Patient Perspectives on Primary Healthcare Reforms in Saudi Arabia: A Qualitative Study

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Valderas, Manal Almalki, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7580269/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 13 You are reading this latest preprint version Abstract Background In Saudi Arabia, the Vision 2030 health reform agenda aim to transform primary health care (PHC) through service expansion and digital innovation. Early indicators suggest progress; however, limited research has explored how patients perceive these changes. Objective This study explores patient experiences of PHC and PHC reforms in Saudi Arabia. Methods A qualitative study was conducted using 11 focus groups with 44 patients across four regions of Saudi Arabia. Participants were recruited through purposive sampling. Thematic analysis, guided by both inductive and deductive coding, was used to explore patient perceptions. Results Besides the predefined themes which included accessibility, continuity, coordination, and comprehensiveness, findings revealed strong approval for digital tools like Mawid (appointment booking) and Wasfaty (e-prescription), which improved access to appointments and medications. However, barriers remained, including limited parking, challenges with digital literacy, and difficulties securing timely appointments especially for dental care. Relational continuity was weak due to frequent changes in providers, though electronic medical records supported informational continuity. The Ehalati (referral system) improved access to secondary care, but a lack of feedback from specialists limited coordination. Participants recognized expanded diagnostic services, but persistent gaps were noted in dental and mental health access. Conclusion Participants reported improved patient experience in several areas, particularly through digital transformation and expanded services. Yet challenges in continuity, coordination, and service availability remain. Addressing these issues is essential for achieving a fully integrated, patient-centered PHC system aligned with Vision 2030 goals. Primary Health Care Patient Experience Healthcare Reform Digital Health Saudi Arabia Contributions to the Literature First comprehensive patient perspective study of Saudi Arabia's Vision 2030 primary healthcare transformation, providing insights into large-scale healthcare reform implementation. Practical evidence on digital health implementation in primary care, documenting patient acceptance and barriers to tools like Mawid and Wasfaty. Systematic evaluation framework for assessing patient experiences across core primary healthcare domains during health system transformation. Implementation barriers identification including digital literacy gaps and care coordination breakdowns that persist despite technological advances. Transferable insights for countries implementing primary healthcare reforms, particularly balancing digital innovation with patient-centered care principles. 1. Introduction Primary health care (PHC) is widely recognized as the cornerstone of effective health systems, offering accessible, comprehensive, coordinated, and patient-centered services that address the majority of individuals’ health needs across their lifespan [ 1 , 2 ]. It plays a pivotal role in promoting health, preventing disease, and managing chronic conditions; hence, contributing to improved population health outcomes, reduced healthcare costs, and enhanced health equity [ 3 , 4 ]. In recent years, Saudi Arabia has embarked on an ambitious reform of its PHC system under the framework of Vision 2030, a national initiative aimed at transforming various sectors, including healthcare [ 5 ]. As part of this initiative, the Ministry of Health (MoH) launched a transformation program in 2016 to elevate PHC to international standards, with a focus on addressing the growing burden of non-communicable diseases and enhancing service delivery. By mid-2019, tangible improvements were reported: PHC utilization increased by 37.5%, rural health coverage rose from 78% to 83%, and patient satisfaction showed a modest improvement of approximately 4.7% [ 6 ]. Several studies have documented enhancements in clinic infrastructure, staff performance, and overall service quality under these reforms [ 6 , 7 ]. A defining feature of Saudi Arabia’s PHC transformation has been the rapid integration of digital health technologies. Initiatives such as Mawid (an appointment-booking app), and Wasfaty (an e-prescription service), were launched around 2019 and quickly gained traction. For instance, Mawid’s user base surged from 4 million to over 25 million in a short period, reflecting the growing demand for digital health access [ 8 ]. Similarly, Ehalati (the national electronic referral system), introduced in 2017, has become a key component of the referral process within PHC. These innovations have helped mitigate long-standing issues such as overcrowding and long wait times. Yet, while communication between providers received high satisfaction ratings (83%), reflecting improvements in care coordination, however, access to care remained a challenge, with only 42% of patients satisfied with appointment availability indicating that despite technological advances like Ehalati, structural access barriers persist [ 9 , 10 ]. Despite these advancements, gaps remain in understanding how these reforms have impacted patient experience—a critical metric for evaluating healthcare quality and system responsiveness. While previous studies have acknowledged the importance of patient-centered care and satisfaction, few have examined patient experiences in relation to the specific domains of PHC—namely, accessibility, continuity, coordination, and comprehensiveness—within the context of Saudi Arabia’s reform efforts [ 7 , 11 ]. Therefore, the objective of this study is to explore and analyze patient experiences across key PHC domains in Saudi Arabia, based on recent reforms, using qualitative insights drawn from focus group discussions conducted across multiple regions. This exploration is vital to inform policy adjustments, enhance service delivery, and ensure that PHC transformation efforts align with the evolving needs and expectations of the population. 2. Methods 2.1 Study Sampling and Recruitment Participants were recruited in January and February 2022 through purposive sampling to capture diverse patient experiences across different regions of Saudi Arabia. The study included participants from the Southern, Eastern, Western, and Northern regions. Eligibility criteria included: being registered at the selected PHC centers (PHCCs) for at least four years, visiting the PHCC at least twice in the previous year, having experience of visiting PHC centers before and after the reforms, their age of 18 years or more. All participants signed a consent form before each focus group began. Eligible participants were identified by PHCCs’ managers and receptionists and invited via the receptionists in the PHCCs through text messages. This study was approved by the ethical committee of College of Medicine and Health, University of Exeter, No. 489743, on 01/26/2022. In addition, an ethical approval was obtained from ethics committee of Jazan health affairs in Saudi Arabia No. 2181, on 24/10/2021. 2.2 Data Collection This qualitative study formed part of a larger mixed-methods study about measuring patient experience of primary care and capturing patients’ perceptions of the primary care reforms in Saudi Arabia. A focus group (FG) approach was chosen to gather insights from participants about their experiences as patients in PHCCs [ 12 ]. Focus groups were chosen to explore how patients' experiences might be influenced by hearing others' perspectives and to identify areas of consensus or disagreement about PHC reforms. Focus group topic guide was developed for this study (Supplement 1). All sessions were conducted in PHCC’s meeting rooms during regular working hours. The focus groups were moderated by the lead researcher (AM), with support from a trained Saudi registered nurse who assisted with session preparation and note-taking. At the beginning of each session, the moderator welcomed participants, introduced themselves, and explained the purpose of the study. Participants were assured that their responses would remain anonymous and confidential and that they had the right to withdraw at any time. Prior to starting the discussion, each participant completed a brief demographic form to capture information on demographic characteristics such age, gender, level of education, chronic diseases, and the number of years registered in the PHCC. The focus groups were conducted in Arabic and recorded with participant consent. Recordings were later transcribed and translated into English. To ensure quality of the transcription and translation, a professional agent qualified in transcription and translation, and a native Arabic language speaker and fluent in English language were recruited. A confidentiality agreement was signed by each agent before sharing the recordings and starting the work. A comprehensive revision for each Arabic transcript and English translated version of the recording was done by the researcher during the agent’s work and feedback was given to the agent on each stage. Random selections of transcripts and translated copies of the work were double checked by an Arabic teacher specialized in Teaching English to Speakers of Other Languages (TESOL) from School of Education at the University of Exeter. 