Introduction
The primary objective of a healthcare system is to enhance the health status of individuals and populations, enabling active participation in economic and social activities (Franken and Koolman, Reference Franken and Koolman2013). The World Health Organization (WHO) strongly advocates for primary health care (PHC) as the foremost strategy for countries to achieve this goal (Starfield et al., Reference Starfield, Shi and Macinko2005). In the early 21st century, there is a renewed emphasis on PHC to attain health objectives, improve health indicators, and effectively address current and future population needs (Hone et al., Reference Hone, Macinko and Millett2018). A crucial historical milestone in healthcare services provision was the international community’s decision to adopt the primary healthcare strategy, aiming to introduce justice into the health system (King, Reference King2000).
WHO’s annual reports in 2003 and 2008 reiterated the importance of PHC (Van Lerberghe, Reference Van Lerberghe2008; World Health Organization, 2003). The global conference on PHC held in October 2018, marking the 40th anniversary of the Almaty Declaration, aims to celebrate its principles and reaffirm political commitment to making PHC the cornerstone of global health coverage and sustainable development goals (World Health Organization, 2018).
After 45 years, PHC has yielded remarkable results, particularly in rural areas, but recent years have presented challenges, especially in urban areas. Key challenges include an aging population, a shift from infectious diseases to non-communicable diseases, evolving healthcare needs, resource instability, a hospital-oriented approach, use of untrained physicians in managerial roles, urbanization, and increased health needs in suburbs (Sheikhattari and Kamangar, Reference Sheikhattari and Kamangar2010, Macinko et al., Reference Macinko, Starfield and Erinosho2009, Jenkins-Clarke and Carr-Hill, Reference Jenkins-Clarke and Carr-Hill2001, Tabrizi et al., Reference Tabrizi, Gholipour, Farahbakhsh and Hasanzadeh2017). Developing countries face additional issues like poor quality of care, inadequate financial resources, insufficient equipment and training, problems in the referral system, and a tendency to allocate resources to higher service levels (Sturmberg et al., Reference Sturmberg, O’Halloran and Martin2012).
While most studies on health service quality improvement have focused on diagnostic and medical processes in secondary and tertiary service levels, PHC is also susceptible to process errors, organizational flaws, communication issues, and staff errors. Recognizing the need for change and reform in existing processes is imperative, as studies confirm the severe complications arising from errors in low-quality PHC (Allen, Reference Allen2000, Azimzadeh et al., Reference Azimzadeh, Tabrizi, Azami and Gholipour2023, Gholipour et al., Reference Gholipour, Tabrizi, Asghari Jafarabadi, Iezadi, Farshbaf, Farzam Rahbar and Afsharniya2016). Therefore, a fresh perspective accompanied by change, reform, innovation, and initiative is crucial for PHC.
In recent years, numerous countries have acknowledged the necessity of designing programs and interventions to enhance and innovate their PHC systems. Notably, the United Kingdom has established Accountable Care Organizations (Shortell et al., Reference Shortell, Addicott, Walsh and Ham2014), Australia has initiated PHC networks (Booth et al., Reference Booth, Hill, Moore, Dalla, Moore and Messenger2016), South Africa has undertaken the ‘Primary Health Care Reengineering’ project and instituted the District Health System (Kautzky and Tollman, Reference Kautzky and Tollman2008), and Estonia has introduced a family medicine-centered PHC model (De Maeseneer, Reference De Maeseneer2016). Additionally, Bosnia has implemented autonomous health teams (Atun et al., Reference Atun, Kyratsis, Jelic, Rados-Malicbegovic and Gurol-Urganci2007), Canada has launched Family Medicine Groups, incorporating local service, network, and network clinic models (Levesque et al., Reference Levesque, Pineault, Provost, Tousignant, Couture, da Silva and Breton2010, Pineault et al., Reference Pineault, da Silva, Prud’homme, Fournier, Couture, Provost and Levesque2014b), Turkey has established a Family Medicine model unit (Hone et al., Reference Hone, Gurol-Urganci, Millett, Başara, Akdağ and Atun2017), Brazil has embraced multi-professional teams in basic health units(de Mello et al., Reference de Mello, Tonini, da Silva, Dutt-Ross and de Souza Velasque2017), Spain has initiated a multidisciplinary teams-risk stratification model (Doñate-Martínez, Reference Doñate-Martínez2017), and Kazakhstan has established HealthCity and disease management programs (Sharman, Reference Sharman2014). These initiatives, along with various projects and programs in other countries, underscore the global recognition of the significance of the PHC system and the collective effort to reform and strengthen it.
