Background

The health system is a complex network that encompasses individuals, groups, and organizations engaged in policymaking, financing, resource generation, and service provision. These efforts collectively aim to safeguard and enhance people health, meet their expectations, and provide financial protection [1]. The World Health Organization's (WHO) framework outlines six foundational building blocks for a robust health system: governance and leadership, financing, workforce, infrastructure along with technologies and medicine, information systems, and service delivery. Strengthening these elements is essential for health systems to realize their objectives of advancing and preserving public health [2].

Effective governance in health systems encompasses the organization of structures, processes, and authority, ensuring resource stewardship and aligning stakeholders’ behaviors with health goals [3]. Financial mechanisms are designed to provide health services without imposing financial hardship, achieved through strategic fund collection, management and allocation [4, 5]. An equitable, competent, and well-distributed health workforce is crucial in delivering healthcare services and fulfilling health system objectives [2]. Access to vital medical supplies, technologies, and medicines is a cornerstone of effective health services, while health information systems play a pivotal role in generating, processing, and utilizing health data, informing policy decisions [2, 5]. Collectively, these components interact to offer quality health services that are safe, effective, timely, affordable, and patient-centered [2]

The WHO, at the 1978 Alma-Ata conference, introduced primary health care (PHC) as the fundamental strategy to attain global health equity [6]. Subsequent declarations, such as the one in Astana in 2018, have reaffirmed the pivotal role of PHC in delivering high-quality health care for all [7]. PHC represents the first level of contact within the health system, offering comprehensive, accessible, community-based care that is culturally sensitive and supported by appropriate technology [8]. Essential care through PHC encompasses health education, proper nutrition, access to clean water and sanitation, maternal and child healthcare, immunizations, treatment of common diseases, and the provision of essential drugs [6]. PHC aims to provide protective, preventive, curative, and rehabilitative services that are as close to the community as possible [9].

Global health systems, however, have faced significant disruptions from various shocks and crises [10], with the COVID-19 pandemic being a recent and profound example. The pandemic has stressed health systems worldwide, infecting over 775 million and claiming more than 7.04 million lives as of April 13th, 2024 [11]. Despite the pandemic highlighting the critical role of hospitals and intensive care, it also revealed the limitations of specialized medicine when not complemented by a robust PHC system [12].

The pandemic brought to light the vulnerabilities of PHC systems, noting a significant decrease in the use of primary care for non-emergency conditions. Routine health services, including immunizations, prenatal care, and chronic disease management, were severely impacted [13]. The challenges—quarantine restrictions, fears of infection, staffing and resource shortages, suspended non-emergency services, and financial barriers—reduced essential service utilization [14]. This led to an avoidance of healthcare, further exacerbating health inequalities and emphasizing the need for more resilient PHC systems [15,16,17].

Resilient PHC systems are designed to predict, prevent, prepare, absorb, adapt, and transform when facing crises, ensuring the continuity of routine health services [18]. Investing in the development of such systems can not only enhance crisis response but also foster post-crisis transformation and improvement. This study focuses on identifying global interventions and strategies to cultivate resilient PHC systems, aiding policymakers and managers in making informed decisions in times of crisis.

Methods

In 2023, we conducted a scoping review to collect and synthesize evidence from a broad spectrum of studies addressing the COVID-19 pandemic. A scoping review allows for the assessment of literature's volume, nature, and comprehensiveness, and is uniquely inclusive of both peer-reviewed articles and gray literature—such as reports, white papers, and policy documents. Unlike systematic reviews, it typically does not require a quality assessment of the included literature, making it well-suited for rapidly gathering a wide scope of evidence [19]. Our goal was to uncover the breadth of solutions aimed at bolstering the resilience of the PHC system throughout the COVID-19 crisis. The outcomes of this review are intended to inform the development of a model that ensures the PHC system's ability to continue delivering not just emergency services but also essential care during times of crisis.

