Open Access Highly Accessed Research article

The european primary care monitor: structure, process and outcome indicators

Dionne S Kringos1*, Wienke GW Boerma1, Yann Bourgueil2, Thomas Cartier2, Toralf Hasvold3, Allen Hutchinson4, Margus Lember5, Marek Oleszczyk6, Danica Rotar Pavlic7, Igor Svab7, Paolo Tedeschi8, Andrew Wilson9, Adam Windak6, Toni Dedeu10 and Stefan Wilm11

Author Affiliations

1 NIVEL, Netherlands Institute for Health Services Research, Otterstraat 114-118, 3500 BN Utrecht, Netherlands

2 Institute for Research and Information in Health Economics IRDES, 10 rue Vauvenargues, 75018 Paris, France

3 University of Tromsø, Department of Community Medicine ISM, Department of Community Medicine, Faculty of Health Sciences, University of Tromsø, 9037 Tromsø, Norway

4 University of Sheffield, School of Health and Related Research ScHARR, Regent Court 30, Regent Street, S1 4DA Sheffield, UK

5 University of Tartu, Department of Polyclinical and Family Medicine, Ülikooli 18, 50090 Tartu, Estonia

6 Jagiellonian University Medical College, Department of Family Medicine, Bochenska 4, 31-061 Krakow, Poland

7 University of Ljubljana, Department of Family Medicine, Vrazov trg 2, 1000 Ljubljana, Slovenia

8 Bocconi University, Centre for Research on Health and Social Care Management CERGAS, Via Sarfatti 25, 20135 Milan, Italy

9 University of Leicester, Department of Health Sciences, 22-28 Princess Road West, LE1 6TP Leicester, UK

10 Primary Care Research Institute IDIAP Jordi Gol, Av. Gran Via de les Corts Catalanes, 587 Àtic, 08007 Barcelona, CIF G-60954104, Spain

11 Private University Witten/Herdecke gGmbH, Institute of General Practice and Family Medicine, Alfred-Herrhausen-Straße 50 D - 58448 Witten, Germany

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BMC Family Practice 2010, 11:81  doi:10.1186/1471-2296-11-81

Published: 27 October 2010



Scientific research has provided evidence on benefits of well developed primary care systems. The relevance of some of this research for the European situation is limited.

There is currently a lack of up to date comprehensive and comparable information on variation in development of primary care, and a lack of knowledge of structures and strategies conducive to strengthening primary care in Europe. The EC funded project Primary Health Care Activity Monitor for Europe (PHAMEU) aims to fill this gap by developing a Primary Care Monitoring System (PC Monitor) for application in 31 European countries. This article describes the development of the indicators of the PC Monitor, which will make it possible to create an alternative model for holistic analyses of primary care.


A systematic review of the primary care literature published between 2003 and July 2008 was carried out. This resulted in an overview of: (1) the dimensions of primary care and their relevance to outcomes at (primary) health system level; (2) essential features per dimension; (3) applied indicators to measure the features of primary care dimensions. The indicators were evaluated by the project team against criteria of relevance, precision, flexibility, and discriminating power. The resulting indicator set was evaluated on its suitability for Europe-wide comparison of primary care systems by a panel of primary care experts from various European countries (representing a variety of primary care systems).


The developed PC Monitor approaches primary care in Europe as a multidimensional concept. It describes the key dimensions of primary care systems at three levels: structure, process, and outcome level. On structure level, it includes indicators for governance, economic conditions, and workforce development. On process level, indicators describe access, comprehensiveness, continuity, and coordination of primary care services. On outcome level, indicators reflect the quality, and efficiency of primary care.


A standardized instrument for describing and comparing primary care systems has been developed based on scientific evidence and consensus among an international panel of experts, which will be tested to all configurations of primary care in Europe, intended for producing comparable information. Widespread use of the instrument has the potential to improve the understanding of primary care delivery in different national contexts and thus to create opportunities for better decision making.