Table 1

Threats, policy recommendations and key references

ThreatsPolicy recommendationsKey references
Insecurity, conflicts and disease outbreaks
  • Position Universal Health Coverage and primary health care as central to global security and prosperity

  • Design PHC systems conflict-resilient and as part of prevention, early detection and mitigation of disease outbreaks

  • Use the rebuilding of the health sector after conflict as an opportunity to correct failures in the preconflict health systems

  • Global health security and universal health coverage: from a marriage of convenience to a strategic, effective partnership in BMJ Global Health 201952

  • Primary health care and health emergencies. WHO 201853

  • Rehabilitating health systems in post-conflict situations. United Nations University World Institute for Development Economics Research 200754

Lack of sustained political commitment and appropriate monitoring and evaluation structures
  • Ensure that PHC is a central part of the SDG and the UHC agendas

  • Generate political support for broad implementation of indicators such as the Primary Health care Performance Initiative ‘Vital Signs Profiles’ on national levels

  • Evaluate stewardship, financing, resource generation and service delivery

  • Revisiting Alma-Ata: what is the role of primary health care in achieving the Sustainable Development Goals? The Lancet 201822

  • Indicator Library of the Primary Health care Performance Initiative 201955

  • Primary Care Evaluation Tool of WHO (Europe) 201056

No appropriate and sustainable financing models
  • Invest significantly in tax-based UHC systems free at the point of care with financing models adapted to the local context

  • Incentivise team-based and community-oriented PHC, including value-based contracting and capitation-based elements

  • Support research on ‘(1) interventions to limit out-of-pocket costs; (2) financing models to enhance health system performance and maintain PHC budgets; (3) the design of incentives to promote optimal care without unintended consequences and (4) the comparative effectiveness of different PHC service delivery strategies using local data’

  • Foster ODA in PHC in a way that reinforces shared priorities (eg, NCDs, preparedness and PHC agendas can be mutually reinforcing)

  • Create multisectoral ‘health in all policies’ frames that allow for synergies and the inclusion of resources from others sectors to achieve health related outcomes

  • Guide posts for investment in primary health care and projected resource needs in 67 low-income and middle-income countries: a modelling study in Lancet Global Health 201957

  • Community-orientated primary care: a scoping review of different models, and their effectiveness and feasibility in sub-Saharan Africa in BMJ Glob Health 201958

  • Primary health care financing interventions: a systematic review and stakeholder-driven research agenda for the Asia-Pacific region in BMJ Glob Health 201959

  • Reimagining development assistance for health in the New England Journal of Medicine 201960

  • Identifying health policy and systems research priorities on multisectoral collaboration for health in low-income and middle-income countries in the2 BMJ Global Health 201861

Insufficient health workforce recruitment, employment and retention
  • Prioritise public investment in training new appropriately skilled and competent PHC providers

  • Create a positive practice environment and manage local human resources effectively adapted to the community need

  • Set-up multiprofessional health care teams, led by physicians, midwives and nurses, supplemented by other health professionals and community health workers (CHWs)—making best use of the skills and resources available in the respective setting

  • Allow task shifting, in particular in settings with health workforce shortages

  • Health professionals for a new century: transforming education to strengthen health systems in an interdependent world in The Lancet 201062

  • Human resources for health and universal health coverage: fostering equity and effective coverage in Bulletin of the World Health Organization 201363

  • Expanding the Role of Nurses in Primary Care. The Pan American Health Organization 201864

  • Community health volunteers could help improve access to and use of essential health services by communities in LMICs: an umbrella review in Health Policy and Planning 201865 66

Missing support from the physicians and the medical profession
  • Involve physicians in decision making adequate to their expertise and role in the health care system to ensure a shared agenda

  • Further establish family medicine professionally, academically and within the medical profession

  • General Practitioners: Allies or Enemies of Primary Health Care in Scandinavian Journal of Primary Care 198441

  • Strengthening Primary Care Through Family Medicine Around the World Collaborating Toward Promising Practices in Family Medicine 201867

Addressing the needs of communities inadequately
  • Support health literacy to ensure patients can navigate health care systems efficiently and make appropriate health decisions

  • Involve patients and communities in health systems design and local solutions

  • Identify and consider local power structures when implementing participation

  • Improving health literacy in community populations: a review of progress in Health Promotion International 201868

  • Examining the links between community participation and health outcomes: a review of the literature in Health Policy and Planning 201444

  • Community participation for transformative action on women's, children's and adolescents' health in Bulletin of the World Health Organization 201669

No attention to gender equity
  • Make the PHC sector and workforce a role model for gender equity by integrating a gender perspective into all health policies and programme

  • Mainstreaming gender in pre-service and in-service training of all health professionals

  • Gender, women and primary health care renewal: a discussion paper. WHO 2010

  • Gender and global health: evidence, policy and inconvenient truths in the Lancet 201348

  • NCD, non-communicable disease; ODA, Official Development Assistance; PHC, primary health care.