Primary health care as the main guarantor of a healthy population in the country and a global challenge in the world: a systematic review

Introduction

Despite rapid advancements in medical technology worldwide, including in Georgia, alarming medical statistics reveal a persistent gap between technological progress and overall population health. Approximately 80% of global deaths are attributed to preventable chronic diseases, underscoring the critical need for effective prevention strategies. Primary healthcare (PHC) is widely regarded as a cornerstone in addressing this issue. This systematic review aims to comprehensively examine existing research on the role of PHC in improving population health, identify common challenges, and propose recommendations based on international best practices. By understanding the factors influencing PHC effectiveness, we seek to contribute to enhanced population health outcomes.

The World Health Organization recommends evaluating health systems using a primary healthcare approach. Evidence suggests that 90% of key universal health coverage (UHC) interventions could be implemented through a PHC framework, potentially saving 60 million lives and increasing average global life expectancy by 3.7 years by 2030. By sharing the findings, knowledge, and best practices from this systematic review, we can collectively assess the effectiveness of various PHC models and work towards a shared vision for improving population health (WHO-PHC-2023).

As a developing country, Georgia has undergone numerous reforms in its PHC system. However, PHC remains underdeveloped. To address these challenges and promote a healthier population, it is crucial to learn from the experiences of other countries and collaborate with global health organizations to develop the most effective recommendations.

Twenty-five years have passed since healthcare reforms began in Georgia, yet an effective primary healthcare (PHC) system has not been fully established. In 2000, the Department of Primary Health Care was created within the Ministry of Health. A year later, it merged with the Department of Public Health to better integrate public health initiatives. However, the success of these efforts has been limited. Low patient referrals to family doctors and a general lack of trust in primary care providers remain significant challenges.¹

One key indicator of the underdevelopment of Georgia’s PHC system is the low number of referrals to outpatient medical institutions, with only 2.3 visits per capita, compared to up to 7.5 in European countries. This disparity highlights the insufficient development of primary care in Georgia. As a result, self-medication is widespread, driven by a lack of confidence in primary care services. This situation has led to a concerning outcome: medicinal costs now account for a catastrophically high 40% of total healthcare expenditures in Georgia, compared to 10-15% in European countries.

Given these challenges, it is crucial to analyze the strategies employed by other countries through our systematic review and develop joint recommendations to improve PHC in Georgia.

Therefore, our systematic review aimed to examine and evaluate the experiences of different countries with primary health care (PHC) models, focusing on [specific countries or regions] between [start date] and [end date]. By analyzing these experiences, we sought to identify valuable recommendations for improving PHC systems. Consequently, our research questions were:

Is a well-structured PHC a guarantor of a healthy population?

What are the relationships between PHC and health outcomes in various countries? Our review sought to conduct a detailed analysis based on existing studies to inform policy and practice.

Primary health care (PHC) is an essential component of any healthcare system and is regarded as the foundation of any healthcare delivery system worldwide.² It is the first point of contact for individuals seeking medical care. It aims to provide accessible, affordable, and high-quality healthcare services to everyone regardless of socioeconomic status.³ The PHC system includes a range of services, such as disease prevention, health promotion, diagnosis, treatment, and rehabilitation.³ The World Health Organization (WHO) defines PHC as “an essential health care based on practical, scientifically sound, and socially acceptable methods and technology, made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination”.⁴

PHC is essential for maintaining the health of individuals and communities, particularly in developing countries where access to healthcare is limited.⁵ PHC services are particularly important for vulnerable populations, such as children, pregnant women, and the elderly.^6,7 In many low-income countries, access to health care services is limited, and PHC is often the only available source of medical care.⁷ The importance of PHC in improving health outcomes and reducing health disparities has been recognized globally, and efforts are being made to strengthen PHC systems worldwide.⁸

Despite the importance of PHC, there still needs to be more in delivering PHC services in many countries, including developing and developed countries. These gaps may include inadequate funding, human resources, lack of medical supplies and equipment, inadequate infrastructure, and inadequate health policies and regulations. These gaps may prevent individuals from accessing the necessary medical care and may negatively impact health outcomes, particularly in vulnerable populations.^9,10

