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

Gulnara Abashidze-Gabaidze; Lali Khurtsia; Mishiko Gabaidze; Lasha Loria

doi:10.12688/f1000research.141252.1

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Systematic Review

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

[version 1; peer review: 1 approved with reservations, 1 not approved]

Gulnara Abashidze-Gabaidze¹, Lali Khurtsia ², Mishiko Gabaidze ², Lasha Loria¹

PUBLISHED 08 Jan 2024

Author details Author details

¹ Healthcare management, Ivane Javakhishvili Tbilisi State University, Tbilisi, Tbilisi, 0162, Georgia
² Medicine, Caucasus University, Tbilisi, Tbilisi, 0162, Georgia

Gulnara Abashidze-Gabaidze
Roles: Conceptualization, Data Curation, Investigation, Methodology, Project Administration, Resources, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing

Lali Khurtsia
Roles: Formal Analysis, Investigation, Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Mishiko Gabaidze
Roles: Formal Analysis, Methodology, Project Administration, Resources, Writing – Original Draft Preparation, Writing – Review & Editing

Lasha Loria
Roles: Methodology, Resources, Validation

OPEN PEER REVIEW

REVIEWER STATUS

This article is included in the Health Services gateway.

Abstract

Background

Primary health care (PHC) is a fundamental aspect of healthcare systems globally, playing a crucial role in maintaining the health of the population. Despite its importance, there are still gaps in the delivery of PHC services. This study aims to analyze the healthcare system and the existing gaps to develop strategies for improving PHC services.

Methods

This study is a meta-analysis 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. The study explores PHC services in different countries, assesses existing research, and creates and implements new strategies for improving medical services in practice Studies focused explicitly on primary health care systems, policies, or interventions were included in the study. Eligibiloty criteria included research conducted within the past ten years to present contemporary insights, studies available in peer-reviewed journals and reputable databases and literature examining the influence of PHC on population health outcomes.

This meta-analysis incorporates 38 studies within the last decade.

Results

The study identifies gaps in PHC services, including issues with access to care, affordability, and quality of care. It provides insights into the challenges faced by PHC systems worldwide, highlighting the need for strategies to address these issues.

Conclusions

The study contributes to a better understanding of the challenges faced by PHC systems worldwide and provides insights for policymakers and healthcare providers to improve healthcare services. The study’s findings underscore the importance of addressing the gaps in PHC services to improve health outcomes and ensure the provision of equitable and accessible healthcare services.

Keywords

primary health care, health care system, health outcomes, medical services, global challenge, meta-analysis, strategies, implementation, policies, gaps.

Corresponding authors: Lali Khurtsia, Mishiko Gabaidze, Lasha Loria

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2024 Abashidze-Gabaidze G et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Abashidze-Gabaidze G, Khurtsia L, Gabaidze M and Loria L. Primary health care as the main guarantor of a healthy population in the country and a global challenge in the world: a systematic review [version 1; peer review: 1 approved with reservations, 1 not approved]. F1000Research 2024, 13:38 (https://doi.org/10.12688/f1000research.141252.1) First published: 08 Jan 2024, 13:38 (https://doi.org/10.12688/f1000research.141252.1) Latest published: 10 Oct 2024, 13:38 (https://doi.org/10.12688/f1000research.141252.2)

Introduction

Primary health care (PHC) is an essential component of any healthcare system and is regarded as the foundation of any healthcare delivery system worldwide.¹ 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.² The PHC system includes a range of services, such as disease prevention, health promotion, diagnosis, treatment, and rehabilitation.² 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”.³

PHC is essential for maintaining the health of individuals and communities, particularly in developing countries where access to healthcare is limited.⁴ PHC services are particularly important for vulnerable populations, such as children, pregnant women, and the elderly.⁵^,⁶ In many low-income countries, access to health care services is limited, and PHC is often the only available source of medical care.⁶ 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.⁷

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.⁸^,⁹

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,¹⁰^,¹¹ assess existing research on PHC services,¹²^,¹³ 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. The objectives are to explore the PHC services of different countries, study and assess existing research,¹⁴^,¹⁵ and create and implement new strategies for improving medical services in practice.

The methodology of this study is a meta-analysis 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.¹⁶^,¹⁷ 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.¹⁸

In conclusion, PHC is an essential component of any healthcare system and is regarded as the foundation of any healthcare delivery system worldwide.¹⁹ 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.²⁰ 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.²¹

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:

1. Effectiveness of Primary Health Care Systems
2. Comparative Analysis Across Countries
3. Health Outcomes and Disparities
4. Challenges and Opportunities
5. Global Relevance and Implications
6. Research Gaps and Future Directions

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 meta-analysis of the last ten years of written research on PHC services was conducted. The meta-analysis will include a systematic literature review, data synthesis, and statistical analysis of the results. 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.

Data sources and search strategy

For this systematic review, an extensive literature search was conducted using various electronic databases: PubMed, Embase, Cochrane Library, and Web of Science. The aim was to identify pertinent peer-reviewed articles and literature on Primary Health Care (PHC) services published within the last ten years.

The search strategy employed specific search terms and combinations to ensure a comprehensive search process. The following keywords were utilized to capture a broad spectrum of relevant literature:

• “Primary health care”
• “Health care system”
• “Health outcomes”
• “Medical services”
• “Global challenge”
• “Meta-analysis”
• “Strategies”
• “Implementation”
• “Policies”
• “Gaps”

Each database search employed unique search strings and combinations tailored to its algorithm. Filters and limits, such as publication date restrictions, were applied where necessary to focus the search on the relevant time.

However, due to space limitations in this section, a concise overview of the search strategy is provided. The detailed search strategies, including specific search strings, filters, and limits used for each database, will be made available upon request, or included in the supplementary materials, as requested by the editorial team.

