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Primary health care reforms: a scoping review

Published online by Cambridge University Press:  18 August 2025

Ahmad Shirjang Open the ORCID record for Ahmad Shirjang [Opens in a new window] ,
Leila Doshmangir Open the ORCID record for Leila Doshmangir [Opens in a new window] ,
Mohammad Bazyar Open the ORCID record for Mohammad Bazyar [Opens in a new window]  and
Vladimir Sergeevich Gordeev Open the ORCID record for Vladimir Sergeevich Gordeev [Opens in a new window]
Ahmad Shirjang
Affiliation:
National Center for Health Insurance Research, Iran Health Insurance Organization, Tehran, Iran
Leila Doshmangir*
Affiliation:
Department of Health Policy & Management, Health Services Management Research Center, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran Social Determinants of Health Research Center, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
Mohammad Bazyar
Affiliation:
Health and Environment Research Center, Ilam University of Medical Sciences, Ilam, Iran Department of Health Management and Economics, Faculty of Health, Ilam University of Medical Sciences, Ilam, Iran
Vladimir Sergeevich Gordeev
Affiliation:
Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
*
Corresponding author: Leila Doshmangir; Email: dosmangirl@tbzmed.ac.ir
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Abstract

Background:

Demographic transitions, societal changes, and evolving population health needs are placing increasing pressure on healthcare systems, necessitating ongoing reforms. Primary health care (PHC) is a foundational component of Universal Health Coverage (UHC) and sustainable health systems. Many countries have undertaken PHC reforms aimed at improving population health. This review explores the objectives, implementation mechanisms, challenges, and outcomes of these reforms.

Methods:

We conducted a systematic review of studies sourced from five databases (PubMed, Scopus, Proquest, Embase, and Science Direct), applying the World Health Organization’s Health Systems Framework for deductive content analysis. The PRISMA guidelines were followed to ensure transparency and rigour in summarizing the published literature.

Results:

A total of 147 types of interventions were identified, with most targeting service delivery and financing. Key reform objectives included expanding access to care, improving financing and payment systems, scaling up family physician programmes, increasing government health expenditure, leveraging private sector capacities, and strengthening the PHC workforce. These interventions resulted in expanded public health coverage, enhanced access to PHC, increased utilization of services among low-income populations, broader social insurance coverage, and improved service quality, contributing to better community health outcomes.

Conclusion:

The success of PHC reforms depends on their alignment with political, social, and cultural contexts, as well as consideration of the social determinants of health. Strong governmental support, managerial stability, decentralization, and regional capacity building are essential for sustainable implementation. Reforms should be gradual, supported by accurate forecasting, adequate and sustainable resources, and evidence-based strategies, drawing on international experiences.

Keywords

health policy and systems researchhealth reformprimary health carepublic health

Information

Type
Review
Information
Primary Health Care Research & Development , Volume 26 , 2025 , e74
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Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.
Copyright
© The Author(s), 2025. Published by Cambridge University Press

Introduction

Primary health care (PHC) is built on the fundamental premise that individuals, families, and communities have the right to better healthcare. It provides a whole-of-society approach to health and well-being centred on the needs and preferences of all (Allen Reference Allen2000, Doshmangir, Moshiri et al. Reference Doshmangir, Moshiri, Mostafavi, Sakha and Assan2019). This notion rendered PHC an essential component of healthcare delivery, encompassing health promotion, disease prevention, treatment, rehabilitation and palliative care. PHC represents the first level of care committed to promoting social justice principles, inter-sectoral cooperation, and public participation (Bagyani-Mogadam and Ehraampoosh Reference Bagyani-Mogadam and Ehraampoosh2003). These principles are well outlined in several global public health milestones and considered the most efficient and effective ways to achieve health for all (Malekafzali Reference Malekafzali2014).

By fortifying primary healthcare, the reform can foster a transition from a predominantly remedial model to a preventive and promotive one, with the objective of ameliorating overall health outcomes and diminishing healthcare expenditures (Barnes et al., Reference Barnes, Heaton, Goates and Packer2016). Consequently, primary healthcare reform assumes a pivotal role in engendering a more sustainable and patient-centric healthcare system (Majid and Wasim Reference Majid and Wasim2020).

