In total 40 primary care providers participated in the focus groups: 12 physicians, 6 nurses, 10 medical assistants and 12 administrators. The participants’ mean ± SD age was 34.4 ± 7.8 years and their median experience in the health system was 7 years (range 1 to 30 years). Details of demographic and professional characteristics of the participants are shown in Table . The four focus groups provided a wide representation of views and sufficient saturation. Problems in the primary care system as emerged from the focus groups can be classified under five main themes: 1) inappropriate health services delivery, 2) health workforce challenges, 3) shortage in resources, 4) poor information technology, and 5) poor leadership/governance.
Demographic and professional characteristics of participants
Inappropriate health services delivery
Issues related to health services delivery particularly in terms of organization of these services were the main focus of all focus groups. These issues can be classified under the following subthemes:
Irrational use of health services
Focus group participants thought that PHCCs suffer from overcrowding which prevents physicians from having adequate time to provide quality care to patients. “[We see] patients from9:00 to 11:00 a.m.I can [only give]two minutes for each[patient] because of crowdingand because patients arealways in a hurryand impatient to wait” (F(=female)7, physician). Participants thought that overcrowding is partially the result of patients seeking unnecessary care.
Participants thought the low consultation fees (250 Iraqi Dinars ($0.2)) charged by PHCCs encouraged irrational and repeated visits to PHCCs. They suggested that increasing the fees to 1000 or 2000 Iraqi Dinars per consult might help in reducing many unnecessary visits and lower the irrational use of services. One medical assistant suggested “the [services can beimproved] by increasing thefees with provision ofbetter care and [sufficient]drugs” (F8, medical assistant). However, some participants had concerns about introducing higher initial fees that might make some patients, particularly the poor and uneducated, hesitant to visit PHCCs. It was mentioned that some patients may not know the seriousness of their illness or they may even turn to inappropriate health seeking strategies like visiting the private nurse clinics. Therefore, they suggested keeping the initial consultation fees at the current rate and charging additional fees for prescription and further services like laboratory tests and x-rays. “We cannot increase theuser fees. Even at[this] very low [rate],many patients can not[afford] visiting PHCCs. Itis better to obtainadditional fees for extraservices like investigations [toreduce] unnecessary requests forinvestigations” (M(=male)27, administrator).
Some participants, particularly physicians, expressed great concerns about unlicensed drug sellers including some private clinics. “Many medical assistants andnurses have opened clinicswhere they prescribe alltypes of medicines includingthose that can causeaddiction or lead toserious side effects. Withmy respect to theirlong experience, [I think]the medicines they prescribeshould be restricted” (M7, physician). Another participant noted that these clinics “have taught people totake [many types] ofdrugs together to get[rapid] relief. During the[flu] epidemic of thisyear, different [combinations] ofinjections and several typesof drugs were providedto patients at theseclinics to [get] immediaterelief” (M13, medical assistant).
Many participants emphasized the need to adopt a family medicine approach in the primary care system. Under a family medicine model patients would visit only the PHCC in their catchment area and see their own family medicine physician. Each family medicine physician would maintain electronic records for all patients. Participants thought this approach would help control irrational and repeated visits by patients. “If the system ischanged to a familymedicine system, it willbenefit both the providerand the patient asbetter and more organizedservices will be providedto people and theproviders can interact ina good way withpatients” (M1, physician). The positive experience of the only family medicine center in Erbil was frequently cited as a model that could be adopted in the primary care system.
The type of treatment provided at the PHCCs was described by some participants as irrational and based primarily on symptomatic treatment. “Frankly speaking, we providetreatment for symptoms withoutknowing the actual causeof these symptoms” (M3, physician). They attributed this to time constraints related to the high number of patients and a shortage of medicines and diagnostic facilities. “We only have someantibiotics and simple analgesics.So when [receiving] apatient, whatever he has,I nearly have writtenthe prescription [when] hestarts talking” (M12, medical assistant). Furthermore, some respondents reported lacking motivation to take good patient histories and conduct physical examinations. “We have no motivationin this job andthere are many patients.So we write theprescription immediately and sendthe patient out ofroom” (M14, physician).
Poor referral system
Participants indicated that many patients attend PHCCs only to ask for a referral to a specific hospital or consultation department without having a real reason for the referral. “Referral is [very common]with patients requesting referralfor even very simpleillnesses. We tell thepatient; please sit downand let [a] physiciansee you [as] youmay not require areferral. [But he insiststhat] he needs togo to [that] particularhospital” (M19, administrator). Physicians usually resist providing these inappropriate referrals, and participants agreed that provision of better services and increasing the health awareness of the people will help in reducing self-requested referrals. “If proper health careservices are provided atPHCCs and people becomeaware that most ofthe cases can be[dealt with] at thePHCC, we can controlthese unnecessary referrals” (M14, physician).
