Optimising the secondary analysis of primary health care country case studies: qualitative meta-analysis of 52 country cases through a sexual and reproductive health and rights lens

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This analysis developed a method for secondary analysis of these country case studies focused on sexual and reproductive health and rights (SRHR), examining: (1) how and where SRHR been prioritised in country PHC-oriented transformations; (2) the impact of the COVID-19 pandemic on SRHR; and (3) emerging SRHR policy priorities. Methods : We conducted a meta-analysis of SRHR themes in a sample of 52 country case studies from 42 countries. The sequence of steps included: sampling PHC country case studies; developing and piloting an assessment instrument guided by 8 SRHR areas and PHC levers clustered by structures, inputs and processes; extracting data; analyzing and validating the findings. Elaborative coding and thematic analysis was used to explore the findings by research question. Results : Policy interventions were skewed towards specific SRH services including HIV/STIs, family planning and reproductive health over other services like reproductive cancers and cross-cutting issues like gender-based rights. Policy interventions were also predominately related to structures (governance and financing), followed by processes (models of care). The pandemic caused several disruptions across SRHR areas investigated by exacerbating gender inequalities, increasing gender-based violence, changing utilization patterns, and suspending services. Common priority areas included extending coverage, implementing integrated models of care, addressing workforce shortages, improving supply management and enhancing engagement with target groups. Conclusions : While SRHR has been central to PHC-oriented health system transformations, the analysis reveals uneven implementation of interventions across SRHR areas and components of PHC. This secondary analysis of case studies using a tracer policy priority like SRHR offers a high-level overview of the policy landscape across countries. While reliant on the quality of the original case studies and limited by the data that lies within, methods like that applied here, can facilitate crosscountry learning and policy transfer beyond individual cases and merits further application. Primary health care sexual and reproductive health health policy qualitative research health systems Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Primary health care (PHC)-oriented reforms should be guided by the best available context-appropriate evidence of what works and how ( 1 – 3 ). Country case studies documenting the reorientation of health systems towards the PHC approach provide valuable knowledge translation and policy transfer. Country case studies are unique in their ability to comprehensively capture priorities, content and lessons from reforms through predominately country-led and validated storytelling ( 4 ). The rich, contextualised intelligence of country cases has been found to make reforms more efficient and effective ( 5 ). To accelerate the reorientation of health systems towards the PHC approach, growing emphasis has been placed to comprehensively document reforms through country case studies, particularly in low- and middle-income countries (LMICs) ( 1 , 6 ). This focus on country case studies has led to the refinement and standardization of rigorous, holistic methods that strengthen the PHC evidence base while enhancing cross-context comparability. This focus is evident in the work of many, including recent case study series by groups like the Alliance for Health Systems and Policies (the Alliance) ( 7 , 8 ) and the UHC Partnership ( 9 ) and initiatives like Exemplars in Global Health ( 4 ) and WHO’s PHC Implementation Solutions Initiative. New portals like the WHO PHC Country Case Study Compendium ( 10 )—a web-based repository for accessing PHC country case studies—demonstrate the growing volume of cases and their value as an evidence source. Despite progress in generating high-quality, comprehensive PHC country case studies, significant barriers to their secondary use remain. As predominately non-indexed qualitative studies, they often lie outside the scope of scientific reviews. The policy-oriented nature of the evidence also demands tailored approaches to systematically aggregate the findings in ways that pragmatically address the information needs of policy-makers. While well-developed methods exist for comparative case study methods on PHC (e.g., ( 11 – 13 )), these typically rely on primary data collection rather than secondary analysis of existing cases. Failing to leverage the potential within existing case studies risks their underuse, misuse, pro-forma documenting of country case studies, or worse, misinformed policy decisions. In this context, a systematic, policy-driven analysis is needed. Langlois et al ( 2 ) have demonstrated the value of secondary analysis of multi-country PHC country case studies. We argue that beyond merely aggregating findings across cases, to best inform decision-making, an approach should allow for the “zooming in” on the policy priorities of decision-makers for intelligence that is fit for purpose and use ( 14 ). Specifically, a topic-focused, PHC-oriented approach to analysing country case studies can provide a comprehensive overview of a given policy “maker” or tracer, while facilitating a deeper understanding of the dynamics between identified policy interventions ( 15 , 16 ). Study aims This analysis aimed to develop and apply a method for the secondary analysis of PHC country case studies using a policy-oriented approach. Sexual and reproductive health and rights (SRHR) was selected as the policy priority area to investigate. SRHR is central to achieving universal health coverage and health for all and the PHC approach is integral for the integrated and comprehensive delivery of services for improving the health of women, children, and adolescents ( 17 ). Despite significant progress that has led to decrease in maternal mortality from 2000 to 2015, this positive trend has since stagnated or even increased in some instances from 2016 to 2020 with growing inequalities in some contexts ( 6 , 18 ). While previous research has examined the integration of SRHR elements within broader PHC transformations (e.g., ( 19 – 21 )), these typically pertain to one or two SRHR areas described in a limited number of countries and settings or lack a focus on capturing a PHC-orientation ( 22 , 23 ). In this context, SRHR-related themes are found within existing PHC country case studies, though an overview of the status of SRHR policy interventions requires supplementary analysis to distill these findings. To do so, three policy-relevant questions were defined to guide our synthesis: ( 1 ) how and where has SRHR been prioritised in country PHC transformations? ( 2 ) What changes to SRHR are captured related to the COVID-19 pandemic? And ( 24 ) what SHRH-related areas are signaled as priorities for continued policy attention? Methods Study design The study adheres to the ENTREQ Checklist ( 25 ) and PRISMA 2020 Checklist. The study design was guided by a qualitative meta-analytic approach to aggregate and thematically synthesise findings from (qualitative) country case studies on the same general research topic (i.e., PHC) ( 26 , 27 ). The method allows for new integrative interpretation of findings that is more substantive for the specific research question (i.e., SRHR) ( 26 ), rather than a re-interpretation of the entirety of case study results ( 28 ). The study team included topic expertise on both PHC (EB, NF, KR, LZ, FK) and SRHR (CL, VG) and a mix of professional profiles, including clinician researchers (NF, KR, LZ), global policy advisers (FK, VG), and health systems and services researchers (EB, CL). Country case study sample Country case studies from the grey literature were selected as the primary data source for this research as they provide comprehensive, policy-oriented evidence that has been validated at country-level. Additionally, when conducted as part of a series in multiple countries, these case studies offer comparable evidence, which is an advantage over standalone country cases. Cases were sampled in November 2023 from the WHO PHC Country Case Study Compendium ( 10 ), the largest hub known to the authors of PHC country case studies published as grey literature (n = 186). Our sampling strategy was designed to be thorough rather than exhaustive. Case study series were selected according to the following criteria: diverse collection of case studies (i.e., series implemented in multiple and varied contexts); broad yet in-depth health systems orientation; and developed in the past 10 years (2013 onward). Three case study series met these criteria and were included: ( 1 ) Primary health care systems (PRIMASYS) initiative (n = 20) commissioned by the Alliance and published by WHO in 2017 ( 7 ); ( 2 ) PHC case studies in the context of the COVID-19 pandemic series (n = 23) commissioned by the Alliance and published by WHO in 2023 ( 8 ); and ( 3 ) SRHR country case studies (n = 9) developed by WHO with funding from the Susan Thompson Buffett Foundation and provided to the study team in draft form. The sample of cases for screening comprised 52 country case studies representing 42 countries. Representation across all six WHO regions served as a saturation criterion, and no exclusion criteria were applied (Fig. 1 ). The sample includes mostly LMICs, on the lower-end of the UHC index and many of which are experiencing vulnerable and/or conflict conditions. The sample of country cases also show a variety of SRHR-related contexts, including variable but generally high maternal and infant mortality rates and HIV prevalence (Supplementary file 1). The assessment of conduct, reporting, content and utility of the findings of each case study in the PRIMASYS and PHC/COVID-19 series was overseen by their commissioner, the Alliance. The Alliance has its own trusted and extensive review process to appraise each publication which is further reviewed by the publisher, WHO. For the nine draft case studies, quality was evaluated using the CASP Appraisal Tool for qualitative studies by one reviewer (NF) ( 29 ). Despite varying levels of methodological reporting regarding aims, data collection and analysis processes, these draft cases were deemed valuable contributions due to their addressing of significant literature gaps and the quality of their reference sources. Assessment instrument A study-specific assessment instrument was developed to guide data extraction as well as the approach analysis. A matrix of themes was designed rooted in SRHR priority interventions on one axis, informed by the sexual and reproductive health interventions of the WHO UHC Compendium ( 30 ) and Framework for Operationalizing Sexual Health and its Linkages to Reproductive Health ( 30 , 31 ) and PHC themes on the other axis, informed by the PHC measurement framework and indicator set and its cascading theory of change differentiated as structures (governance, adjustment to population health needs), inputs (physical infrastructure, health workforce, medicines and other health products, health information, digital technologies for health), and processes (models of care, systems for improving quality of care, resilient health facilities and services) ( 32 ). Analyzing outputs and outcomes and their linkages to impact was outside the scope of the study research questions. Informed by the existing WHO guidance, the research team (EB, CL, FK) identified eight main SRHR areas to serve as the foundation of the assessment instrument to sift through and extract mentions to SRHR in the cases (Table 1 ). Five more service-oriented areas and three cross-cutting topics. For each area, a series of related terms were identified. An Excel-based tool (Microsoft Cooperation) was developed in the approach set out by Meyer and Avery ( 33 ) to record our findings. Two researchers (EB, CL) piloted the assessment instrument against a sample of 5 country cases to confirm the sensitivity of the main areas and representation of each in the sample. The pilot data was reviewed to assess the consistency of process (i.e., same number of text excerpts) and meaningfulness of coding (i.e., coded themes meaningfully differentiated between the sentiment of text). The extracted data was reviewed jointly with another team member ( 34 ). Minor adjustments to further refine the keywords per service area or cross-cutting theme were introduced. Table 1 Overview of assessment tool SRHR areas Words used for data extraction Services Reproductive health/ maternal and child health reproductive health, reproductive services, antenatal care, newborn health, pregnancy, labor and childbirth care, neonatal care, perinatal care, postnatal care, postpartum care Family planning family planning, contraception, infertility Abortion abortion HIV and STI services HIV, STI, STIs, sexually transmitted infections Reproductive cancers cervical cancer, breast cancer, prostate cancer, ovarian cancer, uterine cancer Cross-cutting services/themes Sexual and reproductive health education Comprehensive sexual education and counselling, reproductive health education Gender gender equity, masculinity, gender-based violence, intimate partner violence, social norms Rights and advocacy sexual rights, reproductive rights, sexual orientation Data extraction Data extraction was conducted by two team members (EB, CL) who independently reviewed