2.3 Data Analysis Thematic analysis was used to identify key patterns and themes [ 13 ], combining both deductive and inductive coding approaches [ 14 ]. Four predefined themes were derived from[ 2 ] which were: accessibility, continuity, coordination, and comprehensiveness. Accessibility in primary care encompasses factors like convenient location, timely appointments, and affordability [ 15 , 16 ]. Continuity of care refers to the degree to which patients experience care over time as cohesive and with consistent providers [ 1 ]. It encompasses two facets: relational continuity (seeing the same clinician regularly) and informational continuity (having your medical information follow you) [ 1 ]. Coordination focuses on the integration of primary care with other parts of healthcare to ensure seamless patient care [ 17 ]. Lastly, refers to PHCC’ ability to address a wide range of health needs, either directly or through arranged services [ 18 ]. In addition to the predefined themes, three important areas were explored during the focus group and represented as themes which were: Mawid, Wasfaty, and dental services. Mawid and Wasfaty are two digital systems; Mawid is a digital system for booking appointments in PHCCs, and Wasfaty is a system for outsourcing patients’ medication in PHCCs. Both Mawid and Wasfaty were merged into digital health in the discussion. This thematic analysis was conducted using NVivo software (version 1.6.1). It involved the following steps [ 19 ]: 1) transcripts were read multiple times to ensure immersion in the data; 2) coding was conducted to identify relevant segments of data related to patient experience; 3) codes were then organized into broader themes; 4) themes were refined and consolidated through iterative discussions between researchers (AM, EP, CH, JV, and IP) to ensure coherence and consistency; 5) distinct and reflective definitions were developed for each theme; and 6) the final themes were structured and organized to provide an overarching insights of patient experiences in Saudi PHCC. 3. Results 3.1 Participants’ Characteristics A total of 44 out of 60 agreed and consented to participate in 11 focus groups. These groups included 93.1% Saudi, 52.3% males and 47.7% females, evenly split between ages 20–39 and 40 years and above, as shown in Table 1 . About 50.0% had secondary education or less, and 40.9% held a bachelor’s degree. Regionally, participants were distributed across four areas: Southern region (38.6%, 5 FGs), Western region (22.8%, 2 FGs), Eastern region (20.4%, 2 FGs), and Northern region (18.1%, 2 FGs) (Table 1 ). Table 1 Participants’ characteristics Variables N % Gender Male 23 52.3 Female 21 47.7 Age group 20–39 22 50.0 40 and above 22 50.0 Education highest level achieved Secondary or less 22 50.0 Bachelor’s degree 18 40.9 Not specified 4 09.0 Nationality Saudi 41 93.1 Non-Saudi 3 6.9 Participants per region (Total FGs) PHCC1: Southern (FG = 5) 17 38.6 PHCC2: Northern (FG = 2) 8 18.1 PHCC3: Eastern (FG = 2) 9 20.4 PHCC4: Western (FG = 2) 10 22.8 3.2 Overview of Themes The thematic analysis identified several key themes related to patient experience, categorized into predefined domains of Accessibility, Continuity, Coordination, and Comprehensiveness. Moreover, three more domains were identified during the focus group which included Mawid, Wasfaty, and dental services. The discussion included participants’ general views on PHC reforms in Saudi Arabia, and their perceptions of accessibility, continuity, coordination, and comprehensiveness. 3.2.1 Accessibility Most participants reported that the geographical location of PHCC was convenient and accessible. However, three significant categories of barriers were identified that limited patients' ability to fully access services: infrastructure-related, digital/technological, and systemic/service-level barriers. In terms of infrastructure-related barriers, the most reported issue was the lack of adequate parking facilities, especially in urban areas. This physical constraint made it difficult for patients to reach PHCC conveniently. For example, Participant 7 from PHCC2 identified parking as one of her top three worst experiences, while Participant 1 from PHCC4 said that “If I can't find a place to park inside [the PHCC’s parking area], I have to go and search for a place outside”. Such infrastructure-related challenges created frustration and discouraged regular visits to the centers. In terms of digital/technological barriers, although the Mawid app was widely praised for streamlining the appointment booking process, several participants reported technical issues such as app crashes, slow loading, and poor internet connectivity, particularly in rural areas. In addition, elderly patients and those with limited digital literacy found the app difficult to use. Participant 1 from PHCC2 said that “I myself don't like appointment services because there are old people, and many don't have internet”. These digital barriers limit access for vulnerable groups who are less equipped to navigate technology-based health services. In terms of systemic and service availability barriers, another major concern was the difficulty in securing timely appointments through Mawid, especially for specialized services such as dental care. For example, Participant 6 from PHCC3 said that “In terms of dental appointments, it’s really far, there are no upcoming appointments – they’re all crowded”, while Participant 7 from PHCC2 added that “The Mawid app doesn't permit you to book for the same day”. Without a confirmed appointment, participants were often turned away. Similarly, although the Wasfaty app was appreciated by some for allowing medication pickup from external pharmacies, many found it difficult to locate participating pharmacies nearby. Participant 7 from PHCC2 reported needing to travel 40 km to obtain prescribed medicine, while Participant 2 from PHCC4 noted that in some regions, pharmacy options were limited to a single provider. 3.2.2 Continuity of Care Service continuity was viewed positively by most participants, particularly with respect to the consistent availability of routine check-ups and follow-up appointments. However, relational continuity, which refers to the ability to consistently see the same physician over time, was identified as a major barrier. Many participants expressed dissatisfaction with seeing different doctors at each visit, which hindered the development of trust and familiarity. For example, Participant 4 from PHCC2 said that “Every time I come, I find the doctor is replaced. She is always not the same doctor as the previous time”. Similarly, Participant 4 from PHCC1 said that “I like to be checked up by the same doctor. I don't want any other doctors because she is already aware of my medical condition and history”. On the other hand, informational continuity was somewhat supported through the use of electronic medical records (EMRs), though it was only explicitly appreciated by a few participants. EMRs were seen as useful in ensuring access to patient histories across different providers. For example, Participant 6 from PHCC2 said that “They are all linked to one network. All my data is available – on which date, who is my doctor, my nurse, when was the last time I checked in, my laboratory data”. Similarly, Participant 1 from PHCC3 said that “The medical file that is uploaded by a doctor here on the system appears on screen to any of the doctors who logs into this system”. 3.2.3 Coordination Coordination of care between PHCC and secondary care providers was identified as a critical area for improvement by several participants. A prominent barrier was the lack of referral feedback, where no communication occurred between secondary care providers and the PHCC after a patient was referred. This gap left patients uncertain about follow-up care and created dissatisfaction. For example, Participants 1 from PHCC1 and 5 from PHCC2 both reported that after being referred to secondary care, no information was shared back with the PHCC, resulting in fragmented and uncoordinated care. In contrast, the electronic referral system Ehalati was cited as an enabler by some participants, who appreciated its efficiency in processing referrals and reducing delays. For example, Participant 8 from PHCC5 said that “It was immediate, swiftly I mean – no sooner had I received the medical referral than they immediately received me”. 3.2.4 Comprehensiveness Most participants acknowledged improvements in the comprehensiveness of services offered at PHCC, particularly with the addition of X-ray and laboratory facilities. For example, Participant 1 said that “We used to come and didn't find X-rays or laboratory, but nowadays there is”, and Participant 2 from PHCC1 confirmed, “All the services are available”. However, notable service gaps remained, especially in Dental Services and Mental Health Services. Dental care was a major source of dissatisfaction, reporting long wait times and limited appointment availability. As Participant 6 from PHCC3 said that “In terms of dental appointments, it's really far, there are no upcoming appointments, they are all crowded”. Similarly, Participant 2 from PHCC4 added that “Appointments… Dental clinics… they tell you: three months, and something like that”. 3.2.5 Mawid In respect of the new appointment booking system (Mawid), participants gave a range of views. Some participants argued that this system changed services for the better, while others suggested that this system is an obstacle to accessing health services in PCCs. Supporters of the Mawid application felt that the application helps with managing and organising appointments and that this can positively impact on the quality of the consultation. For instance, participant 6 from PHCC1 said “ I can tell you: previously, the problem was the appointments. I mean, when any patient comes directly to the infirmary without a booking, he was obliged to wait; But now the system has changed… You have to book an appointment, and you have to take enough time to explain your complaints, and everything”. On the other hand, a few participants claimed the Mawid programme encountered periodic technical difficulties, occasionally impeding users from scheduling their appointments. Moreover, those participants suggested that some people do not have access to the internet or may lack experience in using smart devices. For example, participant 1 from PHCC2 said “I myself dislike appointment services, why do you require the patient to book an appointment one or two days before the booking date? Brother Why doesn't the receptionist come down and book an appointment – meaning – What's the problem? There are old people, and there are people who don't have internet… I mean, what does he want? This is a massive problem.”. 3.2.6 Wasfaty Wasfaty is a system linking PCCs with private pharmacies and allowing patients to order their medication free from these private pharmacies. This new system replaced an old system in which patients got their medicines from the PCCs or in a few cases from the nearest hospital if the medicine was not available in the PCC. Wasfaty had several negative comments from participants. The greater part of these negative comments was about the lack of some private pharmacies which caused patients to search for more than one pharmacy to dispense medicine. For example, participant 3 in PHCC2 said “My observation, lies in dispensing the medicine and treatments from the external pharmacies, I go to the external pharmacy and don't find the treatment. I keep searching all over Mecca until I can find this treatment. Sometimes, I go to four or five pharmacies until I can find this treatment or medicine”. 3.2.7 Dental services Dentistry services were transitioned from outpatient clinics in hospitals and dental polyclinics and merged into PCCs in recent years. The majority of participants who needed these services had negative observations about dentistry services. The common negative issue reported by the participants about dental clinics was the long waiting time before getting an appointment and seeing the dentist. For instance, participant 6 from PHCC3 said “No In terms of dental appointments, it's really far, there are no upcoming appointments, they are all crowded…”. Other negative issues that were less reported were the quality of the services presented in the clinic, including the lack of experience of the dentist’s physicians and lack of equipment. Another participant (6) from PHCC5 said “Some PCCs – which I don't remember their names – whenever I go to them, they tell us: The dental fillings ran out, the dental implants ran out…”. 