Romania | 1 | |
| Serbia | 1 | Serbian Medical Association, Section of General Practice |
| Slovakia | 2 | Slovak Society of General Practice |
| Slovenia | 1 | Slovenian Family Medicine Society |
| Spain | 5 | semFYCa |
| Sweden | 1 | |
| Switzerland | 1 | |
| Turkey | 2 | TAHUDa |
| Ukraine | 1 |
aNote: BGPSRE: Bulgarian General Practice Society for Research and Education, semFYC: Spanish Society of Family and Community Medicine, TAHUD: Turkish Association of Family Physicians.
Given the exploratory design and limited respondents per country, the findings are represented as collective perceptions expressed by participants rather than as definitive national positions.
Advocacy priorities in global family medicine
Respondents from several nations, including Ireland, Portugal, Serbia, Spain, and Turkey, emphasised the need for improved population access to FM, focusing on preventive services and mental health. Participants from Bulgaria, Croatia, Greece, Italy, Norway, Spain, and Turkey indicated that workload and patient list management were important concerns in their settings. Respondents from Germany and Norway stated that reducing health care bureaucracy was a key advocacy issue. These identfied advocacy priorities areas for FM are summarised in Table 2.
Table 2.
Key advocacy topics are outlined according to each country participant.
| Better access to family medicine including preventive services and mental health | Ireland, Portugal, Serbia, Spain, Turkey |
| Workload/patients list | Bulgaria, Croatia, Greece, Italy, Norway, Spain, Turkey |
| Reducing bureaucracy | Germany, Norway |
| Improving the infrastructure (including IT systems) | Bulgaria, Greece, Germany, Romania, Slovakia, Spain |
| Finance systems/ family doctors’ salary | Austria, Bulgaria, Greece, Spain, Switzerland, Turkey |
| Lack of family doctors | Croatia, Greece, Italy, Romania, Spain, Sweden, Switzerland, Turkey |
| Gender inequality in family medicine | Czech Republic |
| Presence of family medicine in university | Greece, Spain |
| Strengthening the positive image of family medicine | Germany, Spain |
IT: information technology.
Infrastructure enhancement, particularly information technology, was described as a critical need in Bulgaria, Greece, Germany, Romania, Slovakia, and Spain. Financial issues, such as doctor salaries, were raised as under scrutiny in Austria, Bulgaria, Greece, Spain, Switzerland, and Turkey. A notable shortage of family doctors was identified in Croatia, Greece, Italy, Romania, Spain, Sweden, Switzerland, and Turkey.
Gender inequality in FM was raised as a concern in the Czech Republic. Advocacy efforts in Greece and Spain were described as aiming to integrate and enhance FM recognition in University curricula. Finally, Germany and Spain were described as working to bolster the positive social perception of FM.
Active engagement of MOs in healthcare policy
Eleven MOs reported actively engaging with their national governments, assuming significant roles in policy discussions. This involvement was described as ranging from participating in stakeholder meetings in Austria to maintaining regular interactions with Health Ministries in Bulgaria, Czech Republic, Ireland, Kazakhstan, Portugal, Slovakia, Spain, and Turkey. Specific Members of the European Parliament, with a strong focus on healthcare, were identified by respondents in Greece, Romania, and Spain, suggesting perceived links between healthcare advocacy and legislative awareness.
Discussions between MOs and policymakers were described as addressing critical topics including family doctor′s training and accreditation, labour conditions, professional status, and direct involvement in policymaking. MOs were described as actively participating in governmental working groups and as contributing to amendments to healthcare laws.
Enhancing public visibility for PHC: Strategies and initiatives
Public visibility and advocacy efforts were described through diverse channels. Ireland, Slovakia, and Spain were said to have launched public campaigns for Family Doctor′s Day, whereas the Czech Republic and Slovakia were described as using press releases, with the former engaging a Public Relations agency for media representation. Germany, Romania, Slovakia, and Spain were described as engaging with mass media, with Austria, Germany, Greece, Kazakhstan, and Turkey were said to use social media for outreach. Furthermore, Turkey was cited as an example of effective advocacy by deploying mobile clinics during an earthquake, highlighting family doctors’ proactive role in public health crises. In terms of communication strategy, MOs anticipate that crafting impactful press releases, curating relevant social media content, and developing joint statements with global institutions such as the WHO, EU, and OECD will significantly enhance the impact of PHC.
WEWPPA’s role in strengthening PHC
MOs expressed expectations that WEWPPA would support national efforts to enhance PHC by highlighting its importance in healthcare systems and advocating for adequate time and resources for family doctors. They also sought help with research, including data on PHC access, its impact on morbidity and healthcare costs, and work conditions.
