Challenges to Quality Primary Health Care in Saudi Arabia and Potential Improvements Implemented by Other Systems: Systematic Review

Introduction: As primary healthcare centres play an important role in implementing Saudi Arabia’s health strategy, this paper offers a review of publications on the quality of the country’s primary health care. With the aim of deciding on solutions for improvement, it provides an overview of healthcare quality in this context and indicates barriers to quality. Method: Using two databases, ProQuest and Scopus, data extracted from published articles were systematically analysed for determining the care quality in Saudi primary health centres and obstacles to achieving higher quality. Results: Twenty-six articles met the criteria for inclusion in this review. The components of healthcare quality were examined in terms of the access to and effectiveness of interpersonal and clinical care. Good access and effective care were identified in such areas as maternal health care and the control of epidemic diseases, whereas poor access and effectiveness of care were shown for chronic disease management programmes, referral patterns (in terms of referral letters and feedback reports), health education and interpersonal care (in terms of language barriers). Several factors were identified as barriers to high-quality care. These included problems with evidence-based practice implementation, professional development, the use of referrals to secondary care and organisational culture. Successful improvements have been implemented by other systems, such as mobile medical units, electronic referrals, online translation tools and mobile devices and their applications; these can be implemented in Saudi Arabia for improving the quality of the primary healthcare system in this country. Conclusion: The quality of primary health care in Saudi Arabia varies among the different services. To improve quality, management programmes and organisational culture must be promoted in primary health care. Professional development strategies are also needed for improving the skills and knowledge of healthcare professionals. Potential improvements can be implemented to improve the quality of the primary health system.

. The process of selecting the 26 articles, which are contained in this review Tables 1 and 2 show summaries of the general characteristics and most important findings of the 26 studies. Among the studies, five were from southern, seven from eastern, eight from central and two from northern and western Saudi Arabia, while three were from Mexico, Canada and Germany. The remaining article incorporated multiple countries, specifically, the United Kingdom, Norway, Finland, Netherlands, Denmark, New Zealand, Canada, Australia and the United States. Most of the studies were carried out in the primary health institutions of the Ministry of Health, while two were carried out in an army health institution. Fifteen studies collected data by questionnaire, seven through medical records and four by interview. The total sample size of all the studies was 9997, while the individual studies' sample sizes ranged from 39 to 1553, with response rates ranging from 61% to 100%.
Most of the studies included in this review focussed on administration, clinical care and interpersonal care ( Table 2). The results of these studies can be divided into two main categories: the quality of care provided and obstacles to providing quality care.

Quality of Care Provided Access
Maternal care was reported to be available in both urban (67%) and rural (96%) areas (El-Gilany & Aref, 2000). The distances between PHCCs and patients' homes were reported to be acceptable and to provide easy access to centres (86%). Access to the chronic diseases programme was observed to be below target (Al-Jaber & Da'ar, 2016;Al-Khaldi & Khan, 2000;Al-Mustafa & Abulrahi, 2003). For instance, only a small number of registered hypertension patients had visited centres for treatment (16-36%; (Al-Mustafa & Abulrahi, 2003). Dental services were observed to be unavailable in primary health centres (28%), and the cost of private dental services was reported to be high (37%; (Al-Jaber & Da'ar, 2016). Low referral rates and missed appointments reportedly prevented appropriate access to specialist care to health services; most primary care institutions had established registers, appointment systems and follow-up systems (Alhamad, 2013;Kishk & Al Juhani, 2006). Finally, the mobile unit had reduced 35% of attendance for outpatient clinics, which can be a solution to providing health services without needing to provide clinics (Diaz-Perez, Farley, & Cabanis, 2004).

Effectiveness
Many studies have indicated that several primary healthcare programmes have been effective, including diabetes care education (Al-Khaldi & Khan, 2000) and maternal health care (El-Gilany & Aref, 2000). As a result of the diabetes health education programme, about 73% of diabetic patients received health education on relevant topics, which helped physicians communicate more effectively with them (Al-Khaldi & Khan, 2000). The expanded maternal services programme increased maternal care coverage to 96% in rural areas and 67% in urban areas (El-Gilany & Aref, 2000). In contrast, resources for primary diabetic care were inadequate (Al-Khaldi & Al-Sharif, 2002). Many factors contributed to this, including a lack of access to essential drugs (10-18%), lack of coordination with secondary providers regarding diabetic care (65%), lack of appointment systems for diabetic care (10%) and lack of training in diabetic care nurses (57%) and doctors (80%).
Nursing staff were also dissatisfied with working life in primary care, for reasons like inadequate salary (61%), working environments that felt unsafe (60%) and long working hours (71%; (Almalki et al., 2012). A Canadian study from 2011 reported that 85% of the participants used mobile devices and their applications to access new information because such devices allow flexible, quick and easy access to multi-media, journals and medical news (Wallace et al., 2012).