an evenly distributed sample of cases. The extraction process encompassed all sections of the cases using keyword searches based on the SRHR areas identified (Table 1 ). Text excerpts were extracted without manipulation following a line-by-line review to verify the appropriate categorization of themes where identified in text. Each excerpt was assigned one or more SRHR-related area and each line was coded using a three-letter country code and number to aid the analysis stage. Regular weekly meetings between the team allowed for continuous calibration of the data extraction and coding of themes. Data analysis and validation Analysis was performed using elaborative coding and thematic analysis ( 35 , 36 ). The process was conducted by two team members (EB, CL) and reviewed by a third (NF). The corpus of text extracts was consolidated in a common file to allow for the review and filtering of extracts cumulatively. The SRHR areas (services and cross-cutting themes) (level 1) were subcategorised and assigned a level 2 PHC code through a supplementary line-by-line coding to further interrogate the data and allow for secondary PHC-oriented analysis (see Supplementary file 2 for coding matrix). A summary of the interventions identified was done guided by the assessment instrument inspired by both previously mentioned frameworks ( 31 , 32 ). The results were aggregated in summary tables and reviewed by the full study team to appraise their significance by research question and interpret their meaning through joint discussions. Ethics approval No primary data collection was performed, and as such, ethical clearance was not applicable. Results SRHR-relevant content was identified and extracted from 48 country cases, with four cases excluded from analysis due to the absence of any SRHR-related data (Fig. 3 ). The prevalence of relevant themes varied considerably across case studies. For example, in the case of Pakistan 27 mentions of relevant themes were extracted in contrast to the case of Jordan where one theme was identified. The policy interventions identified are mapped in Fig. 4 according to the themes explored and their frequency across the sampled cases. The specific policy interventions can be found in Supplementary file 3. The results are reported by SRHR-related area and summarised across the three research questions. Representative country examples are referenced throughout in text brackets to illustrate key points. Reproductive health/maternal and child health Strengthening maternal and child health services was among the most consistent priority area across the case studies sampled, primarily motivated by aims to reduce maternal mortality and morbidity rates (Egypt, Georgia, Indonesia, Thailand) as well as high infant mortality rates (Dominica, Georgia, Sri Lanka). In numerous contexts, this priority manifested through the development of dedicated national programmes on prenatal care, labor and delivery. Specific intervention areas included: increasing attendance at antenatal care, considering the low or decreasing rates of four antenatal care visits rate (Georgia, Ghana, Rwanda, Tanzania), increasing deliveries in health facilities and deliveries attended by skilled providers, considering the low rates of fully equipped or adequate maternity wards (South Africa, Tanzania), and newborn care (Colombia, Ethiopia, Tanzania, Sri Lanka). Some countries implemented free prenatal and postnatal care (South Africa, Sri Lanka, Tunisia), as well as free delivery care (Colombia, Lao, Kazakhstan) to improve accessibility to these services. Specific interventions also included the development of clinical practice guidelines (Mexico, South Africa), and voucher schemes for maternal and child health services with public and private providers (Pakistan). The models of care described frequently featured nurse/midwife-led care (South Africa, Tunisia) and identified opportunities for service integration (e.g., integrating family planning into postnatal care in Egypt). Disruptions due to COVID-19 were felt across routine health services and maternal and child health services in many contexts (antenatal care, delivery, postnatal care, child immunizations, chronic illness care and follow-up). In some countries, the disruption was more pronounced (Ethiopia, Pakistan, Philippines, South Africa), while in others, no change in the utilization levels was reported throughout the pandemic (Kazakhstan). Concerns about the quality of maternal and child health services during the pandemic were raised (Ethiopia) as well as access, with the lack of public transportation cited as a key obstacle (Pakistan). In Kenya, an emergency number was set up so mothers in labor could access transportation during curfew hours via licensed taxi providers for free. In several contexts, telemedicine services were introduced to complement face-to-face appointments (Indonesia, Morocco), often with the support of development partners who also assisted with online training and guidelines for healthcare workers (Morocco, Sudan, UAE). Models of care were adapted to leverage community health workers to support maternal and child health services at home (Bhutan, Malaysia). Despite overall progress, areas for continued investment were identified, including the need to continue to improve the number of institutional deliveries, enhance maternal and child health service quality, and improve the overall health status of pregnant women. Some contexts highlighted sustainability issues related to the important role of donor support for maternal and child health services (Pakistan) and the importance of continuing to address access barriers, especially for youth (Egypt). Family planning Declines in fertility rates and increased use of modern family planning methods were among the most consistently cited areas of progress across sampled cases in response to high fertility rates and with the objective of reducing the costs related to unintended pregnancy (Bangladesh, Egypt, Kenya, New Zealand, Thailand). Family planning services ranged from the introduction or expansion of family planning counseling, provision of pregnancy tests, information regarding contraception measures, free or affordable access to modern contraceptives, and/or referrals for long-acting contraception methods (Bangladesh, Colombia, Dominica, Ethiopia, Ghana, Jordan, Rwanda, Sri Lanka, Tunisia, Uruguay). Strategies such as the introduction of a computerised logistics management system were described to support contraceptive supplies and the avoidance of stock-outs in districts (Pakistan). Notably, International Development Partners and NGOs (e.g., Planned Parenthood) played an important role around the maintenance of family planning supplies, increasing access to free contraceptives (Bangladesh, Dominica, Pakistan). During the COVD-19 pandemic, some case studies noted the prioritization of contraceptive access (Morocco, Myanmar), while others describe a sharp decline in the use of contraceptives as access to contraceptives showed a drop on average ( 37 ). Despite progress made, some country cases highlighted persistent challenges in access to family planning services, especially for adolescents and unmarried women (Bangladesh, Ghana), married women (Egypt), and in rural settings (Ghana, Tanzania). Evolving social norms, with shifts towards conservatism, spousal refusal or general misconceptions were also described as a barrier to increasing contraceptive usage (Tanzania, Tunisia). Insufficient numbers of health care centers or insufficient facility-based family planning was also described as a barrier to access (Democratic Republic of the Congo, Pakistan). Supply-chain concerns also remain unresolved, with a need for stable and/or increased government funding identified as a priority for improving access to comprehensive family planning services. This is particularly important given the current dependence on private donors and/or NGOs and their tendency to verticalise services and negatively impact capacity-building (Bangladesh, Democratic Republic of the Congo, Pakistan, Tanzania). Abortion The sampled cases captured progress in expanding rights to the voluntary termination of pregnancy and coverage of safe abortion services (New Zealand, Thailand, Uruguay). To improve access to abortion services, models of care have been designed for midwife-administered abortive medication (Tunisia), which has improved access in particularly underserved areas. Other strategies to expand coverage to quality abortion services through PHC-oriented transformation included the development of clinical protocols, training, and expanded access to information and education services (Democratic Republic of the Congo, Kazakhstan, New Zealand). Targeting populations made vulnerable because discrimination on the basis of marital status or age (adolescents), was captured as a priority. Some countries report changes in access to abortion services during the COVID-19 pandemic, including a decline in the utilization of abortion services ( 37 ) and rise in consultations from individuals seeking to terminate pregnancies at advanced stages (11–12 weeks) ( 38 ) potentially related to delayed abortion consultations due to pandemic-related measures in place. Access to abortion services continues to remain a challenge in many contexts. Some countries maintain legal restrictions on abortion services, as is the case in Egypt. Others reported struggles to offer safe abortion care despite legal acceptance, like in the Democratic Republic of the Congo where unsanctioned and illicit services persist (i.e., abortions performed with an unrecognised method by the WHO and/or by an unqualified provider), and in Tunisia, where abortion services are denied at health facilities, showing patriarchal attitudes and embedded stigmatization. In Kenya, despite a strong legal framework for SRHR including the provision of safe abortions for health reasons, accessibility issues, cultural norms and legal constraints continue to hinder comprehensive services, including access to abortion services. HIV/STIs Combating the spread of STIs and HIV was consistently embedded in PHC transformations across multiple countries (Dominica, Egypt, Ethiopia, Kenya, Tanzania, Uruguay). Progress in this area was attributed to various interventions including the high-level policy prioritization of prevention and control (Ethiopia, Indonesia), comprehensive management of STIs (Thailand), expansion of access to ARV treatment ( 37 ), and high coverage of HIV screening and prevention related to mother-to-child transmission (Cameroon, South Africa) as well as support to populations made vulnerable because of discrimination on the basis of age or sexual orientation. In many contexts, the expansion of treatment for HIV/AIDS and STIs was credited to the support of donors in the areas of testing, treatment, and counseling (Kenya, Pakistan, Peru, Rwanda). NGOs have also supported a one-stop-shop model for the prevention of STIs, HIV screening and therapy, and mental health services (Philippines, New Zealand). In some contexts, exemption policies were introduced such as fee waivers for poor households to enable access to a range of services including treatment of STIs. Use of rapid diagnostic tests in primary care has also mitigated workforce shortages (Peru) and integrated models have facilitated the concurrent delivery of screening for related conditions, such as cervical cancer screening with HIV/AIDS care (Kenya). During the pandemic, donors supported expanding and enhancing virtual modes of service delivery, including HIV counseling (Dominica). Despite progress made to increase the availability of services for HIV and STIs in primary care settings, a few cases note persisting challenges to integrate services with broader SRH care, having consequences on the continuity of care and management of referrals (Georgia, Kazakhstan, Tunisia). Tackling the enduring exclusion of populations living in situations of vulnerability also remains a priority, with single women being often excluded from STI treatment and care provided by the Primary Care Centers, which primarily targets married women (Tunisia). Some case studies identified affordability as a priority. For example, in some settings, syphilis testing is included in antenatal care, but patients must pay for their STI treatment. Similarly, for HIV services, the expansion of covered services remains a priority (e.g., in Peru, only 13% of pregnant women at ministry of health facilities receive an integrated care package for pregnant women which includes tests for HIV, among other services). Reproductive cancers Transformative efforts have included the prioritization of clinical practice guidelines for cancer screenings including breast, cervical and prostate cancers (Mexico, UAE). Regulations and national programmes were initiated for the early detection of diseases such as various programmes targeting one or more cancers (breast and cervical, prostate, and uterine) (Colombia, Georgia, Mexico, Singapore). Countries have worked to integrate comprehensive cancer prevention services into the basic package of services to be delivered at primary care centres (Kenya, Tunisia, Thailand), including enabling financing arrangements. Education and wellness programmes have also been leveraged to promote the uptake of pap smears and screening for breast cancer and male reproductive cancers. During the acute stages of the COVID-19 pandemic, cancer screening was disrupted in some contexts. For example, approximately 9,000 screening appointments were cancelled in Qatar and 70% fewer