Therefore, this research aims to analyze the PHC system and identify the gaps in the delivery of PHC services. This research aims to study the PHC services of different countries,^11,12 assess existing research on PHC services,^13,14 and create and implement new strategies for improving medical services in practice. The research question is how the health care system works and how gaps are maintained to develop strategies to improve services. One of the great challenges for the development of primary health care is the accuracy of the production of health statistics in primary health care, as more countries embark on health reforms and strategies to reduce poverty, the need for robust statistics to identify implementation difficulties and evaluate outcomes will become more pressing. Because without it, it is impossible to create a patient-oriented service.¹⁵ The objectives are to explore the PHC services of different countries, study and assess existing research,^15,16 and create and implement new strategies for improving medical services in practice. The study emphasizes the importance of implementing comprehensive NCD management strategies that address both prevention and treatment. This could include providing early diagnosis, screening, and treatment for NCDs, as well as promoting healthy lifestyle behaviors and providing support for patients with chronic conditions.¹⁴ A study of 18 developed OECD countries found that strong primary healthcare systems are crucial for maintaining population health. Specifically, countries with robust primary healthcare systems experienced a significant 26% reduction in overall mortality rates over three decades. Starfield's primary healthcare scale was used to assess these systems, focusing on both structural and practical aspects.¹⁷ The scale's 10 components provide a comprehensive evaluation of primary healthcare, highlighting its essential characteristics. The research conclusively demonstrated that a strong primary care system: Improves health outcomes, Reduces mortality rates and enhances overall population health, Enhances preventive care, Helps prevent diseases and promotes healthy lifestyles, Reduces health disparities, Contributes to more equitable health outcomes across different populations, Improves health system function, Strengthens the overall efficiency and effectiveness of the healthcare system.¹⁷

The methodology of this study is a systematic review of the last ten years of written research on PHC services. The data sources include peer-reviewed articles and other relevant literature on PHC services.^18,19 This study’s expected outcome is identifying gaps in PHC services and developing new strategies to improve health outcomes in practice. This study will contribute to a better understanding of the challenges faced by PHC systems worldwide and provide insights for policymakers and healthcare providers to improve healthcare services. In the article, the researchers proposed a useful PHC monitoring tool called the Primary Care Monitoring System (PC Monitor), which can make a certain contribution to the good monitoring of PHC.²⁰

In conclusion, PHC is an essential component of any healthcare system and is regarded as the foundation of any healthcare delivery system worldwide.²¹ The gaps in the delivery of PHC services need to be identified and addressed to improve health outcomes, particularly in vulnerable populations. This research aims to study the PHC services of different countries, assess existing research on PHC services, and create and implement new strategies for improving medical services in practice. This study will contribute to a better understanding of the challenges faced by PHC systems worldwide and provide insights for policymakers and healthcare providers to improve healthcare services.

In the modern world, the role of public health has especially increased when the pandemic of infectious diseases has become relevant, as already shown by the Covid pandemic, which has had enormous global political and economic consequences in the world.¹⁸ Therefore, modern public health is reviewed in a global context and requires international regulations, transnational actions, and solutions based on coordinated cooperation among different countries of the world.²²

This systematic review on the topic of “Primary Health Care as The Main Guarantor of a Healthy Population in The Country and A Global Challenge in The World” aims to comprehensively investigate and the review seeks to explore several critical aspects and address specific inquiries:

By conducting a systematic review around these aspects, the objective was to synthesize existing knowledge, provide a clear and evidence-based understanding of the role of primary health care in population health, and offer insights that can guide policies, strategies, and practices to optimize the benefits of primary health care in fostering a healthier population locally and globally.

Methods

This research aims to analyze the primary health care (PHC) system and identify the gaps in the delivery of PHC services. To achieve this aim, a systematic review of the last ten years of written research on PHC services was conducted. However, we also included some older articles (published between 2003 and 2009) that provided valuable insights into the historical context and evolution of primary healthcare systems (There were only 6 articles in 2003-2009). A systematic review will include a systematic literature review, data synthesis, of the results. We used a mixed method a combination of documentary analysis and narrative synthesis as an alternative to meta-analysis, which has practical value in the development of PHC. The research question is how the health care system works and how gaps are maintained to develop strategies to improve services. The objectives are to explore the PHC services of different countries, study and assess existing research, and create and implement new strategies for improving medical services in practice. Table 1, Figure 1 (Prisma diagram of study selection) and Figure 2 (PRISMA Checklist) are presented for the visibility of the narrative synthesis analysis of the data source considered during the research.

Figure 1. PRISMA diagram of study selection.

This work is licensed under CC BY 4.0. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/.

Figure 2. PRISMA 2020 Checklist.