In 2007, WHO published a framework known as the ‘WHO building blocks’, focusing on the need to strengthen health systems and providing a common conceptual understanding of a health system for assessment and comparison. The framework comprises six building blocks: financing, health workforce, health information system, medical products and technology, service delivery, and governance. This framework serves as a comprehensive tool for assessing health systems, emphasizing the interconnected nature of its components and their collective effectiveness in delivering high-quality, equitable care to all who need it (Alvarez-Rosete et al., Reference Alvarez-Rosete, Hawkins and Parkhurst2013, WHO, 2007, Jabeen et al., Reference Jabeen, Rabbani and Feroz2021).
Therefore, leveraging the experiences of leading countries and adopting a fresh perspective on PHC can offer practical, evidence-based solutions to achieve universal health coverage and strengthen the health system for health policymakers.
Method
This study aims to identify global initiatives and innovations in PHC through a scoping review. It encompasses articles and reports published from January 1, 2000, onward that detail global interventions, initiatives, and best practices for establishing and reinforcing PHC.
In this study, we adopted the Arkesy and O’Malley framework (Arksey and O’Malley, Reference Arksey and O’Malley2005) the first methodological framework for conducting scoping review research, published in 2005. Following this framework, we executed six steps: identification of the research question, identification of related studies, screening and selection of studies, categorization of data, and, finally, summarization and reporting of results, along with the provision of practical tips and advice.
First step: Identifying the research question
The primary research question is, ‘How are innovations and reforms related to PHC in different countries?’ This encompasses specific queries:
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In which countries are primary healthcare innovations and initiatives prevalent?
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What are the goals/aims of primary healthcare innovations and reforms in different countries?
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For which areas and services have primary healthcare innovations and reforms been applied?
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What mechanisms for financing and payment are considered in primary healthcare innovations and reforms in different countries?
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What are the results and achievements of primary healthcare innovations and reforms in the world?
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What limitations did primary healthcare innovations and reforms face?
Second step: Identifying related studies
We conducted a search using Scopus, Web Of Science, and PubMed databases from January 1, 2000, to December 31, 2022. Keywords were determined through similar studies, expert opinions, librarians’ insights, and Medical Subject Headings (MeSH). Primary search keywords included the following: primary health care, primary health services, basic health care, public health, primary care, reform, Strength*, Transform*, innovation, initiative, etc. Additionally, a manual search of journals, references of selected articles (Reference of Reference), review of organizational reports, published government documents, and websites was conducted. Inclusion criteria for articles and reports included being published after 2000, published in English, and related to innovation in PHC. In this study, innovation refers to programs, plans, interventions, initiatives, and any new changes aimed at reforming and strengthening the primary healthcare system. The innovative model of PHC encompasses changes and innovations in organizational structure, communication between system components, service packages, human resources, main goals and approaches of care, payment systems and resource management, monitoring and evaluation approaches, as well as management and leadership of the PHC system to enhance performance and adapt to the existing requirements and conditions of the country.
