Building Resilient and Inclusive Primary Health Care Systems to Improve Access and Vaccine Uptake During a Pandemic: A Systems Thinking Analysis Using Group Model Building for Persons with Disabilities

Strengthening the resilience and inclusivity of primary health care (PHC) systems during crises is critical to achieving equitable access to health care in low-income countries. The COVID-19 pandemic exposed significant weaknesses in PHC systems, highlighting gaps in inclusivity and resilience, particularly for persons with disabilities (PWDs). Although studies have examined PWDs, few have applied systems thinking approaches such as Group Model Building (GMB). This study aimed to develop a resilient and inclusive PHC system to improve access to services and vaccine uptake among PWDs during pandemics. A mixed-methods design incorporating GMB was employed in three phases. First, quantitative and qualitative data were collected to identify barriers and facilitators to PHC access and vaccine uptake. Second, a stakeholder GMB workshop was conducted in Monze to map system dynamics and develop causal loop diagrams. Third, validation and refinement meetings were held, including a final workshop in Lusaka. Findings identified key endogenous system drivers influencing vaccine uptake and access to PHC services and consumables, including financing mechanisms, human resources, outreach services, transport, staff commitment, and availability of accessible information such as Braille materials. These interact through reinforcing and balancing feedback mechanisms. In addition, critical contextual (exogenous) drivers such as political will, health insurance, community gatekeepers, and road networks shape system performance and influence access and service delivery. Strengthening both endogenous system drivers and contextual factors through inclusive strategies, coordinated financing, and supportive governance is essential for building resilient PHC systems that improve equitable access and vaccine uptake among PWDs during health crises. These findings contribute to Universal Health Coverage and equity by showing that strengthening both health systems drivers and contextual drivers is essential to ensure inclusive, accessible, and fair delivery of PHC services for all populations, including persons with disabilities.