Obstacles to Providing Quality Care
This review identified four factors that delay the achievement of quality primary health care in Saudi Arabia. These are difficulties in the implementation of evidence-based medicine (EBM), problems at the interface with secondary providers, issues with professional development strategies and organisational culture.

Inadequate implementation of EBM
National guidelines have been established for several common conditions; however, some studies have shown that clinical decisions are not adequately evidence based (Al-Ansary & Khoja, 2002;Dashash & Mukhtar, 2003;Khan et al., 2011). This has contributed to inadequate diagnoses, inappropriate clinical decisions, wide practice variations and unsafe prescription patterns (Al-Ansary & Khoja, 2002;Dashash & Mukhtar, 2003). The implementation of evidence-based medicine faces such obstacles as poor guideline dissemination Barriers the course: Lack of personal time (22%), overload (29%), limited to access to references (16%) and internet (10%).
Low level of awareness for: Review publications and journals, and low understanding of the course technical terminology. (Albattal, 2014) Interface with secondary care Management Implementing referral system, reduce 32% of visits in hospital.
The main factors for inappropriate referrals, GP reported: poor awareness of the available clinics of secondary care (67%), lack of referral feedback (86%), difficult to communicate with specialists by phone (91%). To improve referral process, should be periodic referral auditors (84%). (Albrecht et al., 2013) Access/ effectives Language barriers MediBabble application had been implemented in health organisations to overcome language barriers.
Participants reported: -(92% of participants) reducing the time of the visit.
-(92%) improving the quality of health care delivery and patient safety. While, some patients were not satisfied with centers services: 37% patient agreed working hours in center is not suitable, Long waiting time (39%), difficult to get an appointment (37%), not easy to access to center at any time (49%), not contact for missing appointment (65%), not easy to referral procedure to hospital (22%), not seeing the same doctor when they followed up (31%), and clinic does not listen to patients complaints (62% Evening shift (23%), outside duties (81%), and PHCCS administrative transaction is slow (74%). (Dashash & Mukhtar, 2003) Effectives Asthma Guidelines were not followed: Use of non-recommend, over and under prescribing, drug interactions, poor follow up and continuity of care, and suboptimal care for asthmatic children. Unknow correct diagnostic criteria of type 2 diabetes 928%), knew correct angle of insulin injection (35%0, and not agree about diabetic self-management education (87%). (Kishk & Al Juhani, 2006) Organization culture Job satisfaction Characteristics in primary care: work team, corporate work environment, attitude improving between staff.
Job dissatisfaction was: doctors (52%) and nurses (67%), includes: Workload (70%), professional opportunities (78%), and appreciation reward (67%). (Tian, 2011) Interface with secondary care Electronic-Referral E-referral had successful reducing wait times and improve access to secondary, quality of referral communication, and complete and accurate information of referral patients. (Wallace et al., 2012) Effectives Electronic Education 85% of participants reported using mobile devices and their application, can provide easy, quick accessing to journals, news, multimedia.
MOH: Ministry of Health, PHCCs: Primary health care centers, GP: General practice, NA: not applicable, NR, not records, CME: continuous medical education, GP: General practice.

Interface with Secondary Care
In 1986, a referral system was established to improve communication and coordination between primary health care and hospitals (Al-Ahmadi & Roland, 2005). Evidence indicates that the implementation of the referral system reduced hospital outpatient visits by 32% (Albattal, 2014). However, several studies identified a lack of information on referral forms, including history (36%), vital signs (30%), the results of examination (45%), the results of investigation (52%), provisional diagnosis (50%) and the treatment given in PHCCs (47%; (Al-Alfi et al., 2007). In addition, feedback reports were received for only 30% of referrals to hospitals (Al-Alfi et al., 2007;Albattal, 2014). The main factors reportedly contributing to inappropriate referrals in general practice are a poor awareness of available secondary care clinics (67%), a lack of referral feedback (86%) and the difficulty of communicating with specialists by phone (91%; (Albattal, 2014). Moreover, hospital feedback to PHCCs was released only at the request of patients or health centres (Albattal, 2014), and the feedback forms lacked information, including diagnosis (15%), advice (100%) and the results of investigations (21%; (Al-Ahmadi & Roland, 2005). In contrast, electronic referral was related to success in improving the quality of referral communication between primary and secondary health services and providing complete and accurate information about referral patients (Tian, 2011).