Search strategy in PubMed : (“Primary health care“[Title/Abstract] OR “Primary healthcare“[Title/Abstract] OR “Primary care“[Title/Abstract] OR “Primary health service“[Title/Abstract] OR “Public health care“[Title/Abstract] OR “Public healthcare“[Title/Abstract] OR “family medicine“[Title/Abstract] OR “family physician“[Title/Abstract] OR “family practice“[Title/Abstract] OR “Public health service“[Title/Abstract]) AND (“loattrfull text“[Filter] AND 2000/01/01:2022/12/31[Date - Publication] AND “english“[Language]) AND ((“reform“[Title/Abstract] OR “innovat*“[Title/Abstract] OR “transform*“[Title/Abstract] OR “initiat*“[Title/Abstract] OR “strengthen*“[Title/Abstract]) AND (“loattrfull text“[Filter] AND 2000/01/01:2022/12/31[Date - Publication] AND “english“[Language]))
Third step: selection/screening of studies
All stages of article selection and screening were independently conducted by two members of the research team. In the initial stage, any disputed cases were resolved through discussion, and if necessary, a third person with more information and experience was consulted. The first step involved reviewing the titles of all articles, excluding those not aligning with the study’s objectives. Subsequent steps involved studying the abstracts and full texts to identify and exclude studies that met the exclusion criteria, such as poor relevance to study objectives, insufficient information, and focus on specific groups/diseases/ items.
Considering variations in the structure of providing PHC across countries, two researchers examined the information in each study to determine its relevance to PHC and whether it included innovation. Based on the information presented and agreement between the researchers, decisions were made regarding the selection of articles or reports. Any discrepancies between the two researchers were resolved through discussion. In cases where no agreement was reached, a third person with higher expertise and experience in the field of PHC was consulted.
Endnote X9 resource management software was utilized for organizing, reading titles and abstracts, and identifying duplicates. The 2020 PRISMA flowchart was employed to report the results of the selection and screening process.
The fourth step: segmentation of data
Following the elimination of articles that did not meet the inclusion criteria, the full text of all qualifying articles underwent a comprehensive review. The research team designed a data extraction form to gather essential information, including interventions, strategies, achievements, outcomes, innovation components, etc.
Initially, the data extraction form was manually created in the software environment of Microsoft Word 2010. To refine the form, data from three articles were extracted as a test, and any deficiencies or issues were addressed. Two individuals independently extracted the information, and any ambiguities were resolved through consultation with members of the research team. Extracted information encompassed details such as the name and year of the innovation/reform, country, the aim of the innovation/reform, target group, management, financing and payment, type of services, service provider staff, results of the innovation/reform, policy /considerations, and limitations.
In cases where discrepancies arose between the two individuals, consensus was reached through discussion. If no agreement was reached, the contested cases were referred to a third person with greater expertise and experience in the field.
Subsequently, the findings were summarized and classified based on the WHO’s framework of six building blocks, illustrating the changes and performance of health systems. Notably, our analysis revealed no reportable findings for the item of medical products.
The fifth step: Summarizing and reporting the results
Following the extraction of information using the data extraction form, a manual analysis was conducted, and the findings were summarized and reported using the content analysis method. Thematic analysis, a valuable method for qualitative data analysis, was employed to identify, analyze, and report patterns (themes) in the text (Graneheim and Lundman, Reference Graneheim and Lundman2004). Data coding was carried out independently by two researchers. Following the extraction of information using the data extraction form, a manual analysis was conducted, and the findings were summarized and reported using the content analysis method. Thematic analysis, a valuable method for qualitative data analysis, was employed to identify, analyze, and report patterns (themes) in the text. Data coding was carried out independently by two researchers.
The stages of data analysis and coding were as follows: becoming familiar with the text of the articles (immersion in the results of the articles), identifying and extracting the primary fields (articles mostly related to the primary fields), categorizing the articles within specified fields, reviewing and enhancing the results of each field using the findings of the articles, and ensuring the reliability of the fields and extracted results in each field. In cases of disagreement between the two researchers, resolution was reached through discussion, and disputed issues were addressed between the two coders. In the absence of agreement, the dispute was referred to a third person.