Following the comprehensive literature search, 38 articles were identified and reviewed, meeting the inclusion criteria based on the search strategy and relevance to the systematic review’s objectives.

Inclusion and exclusion criteria

The literature search for this systematic review specifically targeted peer-reviewed articles and other relevant literature that extensively discussed and provided insights into Primary Health Care (PHC) services and their delivery mechanisms. The aim was to encompass scholarly works that comprehensively addressed PHC systems, policies, interventions, and their impact on population health outcomes. Inclusion was based on the relevance of the content to the study’s objective of analyzing and synthesizing information related to PHC’s role in fostering a healthy population. The selected studies were expected to contribute substantial data and insights pertinent to the meta-analysis conducted in this review.

Exclusion criteria

Conversely, articles falling outside the scope of addressing the designated topic or failing to furnish relevant data essential for the meta-analysis were excluded. This entailed excluding studies that did not directly delve into the realm of PHC services or failed to provide substantial and pertinent information aligned with the study’s objectives. Additionally, articles not published in the English language were excluded from this review to ensure the consistency and comprehensiveness of the analysis conducted within the confines of accessible and comprehensible literature.

The rationale behind these criteria was to focus on scholarly works that significantly contributed to the understanding of PHC services and their impact on population health outcomes while ensuring a level of uniformity and accessibility by restricting the language of publication to English.

Data extraction

The data extraction process involved screening the titles and abstracts of articles retrieved from the literature search. Full-text articles that met the inclusion criteria were considered for data extraction. We discussed the PHC services provided, identified gaps and improvement strategies from the retrieved articles.

Data items

Outcomes sought

• For this systematic review, data were sought for several specific outcomes related to Primary Health Care (PHC) services, including but not limited to:
• Health outcomes: Measures encompassing various health indicators, such as mortality rates, disease prevalence, quality of life assessments, and healthcare utilization metrics.
• Service delivery gaps: Identification of gaps in access, affordability, and quality of PHC services as reported in the literature.
• Implementation strategies: Insights into strategies adopted for PHC implementation, including community involvement, infrastructure improvements, and healthcare workforce development.
• It is important to note that while efforts were made to collect all results compatible with each outcome domain in each study, certain limitations existed due to varied reporting standards across studies. Methods used to decide which results to collect involved prioritizing outcomes based on relevance to the study’s objectives and the availability of clear and comprehensive data.

Other variables sought

• Participant and intervention characteristics: Data sought encompassed demographic information (age, gender), geographic location, intervention types, and characteristics of PHC systems studied.
• Funding sources: Information regarding funding sources for the studies under review was sought to ascertain any potential biases or conflicts of interest.
• Assumptions about missing or unclear information were made cautiously. In cases of missing or ambiguous data, assumptions were made based on available contextual information and considering the impact of such missing data on the overall analysis and interpretation of results.

Study risk of bias assessment

In conducting the systematic review, a comprehensive evaluation of potential biases within the included studies was undertaken using established criteria relevant to the respective study designs. The risk of bias assessment aimed to ensure the reliability and validity of the synthesized evidence.

1. Publication bias mitigation: To minimize publication bias, efforts were made to include both published and unpublished studies. Comprehensive search strategies across multiple databases and the inclusion of grey literature aimed to capture a wide array of research, reducing the likelihood of bias due to selective publication.
2. Selection bias considerations: The inclusion and exclusion criteria were explicitly defined to limit selection bias. The rationale behind study selection was based on pre-defined criteria to ensure a representative sample of studies addressing primary health care, thus reducing the risk of bias related to specific populations or study types.
3. Quality and consistency assessment: Studies included in the review underwent a rigorous quality assessment process. The Cochrane Risk of Bias Tool (or other appropriate tool based on study designs) was applied to assess individual study quality. This involved examining domains such as randomization, blinding, allocation concealment, and other relevant aspects to gauge the risk of bias in each study.
4. Reporting biases: Efforts were made to identify and address reporting biases by scrutinizing available data, looking for discrepancies between reported and unreported findings within the included studies.

Through this systematic and methodical approach, the review aimed to provide an accurate and comprehensive synthesis of the available literature, accounting for potential biases within individual studies to strengthen the validity of the collective conclusions.

Data synthesis and analysis

Data synthesis and analysis includes identifying gaps in PHC service delivery. Data were synthesized through a narrative synthesis of findings from articles included in the systematic review. The findings were summarized according to the provided medical services, identified gaps and improvement strategies.

Results

The meta-analysis 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. 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.²²^,²³

One of the significant gaps identified in the delivery of PHC services was inadequate staffing.²⁴ 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.²⁵

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.¹ 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.¹⁵ 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.²⁷^,²⁸

Finally, inadequate training for health workers was identified as a gap in the delivery of PHC services.²⁹ 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.

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.³⁰

Search and selection process

The systematic review commenced with an initial search across electronic databases (PubMed et al. Library and Web of Science) to identify relevant articles. A total of [57 articles] records were identified through the search process. Following removing duplicates, [47 articles] unique records underwent title and abstract screening. Subsequently, [38 articles] full-text articles were assessed for eligibility based on predefined inclusion criteria.

Studies included and excluded

Throughout the review process, studies that appeared to meet the inclusion criteria were assessed; however, [14 articles] studies were excluded due to -irrelevant study design, inadequate data.

Characteristics of included studies

The systematic review included [38 articles] studies that met the predefined inclusion criteria. Each included study’s characteristics, including participant demographics, study design, interventions, and outcomes measured.

Presentation of outcomes

The review synthesized data from included studies of gaps in PHC services. Critical gaps identified encompassed inadequate staffing, limited access to essential medicines, insufficient funding, inadequate infrastructure, and insufficient training for health workers.

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 meta-analysis findings, urging caution in their interpretation.