cancer screenings compared to pre-COVID-19 period in Morocco. Sexual and reproductive health education Comprehensive Sexuality Education. Investing in SRH education services has been central to many PHC-oriented transformations (Egypt, Lao People’s Democratic Republic, Mexico, Thailand). Comprehensive Sexuality Education has included enhanced information related to contraceptive measures, safe abortion, reproductive health problems and comprehensive and correct knowledge of HIV/AIDS and STIs. The cases also note efforts to ensure education reach young people (Egypt, Kenya, Indonesia), and women with disabilities (Kazakhstan). Healthcare workers’ training and education. In-service training and continuous professional development for healthcare professionals has also been prioritised. Specifically, countries aimed to expand the skills of health workers to deliver SRH-related services including HIV management, gender-based violence, emergency obstetric and neonatal care (Kenya, Lebanon, Viet Nam). International development partners have played an important role in this training agenda, as well as the development of clinical practice manuals (Kenya, Lebanon). During the COVID-19 pandemic, efforts were made to ensure resources for workforce training related to national guidelines for antenatal, postnatal and pre-conception services, cervical cancer, and child development and protection were recorded and delivered online (Morocco, UAE). Priority areas identified for continued investment include the further expansion of comprehensive sexuality education with a focus on vulnerable groups, specifically youth and girls in their teens who continue in many contexts to encounter the greatest challenges to access education about SRH services and rights (Kenya, Thailand). Continued strengthening of partnerships with NGOs and Civil Society Organizations are also noted. Gender Several country cases note progress in tackling gender-based discrimination, including the related priorities of gender-based violence (GBV), female genital mutilation (FGM), laws and policies to integrate gender equality, and efforts towards gender mainstreaming. Gender-based violence remains a concern for several countries (Egypt, Kazakhstan, Kenya, Lebanon, New Zealand, Thailand) and prevention efforts were described including in Kenya through a government-led multisectoral programme and in Kazakhstan through the funding of crisis centres for victims. Similarly, advocacy platforms implemented in Egypt enable efforts against harmful gender norms and advocate to prevent early and forced marriages. Some countries are also providing resources to help victims through government-funded services or by offering specific training to health workers. For example, New Zealand offers aid services to sex-workers experiencing violence; Lebanon offers training to health workers to help survivors of sexual and rape cases and Kazakhstan has a group of specialized nurses to care for victims of gender-based violence. Female genital mutilation remains a concern for many countries and protection efforts, including legal safeguards, policy frameworks and government-funded services to prevent FGM were established (Egypt, Kenya, New Zealand, Thailand) and resulted in decreased FGM prevalence (Kenya). Policy changes to promote gender equality were reported in several country cases (Dominica, Egypt, New Zealand, Tunisia). For example, Sri Lanka’s free education system for all has allowed women access to learning, knowledge, better health education and overall empowerment, which has in turn resulted in prevention and early treatment of communicable diseases. Kazakhstan’s effort to empower women was done through the Family and Gender Policy Concept, a national strategy aimed at advancing gender equality and fighting discrimination, while Dominica adopted a National Policy and Action Plan for Gender Justice and Equal Rights. In a few contexts, the pandemic was found to exacerbate gender inequalities, discrimination and stigma and to increase gender-based violence (Democratic Republic of Congo, Ethiopia, Iran, Lebanon, Uruguay). Gender inequities were apparent in the provision of vaccines, with countries reporting greater male access to vaccines (Kenya). During this period, the role of international partners and civil society organisations was emphasised, providing support services to protect children and gender-based violence survivors (Lebanon, Morocco, Vietnam). Increased gender-based violence and lockdown conditions were reported to impair access to outpatient procedures for those sharing housing with children and family members ( 38 ). Despite progress in gender equality, sexual/intimate partner violence remains a concern (Egypt, Kenya, Lebanon, New Zealand, Tanzania). Priority areas for continued investment include mainstreaming gender across health systems (budgeting, planning, disaggregation of data for analysis) (Bangladesh); increasing the participation of vulnerable groups in policy including representation on council health boards and health facility committees (Tanzania); and increasing gender-specific services at primary care facilities, including for men (Egypt). Rights and advocacy A number of case studies specifically addressed the “right” element of SRHR. Rights-based policies and new legislation enacted in the period covered by the selected case studies focused on availability of SRHR and the embedding of services in primary care (Democratic Republic of the Congo, Dominica, Egypt, Kazakhstan, Kenya, New Zealand, Thailand, Tunisia, Uruguay). Reported goals of these policies included advocating for and protecting the rights of children, adolescents, HIV-affected persons, sex workers, women with disabilities, and the LGBTQ + community (Kazakhstan, Peru, Sri Lanka, Tunisia, Uruguay). For example, in Colombia the Public Health Ten-year Plan 2012–2021 included sexual rights and sexuality indicators within its seven priority areas. Regarding adolescents’ rights, Kazakhstan modified the law to improve their access to health services by allowing minors to access reproductive health information and by reducing the age limit for independent outpatient service consultation (without parental consent) from 18 to 16 years old. Other areas of progress include laws to advance the right to the voluntary termination of pregnancy, like in Uruguay where a timely multidisciplinary team consultation is mandated within the first 48 hours after the patient’s request and service costs are covered to improve access and safety. There are also legal safeguards to protect women and children against Female Genital Mutilation (Kenya) and legislation to protect women’s rights and safety, like in Tunisia where gender-based violence prevention and management services are integrated into primary care facilities. The case studies did not mention any changes to SRH-related rights in relation to the COVID-19 pandemic. Ultimately, ensuring legal protections for individuals in low socio-economic status and rural areas remains a challenge and signals a need to address persisting policy and legal obstacles that hinder access to SRH services and rights (Thailand, Uruguay). Discussion Principal findings This meta-analysis of a global sample of 52 PHC country case studies set out to develop and test a method for systematically aggregating country case study findings based on a priority policy tracer: sexual and reproductive health and rights (SRHR). A wide range of policy interventions were identified across SRHR-related themes and related to levers of PHC-oriented health systems. They include large-scale policy or national programmes, new rights-based legislation advocating for populations living in situations of vulnerability, laws and legal safeguards for access to abortion, and the protection of women’s rights and safety, targeted financing initiatives (voucher schemes, targeted financial incentives), improved logistic management systems, and the use of rapid diagnostic testing. In addition, case studies reported a number of SRHR-related improvements more specifically related to service delivery across various SRHR-related services and cross-cutting themes including the continued expansion of services provided in primary care settings, models of care for more integrated SRH services delivery with other primary care-based services, nurse-led services, models of care to deliver SRH services to vulnerable groups, and the introduction of initiatives for continuous training and learning of the health workforce. The results show that interventions geared towards strengthening reproductive health, family planning and HIV/STIs services were more commonly prioritised by countries, while abortion services and the cross-cutting areas gender, education, and rights were generally less often prioritised. When mapped to the PHC Operational and Measurement Framework, the policy interventions are found to predominately relate to structures (specifically governance and financing), followed by processes (models of care). We interpret this to reflect the importance of the system structures to pave the way for actions around other levers (domains); any sustainable improvement in the operational levers is unlikely without a strong grounding in the strategic levers. This mapping also serves to spotlight less prioritised levers like processes for improving quality and resilient health facilities and services, inputs like physical infrastructure and health information. The COVID-19 pandemic was associated with several disruptions across SRHR services and cross-cutting areas, most notably, the exacerbation of gender inequalities and a rise in gender-based violence, changes in the utilization patterns (e.g., increase in later-stage abortions), and suspended services (e.g., cancer screenings). The degree of disruption varied considerably, with some contexts no longer on course to meet the Sustainable Development Goals, while others reported little to no change across core indicators. SRH- related innovations included the use of telemedicine in combination with face-to-face appointments, voucher schemes to access taxi services where public transit was unavailable, and many donor-supported initiatives working to minimise disruptions to SRHR and services. Most of these findings correlate with the current literature on the subject, or bring new information, mostly regarding the impact of the COVID-19 pandemic on SRHR ( 17 , 21 , 22 ). When mapped by current SRHR priority themes, five areas of needed improvement meriting further prioritization were more commonly mentioned throughout the case studies: ( 1 ) continuing to expand service coverage, especially to populations made vulnerable because of discrimination on the basis of sex, age, gender identity, sexual orientation, class, ethnicity or disability; ( 2 ) tackling the enduring vertical nature of programmes to ensure services are delivered in an integrated approach (e.g., SRH services, together with prevention and control for noncommunicable diseases); ( 24 ) investing in skilled nurses, including the delivery of continuous learning opportunities, to address growing shortage in health workforce ; ( 4 ) improving sustainability, of services and supplies supported by donors, as well as government-managed resources to address enduring issues of stockouts for essential supplies; and ( 37 ) increasing participation and representation by vulnerable groups on council health boards and health facility committees. Strengths and limitations The study methodology presents a number of advantages. The use of an affordable, accessible, and convenient software (Excel) and the secondary analysis of existing and trustworthy data make this an easily reproducible and relatively efficient method to extract useful and usable policy-guiding information. The method also proved useful for the identification of countries where the policy priority of interest (i.e., SRHR) was highly prominent in the PHC-oriented health system reform and therefore, may warrant further direct secondary analyses or future research. Conversely, the use of previously collected data imparted a number of limitations to the study. First, the information extracted reflects the specific period of time during which the case studies were developed (ranging between 2017 and 2023). Second, the case studies were developed to describe PHC implementation as an orientation of health systems and were not specifically meant to focus or report on SRHR. Because of this, the data extracted using a SRHR lens is less specific and varies in the level of between across case studies. This does not necessarily mean that more and different SRHR-related interventions were absent from PHC transformations but rather that they may have been beyond the scope of the specific case study and therefore, simply not captured. Relatedly, the clustering of SRHR services and cross-cutting areas that informed the analysis was developed specifically for the purpose of this study and through this aggregation of topics, the nuances and inter-relatedness of each could not be fully explored. Third, because the cases capture decision-making or implementation processes with regards to PHC broadly, specific inferences about the implementation of SRHR policies cannot be made. Research and policy implications The methods applied offer policy-relevant guidance on SRHR in the context of PHC-oriented health system reforms. The range of related policy interventions can inform cross-country learning and prompt more in-depth consideration at country-level. The overview of the current SRHR