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Objective: To understand family physicians' perceptions of Manitoba's strategies for primary care renewal or reform (PCR)., Design: Qualitative substudy of an explanatory case study., Setting: Rural and urban Manitoba., Participants: A total of 60 family physicians (31 fee-for-service physicians, 26 alternate-funded physicians, and 3 physicians representing provincial physician organizations)., Methods: Semistructured interviews and focus groups., Main Findings: Many physicians were hesitant to participate in PCR initiatives, perceiving clear risks but uncertain benefits to patients and providers. Additional barriers to participation included concerns about the adequacy and import of communication about PCR, the meaningfulness of opportunities for physician "voice," and the trustworthiness of decision makers. There was an appetite for tailored, clinic-level support in addressing concrete, physician-identified problems; however, the initiatives on offer were not widely viewed as providing such support., Conclusion: Although some of the observed barriers might fade over time, concentrating PCR efforts on the everyday realities of family physician practice might be the best way to build a primary care system that works for patients and providers., (Copyright© the College of Family Physicians of Canada.)

Primary care reform cannot succeed without substantive change on the part of providers. In Canada, these are mostly fee-for-service physicians, who tend to regard themselves as independent professionals and not under managerial sway. Hence, policymakers must balance two conflicting imperatives: ensuring the acceptability of renewal efforts to these physicians while enforcing their accountability for defined actions or outcomes. In its 2011-15 strategy to improve access to primary care, the province of Manitoba introduced several linked initiatives, each striving to blend acceptability- and accountability-promoting elements. Clearly delimited initiatives that directly promoted a specific observable behaviour (accountability) through financial or non-financial support (acceptability) were most successfully implemented. System-wide initiatives with complicated designs (notably a primary care network model that established formal partnership among clinics and regional health authorities) encountered greater difficulties in recruiting and sustaining physician participation. Although such initiatives offered physicians considerable decision-making latitude (acceptability), many physicians questioned the meaningfulness of opportunities for voice within a predetermined structure (accountability). Moreover, policymakers struggled to enhance the acceptability of such initiatives without sacrificing strong accountability mechanisms. Policymakers must carefully consider how acceptability and accountability elements may interact, and design them in such a way as to minimize the risk of mutual interference., (Copyright © 2019. Published by Elsevier B.V.)