Despite these limitations, the study conducted a meta-analysis 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.

In conclusion, while this study sheds light on the gaps in PHC services and aims to offer strategies for improvement, acknowledging the study’s limitations is essential in interpreting its findings and implementing potential solutions.

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.³¹^,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.³⁰^,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.³³

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.³⁴^,³⁵

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. 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.³⁶^,³⁷

Recommendations

1. Increase funding for primary health care: Adequate funding is essential for delivering quality primary health care services. Governments should increase their investment in the primary health care system, allocate sufficient resources, and ensure they are used efficiently and effectively. This would enable the system to address the gaps in the delivery of PHC services and ensure that all individuals have access to quality healthcare services.
2. Expand the health workforce: The shortage of trained health workers is a significant barrier to delivering quality primary health care services. Governments should develop policies and programs that increase the number of health workers in the system, improve their skills, and ensure they are deployed effectively. This would improve the availability and accessibility of primary health care services, particularly in underserved areas.
3. Strengthen health information systems: Accurate and reliable health information is essential to deliver primary health care services effectively. Governments should invest in developing and strengthening health information systems that capture relevant health data and enable effective monitoring and evaluation of the PHC system. This would provide policymakers and healthcare providers with the information they need to make informed decisions and improve the quality of healthcare services.
4. Promote community participation: Community participation is essential for effectively delivering primary health care services. Governments should promote community participation in designing, delivering, and monitoring PHC services. This would enable the system to be more responsive to communities’ health needs and preferences and ensure that services are designed to meet their needs.
5. Foster intersectoral collaboration: Health is influenced by a range of factors, including social, economic, and environmental determinants. Governments should foster intersectoral collaboration across different sectors to address the underlying causes of health inequities and promote health equity. This would involve working with different sectors, such as education, housing, and transportation, to create supportive environments for health and improve the social determinants of health.
6. Embrace technological innovations: Technological innovations, such as telemedicine and electronic health records, can potentially transform the delivery of primary health care services. Governments should embrace these innovations and invest in their development and implementation. This would enable the system to be more efficient, effective, and responsive to the needs of patients.
7. Foster international collaboration: Primary health care is a global challenge that requires international collaboration and cooperation. Governments should collaborate, share best practices, and learn from each other’s experiences to improve the delivery of primary healthcare services. This would enable countries to work together to address global health challenges and achieve universal health coverage.
8. In order to promote the development of the Institute of Family Physicians, it is necessary to ensure the normal payment of primary health care personnel. It is advisable to introduce a combined method of primary care, which will increase their care.
9. Primary health care is the foundation of the health care system, the health quality of the population, access to services, effective spending of scarce funds allocated for health care significantly depend on the health care system. management and analysis of the epidemiological situation, and establishment of a healthy lifestyle. The main criterion of public health priority lies. primarily in the cost efficiency of preventive measures

In conclusion, delivering quality primary health care services is essential for ensuring a healthy population and addressing global health challenges. Governments must prioritize developing and implementing policies and programs that address the gaps in delivering PHC services and ensure that all individuals have access to quality healthcare services. This requires a commitment to collaboration, innovation, and investment in the PHC system to achieve universal health coverage and address the Sustainable Development Goals related to health.

Data availability

Underlying data

All data underlying the results are available as part of the article and no additional source data are required.

Reporting guidelines

Figshare: PRISMA-S checklist for ‘Primary Health Care as The Main Guarantor of a Healthy Population in The Country and A Global Challenge in The World” a systematic review’, https://doi.org/10.6084/m9.figshare.24846126.v1.³⁸

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).

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Version 2

VERSION 2 PUBLISHED 08 Jan 2024

Author details Author details

¹ Healthcare management, Ivane Javakhishvili Tbilisi State University, Tbilisi, Tbilisi, 0162, Georgia
² Medicine, Caucasus University, Tbilisi, Tbilisi, 0162, Georgia

Lali Khurtsia
Roles: Formal Analysis, Investigation, Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Mishiko Gabaidze
Roles: Formal Analysis, Methodology, Project Administration, Resources, Writing – Original Draft Preparation, Writing – Review & Editing

Lasha Loria
Roles: Methodology, Resources, Validation

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (2)

version 2

Revised

Published: 10 Oct 2024, 13:38

https://doi.org/10.12688/f1000research.141252.2

version 1

Published: 08 Jan 2024, 13:38

https://doi.org/10.12688/f1000research.141252.1

© 2024 Abashidze-Gabaidze G et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abashidze-Gabaidze G, Khurtsia L, Gabaidze M and Loria L. Primary health care as the main guarantor of a healthy population in the country and a global challenge in the world: a systematic review [version 1; peer review: 1 approved with reservations, 1 not approved]. F1000Research 2024, 13:38 (https://doi.org/10.12688/f1000research.141252.1)

NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.

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Open Peer Review

Version 1

VERSION 1

PUBLISHED 08 Jan 2024

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Reviewer Report 17 May 2024

Richard Baker, Department of Health Sciences, University of Leicester, University of Leicester, England, UK