landscape can also point to areas in need of further attention. For example, addressing barriers to access services for vulnerable groups and increasing focus on integrated services, especially for reproductive cancers, appear as common improvement priorities. The review also served to signal potential blind spots, in particular related to gender-sensitive quality of care, and the need for embedding quality improvement in the PHC approach. The current study proposes a replicable methodology that uses the secondary analysis of PHC country case studies through the lens of a specific topic or area, to paint a high-level overview of the various dimensions of a topic of interest in PHC-transformation efforts across countries. Other policy tracers that are key to PHC-oriented health system transformations may lend themselves to a similar analysis. For example, priority areas like tuberculosis and HIV care, antimicrobial resistance, and/or the prevention and treatment of noncommunicable diseases could be used as lenses to understand how they are currently addressed in the context of PHC transformation. Moreover, countries that demonstrate a high degree of policy activity with regards to a theme of topic such as SRHR in this case, open the possibility of further investigation to contextualise the interventions and offer a more detailed and comprehensive perspective. In the case of SRHR, the secondary analysis of country case studies provides a starting point for further investigation into relevant reforms, particularly those country contexts that have taken a more comprehensive approach to their operationalization of SRHR. For example, Egypt, Kenya, Pakistan and Tunisia were identified through this study as high-frequency countries (countries with many SRHR interventions) who reported many changes in SRHR services within their PHC transformations and could merit in-depth SRHR country case studies to further understand the contexts and processes. Conclusions The secondary analysis of PHC country case studies using a systematic method through a policy-relevant lens provides a comprehensive overview of policy interventions implemented across countries, recent changes brought on by COVID-19 and current priorities. The study findings clearly indicate that reproductive health, family planning and HIV/STIs have been prioritised over other SRHR services and cross-cutting themes. Additionally, the analysis reveals that structural interventions have been prioritised relative to inputs and processes. The methodological approach applied to analyse the country case studies sampled demonstrates strong potential for replication with other policy priority areas. As the body of comprehensive PHC country case studies continues to broaden, methods for the aggregation of their findings should be prioritised in order to ensure this intelligence is fit for purpose and use by decision-makers. Abbreviations FGM female genital mutilation LMICs low- and middle-income countries NGO non-governmental organization PHC primary health care SRHR sexual and reproductive health and rights STI sexually transmitted infections UHC universal health coverage Declarations During the preparation of this work the authors used Claude.ai on a pre-final version of the manuscript solely for the purpose of shortening the text by reviewing language redundancies. After using this tool, all authors reviewed and edited the final content and take full responsibility for the content of the publication. Ethics approval and consent to participate Not applicable. Consent for publication Not applicable Availability of data and materials The full dataset is available upon reasonable request. Competing interests None to declare. Funding This study has been produced through a grant to the World Health Organization awarded by the Susan Thompson Buffett Foundation. Authors' contributions EB and FK conceived of the study. FK, CL, EB and KR designed the scoping framework applied. EB and CL conducted the initial data extraction. Analysis was supported by FK, NF, KR, LZ, VG, SD. All authors contributed the initial draft of the manuscript and have approved the version submitted. Acknowledgements The authors thank George Danhoundo for reviewing an earlier version of this work. Thanks to the University of Toronto Department of Family and Community Medicine WHO Collaborating Centre on Family Medicine and Primary Care for the collaboration on this review. FK, VG, SD are staff members of the World Health Organization. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of the World Health Organization. References World Health Organization, United Nations Children's Fund. Operational framework for primary health care: transforming vision into action. 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Reproductive health strategy to accelerate progress towards the attainment of international development goals and targets. Geneva: World Health Organization; 2004. Pfitzer A, Maly C, Tappis H, Kabue M, Mackenzie D, Healy S, et al. Characteristics of successful integrated family planning and maternal and child health services: Findings from a mixed-method, descriptive evaluation. F1000Res. 2019;8:229. Cooper CM, Wille J, Shire S, Makoko S, Tsega A, Schuster A, et al. Integrated Family Planning and Immunization Service Delivery at Health Facility and Community Sites in Dowa and Ntchisi Districts of Malawi: A Mixed Methods Process Evaluation. Int J Environ Res Public Health. 2020;17(12). Kabakian-Khasholian T, Quezada-Yamamoto H, Ali A, Sahbani S, Afifi M, Rawaf S, et al. Integration of sexual and reproductive health services in the provision of primary health care in the Arab States: status and a way forward. Sex Reprod Health Matters. 2020;28(2):1773693. Lewis NV, Munas M, Colombini M, d'Oliveira AF, Pereira S, Shrestha S, et al. Interventions in sexual and reproductive health services addressing violence against women in low-income and middle-income countries: a mixed-methods systematic review. BMJ Open. 2022;12(2):e051924. Quezada-Yamamoto H, Dubois E, Mastellos N, Rawaf S. Primary care integration of sexual and reproductive health services for chlamydia testing across WHO-Europe: a systematic review. BMJ Open. 2019;9(10):e031644. UHC2030. UHC2030 Members [Available from: https://www.uhc2030.org/who-we-are/uhc2030-members/. Tong A, Flemming K, McInnes E, Oliver S, Craig J. Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ. BMC Med Res Methodol. 2012;12:181. Timulak L. Meta-analysis of qualitative studies: A tool for reviewing qualitative research findings in psychotherapy. Psychotherapy Research. 2009;19(4-5):591-600. Flemming K, Booth A, Garside R, Tunçalp Ö, Noyes J. Qualitative evidence synthesis for complex interventions and guideline development: clarification of the purpose, designs and relevant methods. BMJ Global Health. 2019;4(Suppl 1):e000882. Levitt HM. How to conduct a qualitative meta-analysis: Tailoring methods to enhance methodological integrity. Psychother Res. 2018;28(3):367-78. Critical Appraisal Skills Programme. CASP Checklists—Critical Appraisal Skills Programme n.d. [Available from: https://casp-uk.net/casp-tools-checklists/qualitative-studies-checklist/. World Health O. Sexual and reproductive health interventions in the WHO UHC Compendium. Geneva: World Health Organization; 2021 2021. World Health O, Undp/Unfpa/Unicef/Who/World Bank Special Programme of Research D, Research Training in Human R. Sexual health and its linkages to reproductive health: an operational approach. Geneva: World Health Organization; 2017 2017. World Health Organization, United Nations Children's Fund. Primary health care measurement framework and indicators: monitoring health systems through a primary health care lens. Geneva: World Health Organization; 2022 2022. Meyer DZ, Avery LM. Excel as a Qualitative Data Analysis Tool. Field Methods. 2008;21(1):91-112. Rifkin SB. Paradigms lost: toward a new understanding of community participation in health programmes. Acta tropica. 1996;61(2):79-92. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3(2):77-101. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Medical Research Methodology. 2008;8(1):45. G20 South Africa 2025. Sherpa Track: Issue Note – Health Working Group. 2024. Pública. UMdS. Avances en la consolidación del Sistema Nacional Integrado de Salud. Montevideo: Ministerio de Salud Pública; 2019. Additional Declarations No competing interests reported. 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2","display":"","copyAsset":false,"role":"figure","size":86520,"visible":true,"origin":"","legend":"\u003cp\u003eOverview of matrices of themes\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6516698/v1/3ca8572bf909409d341d0d52.png"},{"id":82356709,"identity":"bad0ed94-24a7-4d00-9e83-5bb354d0dcdf","added_by":"auto","created_at":"2025-05-09 11:19:29","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":45063,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA diagram\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6516698/v1/38ec869c4bd4aed995c3f646.png"},{"id":82356714,"identity":"053b20fd-f34c-4d6c-80b0-a03d208d47fc","added_by":"auto","created_at":"2025-05-09 11:19:29","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":122094,"visible":true,"origin":"","legend":"\u003cp\u003eFrequency of policy interventions across SRHR services and cross-cutting themes and countries sampled\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6516698/v1/331623faf2777f0e3f4078b0.png"},{"id":101690451,"identity":"b91bd5bb-0c84-42f6-bb67-304876e77f61","added_by":"auto","created_at":"2026-02-02 16:03:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1116919,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6516698/v1/31dffe73-abbd-4a0a-acc2-dd910d7182f1.pdf"},{"id":82356711,"identity":"d7b48cef-a163-4f22-b9b8-23adbeaaf859","added_by":"auto","created_at":"2025-05-09 11:19:29","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":40822,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryfilesSRHRxPHC23042025.docx","url":"https://assets-eu.researchsquare.com/files/rs-6516698/v1/415507d18423ec218e837ee1.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Optimising the secondary analysis of primary health care country case studies: qualitative meta-analysis of 52 country cases through a sexual and reproductive health and rights lens","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePrimary health care (PHC)-oriented reforms should be guided by the best available context-appropriate evidence of what works and how (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Country case studies documenting the reorientation of health systems towards the PHC approach provide valuable knowledge translation and policy transfer. Country case studies are unique in their ability to comprehensively capture priorities, content and lessons from reforms through predominately country-led and validated storytelling (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The rich, contextualised intelligence of country cases has been found to make reforms more efficient and effective (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo accelerate the reorientation of health systems towards the PHC approach, growing emphasis has been placed to comprehensively document reforms through country case studies, particularly in low- and middle-income countries (LMICs) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e6\u003c/span\u003e). This focus on country case studies has led to the refinement and standardization of rigorous, holistic methods that strengthen the PHC evidence base while enhancing cross-context comparability. This focus is evident in the work of many, including recent case study series by groups like the Alliance for Health Systems and Policies (the Alliance) (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e8\u003c/span\u003e) and the UHC Partnership (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e9\u003c/span\u003e) and initiatives like Exemplars in Global Health (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e4\u003c/span\u003e) and WHO\u0026rsquo;s PHC Implementation Solutions Initiative. New portals like the \u003cem\u003eWHO PHC Country Case Study Compendium\u003c/em\u003e (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u0026mdash;a web-based repository for accessing PHC country case studies\u0026mdash;demonstrate the growing volume of cases and their value as an evidence source.\u003c/p\u003e \u003cp\u003eDespite progress in generating high-quality, comprehensive PHC country case studies, significant barriers to their secondary use remain. As predominately non-indexed qualitative studies, they often lie outside the scope of scientific reviews. The policy-oriented nature of the evidence also demands tailored approaches to systematically aggregate the findings in ways that pragmatically address the information needs of policy-makers. While well-developed methods exist for comparative case study methods on PHC (e.g., (\u003cspan additionalcitationids=\"CR12\" citationid=\"CR12\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e13\u003c/span\u003e)), these typically rely on primary data collection rather than secondary analysis of existing cases. Failing to leverage the potential within existing case studies risks their underuse, misuse, pro-forma documenting of country case studies, or worse, misinformed policy decisions.