Impact of Primary Health Care Reforms in Quebec’s Health Care System: A Systematic Review

Abstract

Abstract

Introduction: Primary health care (PHC) reforms in Quebec between 2000 and 2023 aimed to improve accessibility, continuity, efficiency, and equity through organisational transformation, notably the Family Medicine Groups (FMGs), centralised waiting lists (Guichets d’accès), the advanced access model, and legislative instruments such as Bill 20. The evidence on their cumulative impact remains fragmented across disciplines, outcome domains, and study designs. Objective: To systematically identify, appraise, and synthesise the empirical evidence on the association between PHC reforms implemented in Quebec during the 2000–2023 reform cycle and organisational transformation, accessibility, health outcomes, costs, and equity, with mental health service organisation treated as a distinct policy stream outside the scope of this review. Methods: This systematic review followed the PRISMA 2020 statement and a protocol registered with PROSPERO (CRD42023421145). PubMed, EMBASE, Web of Science, and CINAHL were searched on 7 November 2023 and the searches were rerun on 3 September 2026, complemented by structured searches of Quebec governmental and institutional repositories and reference-list checking. Screening, extraction, and appraisal (Mixed Methods Appraisal Tool, MMAT 2018) were performed in duplicate. Reports were analysed for policy documents, implementation, descriptive and qualitative studies, and comparative evaluative studies, and synthesised narratively by reform mechanism and outcome domain, following SWiM guidance for quantitative evidence. Results: 192 reports were included (171 from the original search and 21 from the update), corresponding to 26 policy, institutional, review, or commentary documents, 131 implementation, descriptive, or qualitative studies, and 35 comparative evaluative studies, including one pragmatic randomised trial with reported results. Policy documents and implementation studies consistently describe organisational transformation and rising attachment rates. Comparative evaluative studies report that FMG enrolment and centralised-waiting-list attachment were associated with modest reductions in avoidable emergency department use and improvements in guideline-concordant care processes, whereas quasi-experimental evaluations of enrolment incentives found no meaningful population-level gain in affiliation. Evidence on health outcomes and costs is limited and largely proxy-based; socioeconomic and geographic gradients in access persisted across the period. Early evaluations of the Primary Care Access Points (2024–2026) report high patient-reported unmet needs when no physician appointment is obtained. Conclusions: The reforms were accompanied by substantial structural change and by limited, uneven, and mostly modest associations with patient-level access, outcomes, and equity. Confidence in these conclusions is moderate for organisational and attachment-related findings, low for health outcomes and costs, and constrained throughout by incomplete reporting and the scarcity of counterfactual designs.