4. Discussion The findings indicate several positive developments such as improved availability of basic diagnostic services, the adoption of digital health tools, and the general availability of routine care; however, persistent challenges continue to affect accessibility, continuity, coordination, and comprehensiveness, Mawid, Wasfaty, and Dental services in PHCCs as follows. 4.1 Enhancing Accessibility: The Role of Digital Health in Saudi Primary Care Accessibility in Saudi primary care has significantly improved, particularly through the adoption of digital health platforms such as the Mawid and Wasfaty apps, with strong patient approval reflected. Participants in our focus groups consistently praised Mawid, the national appointment scheduling system, for its convenience and efficiency in streamlining access to care. These perceptions are supported by recent empirical studies. For example, a 2023 cross-sectional study conducted in the Jazan region reported an overall satisfaction rate of 94.3% with Mawid, with most respondents affirming that the app helps regulate patient flow and reduces clinic overcrowding. Another survey found that over 65% of users described Mawid as user-friendly for both accessing information and scheduling appointments [ 20 ]. These results suggest that digital appointment booking has been widely accepted and viewed as a major step forward in improving access and reducing logistical burdens, which our participants’ feedback echoed these findings. Similarly, the Wasfaty e-prescription app has played a transformative role in improving access to medications. By allowing prescriptions to be filled at affiliated community pharmacies outside the clinic, Wasfaty has expanded the geographic and logistical reach of pharmaceutical services [ 21 ]. This innovation has been recognized in the literature as a significant advancement in healthcare in Saudi Arabia [ 21 ]. However, despite its benefits, several challenges persist. High prescription volumes, occasional technical malfunctions, and difficulties among elderly or digitally inexperienced patients have been identified as barriers to optimal use [ 21 ]. These limitations highlight the need for ongoing technical support, public education, and digital literacy training to ensure inclusive access and full utilization of the system. 4.2 Advancing Continuity of Care: Bridging Relational Gaps in the Saudi Primary Care System In terms of continuity of care, our focus group participants shared mixed experiences. While many reported consistently visiting the same PHCC for ongoing health needs to ensure continuity at the service or site level, they frequently encountered different physicians at each visit, which limited relational continuity. This inconsistency disrupted the development of long-term, trust-based relationships between patients and providers [ 22 ]. Patients widely recognize the value of having a regular general practitioner (GP) who is familiar with their medical history, provides consistent advice, and assumes responsibility for their ongoing careers that are only possible through sustained, one-on-one relationships [ 22 ]. Interestingly, some participants in our study were less concerned about seeing different doctors, expressing confidence in EMRs to maintain informational continuity. They felt that, as long as their health data was accessible, any doctor can pick up where the last one was left off. While this reliance on EMRs is promising, it contrasts with international findings that strongly emphasize the unique value of relational continuity. For example, a UK study by Murphy and Salisbury [ 22 ] highlighted that patients often view relational continuity as a safety issue which means that not seeing a familiar GP can lead to concerns of being overlooked or misinterpreted. Similarly, a Swedish study found that 86% of patients valued having a regular GP, and approximately two-thirds were able to consult their preferred provider most of the time [ 23 ]. Evidence consistently shows that continuity of care is associated with higher patient satisfaction, better adherence to medical advice, improved clinical outcomes, and even reduced mortality[ 24 – 27 ] A recent study in Saudi Arabia demonstrated that when patients with chronic conditions were formally assigned to a specific family physician, significant improvements were observed in clinical indicators such as blood pressure and HbA1c levels [ 24 ]. These findings are consistent with global literature indicating that a stable, ongoing relationship with a primary care provider supports preventive care and overall health outcomes [ 22 , 23 ]. In recognition of these benefits, the Ministry of Health (MOH) in Saudi Arabia has initiated efforts to strengthen longitudinal continuity by assigning patients or families to dedicated providers. This includes pilot programs such as the one implemented at King Saud University clinics designed to embed continuity into routine primary care practice as part of broader health system reforms [ 24 ]. 4.3 Strengthening Care Coordination: Enhancing the Referral Feedback Loop in Saudi Primary Care Our study identified notable improvements in referral processes alongside persistent challenges in information flow between primary and secondary care. Our participants widely praised the introduction of Ehalati, Saudi Arabia’s national electronic referral system, for enhancing efficiency and convenience. By digitizing referrals and notifying patients of their specialist appointments, Ehalati reduced the need for paper-based referral letters and streamlined access to secondary care [ 28 ]. However, a critical limitation reported by our participants was the lack of feedback from secondary care providers back to the primary care centers. This disruption in the referral feedback loop led to patient dissatisfaction, as general practitioners were often left relying on patient-reported outcomes to guide follow-up care – a situation that undermines coordinated and continuous care [ 29 ]. These coordination issues are not unique to the Saudi context. International studies have similarly documented breakdowns in communication between general practitioners (GPs) and specialists. A comprehensive 34-country European survey revealed that in many healthcare systems, crucial referral feedback is frequently delayed or omitted, resulting in fragmented care [ 30 ]. Factors such as a lack of shared accountability between levels of care can exacerbate the issue, leaving patients vulnerable to gaps in treatment continuity and providers working with incomplete clinical information [ 29 , 30 ]. Both Saudi and global literature consistently emphasize that closing the referral loop is essential for delivering integrated, patient-centered care. What distinguishes the Saudi context is the existence of a nationwide, advanced electronic referral infrastructure, offering a strong foundation for effective coordination. The key challenge now lies in operationalizing the system fully, particularly by ensuring that specialists consistently provide timely electronic feedback to the referring primary care physicians. Targeted interventions (e.g., automating discharge summaries and specialist reports to be sent directly through the Ehalati system) could significantly enhance care continuity and provider collaboration [ 31 , 32 ]. 4.4 Expanding Comprehensiveness: Integrating Dental and Mental Health Services into Primary Care A key achievement of Saudi Arabia’s PHC reform has been the integration of dental and mental health services into settings that historically focused almost exclusively on general medical care. However, findings from our focus groups indicate that significant gaps remain in the accessibility and availability of these expanded services. In the case of dental health, many participants expressed dissatisfaction with long wait times and limited appointment availability which, in turn, may compel them to seek care in the private sector. A recent review by Almajed et al. [ 33 ] found that many people in Saudi Arabia continue to prefer private dental clinics, citing shorter waiting periods and perceived higher quality of care. This suggests that simply co-locating dental clinics within PHC facilities alone is insufficient; effective dental service delivery also requires adequate staffing, streamlined appointment systems, and stronger patient trust in the quality of public PHC [ 33 ]. The persistence of patient preference for private services underlines the need to enhance confidence in the public PHC dental care system. Mental health care, on the other hand, has seen more significant progress. Traditionally confined to specialized psychiatric hospitals, mental health services in Saudi Arabia had minimal presence in PHC settings [ 34 ]. Recognizing this gap, the MoH launched the Primary Mental Health Care (PMHC) program, in alignment with the World Health Organization’s Mental Health Gap Action Programme (mhGAP), which advocates for integrating mental health into PHC through task-shifting and capacity-building. As of 2022, mental health services (i.e., screening, basic therapy, and referral pathways) had been introduced in 75% of PHCC nationwide [ 34 ]. This initiative has yielded measurable results: approximately 77.2% of patients showed improvement, and only 8% required referral to specialized psychiatric care. These outcomes suggest that common conditions such as mild-to-moderate depression and anxiety are now being effectively managed at the primary care level. From a global perspective, Saudi Arabia’s efforts stand out. Integration of oral and mental health into PHC remains limited in many countries, where these domains are often treated in separate silos. The World Health Organization has flagged oral health as a neglected component of PHC, calling for its inclusion to improve access and reduce inequities [35]. Likewise, while countries such as the UK and the US have implemented programs like Improving Access to Psychological Therapies (IAPT) or collaborative care models, full integration of mental health into PHC is still far from universal. This often results in underdiagnosis and undertreatment of mental health conditions. Globally, it is estimated that up to 60% of PHC patients may suffer from undetected mental health disorders, largely due to insufficient provider training or lack of integrated protocols [ 34 ]. In this context, Saudi Arabia’s phased, system-wide implementation that is supported by provider training, public education, and digital tools such as telepsychiatry has been recognized as a potential global model [ 34 ]. However, challenges remain. Sustaining this progress will require ongoing investment in workforce development, robust referral pathways for complex cases, and systematic monitoring of patient satisfaction and treatment outcomes in both dental and mental health domains. 