Reconfiguring the functional features of primary care in a non-gatekeeping context: A 15-year mixed-methods systematic review from China

Basic medical service is the primary manifestation of primary care within China's healthcare system. Since the 2009 healthcare reform, the theory of primary care functional features has been introduced to China. Chinese researchers have since employed international instruments and developed localized tools to evaluate the process quality of these services across diverse regions and populations. This mixed-methods systematic review aims to synthesize qualitative and quantitative evidence regarding the conceptual connotations, intensity levels, and relationships with health service outcomes of different functional features in China's primary care services. Following the JBI mixed-methods systematic review framework, we searched six databases (PubMed, Embase, Web of Science, Google Scholar, CNKI, and Wanfang) for qualitative, quantitative, and mixed-methods studies published between January 2009 and March 2025. Two reviewers screened literature using Rayyan and assessed methodological quality using JBI tools. Utilizing a convergent segregated approach, we synthesized the qualitative and quantitative findings separately, and subsequently integrated them to explain the pathways and mechanisms underlying the associations between functional features and health service outcomes. The review included 60 studies (52 quantitative studies, 4 qualitative studies, and 3 mixed-methods studies). The functional features of China’s primary care services can be broadly categorized into six core dimensions: First Contact, Accessibility, Comprehensiveness, Continuity, Coordination, and Patient Empowerment. Their local conceptual connotations have undergone significant reconfiguration compared to the original theoretical constructs. Overall, the intensity level of these features is medium-to-high. Stronger measurement levels are positively associated with multiple critical health service outcomes, including improved patient health status, enhanced patient experience, lower healthcare costs, preference for primary care first-contact, and reduced general hospital utilization. Furthermore, clear mechanistic pathways influencing key outcomes were identified for the first five features. This review validates the real-world value of sustained investment by the Chinese government and society in primary healthcare reform. It supports the strategic enhancement of these functional features to maximize their capacity to improve health outcomes. Finally, it highlights the imperative for future research to employ broader, deeper, and more precise methodologies to capture the evolving nature of primary care in China.