Influence of contextual factors on strengthening key strategic and operational levers of primary healthcare to achieve universal health coverage: a protocol for a realist review

INTRODUCTION: Existing scoping reviews on the link between primary healthcare (PHC) and universal health coverage (UHC) have not sufficiently addressed the underlying causal mechanisms in which key strategic and operational PHC levers contribute to improved health system and realisation of UHC. This realist review aims to examine how key PHC levers work (independently and holistically) to achieve an improved health system and UHC, and the conditions and caveats that influence the outcome. METHODS AND ANALYSIS: We will employ a four-step realist evaluation approach: (1) define the review scope and develop initial programme theory, (2) database search, (3) data extraction and appraisal, (4) synthesis of evidence. Electronic databases (PubMed/MEDLINE, Embase, CINAHL, SCOPUS, PsycINFO, Cochrane Library and Google Scholar) and grey literature will be searched to identify initial programme theories underlying the key strategic and operational levers of PHC and empirical evidence to test these matrices of programme theories. Evidence from each document will be abstracted, appraised and synthesised through a process of reasoning using a realistic logic of analysis (ie, theoretical, or conceptual frameworks). The extracted data will then be analysed using a realist context–mechanism–outcome configuration, including what caused an outcome, through which mechanism, and under which context. ETHICS AND DISSEMINATION: Given the studies are scoping reviews of published articles, ethics approval is not required. Key dissemination strategies will include academic papers, policy briefs and conference presentations. By capturing the relationship between sociopolitical, cultural and economic contexts and the pathways in which PHC levers interact with each other and the broader health system, findings from this review will facilitate the design and development of evidence-based, context-sensitive strategies that will enhance effective and sustainable PHC implementation strategies.