In the interim, alongside the function of governmental providers, the function of private providers is of utmost significance, particularly in the latest reforms pertaining to primary healthcare (Sanadgol, Doshmangir et al. Reference Sanadgol, Doshmangir, Majdzadeh and Gordeev2021, Sanadgol, Doshmangir et al. Reference Sanadgol, Doshmangir, Khodayari-Zarnaq and Sergeevich Gordeev2022, Sanadgol, Doshmangir et al. Reference Sanadgol, Doshmangir, Khodayari-Zarnaq and Sergeevich Gordeev2022). In the same direction, the Astana Summit in 2018 reiterated the need for continuous action from governments, global health leaders and development institutions, non-governmental organizations, academia and other professional organizations to improve PHC services (Wass Reference Wass2018). For decades, countries implemented major PHC reforms to meet the changing population’s health needs and expectations. For example, some countries (e.g., Australia, Iran, and the United Kingdom) experienced an improvement in many health indicators following the scaling-up of PHC-based interventions (Saltman and Figueras Reference Saltman and Figueras1998, Asaei Reference Asaei2014). However, the World Health Organization’s (WHO) reports indicated that most health systems worldwide are still underperforming and recommended establishing health systems based on the critical principles of PHC (Malekafzali Reference Malekafzali2014, Auener et al., Reference Auener, Kroon, Wackers, Van Dulmen and Jeurissen2020). Several studies have shown a positive relationship between strengthening the PHC system and socio-economic development, which could serve as the basis for the national health system strengthening (Doshmangir et al., Reference Doshmangir, Bazyar, Majdzadeh and Takian2019, Pinto et al., Reference Pinto, Bondy, Rucchetto, Ihnat and Kaufman2019, Doshmangir et al., Reference Doshmangir, Moshiri and Farzadfar2020) and progress towards Universal Health Coverage (UHC) (Faye, Bob et al. 2012, Organization 2018). Therefore, over the last 20 years, most reforms have expanded and improved PHC services (WHO 2000).

Due to the complex nature of PHC system reforms, understanding countries experiences could help when choosing appropriate policy interventions in PHC systems, facilitating the movement towards UHC, and fostering the 2030 Sustainable Development Goals Agenda. Therefore, this study explored PHC system reform interventions, their aims and achievements through the lens of the primary building blocks of the WHO Health System Framework.

Methods

Our scoping review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol, specifically the extension for Scoping Reviews (PRISMA-ScR) as illustrated in Appendix S1 (Tricco et al., Reference Tricco, Lillie, Zarin, O’Brien, Colquhoun, Levac, Moher, Peters, Horsley and Weeks2018), to the goal of answering the main research question ‘the aims of PHC reforms, their mechanisms of implementation, and their achievements’. The intent of the PRISMA-ScR is to facilitate comprehension among a diverse range of readers, by providing a comprehensive overview of pertinent terminology, fundamental principles, and crucial elements that are essential for conducting scoping reviews (Tricco et al., Reference Tricco, Lillie, Zarin, O’Brien, Colquhoun, Levac, Moher, Peters, Horsley and Weeks2018).

Inclusion and exclusion criteria

We identified and reviewed the literature on PHC reforms, their dimensions, related interventions, and PHC reforms effectiveness in moving towards UHC across countries. We limited our search to papers published in English from January 1990 to January 2023, and our review included summaries, posters, letters to the editor, reviews, commentaries, and opinion pieces.

Data sources and search

We systematically searched for primary and secondary studies using five databases (Proquest, Embase, Scopus, Science Direct, PubMed) and for the objective of guaranteeing inclusivity in the literature reviews, we searched Google Scholar and references within the selected articles. The search was performed using a combination of key terms, including reform, policy, intervention, PHC, primary healthcare or primary health care (complete search strategy show in Appendix S2).

Study selection and data extraction

Results from the bibliographic databases were merged, and duplicates were removed. Articles were included if they had relevant information about reforms in PHC. Two researchers (LD and ASh) independently screened and reviewed the titles, abstracts, and full text. Then discussed the findings, and disagreements were resolved by discussion and consensus. Figure 1 shows the number of papers included and excluded at each phase of the selection process. Data on PHC reforms were extracted and entered in the assessment form. And at this stage too, disagreements were resolved by discussion and consensus.

Figure 1.

Diagram of the selection of articles for review.

Synthesis of results

The extracted data were analyzed using the thematic framework approach (Smith and Firth Reference Smith and Firth2011). The study results were further categorized using the WHO’s six building blocks of the Health System Framework, including service delivery, health workforce, information, medical products, vaccines and technologies, financing, and leadership/governance (Hsiao and Burgess Reference Hsiao and Burgess2009).

