The case for accelerating primary health care strengthening on the 40th anniversary of the Alma-Ata Declaration

500 VOLUME 4 | ISSUE 4 | DECEMBER 2018 | 491–735PUBLIC HEALTH PANORAMA EDITORIAL THE ENDURING CASE FOR PRIMARY HEALTH CARE A staggering 80% to 90% of people’s health needs can be provided by adopting a  primary health care approach to services delivery (1). In other words, when optimally designed, organized and managed to deliver a  broad continuum of quality services, primary health care can effectively meet the majority of health needs people encounter throughout their lives. Furthermore, when primary health care becomes the anchor for health systems in communities, it can connect public health, specialized care and social care services in mutually beneficial ways that embody the foundational principles of the 1978 Declaration of Alma-Ata (2). Four decades following the adoption of the Declaration, a primary health care approach can now be found at the core of any well-functioning health system. There is strong evidence that health systems developed around primary health care deliver better health outcomes at a  lower cost, and that they can mitigate the negative impact of poor economic conditions on health (3, 4). Primary health care has also proved to be the best platform for responding to changing health needs, demographics, environmental challenges and emergencies (5, 6). It is this link between primary health care, health system performance and health outcomes that has solidified its importance and continued relevance in this 40th anniversary year of the Declaration. DECADES OF UNPRECEDENTED CHANGE During these 40 years, the countries of the WHO European Region have transitioned through fundamental political, economic and societal changes. This includes, notably, the countries of the former Soviet Union that have undergone large-scale reforms and, in doing so, have endeavoured without exception to introduce a general practice or family medicine model (7). The case for accelerating primary health care strengthening on the 40th anniversary of the Alma-Ata Declaration Juan Tello Head, WHO European Centre for Primary Health Care, Division of Health Systems and Public Health, WHO Regional Office for Europe Erica Barbazza PhD candidate and HealthPros Fellow, Amsterdam University Medical Centre, Department of Public Health, University of Amsterdam, Amsterdam Public Health Research Institute Hans Kluge Director, Division of Health Systems and Public Health, WHO Regional Office for Europe 501 ТОМ 4 | ВЫПУСК 4 | ДЕКАБРЬ 2018 Г. | 491–735ПАНОРАМА ОБЩЕСТВЕННОГО ЗДРАВООХРАНЕНИЯ At the same time, primary health care has been challenged to continuously decode changing health needs, and then to adapt and evolve. Trends demanding attention include population ageing and the growing burden of noncommunicable diseases and multimorbidities, alongside an epidemic of chronicity, persisting inequalities and widening gender gaps. Coupled with the wide-reaching digitalization of society and the remarkable scale of innovation in technology and advances in medicine, the past 40 years are undoubtedly a period of unprecedented change. THE IMPORTANCE OF ACCELERATING In 2018, despite the progress made at keeping up a good pace, our attention has been called to the critical link between primary health care and universal health coverage, and the work still needed to meet the 2030 Sustainable Development Goals. On services delivery, there is growing recognition that poor quality, independent of access, can be a  barrier to universal health coverage (8). Over the course of 2018, a series of flagship reports have put a  spotlight on deficiencies in the quality of health services (9–11). This work has included measuring the gap between the quality of care delivered and the quality of care that could be delivered, based on best available practice. This gap is estimated to contribute to between 5.7 and 8.4 million deaths annually in low- and middle-income countries (11). That is more than all of the deaths combined globally from HIV, tuberculosis and malaria, making poor quality a major source of loss of life and well-being worldwide (11). Earlier studies from the European Region have also revealed similar quality deficiencies. For example, a  series of country case studies on ambulatory care sensitive conditions (ACSCs) – conditions for which hospitalizations are to a  large extent preventable through services delivery based on strong primary health care – revealed that 40% to 80% of hospitalizations for selected ACSCs were avoidable in the countries studied (12). On the path towards universal health coverage, primary health care also has a critical role in extending coverage. In the Region, widening segments of the population are calling for tailored interventions to extend coverage, including: the aged; patients with multiple, chronic care needs; and vulnerable groups, such as the homeless, refugees and migrant workers. Regarding financing, more work is also needed. For example, a  recent study of 25 countries in the Region found that the share of households impoverished or further impoverished due to out-of-pocket payments on health ranges from 0.3% to 8.2% (13). In Europe, medicines are a major driver of financial hardship. They are also an integral part of primary care (13). THE EVIDENCE AND KNOW- HOW TO DO SO Despite these challenges, there