Methods

The IFCHC definition encompasses the main groups of activities undertaken by CHCs. However, this study sought to determine whether additional elements were considered important by experts across Europe. Discussions during the workshops highlighted collaboration and the dissemination of good practices as additional dimensions that warranted inclusion in the Delphi questionnaire. Although the workshop-based data collection resembled an expert consensus process, it was not formally classified as such due to the informal nature of the workshop settings. Once the list of 35 statements had been finalized, a two-round Delphi process was selected as the most appropriate qualitative method for assessing agreement. Participants were not able to add new statements or provide open comments, as this stage of content generation had already been completed during the workshops.

The Delphi study facilitated cross-national participation among individuals who did not know one another, while allowing time for reflection on the proposed statements. The observed increase in agreement from the first to the second round for most items suggests that opportunities for reconsideration can foster deeper understanding and strengthen consensus, an established advantage of the Delphi method.

Because participants did not know the study coordinator personally, the invitation to participate may have been perceived as impersonal, which may partly explain the modest response rate. The extended timeline and the need for repeated follow-up reminders also contributed to the prolonged duration of the study. Importantly, the second-round questionnaire was sent only to those who completed the first round, all of whom eventually responded after repeated reminders. Purposive sampling of individuals with substantial expertise in primary care enabled context-specific assessment relevant to diverse national settings. This approach did not introduce bias, as participants provided their views anonymously and without knowledge of one another’s identities. All participants had considerable experience in the field, and diversity was ensured by recruiting experts from multiple sectors of PHC (Nasa et al., Reference Nasa, Jain and Juneja2021; Naisola Ruiter, Reference Naisola-Ruiter2022; Shang et al., Reference Shang2023).

Consensus is a central requirement of Delphi studies, although the concept itself is often criticized for lacking a universally accepted definition. Consensus thresholds vary widely in the literature, ranging from 51% to 100%, and are frequently selected arbitrarily (Barrett et al., Reference Barrett and Heale2020; Nasa et al., Reference Nasa, Jain and Juneja2021). In this study, the agreement threshold was predefined as part of the methodological design and was successfully achieved.

Participants

The 16 participating countries represented a wide spectrum of primary care contexts, including those with strong primary care systems (e.g. Belgium, Denmark, Finland, the Netherlands, Portugal, Slovenia, Spain, the UK), as identified in the PHAMEU study (Kringos et al., Reference Kringos, Boerma, Bourgueil, Cartier, Dedeu, Hasvold, Hutchinson, Lember, Oleszczyk and Pavlic2013), as well as countries with more moderate or developing primary care structures (e.g. Italy, Portugal) and those with comparatively lower investment in primary care (e.g. North Macedonia, Croatia, Turkey). This diversity also reflected variation in health system organization, including both Beveridge- and Bismarck-type insurance models, thereby ensuring a broad range of perspectives and experiences. Participants worked in a variety of professional environments, including CHCs, group practices, academic institutions, professional organizations and public agencies. This diversity enabled the inclusion of multiple viewpoints on the functioning and organization of primary care. Representation from both urban and rural settings added an additional layer of insight, particularly regarding differences in service delivery, accessibility and community engagement. Panel members were current or former EFPC affiliates with recognized expertise in primary care, selected to strengthen the qualitative robustness of the consensus process.

Primary health care models versus the Community Health Centre as a model of care

PHC provides integrated, holistic, community- and patient-centred care for populations (Binagwaho et al., Reference Binagwaho and Ghebreyesus2019; WHO, 2022). It is important to distinguish between the content of care and the model through which it is delivered. Many of the highly rated elements in this study, such as accessibility, equity, holistic care, interprofessional collaboration and attention to social determinants of health, are widely recognized principles of high-quality primary care and are not unique to CHCs in terms of the services they provide. The added value of CHCs lies in the way these principles are operationalized. CHCs represent an organizational model in which these elements are systematically implemented, integrated and institutionalized through structured interprofessional teamwork, alignment with social services, population-based responsibility and community engagement (De Maeseneer et al., Reference De Maeseneer, Poplas Susič, Wolfe, Qingyue, Moosa, Raskin, Symondson and Hawkins2019). The effectiveness of primary care depends not only on its core functions but also on how consistently these functions are organized and delivered. Thus, the distinctiveness of CHCs does not lie in the principles themselves, but in their integration within a coherent organizational structure.