Organisational Culture
Several studies reported many positive organisational characteristics in PHCCs, such as work teams, the corporate work environment, continuing education (Al-Mosilhi & Kurashi, 2006) and positive staff attitudes towards improvements through the implementation of EBM (Al-Ansary & Khoja, 2002). However, many studies also pointed out that primary care professionals' general sense of job significance was poor (Almalki et al., 2012;Kishk & Al Juhani, 2006). These studies found that more than half of professionals were dissatisfied with management practices, incentives, workloads and medical facilities (Almalki et al., 2012;Kishk & Al Juhani, 2006). Studies on stress among primary healthcare professionals found that sources of stress included outside duties (81%), paperwork (81%) and slow administrative transactions (74%; (Bawakid et al., 2017;Khan et al., 2011).

Professional Development Strategies
Evidence indicates that the professional development strategies in PHCCs are inadequate (Al-Mosilhi & Kurashi, 2006;Alsharif & Al-Khaldi, 2001). Studies have shown that only about one-third of physicians in primary health care had postgraduate qualifications, and only 2% of these were in primary health care (Al-Mosilhi & Kurashi, 2006;Alsharif & Al-Khaldi, 2001). Even fewer were shown to have access to international journals (Alsharif & Al-Khaldi, 2001). Major additional obstacles to professional development were work pressure, distance from educational institutions, the unavailability of suitable continuous medical education (CME) and a lack of time (Al-Mosilhi & Kurashi, 2006;Alsharif & Al-Khaldi, 2001).