\u003c/p\u003e \u003cp\u003eIn this context, a systematic, policy-driven analysis is needed. Langlois et al (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2\u003c/span\u003e) have demonstrated the value of secondary analysis of multi-country PHC country case studies. We argue that beyond merely aggregating findings across cases, to best inform decision-making, an approach should allow for the \u0026ldquo;zooming in\u0026rdquo; on the policy priorities of decision-makers for intelligence that is fit for purpose and use (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Specifically, a topic-focused, PHC-oriented approach to analysing country case studies can provide a comprehensive overview of a given policy \u0026ldquo;maker\u0026rdquo; or tracer, while facilitating a deeper understanding of the dynamics between identified policy interventions (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eStudy aims\u003c/h3\u003e\n\u003cp\u003eThis analysis aimed to develop and apply a method for the secondary analysis of PHC country case studies using a policy-oriented approach. Sexual and reproductive health and rights (SRHR) was selected as the policy priority area to investigate. SRHR is central to achieving universal health coverage and health for all and the PHC approach is integral for the integrated and comprehensive delivery of services for improving the health of women, children, and adolescents (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Despite significant progress that has led to decrease in maternal mortality from 2000 to 2015, this positive trend has since stagnated or even increased in some instances from 2016 to 2020 with growing inequalities in some contexts (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e18\u003c/span\u003e). While previous research has examined the integration of SRHR elements within broader PHC transformations (e.g., (\u003cspan additionalcitationids=\"CR20\" citationid=\"CR20\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e21\u003c/span\u003e)), these typically pertain to one or two SRHR areas described in a limited number of countries and settings or lack a focus on capturing a PHC-orientation (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this context, SRHR-related themes are found within existing PHC country case studies, though an overview of the status of SRHR policy interventions requires supplementary analysis to distill these findings. To do so, three policy-relevant questions were defined to guide our synthesis: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) how and where has SRHR been prioritised in country PHC transformations? (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2\u003c/span\u003e) What changes to SRHR are captured related to the COVID-19 pandemic? And (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e24\u003c/span\u003e) what SHRH-related areas are signaled as priorities for continued policy attention?\u003c/p\u003e "},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThe study adheres to the ENTREQ Checklist (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e25\u003c/span\u003e) and PRISMA 2020 Checklist. The study design was guided by a qualitative meta-analytic approach to aggregate and thematically synthesise findings from (qualitative) country case studies on the same general research topic (i.e., PHC) (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The method allows for new integrative interpretation of findings that is more substantive for the specific research question (i.e., SRHR) (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e26\u003c/span\u003e), rather than a re-interpretation of the entirety of case study results (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe study team included topic expertise on both PHC (EB, NF, KR, LZ, FK) and SRHR (CL, VG) and a mix of professional profiles, including clinician researchers (NF, KR, LZ), global policy advisers (FK, VG), and health systems and services researchers (EB, CL).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eCountry case study sample\u003c/h3\u003e\n\u003cp\u003eCountry case studies from the grey literature were selected as the primary data source for this research as they provide comprehensive, policy-oriented evidence that has been validated at country-level. Additionally, when conducted as part of a series in multiple countries, these case studies offer comparable evidence, which is an advantage over standalone country cases.\u003c/p\u003e \u003cp\u003eCases were sampled in November 2023 from the \u003cem\u003eWHO PHC Country Case Study Compendium\u003c/em\u003e (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e10\u003c/span\u003e), the largest hub known to the authors of PHC country case studies published as grey literature (n\u0026thinsp;=\u0026thinsp;186). Our sampling strategy was designed to be thorough rather than exhaustive. Case study series were selected according to the following criteria: diverse collection of case studies (i.e., series implemented in multiple and varied contexts); broad yet in-depth health systems orientation; and developed in the past 10 years (2013 onward). Three case study series met these criteria and were included: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) \u003cem\u003ePrimary health care systems\u003c/em\u003e (PRIMASYS) initiative (n\u0026thinsp;=\u0026thinsp;20) commissioned by the Alliance and published by WHO in 2017 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e7\u003c/span\u003e); (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2\u003c/span\u003e) \u003cem\u003ePHC case studies in the context of the COVID-19 pandemic\u003c/em\u003e series (n\u0026thinsp;=\u0026thinsp;23) commissioned by the Alliance and published by WHO in 2023 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e8\u003c/span\u003e); and (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e3\u003c/span\u003e) SRHR country case studies (n\u0026thinsp;=\u0026thinsp;9) developed by WHO with funding from the Susan Thompson Buffett Foundation and provided to the study team in draft form.\u003c/p\u003e \u003cp\u003eThe sample of cases for screening comprised 52 country case studies representing 42 countries. Representation across all six WHO regions served as a saturation criterion, and no exclusion criteria were applied (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The sample includes mostly LMICs, on the lower-end of the UHC index and many of which are experiencing vulnerable and/or conflict conditions. The sample of country cases also show a variety of SRHR-related contexts, including variable but generally high maternal and infant mortality rates and HIV prevalence (Supplementary file 1).\u003c/p\u003e \u003cp\u003eThe assessment of conduct, reporting, content and utility of the findings of each case study in the PRIMASYS and PHC/COVID-19 series was overseen by their commissioner, the Alliance. The Alliance has its own trusted and extensive review process to appraise each publication which is further reviewed by the publisher, WHO. For the nine draft case studies, quality was evaluated using the CASP Appraisal Tool for qualitative studies by one reviewer (NF) (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Despite varying levels of methodological reporting regarding aims, data collection and analysis processes, these draft cases were deemed valuable contributions due to their addressing of significant literature gaps and the quality of their reference sources.\u003c/p\u003e \n\u003ch3\u003eAssessment instrument\u003c/h3\u003e\n\u003cp\u003eA study-specific assessment instrument was developed to guide data extraction as well as the approach analysis. A matrix of themes was designed rooted in SRHR priority interventions on one axis, informed by the sexual and reproductive health interventions of the WHO UHC Compendium (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e30\u003c/span\u003e) and Framework for Operationalizing Sexual Health and its Linkages to Reproductive Health (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e31\u003c/span\u003e) and PHC themes on the other axis, informed by the PHC measurement framework and indicator set and its cascading theory of change differentiated as structures (governance, adjustment to population health needs), inputs (physical infrastructure, health workforce, medicines and other health products, health information, digital technologies for health), and processes (models of care, systems for improving quality of care, resilient health facilities and services) (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Analyzing outputs and outcomes and their linkages to impact was outside the scope of the study research questions.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eInformed by the existing WHO guidance, the research team (EB, CL, FK) identified eight main SRHR areas to serve as the foundation of the assessment instrument to sift through and extract mentions to SRHR in the cases (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Five more service-oriented areas and three cross-cutting topics. For each area, a series of related terms were identified. An Excel-based tool (Microsoft Cooperation) was developed in the approach set out by Meyer and Avery (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e33\u003c/span\u003e) to record our findings. Two researchers (EB, CL) piloted the assessment instrument against a sample of 5 country cases to confirm the sensitivity of the main areas and representation of each in the sample. The pilot data was reviewed to assess the consistency of process (i.e., same number of text excerpts) and meaningfulness of coding (i.e., coded themes meaningfully differentiated between the sentiment of text). The extracted data was reviewed jointly with another team member (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Minor adjustments to further refine the keywords per service area or cross-cutting theme were introduced.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOverview of assessment tool\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSRHR areas\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWords used for data extraction\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eServices\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReproductive health/ maternal and child health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ereproductive health, reproductive services, antenatal care, newborn health, pregnancy, labor and childbirth care, neonatal care, perinatal care, postnatal care, postpartum care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily planning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003efamily planning, contraception, infertility\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbortion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eabortion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHIV and STI services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHIV, STI, STIs, sexually transmitted infections\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReproductive cancers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecervical cancer, breast cancer, prostate cancer, ovarian cancer, uterine cancer\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCross-cutting services/themes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSexual and reproductive health education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComprehensive sexual education and counselling, reproductive health education\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003egender equity, masculinity, gender-based violence, intimate partner violence, social norms\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRights and advocacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003esexual rights, reproductive rights, sexual orientation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eData extraction\u003c/h3\u003e\n\u003cp\u003eData extraction was conducted by two team members (EB, CL) who independently reviewed an evenly distributed sample of cases. The extraction process encompassed all sections of the cases using keyword searches based on the SRHR areas identified (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Text excerpts were extracted without manipulation following a line-by-line review to verify the appropriate categorization of themes where identified in text. Each excerpt was assigned one or more SRHR-related area and each line was coded using a three-letter country code and number to aid the analysis stage. Regular weekly meetings between the team allowed for continuous calibration of the data extraction and coding of themes.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData analysis and validation\u003c/h2\u003e \u003cp\u003eAnalysis was performed using elaborative coding and thematic analysis (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e36\u003c/span\u003e). The process was conducted by two team members (EB, CL) and reviewed by a third (NF). The corpus of text extracts was consolidated in a common file to allow for the review and filtering of extracts cumulatively. The SRHR areas (services and cross-cutting themes) (level 1) were subcategorised and assigned a level 2 PHC code through a supplementary line-by-line coding to further interrogate the data and allow for secondary PHC-oriented analysis (see Supplementary file 2 for coding matrix).\u003c/p\u003e \u003cp\u003eA summary of the interventions identified was done guided by the assessment instrument inspired by both previously mentioned frameworks (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e32\u003c/span\u003e). The results were aggregated in summary tables and reviewed by the full study team to appraise their significance by research question and interpret their meaning through joint discussions.