4.5 Strengths and Limitations This study has its own strengths and limitations. The use of focus groups allowed for rich, in-depth insights into patient perspectives across multiple regions, providing an understanding of how the reforms have impacted accessibility, continuity, coordination, and comprehensiveness of care. However, this study was limited by the lack of representation from the Central region of Saudi Arabia, potentially limiting the transferability of findings to the Central region, where healthcare infrastructure, population demographics, and reform implementation may differ from the studied regions. In addition, potential social desirability bias may have influenced participants to withhold negative feedback in group settings, or to disagree with others in the group. 5. Conclusion This study highlights patients’ generally positive experiences with recent reforms in Saudi Arabia’s primary healthcare system, particularly improvements in accessibility through digital tools like Mawid and Wasfaty. However, challenges persist, including limited relational continuity, weak referral feedback loops, and gaps in service availability especially for dental and mental health care. Electronic systems and service expansions have enhanced care delivery but achieving fully integrated and patient-centered primary care will require continued efforts to strengthen provider continuity, inter-provider communication, and public trust in PHC services. Future studies could address these limitations by incorporating larger and more regionally representative samples, employing quantitative designs, and including the perspectives of healthcare professionals and administrators. This would provide a more comprehensive picture of the successes and challenges in Saudi Arabia’s primary healthcare transformation. Such efforts will be critical for ensuring that healthcare reforms meet the evolving needs and expectations of the Saudi population. Declarations Ethics approval and consent to participate: This study was approved by the ethical committee of College of Medicine and Health, University of Exeter, on 01/26/2022 (Project Number: 489743). The study conducted in compliance with the approved protocol and adhered to the principles outlined in the Declaration of Helsinki. In addition, an ethical approval was obtained from ethics committee of Jazan health affairs in Saudi Arabia No. 2181, on 10/24/2021. Participants gave written informed consent. Consent for publication: Not applicable Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests : None declared. Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article. Author Contributions : AM, EP, CH, JMV, and IP jointly conceptualized and developed the research design. AM conducted data collection and thematic analysis. MA played a central role in drafting and revising the manuscript. HNM reviewed and provided feedback on the final draft. All authors contributed to writing and editing the final version of the manuscript. Disclaimer: The views expressed by the authors do not necessarily reflect the University of Exeter or any other party opinions. References Khatri R, Endalamaw A, Erku D, Wolka E, Nigatu F, Zewdie A et al. 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Available from: http://www.nivel.nl/oc2/page.asp?PageID=10959&path=/Startpunt/Home Hempel S, Ganz D, Saluja S, Bolshakova M, Kim T, Turvey C et al. Care coordination across healthcare systems: development of a research agenda, implications for practice, and recommendations for policy based on a modified Delphi panel. BMJ Open. 2023;13(5). O’Malley AS, Rich EC. Measuring comprehensiveness of primary care: Challenges and opportunities. J Gen Intern Med. 2015;30:568–75. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. Alali E, Al-Dossary R, Al-Rayes S, Al-Ansary N, Alshawan D, Almulla S et al. Evaluation of the Patient Experience with the Mawid App during the COVID-19 Pandemic in Al Hassa, Saudi Arabia. Healthcare 2022, Vol 10, Page 1008 [Internet]. 2022 May 30 [cited 2025 May 6];10(6):1008. Available from: https://www.mdpi.com/2227-9032/10/6/1008/htm Alharthi MS. Exploring challenges and enablers for community pharmacists using electronic prescriptions (Wasfaty) in Makkah region, Saudi Arabia: a qualitative study using the theoretical domains framework. Front Med (Lausanne) [Internet]. 2024 [cited 2025 May 6];11:1487852. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11583241/ Murphy M, Salisbury C. Relational continuity and patients’ perception of GP trust and respect: a qualitative study. Br J Gen Pract. 2020;70(698):E676–83. Cohen E, Lindman I. Importance of continuity of care from a patient perspective – a cross-sectional study in Swedish health care. Scand J Prim Health Care [Internet]. 2024 [cited 2025 May 6];42(1):195. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10851828/ Alsaad SM, Alatawi SA, Alajlan F, Alserhani R, Alhussaini N, Alali N. The Relationship Between Continuity of Care and Enhancement of Clinical Outcomes Among Patients with Chronic Conditions. Patient Prefer Adherence [Internet]. 2024 [cited 2025 May 6];18:1509. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11283798/ Gray DJP, Sidaway-Lee K, White E, Thorne A, Evans PH. Continuity of care with doctors - A matter of life and death? A systematic review of continuity of care and mortality. BMJ Open. 2018;8(6). Almalki ZS, Alahmari AK, Alajlan SAA, Alqahtani A, Alshehri AM, Alghamdi SA et al. Continuity of care in primary healthcare settings among patients with chronic diseases in Saudi Arabia. SAGE Open Med [Internet]. 2023;11. Available from: /pmc/articles/PMC10617268/ Arnold C, Hennrich P, Wensing M. Patient-reported continuity of care and the association with patient experience of cardiovascular prevention: an observational study in Germany. BMC primary care [Internet]. 2022;23(1):176. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med22&NEWS=N&AN=35850657 Alabbasi KH, Kruger E, Tennant M. Strengthening Saudi Arabia’s Primary Health Care through an e-Referral System: A Case Study. Clinics and Practice 2022, Vol 12, Pages 374–382 [Internet]. 2022 May 24 [cited 2025 May 6];12(3):374–82. Available from: https://www.mdpi.com/ 2039-7283/12/3/42/htm. Senitan M, Alhaiti A, Gillespie J. Ehalati: Evaluation of the Referral System in Primary Health Care Centres in Saudi Arabia. Int J Integr Care. 2018;18(s2):326. Scaioli G, Schäfer WLA, Boerma WGW, Spreeuwenberg PMM, Schellevis FG, Groenewegen PP. Communication between general practitioners and medical specialists in the referral process: a cross-sectional survey in 34 countries. BMC Fam Pract [Internet]. 2020 Mar 17 [cited 2025 May 6];21(1):54. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7079351/ Chandra P, Ahmed O, Vajawat B, Ojuawo O, Varshney P, Audit on Discharge Summaries From General Adult Inpatient Units to Primary Care at Black Country Healthcare NHS Foundation Trust. BJPsych Open [Internet]. 2024 Jun [cited 2025 May 6];10(S1):S223–4. Available from: https://www.cambridge.org/core/journals/bjpsych-open/article/audit-on-discharge-summaries-from-general-adult-inpatient-units-to-primary-care-at-black-country-healthcare-nhs-foundation-trust/349974C3ADAF81BDF0C7FF8EAB89526C Ahmad DA, Khan DA, Abiodun MY. Introduction of ECT Discharge Summary- a Quality Improvement Project to Improve Communication Between Treating and Referring Clinicians and Aiming Better Patient Care. BJPsych Open [Internet]. 2022 Jun [cited 2025 May 6];8(Suppl 1):S80. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9378006/ Almajed OS, Aljouie A, Alghamdi R, Alabdulwahab FN, Laheq MT. Transforming Dental Care in Saudi Arabia: Challenges and Opportunities. Cureus [Internet]. 2024 Feb 16 [cited 2025 May 6];16(2). Available from: https://pubmed.ncbi.nlm.nih.gov/38496163/ Al-Khathami AD, Alharbi LS, Alomari SA, Alqahtani AA, Alfadhli DS. Integrating mental healthcare into primary healthcare services: Saudi Arabia progress and achievements (1995–2022). Current Research in Psychiatry,; Volume 5(Issue 1):42–49 [Internet]. 2025 Feb 21 [cited 2025 May 6];Volume 5(Issue 1):42–9. Available from: https://www.probiologists.com/article/integrating-mental-healthcare-into-primary-healthcare-services-saudi-arabia-progress-and-achievements Prasad M, Manjunath C, Murthy A, Sampath A, Jaiswal S, Mohapatra A. Integration of oral health into primary health care: A systematic review. J Family Med Prim Care. 2019;8(6):1838. Additional Declarations No competing interests reported. Supplementary Files V0.2Focusgrouptopicguideversion2.pdf Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 03 Dec, 2025 Reviews received at journal 02 Dec, 2025 Reviews received at journal 30 Oct, 2025 Reviewers agreed at journal 30 Oct, 2025 Reviews received at journal 29 Oct, 2025 Reviewers agreed at journal 26 Oct, 2025 Reviewers agreed at journal 21 Oct, 2025 Reviewers agreed at journal 21 Oct, 2025 Reviewers invited by journal 21 Oct, 2025 Editor assigned by journal 15 Oct, 2025 Editor invited by journal 18 Sep, 2025 Submission checks completed at journal 18 Sep, 2025 First submitted to journal 18 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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07:16:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":836080,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7580269/v1/48558e18-156d-41f8-bf48-940e3c8cc3e5.pdf"},{"id":94985371,"identity":"fda60e62-d23d-4546-96ff-9e57848c788a","added_by":"auto","created_at":"2025-11-03 06:58:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":252202,"visible":true,"origin":"","legend":"","description":"","filename":"V0.2Focusgrouptopicguideversion2.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7580269/v1/236537f9f3b96cbedd38b447.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Patient Perspectives on Primary Healthcare Reforms in Saudi Arabia: A Qualitative Study","fulltext":[{"header":"Contributions to the Literature","content":"\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eFirst comprehensive patient perspective study of Saudi Arabia's Vision 2030 primary healthcare transformation, providing insights into large-scale healthcare reform implementation.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePractical evidence on digital health implementation in primary care, documenting patient acceptance and barriers to tools like Mawid and Wasfaty.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSystematic evaluation framework for assessing patient experiences across core primary healthcare domains during health system transformation.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eImplementation barriers identification including digital literacy gaps and care coordination breakdowns that persist despite technological advances.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eTransferable insights for countries implementing primary healthcare reforms, particularly balancing digital innovation with patient-centered care principles.