We employed Arksey and O'Malley's methodological framework, which consists of six steps: formulating the research question, identifying relevant studies, selecting the pertinent studies, extracting data, synthesizing and reporting the findings, and, where applicable, consulting with stakeholders to inform and validate the results [20]. This comprehensive approach is designed to capture a wide range of interventions and strategies, with the ultimate aim of crafting a robust PHC system that can withstand the pressures of a global health emergency

Stage 1: identifying the research question

Our scoping review was guided by the central question: "Which strategies and interventions have been implemented to enhance the resilience of primary healthcare systems in response to the COVID-19 pandemic?" This question aimed to capture a comprehensive array of responses to understand the full scope of resilience-building activities within PHC systems.

Stage 2: identifying relevant studies

To ensure a thorough review, we conducted systematic searches across multiple databases, specifically targeting literature up to December 31st, 2022. The databases included PubMed, Web of Science, Scopus, Magiran, and SID. We also leveraged the expansive reach of Google Scholar. Our search strategy incorporated a bilingual approach, utilizing both English and Persian keywords that encompassed "PHC," "resilience," "strategies," and "policies," along with the logical operators AND/OR to refine the search. Additionally, we employed Medical Subject Headings (MeSH) terms to enhance the precision of our search. The results were meticulously organized and managed using the Endnote X8 citation manager, facilitating the systematic selection and review of pertinent literature.

Stage 3: selecting studies

In the third stage, we meticulously vetted our search results to exclude duplicate entries by comparing bibliographic details such as titles, authors, publication dates, and journal names. This task was performed independently by two of our authors, LE and MA, who rigorously screened titles and abstracts. Discrepancies encountered during this process were brought to the attention of a third author, AMM, for resolution through consensus.

Subsequently, full-text articles were evaluated by four team members—LE, MA, PI, and SHZ—to ascertain their relevance to our research question. The selection hinged on identifying articles that discussed strategies aimed at bolstering the resilience of PHC systems amidst the COVID-19 pandemic Table 1.

Table 1 Search strategy in databases
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We have articulated the specific inclusion and exclusion criteria that guided our selection process in Table 2, ensuring transparency and replicability of our review methodology

Table 2 Inclusion and exclusion criteria for the scoping review
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Stage 4: charting the data

Data extraction was conducted by a team of six researchers (LE, MA, PI, MA, FE, and SHZ), utilizing a structured data extraction form. For each selected study, we collated details including the article title, the first author’s name, the year of publication, the country where the study was conducted, the employed research methodology, the sample size, the type of document, and the PHC strengthening strategies described.

In pursuit of maintaining rigorous credibility in our study, we adopted a dual-review process. Each article was independently reviewed by pairs of researchers to mitigate bias and ensure a thorough analysis. Discrepancies between reviewers were addressed through discussion to reach consensus. In instances where consensus could not be reached, the matter was escalated to a third, neutral reviewer. Additionally, to guarantee thoroughness, either LE or MA conducted a final review of the complete data extraction for each study.

Stage 5: collating, summarizing and reporting the results

In this stage, authors LE, MZ, and MA worked independently to synthesize the data derived from the selected studies. Differences in interpretation were collaboratively discussed until a consensus was reached, with AMM providing arbitration where required.

We employed a framework thematic analysis, underpinned by the WHO's health system building blocks model, to structure our findings. This model categorizes health system components into six foundational elements: governance and leadership; health financing; health workforce; medical products, vaccines, and technologies; health information systems; and service delivery [2]. Using MAXQDA 10 software, we coded the identified PHC strengthening strategies within these six thematic areas.

Results

Summary of search results and study selection

In total, 4315 articles were found by initial search. After removing 397 duplicates, 3918 titles and abstracts were screened and 3606 irrelevant ones were deleted. Finally, 167 articles of 312 reviewed full texts were included in data synthesis (Fig. 1). Main characteristics of included studies are presented in Appendix 1.

Fig. 1
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PRISMA Flowchart of search process and results

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Characteristics of studies

These studies were published in 2020 (18.6%), 2021 (36.5%) and 2022 (44.9%). They were conducted in 48 countries, mostly in the US (39 studies), the UK (16 studies), Canada (11 studies), Iran (10 studies) and Brazil (7 studies) as shown in Fig. 2.

