WHO South-East Asia Journal of Public Health

: 2021  |  Volume : 10  |  Issue : 3  |  Page : 6--25

Strengthening primary health care in the COVID-19 era: a review of best practices to inform health system responses in low- and middle-income countries

David Peiris1, Manushi Sharma2, Devarsetty Praveen2, Asaf Bitton3, Graham Bresick4, Megan Coffman5, Rebecca Dodd1, Fadi El-Jardali6, Racha Fadlallah6, Maaike Flinkenflögel7, Felicity Goodyear-Smith8, Lisa R Hirschhorn9, Wolfgang Munar10, Anna Palagyi1, KM Saif-Ur-Rahman11, Robert Mash12,  
1 The George Institute for Global Health, UNSW Sydney, Sydney, Australia
2 The George Institute for Global Health, New Delhi, India
3 Ariadne Labs, Brigham and Women’s Hospital and Harvard TH Chan School of Public Health, Boston, United States of America
4 School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
5 Robert Graham Center for Policy Studies in Family Medicine and Primary Care, Washington, DC, United States of America
6 Knowledge to Policy (K2P) Center, American University of Beirut, Beirut, Lebanon
7 KIT Royal Tropical Institute, Amsterdam, The Netherlands
8 University of Auckland, Auckland, New Zealand
9 Feinberg School of Medicine, Northwestern University, Chicago, United States of America
10 Milken Institute School of Public Health, George Washington University, Washington, DC, United States of America
11 Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh
12 Department of Family and Emergency Medicine, Stellenbosch University, Stellenbosch, South Africa

Correspondence Address:
David Peiris
The George Institute for Global Health, UNSW Sydney, Sydney


Amid massive health system disruption induced by the coronavirus disease 2019 (COVID-19) pandemic, the need to maintain and improve essential health services is greater than ever. This situation underscores the importance of the primary health care (PHC) revitalization agenda articulated in the 2018 Astana Declaration. The objective was to synthesize what was already known about strengthening PHC in low- and middle- income countries prior to COVID-19. We conducted a secondary analysis of eleven reviews and seven evidence gap maps published by the Primary Health Care Research Consortium in 2019. The 2020 World Health Organization Operational framework for primary health care was used to synthesize key learnings and determine areas of best practice. A total of 238 articles that described beneficial outcomes were analysed (17 descriptive studies, 71 programme evaluations, 90 experimental intervention studies and 60 literature reviews). Successful PHC strengthening initiatives required substantial reform across all four of the framework’s strategic levers – political commitment and leadership, governance and policy, funding and allocation of resources, and engagement of communities and other stakeholders. Importantly, strategic reforms must be accompanied by operational reforms; the strongest evidence of improvements in access, coverage and quality related to service delivery models that promote integrated services, workforce strengthening and use of digital technologies. Strengthening PHC is a “hard grind” challenge involving multiple and disparate actors often taking years or even decades to implement successful reforms. Despite major health system adaptation during the pandemic, change is unlikely to be lasting if underlying factors that foster health system robustness are not addressed.

How to cite this article:
Peiris D, Sharma M, Praveen D, Bitton A, Bresick G, Coffman M, Dodd R, El-Jardali F, Fadlallah R, Flinkenflögel M, Goodyear-Smith F, Hirschhorn LR, Munar W, Palagyi A, Saif-Ur-Rahman K M, Mash R. Strengthening primary health care in the COVID-19 era: a review of best practices to inform health system responses in low- and middle-income countries.WHO South-East Asia J Public Health 2021;10:6-25

How to cite this URL:
Peiris D, Sharma M, Praveen D, Bitton A, Bresick G, Coffman M, Dodd R, El-Jardali F, Fadlallah R, Flinkenflögel M, Goodyear-Smith F, Hirschhorn LR, Munar W, Palagyi A, Saif-Ur-Rahman K M, Mash R. Strengthening primary health care in the COVID-19 era: a review of best practices to inform health system responses in low- and middle-income countries. WHO South-East Asia J Public Health [serial online] 2021 [cited 2021 Apr 21 ];10:6-25
Available from: http://www.who-seajph.org/text.asp?2021/10/3/6/309867

Full Text


The 2018 Astana Declaration affirmed primary health care (PHC) as vital to attaining the Sustainable Development Goals. The 2019 United Nations Political Declaration on Universal Health Coverage further highlighted the central role of PHC in achieving such lofty aims.[1],[2] The strategic confluence of these complementary global health agendas in the context of the coronavirus disease 2019 (COVID-19) pandemic has revitalized the focus on PHC as a central pillar for health systems strengthening.

As attention shifts to “building back better”,[3] we are at a defining moment in which to reaffirm PHC as essential to attaining universal health coverage (UHC) by 2030. There is a vast body of evidence on what is needed to support comprehensive PHC for all. In 2018, a group of seven academic institutions formed the global Primary Health Care Research Consortium (PHCRC)[4] to support country-specific and global implementation research in the pursuit of high-quality PHC in low- and middle-income countries (LMICs). The consortium conducted literature reviews, evidence gap mapping and consultations with a wide range of stakeholders and proposed a prioritized PHC implementation research agenda.[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17] In this paper, we present the review findings and update the evidence base accumulated as part of the PHCRC’s work and synthesize what was already known about strengthening PHC prior to COVID-19 in LMICs. We identify the health systems strengthening strategies that should be prioritized to promote high-quality, equitable, people-centred PHC and to improve future responses to public health crises in the post-COVID-19 era.


