Governments Still Lack the Policy Blueprint for Integrated Primary Care

Health systems around the world keep promising more integrated primary care, yet the governance arrangements needed to deliver it remain poorly understood and inconsistently applied. That is the central conclusion of a systematized narrative review published in Discover Health Systems, which synthesized 34 empirical studies examining how governments design and formulate policies to support system-level integration in primary care.

The research team set out to fill a conspicuous gap. Within the Rainbow Model of Integrated Care, a widely recognized framework for primary care, system integration is defined as a coherent set of formal and informal political arrangements that enable professionals and organizations to deliver a comprehensive continuum of care. According to the review, this macro level of integration is both conceptually underdeveloped and empirically underexplored compared with clinical, professional and organizational integration. The creators of the model themselves acknowledged, as a limitation of their original Delphi study, the absence of policymakers’ and patient partners’ perspectives.

To analyze the evidence, the authors combined two complementary lenses. The Rainbow Model supplied the descriptive architecture, identifying eight domains of integration across micro, meso and macro levels plus two bridging enablers, normative and functional integration. Because the model offers limited guidance on how policy arrangements can be systematically examined, the team added Knoepfel’s policy analysis framework, focusing specifically on the policy formulation stage. This choice was deliberate: unlike evaluations of policy outcomes, which may require many years before reforms mature, analyzing formulation allows assessment of policy coherence and identification of design strengths and weaknesses that may facilitate or hinder later implementation.

The search initially identified 1,205 records, including 434 duplicates. After screening 771 records by title and abstract and assessing 124 full-text articles, the reviewers included 34 studies. More than half were published between 2020 and 2024, and the most represented countries were Canada with 12 studies, the United Kingdom with 7 and Australia with 4. Common designs included policy analyses, descriptive policy reports, case studies and qualitative studies. Notably, fewer than half of the studies, 13 in total, used a conceptual or theoretical framework, and only two explicitly combined health system integration perspectives with political analysis.

Conceptual ambiguity emerged as a persistent theme. Fewer than one-quarter of the articles, eight, provided an explicit definition of integration, most referring to the World Health Organization’s definition. The review identified more than 175 overlapping definitions of integrated care in the broader literature. Across the included studies, macro-level initiatives primarily sought to connect, align or coordinate multiple system components, whether linking health and social services across levels, fostering collaboration among local providers in defined geographic areas, supporting interprofessional teams, coordinating primary, secondary and tertiary care, or linking public health with primary care delivery. Two studies conceptualized integration as a dynamic process achieved through policymaking itself.

The policy objectives governments pursue under the banner of integration proved remarkably broad. Intermediate goals included improving care coordination and quality, enhancing accessibility, strengthening local empowerment and inter-organizational collaboration, reinforcing prevention, and boosting patient experience and safety. Ultimate objectives encompassed improved system responsiveness, reduced costs, greater efficiency and sustainability, better population health and strengthened equity. Yet in a striking finding aligned with the Rainbow Model, no single studied policy program reported all four essential functions of primary care, first-contact access, continuity, comprehensiveness and coordination, within one program.

Policy instruments fell into four categories: organizational, regulatory, financial and informational. Organizational tools included geographically zoned service organization, creation or merger of meso-level organizations such as primary care networks, interprofessional team models, social prescribing and integrated care pathways. Regulatory instruments ranged from legislation establishing population-based territorial responsibility to contractual arrangements and mandatory reporting. Financial levers covered funding models, payment reforms, incentives for team-based or rural practice, and investments in interoperable health data infrastructure. Informational instruments used clinical guidelines, performance feedback, public reporting and patient engagement mechanisms. The review found these instruments primarily supported organizational, professional and functional integration, while normative integration received comparatively little attention, suggesting shared values and organizational culture remain underdeveloped dimensions of policy design.

Formulation approaches combined top-down, bottom-up, negotiated and participatory strategies, often simultaneously. Bottom-up pilot projects supported locally tailored solutions but, without system-level coordination, frequently produced a fragmented patchwork of small-scale programs. Top-down legislation ensured coherence with national priorities but risked weakening stakeholder engagement and disconnecting from local realities. Negotiations with medical associations were repeatedly reported, underscoring that group’s significant influence on policy content, sometimes overshadowing other actors. The literature also shows growing engagement from researchers, patients, managers, unions, municipalities and insurers, though several studies called for expanding public and frontline provider participation further.

Perhaps the most sobering findings concern the political, economic and social environment. Fragmented responsibilities within ministries, across government departments and between levels of government in federated systems fostered siloed policy development, competing priorities and fragmented accountability, undermining local integration efforts. Unclear or overly numerous system goals diluted strategic direction, change management planning was often lacking, and national governments showed limited capacity to account for local needs. Political cycles constrained reform implementation, historical policy legacies added overlapping or inconsistent instruments, and power dynamics, including physicians’ higher status and hospitals’ privileged position over primary care clinics, complicated integration. Economic factors such as austerity, market-driven competition among providers and physician autonomy further undermined efforts, while demographic transitions and shocks like the COVID-19 pandemic reshaped priorities.

The authors conclude that system-level integration in primary care is dynamic, value-driven and highly context-dependent, and that persistent knowledge gaps remain regarding optimal political arrangements and the causal mechanisms enabling systemic integration. They point to policy integration, coordinating actors and instruments across policy domains, and to complex adaptive systems theory as promising multidisciplinary lenses for future research. Advancing integrated primary care, they argue, requires more coherent policy mixtures, better aligned governance arrangements and sustained attention to inter-actor relationships. The review acknowledges limitations, including the predominance of Canadian studies, exclusion of grey literature, and article selection by a single researcher mitigated through supervisory consensus, but its message is clear: structural reforms alone will not deliver integrated care without coherent, context-sensitive governance.

Subject of Research: Macro-level governance arrangements and policy design strategies supporting system-level integration in primary care

Article Title: A systematized narrative review of macro governance and policy design supporting integrated primary care

Article References: Dupont, M., Hudon, C., Martin, E., & Breton, M. (2026). A systematized narrative review of macro governance and policy design supporting integrated primary care. Discover Health Systems, 5(1), Article 72. https://doi.org/10.1007/s44250-026-00413-z

Image Credits: AI Generated

DOI: 10.1007/s44250-026-00413-z

Keywords: integrated primary care, health policy, system integration, governance, Rainbow Model of Integrated Care, policy instruments, policy formulation, narrative review, health systems, regulatory frameworks, primary care reform, systematized