Fig. 2
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Distribution of reviewed studies by country

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Although the majority of the reviewed publications were original articles (55.1 %) and review papers (21 %), other types of documents such as reports, policy briefs, analysis, etc., were also included in this review (Fig. 3).

Fig. 3
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An overview of the publication types

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Strengthening interventions to build a resilient PHC system

In total, 194 interventions were identified for strengthening the resilience of PHC systems to respond to the COVID-19 pandemic. They were grouped into six themes of PHC governance and leadership (46 interventions), PHC financing (21 interventions), PHC workforce (37 interventions), PHC infrastructures, equipment, medicines and vaccines (30 interventions), PHC information system (21 interventions) and PHC service delivery (39 interventions). These strategies are shown in Table 3.

Table 3 Interventions to strengthen the resilience of PHC systems to respond to COVID-19 pandemic
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Discussion

This scoping review aimed to identify and categorize the range of interventions employed globally to strengthen the resilience of primary healthcare (PHC) systems in the face of the COVID-19 pandemic. Our comprehensive search yielded 194 distinct interventions across 48 countries, affirming the significant international efforts to sustain healthcare services during this unprecedented crisis. These interventions have been classified according to the WHO’s six building block model of health systems, providing a framework for analyzing their breadth and depth. This review complements and expands upon the findings from Pradhan et al., who identified 28 interventions specifically within low and middle-income countries, signaling the universality of the challenge and the myriad of innovative responses it has provoked globally [178].

The review highlights the critical role of governance and leadership in PHC resilience. Effective organizational structure changes, legal reforms, and policy development were crucial in creating adaptive healthcare systems capable of meeting the dynamic challenges posed by the pandemic. These findings resonate with the two strategies of effective leadership and coordination emphasized by Pradhan et al. (2023), and underscore the need for clear vision, evidence-based policy, and active community engagement in governance [178]. The COVID-19 pandemic posed significant challenges for PHC systems globally. A pivotal response to these challenges was the active involvement of key stakeholders in the decision-making process. This inclusivity spanned across the spectrum of general practitioners, health professionals, health managers, and patients. By engaging these vital contributors, it became possible to address their specific needs and to design and implement people-centered services effectively [41,42,43].

The development and implementation of collaborative, evidence-informed policies and national healthcare plans were imperative. Such strategies required robust leadership, bolstered by political commitment, to ensure that the necessary changes could be enacted swiftly and efficiently [41, 45]. Leaders within the health system were called upon to foster an environment of good governance. This entailed promoting increased participation from all sectors of the healthcare community, enhancing transparency in decision-making processes, and upholding the principles of legitimacy, accountability, and responsibility within the health system [10]. The collective aim was to create a more resilient, responsive, and equitable healthcare system in the face of the pandemic's demands.

In the wake of the COVID-19 pandemic, governments were compelled to implement new laws and regulations. These were designed to address a range of issues from professional accreditation and ethical concerns to supporting the families of healthcare workers. Additionally, these legal frameworks facilitated the integration of emerging services such as telemedicine into the healthcare system, ensuring that these services were regulated and standardized [38, 40, 61]. A key aspect of managing the pandemic was the establishment of effective and transparent communication systems for patients, public health authorities, and the healthcare system at large [60, 61]. To disseminate vital information regarding the pandemic, vaccination programs, and healthcare services, authorities leveraged various channels. Public media, local online platforms, and neighborhood networks were instrumental in keeping the public informed about the ongoing situation and available services [53, 60, 86]. For health professionals, digital communication tools such as emails and WhatsApp groups, as well as regular meetings, were utilized to distribute clinical guidelines, government directives, and to address any queries they might have had. This ensured that healthcare workers were kept up-to-date with the evolving landscape of the pandemic and could adapt their practices accordingly [60, 144].

