Towards a sustainable primary healthcare workforce: a meta-narrative review of Denmark and Malawi

Abstract Background With global shortages in primary healthcare (PHC), strengthening the workforce is a priority. However, addressing shortages is complicated by differing views on the composition and governance of the PHC workforce. To better understand what shapes these differences, this review examines the narratives used by stakeholder groups in two contrasting PHC systems - Denmark and Malawi - and how these narratives may influence workforce policies. Methods Following RAMSES guidelines, we conducted a narrative review of 97 documents to map stakeholder groups and workforce narratives in each country. We refined our research questions and reviewed 23 key texts representing divergent perspectives. Findings were synthesized into meta-themes capturing underlying assumptions and tested through peer review and stakeholder interviews. Results Across both countries, a diverse range of stakeholder groups - including public organizations, professional associations, donors, researchers, and civil society - promote distinct and often competing narratives about the PHC workforce. Four meta-themes emerged as key points of contestation: (1) framing of care recipients-as patients, citizens, or consumers; (2) cultural norms about who should provide care; (3) complexity of health governance arrangements; and (4) recognition of the workforce and underpinning power dynamics. Conclusions Differences in views on the PHC workforce reflect deeper assumptions about care, governance, and professional roles across stakeholder groups and countries. Recognizing and addressing these assumptions may support more sustainable PHC policies. Denmark could learn from Malawi's community-driven models, while Malawi might draw on Denmark's experience with long-term workforce planning. However, such policies must be grounded in the specific narratives shaping PHC and its workforce in each country. Key messages • Narratives about who should receive PHC, who should provide it, and how it should be delivered shape differences in how the PHC workforce is viewed across stakeholders and countries. • Recognizing the narratives used by stakeholder groups to understand the PHC workforce is pivotal for addressing workforce shortages and moving towards a sustainable PHC workforce.