The findings were subsequently summarized and classified based on the WHO’s framework of six building blocks (WHO, 2007), illustrating the changes and performance of health systems. The six building blocks, constituting a health system, encompass service delivery, health workforce (human resources), information (data and data systems), medical products, vaccines and technologies, financing, and leadership and governance (stewardship). Strengthening these six building blocks is essential to achieving the overall goals of a health system, including improved health, responsiveness, social and financial risk protection, and improved efficiency. Intermediate goals such as access, coverage, quality, and safety were considered as ‘aims’, while overall goals were referred to as ‘outcomes’. Additionally, two categories, ‘policy /considerations’ and ‘limitations’, were incorporated into the analysis and report. According to our findings, no reportable information was obtained for the item of medical products.
The sixth step: Providing practical guidance and recommendations
Based on the extracted results and the opinions of the research team members, guidance and recommendations were formulated in the form of an article discussion.
Results
Through database searches, we initially identified 39,426 articles, and post-duplicate removal, 28,601 articles remained. Subsequently, these records underwent screening based on title, followed by scrutiny of abstracts and full texts. Upon completing this screening phase, 106 studies were included in the analysis. The search and selection process are visually presented in Figure 1.
Diagram of a scoping review.
The necessary data were then extracted from these final 106 studies, utilizing a data extraction table, which led to the identification of 55 innovations/reforms. Subsequently, data analysis was conducted from various dimensions.
Our study’s findings reveal that the most significant number of reforms and innovations within the PHC systems of different countries occurred during the period 2000–2008. Canada emerged as the leader in implementing reforms, boasting 10 significant reforms, followed by Estonia with six reforms.
Qualitative analysis categorized the study’s findings, as depicted in Figure 2, and these categories will be expounded upon in detail.
Classification of study findings and the respective number of main subcategories for each subject.
In the analysis of innovation/reform ‘Aims’, using the content analysis method, 63 codes were extracted which were classified into 4 categories (Access, Coverage, Quality, and Safety) with 32 subcategories based on six building block framework (Table 1). Improving the quality of care, improving the effectiveness of monitoring and evaluations, improving financial and geographical access, improving the exchange of information at different levels, early diagnosis of diseases, improving the quality and quantity of follow-ups, etc. are among the most frequent aims mentioned in the studies for PHC.
Aims of primary healthcare initiatives
In the analysis of the ‘Stewardship/Leadership’ component, encompassing countries that have undergone changes and reforms in this domain, 33 codes were identified and subsequently categorized into three overarching groups: ‘Level of Management’, ‘Mechanism’, and ‘Interaction (with gov)’. Each of these three categories is further divided into subcategories that delineate various levels and types of stewardship in PHC, the mechanisms and approaches for managing these responsibilities, and the ways in which these organizations interact with governments. Each category comprises several components, providing a comprehensive overview, as outlined in Table 2.
Stewardship of PHC initiatives
In the analysis of the ‘Financing & Payment’ component, examining countries that have initiated changes and reforms in the realm of PHC, we extracted 45 codes. These codes were subsequently organized into 8 overarching themes/categories, with the financing part encompassing ‘State Government’ and Taxation’, and the payment part featuring ‘Salary’, ‘Pay-for-Performance’, ‘Combined Payments’, ‘Capitation’, ‘Budget’, and ‘Bonus’, as illustrated in Table 3.
Financing & payment of PHC initiatives
Among the various payment methods identified in our findings, ‘Pay-for-Performance’ emerged as the most prevalent. This method was evident in PHC innovations and reforms in countries such as Canada, Brazil, Hungary, Portugal, England, and Sri Lanka, where payments are typically contingent on the attainment of diverse indicators, including quality indicators. Following closely, ‘Capitation’ and ‘Combined Payments’ were noted as the next frequently employed payment methods, identified in various studies as suitable mechanisms for remunerating PHC services.