Healthcare facilities function as complex socio-technical entities, combining multiple specialties and adapting to the ever-changing landscape of healthcare needs and environments [179]. To navigate this dynamic, policy makers must take into account an array of determinants—political, economic, social, and environmental—that influence health outcomes. Effective management of a health crisis necessitates robust collaboration across various sectors, including government bodies, public health organizations, primary healthcare systems, and hospitals. Such collaboration is not only pivotal during crisis management but also during the development of preparedness plans [63]. Within the health system, horizontal collaboration among departments and vertical collaboration between the Ministry of Health and other governmental departments are vital. These cooperative efforts are key to reinforce the resilience of the primary healthcare system. Moreover, a strong alliance between national pandemic response teams and primary healthcare authorities is essential to identifying and resolving issues within the PHC system [29]. On an international scale, collaborations and communications are integral to the procurement of essential medical supplies, such as medicines, equipment, and vaccines. These international partnerships are fundamental to ensuring that health systems remain equipped to face health emergencies [63].

To ensure the PHC system's preparedness and response capacity was at its best, regular and effective monitoring and evaluation programs were put in place. These included rigorous quarterly stress tests at the district level, which scrutinized the infrastructure and technology to pinpoint the system’s strengths and areas for improvement [43]. Furthermore, clinical audits were conducted to assess the structure, processes, and outcomes of healthcare programs, thereby enhancing the quality and effectiveness of the services provided [63]. These evaluation measures were crucial for maintaining a high standard of care and for adapting to the ever-evolving challenges faced by the PHC system.

Financial strategies played a critical role in enabling access to essential health services without imposing undue financial hardship. Various revenue-raising, pooling, and purchasing strategies were implemented to expand PHC financing during the pandemic, illustrating the multifaceted approach needed to sustain healthcare operations under strained circumstances [9, 19].

In response to the COVID-19 pandemic, the Indian government took decisive action to bolster the country's healthcare infrastructure. By enhancing the financial capacity of states, the government was able to inject more funds into the Primary Health Care (PHC) system. This influx of resources made it possible to introduce schemes providing free medications and diagnostic services [50]. The benefits of increased financial resources were also felt beyond India's borders, enabling the compensation of health services in various forms. In Greece, it facilitated the monitoring and treatment of COVID-19 through in-person, home-based, and remote health services provided by physicians in private practice. Similarly, in Iran, the financial boost supported the acquisition of basic and para-clinical services from the private sector [21, 65]. These measures reflect a broader international effort to adapt and sustain health services during a global health crisis.

The COVID-19 pandemic presented a formidable challenge to the PHC workforce worldwide. Healthcare workers were subjected to overwhelming workloads and faced significant threats to both their physical and mental well-being. To build resilience in the face of this crisis, a suite of interventions was implemented. These included recruitment strategies, training and development programs, enhanced teamwork, improved protective measures, comprehensive performance appraisals, and appropriate compensation mechanisms, as documented in Table 3. To address staffing needs within PHC centers, a range of professionals including general practitioners, nurses, community health workers, and technical staff were either newly employed or redeployed from other healthcare facilities [63]. Expert practitioners were positioned on the frontlines, providing both in-person services and telephone consultations, acting as gatekeepers in the health system [49, 63]. Support staff with technological expertise played a crucial role as well, assisting patients in navigating patient portals, utilizing new digital services, and conducting video visits [102]. Furthermore, the acute shortage of healthcare workers was mitigated by recruiting individuals who were retired, not currently practicing, or in training as students, as well as by enlisting volunteers. This strategy was key to bolstering the workforce and ensuring continuity of care during the pandemic [109].

During the pandemic, new training programs were developed to prepare healthcare staff for the evolving demands of their roles. These comprehensive courses covered a wide array of critical topics, including the correct use of personal protective equipment (PPE), the operation of ventilators, patient safety protocols, infection prevention, teamwork, problem-solving, self-care techniques, mental health support, strategies for managing stress, navigating and applying reliable web-based information, emergency response tactics, telemedicine, and direct care for COVID-19 patients [74, 95, 100, 108, 110, 112, 117].