Results

Selection and Characteristics of sources of evidence

Of the 3482 articles identified, 88 studies met the eligibility criteria. No additional studies were identified through manual search. The main reason for exclusion was not addressing reforms regarding primary health care. The studies described PHC reforms in 41 countries (more detail is shown in Table 1), including New Zealand (Gauld Reference Gauld2001, Tenbensel Reference Tenbensel2008), China (Xu et al., Reference Xu, Wang, Collins and Tang2007, Tang, Meng et al. Reference Tang, Meng, Chen, Bekedam, Evans and Whitehead2008, Yip and Hsiao Reference Yip and Hsiao2009, Hu et al., Reference Hu, Zou and Shen2011, Sun et al., Reference Sun, Chai, Zhou and Wang2014, Lin et al., Reference Lin, Sun, Peng, Cai, Geanacopoulos, Li, Zhao, Zhang and Chen2015, Di Liang et al., Reference Di Liang, Chen, Zhou, Yang and Huang2020, Pu, Huang et al. Reference Pu, Huang, Wang and Gu2020, Ran et al., Reference Ran, Gao, Han, Hou, Chen and Zhang2020, Tao et al., Reference Tao, Zeng, Dang, Lu, Chuong, Yue, Wen, Zhao, Li and Kominski2020, Zhou et al., Reference Zhou, Xu, Ma, Yuan, Liu, Fang and Meng2020), Chile (Bastías, Pantoja et al. Reference Bastías, Pantoja, Leisewitz and Zárate2008, Unger, De Paepe et al. Reference Unger, De Paepe, Cantuarias and Herrera2008, Cornejo-Ovalle et al., Reference Cornejo-Ovalle, Brignardello-Petersen and Pérez2015), South Africa (Benatar Reference Benatar2004, De Maeseneer and Flinkenflögel Reference De Maeseneer and Flinkenflögel2010, Van Pletzen et al., Reference Van Pletzen, Zulliger, Moshabela and Schneider2013, Schneider, English et al. Reference Schneider, English, Tabana, Padayachee and Orgill2014), Malaysia (Yu, Whynes et al. Reference Yu, Whynes and Sach2011), India (Ghosh Reference Ghosh2014, Rahman, Angeline et al. Reference Rahman, Angeline, David and Christopher2014), Mexico (Frenk, González-Pier et al. Reference Frenk, González-Pier, Gómez-Dantés, Lezana and Knaul2006, van Weel, Turnbull et al. Reference van Weel, Turnbull, Ramirez, Bazemore, Glazier, Jaen, Phillips and Salsberg2016), United Arab Emirates (Koornneef, Robben et al. Reference Koornneef, Robben, Al Seiari and Al Siksek2012, Koornneef, Robben et al. Reference Koornneef, Robben and Blair2017), Georgia (Gamkrelide et al., Reference Gamkrelide, Atun, Gotsadze, MacLehose and McKee2002, Gotsadze et al., Reference Gotsadze, Zoidze and Vasadze2005), USA (Blumenthal and Dixon Reference Blumenthal and Dixon2012, Lankarani Reference Lankarani2012, Harrill and Melon Reference Harrill and Melon2021, O’Mahen and Petersen Reference O’Mahen and Petersen2021), Turkey (Tatar and Kanavos Reference Tatar and Kanavos2006, Yasar Reference Yasar2011, Hone, Gurol-Urganci et al. Reference Hone, Gurol-Urganci, Millett, Başara, Akdağ and Atun2017), Philippines (Obermann, Jowett et al. Reference Obermann, Jowett, Taleon and Mercado2008), Finland (Tynkkynen et al., Reference Tynkkynen, Chydenius, Saloranta and Keskimäki2016), Spain (Larizgoitia and Starfield Reference Larizgoitia and Starfield1997), Kosovo (Buwa and Vuori Reference Buwa and Vuori2006, Percival and Sondorp Reference Percival and Sondorp2010), Sweden (Spak and Andersson Reference Spak and Andersson2008, Forsberg Reference Forsberg2018, Mosquera et al., Reference Mosquera, San Sebastian, Burström, Hurtig and Gustafsson2021), Poland (Mokrzycka, Kowalska-Bobko et al. Reference Mokrzycka, Kowalska-Bobko, Sagan and Włodarczyk2016), Australia (Baum, Freeman et al. Reference Baum, Freeman, Jolley, Lawless, Bentley, Värttö, Boffa, Labonte and Sanders2013, Baum et al., Reference Baum, Freeman, Sanders, Labonté, Lawless and Javanparast2016), Denmark (Setlhare Reference Setlhare2016), Ethiopia (Bradley et al., Reference Bradley, Byam, Alpern, Thompson, Zerihun, Abeb and Curry2012), Armenia (Grigoryan Reference Grigoryan2005), Commonwealth of Independent States of Central Asia (Parfitt Reference Parfitt2009), Slovenia (Vab Reference Vab1995), Uganda (Tashobya Reference Tashobya and Ogwal2004), Albania (Hotchkiss, Piccinino et al. Reference Hotchkiss, Piccinino, Malaj, Berruti and Bose2005), South America (Ramírez et al., Reference Ramírez, Ruiz, Romero and Labonté2011, Acosta Ramírez et al., Reference Acosta Ramírez, Giovanella, Vega Romero, Tejerina Silva, de Almeida, Ríos, Goede and Oliveira2016), Brazil (Almeida et al., Reference Almeida, Travassos, Porto and Labra2000, Kuchenbecker and Polanczyk Reference Kuchenbecker and Polanczyk2012, Soranz et al., Reference Soranz, Pinto and Penna2016, de M Pontes and Santos Reference de M Pontes and Santos2020), Bosnia and Herzegovina (Atun, Kyratsis et al. Reference Atun, Kyratsis, Jelic, Rados-Malicbegovic and Gurol-Urganci2007), Kazakhstan (Organization and UNICEF 1997, Abzalova et al., Reference Abzalova, Wickham, Chukmaitov and Rakhipbekov1998), Croatia (Harvey, Kalanj et al. Reference Harvey, Kalanj and Stevanović2004), Portugal (Szczygieł et al., Reference Szczygieł, Pinto Lima and Santana2011, Biscaia and Heleno Reference Biscaia and Heleno2017), Canada (Harris, Green et al. Reference Harris, Green, Brown, Roberts, Russell, Fournie, Webster-Bogaert, Paquette-Warren, Kotecha and Han2015), Cuba (Sixto Reference Sixto2002, Whiteford and Branch Reference Whiteford and Branch2008), Lithuania (Liseckienė Reference Liseckienė2009, Buivydiene, Starkiene et al. Reference Buivydiene, Starkiene and Smigelskas2010), Greece (Tragakes and Polyzos Reference Tragakes and Polyzos1998, Tountas, Karnaki et al. Reference Tountas, Karnaki and Pavi2002, Myloneros and Sakellariou Reference Myloneros and Sakellariou2021), UK (Blumenthal and Dixon Reference Blumenthal and Dixon2012), Ecuador (Quizhpe et al., Reference Quizhpe, San Sebastian, Teran and Pulkki-Brännström2020, Jimenez and San Sebastián Reference Jimenez and San Sebastián2021), Romania (Bara et al., Reference Bara, Van den Heuvel and Maarse2002), Cypriot (Pallari et al., Reference Pallari, Samoutis and Rudd2020), and Iran (Shadpour Reference Shadpour2006, Lankarani Reference Lankarani2012, Esmailzadeh et al., Reference Esmailzadeh, Rajabi, Rostamigooran and Majdzadeh2013, Lankarani et al., Reference Lankarani, Alavian and Peymani2013, Asaei Reference Asaei2014, Malekafzali Reference Malekafzali2014, Heshmati and Joulaei Reference Heshmati and Joulaei2016).