In the analysis of the ‘services delivery’ component, in the countries that have made changes and reforms in this field of PHC, 84 codes were extracted which were classified into 5 categories/themes (Promotion, Prevention, Diagnosis, Treatment, and Rehabilitation). Among the types of services added or strengthened in new PHC systems, prevention and promotion services had wider and more diverse programs, and more studies have pointed to them. A number of studies have also spoken about the need to include rehabilitation care in PHC. These contents are detailed in Table 4.
Service delivery in PHC initiatives
In the analysis of the ‘workforce’ component, in the countries that have made changes and reforms in this field of PHC, 85 codes were extracted which were classified into 9 categories/themes (physicians, specialist, psychologist, pharmacist, nurse, dentist, community health worker, clinical staff, Administrative staff) as shown in Table 5. The addition of personnel such as nutritionists, psychologists, dentists, and community health worker, to PHC has been an interesting initiative in different countries.
Health workforce of PHC initiatives
In the analysis of the ‘Information’ component, in the countries that have made changes and reforms in this field of PHC, 14 codes were extracted which were classified into 3 categories/themes (Human resource development, Quality improvement, Resource management) as shown in Table 6. Electronic prescriptions, use of electronic health records, creation of extensive databases, paying attention to the social variables of patients using databases and software were some of the initiatives considered in different countries.
Information on PHC initiatives
In the analysis of the ‘Outcomes’ component, in the studies that have mentioned the result/effect of reforms in PHC, 31 codes were extracted which were classified into 4 categories/themes based on the framework of six building blocks (Improved health, Improved efficiency, Responsiveness, and Social & financial protection) which are detailed in Table 7. Reducing hospitalization, increasing life expectancy, reducing the use of medical services, guideline-oriented care, increasing physician productivity, etc. were some of the outcomes of interest for innovation in PHC.
Outcomes of PHC initiatives
In the analysis of ‘Policies/consideration’, in the studies that have mentioned political considerations of PHC reform, 36 codes were extracted which were classified into 7 categories/themes (using facilitator, Gradual change, Flexibility& Integration with existing systems, Evidence-based performance, communication, and interaction & team working, Government/ Political support, Empowerment), the details of which are given in Table 8. Focusing on initial changes before making major changes, flexibility in designing structures and teams, participation of service providers and creating a suitable and flexible environment for implementing innovations, were the common policies/considerations used in different countries to reform and innovate in Primary health care.
Policies/ considerations in PHC initiatives
In the analysis of ‘limitations’ in the studies that have mentioned limitations of PHC reforms, 27 codes were extracted which were classified into 6 categories/themes (economic, management, service delivery, staff, structure, type of services), as shown in Table 9. Requiring substantial investment by the government, lack of an economic evaluation, mainly physician-centric governance, hospital-based system and focusing decisions at the top levels of the organization were the common limitations of many countries in primary health care innovation.
Limitations of PHC initiatives
Discussion
Reforming and reshaping healthcare is a widespread endeavor in numerous countries, constituting a protracted and challenging process. This trend has gained momentum, particularly since the inception of the current century (Kezunovic et al., Reference Kezunovic, Drecun and Svab2013). This study endeavors to synthesize the diverse experiences of various nations in the realm of innovations and reforms within their healthcare systems.
To date, compelling evidence underscores the efficacy of PHC in attaining the fundamental objectives of healthcare systems. In recent years, noteworthy strides in reforms and innovations within this type of care, especially in low- and middle-income countries, have accentuated its success, particularly in dimensions such as access and equity (Kruk et al., Reference Kruk, Porignon, Rockers and Van Lerberghe2010). Nonetheless, the task of fortifying health systems to enhance the prevailing state of service delivery and implementing cost-effective interventions, with varying approaches across different countries, is inherently intricate. This complexity stems from the influence of financial and human resources, coupled with the distinct political perspectives of each country. Moreover, effective governance, financial and delivery structures within health systems, and adept implementation strategies are imperative (Lewin et al., Reference Lewin, Lavis, Oxman, Bastías, Chopra, Ciapponi, Flottorp, Martí, Pantoja and Rada2008).