Acknowledging the psychological and professional pressures faced by the primary healthcare workforce, health managers took active measures to safeguard both the physical and mental well-being of their employees during this challenging period [124]. Efforts to protect physical health included monitoring health status, ensuring vaccination against COVID-19, and providing adequate PPE [63, 72]. To address mental health, a variety of interventions were deployed to mitigate anxiety and related issues among frontline workers. In Egypt, for instance, healthcare workers benefited from psychotherapy services and adaptable work schedules to alleviate stress [126]. Singapore employed complementary strategies, such as yoga, meditation, and the encouragement of religious practices, to promote relaxation among staff [133]. In the United States, the Wellness Hub application was utilized as a tool for employees to enhance their mental health [132]. In addition to health and wellness initiatives, there were financial incentives aimed at motivating employees. Payment protocols were revised, and new incentives, including scholarship opportunities and career development programs, were introduced to foster job satisfaction and motivation among healthcare workers [63].

The resilience of PHC systems during the pandemic hinged on several key improvements. Enhancing health facilities, supplying medicines and diagnostic kits, distributing vaccines, providing medical equipment, and building robust digital infrastructure were all fundamental elements that contributed to the strength of PHC systems, as outlined in Table 3. Safe and accessible primary healthcare was facilitated through various means. Wheelchair routes were created for patients to ensure their mobility within healthcare facilities. , dedicated COVID-19 clinics were established, mass vaccination centers were opened to expedite immunization, and mobile screening stations were launched to extend testing capabilities [23, 33, 63, 140].

In Iran, the distribution and availability of basic medicines were managed in collaboration with the Food and Drug Organization, ensuring that essential medications reached those in need [89]. During the outbreak, personal protective equipment (PPE) was among the most critical supplies. Access to PPE was prioritized, particularly for vulnerable groups and healthcare workers, to provide a layer of safety against the virus [63]. Vaccines were made available at no cost, with governments taking active measures to monitor their safety and side effects, to enhance their quality, and to secure international approvals. Furthermore, effective communication strategies were employed to keep the public informed about vaccine-related developments [32, 83].

These comprehensive efforts underscored the commitment to maintaining a resilient PHC system in the face of a global health every individual in the community could access healthcare services. To facilitate this, free high-speed Wi-Fi hotspots were established, enabling patients to engage in video consultations and utilize a range of e-services without the barrier of internet costs crisis. Significant enhancements were made to the digital infrastructure. This expansion was critical in ensuring that [30, 54]. Complementing these measures, a variety of digital health tools were deployed to further modernize care delivery. Countries like Nigeria and Germany, for instance, saw the introduction of portable electrocardiograms and telemedical stethoscopes. These innovations allowed for more comprehensive remote assessments and diagnostics, helping to bridge the gap between traditional in-person consultations and the emerging needs for telemedicine [141, 180].

Throughout the COVID-19 pandemic, targeted interventions were implemented to bolster information systems and research efforts, as outlined in Table 3. Key among these was the advancement of a modern, secure public health information system to ensure access to health data was not only reliable and timely but also transparent and accurate [33, 45, 49]. The "Open Notes" initiative in the United States exemplified this effort, guaranteeing patient access to, and editorial control over, their health records [141]. Management strategies also promoted the "one-health" approach, facilitating the exchange of health data across various departments and sectors to enhance public health outcomes [10].

In addition to these information system upgrades, active patient surveillance and early warning systems were instituted in collaboration with public health agencies. These systems played a pivotal role in detecting outbreaks, providing precise reports on the incidents, characterizing the epidemiology of pathogens, tracking their spread, and evaluating the efficacy of control strategies. They were instrumental in pinpointing areas of concern, informing smart lockdowns, and improving contact tracing methods [33, 63, 72]. The reinforcement of these surveillance and warning systems had a profound impact on shaping and implementing a responsive strategy to the health crisis [10].

To further reinforce the response to the pandemic, enhancing primary healthcare (PHC) research capacity became crucial. This enabled healthcare professionals and policymakers to discern both facilitators and barriers within the system and to devise fitting strategies to address emerging challenges. To this end, formal advisory groups and multidisciplinary expert panels, which included specialists from epidemiology, clinical services, social care, sociology, policy-making, and management, were convened. These groups harnessed the best available evidence to inform decision-making processes [30]. Consequently, research units were established to carry out regular telephone surveys and to collect data on effective practices, as well as new diagnostic and therapeutic approaches [31, 89]. The valuable insights gained from these research endeavors were then disseminated through trusted channels to both the public and policymakers, ensuring informed decisions at all levels [36].