Table 1.

Study characteristics

Table 2 presents a summary of PHC reforms areas based on the six building blocks of the WHO Health System Framework. Only in several countries reforms focused on all six dimensions of the Health System Framework (e.g., Albania (Hotchkiss, Piccinino et al. Reference Hotchkiss, Piccinino, Malaj, Berruti and Bose2005), Brazil (Almeida et al., Reference Almeida, Travassos, Porto and Labra2000), China (Yip and Hsiao Reference Yip and Hsiao2009), Iran (Shadpour Reference Shadpour2006), Portugal (Biscaia and Heleno Reference Biscaia and Heleno2017), and Turkey (Tatar and Kanavos Reference Tatar and Kanavos2006)). In contrast, others prioritized reforms implementation only in one of the Health System Framework blocks (e.g., (Almeida et al., Reference Almeida, Travassos, Porto and Labra2000, Sixto Reference Sixto2002, Harvey, Kalanj et al. Reference Harvey, Kalanj and Stevanović2004, Hotchkiss, Piccinino et al. Reference Hotchkiss, Piccinino, Malaj, Berruti and Bose2005, Hu et al., Reference Hu, Zou and Shen2011, Yu, Whynes et al. Reference Yu, Whynes and Sach2011, Esmailzadeh et al., Reference Esmailzadeh, Rajabi, Rostamigooran and Majdzadeh2013, Mokrzycka, Kowalska-Bobko et al. Reference Mokrzycka, Kowalska-Bobko, Sagan and Włodarczyk2016, Biscaia and Heleno Reference Biscaia and Heleno2017, Hone, Gurol-Urganci et al. Reference Hone, Gurol-Urganci, Millett, Başara, Akdağ and Atun2017). We further summarize our findings on interventions using Health System Framework building blocks as subsections and Table 2 (detailed overview in Appendix Tables S3, S4, S5). The conceptual presentation of the results can be found in Figure 2.

Table 2.

Primary health care reforms under the six building blocks

Notes: * indicates that the country’s reforms concerned the building block.

Figure 2.

Conceptual presentation of findings.

