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

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.