Poor infrastructure and hygiene
The facilities of most PHCCs were described as old, small and lacking sufficient space to provide health services to the current population. “[This] PHCC was built in1987 when [this residential]area was small [andhad] a small numberof inhabitants. The areahas [grown substantially] and[is now inhabited] bya very large numberof people, but thePHCC [remained] the same” (M17, administrator). Some participants emphasized the poor sanitary situation in PHCCs particularly in the PHCCs located in Erbil city and attributed this mainly to the lack of sufficient numbers of cleaning staff. “We have only threecleaning staff. If theywork properly they may[maintain the cleanliness] well,but two of themare [completely busy] withorganizing visitors at entryto [the consultation room]and cannot do anythingelse” (M11, administrator).
Health workforce challenges
High number of specialists in PHCCs
Participants thought that the PHCCs located in Erbil city are becoming like consultancy units as there are many specialists working in different fields. However, the available facilities and medicines at these PHCCs are very limited. “[This] PHCC has asurgeon, internist, ophthalmologist, otolaryngologist,radiologist, pediatrician and dentist.We just need tochange the name tobecome a consultancy center.But [the available] facilitiesand medicines are stillsimple analgesics and someantibiotics” (M5, administrator). Some participants indicated that PHCCs often gradually increase the number of specialists in different fields as the local hospitals are unable to accommodate the growing number of newly graduating specialists. Whilst many participants, particularly administrative directors, medical assistants and nurses, emphasized the importance of having specialists at PHCCs, physicians argued that there is no need to have specialists at PHCCs as general practitioners can deal with most patients and can refer them to specialized centers if required. “[Within] the Iraqi primarycare system [there isno need] to havespecialists in PHCCs. Thereis a need forhospitals in district orsub-district centers to providespecialist [referral] services” (M18, physician).
Uneven distribution of the health workforce
The uneven distribution of the health workforce in PHCCs, particularly with regards to physicians, skilled nurses and medical assistants, was emphasized by some participants. Specific examples of the shortage of skilled health care workers were in the fields of laboratory and radiology personnel. “We have now anew x-ray unit butit is still notoperating for not havingx-ray [personnel]. There maybe three or four[in a PHCC] butwe do not haveany [at this] PHCC” (M1, physician).
Rapid turnover of the health workforce
A number of participants emphasized the rapid turnover of the health workforce. They indicated that some personnel ask to be transferred to another PHCC shortly after receiving training in a specific job at their current PHCC. They cite different reasons for requesting the transfer, such as moving home to another area. “Sometimes, [after] we sendtwo staff members toget training on aspecific [program], they askto be transferred toanother PHCC. [Even if]we do not agree,they manage to gettransferred through personal connectionsand [this will affect]that program in thePHCC” (M2, administrator).
Physicians indicated that there are no incentives to retain physicians at PHCCs. They also thought that they do not have access to specialty training or postgraduate educational opportunities or benefit from supervision from more senior physicians while working in PHCCs. Furthermore, because of high patient numbers and the resulting short consultation times, as well as a lack of essential facilities and medicines, PHCCs are a challenging working environment. This will eventually result in a rapid turnover of physicians. Physicians usually leave PHCCs to pursue specialty training or postgraduate study. “If I stay atthe PHCC I willremain [a simple employee]without changing anything inmy life” (M7, physician). Rapid turnover of physicians is a big concern particularly in PHCCs outside Erbil city as physicians usually stay for six months to one year before being replaced by other physicians as part of the physicians’ internship system. Some of these physicians also hold the position of director of the PHCC. Thus, this rapid turnover similarly affects the management of PHCCs. “[The doctor and the administrative director] need six months tostart understand each otherand once they understandeach other the doctorwill leave [the PHCC]” (M21, administrator).
Lack of training and education
Focus group participants mentioned a lack of opportunities for professional development and education for primary care providers. The available training courses do not always address the actual needs of the providers. “There are some trainingcourses but these aremainly theoretical [and] cannotbe applied practically. Ipersonally have participated inmany tuberculosis training programs,but we have notimplemented [this program] sofar” (F4, medical assistant).
Participants had concerns about the extreme discrepancies in the salary system. A newly appointed nurse may receive a significantly lower salary than another nurse who has been in the job longer but has the same responsibilities. “A [newly appointed] nursegets 150,000 or 200,000Iraqi Dinars. It isnot reasonable that anothernurse with less educationbut longer [years inservices] to [get] asalary of 1,350,000 IraqiDinars, while the youngone works like oreven harder than theold one” (M4, administrator). They agreed that there should be some difference in salaries but not at the extreme levels that are currently present.
