Not since the Alma-Ata definition of primary care in 1978 has there been so much soul searching on how best to provide a first-contact system that is fair, equitable, accessible, cost effective, sustainable, and above all improves the health and wellbeing of the population it serves. Part of this renewed attention on primary care is the widespread feeling, in high-income countries in particular, that there is an impending crisis with not enough general practitioners, an increasingly unsustainable workload, underfunding by governments, fragmentation between primary and secondary or tertiary services, and a changing burden of disease and risk factor profile in populations. So, how should a primary care system operate in the 21st century? (Editorial)