PHC service delivery

PHC reforms have predominantly aimed to reduce health disparities by enhancing access to health services, minimizing variations in care quality, and optimizing resources across both public and private sectors. A common approach adopted in numerous countries has involved establishing PHC service units in both urban and rural settings to bridge access gaps (Gauld Reference Gauld2001; Yip and Hsiao Reference Yip and Hsiao2009; Hu et al., Reference Hu, Zou and Shen2011; Bradley et al., Reference Bradley, Byam, Alpern, Thompson, Zerihun, Abeb and Curry2012; Ghosh Reference Ghosh2014; Schneider, English, et al. Reference Schneider, English, Tabana, Padayachee and Orgill2014). Additionally, several reforms have emphasized expanding the cadre of family physicians, who function as gatekeepers within health systems (Tatar and Kanavos Reference Tatar and Kanavos2006; Mokrzycka, Kowalska-Bobko, et al. Reference Mokrzycka, Kowalska-Bobko, Sagan and Włodarczyk2016). Governments have also sought to increase competitiveness in service delivery by encouraging private sector participation and volunteer-based health services (Bastías, Pantoja, et al. Reference Bastías, Pantoja, Leisewitz and Zárate2008; Ghosh Reference Ghosh2014; Forsberg Reference Forsberg2018). To enable more holistic patient management, a key objective has been the integration of services such as mental health and rehabilitative care (Schneider et al. Reference Schneider, English, Tabana, Padayachee and Orgill2014). However, in some contexts, PHC systems remain fragmented, with poorly coordinated services that compromise patient outcomes. To better address local health needs, community engagement has been promoted as a critical component (Bastías et al. Reference Bastías, Pantoja, Leisewitz and Zárate2008; Forsberg Reference Forsberg2018). Many countries recognize PHC as a cost-effective model for health service delivery (Tatar and Kanavos Reference Tatar and Kanavos2006; Mokrzycka, et al. Reference Mokrzycka, Kowalska-Bobko, Sagan and Włodarczyk2016), yet workforce shortages and limited funding continue to impede effective service provision in certain regions (Ghosh Reference Ghosh2014).

PHC financing

Many countries have increasingly adopted integrated payment models and performance-based payment systems to incentivize healthcare providers financially (Hu et al., Reference Hu, Zou and Shen2011; Lankarani Reference Lankarani2012; Harris et al., Reference Harris, Green, Brown, Roberts, Russell, Fournie, Webster-Bogaert, Paquette-Warren, Kotecha and Han2015; Biscaia Heleno Reference Biscaia and Heleno2017; Pu et al., Reference Pu, Huang, Wang and Gu2020). Recent reforms in healthcare financing policies have primarily focused on enhancing financial commitments from various governmental bodies (Tountas et al., Reference Tountas, Karnaki and Pavi2002; Bastías et al., Reference Bastías, Pantoja, Leisewitz and Zárate2008; Yip Hsiao Reference Yip and Hsiao2009; Baum et al., Reference Baum, Freeman, Jolley, Lawless, Bentley, Värttö, Boffa, Labonte and Sanders2013; Asaei Reference Asaei2014). Almost all reviewed financing reforms have sought to implement measures aimed at expanding health insurance coverage and mitigating catastrophic expenditures, particularly for marginalized populations, thereby advancing the pursuit of Universal Health Coverage (UHC) (Frenk et al., Reference Frenk, González-Pier, Gómez-Dantés, Lezana and Knaul2006; Unger et al., Reference Unger, De Paepe, Cantuarias and Herrera2008; Buivydiene et al., Reference Buivydiene, Starkiene and Smigelskas2010; Yu et al., Reference Yu, Whynes and Sach2011; Schneider et al., Reference Schneider, English, Tabana, Padayachee and Orgill2014; Heshmati Joulaei Reference Heshmati and Joulaei2016). However, the allocation of financial resources within many primary health care systems, especially in rural and underserved areas, remains a significant challenge (Hu et al., Reference Hu, Zou and Shen2011; Baum et al., Reference Baum, Freeman, Jolley, Lawless, Bentley, Värttö, Boffa, Labonte and Sanders2013). Furthermore, in numerous countries, financing models are heavily dependent on political will and external funding, raising concerns about their long-term sustainability (Lankarani Reference Lankarani2012; Tountas et al., Reference Tountas, Karnaki and Pavi2002).

