Please cite this article in press as: Groenewegen PP, et al. Strengthening weak primary care systems: Steps towards stronger primary care in selected Western and Eastern European countries. Health Policy (2013), http://dx.doi.org/10.1016/j.healthpol.2013.05.024 ARTICLE IN PRESS G Model HEAP-3055; No. of Pages 10 Health Policy xxx (2013) xxx–xxx Contents lists available at SciVerse ScienceDirect Health Policy journa l h om epa ge: www.elsevier.com/locate/healthpol Review Strengthening weak primary care systems: Steps towards stronger primary care in selected Western and Eastern European countries  Peter P. Groenewegen a,* , Paul Dourgnon b,1 , Stefan Greß c,2 , Arnoldas Jurgutis d,3 , Sara Willems e,4 a NIVEL – Netherlands Institute for Health Services Research and Utrecht University, Dep. of Sociology and Dep. of Human Geography, NIVEL, PO Box 1568, 3500 BN Utrecht, The Netherlands b 10 rue Vauvenargues, 75018 Paris, France c University of Applied Sciences Fulda, Dep. of Nursing and Health Sciences, Marquardstrasse 35, D – 36039 Fulda, Germany d Klaip ˙ eda University, Herkaus Manto str. 84, LT – 92294, Klaipeda, Lithuania e Ghent University, Department of Family Medicine and Primary Health Care, 6K3 – De Pintelaan 185, 9000 Gent, Belgium a r t i c l e i n f o Article history: Received 27 August 2012 Received in revised form 22 April 2013 Accepted 31 May 2013 Keywords: Primary care International comparison Health policy a b s t r a c t European health care systems are facing diverse challenges. In health policy, strong primary care is seen as key to deal with these challenges. European countries differ in how strong their primary care systems are. Two groups of traditionally weak primary care systems are distinguished. First a number of social health insurance systems in Western Europe. In these systems we identified policies to strengthen primary care by small steps, characterized by weak incentives and a voluntary basis for primary care providers and patients. Secondly, transitional countries in Central and Eastern Europe (CCEE) that transformed their state- run, polyclinic based systems to general practice based systems to a varying extent. In this policy review article we describe the policies to strengthen primary care. For Western Europe, Germany, Belgium and France are described. The CCEE transformed their systems in a completely different context and urgency of problems. For this group, we describe the situation in Estonia and Lithuania, as former states of the Soviet Union that are now mem- bers of the EU, and Belarus which is not. We discuss the usefulness of voluntary approaches in the context of acceptability of such policies and in the context of (absence of) European policies. © 2013 Elsevier Ireland Ltd. All rights reserved.  This article is based on a key note lecture at the EFPC conference ‘The future of primary care in Europe’ in August 2010 and on the Cochrane Lecture at the Scientific Meeting of the Society of Social Medicine in September 2011 by the first author. * Corresponding author. Tel.: +31 30 2729 665. E-mail addresses: P.Groenewegen@nivel.nl (P.P. Groenewegen), dourgnon@irdes.fr (P. Dourgnon), stefan.gress@hs-fulda.de (S. Greß), jurgutis@klaipeda.aiva.lt (A. Jurgutis), sara.willems@ugent.be (S. Willems). 1 Tel.: +33 1 53934336. 2 Tel.: +49 661 9640 601. 3 Tel.: +370 46 398561. 4 Tel.: +32 9 332 39 84. 1. Introduction Strong primary care is often seen as a solution for the challenges that (European) health care systems face [1,2]. This raises the policy question of how primary care systems can be strengthened and especially those primary care systems that are traditionally weak. This question will be answered in this article by reviewing changes in two broad groups of health care systems with relatively weak primary care that introduced changes towards a stronger position of primary care. The first group consists of Western Euro- pean social health insurance systems; the second group consists of transitional countries in Central and Eastern 0168-8510/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.healthpol.2013.05.024