Primary healthcare (PHC) can be seen as a set of values and principles that guide the health system in its policy, leadership and governance, commitment to universal health coverage and primary care. 1 Governance, economics and the primary care workforce are the key structural determinants of effective primary care systems. 2 The African continent has 25% of the global disease burden, but only 3% of the world’s health workers and less than 1% of the world’s health expenditure. 3 The burden of disease in Africa has historically been dominated by acute and infectious diseases such as malaria, diarrhoeal diseases, lower respiratory tract infections, tuberculosis and measles. Over the last 25 years, however, chronic communicable and non-communicable diseases, such as HIV/AIDS, ischaemic heart disease, stroke and diabetes have become major contributors to the burden of disease. 4 Additional contributors include newer threats such as Ebola and global warming, conflicts and displacement of persons, issues of gender and poverty with high rates of interpersonal violence, disadvantage for women in education and earnings and continued high risks during pregnancy and childbirth. Government in Africa is often characterised by flawed democracies and authoritarian regimes, which may not prioritise healthcare. 5 Few countries meet the target of 15% of general government expenditure on healthcare that was agreed in the Abuja Declaration of 2001. 6 In low-income countries, there are fewer resources to go around, and those resources available are often concentrated in prestigious central referral hospitals. Most countries meet the WHO criteria for having a critical shortage of health workers, defined as fewer than 2.28 doctors, nurses and midwives per 1000 population. 7 Health systems in many countries, such as Malawi, rely on mission hospitals, non-government organisations and external donors to fund and provide services. 8 These agencies often drive vertical disease-orientated programmes, skew central planning and priorities and by offering higher salaries to health workers create an internal ‘brain drain’, where health workers move out of the public sector. 9 Stories are told of patients wishing they had HIV rather than diabetes because of this inequity by disease and fragmentation of the health system. Out-of-pocket expenses to access healthcare may not only act as a barrier to care but also lead to catastrophic health expenditure for families. In Zimbabwe, for example, it is reported that 7.6% of households suffered catastrophic health expenditure in 2001 10 and in rural areas people may even ‘pay-inkind’for health services with chickens or goats. Some countries, however, such as Ghana, have introduced a national health insurance scheme with a focus on universal health coverage and community-orientated primary care (COPC). 11 COPC has been defined as a ‘continuous process by which PHC is provided to a defined community on the basis of its assessed health needs, by the planned integration of primary care practice and public health’. 12 Although many countries in Africa use community health workers, not many have fully integrated them into their health services along with a commitment to COPC. Brazil has been lauded as a successful example of COPC, 13 and South Africa is hoping to emulate their model. 14 In the Brazilian model, a PHC team that includes community health workers, nurses and a family doctor is responsible for a designated population and works at the community and household levels with a focus on health promotion and disease prevention, as well as offering facility-based primary care. 13 In many countries …