This aligns with the understanding of PHC as a system-level approach, which is much easier to deliver within CHCs than as a set of discrete services (Nagel et al., Reference Nagel, Keeping-Burke and Shamputa2021). This interpretation is consistent with the system-level perspective demonstrated in the PHAMEU research led by Kringos et al. (Reference Kringos, Boerma, Bourgueil, Cartier, Dedeu, Hasvold, Hutchinson, Lember, Oleszczyk and Pavlic2013), which identified substantial variation in the strength of primary care across European countries. Countries with strong primary care systems tend to have more developed organizational structures that support integrated, community oriented care, making them particularly conducive environments for CHC type models. Furthermore, the 2025 report of the Canadian Association of CHCs (The Canadian Association of Community Health Centres, 2025) reaffirms similar conclusions, emphasizing that CHCs are most effective when embedded within strong primary care systems and supported by policies that promote integration, equity and community participation. These findings reinforce the relevance of the CHC model as a structured approach to delivering comprehensive primary care.

Contextualizing the CHC model of care

The CHC model was defined through 35 key statements, of which 32 and 16 received average acceptability and feasibility scores of ≥4 on a 5-point Likert scale (4 = agree, 5 = strongly agree), respectively. This reflects strong endorsement of CHCs as interprofessional, team based primary care structures integrated with broader health, social and community services, consistent with findings from previous research (Nagel et al., Reference Nagel, Keeping-Burke and Shamputa2021; Saloner et al., Reference Saloner, Wilk and Levin2020). All remaining statements also had average values above 3.2, indicating general agreement in principle. The median values show that most respondents provided high ratings, while the standard deviations indicate some dispersion, suggesting that although opinions were not entirely unanimous, the overall trend was strongly positive. It is understandable that agreement with statements defining health care as a model of care is more relevant to acceptability than to feasibility in practice.

Although differences across work settings, countries or participant groups might have been informative, such comparisons were not undertaken. The study aimed to develop a uniform template for CHC implementation across Europe, and the focus therefore remained on achieving consensus among all participants.

Core elements such as health promotion, community engagement and responsibility for a defined population were considered both appropriate and essential for contemporary European health systems. These values align with global policy frameworks on primary care, including the Alma-Ata and Astana Declarations (Chan et al., Reference Chan2008; Kluge et al., Reference Kluge, Kelley, Birtanov, Theodorakis, Barkley, Aidossov and Valderas2019), and reflect WHO Europe’s vision for integrated and equitable care (World Health Organisation, 2022).

Although the model’s acceptability was overwhelmingly high, participants expressed greater caution regarding its feasibility, particularly in components requiring complex organizational or governance structures. This likely reflects their direct experience with the constraints and variability inherent in their respective health systems.

The social mission of CHCs, grounded in respect for human rights, accessibility and inclusion, was strongly affirmed. Statements emphasizing universal access and integrated, people-centred care received the highest scores, reinforcing earlier findings that CHCs are well-positioned to promote health equity (De Maeseneer et al., Reference De Maeseneer, Poplas Susič, Wolfe, Qingyue, Moosa, Raskin, Symondson and Hawkins2019; Pourat et al., Reference Pourat, Lu, Huerta, Hair, Hoang and Sripipatana2023). This consensus highlights CHCs as fundamentally inclusive and ethically grounded institutions.

Statements relating to social determinants of health and community engagement received high acceptability but slightly lower feasibility scores, indicating broad agreement with the principles but recognition of the practical challenges associated with implementation.

An important theme emerging from workshops, though not explicitly included in the IFCHC definition, was the role of CHCs in disseminating good practice, fostering inter-regional learning, and building shared knowledge bases. European networks such as WONCA, EFPC and EQUIP actively support these processes through conferences, communities of practice and cross-border collaboration (EFPC, 2020).

High scores for interprofessional collaboration and coordination among care providers underscored the value of team-based care within CHCs. Evidence links effective collaboration to improved outcomes and patient satisfaction. However, this is not yet standard practice in all settings, and further investment in interprofessional education is needed. Such education supports professionals in developing collaborative competencies and complements mono-professional training by fostering confidence and mutual understanding (Miller et al., Reference Miller, Scherpbier, van Amsterdam, Guedes and Pype2019).

Given ongoing demographic shifts, migration and increasing cultural diversity, coordination across regions and providers is essential for delivering consistent, culturally sensitive, high-quality care tailored to local populations. Research supports the benefits of cross-regional and cross-national cooperation, especially in responding to migration and refugee health needs (Lebano et al., Reference Lebano, Hamed, Bradby, Gil-Salmerón, Durá-Ferrandis, Garcés-Ferrer, Azzedine, Riza, Karnaki and Zota2020; Priebe et al., Reference Priebe2011).