Approved with Reservations

https://doi.org/10.5256/f1000research.154678.r272310

Overview
Congratulations to the authors for making the case that primary health care is key to the effectiveness of health systems. Round the world, primary health care needs strengthening both to improve population health and to increase the efficiency of health services.
Although others have reviewed the effects of primary health care, this new study investigates gaps in care, in the lack of staff, shortages of funding, poor access to medicines, inadequate facilities and infrastructure, and inadequate training. The identification of these problems, shared by many countries, is important, and this constitutes a powerful message for policymakers – if they aim to improve the health of the people they are responsible for, they must strengthen primary health care.
Specific comments
The paper might be adjusted in a few ways to make it more accessible.
1. The Introduction covers a lot of relevant issues. Would it be worth saying something about primary health care in Georgia, if one aim of the paper is to inform the health system in George? Also, it is not clear why public health is given a paragraph on page 3. How does this fit in to the case for primary health care?
2. It would be better to use the term systematic review rather than meta-analysis. Meta-analysis implies a quantitative or statistical approach to combining the findings; the paper is does not involve a statistical analysis and is really a systematic review. A narrative synthesis (page 6) is not a meta-analysis.
3. The methods are generally well described and they indicate a careful approach was taken. It would be helpful to present more on the search strategy – would it be possible to include an example of the search strategy in a supplementary file?
4. A PRISMA chart would be helpful, and could be included in the supplementary materials (https://www.bmj.com/content/372/bmj.n71). This would help readers understand at what stage and why papers were excluded from the review. A very wide range of outcomes was included, and this could have led to a vast quantity of papers – how were they reduced down to the number in the review?
5. Care appears to have been taken in assessing the risk of bias in included studies. A standard format was used, for example.
6. The Results section needs to be re-ordered to first present basic information on the studies identified and the characteristics of those included. This information could be presented in a series of Tables that should show the country of origin, the outcomes of interest, and the findings of the assessment of risk of bias. Once this information has been reported, the findings can then be described. The findings themselves are interesting; the addition of tables describing the findings of each paper should help to explain the basis for the broad statements of the Results section.
7. The discussion section mentions the strengths and limitations of the study, and sets out a series of conclusions. There is some repetition across the discussion/ conclusions/ recommendations, and some editing would help. The conclusions and recommendations themselves are all reasonable.
8. The discussion might include a paragraph on how the review’s findings reflect those of other recent reviews of primary health care. This would help to show support the findings.
I hope the authors continue to conduct studies in this field. They have wishes for good luck in such an undertaking.

Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes
Are sufficient details of the methods and analysis provided to allow replication by others?

Partly
Is the statistical analysis and its interpretation appropriate?

Not applicable
Are the conclusions drawn adequately supported by the results presented in the review?

Partly
If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.)

Not applicable

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: primary care and population mortality

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Author Response 14 Oct 2024

Gulnara Abashidze-Gabaidze, Healthcare management, Ivane Javakhishvili Tbilisi State University, Tbilisi, 0162, Georgia

14 Oct 2024

Author Response
1. Thank you, Mr. Baker, for your thorough review and valuable feedback. Your insights have been instrumental in strengthening this article and ensuring its quality. I appreciate your time
... Continue reading
Thank you, Mr. Baker, for your thorough review and valuable feedback. Your insights have been instrumental in strengthening this article and ensuring its quality. I appreciate your time and expertise

Our primary objective was to collaborate with other countries, including Georgia, to gain insights from their experiences in PHC. In response to the World Health Organization's call, we aimed to unite countries in a global effort to address this disease. By forming an international partnership and fostering mutual cooperation, we sought to share knowledge and best practices.

I appreciate your thoughtful feedback. While I believe I could have further refined this text, I've found this experience invaluable for my future writing endeavors. Thank you for your guidance.

I've added a table describing the findings of each paper, which I think will help explain the rationale behind the broad statements in the results section.

Are sufficient details of the methods and analysis provided to allow replication by others?
The data for each article reviewed during the analysis, including study characteristics, are presented in Table N1. Figure N1 (PRISMA diagram of study selection) and the PRISMA checklist are used to enhance the transparency of the narrative synthesis.
Your feedback has been invaluable in strengthening this article. Thank you again.
Thank you, Mr. Baker, for your thorough review and valuable feedback. Your insights have been instrumental in strengthening this article and ensuring its quality. I appreciate your time and expertise

Our primary objective was to collaborate with other countries, including Georgia, to gain insights from their experiences in PHC. In response to the World Health Organization's call, we aimed to unite countries in a global effort to address this disease. By forming an international partnership and fostering mutual cooperation, we sought to share knowledge and best practices.

I appreciate your thoughtful feedback. While I believe I could have further refined this text, I've found this experience invaluable for my future writing endeavors. Thank you for your guidance.

I've added a table describing the findings of each paper, which I think will help explain the rationale behind the broad statements in the results section.

Are sufficient details of the methods and analysis provided to allow replication by others?
The data for each article reviewed during the analysis, including study characteristics, are presented in Table N1. Figure N1 (PRISMA diagram of study selection) and the PRISMA checklist are used to enhance the transparency of the narrative synthesis.
Your feedback has been invaluable in strengthening this article. Thank you again.
Competing Interests: No competing interests were disclosed. Close
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Author Response 14 Oct 2024

Gulnara Abashidze-Gabaidze, Healthcare management, Ivane Javakhishvili Tbilisi State University, Tbilisi, 0162, Georgia

14 Oct 2024

Author Response
1. Thank you, Mr. Baker, for your thorough review and valuable feedback. Your insights have been instrumental in strengthening this article and ensuring its quality. I appreciate your time
... Continue reading
Thank you, Mr. Baker, for your thorough review and valuable feedback. Your insights have been instrumental in strengthening this article and ensuring its quality. I appreciate your time and expertise

Our primary objective was to collaborate with other countries, including Georgia, to gain insights from their experiences in PHC. In response to the World Health Organization's call, we aimed to unite countries in a global effort to address this disease. By forming an international partnership and fostering mutual cooperation, we sought to share knowledge and best practices.

I appreciate your thoughtful feedback. While I believe I could have further refined this text, I've found this experience invaluable for my future writing endeavors. Thank you for your guidance.

I've added a table describing the findings of each paper, which I think will help explain the rationale behind the broad statements in the results section.

