A positive viewpoint and three different negative viewpoints among PHC providers towards the Iraqi PHC system were identified in this explorative study. Reporting the presence of differences in viewpoints concerning the Iraqi PHC system among PHC providers might not be totally new knowledge by itself. However, this study was able to identify and characterize these differences in a novel and insightful way. It is certainly difficult to argue at this stage that this is the definitive range and variety of viewpoints among the PHC providers on the basis of one explorative study. However, we consider these viewpoints to be representative of the range and varieties of viewpoints existing among PHC providers in Erbil governorate and Iraqi Kurdistan region in general.
As PHC providers have a pivotal role in delivering PHC services, they can be considered “street-level bureaucrats” who are confronted with real world challenges in the primary care sector, yet face inadequacies of under-funded government systems. Superficially, street-level bureaucrats constitute a level of implementation of public policies as they are tasked with ensuring policies are carried out. Yet as individuals, PHC providers represent a small-scale level of policy making. They decide the specific operation and execution of policies. On a larger scale, the combined actions and decisions of street-level bureaucrats in their bureaucracy amalgamate to form an agenda and heavily influence the direction of policy . Therefore, the viewpoints of study participants can provide valuable information to health policy makers and PHC managers to direct actions to improve the PHC system and the related health services.
This study identified a number of positive aspects of the current PHC system of Iraq but highlighted enormous problems the system faces as illustrated by the characterizing and distinguishing statements of the different identified factors. Many of these aspects correspond well with the findings of the focus groups  and open-ended questionnaire survey  that preceded this study as well as with the limited relevant research from Iraq. The relatively easy accessibility and provision of convenient services to the poor were also reported by three other studies from Iraq [24, 25, 30]. Easy access to PHC facilities is also a common feature in settings similar to Iraq. For example, a study from Egypt revealed easy accessibility of PHC facilities with majority of patients (58%) reaching the facility in less than 10 minutes . Another study from Iran showed a high clients’ satisfaction with access to PHC with a high proportion of patients (51.3%) accessed the PHC centers by walking .
The problems related to poor service delivery, particularly irrational use of services, irrational treatment, poor provision of health education and poor referral system, were also reported by the focus groups study of the PHC providers that preceded this study . While the coverage of PHC in Iran has substantially increased, improving the quality of care remained one of the main concerns in PHC especially in urban areas . In Iran again clients’ satisfaction with continuity of care, comprehensiveness of care and provision of health educational materials was much lower than other aspects of access to services and effectiveness of care . A study from Jordan revealed an increase in client visits to PHC centers resulting in longer waiting times and sometimes necessitating a return visit and shorter provider-patient contact affecting both the quality of service and client satisfaction . The low user fees as a main reason for repeated and irrational visits to PHC centers and increasing such fees to prevent irrational visits remain a matter of debate. Experience from a number of African countries showed that introducing or increasing user fees impose a heavier burden on the poor who are most likely facing a high burden of disease .
Problems related to workforce development including uneven distribution, rapid turnover and lack of professional development opportunities were also reported by two other studies from Iraq [13, 36]. In Turkey, primary care physicians are unevenly distributed provincially . Few opportunities for professional development of primary care providers were also reported in Serbia .
The general preference for the establishment of a family medicine system has been emphasized by several studies from Iraq [9, 11, 13, 25]. Introduction of the specialty of family medicine as the population’s first line of care and adapting the current PHC centers into family health centers staffed with physicians trained in family medicine was similarly recognized in Serbia as a main priority to improve the organization of the primary care in Serbia .
To the best of our knowledge this is the first Q-study in Iraq. However, we found it a feasible research method and useful way to analyze PHC providers’ viewpoints towards the PHC system. The PHC providers found it interesting to participate in the study and were confident in ranking the statements. During the ranking of the statements the participants remained involved and willing to discuss different statements and issues related to the system. Based on this unique experience of using Q-methodology in the Iraqi context, we think that this methodology is a useful and practical tool for future health system research and studying the perspectives of different actors in the health system. However, this study involves a number of limitations. Due to the small number of participants included in studies employing Q-methodology, generalization is limited and finding out the proportion of respondents that hold particular viewpoints is not possible [38, 39]. However, generalization in this study was not intended as Q-methodology is exploratory in nature that can provide a useful insight to the available viewpoints in the society and characterization of each viewpoint. It might also provide an initial understanding of the sociodemographic characteristics associated with each viewpoint. As a hypothesis generating tool, Q-methodology can be followed up with larger surveys to examine these uncovered viewpoints and associated factors .
The results of Q-studies depend to a certain degree on the methods and the model used to develop and structure the representative statements and interpret the factors. In this study, focus groups of PHC providers  and open questionnaire survey of PHC managers, policy makers and academics  were used to develop the study concourse while a modified version of the WHO conceptual framework of health system building blocks was used to develop and structure the representative statements . The WHO conceptual framework of health system building blocks was adopted because it is a valid and widely used framework for health system studies in addition to be generally applicable and sufficiently comprehensive to suit well the purpose of this study. The initial aim was to use this framework to interpret the factors, however due to the diversity of viewpoints, this framework was of benefit in interpreting factor 4 only. Thus, lack of a reliable framework for interpreting all the factors is considered a limitation of this study. A number of alternative methods for concourse development and different models for developing and structuring statements and interpreting factors related to health system could have been used that might have resulted in different findings. However, this should not be considered an issue of great concern as the limited number of comparative studies that have been carried out indicate that different sets of statements structured in different ways can nevertheless be expected to come with the same conclusions . Being new to this field we did not use the opportunity of conducting follow-up interviews to obtain more information. Such interviews could have been helpful in interpreting and describing the statistical results and might have provided us with more insights into the relation between viewpoints and the experience of PHC providers from different backgrounds.