We drew on the Primary Health Care Performance Initiative (PHCPI) conceptual framework to conduct a secondary analysis of reviews and evidence gap maps (EGMs) completed by the PHCRC in 2018. The PHCPI conceptual framework draws on the World Health Organization (WHO) definitions and focuses particularly on PHC services and people-centred care [Figure 1].[18] The PHCPI focuses particularly on health services (including primary care and public health services) and less on the other two PHC domains of multisectoral engagement and empowered people and communities. It examines the systems, inputs and service delivery components that have the potential to lead to improved effective service coverage and a range of health and health system outcomes.{Figure 1}

As part of the original evidence synthesis and EGM research, four domains were prioritized following a stakeholder consultation and prioritization process: PHC policy and governance; PHC organization and care delivery models; PHC financing; and PHC performance, safety and quality. Eleven reviews and seven EGMs were conducted across these four domains [Box 1].


[Annex 1] [SUPPORTING:1] provides a detailed description of the methods for data extraction and coding using the PHCPI framework. To synthesize key learnings from this body of work and to determine areas of best practice, we used the WHO Operational framework for primary health care.[20] It describes core strategic levers (political commitment and leadership, governance and policy frameworks, funding and allocation of resources, and engagement of communities) and operational levers (e.g. models of care, workforce, digital health, systems for enhancing quality, payment systems) required to transform the 2018 Astana Declaration commitments into action [Figure 2]. When referring to all three PHC approaches (integrated health services, empowered people and communities, and multisectoral policy and action), we use the term “PHC”; when specifically describing services, we use the term “primary care”.{Figure 2}


By examining 1003 article abstracts identified from the source reviews and EGMs, 201 articles were identified as describing beneficial outputs or outcomes. An additional 37 articles were included from supplementary searches. Of the 238 included articles, 61% were published in 2013 or later. [Annex Figure 1] [SUPPORTING:2] provides a breakdown of the articles by study type and region. Almost half of the articles reported on studies from the African and Eastern Mediterranean regions. The distribution of study types was similar across regions, with multiregion studies being mainly review articles. [Annex Table 1] breaks the included articles down by PHCPI domain and study type. Governance and leadership, adjustment to population health needs, and workforce were the most common system and input domains, while availability of effective PHC services, and high-quality PHC were the most common service delivery domains studied, with a similar distribution across all study types. Only 35% of articles had documented outputs related to effective service coverage (most commonly, these were in the areas of reproductive, maternal, newborn and child health; childhood illnesses; and noncommunicable diseases and mental health). Relatively few studies documented benefits in PHCPI outcome domains [Annex Table 1] [SUPPORTING:3].

[Annex 2] [SUPPORTING:4] provides a detailed summary of best practices identified for each of the WHO operational framework levers. [Table 1] provides examples of best practices organized by operational framework lever. In most examples, more than one strategic or operational lever was being used, and therefore we highlight additional “moderating levers” that appeared to be important to achieving success with the primary lever. In many articles, it was difficult to distinguish between the PHC- oriented research levers and the monitoring and evaluation levers, and consequently these were grouped together in the analysis. [Annex Table 2] [SUPPORTING:5] provides the references for each of these best practice examples. Taking these findings together, it can be observed that many best practices are complex strategies, focusing on multiple strategic and operational levers rather than acting exclusively on any one lever.{Table 1}


The highly varied country responses to the COVID-19 pandemic have emphasized that health systems need a strong equity orientation to ensure that no one is left behind – both during a disaster and in recovery. The Astana Declaration reaffirmed PHC as a fundamental enabler of UHC, with its three core functions of meeting people’s needs throughout life and not only during sickness; countering social determinants of health such as financial hardship and limited access to education; and empowering individuals and communities to engage in maintaining and enhancing their health and well-being.[2]

The concept of “building back better” was used at the Third UN World Conference on Disaster Risk Reduction to describe an approach to post-disaster recovery that reduces vulnerability to future disasters and builds community resilience to address physical, social, environmental and economic vulnerabilities and shocks.[3] Abimbola and Topp consider health system resilience a dualistic concept encompassing both adaptation and robustness – the two being necessary and interrelated conditions for resilience.[21] The extent to which health systems are robust is determined by the pre-disaster context. The adequacy of the adaptation response is dependent on how robust the system was to begin with. For example, rapid acceleration of telehealth care (an adaptive response) requires adequate digital health infrastructure (system robustness). In the presence of weak, fragmented information systems, telehealth models of care could increase vulnerability and expose inequity.[22],[23],[24]

In this paper, we present the substantial evidence of what was already known pre-COVID-19 to support strengthening PHC and fostering robust health systems. Priority needs to be given to the strategic levers of political commitment and leadership, governance and policy frameworks, funding and allocation of resources, and engagement of decision- makers, communities and other stakeholders. The “hard grind” of producing change in these areas remains a complex undertaking long after the adaptive response to a public health emergency has been implemented.[21]

