A new Lancet review of 57 studies across 22 countries finds the strongest path to equitable access comes from combining multilevel reform, not isolated fixes.
Fee reductions and financial incentives alone won’t close the primary care equity gap, a new review in Lancet Primary Care has found, echoing recent research from RACGP president and health economist Dr Michael Wright.
The scoping review examined primary care policies and interventions across 57 studies in 22 countries over 25 years, from 2001 to 2025.
Fee reductions alone seldom lead to significant equity improvements, the review found, with only modest, short-term benefits reported in South Africa and Sweden – especially when barriers including transport, workforce, or service availability persisted.
Expanded insurance coverage, including US Medicaid and community health schemes in Armenia, also reported modest access gains, but these were unevenly distributed, with rural or underserved areas continuing to lag despite coverage.
In rural Australia, rising bulk-billing rates and a lagging Medicare funding index have led to clinic closures, depriving regions of access to care closer to home.
Meso-level strategies, including organisational and service delivery, were most linked to tackling multilayered barriers to access, improving attendance, continuity, and engagement, compared with national policy or clinician initiatives.
Of the 24 unique policies and interventions identified, meso-level strategies accounted for 63%, more than double the share of national-level reforms (29%) or micro-level barriers, such as clinician-patient interactions (8%).
Meso-level strategies were often delivered as multicomponent packages, including mobile clinics, patient navigation and mediation services, and interpretation support, such as Australia’s bilingual community navigators and refugee health nurses.
These initiatives particularly benefited migrants, Indigenous patients, and socially excluded groups, though their impact often depended on integration with local primary care systems, sustained funding and alignment with community needs.
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Micro-level interventions such as GP education programs for perinatal depression were associated with improved patient trust, shared decision-making, and chronic care engagement, though these gains were often modest or not sustained without broader system support.
The report concluded that interventions must address multiple overlapping barriers – geographical, financial, organisational, and linguistic – within the same intervention.
Most studies were conducted in high-income countries, primarily targeting low-income or uninsured groups (47%) and rural residents (40%).
Mapped against the Levesque access framework, most interventions targeted availability and appropriateness, with affordability being the least addressed. Where affordability was targeted, it was mostly through macro-level measures.
Telehealth and other digital care models, often promoted as equity-enhancing innovations, were highly context-dependent and unevenly distributed, especially in settings where digital literacy, language barriers, and infrastructure suffered.
Notably, no policies or interventions were specifically targeted inequities related to religion, a gap the authors flagged for future research in culturally responsive care.
The review deliberately framed accessibility primarily around service-side factors– hours, costs, location, staffing – rather than patient health literacy or health-seeking behaviour.
RACGP president and health economist Dr Michael Wright co-authored a recently-published analysis of primary care funding in Australia over the past two decades.
Dr Wright’s 20-year trend analysis illustrated a persistent decline in primary health care spending, below the OECD average of 14%.
“The motivation for our research was to understand whether the desire to strengthen general practice and primary care through multiple reforms is being reflected in funding and resourcing for that purpose,” he said.
“International comparisons suggest that Australia is behind,” the report read.
Australia’s primary care service funding has shrunk from 8.0% in 2003 to just 5.5% in 2023.
“Costs of providing hospital care are increasing much more rapidly than the investment to keep people well in the community,” Dr Wright said.
In the 2026-27 federal budget, Commonwealth funding for public hospitals hit a record $220 billion over five years.
Dr Wright and co-authors wrote in MJA InSight+ that hospital spending is politically attractive because its impacts – shorter waits, more beds – are visible.
But they warned underinvesting in primary care, which keeps patients out of hospital, may worsen the very pressure hospital spending intends to alleviate.
“Prevention is a less visible investment in the short term, which makes it a less obvious investment,” Dr Wright told TMR.
“But increasingly, there is international evidence that shows that investing in primary care is the best investment for the health of communities and the long-term sustainability of [countries’] health systems.
“For many GPs, the cost of care has been going up, and there are financial pressures on many practices,” he said.
“These results confirm that without clear process[es] to record and evaluate the amount of funding that’s going into primary care and general practice, we tend to see funding go elsewhere within the health system,” he said.
“The college has been advocating particularly in terms of expanding funding through the workforce incentive payments within the PIP program to increase flexibility for practices to employ additional staff that help [clinics] practice as a multidisciplinary team.
“Currently, funding is allocated for practice nurses, but additional flexible funding for practices would assist in employing care coordination and navigation roles.”
