The COVID-19 pandemic has brought the need for well-functioning primary health care (PHC) into sharp focus. PHC is the best platform for providing basic health interventions (including effective management of non-communicable diseases) and essential public health functions. PHC is widely recognised as a key component of all high-performing health systems and is an essential foundation of universal health coverage. PHC was famously set as a global priority in the 1978 Alma-Ata Declaration. More recently, the 2018 Astana Declaration on PHC made a similar call for universal coverage of basic health care across the life cycle, as well as essential public health functions, community engagement, and a multisectoral approach to health. Yet in most low-income and middle-income countries (LMICs), PHC is not delivering on the promises of these declarations. In many places across the globe, PHC does not meet the needs of the people—including both users and providers—who should be at its centre. Public funding for PHC is insufficient, access to PHC services remains inequitable, and patients often have to pay out of pocket to use them. A vicious cycle has undermined PHC: underfunded services are unreliable, of poor quality, and not accountable to users. Therefore, many people bypass primary health-care facilities to seek out higher-level specialist care. This action deprives PHC of funding, and the lack of resources further exacerbates the problems that have driven patients elsewhere.