It is important to note that, since our systematic review focused on primary healthcare (PHC), we considered it relevant to include articles from 2002 to 2008 due to their valuable historical data. Of the 38 articles included, 6 were published between 2002 and 2009, while the remaining 32 were published between 2010 and 2023. Two reviewers participated in the review process to ensure the reliability of inter-evaluator assessments.

Results

The systematic review of the last ten years of written research on primary health care (PHC) services revealed that while the PHC system is crucial in ensuring a healthy population, there are significant gaps in its delivery across countries.²² These gaps significantly impact the health outcomes of individuals and communities, and the PHC system needs to be strengthened to address them effectively.

The review identified a range of PHC services provided across different countries, including preventive services, such as vaccinations, health education, and screening and curative services, such as treatment for acute and chronic conditions. Study found that consultation times in primary care are often too short, with many patients spending less than 5 minutes with their physicians. This is a concerning trend that can negatively impact patient care and outcomes. Short consultation times:18 countries results - Approximately 50% of population spends less than 5 minutes with their primary care physicians which is Negative impact on patient care: Inadequate consultation time can lead to poor health outcomes, including missed diagnoses, inadequate treatment, and reduced patient satisfaction.²³ Despite the variation in the services provided, several gaps were identified in delivering PHC services across countries. These gaps included inadequate staffing, limited access to essential medicines, insufficient funding, inadequate infrastructure, and inadequate training for health workers.^17,24

One of the significant gaps identified in the delivery of PHC services was inadequate staffing.²⁵ Many countries need more health workers, particularly in rural and remote areas with inadequate health facilities. The shortage of health workers affects the quality and accessibility of PHC services and leads to long waiting times, reduced patient satisfaction, and poor health outcomes. In addition, the shortage of health workers exacerbates the burden of communicable and non-communicable diseases, contributing to a high mortality rate.²³

Another significant gap identified in the delivery of PHC services was limited access to essential medicines.²⁶ Many PHC facilities in low- and middle-income countries face shortages of essential medicines, which affects the quality of care and health outcomes. The lack of essential medicines often leads to inappropriate treatment, prolonged illness, and complications, which significantly impact the quality of life of patients and their families.

Insufficient funding was another gap identified in the delivery of PHC services.² Many countries need more funding for the PHC system, which affects the quality and availability of services. The lack of funding leads to adequate infrastructure, adequate staffing, and limited access to essential medicines and medical equipment. As a result, patients face long waiting times, reduced patient satisfaction, and poor health outcomes.

Inadequate infrastructure was also identified as a gap in the delivery of PHC services.¹⁶ In primary health care, the impact of access to medicines on quality of care is also important. The current study analyzes data from 45 WHO/HAI surveys conducted in 36 countries to assess the availability, affordability and cost of medicines and found evidence that this has a negative impact on poor health outcomes such as: non-adherence to treatment, Financial hardship, increased mortality. To address these challenges, countries should implement a number of policies and interventions, including implementation of price controls, promotion of generic drugs, strengthening of public procurement systems, strengthening of international cooperation, expansion of health insurance coverage, investment in domestic production of drugs.²⁷ Many PHC facilities need more basic amenities, such as clean water, electricity, and adequate sanitation facilities, affecting care quality and safety. The lack of infrastructure often leads to poor hygiene, increased risk of infection, and reduced patient comfort, which affects patient satisfaction and health outcomes.^28,29

A systematic review highlights the critical role of appropriate counseling and health education in providing evidence-based care. Despite the importance of these elements, many primary healthcare providers in low-income and middle-income countries (LMICs) are unable to offer adequate counseling on topics like pregnancy complications, HIV prevention, contraceptive side effects, and chronic disease management. To address these deficiencies and improve overall healthcare outcomes, there is a growing interest in strengthening primary care.²⁹ Primary care has traditionally been a cornerstone of healthcare in LMICs, but evolving disease patterns, urbanization, and increasing demand for specialized services are challenging the current model. Research indicates that many primary care providers do not follow management guidelines and may not be practicing prevention effectively. This underscores the need to balance access and quality in healthcare. While access is important, ensuring a minimum level of quality for all is essential for achieving equitable health outcomes and avoiding wasted resources. To improve healthcare quality, it is crucial to measure and report on health system performance. This includes tracking health outcomes, user experience, and system competence. However, existing data often lacks the necessary depth and breadth to inform decision-making and guide improvements. Efforts to strengthen primary care and improve healthcare quality must be comprehensive and address both the individual provider level and the broader healthcare system. By focusing on evidence-based practices, enhancing counseling skills, and addressing systemic issues, LMICs can make significant strides in improving the quality of care provided to their populations.²⁹

Finally, inadequate training for health workers was identified as a gap in the delivery of PHC services.³⁰ Many health workers need more skills and knowledge to provide quality care, particularly in managing non-communicable diseases. The lack of training leads to poor diagnosis, inappropriate treatment, and reduced patient satisfaction, which affects health outcomes.

