Review of 'Primary care in Caribbean Small Island Developing States'

This is an interesting initial study on primary care in Caribbean Small Island Developing States. Although the manuscript is well written there are some important points to be improved.

1) The manuscript does not provide a general view on the administrative structure, demographic and socioeconomic characteristics and health status of the states. I recommend that the authors prepare a table on the social determinants of health using the available data. This table should present indicators such as per capita income, percentage of the population below the poverty, hunger, and educational level, literacy rate for men and women, employment rate and the ones that are presenting the sanitation conditions, water quality, food security etc. In addition to quantitative data, brief qualitative information should be given on the socio-political context of the states.

2) Today, inequalities are among the most challenging problems of health care systems and in reducing health inequalities primary care has a very important role. Therefore the authors should give brief information on inequalities in these states.

3) Primary care is defined in the second paragraph of the framework section. However this definition belongs to primary health care. Primary care and primary health care are very close, but different concepts. I recommend rephrasing the concepts according to definitions made by Barbara Starfield. In connection with this, although it has not been assessed in the study the process of primary care should also be explained shortly.

4) Results, primary structure. Co-payment is a very critical issue, since it creates a barrier to primary care for those in greatest need. Authors should give information on co-payments.

5) Regarding primary care, maternal and child health indicators such as infant mortality rate, maternal mortality ratio, percentages of mothers who received any antenatal care, immunization rates, etc are more critical than the ones related to noncommunicable diseases. There is no mention on these indicators in the article. The authors should present the available data. It is also important to know the weight of these indicators in the calculation of health status sub-dimension.  

6) As the authors have stated there are a number of factors limiting the validity of the assessment between the primary care structure and health status. However, the most important problem is the fact that this relationship has been dealt with without considering the social determinants of health. Additionally, the weight of indicators that are closely related to primary care (for example maternal health measures) in the scores of health status determines the validity of this assessment. In the presence of these important limitations, this assessment does not provide any explorative information.

7) Especially in the discussion section, the authors emphasised that primary care is very important for low-income countries. I think that this emphasis should be changed as primary care is important for all countries including the most affluent ones.

8) The author should explain in the discussion on governance of primary care what they mean by “stakeholder”. Do they recommend mechanisms of community participation which is one of the most important features of community-oriented primary care approach or offer the participation of national and international organizations?