Shortage in resources
Participants agreed that medicines provided to patients in PHCCs often do not cover a full course treatment. The supplied medicines may be sufficient for one or two days only, even if the treatment is required for five or seven days. Prescribing insufficient quantities of medicines is mainly due to the shortage or unavailability of medicines. “We see patients [atPHCC] for six hours[each day]. Medicines areavailable in the firsttwo hours only. Thenhalf of the patientswill return [home] withouttreatment or [we are]obliged to prescribe medicinesfrom outside the PHCC” (M18, physician). Many times patients need to come back for another consultation where they may see a different doctor and receive a completely different treatment regimen depending on that physician’s opinion or availability of drugs. “If a patient haschest infection, he willreceive few capsules thatwill meet two days’need. Since he isnot going to completea full treatment course,he will [return to]you. [The physician] shouldremember the drug [thatwas] prescribed for himtwo days ago” (M5, administrator).
Some participants emphasized the poor quality of some drugs. “Many drugs are ofpoor quality that donot function well [and] lack real benefit topatients. The poor quality isrelated to both [poor] quality control and poorstorage conditions [that is largely related] to lack of continuouselectricity particularly in hotweather” (M6, administrator). Others reported a shortage in some laboratory materials like blood sugar test strips. “[This] small PHCC [that does not] have large number ofpatients, [receives] the same quantity oflaboratory materials [that is] provided to other PHCCthat are bigger and [receive] more patients. The supplies that wereceive every two monthsmeet the needs oftwo weeks only ifwe use them properly, so imagine the situationin the bigger PHCCs” (M3, physician). Participants from PHCCs outside Erbil city noted the role of sector directorates in facilitating the supply and purchase of materials and medicines. The process of obtaining additional supplies and purchasing additional drugs by PHCCs seemed to be easier in PHCCs outside Erbil city compared to those located in Erbil city. “The administration here isvery helpful; having a sector directoratein the district hadmade a lot offacilitation. If we have shortagein some supplies likedentistry needles, I can process arequest in half anhour. If this [is] done through Erbil, it could take [longer] time [or not] done at all” (M27, administrator).
Some participants strongly emphasized the need for PHCCs to have a petty cash fund to be able to take care of urgent maintenance and procurement requirements. Currently PHCCs must follow the usual procurement procedures through the Directorate of Health for all supply and maintenance requests. “The Directorate of Healthwill carry out theworks, but with [considerable] delay. For example it maytake three months [to have a new] air-conditioner, but we [will have it] at end” (M1, physician). In the PHCCs outside Erbil city, reimbursement of these expenses is easier when facilitated by sector Directorates, but still advance cash payment was a requirement. “If there is [an] urgent need, we will do itand ask for reimbursementfrom the sector Directorate. Even if there [is] some delay, we will eventually getreimbursed” (M14, physician).
Poor use of information technology
Many participants were concerned about the improper use of information technology in PHCCs and limited efforts by health authorities to incorporate this important field in the primary care system. “We have abolished therole of internet andemail. [At] the Ministry of Healthin Baghdad we weredoing [most of the] work through email. The work was doneimmediately without the needto send letters orrequests [by mail] and wait [to get a response]. Each PHCC should haveits own email andknow how to contacteach unit or department” (M7, physician). Participants agreed that integration of information technology in the primary care system can have a role in improving the organization of health services, disease reporting and communication with the Directorate of Health. While some PHCCs possess computers, they are not used efficiently. “Each year many graduatesfrom Erbil computer institutecould be recruited bythe Ministry of Healthand [with providing] 2–3 computers [to] each PHCC a goodinformation system [can be] established” (M4, administrator).
Participants raised a number of issues related to leadership and governance that adversely affect the primary care system. They strongly emphasized the lack of effective monitoring and evaluation within the primary health care system. For example, there is a large problem related to irregular staff attendance; some staff members fail to show up for work without reason and many others leave early before the end of official working hours. “There is no effectivemonitoring system. Even if there aremeasures taken to changethis system, for example controlling staffattendance to PHCCs duringworking hours, the change will lastonly few days ifthere is no goodmonitoring and follow upon [implementation] of the new measures” (M3, physician). They also emphasized the poor regulations of public-private practice and poor control of problems resulting from primary care providers moonlighting in the private sector. Some participants indicated that providers may intentionally provide poor care in the PHCCs in the morning working hours to encourage patients to visit their private clinics after the official working hours. “The physician may providegood care to thepatients that visit theprivate clinic but maynot provide that goodcare while working inthe public sector” (M25, medical assistant).
Many of the problems at the PHCCs that were mentioned in the different themes and sub-themes like uneven distribution of the health workforce, poor professional development, poor infrastructure and hygiene, shortage and poor quality of medicines are also related to poor governance/leadership. For example, the participants strongly emphasized poor distribution of workforce skills. “Sometimes the PHCC isoverstaffed but there maybe shortage in aspecific field like askilled nurse. The directorate of healthsends a person tocover this shortage, but they send usa clerk. How can we carryout health work witha clerk?” (M3, physician).