Discussion
The Saudi primary healthcare programme has achieved considerable success, and it is considered a pioneering programme in the country within a few years of its establishment. This is reflected in certain effective and accessible primary healthcare services, such as diabetes care education and maternal health care. However, dental services are still unavailable in most PHCCs, and variations in some aspects of primary care quality, such as the management of chronic diseases, have been identified. In a study performed in Canada, similar variations in primary healthcare quality were observed (Lévesque et al., 2012).
Mobile medical units have been implemented as an alternative solution to supply the standard of dental care to reach the underserved population in several countries. These units have been shown to be highly successful in improving access and cost-efficiency (Diaz-Perez et al., 2004). A school-based study in the south of Africa showed that having a mobile dental unit was cost effective; it showed cost savings of 9.1% and eliminated missed appointments (Molete, Chola, & Hofman, 2016). Similarly, a cross-sectional study comparing the costs of a fixed facility and mobile dental unit in Thailand stated that the mobile dental unit provided comprehensive oral health at a lower cost (Tianviwat, Chongsuvivatwong, & Birch, 2009). Thus, this intervention can be implemented as alternative solution for unviable dental services in some primary healthcare settings in Saudi Arabia.
The clinical care quality is affected by failures to adhere to the appropriate referral patterns and guidelines of EBM.
Attempts have been made to promote the practices of EBM in Saudi primary health care, but because of poor professional development and guideline dissemination, these efforts have yet to achieve their potential. Studies have shown that physicians face barriers to education, such as work pressure, distance, the unavailability of suitable CME and a lack of time. In addition, few physicians have access to international journals. Kredo et al. (2016) point out that increased implementation of evidence-based clinical guidelines will contribute to improving the quality of primary care. This review found that Saudi physicians have positive attitudes towards EBM; however, their lack of training in EBM practices prevents its implementation. This is similar to the findings that general practitioners in Australia have positive attitudes towards EMB, but in daily practice, they are not employing the terminology and performing the tasks involved in EBM implementation (Young & Ward, 2001).
The quality of feedback reports and referral letters demonstrates that communication between primary care physicians and hospital specialists is poor. This review observed a worrying lack of basic clinical information in both referral letters and feedback reports, including the results of clinical examinations and investigations and the duration of complaints. Senitan, Alhaiti, Gillespie, Alotaibi, and Lenon (2017) report that providing hospital specialists with adequate clinical information about the health status of patients, including evaluations of their initial health conditions and all specific questions that need to be addressed, is important for saving patients' lives.
Electronic referral (e-referral) may improve the interfacing between primary and secondary healthcare providers by allowing general practitioners from primary health care to electronically request referrals to specialist health professionals (Naseriasl, Adham, & Janati, 2015). E-referrals have been defined as the method of transferring patient care responsibility from referring healthcare providers to specialist healthcare providers and the responsibility for transferring appropriate information back in an appropriate timeframe (Tian, 2011). Several countries, including the United States, United Kingdom, Australia, New Zealand, Denmark and the Netherlands, have implemented e-referrals to improve the quality of the referral system in health care (Naseriasl et al., 2015;Tian, 2011). Consequently, these countries have noted improvements in the quality of the interface, accurate transfers, reduced wait times, more accurate feedback information and complete health information. Thus, the health referral system may be improved by implementing e-referral in Saudi Arabia.
In this review, wide variations in the quality of interpersonal care were observed. These variations are related to language barriers and cultural gaps between patients and healthcare professionals. Most of Saudi Arabia's primary healthcare professionals are non-Saudi, and they may not speak Arabic, their patients' main language. Online translation tools like MediBabble offer a possible solution for overcoming challenges related to language barriers. MediBabble presents medical professionals a fast, convenient and free interpreter. Using advanced voice recognition software, translations of medical instructions and questions are presented to obtain a standard medical history (Irfan & Ginige, 2018;Rahman, 2017). This tool can be used both offline and online (Sheik-Ali, Dowlut, & McConaghie, 2016), and it translates to six languages, namely, English, Russian, Cantonese, Haitian Creole, Mandarin and Spanish (Sheik-Ali et al., 2016). A case study showed that both patients and medical professionals were highly satisfied with MediBabble, reporting that the tool was easy and fast in terms of collecting and translating information (Boujon, Bouillon, Spechbach, Gerlach, & Strasly, 2018). In brief, the MediBabble application shows success as a medical translator; therefore, it can be applied in Saudi Arabia.
Primary healthcare professionals' lack of access to information and training is a major concern, as they are unable to maintain their skills and knowledge (Hughes, 2008); Johnston, Crombie, Alder, Davies, and Millard (2000) pointed out that improving professionals' access to evidence-based guidelines and medical information is an essential requirement for improving the quality of primary health care.
Mobile devices and their applications present a possible solution for helping healthcare professionals overcome the barriers to education and the practice of EBM. These devices have become common in healthcare settings, contributing to the fast growth in the development of medical software applications in this field (Wallace et al., 2012). Mobile applications like QuantiaMD and MedPage Today are used by practicing healthcare professionals to continuously engage in medical education activities that keep them informed about recent medical practice and evidence-based information (Ventola, 2014). The QuantiaMD application provides well-scripted interactive case studies that make it possible to share with colleagues (Ozdalga, Ozdalga, & Ahuja, 2012). In addition, MedPage Today is a popular mobile application that provides continuing medical education news services and free continuing education among healthcare professionals (Ventola, 2014). A 2011 survey of Canadian medical schools showed that 55%, 95% and 75% of students, residents and faculty, respectively, agreed that mobile devices provide fast access to educational resources and have positive education effects (Wallace et al., 2012). Therefore, the Saudi primary healthcare system can benefit from implementing mobile devices and their applications.
The motivation and morale of healthcare centre staff may be improved by concentrating on patient load, working hours, salaries and the improvement of facilities and resources. The employment conditions of non-Saudi professionals and their roles in improving quality must also be examined. A sense of job security should be granted through contract conditions. This review has certain limitations. Most of the studies examined were carried out in Ministry of Health institutions, the country's major providers of primary health care, while other providers included military health institutions. Factors that delay the achievement of quality vary from one provider to another because each primary healthcare provider has different goals and priorities for providing quality services. The studies in this review were varied in their design method and in the aspects of care studied, limiting the option of pooling their evidence.

Conclusion
This review found that the primary healthcare agenda faces significant challenges in Saudi Arabia. These challenges include the lack of some services in PHCCs, such as dental care; issues of interfaces with hospitals, such as missing important clinical information from referral letters and feedback reports; language barriers between health professionals and patients; and primary healthcare professionals' lack of access to information and training. The challenges identified in this review can be addressed by improving all aspects of the primary healthcare system and establishing a comprehensive quality assessment system. This review suggests some potential improvements that have been implemented by other systems to address these challenges. First, mobile dental units have been implemented as an alternative successful solution for limited dental services in the healthcare system in many countries, and these units can be adopted in Saudi Arabia. Second, an effective solution for challenges in the referral system that may be applicable is an e-referral system, which has been implemented in several countries, including the United States and Australia. Such e-referral systems present complete, accurate information about referred patients. Third, the MediBabble application presents a possible solution for overcoming language barriers. Fourth, mobile applications, such as QuantiaMD and MedPage Today, provide easy and fast access to health education resources and keep health professionals informed about recent medical practice and evidence-based information. Further research on adopting solutions in Saudi Arabia that have been successfully implemented elsewhere is needed.