The COVID-19 pandemic acted as a catalyst for the swift integration of telemedicine into healthcare systems globally. This period saw healthcare providers leverage telecommunication technologies to offer an array of remote services, addressing medical needs such as consultations, diagnosis, monitoring, and prescriptions. This transition was instrumental in ensuring care continuity and mitigating infection risks for both patients and healthcare workers, highlighting an innovative evolution in healthcare delivery [170, 181].

Countries adapted to this new model of healthcare with varied applications: Armenia established telephone follow-ups and video consultations for remote patient care, while e-pharmacies and mobile health tools provided immediate access to medical information and services [29]. In France and the United States, tele-mental health services and online group support became a means to support healthy living during the pandemic [147, 158] . New Zealand introduced the Aroha chatbot, an initiative to assist with mental health management [139].

The implementation and effectiveness of these telehealth services were not limited by economic barriers, as underscored by Pradhan et al. (2023), who noted the key role of telemedicine in low and middle-income countries. These countries embraced the technology to maintain health service operations, proving its global applicability and utility [178]. The widespread adoption of telemedicine, therefore, represents a significant and perhaps lasting shift in healthcare practice, one that has redefined patient care in the face of a global health crisis and may continue to shape the future of healthcare delivery [170, 178, 181].

Conclusion

The study highlighted PHC strengthening strategies in COVID-19 time . Notably, the adaptations and reforms spanned across governance, financing, workforce management, information system, infrastructural readiness, and service delivery enhancements. These interventions collectively contributed to the robustness of health systems against the sudden surge in demand and the multifaceted challenges imposed by the pandemic and resulted.

Significantly, the findings have broader implications for health policy and system design worldwide. The pandemic has highlighted the critical need for resilient health systems that are capable of not only responding to health emergencies but also maintaining continuity in essential services. The strategies documented in this review serve as a template for countries to fortify their health systems by embedding resilience into their PHC frameworks (Fig. 4). Future health crises can be better managed by learning from these evidenced responses, which emphasize the necessity of integrated, well-supported, and dynamically adaptable health care structures.

Fig. 4
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A model for strengthening the resilience of the primary health care system

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Looking ahead, realist reviews could play a pivotal role in refining PHC resilience strategies. By understanding the context in which specific interventions succeed or fail, realist reviews can help policymakers and practitioners design more effective health system reforms, as echoed in the need for evidence-based planning in health system governance [9] ​​. These reviews offer a methodological advantage by focusing on the causality between interventions and outcomes, aligning with the importance of effective health system leadership and management [50, 182] ​​. They take into account the underlying mechanisms and contextual factors, thus providing a nuanced understanding that is crucial for tailoring interventions to meet local needs effectively [28, 86] ​​, ultimately leading to more sustainable health systems globally. This shift towards a more analytical and context-sensitive approach in evaluating health interventions, as supported by WHO's framework for action [2, 10] ​​, will be crucial for developing strategies that are not only effective in theory but also practical and sustainable in diverse real-world settings.

Limitations and future research

In our comprehensive scoping review, we analyzed 167 articles out of a dataset of 4,315, classifying 194 interventions that build resilience in primary healthcare systems across the globe in response to pandemics like COVID-19. While the review's extensive search provides a sweeping overview of various strategies, it may not capture the full diversity of interventions across all regions and economies. Future research should focus on meta-analyses to evaluate the effectiveness of these interventions in greater detail and employ qualitative studies to delve into the specific challenges and successes, thus gaining a more nuanced understanding of the context. As the review includes articles only up to December 31, 2022, it may overlook more recent studies. Regular updates, a broader linguistic range, and the inclusion of a more diverse array of databases are recommended to maintain relevance and expand the breadth of literature, ultimately guiding more focused research that could significantly enhance the resilience of PHC systems worldwide.