PHC health workforce

Our analysis indicates that most reforms have aimed to enhance the training of personnel for primary health care while promoting the equitable distribution of qualified health professionals across various levels of health service delivery (Tashobya Reference Tashobya and Ogwal2004; Tatar Kanavos Reference Tatar and Kanavos2006; Yip Hsiao Reference Yip and Hsiao2009). Specific interventions have been designed to improve and expand training services by reforming medical education and implementing capacity-building programmes for primary health care workers, family physicians, community health professionals, and health graduate students. These initiatives are essential for equipping professionals to meet the evolving demands of clients and health systems, enabling them to provide comprehensive health services that encompass health promotion, prevention, improvement, and rehabilitation (Larizgoitia Starfield Reference Larizgoitia and Starfield1997; Hotchkiss et al., Reference Hotchkiss, Piccinino, Malaj, Berruti and Bose2005; Yasar Reference Yasar2011; Rahman et al., Reference Rahman, Angeline, David and Christopher2014; Setlhare Reference Setlhare2016). Nevertheless, critical issues such as shortages of well-trained primary health care personnel, inequitable distribution of the workforce, burnout, and job dissatisfaction must be urgently addressed to ensure the effectiveness and sustainability of primary health care systems.

PHC leadership and governance

Effective leadership and governance are pivotal in shaping robust PHC systems. Most reforms have prioritized initiatives aimed at enhancing service quality and ensuring accountability among health consumers and providers. This has been achieved through the implementation of comprehensive legislation, regulations, and standards designed to improve management, planning, healthcare purchasing, and monitoring and evaluation (Frenk et al., Reference Frenk, González-Pier, Gómez-Dantés, Lezana and Knaul2006; Bastías et al., Reference Bastías, Pantoja, Leisewitz and Zárate2008). Key strategies include the decentralization of administrative and regulatory functions, alongside the delivery of health services across various levels (Gauld Reference Gauld2001; Obermann et al., Reference Obermann, Jowett, Taleon and Mercado2008). Furthermore, promoting public-private partnerships, fostering multisectoral cooperation, strengthening the institutional capacities of Ministries of Health, and encouraging social participation have been critical. Political and religious commitments to provide financial, material, and human resources are also essential for enhancing health service delivery (Ghosh Reference Ghosh2014; van Weel et al., Reference van Weel, Turnbull, Ramirez, Bazemore, Glazier, Jaen, Phillips and Salsberg2016). Despite these advancements in leadership and governance within PHC, challenges remain. Effective coordination, community engagement, and equitable access to health services must be prioritized to fully realize the potential of these reforms.

PHC medical products, vaccines, and technologies

Recent reforms have focused on the introduction and improvement of essential medicines (Harvey et al., Reference Harvey, Kalanj and Stevanović2004; Hu et al., Reference Hu, Zou and Shen2011; Koornneef et al., Reference Koornneef, Robben, Al Seiari and Al Siksek2012), as well as the establishment of guidelines for drug production, prescription, pricing, and supply (Tenbensel Reference Tenbensel2008; Yip Hsiao Reference Yip and Hsiao2009; Koornneef et al., Reference Koornneef, Robben and Blair2017). Additionally, efforts to enhance infrastructure and increase the availability of essential equipment at the PHC level have been emphasized (Hotchkiss et al., Reference Hotchkiss, Piccinino, Malaj, Berruti and Bose2005; Atun et al., Reference Atun, Kyratsis, Jelic, Rados-Malicbegovic and Gurol-Urganci2007; Parfitt Reference Parfitt2009; Yasar Reference Yasar2011; Kuchenbecker Polanczyk Reference Kuchenbecker and Polanczyk2012). These interventions have successfully controlled prescription drug price inflation, facilitated service provision, ensured access to essential drugs, expanded vaccine coverage, improved the quality of prescribing practices by physicians, and updated leading health services. However, despite these efforts to improve access to medical products, vaccines, and technologies, inequities persist. During crises or pandemics, disruptions in supply chains have exacerbated vulnerabilities in access to essential medicines and vaccines (Harvey et al., Reference Harvey, Kalanj and Stevanović2004; Hotchkiss et al., Reference Hotchkiss, Piccinino, Malaj, Berruti and Bose2005).

PHC information

Several PHC information reforms have focused on enhancing health management through the establishment and implementation of advanced information systems (Gauld Reference Gauld2001; Hotchkiss, Piccinino, et al. Reference Hotchkiss, Piccinino, Malaj, Berruti and Bose2005; Xu et al., Reference Xu, Wang, Collins and Tang2007; Blumenthal and Dixon Reference Blumenthal and Dixon2012; Koornneef, Robben, et al. Reference Koornneef, Robben, Al Seiari and Al Siksek2012), the upgrading of health information systems (Frenk, González-Pier, et al. Reference Frenk, González-Pier, Gómez-Dantés, Lezana and Knaul2006; Yasar Reference Yasar2011), and the adoption of electronic health records (Tountas, Karnaki, et al. Reference Tountas, Karnaki and Pavi2002; Blumenthal and Dixon Reference Blumenthal and Dixon2012). Additionally, information technology networks have been established to facilitate seamless data exchange (Setlhare Reference Setlhare2016). These initiatives have collectively improved access to comprehensive health data, bolstered health information protection, enabled access to electronic records, facilitated indicator evaluation through electronic records, and supported continuous and effective service monitoring, thus preserving and utilizing health records to enhance patient care. Enhanced access to information has also provided policymakers with a robust basis for making informed decisions that aim to improve health outcomes (Yasar Reference Yasar2011; Setlhare Reference Setlhare2016). With the digitalization of health data, however, concerns around data privacy and security have become increasingly prominent (Blumenthal and Dixon Reference Blumenthal and Dixon2012; Yasar 2022). Furthermore, equitable access to health information remains a critical issue, necessitating careful consideration in the design and implementation of PHC reforms to ensure inclusivity in both availability and use (Frenk et al. Reference Frenk, González-Pier, Gómez-Dantés, Lezana and Knaul2006; Tountas et al. Reference Tountas, Karnaki and Pavi2002).