Divergent viewpoints also exist regarding the constituent elements of health systems. An alternative perspective introduces a taxonomy of health system arrangements, which further categorizes and distinguishes between governance arrangements (pertaining to political, economic, and administrative authority in health system management), financial arrangements (encompassing funding and incentive systems, as well as financing), delivery arrangements (including human resources for health and service delivery), and interventions (comprising programs, services, and technologies) (Lavis et al., Reference Lavis, Ross and Hurley2002; Europe, 2006). Notably, many explanations of health system elements overlook the crucial aspect of implementation strategies supporting the utilization of cost-effective interventions (Grol and Grimshaw, Reference Grol and Grimshaw2003).
The health systems of various countries have endeavored to implement changes and reforms across diverse aspects and elements of their PHC, tailoring these initiatives to address specific needs and existing challenges. Each nation has strategically planned innovations and reforms, each with distinct aims and goals. The outcomes of these endeavors have yielded results and consequences, sometimes aligning with their original objectives and at other times deviating from them.
Our findings indicate a discernible trend where countries are increasingly modifying their primary care systems with overarching aims and goals. These include enhancing the quality of care and mitigating the likelihood of hospitalization, establishing an integrated model spanning primary, hospital, and home levels, ensuring superior patient management, facilitating better access to comprehensive health services, fostering an interprofessional care model, restructuring primary care, refining referral systems, enhancing the coordination of care, and transitioning care away from hospitals, among other objectives. Notably, the long-term outcomes of these changes have consistently manifested in improvements in the overall health of the society, increased equity in health, enhanced access to services, improved responsiveness of the health system, and heightened efficiency in service provision. These achievements align with the parameters outlined in the six building block framework.
Concerning the interaction with the government in innovative PHC ‘stewardship/leadership’, various systems exhibit different approaches, categorized as government-dependent, independent, coordinated, or participatory. For instance, Canada’s Family Health Networks (FHNs) exemplify a coordinated system where physicians, either physically co-located or working virtually, emphasize system coordination (Aggarwal and Williams, Reference Aggarwal and Williams2019). In government-dependent systems, tasks such as planning, monitoring, and setting regulations often involve government intervention. In Estonia, for instance, the government takes on responsibilities for planning and regulatory functions (Koppel et al., Reference Koppel, Leventhal and Sedgley2009). Similarly, Bosnia and Herzegovina adopts a decentralized approach, with a federal ministry facilitating services through contracts between insurers and PHC providers (Atun et al., Reference Atun, Menabde, Saluvere, Jesse and Habicht2006). Brazil showcases decentralization in public health monitoring (de Mello et al., Reference de Mello, Tonini, da Silva, Dutt-Ross and de Souza Velasque2017). In China, the government assumes a central role in community health services, where services are delivered by centers under government leadership. This underscores the significant influence of the government in shaping and overseeing PHC initiatives (mention the source if available) (Lin et al., Reference Lin, Sun, Peng, Cai, Geanacopoulos, Li, Zhao, Zhang and Chen2015). Our findings indicate a general trend over the past 22 years wherein new PHC structures have transitioned from governmental control to more participatory models involving municipalities. This shift has been substantiated by several studies (Lahariya, Reference Lahariya2019, Nickell et al., Reference Nickell, Tracy, Bell and Upshur2020) which assert that management by municipalities can yield superior outcomes in health management and contribute to the enhancement of health indicators. This is attributed to the comprehensive understanding that local managers possess regarding their regions, enabling them to have a profound knowledge of the health and social challenges faced by the residents in those areas.
In terms of ‘payment’ methods, PHC systems have undergone diverse experiences. Certain countries, like Canada, have consistently expressed a clear preference for the combined payment method, emphasizing its use over the years (Aggarwal and Williams, Reference Aggarwal and Williams2019). A crucial point highlighted in our findings is that Fee-for-Service payments were exclusively in the form of combined payments within PHC systems, with no separate instances of utilization.