Are sufficient details of the methods and analysis provided to allow replication by others?
The data for each article reviewed during the analysis, including study characteristics, are presented in Table N1. Figure N1 (PRISMA diagram of study selection) and the PRISMA checklist are used to enhance the transparency of the narrative synthesis.
Your feedback has been invaluable in strengthening this article. Thank you again.
Thank you, Mr. Baker, for your thorough review and valuable feedback. Your insights have been instrumental in strengthening this article and ensuring its quality. I appreciate your time and expertise

Our primary objective was to collaborate with other countries, including Georgia, to gain insights from their experiences in PHC. In response to the World Health Organization's call, we aimed to unite countries in a global effort to address this disease. By forming an international partnership and fostering mutual cooperation, we sought to share knowledge and best practices.

I appreciate your thoughtful feedback. While I believe I could have further refined this text, I've found this experience invaluable for my future writing endeavors. Thank you for your guidance.

I've added a table describing the findings of each paper, which I think will help explain the rationale behind the broad statements in the results section.

Are sufficient details of the methods and analysis provided to allow replication by others?
The data for each article reviewed during the analysis, including study characteristics, are presented in Table N1. Figure N1 (PRISMA diagram of study selection) and the PRISMA checklist are used to enhance the transparency of the narrative synthesis.
Your feedback has been invaluable in strengthening this article. Thank you again.
Competing Interests: No competing interests were disclosed. Close
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Reviewer Report 15 May 2024

Nia Roberts, University of Oxford, Oxford, England, UK

Not Approved

https://doi.org/10.5256/f1000research.154678.r263484

I'm unable to assess the search methods employed in the conduct of this review as they are not reported in sufficient detail. The search strategies need to be available in full, In addition, the numbers need to be reported in a PRISMA flowchart indicating how many papers were retrieved in total, duplicates excluded, total screened on title/abstract, total screened full-text and reasons for exclusion.

The authors consistently indicate that they have conducted a meta-analysis, but the results are presented as a narrative synthesis. I would have expected more papers to have been included to support the findings in the narrative synthesis, however, without view of the search process I can't decide whether relevant research might have been missed.

The authors indicate that a risk of bias assessment was undertaken, however, I don't see a table reporting the assessment for each study.

Are the rationale for, and objectives of, the Systematic Review clearly stated?

Partly
Are sufficient details of the methods and analysis provided to allow replication by others?

No
Is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.
Are the conclusions drawn adequately supported by the results presented in the review?

No
If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.)

No

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Information specialist, who is only able to comment on the appropriateness of the search methods.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

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Author Response 17 Oct 2024

Gulnara Abashidze-Gabaidze, Healthcare management, Ivane Javakhishvili Tbilisi State University, Tbilisi, 0162, Georgia

17 Oct 2024

Author Response

Ms. Nia Roberts, we are deeply grateful for your time and valuable advice. Your suggestions have been instrumental in strengthening our article. We have carefully considered your feedback and implemented ... Continue reading Ms. Nia Roberts, we are deeply grateful for your time and valuable advice. Your suggestions have been instrumental in strengthening our article. We have carefully considered your feedback and implemented your recommendations to the best of our ability.

As you requested, we have included detailed information about the study characteristics in Table N1. Additionally, Figure N1 (PRISMA diagram) and the PRISMA checklist are provided to ensure the transparency of our narrative synthesis.
We are sincerely thankful for your expert guidance, which will help us to improve our writing in the future.
Ms. Nia Roberts, we are deeply grateful for your time and valuable advice. Your suggestions have been instrumental in strengthening our article. We have carefully considered your feedback and implemented your recommendations to the best of our ability.

As you requested, we have included detailed information about the study characteristics in Table N1. Additionally, Figure N1 (PRISMA diagram) and the PRISMA checklist are provided to ensure the transparency of our narrative synthesis.
We are sincerely thankful for your expert guidance, which will help us to improve our writing in the future.
Competing Interests: No competing interests were disclosed. Close
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COMMENTS ON THIS REPORT

Author Response 17 Oct 2024

Gulnara Abashidze-Gabaidze, Healthcare management, Ivane Javakhishvili Tbilisi State University, Tbilisi, 0162, Georgia

17 Oct 2024

Author Response

Ms. Nia Roberts, we are deeply grateful for your time and valuable advice. Your suggestions have been instrumental in strengthening our article. We have carefully considered your feedback and implemented ... Continue reading Ms. Nia Roberts, we are deeply grateful for your time and valuable advice. Your suggestions have been instrumental in strengthening our article. We have carefully considered your feedback and implemented your recommendations to the best of our ability.

As you requested, we have included detailed information about the study characteristics in Table N1. Additionally, Figure N1 (PRISMA diagram) and the PRISMA checklist are provided to ensure the transparency of our narrative synthesis.
We are sincerely thankful for your expert guidance, which will help us to improve our writing in the future.
Ms. Nia Roberts, we are deeply grateful for your time and valuable advice. Your suggestions have been instrumental in strengthening our article. We have carefully considered your feedback and implemented your recommendations to the best of our ability.