Enhanced access to information has also provided policymakers with a robust basis for making informed decisions that aim to improve health outcomes (Yasar Reference Yasar2011; Setlhare Reference Setlhare2016). With the digitalization of health data, however, concerns around data privacy and security have become increasingly prominent (Blumenthal and Dixon Reference Blumenthal and Dixon2012; Yasar 2022). Furthermore, equitable access to health information remains a critical issue, necessitating careful consideration in the design and implementation of PHC reforms to ensure inclusivity in both availability and use (Frenk et al. Reference Frenk, González-Pier, Gómez-Dantés, Lezana and Knaul2006; Tountas et al. Reference Tountas, Karnaki and Pavi2002).

Discussion

We systematically reviewed studies on interventions aimed at reforming PHC systems, assessing their objectives and outcomes using the WHO Health System Framework as a reference. Our findings indicate that most policy reforms focused on expanding service delivery, improving financing, and providing essential medicines and technology to meet the health care needs of populations.

In response to the challenges facing PHC, numerous countries have implemented targeted reforms to strengthen their health systems (Mulligan and Castañeda Reference Mulligan and Castañeda2018). The specific context of each country, alongside the priorities set by policymakers and planners, has influenced the nature and scope of these reforms. For example, in the United States, the Affordable Care Act was enacted to expand health insurance coverage and improve access to care (Gaffney and McCormick Reference Gaffney and McCormick2017). In the United Kingdom, the National Health Service (NHS) has undergone multiple reforms aimed at increasing system efficiency and enhancing patient outcomes (Alderwick and Dixon Reference Alderwick and Dixon2019). Iran, likewise, has introduced several notable PHC reforms over recent decades, including the NHS Corps Law (1964), the establishment of the National Health Network (1985), the implementation of the Rural Family Physician programme (2005) (Shirjang et al. 2020), and the Health Transformation Plan (2014) (Nasseri et al. Reference Nasseri, Sadrizadeh, Malek-Afzali, Mohammad, Chamsa, Cheraghchi-Bashi, Haghgoo and Azmoodeh1991; Heshmati and Joulaei Reference Heshmati and Joulaei2016; Takian et al. Reference Takian, Rashidian and Doshmangir2015; Doshmangir et al. Reference Doshmangir, Moshiri, Mostafavi, Sakha and Assan2019). These initiatives reflect a range of strategies adapted to meet local needs and priorities in strengthening PHC delivery. Reform efforts are often shaped by each country’s specific challenges, political environment, and economic conditions (Chernichovsky Reference Chernichovsky2019). In Western Europe, for example, health systems tend to focus on equitable access, public financing, and comprehensive coverage (Van Loenen et al. Reference Van Loenen, Van den Berg, Heinemann, Baker, Faber and Westert2016), whereas the U.S. relies more on a private, market-driven health care system (Mulligan and Castañeda Reference Mulligan and Castañeda2018). In Latin America, reforms emphasize universal health coverage and strengthening primary care, as seen in Brazil’s Integrated Health System (SUS) and Mexico’s Seguro Popular programme (Arredondo et al. Reference Arredondo, Orozco and Recaman2018).

Despite these reforms, some critical areas are often neglected. For example, prevention and primary care do not always receive the attention they deserve, and mental health is still widely overlooked in many countries (McConville and Hooven Reference McConville and Hooven2021; Stumbo et al. Reference Stumbo, Yarborough, Yarborough and Green2018). Health inequities, driven by socioeconomic or geographic disparities, remain inadequately addressed in many systems (Oberg et al. Reference Oberg, Colianni and King-Schultz2016). In terms of service delivery, many countries have prioritized expanding PHC services in both urban and rural areas. This has often involved collaboration between public and private providers, especially in nations like New Zealand (Gauld Reference Gauld2001), China (Yip and Hsiao Reference Yip and Hsiao2009), South Africa (Schneider et al. Reference Schneider, English, Tabana, Padayachee and Orgill2014), and Mexico (Frenk et al. Reference Frenk, González-Pier, Gómez-Dantés, Lezana and Knaul2006). The Family Physician programme has proven effective in delivering comprehensive care at a low cost, which has made it a central feature of many health reforms (Yordy and Vanselow Reference Yordy and Vanselow1994; Shirjang et al. Reference Shirjang, Mahfoozpour, Masoudi Asl and Doshmangir2020). Countries such as Turkey, Spain, Kosovo, Sweden, Australia, and Iran have all focused on improving PHC as a critical element of their reform efforts (Tatar and Kanavos Reference Tatar and Kanavos2006; Larizgoitia and Starfield Reference Larizgoitia and Starfield1997; Percival and Sondorp Reference Percival and Sondorp2010; Forsberg Reference Forsberg2018; Heshmati and Joulaei Reference Heshmati and Joulaei2016).