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthics approval\u003c/h3\u003e\n\u003cp\u003eNo primary data collection was performed, and as such, ethical clearance was not applicable.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eSRHR-relevant content was identified and extracted from 48 country cases, with four cases excluded from analysis due to the absence of any SRHR-related data (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The prevalence of relevant themes varied considerably across case studies. For example, in the case of Pakistan 27 mentions of relevant themes were extracted in contrast to the case of Jordan where one theme was identified. The policy interventions identified are mapped in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e according to the themes explored and their frequency across the sampled cases. The specific policy interventions can be found in Supplementary file 3. The results are reported by SRHR-related area and summarised across the three research questions. Representative country examples are referenced throughout in text brackets to illustrate key points.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eReproductive health/maternal and child health\u003c/h2\u003e \u003cp\u003eStrengthening maternal and child health services was among the most consistent priority area across the case studies sampled, primarily motivated by aims to reduce maternal mortality and morbidity rates (Egypt, Georgia, Indonesia, Thailand) as well as high infant mortality rates (Dominica, Georgia, Sri Lanka). In numerous contexts, this priority manifested through the development of dedicated national programmes on prenatal care, labor and delivery. Specific intervention areas included: increasing attendance at antenatal care, considering the low or decreasing rates of four antenatal care visits rate (Georgia, Ghana, Rwanda, Tanzania), increasing deliveries in health facilities and deliveries attended by skilled providers, considering the low rates of fully equipped or adequate maternity wards (South Africa, Tanzania), and newborn care (Colombia, Ethiopia, Tanzania, Sri Lanka). Some countries implemented free prenatal and postnatal care (South Africa, Sri Lanka, Tunisia), as well as free delivery care (Colombia, Lao, Kazakhstan) to improve accessibility to these services. Specific interventions also included the development of clinical practice guidelines (Mexico, South Africa), and voucher schemes for maternal and child health services with public and private providers (Pakistan). The models of care described frequently featured nurse/midwife-led care (South Africa, Tunisia) and identified opportunities for service integration (e.g., integrating family planning into postnatal care in Egypt).\u003c/p\u003e \u003cp\u003eDisruptions due to COVID-19 were felt across routine health services and maternal and child health services in many contexts (antenatal care, delivery, postnatal care, child immunizations, chronic illness care and follow-up). In some countries, the disruption was more pronounced (Ethiopia, Pakistan, Philippines, South Africa), while in others, no change in the utilization levels was reported throughout the pandemic (Kazakhstan). Concerns about the quality of maternal and child health services during the pandemic were raised (Ethiopia) as well as access, with the lack of public transportation cited as a key obstacle (Pakistan). In Kenya, an emergency number was set up so mothers in labor could access transportation during curfew hours via licensed taxi providers for free.\u003c/p\u003e \u003cp\u003eIn several contexts, telemedicine services were introduced to complement face-to-face appointments (Indonesia, Morocco), often with the support of development partners who also assisted with online training and guidelines for healthcare workers (Morocco, Sudan, UAE). Models of care were adapted to leverage community health workers to support maternal and child health services at home (Bhutan, Malaysia).\u003c/p\u003e \u003cp\u003eDespite overall progress, areas for continued investment were identified, including the need to continue to improve the number of institutional deliveries, enhance maternal and child health service quality, and improve the overall health status of pregnant women. Some contexts highlighted sustainability issues related to the important role of donor support for maternal and child health services (Pakistan) and the importance of continuing to address access barriers, especially for youth (Egypt).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eFamily planning\u003c/h2\u003e \u003cp\u003eDeclines in fertility rates and increased use of modern family planning methods were among the most consistently cited areas of progress across sampled cases in response to high fertility rates and with the objective of reducing the costs related to unintended pregnancy (Bangladesh, Egypt, Kenya, New Zealand, Thailand). Family planning services ranged from the introduction or expansion of family planning counseling, provision of pregnancy tests, information regarding contraception measures, free or affordable access to modern contraceptives, and/or referrals for long-acting contraception methods (Bangladesh, Colombia, Dominica, Ethiopia, Ghana, Jordan, Rwanda, Sri Lanka, Tunisia, Uruguay).\u003c/p\u003e \u003cp\u003eStrategies such as the introduction of a computerised logistics management system were described to support contraceptive supplies and the avoidance of stock-outs in districts (Pakistan). Notably, International Development Partners and NGOs (e.g., Planned Parenthood) played an important role around the maintenance of family planning supplies, increasing access to free contraceptives (Bangladesh, Dominica, Pakistan). During the COVD-19 pandemic, some case studies noted the prioritization of contraceptive access (Morocco, Myanmar), while others describe a sharp decline in the use of contraceptives as access to contraceptives showed a drop on average (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite progress made, some country cases highlighted persistent challenges in access to family planning services, especially for adolescents and unmarried women (Bangladesh, Ghana), married women (Egypt), and in rural settings (Ghana, Tanzania). Evolving social norms, with shifts towards conservatism, spousal refusal or general misconceptions were also described as a barrier to increasing contraceptive usage (Tanzania, Tunisia). Insufficient numbers of health care centers or insufficient facility-based family planning was also described as a barrier to access (Democratic Republic of the Congo, Pakistan). Supply-chain concerns also remain unresolved, with a need for stable and/or increased government funding identified as a priority for improving access to comprehensive family planning services. This is particularly important given the current dependence on private donors and/or NGOs and their tendency to verticalise services and negatively impact capacity-building (Bangladesh, Democratic Republic of the Congo, Pakistan, Tanzania).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eAbortion\u003c/h2\u003e \u003cp\u003eThe sampled cases captured progress in expanding rights to the voluntary termination of pregnancy and coverage of safe abortion services (New Zealand, Thailand, Uruguay). To improve access to abortion services, models of care have been designed for midwife-administered abortive medication (Tunisia), which has improved access in particularly underserved areas. Other strategies to expand coverage to quality abortion services through PHC-oriented transformation included the development of clinical protocols, training, and expanded access to information and education services (Democratic Republic of the Congo, Kazakhstan, New Zealand). Targeting populations made vulnerable because discrimination on the basis of marital status or age (adolescents), was captured as a priority.\u003c/p\u003e \u003cp\u003eSome countries report changes in access to abortion services during the COVID-19 pandemic, including a decline in the utilization of abortion services (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e37\u003c/span\u003e) and rise in consultations from individuals seeking to terminate pregnancies at advanced stages (11\u0026ndash;12 weeks) (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e38\u003c/span\u003e) potentially related to delayed abortion consultations due to pandemic-related measures in place.\u003c/p\u003e \u003cp\u003eAccess to abortion services continues to remain a challenge in many contexts. Some countries maintain legal restrictions on abortion services, as is the case in Egypt. Others reported struggles to offer safe abortion care despite legal acceptance, like in the Democratic Republic of the Congo where unsanctioned and illicit services persist (i.e., abortions performed with an unrecognised method by the WHO and/or by an unqualified provider), and in Tunisia, where abortion services are denied at health facilities, showing patriarchal attitudes and embedded stigmatization. In Kenya, despite a strong legal framework for SRHR including the provision of safe abortions for health reasons, accessibility issues, cultural norms and legal constraints continue to hinder comprehensive services, including access to abortion services.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eHIV/STIs\u003c/h2\u003e \u003cp\u003eCombating the spread of STIs and HIV was consistently embedded in PHC transformations across multiple countries (Dominica, Egypt, Ethiopia, Kenya, Tanzania, Uruguay). Progress in this area was attributed to various interventions including the high-level policy prioritization of prevention and control (Ethiopia, Indonesia), comprehensive management of STIs (Thailand), expansion of access to ARV treatment (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e37\u003c/span\u003e), and high coverage of HIV screening and prevention related to mother-to-child transmission (Cameroon, South Africa) as well as support to populations made vulnerable because of discrimination on the basis of age or sexual orientation.\u003c/p\u003e \u003cp\u003eIn many contexts, the expansion of treatment for HIV/AIDS and STIs was credited to the support of donors in the areas of testing, treatment, and counseling (Kenya, Pakistan, Peru, Rwanda). NGOs have also supported a one-stop-shop model for the prevention of STIs, HIV screening and therapy, and mental health services (Philippines, New Zealand). In some contexts, exemption policies were introduced such as fee waivers for poor households to enable access to a range of services including treatment of STIs. Use of rapid diagnostic tests in primary care has also mitigated workforce shortages (Peru) and integrated models have facilitated the concurrent delivery of screening for related conditions, such as cervical cancer screening with HIV/AIDS care (Kenya).\u003c/p\u003e \u003cp\u003eDuring the pandemic, donors supported expanding and enhancing virtual modes of service delivery, including HIV counseling (Dominica).\u003c/p\u003e \u003cp\u003eDespite progress made to increase the availability of services for HIV and STIs in primary care settings, a few cases note persisting challenges to integrate services with broader SRH care, having consequences on the continuity of care and management of referrals (Georgia, Kazakhstan, Tunisia). Tackling the enduring exclusion of populations living in situations of vulnerability also remains a priority, with single women being often excluded from STI treatment and care provided by the Primary Care Centers, which primarily targets married women (Tunisia).\u003c/p\u003e \u003cp\u003eSome case studies identified affordability as a priority. For example, in some settings, syphilis testing is included in antenatal care, but patients must pay for their STI treatment. Similarly, for HIV services, the expansion of covered services remains a priority (e.g., in Peru, only 13% of pregnant women at ministry of health facilities receive an integrated care package for pregnant women which includes tests for HIV, among other services).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eReproductive cancers\u003c/h2\u003e \u003cp\u003eTransformative efforts have included the prioritization of clinical practice guidelines for cancer screenings including breast, cervical and prostate cancers (Mexico, UAE). Regulations and national programmes were initiated for the early detection of diseases such as various programmes targeting one or more cancers (breast and cervical, prostate, and uterine) (Colombia, Georgia, Mexico, Singapore). Countries have worked to integrate comprehensive cancer prevention services into the basic package of services to be delivered at primary care centres (Kenya, Tunisia, Thailand), including enabling financing arrangements. Education and wellness programmes have also been leveraged to promote the uptake of pap smears and screening for breast cancer and male reproductive cancers.\u003c/p\u003e \u003cp\u003eDuring the acute stages of the COVID-19 pandemic, cancer screening was disrupted in some contexts. For example, approximately 9,000 screening appointments were cancelled in Qatar and 70% fewer cancer screenings compared to pre-COVID-19 period in Morocco.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSexual and reproductive health education\u003c/h2\u003e \u003cp\u003e \u003cem\u003eComprehensive Sexuality Education.