The strength of primary care in Europe

Abstract

This thesis aimed to get insight into the elements that form (the strength of) primary care (PC) in Europe, their determinants and their impact on health care system outcomes. The results strengthen the evidence-base for policymakers to prioritise PC strengthening on the health policy agenda and invest in improving the quality and completeness of PC information infrastructures, for funding agencies to invest in PC research, for researchers to further improve our understanding of the functioning of PC at macro, meso and micro level, and for PC professionals for the importance of their work for improving population health, reducing socio-economic inequality in self-assessed health and reducing avoidable hospitalizations. More specifically, we developed a Primary Care Monitoring Instrument measuring the strength of 9 key PC dimensions with in total 99 indicators. The strength of PC is determined by the degree in which its key dimensions are developed in a health care system. The structure of PC consists of: 1. governance; 2. economic conditions; and 3. workforce development. The PC process is determined by: 4. accessibility; 5. continuity of care; 6. coordination of care; and 7. comprehensiveness of care. The outcome of PC includes at least: 8. quality of PC; 9. efficiency of PC. By applying all indicators in 31 European countries it became clear that the theoretical notion of ‘PC strength’ cannot be captured by one (summary) measure or score. It is possible to summarize the strength of PC at structure level by one score for each country, but the strength of PC at process level can only by measured by analysing each of the 4 process dimensions separately. We have shown variation in PC strength across Europe, indicating a discrepancy in the responsibility given to PC in (inter)national policy initiatives and the needed investments in PC to solve e.g. future workforce shortages. To improve PC performance management there is a need for countries to improve their PC information infrastructure. We found that the national political agenda, economy, prevailing values, and type of health care system are all important factors that can both favour and hamper the development of strong PC. For example, countries that have been governed by a predominantly left-wing government over the past years have a stronger PC structure, accessibility and coordination of PC. Strengthening PC is in the end a political decision which can only be taken if it is in line with prevailing values in a country. In terms of outcomes, we showed that currently, countries with relatively strong PC have higher total health care expenditures than countries with relatively weak PC in Europe. In financially flourishing times, the total health care expenditures will increase despite strong PC. The results confirm that strong PC has a positive impact on population health, reducing disparity in health, and avoiding unnecessary hospitalizations in Europe. This thesis shows that in the beginning of the twenty-first century strong PC in Europe seems to be conducive to reaching important health care system goals.