Critical determinants of the rapid decline in the primary healthcare workforce: empirical insights from economically disadvantaged regions in China

Primary healthcare workforce capacity is essential for high-quality care and universal health coverage, yet workforce shortages and retention difficulties remain widespread. In China, rapid population ageing, increasing chronic disease burden and regional disparities have intensified pressure on the primary healthcare workforce, particularly in regions experiencing persistent economic disadvantage. This study examined the institutional, professional and contextual barriers that exacerbate primary healthcare workforce instability in economically disadvantaged regions of China. Ten focus group discussions were conducted between January and October 2025 with 75 participants from six Chinese provinces experiencing persistent relative economic disadvantage. Participants included frontline primary care providers, managers, educators and researchers, and policymakers or government administrators. Data were analysed using thematic analysis, informed by a health labour market perspective and the WHO framework for rural health workforce retention. Five interrelated barriers were identified: employment insecurity and fragmented workforce management; weak professional training and constrained career development; mismatch between workload, remuneration and recognition; limited infrastructure and team support; and restricted mobility and life-course constraints. These barriers interacted to reduce the attractiveness of primary care posts, weaken recruitment and retention, and limit the service capacity of primary healthcare institutions. Primary healthcare workforce instability in economically disadvantaged regions of China is not simply a numerical shortage, but a product of interacting governance, professional and place-based mechanisms. Policy responses should reduce segmentation between official and contract-based workers, establish primary-care-specific promotion pathways, align remuneration with clinical, public health and coordination responsibilities, strengthen multidisciplinary team capacity, and provide place-based family and mobility support. Future research should evaluate whether such reforms improve workforce stability and primary care service capacity in economically disadvantaged settings.