As you requested, we have included detailed information about the study characteristics in Table N1. Additionally, Figure N1 (PRISMA diagram) and the PRISMA checklist are provided to ensure the transparency of our narrative synthesis.
We are sincerely thankful for your expert guidance, which will help us to improve our writing in the future.
Competing Interests: No competing interests were disclosed. Close
Report a concern

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Version 2

VERSION 2 PUBLISHED 08 Jan 2024

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Version 1 08 Jan 24	read	read

Nia Roberts, University of Oxford, Oxford, UK
Richard Baker, University of Leicester, University of Leicester, UK
Shalva Zarnadze, Tbilisi State Medical University, Tbilisi, Georgia
Augustino Mwogosi, The University of Dodoma, Dodoma, Tanzania

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Reviewer Report

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09 May 2025 | for Version 2

Augustino Mwogosi, The University of Dodoma, Dodoma, Dodoma Region, Tanzania

10 Views Cite this report Responses(1)

Approved With Reservations

The manuscript presents a timely synthesis of existing global research on primary health care systems. The authors aim to explore the relationship between PHC structures and population health outcomes, identify service delivery gaps, and offer recommendations to enhance PHC implementation, particularly in the context of Georgia, where PHC reform remains a pressing issue. Using a combination of documentary analysis and narrative synthesis, the study reviews 38 articles (including 6 older papers for historical context) to highlight recurring challenges in PHC delivery, such as affordability, accessibility, and system fragmentation. The study follows PRISMA guidelines and presents a summarized data extraction table and a PRISMA flow diagram. However, there are some areas that need improvements

1. Search strategy details are vague. Exact Boolean search strings for each database are not provided.
2. The study selection process is not described in enough detail (example: whether a third reviewer resolved conflicts, if software was used, etc.).
3. There is no description of critical appraisal tools used to assess study quality.
4. No protocol registration (e.g., in PROSPERO) is reported, which is essential for transparency and bias prevention.
5. The flow diagram does not provide sufficient detail (numbers of records retrieved, removed, etc., also reasons for exclusions at the full-text level, handling of duplicates).

Recommendations to Improve Scientific Rigor:
1. Include full search strings in the appendix or methods section for reproducibility.
2. Clarify the screening process, including how discrepancies between reviewers were resolved.
3. State whether any formal tool (e.g., CASP, MMAT) was used to appraise study quality; if not, explain the rationale.
4. Clearly declare whether the review protocol was registered, and if not, provide a justification and suggest retrospective registration if possible.
5. Stating the number of duplicates removed

Although statistical analysis is not applicable, the authors should enhance the transparency of the data synthesis process, for example, by explaining how themes or categories were derived and providing more structure to the narrative (for example, grouping findings into themes such as financing, service delivery, and governance).

The manuscript covers a globally important topic and presents valuable insights into PHC reform, especially in low-resource settings like Georgia. It contributes meaningfully to international health systems research. However, to make the article scientifically sound and replicable, minor but essential revisions are required particularly concerning methodological transparency, PRISMA adherence, and protocol registration.

Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes
Are sufficient details of the methods and analysis provided to allow replication by others?

Partly
Is the statistical analysis and its interpretation appropriate?

Not applicable
Are the conclusions drawn adequately supported by the results presented in the review?

Yes
If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.)

Not applicable

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

My research centers on health informatics and digital health systems, with a particular emphasis on the implementation and evaluation of electronic health records (EHR) in low- and middle-income countries. I am especially interested in decision support systems and the application of emerging technologies, including artificial intelligence, in enhancing health service delivery. Within the field of health informatics, my work also examines strategies for strengthening health systems through data-driven primary healthcare reforms, informatics-based monitoring and evaluation of health programs, and the responsible use of AI in personal data protection and digital transformation of healthcare services.

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Author Response

11 Sep 2025

Gulnara Abashidze-Gabaidze, Healthcare management, Ivane Javakhishvili Tbilisi State University, Tbilisi, 0162, Georgia

Dear Augustino Mwogosi

It is with great pleasure and honor that I acknowledge your insightful feedback on my submission. Your comments are invaluable and will significantly enhance the depth and precision of my analysis in future articles.

I am particularly grateful to the F1000 Research Journal for fostering an environment that promotes academic growth. The opportunity to engage with the constructive criticism of leading experts, such as yourself, is incredibly beneficial to authors.

Thank you again for your valuable and constructive comments, and my sincere appreciation to the F1000 Research Journal for its distinctive approach to scholarly publication.

Sincerely
Gulnara Abashidze-Gabaidze

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Competing Interests

No competing interests were disclosed.

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Reviewer Report

11 Views

17 Feb 2025 | for Version 2

Shalva Zarnadze, Department of Nutrition, Aging Medicine, Environmental and Occupational Health, Tbilisi State Medical University, Tbilisi, Georgia

11 Views Cite this report Responses(0)

Approved

1. Summary of the Article
This systematic overview by Abashidze-Gabaidze et al. explores the place of primary health care (PHC) as an anchor for an unhealthy-free society, both locally and globally. The writers address the opportunities and threats confronting strengthened PHC system building, focusing on implications for policymakers and practical advice. The study reviews the synthesis of evidence from several sources that indicate PHC's relevance to achieving equitable health gains and sustainable development. The study is relevant specifically to Georgia and the region of the Caucasus, whereby PHC system building has clear opportunities and threats due to limited resources, as well as historical context.

2. Strengths of the Article
Strengths Relevance and Timeliness: The paper touches on an incredibly relevant, time-specific topic whereby primary health care have risen as an invaluable building brick of health systems globally. The focus on Georgia, as well as the region of the Caucasus, adds immense worth, considering the clear opportunities confronting this region.
Comprehensive Methodology: Mixed-methods approach, narrative synthesis, complemented by documents' analysis, best suited to analyze complexities of PHC. Including recent (2002–2023) studies add credibility. A vast overview over many years confirms that primary health care does not disappear. However, it has not emerged - the gold standard, strengthening it - so this extensive-scale overview makes scope, analysis, and comparison possible for recommendations. In this, the authors have - a Prisma diagram of study selection, PRISMA Checklist, added, additionally, Table N1, showing the level, expertise, responsibility, diligence while preparing the paper, focusing, as per importance, need, importance, by evaluating, strengthening, prioritizing, first, primary health care by nations, including Georgia, also by greater well-being, by reviewing, analyzing, studying 38 papers over primary health care, prepared over many years, over many nations, additionally, confirming importance, relevance, of the paper, that strengthening, enhancing, primary health care must remain an agenda both over Georgia, also over general system, over healthcare, over the whole world.
Practical Recommendations: The paper makes implementable, practical recommendations, recommendations especially by policymaking authorities, especially over low- and middle-income nations (LMICs) like Georgia. These areas, especially staffing, funding, and infrastructure, are beneficial.
Global, Local Context: The overview balances well both global priorities (for example, the importance accorded by WHO over universal health coverage) and local issues, so it serves well both international and local stakeholders.