Within combined payments, bonus and incentive payments played a significant role, addressing various factors such as enhancing access and providing specialized services. It is noteworthy that some argue that, considering the nature of PHC services, which may not induce additional needs, using the combined payment method is a suitable approach. Nevertheless, regardless of the payment method chosen, models for PHC should ideally be flexible, forward-looking, and oriented towards achieving end outcomes rather than solely focusing on process measures. Such models contribute to both patient and provider satisfaction (Azimzadeh et al., Reference Azimzadeh, Tabrizi, Azami and Gholipour2023, Bazemore et al., Reference Bazemore, Phillips, Glazier and Tepper2018).
In the context of ‘services provided’ within the primary care systems of countries spearheading reforms, there is a notable emphasis on prevention and early patient identification. Consequently, preventive and diagnostic services, including laboratory tests and imaging, are particularly focused on screening for chronic diseases such as diabetes, cardiovascular disease, and cancer. Additionally, acknowledging the contemporary living conditions, mental health has been integrated into the primary care structure in a significant number of countries.
Beyond these aspects, several countries have directed their attention to health promotion services. By offering services such as behavioral health, physical exercise programs, promotion activities addressing obesity and healthy lifestyle behaviors, environmental health services, and communicable disease surveillance; they aim to achieve long-term results and prevent diseases from permeating communities. This approach aligns with the fundamental nature of PHC, which centers on delivering services at the family and community levels, with the goal of reducing the incidence and spread of diseases within communities. (Bheekie and Bradley, Reference Bheekie and Bradley2016, Ditta and Ahmed, Reference Ditta and Ahmed2019, Matulis and Lloyd, Reference Matulis and Lloyd2018). The linkage between the services provided and payment methods is crucial. Shifting payment methods towards health-oriented care with long-term outcomes improves both the quantity and quality of these services. For instance, when payments are directed towards services such as self-care education, healthy lifestyle promotion, and screening, providers prioritize these essential aspects. Therefore, paying careful attention to payment methods is fundamental when planning the types of services to be prioritized.
However, in certain countries, like Canada, the overarching goal has been to encompass all types of services and provide comprehensive care within the structure of the primary care system (Aggarwal, Reference Aggarwal2009; Aggarwal and Williams, Reference Aggarwal and Williams2019; Goldman et al., Reference Goldman, Meuser, Rogers, Lawrie and Reeves2010).
Concerning the ‘health workforce’, various countries have employed diverse job fields. However, a noteworthy revelation from our findings is the recent trend in numerous countries towards utilizing multi-tasking and multi-skilled personnel. This includes professionals such as general practitioners, family physicians, community health workers, nurses, and clinical staff. This shift has been underscored in studies related to PHC initiatives, emphasizing the efficiency and cost-effectiveness of such personnel. Moreover, this approach presents opportunities for expanding coverage and mitigating human resource shortages. Studies also highlight the pivotal role of working conditions, personnel training, and collaborative activities within health teams in enhancing the productivity of human resources. These aspects have been consistently emphasized in the literature. (Rule et al., Reference Rule, Ngo, Oanh, Asante, Doyle, Roberts and Taylor2014; Lewin et al., Reference Lewin, Lavis, Oxman, Bastías, Chopra, Ciapponi, Flottorp, Martí, Pantoja and Rada2008; Rabkin et al., Reference Rabkin, Mutiti, Mwansa, Macheka, Austin-Evelyn and El-Sadr2015).
