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Introduction
There is considerable and growing agreement among policy makers that a strong primary care system is necessary to reach objectives related to health-care delivery (Saltman et al., 2006; WHO, 2008). There is less agreement, however, regarding appropriate organisational models to support such a development.
The traditional model of primary care in Sweden, with its focus on publicly owned health centres employing a multidisciplinary workforce with responsibility for population health within a geographical area, is rather unusual in an international perspective. Typically, a Swedish public primary care centre will employ 4-10 general practitioners (GPs) and several other professionals including district nurses, physiotherapists, social workers, work therapists, psychologists and specialist nurses in areas such as diabetes and asthma/COPD (Anell, 2005a; Glenngård et al., 2005). In most other OECD (Organisation for Economic Co-operation and Development) countries, primary care is traditionally provided by private GPs working in small groups or alone and with responsibility to provide care to patients who seek to visit them or who are registered on their lists. Payments are often based on the volume of doctor visits and services, sometimes in combination with a fixed risk-adjusted payment for registered patients (Lamarche et al., 2003).
Recent developments suggest a convergence between primary care in Sweden and other countries in at least some dimensions. Since the early 1990s, more possibilities for patients to choose their provider have been introduced in Swedish health care (Glenngård et al., 2005). In practice, however, money has often not followed the choice of patients and public providers have had no financial incentives to attract new patients. The share of private primary care providers has increased but was still <30% in 19 of the 21 county councils responsible for financing and providing health care in Sweden in 2006. In parallel, primary care in several other countries in northern Europe has developed towards Swedish standards in terms of less reliance on solo-practices and more integration with other health-care services (Godber et al., 1997; Dixon et al., 1998; Vallgårda et al., 2001; WHO, 2001; Exter et al., 2004; Saltman, 2006). In the United Kingdom, about one-third of all GPs have even chosen to be employed by local authorities rather...