is a shared sentiment that efforts to reinvigorate primary health care have never before been more likely to succeed (14). This can be credited in large part to the coupling of political leadership, marked by the endorsement of the Declaration of Astana (15), with a critical mass of evidence and know-how. Over the course of this anniversary year alone, a  record number of scientific journals have dedicated special issues to primary health care and family medicine, from the Lancet (16), BMJ (17) and the Journal of Primary Health Care Research and Development (18), to policy-oriented journals, including the Pan American Journal of Public Health (19) and this edition of Public Health Panorama. In addition to this are the numerous international and national events, blogs and commentaries that have been inspired by the important 40th anniversary. Taken together, it is clear that the current alignment of policy momentum and scientific and practical intelligence is an opportunity that cannot be missed. And with a view to 2030, there is no time to waste. REFERENCES1 1. The Astana Declaration: the future of primary health care? Lancet. 2018;392:1369. 2. Declaration of Alma-Ata. Adopted at the International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 September 1978 (https://www.who.int/publications/ almaata_declaration_en.pdf). 3. From Alma-Ata to Astana: Primary health care – reflecting on the past, transforming for the future Copenhagen: WHO Regional Office for Europe; 2018 (http://www.who.int/ docs/default-source/primary-health-care-conference/phc- regional-report-europe.pdf?sfvrsn=cf2badeb_2). 4. The World Health Report 2008 – Primary health care: now more than ever. Geneva: World Health Organization; 2008. 5. Ghebreyesus TA, Fore H, Birtanov Y, Jakab Z. Primary health care for the 21st century, universal health coverage, and the Sustainable Development Goals. Lancet. 2018;392:1371–2. 1 All references were accessed 4 December 2018. EDITORIAL 502 VOLUME 4 | ISSUE 4 | DECEMBER 2018 | 491–735PUBLIC HEALTH PANORAMA EDITORIAL 6. Balabanova D, Mills A, Conteh L, Akkazieva B, Banteyerga H, Dash U et al. Good health at low cost 25 years on: lessons for the future of health systems strengthening. Lancet. 2013;15:2118–33. 7. Rechel B, Richardson E, McKee M, editors. Trends in health systems in the former Soviet countries. Copenhagen: WHO Regional Office for Europe; 2014. 8. Hanefeld J, Powell-Jackson T, Baladanova D. Understanding and measuring quality of care: dealing with complexity. Bull World Health Organ. 2017;95:368–74. 9. Delivering quality health services: a  global imperative for universal health coverage. Geneva: World Health Organization, Organisation for Economic Co-operation and Development, and the World Bank; 2018 (http://documents. worldbank.org/curated/en/482771530290792652/ pdf/127816-REVISED-quality-joint-publication-July2018- Complete-vignettes-ebook-L.pdf). 10. Kruk M, Gage AD, Arsenault C, Jordan K, Leslie H, Roder- DeWan S et al. High-quality health systems in the Sustainable Development Goals era: time for a  revolution. Lancet Glob Health. 2018;6:e1196–252. 11. National Academies of Sciences, Engineering and Medicine. Crossing the global quality chasm: Improving health care worldwide. Washington (DC): The National Academies Press; 2018. doi: 10.17226/25152. 12. Assessing health services delivery performance with hospitalizations for ambulatory care sensitive conditions. Copenhagen: WHO Regional Office for Europe; 2016 (http:// www.euro.who.int/__data/assets/pdf_file/0010/305875/ Assessing-HSD-performance-with-ACSH.pdf?ua=1). 13. Can people afford to pay for health care? New evidence on financial protection in Europe. Copenhagen: WHO Regional Office for Europe; 2018 (EUR/RC68/11; http://www.euro. who.int/__data/assets/pdf_file/0005/378293/68wd11e_ CanPeopleAffordHealthCare_180443.pdf?ua=1). 14. Kluge H, Kelley E, Barkley S, Theodorakis PN, Yamamoto N, Tsoy A et al. How primary health care can make universal health coverage a reality, ensure healthy lives, and promote wellbeing for all. Lancet. 2018;392:1372–4. 15. Declaration of Astana. Global Conference on Primary Health Care: from Alma-Ata towards universal health coverage and the Sustainable Development Goals. Astana, Kazakhstan, Oct 25–26, 2018. Geneva and New York (NY): World Health Organization and the United Nations Children’s Fund; 2018 (https://www.who.int/docs/default-source/primary-health/ declaration/gcphc-declaration.pdf). 16. James A, Summerskill W, Horton R. Primary care research: a call for papers. Lancet. 2018 17;391:642. 17. Topp SM, Abimbola S. Call for papers  – the Alma Ata Declaration at 40: reflections on primary healthcare in a new era. BMJ Global Health. 2018;3:e000791 (http://gh.bmj. com/content/3/2/e000791.abstract). 18. Primary Health Care Research and Development. Call for papers – 40 years after the Alma-Ata Declaration [website]. Cambridge: Cambridge University Press; 2018 (https://www. cambridge.org/core/journals/primary-health-care-research- and-development/call-for-papers-40-years-after-thealma- ata-declaration). 19. Special issue on primary health care in the Americas: 40 years after Alma-Ata. In: Primary Health Care/Alma-Ata [website]. Washington (DC): Pan American Journal of Public Health; 2018 (https://www.paho.org/journal/index.php?option=com_ content&view=article&id=251:primary-health-care-alma- ata&Itemid=861). n