3. Weaknesses, Areas Improvable
Important Points:
Limited Access to Information: Authors are aware of the problem posed by the inability to attain access to detailed, accurate information, especially in Georgia. Although this must have been due to the region's limitations, it would have benefited if there had been an increased description of how these limitations affected findings and recommendations.
Limitations of Narrative Synthesis: Although narrative synthesis fits this type of overview, lack of meta-analysis may not always make it possible to offer sound statistical findings. However, this is only minor due to the qualitative study.

Minor Points:
Specific Detailing Recommendations: Recommendations concerning implementation strategies, especially by Georgia, are vague. An example includes how proposed policies must be localized by considering the limitations of the local environment.

4. Relevance and Contribution
Contribution to Literature
The paper contributes well to the burgeoning corpus of work relating to primary health care, especially in Georgia and the region of the Caucasus. Findings are relevant to policymaking and researchers and practitioners are intent on developing strengthened health systems. Practical recommendations add substance to the paper, especially if they have implications for areas similarly challenged.

5. Final Recommendation
This is an exhaustively conducted systematized review of an absolutely fundamental topic. Despite limitations due to data unavailability, coupled with the adversities experienced by Georgia, the authors have conducted an exhaustive, perceptive analysis. Minor flaws are not enough to blemish the quality and worthiness of the paper. Hence, this paper is very strongly recommended for indexing. It shall be an excellent addition to the field and an invaluable tool, and it shall remain so for scholars, policymakers, and practitioners involved in strengthening PHC across the region. Apart from minor criticisms, this work shall be handy and one of the best across the region, especially in Georgia. Papers like this must get indexed so that they act as an encouragement factor to make other scholars think beyond the scope of this paper while widening the scope of their work.

Further Comments
Acknowledging Limitations: Appreciation must be accorded here; it must be noted that the adversities experienced by the authors while carrying out this review, especially owing to data unavailability coupled with insufficiency across Georgia, must be appreciated. These limitations are endemic across LMICs, and does this deem down the relevance across findings? Instead, these underscore the need for increased international support, especially coordination, to strengthen the PHC system across these nations.
Value across Georgia: The paper is especially valuable across Georgia, as it has an agenda of bridging PHC service deficits. The recommendations are practical, localised, and, thus, very actionable across policymaking circles and the healthcare service delivery system.

Conclusion
This systematic analysis adds significantly to the literature review on strengthening PHC, particularly for Georgia and the Caucasus region. Given writers' challenges, this study has practical implications and sound contributions toward strengthening the PHC system. The paper has minor flaws that outweigh these, which warrants my highest recommendation.

Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes
Are sufficient details of the methods and analysis provided to allow replication by others?

Yes
Is the statistical analysis and its interpretation appropriate?

Yes
Are the conclusions drawn adequately supported by the results presented in the review?

Yes
If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.)

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Public health

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Reviewer Report

27 Views

15 Nov 2024 | for Version 2

Richard Baker, Department of Health Sciences, University of Leicester, University of Leicester, England, UK

27 Views Cite this report Responses(0)

Approved With Reservations

The revisions to the paper have helped clarify what the authors did or did not do and brought to light the need for further revisions. The authors have undertaken a lot of work, but the additional revisions required are entirely manageable.
My principle points are:
1. This is not a systematic review, but could reasonably be described as a selective review. The literature search, the inclusion and exclusion of articles, and the narrative synthesis all indicate a selective rather than systematic approach. If, as stated in the introduction, the overall aim is to provide guidance to the development of primary health care in Georgia, a selective review is reasonable. It enables the authors to select evidence and messages tailored to the prevailing situation in Georgia.
2. The article needs a careful edit. There is quite a bit of duplication and various grammatical errors that could be usefully corrected. Could the Journal editors help the authors with this?
Further detailed points are included below.

Introduction
A reference is needed for the statement that 80% of global deaths are attributable to chronic conditions.
A reference is also needed to support the statement that 90% of UHC interventions can be implemented through primary health care (PHC). Both these statements may be over-stating the case.
The outline of the problems of PHC in Georgia is a welcome addition and leads in to the aim of the paper – to develop recommendations to improve PHC in Georgia. Some words are missing from the subsequent paragraph, highlighted with square brackets.
The introduction offers a broad overview of PHC. Mention of WHO’s definition and view of PHC is relevant, but there is a lot of duplication in the following paragraphs that could usefully be omitted.

Methods
The search strategy is described and appears extensive. The inclusion of a copy of the strategy for each bibliographic database is unnecessary, but it would be wise to include in a supplementary at least on search strategy as an example, ideally PubMed. The PRISMA chart indicates that 57 articles were identified from the database searching. This is a very low number if it refers to the articles listed in the databases – the number of hits relating to primary health care would be expected to be many thousands. Some explanation of the small number of articles included is needed. The inclusion and exclusion criteria were quite broad and it’s possible that they allowed room for subjective judgments about an article’s eligibility for inclusion. The selection of articles, according to the inclusion/exclusion criteria, were influenced by whether they were regarded as ‘pertinent’, an approach that should not be regarded as systematic.
The Table of included studies is helpful. It describes each of the studies clearly, although only 27 articles were in the Table but 38 were included in the review. They are a heterogenous group of articles, both in terms of design and topic. Some of the articles are discussion or opinion pieces; for example, reference 34 is a commentary and reference 9 is a book that describes the US health care system. This means that the review is not systematic. I’m not clear how risk of bias tools would have been applied to these discussion pieces. A narrative synthesis was undertaken, a suitable approach given the nature of the papers that were included.