In PHC delivery, private sector has a larger role. Countries like Sweden, Australia, and Iran have harnessed the capacities of non-governmental organizations (NGOs) and private providers to address health care challenges, particularly in underserved areas (Palmer Reference Palmer2000). These efforts have contributed to the progress toward Universal Health Coverage (UHC), as evidenced by increased access to PHC in countries such as China, Turkey, Sweden, Uganda, Brazil, and Iran (Yip and Hsiao Reference Yip and Hsiao2009; Hone et al. Reference Hone, Gurol-Urganci, Millett, Başara, Akdağ and Atun2017; Tashobya Reference Tashobya and Ogwal2004; Shadpour Reference Shadpour2006). In some countries like Sweden, voluntary providers, such as NGOs, community health workers, and other non-profit entities provides PHC services such as prevention, promotion and chronic disease management, particularly in remote and underdeveloped areas.

Health financing reforms have been another major focus, with many countries revising service packages and reducing out-of-pocket expenses to protect low-income groups (Kutzin Reference Kutzin2013; Kieny and Evans Reference Kieny and Evans2013). Performance-based financing mechanisms have been used to encourage preventive care, especially in remote areas, as seen in countries like China, Turkey, Canada, and Iran (Tang et al. Reference Tang, Meng, Chen, Bekedam, Evans and Whitehead2008; Heshmati and Joulaei Reference Heshmati and Joulaei2016). Expanding social health insurance has also been a successful strategy in countries such as China, Chile, South Africa, Mexico, and Iran to improve access and reduce the financial burden of medical expenses (Meessen et al. Reference Meessen, Soucat and Sekabaraga2011).

Finally, evidence highlights the importance of strong political leadership and sustained financial investment in ensuring successful health system reforms (Faye et al. Reference Faye, Bob, Fall and Fall2012). Countries that implement reforms with robust monitoring systems tend to experience fewer challenges and better health outcomes (Griswold et al. Reference Griswold, Makoka, Gunn and Johnson2018).

Strengths and Limitations of the study

Given the broad scope of the subject, our study was restricted to peer-reviewed publications, excluding grey literature, which may have limited the comprehensiveness of our review. However, by incorporating a wide range of study designs, including qualitative, quantitative, and mixed-methods research, we were able to provide a thorough and nuanced analysis of the available evidence.

Conclusion

Despite substantial progress towards UHC, health systems globally continue to face persistent challenges that threaten sustainable health development. Many of the reviewed reforms in PHC and public health have focused on advancing UHC by expanding service delivery in both rural and urban areas, establishing and enhancing service provider networks, increasing budget allocations to public health and PHC, and expanding family physician programmes, alongside efforts to build the capacity of PHC workers. Achieving sustainable progress towards UHC requires carefully planned, evidence-based policy interventions that strengthen the PHC system, with a focus on improving governance and leadership. While cross-national learning is essential, reform strategies must be tailored to the specific national context through the application of contextually relevant models.

Supplementary material

The supplementary material for this article can be found at https://doi.org/10.1017/S1463423625000271

Acknowledgements

We acknowlege the financial support from Tabriz Health Services Management Research Center, Tabriz Unviersity of Medical Sciences, Tabriz, Iran.

Author contributions

L.D and A.Sh designed and conducted the study, analyzed the data and drafted the manuscript. MB contributed in reviewing articles, extracting the data and finalizing the manuscript. VSG contributed to interpreting the findings and revising the manuscript intellectually. The authors read and approved the final manuscript.

Funding statement

The study was funded by Tabriz Health Services Management Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.

Ethical standards

This study was approved by the Ethics Committee of Tabriz University of Medical Sciences, Tabriz, Iran (Approval No: IR.TBZMED.REC.1398.196)

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Figure 0

Figure 1. Diagram of the selection of articles for review.

Figure 1

Table 1. Study characteristics

Figure 2

Table 2. Primary health care reforms under the six building blocks

Figure 3

Figure 2. Conceptual presentation of findings.

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