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e"},{"header":"1. Introduction","content":"\u003cp\u003ePrimary health care (PHC) is widely recognized as the cornerstone of effective health systems, offering accessible, comprehensive, coordinated, and patient-centered services that address the majority of individuals\u0026rsquo; health needs across their lifespan [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It plays a pivotal role in promoting health, preventing disease, and managing chronic conditions; hence, contributing to improved population health outcomes, reduced healthcare costs, and enhanced health equity [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn recent years, Saudi Arabia has embarked on an ambitious reform of its PHC system under the framework of Vision 2030, a national initiative aimed at transforming various sectors, including healthcare [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. As part of this initiative, the Ministry of Health (MoH) launched a transformation program in 2016 to elevate PHC to international standards, with a focus on addressing the growing burden of non-communicable diseases and enhancing service delivery. By mid-2019, tangible improvements were reported: PHC utilization increased by 37.5%, rural health coverage rose from 78% to 83%, and patient satisfaction showed a modest improvement of approximately 4.7% [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Several studies have documented enhancements in clinic infrastructure, staff performance, and overall service quality under these reforms [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA defining feature of Saudi Arabia\u0026rsquo;s PHC transformation has been the rapid integration of digital health technologies. Initiatives such as Mawid (an appointment-booking app), and Wasfaty (an e-prescription service), were launched around 2019 and quickly gained traction. For instance, Mawid\u0026rsquo;s user base surged from 4\u0026nbsp;million to over 25\u0026nbsp;million in a short period, reflecting the growing demand for digital health access [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Similarly, Ehalati (the national electronic referral system), introduced in 2017, has become a key component of the referral process within PHC. These innovations have helped mitigate long-standing issues such as overcrowding and long wait times. Yet, while communication between providers received high satisfaction ratings (83%), reflecting improvements in care coordination, however, access to care remained a challenge, with only 42% of patients satisfied with appointment availability indicating that despite technological advances like Ehalati, structural access barriers persist [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite these advancements, gaps remain in understanding how these reforms have impacted patient experience\u0026mdash;a critical metric for evaluating healthcare quality and system responsiveness. While previous studies have acknowledged the importance of patient-centered care and satisfaction, few have examined patient experiences in relation to the specific domains of PHC\u0026mdash;namely, accessibility, continuity, coordination, and comprehensiveness\u0026mdash;within the context of Saudi Arabia\u0026rsquo;s reform efforts [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTherefore, the objective of this study is to explore and analyze patient experiences across key PHC domains in Saudi Arabia, based on recent reforms, using qualitative insights drawn from focus group discussions conducted across multiple regions. This exploration is vital to inform policy adjustments, enhance service delivery, and ensure that PHC transformation efforts align with the evolving needs and expectations of the population.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Study Sampling and Recruitment\u003c/h2\u003e\u003cp\u003eParticipants were recruited in January and February 2022 through purposive sampling to capture diverse patient experiences across different regions of Saudi Arabia. The study included participants from the Southern, Eastern, Western, and Northern regions. Eligibility criteria included: being registered at the selected PHC centers (PHCCs) for at least four years, visiting the PHCC at least twice in the previous year, having experience of visiting PHC centers before and after the reforms, their age of 18 years or more. All participants signed a consent form before each focus group began. Eligible participants were identified by PHCCs\u0026rsquo; managers and receptionists and invited via the receptionists in the PHCCs through text messages. This study was approved by the ethical committee of College of Medicine and Health, University of Exeter, No. 489743, on 01/26/2022. In addition, an ethical approval was obtained from ethics committee of Jazan health affairs in Saudi Arabia No. 2181, on 24/10/2021.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Data Collection\u003c/h2\u003e\u003cp\u003eThis qualitative study formed part of a larger mixed-methods study about measuring patient experience of primary care and capturing patients\u0026rsquo; perceptions of the primary care reforms in Saudi Arabia. A focus group (FG) approach was chosen to gather insights from participants about their experiences as patients in PHCCs [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Focus groups were chosen to explore how patients' experiences might be influenced by hearing others' perspectives and to identify areas of consensus or disagreement about PHC reforms. Focus group topic guide was developed for this study (Supplement 1). All sessions were conducted in PHCC\u0026rsquo;s meeting rooms during regular working hours. The focus groups were moderated by the lead researcher (AM), with support from a trained Saudi registered nurse who assisted with session preparation and note-taking. At the beginning of each session, the moderator welcomed participants, introduced themselves, and explained the purpose of the study. Participants were assured that their responses would remain anonymous and confidential and that they had the right to withdraw at any time.\u003c/p\u003e\u003cp\u003ePrior to starting the discussion, each participant completed a brief demographic form to capture information on demographic characteristics such age, gender, level of education, chronic diseases, and the number of years registered in the PHCC. The focus groups were conducted in Arabic and recorded with participant consent. Recordings were later transcribed and translated into English. To ensure quality of the transcription and translation, a professional agent qualified in transcription and translation, and a native Arabic language speaker and fluent in English language were recruited. A confidentiality agreement was signed by each agent before sharing the recordings and starting the work. A comprehensive revision for each Arabic transcript and English translated version of the recording was done by the researcher during the agent\u0026rsquo;s work and feedback was given to the agent on each stage. Random selections of transcripts and translated copies of the work were double checked by an Arabic teacher specialized in Teaching English to Speakers of Other Languages (TESOL) from School of Education at the University of Exeter.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Data Analysis\u003c/h2\u003e\u003cp\u003eThematic analysis was used to identify key patterns and themes [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], combining both deductive and inductive coding approaches [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Four predefined themes were derived from[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] which were: accessibility, continuity, coordination, and comprehensiveness. Accessibility in primary care encompasses factors like convenient location, timely appointments, and affordability [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Continuity of care refers to the degree to which patients experience care over time as cohesive and with consistent providers [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It encompasses two facets: relational continuity (seeing the same clinician regularly) and informational continuity (having your medical information follow you) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Coordination focuses on the integration of primary care with other parts of healthcare to ensure seamless patient care [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Lastly, refers to PHCC\u0026rsquo; ability to address a wide range of health needs, either directly or through arranged services [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In addition to the predefined themes, three important areas were explored during the focus group and represented as themes which were: Mawid, Wasfaty, and dental services. Mawid and Wasfaty are two digital systems; Mawid is a digital system for booking appointments in PHCCs, and Wasfaty is a system for outsourcing patients\u0026rsquo; medication in PHCCs. Both Mawid and Wasfaty were merged into digital health in the discussion.\u003c/p\u003e\u003cp\u003eThis thematic analysis was conducted using NVivo software (version 1.6.1). It involved the following steps [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]: 1) transcripts were read multiple times to ensure immersion in the data; 2) coding was conducted to identify relevant segments of data related to patient experience; 3) codes were then organized into broader themes; 4) themes were refined and consolidated through iterative discussions between researchers (AM, EP, CH, JV, and IP) to ensure coherence and consistency; 5) distinct and reflective definitions were developed for each theme; and 6) the final themes were structured and organized to provide an overarching insights of patient experiences in Saudi PHCC.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Participants\u0026rsquo; Characteristics\u003c/h2\u003e\u003cp\u003eA total of 44 out of 60 agreed and consented to participate in 11 focus groups. These groups included 93.1% Saudi, 52.3% males and 47.7% females, evenly split between ages 20\u0026ndash;39 and 40 years and above, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. About 50.0% had secondary education or less, and 40.9% held a bachelor\u0026rsquo;s degree. Regionally, participants were distributed across four areas: Southern region (38.6%, 5 FGs), Western region (22.8%, 2 FGs), Eastern region (20.4%, 2 FGs), and Northern region (18.1%, 2 FGs) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipants\u0026rsquo; characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e52.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e47.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge group\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20\u0026ndash;39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e40 and above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEducation highest level achieved\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary or less\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e40.