Familycentred care, one of the lowestrated items, depends simultaneously on provider skills, family dynamics and organizational support. Panellists likely perceived low feasibility because these models require systemlevel redesign rather than incremental practice change, as well as the capacity to manage vulnerable or specific population groups, an approach widely recommended but difficult to implement. Barriers include socioeconomic disadvantage, low health literacy and weak social support systems. Programmes often fail when services do not match community needs. These interventions require tailored, contextsensitive approaches that are resourceintensive and difficult to standardize, which may explain the lower feasibility ratings. Both familycentred care and targeted population approaches are conceptually strong but operationally demanding, which helps explain why experts consistently judged them challenging to implement in realworld primary care (Pourat et al., Reference Pourat, Lu, Huerta, Hair, Hoang and Sripipatana2023). These lower scores likely reflect structural, legislative or cultural barriers, as well as uncertainty or skepticism about practical implementation, highlighting areas for further education and innovation.

The lowest score was assigned to community involvement in governance. While in some jurisdictions the mandate and direction of CHCs may be determined solely by the state, in many contexts, policy explicitly requires that boards of directors include active participation from community stakeholders. Strong leadership and effective management are therefore essential for maintaining relationships with the community, fostering collaborative partnerships and ensuring the efficient day-to-day operation (Nagel et al., Reference Nagel, Keeping-Burke and Shamputa2021). The current definition of CHCs as a model of care did not sufficiently emphasize the role of management, despite its critical importance in fostering staff engagement and service quality (Szilvassy et al., Reference Szilvassy and Širok2022). This omission may reflect participants’ focus on the substantive characteristics of the CHC model rather than operational considerations. Nonetheless, effective management significantly influences employee performance and care delivery (Curry et al., Reference Curry, Ayedun, Cherlin, Allen and Linnander2020). Despite these concerns, the literature supports the potential of participatory governance and distributive leadership to enhance transparency, trust and responsiveness.

For example, CHCs in the Netherlands incorporate client advisory boards or cooperative ownership models that enable community influence (Schäfer et al., Reference Schäfer2010). Swedish regional governance often includes citizen representatives on health committees (Saltman et al., Reference Saltman2007). Italy’s Tuscany region has experimented with patientrepresentative health councils (Nuti et al., Reference Nuti and Vainieri2012), while in Flanders, patients and informal caregivers participate in Boards of Directors within Primary Care Zones (World Health Organisation, 2019).

Conversely, governance in Central and Eastern Europe (e.g. Poland, Slovenia) tends to remain top-down and professionally driven, with limited civic participation (Kowalska-Bobko et al., Reference Kowalska-Bobko2020; Zavrnik et al., Reference Zavrnik2021). These systemic contrasts help explain feasibility differences and underscore the need for adaptable frameworks that respect national contexts while gradually integrating participatory elements.

Community-based care and co-production in service design offer additional promise. Involving patients and community members in identifying priorities and developing interventions enhances service relevance, satisfaction and outcomes (Morton et al., Reference Morton and Pauly2020; Rijken et al., Reference Rijken, van Ginneken, Schellevis and Kroneman2021). Migrant-sensitive and culturally adapted pathways are essential for improving quality and equity, particularly in diverse urban settings (Bradby et al., Reference Bradby, Humphris, Newall and Phillimore2015; Ingleby et al., Reference Ingleby2012).

The experience of the EFPC demonstrates the power of global collaboration among professionals across disciplines, including those in the social sector, as a vital strategy to strengthening primary care in Europe and beyond (De Maeseneer et al., Reference De Maeseneer2017).

CHC – A feasible European model of care

The IFCHC definition, expanded in this study through additional statements on collaboration and knowledge dissemination, was fully endorsed by the panellists, who viewed CHCs as a concept aligned with a European model of care. The shift from conceptual acceptance to practical implementation indicates that, while the model is normatively supported, its operationalization remains less certain. This variability may be linked to differences in governance and financing arrangements, workforce capacity, health system models and levels of coordination across settings, all of which may influence the feasibility of implementation (European Observatory on Health Systems and Policies, Reference Kringos, Boerma, Hutchinson and Saltman2015).

Nevertheless, CHCs as a model for delivering health care uphold fundamental principles of PHC. In the context of rapidly evolving health system demands, it is essential that population-based care delivered through the CHC model remains timely, comprehensive and responsive to people’s needs. This can be achieved more effectively when cooperation, coordination and the exchange of knowledge and experience are explicitly emphasized, as highlighted by the findings of this study.