patients can choose any gp but as there is no gatekeeping system they can also choose to visit any medical specialist directly there are low outpatient contacts per person in and weak primary care governance eg lack of state inspection supportive primary care policies there is also relative underdevelopment of the primary care workforce with low income levels relative to specialists more positively the primary care system has been judged to be relatively effective and efficient in regard to coordination and comprehensiveness of care ktingos et al kringosetal