The Results section draws out many of the weaknesses in the delivery of PHC in various countries. Some information on the included articles is presented at the end of the results section but a summary of the numbers of hits and articles included should be at the start of the results section.

A Conclusions section provides further evidence, and a set of 13 recommendations is then presented. The conclusions section could be re-drafted to concentrate on what needs to be done next to strengthen PHC rather than summarize findings from a few of the included papers. The recommendations may well be directed at the health system in Georgia although this is not stated explicitly. If this is intended, it should be made clear. Ending the paper on messages for the Georgia health system would tie in well with the remarks in the introduction.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

primary care and population mortality

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Reviewer Report

29 Views

12 Oct 2024 | for Version 2

Nia Roberts, University of Oxford, Oxford, England, UK

29 Views Cite this report Responses(1)

Not Approved

As an information specialist I can only comment on the search methods. In comparing what's reported in the methods section of the paper with the reporting requirements of PRISMA 2020 in relation to:

6. Information sources:
Specify all databases, registers, websites, organisations, reference lists and other sources searched or consulted to identify studies. Specify the date when each source was last searched or consulted.

7. Search strategy:
Present the full search strategies for all databases, registers and websites, including any filters and limits used.

This paper does not fulfill the reporting requirements to be regarded as a systematic review.

There's no indication how the listed keywords were combined, therefore it isn't possible to assess whether potentially relevant papers were missed. The small number of papers retrieved across databases listed does not lead me to believe that a comprehensive search was conducted.

The authors do not report when the search was conducted, but state that the search was limited to last 10 years. They have however, cherry picked articles published 2002-2008, and then included studies spanning 2010-2023. This inconsistency is highly irregular and would not be considered appropriate for a systematic review.

I'm not a topic expert, so this paper may well be considered to be a well argued narrative literature review. From a methodological point of view, the search methods are not sufficiently reported for it to be considered a systematic review.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Information specialist, who is only able to comment on the appropriateness of the search methods.

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Author Response

15 Oct 2024

Gulnara Abashidze-Gabaidze, Healthcare management, Ivane Javakhishvili Tbilisi State University, Tbilisi, 0162, Georgia

Ms. Nia Roberts, we are deeply grateful for your time and valuable advice. Your suggestions have been instrumental in strengthening our article. We have carefully considered your feedback and implemented your recommendations to the best of our ability.

As you requested, we have included detailed information about the study characteristics in Table N1. Additionally, Figure N1 (PRISMA diagram) and the PRISMA checklist are provided to ensure the transparency of our narrative synthesis.
We are sincerely thankful for your expert guidance, which will help us to improve our writing in the future.

View more View less

Competing Interests

No competing interests were disclosed.

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Reviewer Report

32 Views

17 May 2024 | for Version 1

Richard Baker, Department of Health Sciences, University of Leicester, University of Leicester, England, UK

32 Views Cite this report Responses(1)

Approved With Reservations

Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes
Are sufficient details of the methods and analysis provided to allow replication by others?

Partly
Is the statistical analysis and its interpretation appropriate?

Not applicable
Are the conclusions drawn adequately supported by the results presented in the review?

Partly
If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.)

Not applicable

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

primary care and population mortality

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Responses (1)

Author Response

14 Oct 2024

Gulnara Abashidze-Gabaidze, Healthcare management, Ivane Javakhishvili Tbilisi State University, Tbilisi, 0162, Georgia

Thank you, Mr. Baker, for your thorough review and valuable feedback. Your insights have been instrumental in strengthening this article and ensuring its quality. I appreciate your time and expertise
Our primary objective was to collaborate with other countries, including Georgia, to gain insights from their experiences in PHC. In response to the World Health Organization's call, we aimed to unite countries in a global effort to address this disease. By forming an international partnership and fostering mutual cooperation, we sought to share knowledge and best practices.
I appreciate your thoughtful feedback. While I believe I could have further refined this text, I've found this experience invaluable for my future writing endeavors. Thank you for your guidance.
I've added a table describing the findings of each paper, which I think will help explain the rationale behind the broad statements in the results section.

Are sufficient details of the methods and analysis provided to allow replication by others?
The data for each article reviewed during the analysis, including study characteristics, are presented in Table N1. Figure N1 (PRISMA diagram of study selection) and the PRISMA checklist are used to enhance the transparency of the narrative synthesis.
Your feedback has been invaluable in strengthening this article. Thank you again.

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Competing Interests

No competing interests were disclosed.

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Reviewer Report

37 Views

15 May 2024 | for Version 1

Nia Roberts, University of Oxford, Oxford, England, UK

37 Views Cite this report Responses(1)

Not Approved

Are the rationale for, and objectives of, the Systematic Review clearly stated?

Partly
Are sufficient details of the methods and analysis provided to allow replication by others?

No
Is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.
Are the conclusions drawn adequately supported by the results presented in the review?

No
If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.)

No

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Information specialist, who is only able to comment on the appropriateness of the search methods.

Respond to this report

Responses (1)

Author Response

17 Oct 2024

Gulnara Abashidze-Gabaidze, Healthcare management, Ivane Javakhishvili Tbilisi State University, Tbilisi, 0162, Georgia

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Competing Interests

No competing interests were disclosed.

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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

Abstract

Background

Methods

Results

Conclusions

Keywords

Introduction

Methods

Data sources and search strategy

Data items

Study risk of bias assessment

Data synthesis and analysis

Results

Search and selection process

Studies included and excluded

Characteristics of included studies

Discussion

Conclusion

Recommendations

Data availability

Underlying data

Reporting guidelines

References

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