Despite ongoing efforts to enhance chronic disease management, the global mortality rate from these conditions remains high. This research has interesting findings—proposing a conceptual framework for a chronic care model (CCM)—to improve care for patients with chronic diseases. The core components of CCM are self-management support, delivery system design, decision support, clinical information systems: electronic health records and Using other information systems to support chronic care.²⁸

With the help of primary care services, patients are under constant monitoring and the doctor observes the patient throughout his life. As a result, the doctor has complete information about the patient’s disease, how it developed and how it is developing. This allows the doctor to better manage the disease. Another distinctive feature of primary care is the comprehensiveness of care because the family doctor cares not only for the patient’s physical, but also for his spiritual and social well-being. Health care is a complex system that also has a kind of coordination function.

The family doctor coordinates the full service of the patient, and he is not only a doctor but also a supporter, guide and coordinator who can protect patients and help them make the right choice during medical care. Through the doctor’s coordination, the patient receives the appropriate service at the appropriate time and place.¹

Discussion

The gaps identified in the delivery of PHC services significantly impact the health outcomes of individuals and communities, especially in low- and middle-income countries. This study, however, has limitations. Firstly, the literature search was confined to articles published in English, potentially excluding relevant information published in other languages. Secondly, the quality of the included articles might have constrained the systematic review findings, urging caution in their interpretation.

Despite these limitations, the study conducted a systematic review over the past decade, examining written research on healthcare services utilizing peer-reviewed articles and pertinent literature on PHC services. The study’s primary objective was to identify PHC service gaps and propose strategies to improve health outcomes.

Comprehensive and coordinated strategies targeting the root causes are imperative to address these identified gaps effectively. Policy interventions addressing staffing shortages, increased funding for the PHC system, infrastructure enhancement, and adequate training and support for healthcare workers are critical.

A pivotal strategy involves bolstering health systems, necessitating the formulation of policies and programs enhancing the quality, accessibility, and affordability of health services. Achieving this may entail appropriate financing mechanisms, robust health governance systems, bolstered health workforce, and refined health information systems.

Furthermore, integrating PHC services into the broader health system is another crucial strategy. This integration can bridge gaps and synergize efforts, ensuring more comprehensive and efficient healthcare delivery.

The US spends the most on healthcare per capita but has poor health outcomes. This could be due to factors like the fee-for-service model that incentivizes more procedures instead of preventive care. Team-based care and technological integration are crucial for transforming primary healthcare. While many practices already utilize teams, a higher level of collaboration is required.²¹ This involves defining new roles, partnering with social services and other specialties, and adopting a patient-centered approach. Additionally, traditional hierarchical structures within healthcare delivery must adapt to support these team-based models. Integrating technology is essential. Patient-facing technologies, such as patient portals, data collection tools, and personalized coaching, can enhance patient satisfaction, improve efficiency, and elevate care quality. For instance, patient portals enable asynchronous communication with care teams, leading to greater convenience and better outcomes.²¹ The study was conducted in 31 countries (including 27 EU members States, Iceland, Norway, Switzerland and Turkey) - A study was conducted to assess The strength of primary care in Europe and although many countries prioritize the development of primary care,³¹ there are challenges that need to be addressed: Strengthening primary care governance: establishing a clear government vision and policy for primary care, ensuring effective governance and accountability Improving economic conditions. Addressing income inequality for primary care providers, particularly in Eastern Europe Investing in workforce development. Addressing workforce shortages by investing in education and training of primary care professionals. Increasing access. Implementing policies to improve geographic access to primary care Promoting continuity of care Implement patient registration systems and encourage long-term relationships between patients and primary care providers. Leverage technology - Equip primary care practices with adequate technology to support efficient operations and improve communication. Enhance patient-provider relationships - Focus on improving communication skills and building trust between primary care providers and patients on formation.

