Contrasting approaches to primary care performance governance in Denmark and New Zealand

In high-income countries, the arena of primary health care is becoming increasingly subject to 'performance governance' - the harnessing of performance information to the broader task of governance. Primary care presents many governance challenges because it is predominantly provided by sole practitioners or small organisations. In this article we compare Denmark and New Zealand, two small countries with tax-funded health systems which have adopted quite different instruments for performance governance in primary care. Denmark has adopted a 'soft hierarchy' approach to primary care performance based on accreditation processes but few strong sanctions, whilst New Zealand has relied on a combination of explicit hierarchical targets and financial incentives. These differences are attributable to: primary care institutional arrangements, - specifically, the presence or absence of 'intermediate organisations'- ; the degree to which policy processes are corporatist or pluralist; and the mix of objectives of primary care policies. We conclude that New Zealand's approach has relied heavily on 'extrinsic' incentives, whereas Denmark exhibits the opposite problem of overreliance on intrinsic motivation to improve quality, without 'extrinsic' instruments to address other important goals such as population health and equity. Our comparative framework has the potential to be applied across a wider range of countries.