The role of the state in financing and regulating primary care in Europe: a taxonomy

• Published in: Health policy (Amsterdam) 2021-02, Vol.125 (2), p.168-176
• Main Authors: Espinosa-González, Ana Belén, Delaney, Brendan C., Marti, Joachim, Darzi, Ara
• Format: Article
• Language: English
• Subjects: actors; Centralization; Classification; Clinical outcomes; Clustering; decentralisation; Decentralization; Europe; Financing; Gatekeeping; Governance; Health; Health administration; Health status; health systems; Primary care; Public finance; Regulation; Segmentation; State role; Taxonomy; Typology
• ISSN: 0168-8510; 1872-6054
• DOI: 10.1016/j.healthpol.2020.11.008

[Display omitted] •24 WHO European Region countries primary care systems have been analysed under common criteria•Assessing the type of actor (state, societal, private) involved in and level of fragmentation of health functions is equivalent to quantifying their degree of decentralisation•We found four clusters with different degrees of decentralisation of health system governance and primary care financing and regulation•Clusters with less private involvement in and/or less fragmentation of PC financing and regulation had gatekeeping implemented Traditional health systems typologies were based on health system financing type, such as the well-known OECD typology. However, the number of dimensions captured in classifications increased to reflect health systems complexity. This study aims to develop a taxonomy of primary care (PC) systems based on the actors involved (state, societal and private) and mechanisms used in governance, financing and regulation, which conceptually represents the degree of decentralisation of functions. We use nonlinear canonical correlations analysis and agglomerative hierarchical clustering on data obtained from the European Observatory on Health Systems and Policy and informants from 24 WHO European Region countries. We obtain four clusters: 1) Bosnia Herzegovina, Czech Republic, Germany, Slovakia and Switzerland: corporatist and/or fragmented PC system, with state involvement in PC supply regulation, without gatekeeping; 2) Greece, Ireland, Israel, Malta, Sweden, and Ukraine: public and (re)centralised PC financing and regulation with private involvement, without gatekeeping; 3) Finland, Norway, Spain and United Kingdom: public financing and devolved regulation and organisation of PC, with gatekeeping; and 4) Bulgaria, Croatia, France, North Macedonia, Poland, Romania, Serbia, Slovenia and Turkey: public and deconcentrated with professional involvement in supply regulation, and gatekeeping. This taxonomy can serve as a framework for performance comparisons and a means to analyse the effect that different actors and levels of devolution or fragmentation of PC delivery may have in health outcomes.