The significance of collecting and utilizing ‘information’ in the health sector has been underscored in various studies, playing a pivotal role in the PHC initiatives of different countries. For instance, Spain’s PHC innovations are grounded in information use, emphasizing continuous improvement and real innovation through relevant software utilization and the creation of extensive databases. In Spain, the implementation of a variety of care programs based on the health and social needs of patients was sought through the utilization of variables in electronic Health Information Systems (Abos Mendizabal et al., Reference Abos Mendizabal, Nuño Solinís and Zaballa González2013; Doñate-Martínez, Reference Doñate-Martínez2017, Prades and Borràs, Reference Prades and Borras2011). Similarly, numerous countries have pursued innovations in PHC by seeking electronic prescriptions, utilizing electronic health records, maintaining computer-based medicine records, and facilitating information exchange between clinical settings to enhance efficiency and reduce paperwork and duplication (Atun et al., Reference Atun, Gurol-Urganci, Hone, Pell, Stokes, Habicht, Lukka, Raaper and Habicht2016, de Mello et al., Reference de Mello, Tonini, da Silva, Dutt-Ross and de Souza Velasque2017, Lahariya, Reference Lahariya2019). Technological advances have paved the way for online health services like remote monitoring and consultation, enabling greater service accessibility irrespective of geographic location and empowering patients to actively participate in their clinical treatment. This active role encompasses patient participation, involvement, adherence, and compliance (Menichetti et al., Reference Menichetti, Libreri, Lozza and Graffigna2016). Digital tools such as patient portals and mobile applications offer convenience to both providers and patients, providing easier access to health records and clinical expertise while minimizing the collection of health data. These tools have the potential to enhance patient experiences and transform the patient-provider relationship from a paternalistic to a patient-centered model (Perakslis and Ginsburg, Reference Perakslis and Ginsburg2021, Ravoire et al., Reference Ravoire, Lang, Perrin, Audry, Bilbault, Chekroun, Demerville, Escudier, Gueroult-Accolas and Guillot2017, Schofield et al., Reference Schofield, Shaw and Pascoe2019).
Despite the evident benefits, countries encountered challenges and limitations in implementing reforms and initiatives within their existing PHC. To address these challenges, they employed necessary considerations and policies, aiming to eliminate or reduce the adverse effects caused by the implementation of new systems and ensure compatibility. Various challenges – economic, structural, and managerial – sometimes emerge unexpectedly in the path of PHC innovations and initiatives. However, drawing from the experiences of others and the findings of similar studies, it is possible to mitigate and reduce their effects. For example, Abos Mendizabal et al.’s study in 2013 emphasizes the need for a comprehensive economic evaluation of the value of ideas against the cost of their development and implementation before initiating innovations and reforms (Abos Mendizabal et al., Reference Abos Mendizabal, Nuño Solinís and Zaballa González2013). Rabkin et al.’s study in 2015 suggests that more research may be necessary to determine optimal approaches to program design and delivery, emphasizing that changes should not be rushed (Rabkin et al., Reference Rabkin, Mutiti, Mwansa, Macheka, Austin-Evelyn and El-Sadr2015). Fausto MCR et al.’s study in 2018 points out that some challenges are related to the objective aspects of work organization, advocating for operational and pilot investigations before the final launch (Fausto et al., Reference Fausto, Rizzoto, Giovanella, Seidl, Bousquat, Almeida and Tomasi2018).
Conclusion
In conclusion, it can be affirmed that the fortification of PHC necessitates the commitment, coordination, and collaboration of a broad spectrum of organizations, both health-related and unrelated, requiring a comprehensive health-oriented approach within the country’s macro-policies.
The findings of this study offer distinct insights for policymakers and health system managers, potentially yielding valuable outcomes. These outcomes include advocating for the prioritization of primary and community-oriented care over secondary and patient-oriented care, expanding and enhancing existing information systems in PHC beyond primary data collection, reinforcing health teams and health service packages, as well as cultivating trust, participation, and engagement among the public, involving them in the management of their health. Considering the profound and undeniable consequences of these measures across various dimensions, their necessity and importance are increasingly apparent to all stakeholders.
Acknowledgements
The authors thank School of Management and Medical Informatics for their involvement and financial support in this project, which is a part of PhD thesis in Tabriz University of Medical Science.
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