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot specified\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e09.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNationality\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSaudi\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e93.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon-Saudi\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eParticipants per region (Total FGs)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePHCC1: Southern (FG\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e38.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePHCC2: Northern (FG\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e18.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePHCC3: Eastern (FG\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePHCC4: Western (FG\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e22.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Overview of Themes\u003c/h2\u003e\u003cp\u003eThe thematic analysis identified several key themes related to patient experience, categorized into predefined domains of Accessibility, Continuity, Coordination, and Comprehensiveness. Moreover, three more domains were identified during the focus group which included Mawid, Wasfaty, and dental services. The discussion included participants\u0026rsquo; general views on PHC reforms in Saudi Arabia, and their perceptions of accessibility, continuity, coordination, and comprehensiveness.\u003c/p\u003e\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\u003ch2\u003e3.2.1 Accessibility\u003c/h2\u003e\u003cp\u003eMost participants reported that the geographical location of PHCC was convenient and accessible. However, three significant categories of barriers were identified that limited patients' ability to fully access services: infrastructure-related, digital/technological, and systemic/service-level barriers.\u003c/p\u003e\u003cp\u003eIn terms of infrastructure-related barriers, the most reported issue was the lack of adequate parking facilities, especially in urban areas. This physical constraint made it difficult for patients to reach PHCC conveniently. For example, Participant 7 from PHCC2 identified parking as one of her top three worst experiences, while Participant 1 from PHCC4 said that \u0026ldquo;If I can't find a place to park inside [the PHCC\u0026rsquo;s parking area], I have to go and search for a place outside\u0026rdquo;. Such infrastructure-related challenges created frustration and discouraged regular visits to the centers.\u003c/p\u003e\u003cp\u003eIn terms of digital/technological barriers, although the Mawid app was widely praised for streamlining the appointment booking process, several participants reported technical issues such as app crashes, slow loading, and poor internet connectivity, particularly in rural areas. In addition, elderly patients and those with limited digital literacy found the app difficult to use. Participant 1 from PHCC2 said that \u0026ldquo;I myself don't like appointment services because there are old people, and many don't have internet\u0026rdquo;. These digital barriers limit access for vulnerable groups who are less equipped to navigate technology-based health services.\u003c/p\u003e\u003cp\u003eIn terms of systemic and service availability barriers, another major concern was the difficulty in securing timely appointments through Mawid, especially for specialized services such as dental care. For example, Participant 6 from PHCC3 said that \u0026ldquo;In terms of dental appointments, it\u0026rsquo;s really far, there are no upcoming appointments \u0026ndash; they\u0026rsquo;re all crowded\u0026rdquo;, while Participant 7 from PHCC2 added that \u0026ldquo;The Mawid app doesn't permit you to book for the same day\u0026rdquo;. Without a confirmed appointment, participants were often turned away. Similarly, although the Wasfaty app was appreciated by some for allowing medication pickup from external pharmacies, many found it difficult to locate participating pharmacies nearby. Participant 7 from PHCC2 reported needing to travel 40 km to obtain prescribed medicine, while Participant 2 from PHCC4 noted that in some regions, pharmacy options were limited to a single provider.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section3\"\u003e\u003ch2\u003e3.2.2 Continuity of Care\u003c/h2\u003e\u003cp\u003eService continuity was viewed positively by most participants, particularly with respect to the consistent availability of routine check-ups and follow-up appointments. However, relational continuity, which refers to the ability to consistently see the same physician over time, was identified as a major barrier. Many participants expressed dissatisfaction with seeing different doctors at each visit, which hindered the development of trust and familiarity. For example, Participant 4 from PHCC2 said that \u0026ldquo;Every time I come, I find the doctor is replaced. She is always not the same doctor as the previous time\u0026rdquo;. Similarly, Participant 4 from PHCC1 said that \u0026ldquo;I like to be checked up by the same doctor. I don't want any other doctors because she is already aware of my medical condition and history\u0026rdquo;.\u003c/p\u003e\u003cp\u003eOn the other hand, informational continuity was somewhat supported through the use of electronic medical records (EMRs), though it was only explicitly appreciated by a few participants. EMRs were seen as useful in ensuring access to patient histories across different providers. For example, Participant 6 from PHCC2 said that \u0026ldquo;They are all linked to one network. All my data is available \u0026ndash; on which date, who is my doctor, my nurse, when was the last time I checked in, my laboratory data\u0026rdquo;. Similarly, Participant 1 from PHCC3 said that \u0026ldquo;The medical file that is uploaded by a doctor here on the system appears on screen to any of the doctors who logs into this system\u0026rdquo;.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section3\"\u003e\u003ch2\u003e3.2.3 Coordination\u003c/h2\u003e\u003cp\u003eCoordination of care between PHCC and secondary care providers was identified as a critical area for improvement by several participants. A prominent barrier was the lack of referral feedback, where no communication occurred between secondary care providers and the PHCC after a patient was referred. This gap left patients uncertain about follow-up care and created dissatisfaction. For example, Participants 1 from PHCC1 and 5 from PHCC2 both reported that after being referred to secondary care, no information was shared back with the PHCC, resulting in fragmented and uncoordinated care.\u003c/p\u003e\u003cp\u003eIn contrast, the electronic referral system Ehalati was cited as an enabler by some participants, who appreciated its efficiency in processing referrals and reducing delays. For example, Participant 8 from PHCC5 said that \u0026ldquo;It was immediate, swiftly I mean \u0026ndash; no sooner had I received the medical referral than they immediately received me\u0026rdquo;.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003e3.2.4 Comprehensiveness\u003c/h2\u003e\u003cp\u003e Most participants acknowledged improvements in the comprehensiveness of services offered at PHCC, particularly with the addition of X-ray and laboratory facilities. For example, Participant 1 said that \u0026ldquo;We used to come and didn't find X-rays or laboratory, but nowadays there is\u0026rdquo;, and Participant 2 from PHCC1 confirmed, \u0026ldquo;All the services are available\u0026rdquo;. However, notable service gaps remained, especially in Dental Services and Mental Health Services. Dental care was a major source of dissatisfaction, reporting long wait times and limited appointment availability. As Participant 6 from PHCC3 said that \u0026ldquo;In terms of dental appointments, it's really far, there are no upcoming appointments, they are all crowded\u0026rdquo;. Similarly, Participant 2 from PHCC4 added that \u0026ldquo;Appointments\u0026hellip; Dental clinics\u0026hellip; they tell you: three months, and something like that\u0026rdquo;.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\u003ch2\u003e3.2.5 Mawid\u003c/h2\u003e\u003cp\u003eIn respect of the new appointment booking system (Mawid), participants gave a range of views. Some participants argued that this system changed services for the better, while others suggested that this system is an obstacle to accessing health services in PCCs. Supporters of the Mawid application felt that the application helps with managing and organising appointments and that this can positively impact on the quality of the consultation. For instance, participant 6 from PHCC1 said \u0026ldquo; I can tell you: previously, the problem was the appointments. I mean, when any patient comes directly to the infirmary without a booking, he was obliged to wait; But now the system has changed\u0026hellip; You have to book an appointment, and you have to take enough time to explain your complaints, and everything\u0026rdquo;. On the other hand, a few participants claimed the Mawid programme encountered periodic technical difficulties, occasionally impeding users from scheduling their appointments. Moreover, those participants suggested that some people do not have access to the internet or may lack experience in using smart devices. For example, participant 1 from PHCC2 said \u0026ldquo;I myself dislike appointment services, why do you require the patient to book an appointment one or two days before the booking date? Brother Why doesn't the receptionist come down and book an appointment \u0026ndash; meaning \u0026ndash; What's the problem? There are old people, and there are people who don't have internet\u0026hellip; I mean, what does he want? This is a massive problem.\u0026rdquo;.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\u003ch2\u003e3.2.6 Wasfaty\u003c/h2\u003e\u003cp\u003eWasfaty is a system linking PCCs with private pharmacies and allowing patients to order their medication free from these private pharmacies. This new system replaced an old system in which patients got their medicines from the PCCs or in a few cases from the nearest hospital if the medicine was not available in the PCC. Wasfaty had several negative comments from participants. The greater part of these negative comments was about the lack of some private pharmacies which caused patients to search for more than one pharmacy to dispense medicine. For example, participant 3 in PHCC2 said \u0026ldquo;My observation, lies in dispensing the medicine and treatments from the external pharmacies, I go to the external pharmacy and don't find the treatment. I keep searching all over Mecca until I can find this treatment. Sometimes, I go to four or five pharmacies until I can find this treatment or medicine\u0026rdquo;.