Conclusion

Primary health care (PHC) is crucial in ensuring a healthy population and addressing global health challenges. However, there are significant gaps in the delivery of PHC services across countries, which significantly impact the health outcomes of individuals and communities.

Our study revealed several gaps in the delivery of PHC services, including inadequate staffing, limited access to essential medicines, insufficient funding, inadequate infrastructure, and inadequate training for health workers.^27,32 These gaps affect the quality and accessibility of PHC services, and lead to long waiting times, reduced patient satisfaction, and poor health outcomes.

To address these gaps effectively, comprehensive, and coordinated strategies are needed that address the underlying causes of these gaps. These strategies should include policies to address staffing shortages, increase funding for the PHC system, improve infrastructure, and provide training and support for health workers.^1,32

Strengthening health systems is a key strategy for addressing the gaps in PHC services. This involves the development of policies and programs that improve the quality, accessibility, and affordability of health services. This can be achieved through the development of appropriate financing mechanisms, the establishment of effective health governance systems, the expansion of the health workforce, and the improvement of health information systems.³¹

Integrating PHC services into the broader health system is another strategy for addressing the gaps in PHC services. Integration involves coordinating services across distinct levels of care and involving different stakeholders, including governments, healthcare providers, and communities. This can help to improve the quality and accessibility of services, reduce duplication and fragmentation of services, and enhance the efficiency and effectiveness of the health system.^33,34

In conclusion, this study highlights the importance of PHC services in ensuring a healthy population and addressing global health challenges. It identifies significant gaps and challenges facing the PHC system and provides strategies for improving PHC services in practice. Studies have shown that among 90 countries with a gross national income of less than $10,000 per person, those that shifted to primary care and 30 such countries showed better health outcomes, reduced mortality, and concluded that increasing primary care physicians is associated with: 1.44 fewer deaths per 10,000 population , 2.5% reduction in infant mortality, 3.2% reduction in underweight,²⁵ countries that moved to universal primary health care achieved lower under-five mortality, more equitable distribution of health care, lower rates of breast cancer, reduced hospital use in these countries: 6% less inpatient admission, 5% fewer outpatient visits, 10% fewer emergency room visits, 7% less operations - Lower health care costs - these data are supported by strong studies that further support the evidence for the need to strengthen primary care.²⁵

These strategies are essential for achieving universal health coverage and addressing the Sustainable Development Goals related to health. Implementing these strategies requires the commitment and collaboration of all stakeholders, including governments, healthcare providers, and communities, to deliver high-quality, accessible, and affordable PHC services for all.^35,36

The current overview consolidates evidence supporting the development of primary healthcare (PHC) and the creation of a patient-oriented PHC system. To achieve this, it is essential to involve the public, gain political support, and focus on developing a model tailored to the needs of patients with multimorbidity. Prioritizing public education and enhancing self-esteem are crucial steps in this process.

Additionally, establishing home care services and providing organizational support can help reduce the burden of hospitalization. Developing information technology is also vital, as it will significantly improve the quality of care, facilitate tracking of health services, and positively impact health processes and outcomes.

This study, which is a scoping review, also highlights the need for further research into innovative health policies and programs to maintain a healthy population.³⁷

In 2022, the Chinese government prioritized increasing investment in primary healthcare (PHC) improvements, signaling to the international community that PHC is a crucial pathway to achieving a healthy population. This aligns with a significant study that applied an improved three-stage model (Data Envelopment Analysis, DEA) using the Global Benchmarking Technique (GBT) to evaluate China’s PHC system.

The large-scale study demonstrated that the availability of medical services is directly linked to improvements in PHC, underscoring the need for greater investment in its development. The findings revealed that PHC efficiency positively impacts population health. However, the study also showed a decline in three key indicators of PHC efficiency between 2010 and 2021: Total Efficiency (TE) decreased from 0.807 to 0.546, Pure Technical Efficiency (PTE) dropped from 0.870 to 0.594, and Scale Efficiency (SE) fell from 0.934 to 0.917.

These declines indicate a deterioration in performance, suggesting that increased financial investment and favorable policies alone are insufficient for the successful functioning of PHC. To address this, it is necessary to focus on:

In the Current article While the study focused on data from 1980-1995, its findings remain highly relevant today. This research demonstrates the enduring importance of primary care, particularly family medicine, in improving population health outcomes, as evidenced by its significant association with lower mortality rates. These findings align with our systematic review, further reinforcing the value of primary care as a cornerstone of healthcare systems.³³