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

Abstract

Healthcare system reforms increasingly promote integrated primary care to address fragmentation, population needs, and system sustainability. Implementing such reforms requires strong political leadership as well as coherent alignment of actions across the micro (clinical integration), meso (professional and organizational integration), and macro (system integration) levels. Despite its strategic importance, system-level integration—defined as a coherent set of political arrangements—remains both conceptually underdeveloped and empirically underexplored. This review aims to synthesize empirical evidence on macro-level governance arrangements and policy design strategies supporting system-level integration in primary care. A systematized narrative review was conducted using Medline, CINAHL, ABI/Inform, Health & Medical Collection, and International Political Science Abstracts (up to March 2025). Empirical, peer-reviewed studies (2010–2025) examining macro-level policies or national strategies for integrated primary care within specific national contexts were included. The analysis drew on the Rainbow Model of Integrated Care (RMIC) to assess essential primary care functions and integration domains, and on Knoepfel’s policy analysis framework to examine policy objectives, instruments, and formulation processes. Thirty-four empirical studies were included. The results showed that the RMIC provides valuable descriptive insights into integration domains, while policy analysis perspectives clarify how these domains are operationalized through policy. Policy programs supporting integrated primary care reflect a broad range of goals—emphasizing care coordination, quality of care, accessibility, system responsiveness, and cost reduction—and rely on mixtures of organizational, regulatory, financial, and informational instruments. Policy formulation approaches combine top-down, bottom-up, negotiated, and participatory strategies. However, macro-governance structures and fragmented responsibilities, together with broader political, economic, and social contexts, frequently undermine regulatory alignment, constraining system-level coherence and integration efforts. Overall, these findings reveal persistent knowledge gaps regarding optimal political arrangements and the causal mechanisms enabling systemic integration. System level integration in primary care is dynamic, value driven, and highly context dependent. Advancing integrated primary care requires more coherent policy mixtures, better aligned governance arrangements, and sustained attention to inter actor relationships. Generating new empirical knowledge grounded in a multidisciplinary framework is essential to further enrich the RMIC and support policymakers in designing and implementing integrated primary care reforms with synergistic impacts.