\u003c/em\u003e Investing in SRH education services has been central to many PHC-oriented transformations (Egypt, Lao People\u0026rsquo;s Democratic Republic, Mexico, Thailand). Comprehensive Sexuality Education has included enhanced information related to contraceptive measures, safe abortion, reproductive health problems and comprehensive and correct knowledge of HIV/AIDS and STIs. The cases also note efforts to ensure education reach young people (Egypt, Kenya, Indonesia), and women with disabilities (Kazakhstan).\u003c/p\u003e \u003cp\u003e \u003cem\u003eHealthcare workers\u0026rsquo; training and education.\u003c/em\u003e In-service training and continuous professional development for healthcare professionals has also been prioritised. Specifically, countries aimed to expand the skills of health workers to deliver SRH-related services including HIV management, gender-based violence, emergency obstetric and neonatal care (Kenya, Lebanon, Viet Nam). International development partners have played an important role in this training agenda, as well as the development of clinical practice manuals (Kenya, Lebanon).\u003c/p\u003e \u003cp\u003eDuring the COVID-19 pandemic, efforts were made to ensure resources for workforce training related to national guidelines for antenatal, postnatal and pre-conception services, cervical cancer, and child development and protection were recorded and delivered online (Morocco, UAE).\u003c/p\u003e \u003cp\u003ePriority areas identified for continued investment include the further expansion of comprehensive sexuality education with a focus on vulnerable groups, specifically youth and girls in their teens who continue in many contexts to encounter the greatest challenges to access education about SRH services and rights (Kenya, Thailand). Continued strengthening of partnerships with NGOs and Civil Society Organizations are also noted.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eGender\u003c/h2\u003e \u003cp\u003eSeveral country cases note progress in tackling gender-based discrimination, including the related priorities of gender-based violence (GBV), female genital mutilation (FGM), laws and policies to integrate gender equality, and efforts towards gender mainstreaming.\u003c/p\u003e \u003cp\u003eGender-based violence remains a concern for several countries (Egypt, Kazakhstan, Kenya, Lebanon, New Zealand, Thailand) and prevention efforts were described including in Kenya through a government-led multisectoral programme and in Kazakhstan through the funding of crisis centres for victims. Similarly, advocacy platforms implemented in Egypt enable efforts against harmful gender norms and advocate to prevent early and forced marriages. Some countries are also providing resources to help victims through government-funded services or by offering specific training to health workers. For example, New Zealand offers aid services to sex-workers experiencing violence; Lebanon offers training to health workers to help survivors of sexual and rape cases and Kazakhstan has a group of specialized nurses to care for victims of gender-based violence.\u003c/p\u003e \u003cp\u003eFemale genital mutilation remains a concern for many countries and protection efforts, including legal safeguards, policy frameworks and government-funded services to prevent FGM were established (Egypt, Kenya, New Zealand, Thailand) and resulted in decreased FGM prevalence (Kenya).\u003c/p\u003e \u003cp\u003ePolicy changes to promote gender equality were reported in several country cases (Dominica, Egypt, New Zealand, Tunisia). For example, Sri Lanka\u0026rsquo;s free education system for all has allowed women access to learning, knowledge, better health education and overall empowerment, which has in turn resulted in prevention and early treatment of communicable diseases. Kazakhstan\u0026rsquo;s effort to empower women was done through the Family and Gender Policy Concept, a national strategy aimed at advancing gender equality and fighting discrimination, while Dominica adopted a National Policy and Action Plan for Gender Justice and Equal Rights.\u003c/p\u003e \u003cp\u003eIn a few contexts, the pandemic was found to exacerbate gender inequalities, discrimination and stigma and to increase gender-based violence (Democratic Republic of Congo, Ethiopia, Iran, Lebanon, Uruguay). Gender inequities were apparent in the provision of vaccines, with countries reporting greater male access to vaccines (Kenya). During this period, the role of international partners and civil society organisations was emphasised, providing support services to protect children and gender-based violence survivors (Lebanon, Morocco, Vietnam). Increased gender-based violence and lockdown conditions were reported to impair access to outpatient procedures for those sharing housing with children and family members (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite progress in gender equality, sexual/intimate partner violence remains a concern (Egypt, Kenya, Lebanon, New Zealand, Tanzania). Priority areas for continued investment include mainstreaming gender across health systems (budgeting, planning, disaggregation of data for analysis) (Bangladesh); increasing the participation of vulnerable groups in policy including representation on council health boards and health facility committees (Tanzania); and increasing gender-specific services at primary care facilities, including for men (Egypt).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eRights and advocacy\u003c/h2\u003e \u003cp\u003eA number of case studies specifically addressed the \u0026ldquo;right\u0026rdquo; element of SRHR. Rights-based policies and new legislation enacted in the period covered by the selected case studies focused on availability of SRHR and the embedding of services in primary care (Democratic Republic of the Congo, Dominica, Egypt, Kazakhstan, Kenya, New Zealand, Thailand, Tunisia, Uruguay). Reported goals of these policies included advocating for and protecting the rights of children, adolescents, HIV-affected persons, sex workers, women with disabilities, and the LGBTQ\u0026thinsp;+\u0026thinsp;community (Kazakhstan, Peru, Sri Lanka, Tunisia, Uruguay). For example, in Colombia the Public Health Ten-year Plan 2012\u0026ndash;2021 included sexual rights and sexuality indicators within its seven priority areas. Regarding adolescents\u0026rsquo; rights, Kazakhstan modified the law to improve their access to health services by allowing minors to access reproductive health information and by reducing the age limit for independent outpatient service consultation (without parental consent) from 18 to 16 years old. Other areas of progress include laws to advance the right to the voluntary termination of pregnancy, like in Uruguay where a timely multidisciplinary team consultation is mandated within the first 48 hours after the patient\u0026rsquo;s request and service costs are covered to improve access and safety. There are also legal safeguards to protect women and children against Female Genital Mutilation (Kenya) and legislation to protect women\u0026rsquo;s rights and safety, like in Tunisia where gender-based violence prevention and management services are integrated into primary care facilities.\u003c/p\u003e \u003cp\u003eThe case studies did not mention any changes to SRH-related rights in relation to the COVID-19 pandemic.\u003c/p\u003e \u003cp\u003eUltimately, ensuring legal protections for individuals in low socio-economic status and rural areas remains a challenge and signals a need to address persisting policy and legal obstacles that hinder access to SRH services and rights (Thailand, Uruguay).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003ePrincipal findings\u003c/h2\u003e \u003cp\u003eThis meta-analysis of a global sample of 52 PHC country case studies set out to develop and test a method for systematically aggregating country case study findings based on a priority policy tracer: sexual and reproductive health and rights (SRHR). A wide range of policy interventions were identified across SRHR-related themes and related to levers of PHC-oriented health systems. They include large-scale policy or national programmes, new rights-based legislation advocating for populations living in situations of vulnerability, laws and legal safeguards for access to abortion, and the protection of women\u0026rsquo;s rights and safety, targeted financing initiatives (voucher schemes, targeted financial incentives), improved logistic management systems, and the use of rapid diagnostic testing. In addition, case studies reported a number of SRHR-related improvements more specifically related to service delivery across various SRHR-related services and cross-cutting themes including the continued expansion of services provided in primary care settings, models of care for more integrated SRH services delivery with other primary care-based services, nurse-led services, models of care to deliver SRH services to vulnerable groups, and the introduction of initiatives for continuous training and learning of the health workforce.\u003c/p\u003e \u003cp\u003eThe results show that interventions geared towards strengthening reproductive health, family planning and HIV/STIs services were more commonly prioritised by countries, while abortion services and the cross-cutting areas gender, education, and rights were generally less often prioritised. When mapped to the PHC Operational and Measurement Framework, the policy interventions are found to predominately relate to structures (specifically governance and financing), followed by processes (models of care). We interpret this to reflect the importance of the system structures to pave the way for actions around other levers (domains); any sustainable improvement in the operational levers is unlikely without a strong grounding in the strategic levers. This mapping also serves to spotlight less prioritised levers like processes for improving quality and resilient health facilities and services, inputs like physical infrastructure and health information.\u003c/p\u003e \u003cp\u003eThe COVID-19 pandemic was associated with several disruptions across SRHR services and cross-cutting areas, most notably, the exacerbation of gender inequalities and a rise in gender-based violence, changes in the utilization patterns (e.g., increase in later-stage abortions), and suspended services (e.g., cancer screenings). The degree of disruption varied considerably, with some contexts no longer on course to meet the Sustainable Development Goals, while others reported little to no change across core indicators. SRH- related innovations included the use of telemedicine in combination with face-to-face appointments, voucher schemes to access taxi services where public transit was unavailable, and many donor-supported initiatives working to minimise disruptions to SRHR and services. Most of these findings correlate with the current literature on the subject, or bring new information, mostly regarding the impact of the COVID-19 pandemic on SRHR (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhen mapped by current SRHR priority themes, five areas of needed improvement meriting further prioritization were more commonly mentioned throughout the case studies: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) continuing to expand service coverage, especially to populations made vulnerable because of discrimination on the basis of sex, age, gender identity, sexual orientation, class, ethnicity or disability; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2\u003c/span\u003e) tackling the enduring vertical nature of programmes to ensure services are delivered in an integrated approach (e.g., SRH services, together with prevention and control for noncommunicable diseases); (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e24\u003c/span\u003e) investing in skilled nurses, including the delivery of continuous learning opportunities, to address growing shortage in health workforce ; (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e4\u003c/span\u003e) improving sustainability, of services and supplies supported by donors, as well as government-managed resources to address enduring issues of stockouts for essential supplies; and (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e37\u003c/span\u003e) increasing participation and representation by vulnerable groups on council health boards and health facility committees.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThe study methodology presents a number of advantages. The use of an affordable, accessible, and convenient software (Excel) and the secondary analysis of existing and trustworthy data make this an easily reproducible and relatively efficient method to extract useful and usable policy-guiding information. The method also proved useful for the identification of countries where the policy priority of interest (i.e., SRHR) was highly prominent in the PHC-oriented health system reform and therefore, may warrant further direct secondary analyses or future research.