WEWPPA was viewed by respondents as a platform to facilitate the exchange of successful advocacy strategies and best practices (Table 3) and offer training in leadership, diplomacy, and negotiation. Support was also described as being needed to bring GP challenges to the forefront of the political arena, fostering robust relationships with key policymakers to champion PHC, and enhancing community engagement to ensure that PHC continues to be a central focus in discussions about healthcare.
Table 3.
Expectations from WONCA Europe policy advocacy working party.
| Support in National Efforts to underscoring PHC Role. | MOs expect support in highlighting the critical role of PHC within national healthcare systems and advocating for adequate resources and time for family doctors. |
| Research Support. | Providing data and insights on access to PHC, its impact on morbidity and healthcare costs, and labour conditions within the sector is crucial for informed advocacy. |
| Exchange of Best Practices. | WONCA Europe is expected to facilitate the exchange of successful advocacy strategies and best practices among member countries. |
| Training Programs for skills enhancement. | Training programs in leadership, diplomacy, and negotiation are sought to enhance the advocacy capabilities of MOs. |
| Political Engagement for PHC Political Advocacy. | Support is expected in bringing GP challenges to the forefront of the political arena, fostering relationships with key politicians, and ensuring PHC remains a significant part of health policy discussions. |
GP: general practitioner; MO: member organisation; PHC: primary health care.
Discussion
The results of the survey provided insights that can inform to structure the action plan of the Working Party and shed light on the challenges that were described by respondents in PHC systems in European countries. Although the response rate from MOs was low, the survey captured input primarily from MOs within the EU. Eleven MOs reported engagement with their national governments. Key advocacy topics identified by respondents included the shortage of family doctors (highlighted by 8 countries) and high workload (noted by 7 countries). Additionally, 6 countries emphasised the need for improved infrastructure and changes to financial systems. The visibility of FM was described as varying significantly across the continent. The WEWPPA was viewed by respondents as a potential support strategies for more effective policy advocacy.
Recent technical reports from WHO Europe Primary Care Office have underscored a pressing need to expand FM beyond its traditional roles, suggesting that preventive care and expanding telemedicine, community outreach programs, and integration of mental health services within primary care could enhance accessibility. This shift reflects the importance of comprehensive healthcare that addresses both physical and mental well-being [19]. However, family doctors were described by respondents and the literature as facing significant challenges, such as heavy workloads and extensive patient lists. To alleviate these burdens ensuring high-quality care, potential solutions have been proposed, including improving staffing levels, redistributing tasks among healthcare teams, and enhancing support systems for practitioners [10]. Streamlining administrative processes within healthcare systems with the support of IT has been described as important to enhance efficiency and reduce bureaucratic obstacles that hinder patient care [20]. Additionally, fostering teamwork and advancing competencies through specialised training programs for PHC staff have been identified as essential initiatives [21]. The healthcare infrastructure, especially information technology systems, has also been described as requiring substantial improvement and funding to support effective patient care and efficient data management and interoperability among healthcare levels to have access to patients’ healthcare information along their journey in the health system [13].
Compensation models for family doctors have been shown to vary widely, impacting job satisfaction, recruitment, and retention. Value-based payment models, which reward quality over quantity and coordinated care, have been proposed as key to enanbling family doctors to provide high-quality care without financial strain [17]. Addressing the shortage of family physicians has been described as requiring better recruitment strategies, comprehensive training programs, and effective retention policies [22]. WE issued a statement regarding the shortage of the European primary care workforce, which was presented during the 73rd Session of the WHO Regional Committee for Europe with the support of eight institutions [23]. However, this statement has not yet been followed by EU-level legislation to promote real solutions, despite clear evidence of the necessary steps to improve working conditions for family doctors [10]. It is also crucial to address the situation in rural areas and manage the workload of the rural health workforce to prevent health inequities. One crucial aspect highlighted in the literature is rethinking the funding of primary care to ensure patient-centered care [12,24]. Funding has been described as requiring a genuine and sustained political commitment, not just during crises but over the long term [25].
Gender disparities within FM were also reflected in respondents’ accounts and the literature. Gender inequality in FM has been described as manifesting in disparities in pay, leadership opportunities, and work-life balance. Addressing these issues has been proposed as requiring targeted policies, mentorship programs, and promoting flexible working arrangements, particularly due to feminisation of FM in Europe [26].
Furthermore, integrating FM more prominently into medical school curricula has been suggested as a way to inspire more students to pursue this specialty. Exposure to FM early in training has been associated with a greater appreciation of its broad scope and impact. Educational research has suggested that curricula emphasising primary care and community health increase interest in FM [27]. In general, improving public perception of FM has been identified as vital for its continued growth and recognition as a cornerstone of healthcare provision [28].
Strengths and limitations
The first WONCA Europe survey on policy advocacy identified common advocacy topics across various countries, suggesting the potential for collaborative efforts to strengthen national policies and promote European-level engagement for comprehensive PHC. The survey identified the needs and expectations of MOs and family doctors in healthcare policy.
