Although there is widespread recognition of the benefits of moving towards more flexible contractual arrangements and payment based on performance, collective agreements have prevented modernisation of the incentive system. Although there is a fair amount of variation in approaches depending on national context, a common feature across these national experiences has been the gradual implementation of the purchaser-provider split in the system, as opposed to a “big-bang” strategy, generally with positive results for the health system. Internally, within each SS institute, the purchaser-side should demand increasing refined information on activities, costs and outcomes from the provider-side.