\u003c/p\u003e \u003cp\u003eConversely, the use of previously collected data imparted a number of limitations to the study. First, the information extracted reflects the specific period of time during which the case studies were developed (ranging between 2017 and 2023). Second, the case studies were developed to describe PHC implementation as an orientation of health systems and were not specifically meant to focus or report on SRHR. Because of this, the data extracted using a SRHR lens is less specific and varies in the level of between across case studies. This does not necessarily mean that more and different SRHR-related interventions were absent from PHC transformations but rather that they may have been beyond the scope of the specific case study and therefore, simply not captured. Relatedly, the clustering of SRHR services and cross-cutting areas that informed the analysis was developed specifically for the purpose of this study and through this aggregation of topics, the nuances and inter-relatedness of each could not be fully explored. Third, because the cases capture decision-making or implementation processes with regards to PHC broadly, specific inferences about the implementation of SRHR policies cannot be made.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eResearch and policy implications\u003c/h2\u003e \u003cp\u003eThe methods applied offer policy-relevant guidance on SRHR in the context of PHC-oriented health system reforms. The range of related policy interventions can inform cross-country learning and prompt more in-depth consideration at country-level. The overview of the current SRHR landscape can also point to areas in need of further attention. For example, addressing barriers to access services for vulnerable groups and increasing focus on integrated services, especially for reproductive cancers, appear as common improvement priorities. The review also served to signal potential blind spots, in particular related to gender-sensitive quality of care, and the need for embedding quality improvement in the PHC approach.\u003c/p\u003e \u003cp\u003eThe current study proposes a replicable methodology that uses the secondary analysis of PHC country case studies through the lens of a specific topic or area, to paint a high-level overview of the various dimensions of a topic of interest in PHC-transformation efforts across countries. Other policy tracers that are key to PHC-oriented health system transformations may lend themselves to a similar analysis. For example, priority areas like tuberculosis and HIV care, antimicrobial resistance, and/or the prevention and treatment of noncommunicable diseases could be used as lenses to understand how they are currently addressed in the context of PHC transformation.\u003c/p\u003e \u003cp\u003eMoreover, countries that demonstrate a high degree of policy activity with regards to a theme of topic such as SRHR in this case, open the possibility of further investigation to contextualise the interventions and offer a more detailed and comprehensive perspective. In the case of SRHR, the secondary analysis of country case studies provides a starting point for further investigation into relevant reforms, particularly those country contexts that have taken a more comprehensive approach to their operationalization of SRHR. For example, Egypt, Kenya, Pakistan and Tunisia were identified through this study as high-frequency countries (countries with many SRHR interventions) who reported many changes in SRHR services within their PHC transformations and could merit in-depth SRHR country case studies to further understand the contexts and processes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe secondary analysis of PHC country case studies using a systematic method through a policy-relevant lens provides a comprehensive overview of policy interventions implemented across countries, recent changes brought on by COVID-19 and current priorities. The study findings clearly indicate that reproductive health, family planning and HIV/STIs have been prioritised over other SRHR services and cross-cutting themes. Additionally, the analysis reveals that structural interventions have been prioritised relative to inputs and processes. The methodological approach applied to analyse the country case studies sampled demonstrates strong potential for replication with other policy priority areas. As the body of comprehensive PHC country case studies continues to broaden, methods for the aggregation of their findings should be prioritised in order to ensure this intelligence is fit for purpose and use by decision-makers.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFGM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003efemale genital mutilation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLMICs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elow- and middle-income countries\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNGO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003enon-governmental organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eprimary health care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSRHR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003esexual and reproductive health and rights\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSTI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003esexually transmitted infections\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUHC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003euniversal health coverage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eDuring the preparation of this work the authors used Claude.ai on a pre-final version of the manuscript solely for the purpose of shortening the text by reviewing language redundancies. After using this tool, all authors reviewed and edited the final content and take full responsibility for the content of the publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe full dataset is available upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has been produced through a grant to the World Health Organization awarded by the Susan Thompson Buffett Foundation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEB and FK conceived of the study. FK, CL, EB and KR designed the scoping framework applied. EB and CL conducted the initial data extraction. Analysis was supported by FK, NF, KR, LZ, VG, SD. All authors contributed the initial draft of the manuscript and have approved the version submitted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank George Danhoundo for reviewing an earlier version of this work. Thanks to the University of Toronto Department of Family and Community Medicine WHO Collaborating Centre on Family Medicine and Primary Care for the collaboration on this review. FK, VG, SD are staff members of the World Health Organization. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of the World Health Organization.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization, United Nations Children\u0026apos;s Fund. Operational framework for primary health care: transforming vision into action. Geneva: World Health Organization; 2020 2020.\u003c/li\u003e\n\u003cli\u003eLanglois EV, McKenzie A, Schneider H, Mecaskey JW. Measures to strengthen primary health-care systems in low- and middle-income countries. Bull World Health Organ. 2020;98(11):781-91.\u003c/li\u003e\n\u003cli\u003eDolowitz D, Marsh D. Who Learns What from Whom: a Review of the Policy Transfer Literature. Political Studies. 1996;44(2):343-57.\u003c/li\u003e\n\u003cli\u003eCarter A, Akseer N, Ho K, Rothschild O, Bose N, Binagwaho A, et al. 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[Available from: https://casp-uk.net/casp-tools-checklists/qualitative-studies-checklist/.\u003c/li\u003e\n\u003cli\u003eWorld Health O. Sexual and reproductive health interventions in the WHO UHC Compendium. Geneva: World Health Organization; 2021 2021.\u003c/li\u003e\n\u003cli\u003eWorld Health O, Undp/Unfpa/Unicef/Who/World Bank Special Programme of Research D, Research Training in Human R. Sexual health and its linkages to reproductive health: an operational approach. Geneva: World Health Organization; 2017 2017.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization, United Nations Children\u0026apos;s Fund. Primary health care measurement framework and indicators: monitoring health systems through a primary health care lens. Geneva: World Health Organization; 2022 2022.\u003c/li\u003e\n\u003cli\u003eMeyer DZ, Avery LM. Excel as a Qualitative Data Analysis Tool. Field Methods. 2008;21(1):91-112.\u003c/li\u003e\n\u003cli\u003eRifkin SB. Paradigms lost: toward a new understanding of community participation in health programmes. Acta tropica. 1996;61(2):79-92.\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3(2):77-101.\u003c/li\u003e\n\u003cli\u003eThomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Medical Research Methodology. 2008;8(1):45.\u003c/li\u003e\n\u003cli\u003eG20 South Africa 2025. Sherpa Track: Issue Note \u0026ndash; Health Working Group. 2024.\u003c/li\u003e\n\u003cli\u003eP\u0026uacute;blica. UMdS. Avances en la consolidaci\u0026oacute;n del Sistema Nacional Integrado de Salud. Montevideo: Ministerio de Salud P\u0026uacute;blica; 2019.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Primary health care, sexual and reproductive health, health policy, qualitative research, health systems","lastPublishedDoi":"10.21203/rs.3.rs-6516698/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6516698/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Primary health care (PHC) country case studies provide valuable insights into PHC-oriented transformations. This analysis developed a method for secondary analysis of these country case studies focused on sexual and reproductive health and rights (SRHR), examining: (1) how and where SRHR been prioritised in country PHC-oriented transformations; (2) the impact of the COVID-19 pandemic on SRHR; and (3) emerging SRHR policy priorities.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: We conducted a meta-analysis of SRHR themes in a sample of 52 country case studies from 42 countries. The sequence of steps included: sampling PHC country case studies; developing and piloting an assessment instrument guided by 8 SRHR areas and PHC levers clustered by structures, inputs and processes; extracting data; analyzing and validating the findings. Elaborative coding and thematic analysis was used to explore the findings by research question.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Policy interventions were skewed towards specific SRH services including HIV/STIs, family planning and reproductive health over other services like reproductive cancers and cross-cutting issues like gender-based rights. Policy interventions were also predominately related to structures (governance and financing), followed by processes (models of care). The pandemic caused several disruptions across SRHR areas investigated by exacerbating gender inequalities, increasing gender-based violence, changing utilization patterns, and suspending services. Common priority areas included extending coverage, implementing integrated models of care, addressing workforce shortages, improving supply management and enhancing engagement with target groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: While SRHR has been central to PHC-oriented health system transformations, the analysis reveals uneven implementation of interventions across SRHR areas and components of PHC. This secondary analysis of case studies using a tracer policy priority like SRHR offers a high-level overview of the policy landscape across countries. While reliant on the quality of the original case studies and limited by the data that lies within, methods like that applied here, can facilitate crosscountry learning and policy transfer beyond individual cases and merits further application.\u003c/p\u003e","manuscriptTitle":"Optimising the secondary analysis of primary health care country case studies: qualitative meta-analysis of 52 country cases through a sexual and reproductive health and rights lens","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-09 11:19:24","doi":"10.21203/rs.3.rs-6516698/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-23T11:40:08+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-22T09:12:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"201571691330761485831077983067475104295","date":"2025-09-22T07:07:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"42712849835852372645627448995583446394","date":"2025-09-16T07:25:46+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-10T22:11:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"60874146566585363154451537440619955336","date":"2025-07-02T20:12:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"278402854127371772727909373161743748470","date":"2025-05-08T00:02:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"232687000104641749859573160936675927149","date":"2025-05-07T20:36:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-05T19:03:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-05T18:58:50+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-05T15:10:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-02T12:28:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-05-02T12:27:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"79bf7468-d789-44f2-9646-7de9ba8a2ed8","owner":[],"postedDate":"May 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-02T16:00:54+00:00","versionOfRecord":{"articleIdentity":"rs-6516698","link":"https://doi.org/10.1186/s12913-026-14051-x","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2026-01-31 15:58:29","publishedOnDateReadable":"January 31st, 2026"},"versionCreatedAt":"2025-05-09 11:19:24","video":"","vorDoi":"10.1186/s12913-026-14051-x","vorDoiUrl":"https://doi.org/10.1186/s12913-026-14051-x","workflowStages":[]},"version":"v1","identity":"rs-6516698","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6516698","identity":"rs-6516698","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}