TABLE 2.

Progress in 12 health systems on four WHO PHC reform dimensions

		Universal Coverage Reforms	Service Delivery Reforms	Public Policy Reforms	Leadership Reforms
Asia	Hong Kong	Little progress in reforming historical institutional arrangements. No government or social insurance funding.	Recognition that these are required; plans outlined, but limited action yet.	Various initiatives but not coordinated or linked with PHC.	No changes to traditional decision-making methods.
	Japan	Varied access to service and prevention services, with patient co-payments.	Little progress in changing the current system of service delivery.	Government interested in promoting PHC, but emphasis remains on hospital care.	No changes to traditional decision-making methods.
	Singapore	Attempts to increase access, but cost barriers and inequities remain.	Some changes to improve services for chronic disease and other patients.	Some initiatives implemented, but limited population coverage.	No changes to traditional decision-making methods.
	South Korea	Universal access to PHC with few barriers and little restriction other than co-payments.	Little progress in changing the current system of service delivery.	No initiatives implemented, but some discussions on reform began recently.	No changes to traditional decision-making methods.
	Taiwan	Universal access to PHC with few barriers and restrictions. Small co-payments.	Efforts but limited progress towards changing the service delivery system.	Since NHI, some initiatives but not coordinated or linked with PHC.	Some change in name but not substance.
Australasia	Australia	Universal PHC access is guaranteed through the Medicare scheme, with some co-payments.	Various funding reforms to improve collaboration among PHC providers and promote better chronic disease management. PHC remains separate from hospitals.	Expectations that PHC works collaboratively with other sectors, but restricted by funding complexity.	Divisions of General Practice promote PHC alongside government, but no common goals.
	New Zealand	Policy to reduce PHC charges, but these remain a barrier to genuine universal access.	PHOs created from 2003. PHC remains separate from hospitals; lack of patient coordinating capacity.	PHC gets funding for public health initiatives. Expected to coordinate with other sectors, but limited by funding.	Elected district health boards are expected to consult with stakeholders in planning.
Europe	Germany	Universal coverage introduced in 2009; 10€ co-payment introduced in 2004 set an incentive to visit the GP first, but constrains access for lower-income groups.	Besides pilot projects or rather weak incentives (to strengthen integrated care), no major service delivery reform has taken place. PHC remains separate from hospitals; lack of patient coordinating capacity.	Sickness funds can spend a very limited amount on public policy measures.	Doctors' associations and sickness funds are still the main stakeholders in the system.
	Netherlands	Every citizen has private health insurance; PHC is free of charge.	Collaborative groups offer 24-hour PHC services; these groups offer care for chronic patients, such as diabetes and COPD, but remain separate from hospitals.	Health insurers increasingly take initiatives to set up prevention programs, involving schools and PHC disciplines.	Doctors' association and government are main stakeholders, but do not as yet have common goals for PHC.
	UK	Universal access is provided by government funding. Co-payments for pharmaceuticals being abolished in Scotland, Wales and Northern Ireland.	PCOs created in 2002 but restructured in 2006. Major pay-for-performance incentive for GPs introduced in 2004. Moves to better integrate primary, community and secondary care services.	Focus of financial incentives has been secondary prevention. Better alignment of PHC with major public health priorities needed. PCO engagement with local governments on public health agenda variable.	PCOs developed to improve professional and patient engagement. Practice-based commissioning.
North America	Canada	Universal coverage is governed by the Canada Health Act. This limits coverage of non–hospitalbased care to physician services, representing a major hurdle for progress.	Key service delivery reforms reflect efforts to establish electronic health records and multidisciplinary teams. However, these are highly variable across the provincial health systems.	A number of national primary care policy initiatives have been established over the last decade. However, with provincial jurisdictional responsibility for healthcare systems, primary care reforms lack coordination.	Regionalized governance of health services is dominant in most provincial systems, although there are recent examples of shifts to more centralized governance in Alberta and Prince Edward Island.
	United States	Insurance and payment reforms expected to cut the uninsured rate by two-thirds, with improved access to PHC for lower-income families.	PCMHs and ACOs expected to increase under reforms and strengthen PHC delivery, but PHC mostly separate from hospitals.	Reforms emphasize preventive services in PHC, especially immunizations and screening for chronic illnesses.	Payment and service delivery reforms will aid PHC, but there is no coordinated leadership around PHC.