Poor organization of health services delivery in Iraqi PHCCs was also reported by other studies [5, 14, 15]. Such poor organization, the related overuse of services and unnecessary workload on the primary care providers and primary care facilities can have negative effects on the quality of the provided services, particularly on the provider-patient interaction and communication in addition to consultation length . Poor primary care referral in Iraq with high and inefficient referrals and a high rate of self-requested referrals have been underlined by two other studies [17, 18]. In fact, optimal referring processes are crucial for the effectiveness, safety and efficiency of health care . Irrational treatment, which is a newly reported problem in the Iraqi primary care system, and provision of incomplete courses of treatment were strongly and repeatedly emphasized by focus group participants. This may lead to non-compliance with its undesirable impact on clinical outcomes and increased financial burden on society .
While the problem of health workforce shortages was a main concern in the Iraqi health system a decade ago [1, 2], uneven distribution of human resources for health, particularly of the skilled workforce, is becoming a bigger concern today [1, 2, 5, 21]. The uneven distribution of the health workforce, with doctors or other skilled workers concentrated in main PHCCs and not in smaller PHCCs or in the PHCCs located in city centers and not outside the city centers, is an inefficient allocation of staff and contributes to inequity in health provision . Poor professional development for health care providers has also been reported by other studies from Iraq where poor training of primary care providers and the importance of increasing public investment in this area and reviewing the professional and medical standardization have been emphasized [12, 23, 24]. This is also a common problem in other post-conflict countries like Serbia where few opportunities for professional development of primary care providers have been reported . While the negative effects of brain drain on the Iraqi health system are well documented [24, 26], the effect of rapid turnover of skilled workforce has rarely been reported even though it is an established problem in the primary care system.
Poor governance and leadership in the Iraqi health system has also been emphasized by other studies where the system was described as hospital-based and capital-intensive requiring large quantities of imported medicines, medical supplies and equipment. Other studies have found poor governance and policy processes to be the main concerns of the health system [1, 27]. Similarly, reorganization of services and leadership were recognized as the main priorities for reforming the primary care system in Serbia .
Several suggestions to improve the primary care system in Iraq that were identified by this study correspond well with other studies from Iraq including application of a family medicine approach [5, 12, 28], regulation of public-private practice  and improving the quantity and quality of medications . Moreover, new priority needs were emerged from this study including establishment of a functioning recording system, increasing the health awareness of the population, provision of incentives to retain staff, integration of health education services in the primary care system and establishment of a strong planning, evaluation and monitoring system at the Directorate of Health and Ministry of Health levels. Increasing user fees to prevent irrational use of services and overcome other problems related to inappropriate health services delivery as outlined in this paper remains a matter of debate.
Most of the problems identified by study participants, such as the uneven distribution and rapid turnover of the health workforce, shortage in resources, lack of information technology and poor planning and monitoring have their roots in the poor leadership and governance of the health system at the national level. While the perspectives of health care providers and managers are important for care improvement and policies formulation, this should be done through proper channels and with full support of the Ministry of Health and not only the Directorates of Health. Therefore, this process should be properly planned and guided by a clear strategy involving all key stakeholders, and not solely based on the opinions of one group of health care providers.
The use of focus group discussions in this study was a new approach in Iraq. Our findings highlight the importance of using qualitative data to facilitate an in-depth and wider understanding of the challenges facing the primary care system . Participants from a range of professions in the primary care setting were included in the study to maximize exploration of different perspectives within a group setting [30, 31]. The results, therefore, give a reasonable representation of primary care providers and of different opinions and concerns. Though this variation encouraged interaction and exploration of different perspectives which in many cases led to discordant opinions, we noticed that physicians and administrative directors dominated the discussions. Thus, this study may under-represent the opinion of nurses and medical assistants.
The problems and priority needs of the Iraqi primary care system identified by this study reflect only the perspectives and experience of primary care providers. We recognize that this does not give the entire picture of the problems facing the system and how services need to change as it does not include the perspectives of beneficiaries and decision makers at the Directorate of Health. Nonetheless, these findings are a first step towards improving the system, especially because primary care providers will have an important role in implementing any reform [6, 7].
The trustworthiness of this qualitative research can be considered in terms of credibility, dependability and transferability . With regards to credibility, this study had a clear focus and the processes of data collection and analysis have confidently addressed this focus. As the study was carried out over a limited period of time with four focus groups conducted during a three month period, the study should have fair dependability. The chief limitation of qualitative studies remains the inability to generalize findings. However, the results are transferable to populations and contexts similar in characteristics as the data have been carefully collected and analyzed, with the main aim of understanding instead of seeking explanations . Moreover, the focus group climate was open and the respondents willing to share information were free and comfortable to do so, but underestimation cannot be ruled out. The predominance of male providers in the sample might be seen as a limitation. However, the female providers participated actively in the discussions and felt free and comfortable to express their opinions about the primary care system. We could not recognize any clear differences between male and female providers in their perspectives about different aspects of the primary care system.
These findings may provide insight for primary care managers and providers to improve the primary care services in Kurdistan. However, most of the problems described in the focus groups are largely outside the control of managers and providers. The findings may also inform and influence managers at the Directorate of Health and Ministry of Health and other policy makers of the wider contextual issues affecting primary care settings. Further similar research in other governorates of Kurdistan and Iraq could show how generalizable these findings are. Additionally, research is needed on the perspectives of primary care users and the general population.