Despite global declarations, PHC receives variable and often fleeting attention from government leaders and is grossly underfunded in most LMICs; furthermore, there is a lack of accountability mechanisms to maximize population-level health outcomes and social participation in health system governance and service delivery functions.[25] “Social vaccines” that protect communities from disasters by addressing underlying social determinants of health are needed just as much as COVID-19 vaccines.[26] Despite several knowledge deficits, country case studies and large-scale policy evaluations clearly identify many areas of success that can be adapted to and adopted in other settings. Policy interventions such as incorporating health into all policies;[27] institution building to strengthen governance structures and processes at national, regional and local levels; major increases in health expenditures and reallocation of funds to primary care from hospital specialist services; and engagement of civil society organizations in decision-making and demand generation are components of successful PHC reforms.

Despite the primacy of the strategic levers, we found that many successful reform strategies required these to be combined with a wide range of operational levers. The most mature evidence relates to workforce strengthening initiatives. Adequately motivated, digitally enabled, supportively supervised PHC teams with ample autonomy and decision space, and clearly delineated and complementary tasks, can improve service access, coverage and quality while also improving workforce satisfaction and retention. Professionalization of and continuing support for the community health workforce is a core priority.[28] Investment in strategies that embrace the complex leadership roles of highly trained primary care professionals such as doctors and nurses is also needed, such that management and clinical skills are equally valued.[29] Strategies to effectively regulate and engage with private sector health professionals are also critically important, given that they are the first point of contact in many countries. This again highlights the importance of strategic levers (regulation) being combined with operational levers (workforce engagement and strengthening).

More case studies of excellence are also critical motivators for change. The Exemplars in Global Health initiative is a good example of a systematic approach to sharing experiences of success and carefully documenting the factors that drove that success.[30],[31] The PHCPI Vital Signs Profiles provide measurement tools to enable a range of stakeholders to better understand and improve primary care in highly varied country contexts.[32] Such initiatives have strong potential to improve measurement of primary care performance and to stimulate learning and knowledge sharing. And, finally, although there is a large evidence base to draw from, there remain many areas where knowledge is relatively limited. These are extensively documented in the PHCRC’s previous EGM work (see [Box 1]). Innovative models of care that integrate services across the life course, across diseases and across health care sectors are a priority area to be explored further. More research is also needed on performance management systems that focus on organizations rather than people and can be implemented at scale. Evidence-based priority setting through health technology assessments is becoming more common in several LMICs; however, the focus remains on high-cost technologies and its use in designing PHC benefits packages is another priority area to support PHC reforms.[33],[34],[35],[36] Embedded implementation research that forges multisectoral partnerships and embraces blurred boundaries between knowledge generators and knowledge users offers us a way forward to address these knowledge gaps.[37]


COVID-19 has revealed gross deficiencies in health systems around the world, highlighting the need for transformational change, at the centre of which should be the strengthening of PHC. This secondary analysis of literature reviews, EGMs and recent literature informed by experts in the field synthesizes what was already known about best practices to strengthen PHC prior to COVID-19. Using the WHO Operational framework for primary health care, we emphasize in each domain the factors that are known to have contributed to success. In order to achieve transformational change in PHC, major shifts are needed in the framework’s four strategic levers: political commitment and leadership, governance and policy, funding and allocation of resources, engagement of communities and other stakeholders. However, where we found sufficient evidence of programmes and interventions that have resulted in improvements, attention to these strategic levers was accompanied by substantive investment in a range of operational levers, particularly in the areas of models of care, workforce strengthening and use of digital health technologies. In several areas, there remain knowledge gaps, and we endorse recent calls to strengthen implementation research in which multisectoral stakeholders come together to determine contextually calibrated priority research questions and adhere to codesign principles to answer those questions. There has been vast health system adaptation as a result of the pandemic, but such adaptation is precarious when underlying health system robustness is not addressed and could worsen inequities. The factors that foster robust health systems are the “hard grind” factors that can take years or even decades to implement at scale and require consistent, long-term investment in PHC. We document many case studies demonstrating success in undertaking lasting PHC reforms in a variety of country contexts – reforms that will stand these nations in good stead when it comes to adaptation during the pandemic and its aftermath.

Acknowledgements: We gratefully acknowledge the contribution of the coauthors of the primary review and EGM papers that underpin the analyses in this paper. Many thanks also to Dr Arpita Ghosh, who assisted with the frequency analyses for the tables presented in this paper.

Source of support: The Primary Health Care Research Consortium is supported by a grant from the Bill & Melinda Gates Foundation. The findings and conclusions included in this paper are those of the authors and do not necessarily reflect positions or policies of the Bill & Melinda Gates Foundation.

Conflict of interest: None declared.

Authorship: All authors were involved in the study design and provided recommendations of new articles to include in the review. MS extracted the articles from the original reviews and MS and DPr coded the data. DPe, MS, DPr and AP analysed the data to identify priority themes. DPe wrote the first draft and all authors contributed to subsequent drafts and approved the final version for submission.


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