However, the survey had a relatively low response rate and unequal numbers of respondents per country, which may limit the representativeness of findings.
In addition, the absence of external data triangulation limited the ability to validate responses. Moreover, no external verification through grey literature, policy documents, or secondary data sources was undertaken, which restricted the possibility of cross-checking the accuracy of the information provided. Future studies should consider incorporating multiple informants and document review to increase validity.
Expanding the survey to include more countries, younger GPs, rural areas, and other primary care professionals would be important. Complementary qualitative research could provide deeper contextual insights and enhance data reliability.
To improve participation and coordination, the WEWPPA could consider appointing a reference person in each country to maintain consistent advocacy across the EU, leveraging the success of similar approaches in other networks.
Implications for practice and research
MOs were described as working in collaboration with national governments on health and FM policies. However, there was perceived to be no efficient system within WE for sharing good practices, although efforts such as the WE statements and statements from its networks were viewed as helping to clarify the message at the European level.
Recently, the WHO Europe launched a new innovative product, WHO Primary Health Care Demonstration Platform [29]. The experience was described as consisting four- to five-day visits connecting national and regional policy-makers and practitioners from the host and visiting countries. The WEWPPA may contribute to this role for sharing good practices among MOs and intends to include this role on its action plan.
Additionally, respondents suggested that to involve future family doctors it is necessary to include policy advocacy in the curriculum of FM residency programs so that they understand how political decisions are made within national health systems and insurance companies.
MOs within the EU were described as being committed to policy advocacy, but respondents expressed the need for a more unified European strategy to enhance policy advocacy at the European level with shared values and priorities, to ensure that all MOs are represented in WE’s interactions with other European institutions and stakeholders [30]. Ensuring patient-centered primary care, with particular attention to longitudinal and comprehensive care, was described as still requiring significant efforts to provide high-quality care across the continent [12]. This collaboration addresses critical PHC challenges and aims to raise the standard of healthcare for EU citizens.
The implementation of an action plan and its assessment will lead to further research to identify future needs in policy advocacy for FM and to map resources across Europe. This will help strengthen relationships among key stakeholders and principal actors in the healthcare system, facilitating the dissemination of a unified message that can drive meaningful changes in practice and promote patient-centered care in PHC.
Conclusion
This exploratory study highlighted, through respondents’ accounts, the diverse and critical advocacy priorities for FM throughout Europe. Expanding access, tackling workload and administrative hurdles, enhancing infrastructure, ensuring equitable compensation, addressing gender disparities and integrating FM more prominently into medical school curricula were identified as key concerns. The findings underscore the need for continued collaboration and data-driven advocacy rather than drawing definitive conclusions about country-level situations. We was described as playing a pivotal role in supporting these endeavours by conducting research, facilitating the exchange of best practices, providing training, and engaging in political advocacy to bolster PHC systems across the continent.
Supplementary Material
Acknowledgements
We wish to sincerely thank all the MOs who answered the survey and WE for their support, resources, and encouragement that made this work possible. We also deeply appreciate our colleagues for responding to the questionnaires and for their invaluable input, feedback, and steadfast support throughout the research project. Their involvement has been crucial in gaining a thorough understanding of the context and drawing meaningful conclusions.
Funding Statement
ALN is supported by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration Northwest London (NWL) and NIHR NWL Patient Safety Research Collaboration, with infrastructure support from NIHR Imperial Biomedical Research Centre. The views expressed in this publication are those of the author(s) and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care. This study was supported by WONCA Europe.
Authors’ contributions
MPAP, RGB, MGC, NM, and SAB developed the research idea. SAB and RGB carried out the body of the analysis with support of RGB, MGC, and SAB. MPAP, RGB, MGC, NM, SLH, and SAB wrote the manuscript. All other authors contributed to the research idea, collection of data, discussion, and comments on the manuscript.
Ethical approval
Ethical approval was not required for this study because the participants contributed as key informants, providing publicly accessible or professional information about their country rather than personal or sensitive data. Their participation involved sharing insights, expertise, and factual knowledge relevant to the research topic, ensuring that no private, identifiable, or ethically sensitive information was collected. This approach aligns with research guidelines that exempt such data collection from formal ethical review processes.
Participants were informed about the purpose of the research and agreed to participate voluntarily. Their involvement was part of their commitment to the Working Party on Policy Advocacy of WONCA Europe. As key informants, they provided insights and professional information relevant to the study, reflecting their expertise and dedication to advancing primary care policy and advocacy across Europe.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Data availability statement
All data generated or analysed during this study are included in this published article/Supplementary material. Data will be available upon request to the corresponding author.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
All data generated or analysed during this study are included in this published article/Supplementary material. Data will be available upon request to the corresponding author.