BACKGROUND Enhancing primary health care (PHC) is considered a policy priority for health systems strengthening due to PHC's ability to provide accessible and continuous care and manage multimorbidity. Research in PHC often focuses on the effects of specific interventions (e.g. physicians' contracts) in health care outcomes. This informs narrowly designed policies that disregard the interactions between the health functions (e.g. financing and regulation) and actors involved (i.e. public, professional, private), and their impact in care delivery and outcomes. The purpose of this study is to analyse the interactions between PHC functions and their impact in PHC delivery, particularly in providers' behaviour and practice organisation. METHODS Following a systems thinking approach with data obtained through a three-round European Delphi process, we developed a framework that captures (1) the interactions between PHC functions by analysing correlations between PHC characteristics of participating countries, (2) how actors involved shaped these interactions by identifying the actor and level of devolution (or fragmentation) in the analysis, and (3) their potential effect on care delivery by exploring panellists' opinions. RESULTS A total of 59 panellists from 24 countries participated in the first round and 76% of the initial panellists (22 countries) completed the last round. Findings show correlations between governance, financing and regulation based on their degree of decentralisation. This is supported by panellists, who agreed that the actors involved in health system governance determine the type of PHC financing (e.g. ownership or payment mechanisms) and regulation (e.g. competences or gatekeeping), and this may impact care delivery and outcomes. Governance in our framework is an overarching function whose impact in PHC delivery is mediated through the degree of decentralisation (both delegation and devolution) of PHC financing and regulation. CONCLUSIONS The application of this approach in policy implementation assessment intends to uncover limitations due to poor accountability and commitment to shared objectives. Its application in the design of health strategies helps foresee (and prevent) undesired or unexpected effects of narrow interventions. This approach will assist in the development of the realistic and long-term policies required for health systems strengthening.

中文翻译：

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治理对初级卫生保健提供的影响：欧洲专家小组的系统思考方法。

背景技术由于初级保健（PHC）具有提供无障碍和连续护理以及管理多种疾病的能力，因此被认为是加强卫生系统的政策重点。PHC的研究通常集中在特定干预措施（例如医生合同）对医疗保健结果的影响上。这为设计狭窄的政策提供了依据，这些政策忽视了卫生职能（例如筹资和监管）与相关参与者（即公共，专业，私人）之间的相互作用，以及它们对医疗服务和结果的影响。这项研究的目的是分析PHC功能之间的相互作用及其对PHC交付的影响，尤其是在提供者的行为和实践组织中。方法采用系统思维方法，通过欧洲三轮Delphi流程获得的数据，我们开发了一个框架，该框架捕获（1）PHC功能之间的相互作用，方法是分析参与国的PHC特征之间的相关性，（2）参与者如何塑造这些国家通过在分析中确定行动者和权力下放（或分裂）的程度来进行互动，以及（3）通过探讨小组成员的意见来评估其对护理提供的潜在影响。结果第一轮共有来自24个国家的59名小组成员参加，最后一轮（22个国家）的76％的小组成员完成了最后一轮。调查结果显示，基于权力下放的程度，治理，融资和监管之间具有相关性。小组成员对此表示支持，谁同意参与卫生系统治理的行为者确定PHC融资的类型（例如所有权或支付机制）和法规（例如能力或看门人），这可能会影响医疗服务和结果。我们框架中的治理是一项总体职能，其对PHC交付的影响是通过PHC融资和监管的权力下放程度（委托和下放）来调节的。结论在政策执行评估中采用这种方法的目的是发现由于责任心薄和对共同目标的承诺而导致的局限性。它在健康策略设计中的应用有助于预见（并预防）狭窄干预措施的不良后果。