The impact of primary care structure in care delivery and outcomes: an analysis using European country cases

Background: The rise in noncommunicable diseases (NCDs) and multimorbidity prompted a renewed interest in primary health care (PHC), as a multisectoral approach to improve population health. Within PHC, primary care (PC) plays the crucial role of delivering high-quality accessible care according to health needs. Efforts to develop PC have spawned a variety of organisational arrangements (e.g., structure and delivery mechanisms) in developed and developing countries. Aim: To identify the PC structure characteristics (e.g., financing, regulation), considering the role of actors involved (i.e., public, professional and private), that seem to improve care delivery, particularly providers’ use of resources and PC practice organisation, and outcomes, particularly equity and costs, in Europe. Methods: Firstly, a systems thinking approach was followed to develop a PC structure framework consisting of structure characteristics for which there was evidence on their impact in care delivery and outcomes using data obtained through a three-round Europe-based Delphi process. Secondly, the framework was applied to identify a PC structure taxonomy within the group of countries participating in the Delphi process. This involved the reduction of the framework dimensions with nonlinear canonical correlation analysis (NCCA) and using the obtained dimension as input to obtain the taxonomy through agglomerative hierarchical clustering (AHC). The third step was the comparison of the taxa on specific NCDs outputs and outcomes and policy context using Kruskal-Wallis, Mann-Whitney U and Pearson chi-square tests. Results: Panellists from 24 WHO European Region countries took part in the Delphi process. In the final framework, governance emerged as an overarching function whose impact in PC delivery is mediated through the degree of decentralisation (both delegation and devolution) of PC financing (e.g., facilities’ ownership or payments) and PC regulation (e.g., providers’ licensing or gatekeeping). The reduced dimension allowed the arrangement of the countries in ascending order of state involvement, integration and/or regulation of PC supply and demand. The identified taxonomy consisted of four clusters characterised by different degrees of decentralisation of governance, PC financing and PC regulation. The comparison of the taxa pointed out an increased PC orientation as well as an improvement in NCDs outputs and outcomes in clusters with higher public actor (or lower private actor) involvement and less fragmentation of the functions considered since these may have a positive effect in PC delivery, actors’ accountability and development of shared goals. Conclusion: The strengthening of PC is a priority and should be adapted to countries’ socio-political context. The involvement of public actor in, and lack of fragmentation of, PC financing and regulation seems to positively affect health systems’ PC orientation and NCDs outcomes. The findings of the study could inform future and ongoing PC systems reforms, although they should be interpreted cautiously and serve as a basis for further studies.Open Acces