Institutional alignment without full functional transition: Primary health care reform in Greece since 2017: A narrative review

Abstract

Primary Health Care (PHC) is internationally recognized as a foundational pillar of effective, equitable, and sustainable health systems. In Greece, however, PHC has historically evolved through fragmented institutional arrangements, resulting in persistent challenges related to coordination, continuity of care, and population-based service delivery. In response to these long-standing structural characteristics, a comprehensive PHC reform was introduced in 2017, aiming to align national primary care organization with internationally endorsed PHC principles. This narrative review examines whether the institutional alignment achieved through the 2017 reform was accompanied by a corresponding functional transformation in PHC service delivery. The analysis draws on national legislation, policy documents, and international PHC literature, and analytically distinguishes between institutional design and operational outcomes across key dimensions, including governance arrangements, workforce capacity, accessibility, coordination, continuity of care, preventive activities, and financing mechanisms. The findings indicate that while the 2017 reform achieved substantial institutional convergence with international PHC models, functional transformation remained partial and uneven. Implementation was characterized by regional variability, workforce shortages, limited operational integration of preventive and health promotion services, and persistent challenges in care coordination and continuity. These patterns are consistent with international evidence suggesting that legislative and organizational redesign alone is insufficient to ensure effective functional change in primary care systems. By situating the Greek experience within the broader international PHC policy framework, this review contributes to comparative health system analysis by illustrating how institutional reforms are mediated by system capacity and implementation dynamics. The article highlights the importance of sustained alignment between institutional arrangements and operational conditions and offers analytically transferable insights relevant to health systems pursuing PHC strengthening under comparable structural, organizational, and fiscal constraints.