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section3\"\u003e\u003ch2\u003e3.2.7 Dental services\u003c/h2\u003e\u003cp\u003eDentistry services were transitioned from outpatient clinics in hospitals and dental polyclinics and merged into PCCs in recent years. The majority of participants who needed these services had negative observations about dentistry services. The common negative issue reported by the participants about dental clinics was the long waiting time before getting an appointment and seeing the dentist. For instance, participant 6 from PHCC3 said \u0026ldquo;No In terms of dental appointments, it's really far, there are no upcoming appointments, they are all crowded\u0026hellip;\u0026rdquo;. Other negative issues that were less reported were the quality of the services presented in the clinic, including the lack of experience of the dentist\u0026rsquo;s physicians and lack of equipment. Another participant (6) from PHCC5 said \u0026ldquo;Some PCCs \u0026ndash; which I don't remember their names \u0026ndash; whenever I go to them, they tell us: The dental fillings ran out, the dental implants ran out\u0026hellip;\u0026rdquo;.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe findings indicate several positive developments such as improved availability of basic diagnostic services, the adoption of digital health tools, and the general availability of routine care; however, persistent challenges continue to affect accessibility, continuity, coordination, and comprehensiveness, Mawid, Wasfaty, and Dental services in PHCCs as follows.\u003c/p\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Enhancing Accessibility: The Role of Digital Health in Saudi Primary Care\u003c/h2\u003e\u003cp\u003eAccessibility in Saudi primary care has significantly improved, particularly through the adoption of digital health platforms such as the Mawid and Wasfaty apps, with strong patient approval reflected. Participants in our focus groups consistently praised Mawid, the national appointment scheduling system, for its convenience and efficiency in streamlining access to care. These perceptions are supported by recent empirical studies. For example, a 2023 cross-sectional study conducted in the Jazan region reported an overall satisfaction rate of 94.3% with Mawid, with most respondents affirming that the app helps regulate patient flow and reduces clinic overcrowding. Another survey found that over 65% of users described Mawid as user-friendly for both accessing information and scheduling appointments [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. These results suggest that digital appointment booking has been widely accepted and viewed as a major step forward in improving access and reducing logistical burdens, which our participants\u0026rsquo; feedback echoed these findings.\u003c/p\u003e\u003cp\u003eSimilarly, the Wasfaty e-prescription app has played a transformative role in improving access to medications. By allowing prescriptions to be filled at affiliated community pharmacies outside the clinic, Wasfaty has expanded the geographic and logistical reach of pharmaceutical services [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This innovation has been recognized in the literature as a significant advancement in healthcare in Saudi Arabia [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, despite its benefits, several challenges persist. High prescription volumes, occasional technical malfunctions, and difficulties among elderly or digitally inexperienced patients have been identified as barriers to optimal use [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. These limitations highlight the need for ongoing technical support, public education, and digital literacy training to ensure inclusive access and full utilization of the system.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003e4.2 Advancing Continuity of Care: Bridging Relational Gaps in the Saudi Primary Care System\u003c/h2\u003e\u003cp\u003eIn terms of continuity of care, our focus group participants shared mixed experiences. While many reported consistently visiting the same PHCC for ongoing health needs to ensure continuity at the service or site level, they frequently encountered different physicians at each visit, which limited relational continuity. This inconsistency disrupted the development of long-term, trust-based relationships between patients and providers [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Patients widely recognize the value of having a regular general practitioner (GP) who is familiar with their medical history, provides consistent advice, and assumes responsibility for their ongoing careers that are only possible through sustained, one-on-one relationships [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eInterestingly, some participants in our study were less concerned about seeing different doctors, expressing confidence in EMRs to maintain informational continuity. They felt that, as long as their health data was accessible, any doctor can pick up where the last one was left off. While this reliance on EMRs is promising, it contrasts with international findings that strongly emphasize the unique value of relational continuity. For example, a UK study by Murphy and Salisbury [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] highlighted that patients often view relational continuity as a safety issue which means that not seeing a familiar GP can lead to concerns of being overlooked or misinterpreted. Similarly, a Swedish study found that 86% of patients valued having a regular GP, and approximately two-thirds were able to consult their preferred provider most of the time [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEvidence consistently shows that continuity of care is associated with higher patient satisfaction, better adherence to medical advice, improved clinical outcomes, and even reduced mortality[\u003cspan additionalcitationids=\"CR25 CR26\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] A recent study in Saudi Arabia demonstrated that when patients with chronic conditions were formally assigned to a specific family physician, significant improvements were observed in clinical indicators such as blood pressure and HbA1c levels [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. These findings are consistent with global literature indicating that a stable, ongoing relationship with a primary care provider supports preventive care and overall health outcomes [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In recognition of these benefits, the Ministry of Health (MOH) in Saudi Arabia has initiated efforts to strengthen longitudinal continuity by assigning patients or families to dedicated providers. This includes pilot programs such as the one implemented at King Saud University clinics designed to embed continuity into routine primary care practice as part of broader health system reforms [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003e4.3 Strengthening Care Coordination: Enhancing the Referral Feedback Loop in Saudi Primary Care\u003c/h2\u003e\u003cp\u003eOur study identified notable improvements in referral processes alongside persistent challenges in information flow between primary and secondary care. Our participants widely praised the introduction of Ehalati, Saudi Arabia\u0026rsquo;s national electronic referral system, for enhancing efficiency and convenience. By digitizing referrals and notifying patients of their specialist appointments, Ehalati reduced the need for paper-based referral letters and streamlined access to secondary care [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. However, a critical limitation reported by our participants was the lack of feedback from secondary care providers back to the primary care centers. This disruption in the referral feedback loop led to patient dissatisfaction, as general practitioners were often left relying on patient-reported outcomes to guide follow-up care \u0026ndash; a situation that undermines coordinated and continuous care [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThese coordination issues are not unique to the Saudi context. International studies have similarly documented breakdowns in communication between general practitioners (GPs) and specialists. A comprehensive 34-country European survey revealed that in many healthcare systems, crucial referral feedback is frequently delayed or omitted, resulting in fragmented care [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Factors such as a lack of shared accountability between levels of care can exacerbate the issue, leaving patients vulnerable to gaps in treatment continuity and providers working with incomplete clinical information [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eBoth Saudi and global literature consistently emphasize that closing the referral loop is essential for delivering integrated, patient-centered care. What distinguishes the Saudi context is the existence of a nationwide, advanced electronic referral infrastructure, offering a strong foundation for effective coordination. The key challenge now lies in operationalizing the system fully, particularly by ensuring that specialists consistently provide timely electronic feedback to the referring primary care physicians. Targeted interventions (e.g., automating discharge summaries and specialist reports to be sent directly through the Ehalati system) could significantly enhance care continuity and provider collaboration [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003e4.4 Expanding Comprehensiveness: Integrating Dental and Mental Health Services into Primary Care\u003c/h2\u003e\u003cp\u003eA key achievement of Saudi Arabia\u0026rsquo;s PHC reform has been the integration of dental and mental health services into settings that historically focused almost exclusively on general medical care. However, findings from our focus groups indicate that significant gaps remain in the accessibility and availability of these expanded services. In the case of dental health, many participants expressed dissatisfaction with long wait times and limited appointment availability which, in turn, may compel them to seek care in the private sector. A recent review by Almajed et al. [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] found that many people in Saudi Arabia continue to prefer private dental clinics, citing shorter waiting periods and perceived higher quality of care. This suggests that simply co-locating dental clinics within PHC facilities alone is insufficient; effective dental service delivery also requires adequate staffing, streamlined appointment systems, and stronger patient trust in the quality of public PHC [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The persistence of patient preference for private services underlines the need to enhance confidence in the public PHC dental care system.