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Primary care reform: international evidence and primary care doctors’ perspectives within the context of health system reform in Saudi Arabia
University College Cork
Background The Kingdom of Saudi Arabia (KSA) has launched and ambitious reform programme Vision 2030 including health system reform (Government of Saudi Arabia, 2016a). The health system challenges include the increasing burden of chronic diseases, inadequate access to healthcare, and health service fragmentation. The health strategy articulates a new model of care (MOC), targeting financial reform, provider reform, eHealth development, and public private partnerships. A strategic priority for the KSA health system is to strengthen primary healthcare (PHC) and to position primary care (PC) as the first point of access to healthcare. To date there is limited evaluation of the health reforms with a particular evidence gap on reform implementation in PC. The research aims: 1) to examine the international evidence on the implementation of PHC reform for chronic conditions in countries with high or very high human development index (Review 1); 2) to examine the qualitative evidence on PC doctors’ perspectives on PC reform within the context of health system reforms (Review 2); 3) to explore PC doctors’ perspectives on PC reform within the context of the health system reform in the KSA using a qualitative study design. Methods Review 1 was guided by the PRISMA statement including academic articles and grey literature from 1 March 2008 to 1 September 2020. Descriptive analysis and narrative synthesis were applied. Review 2 used a thematic synthesis of qualitative studies guided by Thomas and Harden (2008) three stage framework to identify descriptive and analytical themes. The qualitative study used interpretive description (ID) methodology. Semi-structured interviews were conducted with a purposive sample of 14 PC doctors (general practitioners (GPs) & family physicians (FPs)), recruited from primary health care centers (PHCC) in the Makkah region of KSA. Constant comparative analysis and Thorne (2016) six-steps was used to analyze the data. Results Review 1 included eight articles from four countries. It revealed a shift in chronic disease management from hospital to PC services involving new organizational and funding models (PC networks, commissioning of services, and shared governance structures). The need for leadership and engagement from PC doctors to support PC reform was identified. Review 2 included sixteen qualitative studies from eight countries. Three themes were identified: (1) Health system reform: lacking integrated and co-ordinated services; (2) Funding primary care: competition versus collaboration; and (3) GP/FP engagement in shaping primary care reform. The qualitative study on PC doctors’ perspectives on KSA PC reform identified five major themes: Changes in daily practice; Changes in the infrastructure of PC; Changes in Relationships, Gradation of awareness to understanding of the PC reform; and Barriers and enablers to engaging in PC reform. Participants observed changes in their daily practice with reference to chronic disease prevention and early intervention with a shift from hospital to PC management model. This corresponded to changes in infrastructure especially diagnostic services, access to medication, and information systems. Changes in relationships with patients were perceived as more patient/person-centred wile relationships between PHCCs were described as more collaborative which was attributed to the formation of health clusters as a collective of PHCC and acute hospitals serving a defined population. In contrast, participants’ viewed relationships with the hospital sector as largely hierarchical with no real collaboration. Participants’ understandings and engagement with the PC reforms as stakeholders varied. While there was some understanding of the MOC especially among FP participants, their understanding of financial reform and provider payments was limited. The GP/FP participants believed they had an important contribution to make to the reform agenda as frontline providers. Barriers and enablers to engagement related to trusted sources of information, education and leadership opportunities, and communication with policy decision making. Conclusion This thesis provides important insights from the literature reviews and the qualitative study into the crucial role that PC doctors as frontline health service providers can play in PC reform. PC doctors’ experiences need to be considered by policy makers to ensure successful implementation of PC reform that meets individual and population needs, and that are adequately resourced financially. There is a need for a deliberate process to engage with PC doctors to help them appreciate how observed changes link to policy and to support them as change agents rather than passive actors in the reorientation of the KSA PHC and wider health system.
Primary care reform , Health system , Health reform
Alyousef, M. 2023. Primary care reform: international evidence and primary care doctors’ perspectives within the context of health system reform in Saudi Arabia. PhD Thesis, University College Cork.