\u003c/p\u003e\u003cp\u003eMental health care, on the other hand, has seen more significant progress. Traditionally confined to specialized psychiatric hospitals, mental health services in Saudi Arabia had minimal presence in PHC settings [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Recognizing this gap, the MoH launched the Primary Mental Health Care (PMHC) program, in alignment with the World Health Organization\u0026rsquo;s Mental Health Gap Action Programme (mhGAP), which advocates for integrating mental health into PHC through task-shifting and capacity-building. As of 2022, mental health services (i.e., screening, basic therapy, and referral pathways) had been introduced in 75% of PHCC nationwide [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. This initiative has yielded measurable results: approximately 77.2% of patients showed improvement, and only 8% required referral to specialized psychiatric care. These outcomes suggest that common conditions such as mild-to-moderate depression and anxiety are now being effectively managed at the primary care level.\u003c/p\u003e\u003cp\u003eFrom a global perspective, Saudi Arabia\u0026rsquo;s efforts stand out. Integration of oral and mental health into PHC remains limited in many countries, where these domains are often treated in separate silos. The World Health Organization has flagged oral health as a neglected component of PHC, calling for its inclusion to improve access and reduce inequities [35]. Likewise, while countries such as the UK and the US have implemented programs like Improving Access to Psychological Therapies (IAPT) or collaborative care models, full integration of mental health into PHC is still far from universal. This often results in underdiagnosis and undertreatment of mental health conditions. Globally, it is estimated that up to 60% of PHC patients may suffer from undetected mental health disorders, largely due to insufficient provider training or lack of integrated protocols [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this context, Saudi Arabia\u0026rsquo;s phased, system-wide implementation that is supported by provider training, public education, and digital tools such as telepsychiatry has been recognized as a potential global model [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. However, challenges remain. Sustaining this progress will require ongoing investment in workforce development, robust referral pathways for complex cases, and systematic monitoring of patient satisfaction and treatment outcomes in both dental and mental health domains.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003e4.5 Strengths and Limitations\u003c/h2\u003e\u003cp\u003eThis study has its own strengths and limitations. The use of focus groups allowed for rich, in-depth insights into patient perspectives across multiple regions, providing an understanding of how the reforms have impacted accessibility, continuity, coordination, and comprehensiveness of care. However, this study was limited by the lack of representation from the Central region of Saudi Arabia, potentially limiting the transferability of findings to the Central region, where healthcare infrastructure, population demographics, and reform implementation may differ from the studied regions. In addition, potential social desirability bias may have influenced participants to withhold negative feedback in group settings, or to disagree with others in the group.\u003c/p\u003e\u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis study highlights patients\u0026rsquo; generally positive experiences with recent reforms in Saudi Arabia\u0026rsquo;s primary healthcare system, particularly improvements in accessibility through digital tools like Mawid and Wasfaty. However, challenges persist, including limited relational continuity, weak referral feedback loops, and gaps in service availability especially for dental and mental health care. Electronic systems and service expansions have enhanced care delivery but achieving fully integrated and patient-centered primary care will require continued efforts to strengthen provider continuity, inter-provider communication, and public trust in PHC services. Future studies could address these limitations by incorporating larger and more regionally representative samples, employing quantitative designs, and including the perspectives of healthcare professionals and administrators. This would provide a more comprehensive picture of the successes and challenges in Saudi Arabia\u0026rsquo;s primary healthcare transformation. Such efforts will be critical for ensuring that healthcare reforms meet the evolving needs and expectations of the Saudi population.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e This study was approved by the ethical committee of College of Medicine and Health, University of Exeter, on 01/26/2022 (Project Number: 489743). The study conducted in compliance with the approved protocol and adhered to the principles outlined in the Declaration of Helsinki. In addition, an ethical approval was obtained from ethics committee of Jazan health affairs in Saudi Arabia No. 2181, on 10/24/2021. Participants gave written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: None declared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The author(s) received no financial support for the research, authorship, and/or publication of this article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e: AM, EP, CH, JMV, and IP jointly conceptualized and developed the research design. AM conducted data collection and thematic analysis. MA played a central role in drafting and revising the manuscript. HNM reviewed and provided feedback on the final draft. All authors contributed to writing and editing the final version of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclaimer:\u003c/strong\u003e The views expressed by the authors do not necessarily reflect the University of Exeter or any other party opinions.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKhatri R, Endalamaw A, Erku D, Wolka E, Nigatu F, Zewdie A et al. Continuity and care coordination of primary health care: a scoping review. BMC Health Serv Res. 2023;23(1).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKringos DS, Boerma WG, Hutchinson A, Van Der Zee J, Groenewegen PP. The breadth of primary care: A systematic literature review of its core dimensions. 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Integrating mental healthcare into primary healthcare services: Saudi Arabia progress and achievements (1995\u0026ndash;2022). Current Research in Psychiatry,; Volume 5(Issue 1):42\u0026ndash;49 [Internet]. 2025 Feb 21 [cited 2025 May 6];Volume 5(Issue 1):42\u0026ndash;9. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.probiologists.com/article/integrating-mental-healthcare-into-primary-healthcare-services-saudi-arabia-progress-and-achievements\u003c/span\u003e\u003cspan address=\"https://www.probiologists.com/article/integrating-mental-healthcare-into-primary-healthcare-services-saudi-arabia-progress-and-achievements\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePrasad M, Manjunath C, Murthy A, Sampath A, Jaiswal S, Mohapatra A. Integration of oral health into primary health care: A systematic review. J Family Med Prim Care. 2019;8(6):1838.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Primary Health Care, Patient Experience, Healthcare Reform, Digital Health, Saudi Arabia","lastPublishedDoi":"10.21203/rs.3.rs-7580269/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7580269/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eIn Saudi Arabia, the Vision 2030 health reform agenda aim to transform primary health care (PHC) through service expansion and digital innovation. Early indicators suggest progress; however, limited research has explored how patients perceive these changes.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eThis study explores patient experiences of PHC and PHC reforms in Saudi Arabia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA qualitative study was conducted using 11 focus groups with 44 patients across four regions of Saudi Arabia. Participants were recruited through purposive sampling. Thematic analysis, guided by both inductive and deductive coding, was used to explore patient perceptions.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eBesides the predefined themes which included accessibility, continuity, coordination, and comprehensiveness, findings revealed strong approval for digital tools like Mawid (appointment booking) and Wasfaty (e-prescription), which improved access to appointments and medications. However, barriers remained, including limited parking, challenges with digital literacy, and difficulties securing timely appointments especially for dental care. Relational continuity was weak due to frequent changes in providers, though electronic medical records supported informational continuity. The Ehalati (referral system) improved access to secondary care, but a lack of feedback from specialists limited coordination. Participants recognized expanded diagnostic services, but persistent gaps were noted in dental and mental health access.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eParticipants reported improved patient experience in several areas, particularly through digital transformation and expanded services. Yet challenges in continuity, coordination, and service availability remain. Addressing these issues is essential for achieving a fully integrated, patient-centered PHC system aligned with Vision 2030 goals.\u003c/p\u003e","manuscriptTitle":"Patient Perspectives on Primary Healthcare Reforms in Saudi Arabia: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-31 10:22:13","doi":"10.21203/rs.3.rs-7580269/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-04T03:20:01+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-02T10:54:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-30T13:38:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"128206362582881140412674584904975346777","date":"2025-10-30T09:38:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-29T12:44:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"317044295188910819516846724875328555811","date":"2025-10-26T16:14:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"165088632791810939132495341938029922187","date":"2025-10-21T12:27:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"19474888461762647040727325848410353740","date":"2025-10-21T11:50:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-21T10:18:59+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-15T18:24:16+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-19T03:32:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-18T13:06:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-09-18T11:30:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"130eb8ba-1766-460c-9071-c0ff881caebb","owner":[],"postedDate":"October 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-21T05:24:46+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-31 10:22:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7580269","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7580269","identity":"rs-7580269","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}