Revitalizing primary health care for the 21st century
The Global Conference on Primary Health Care, which took place in Astana, Kazakhstan, on 25–26 October 2018, brought together 1 200 delegates from more than 120 countries to recommit to strengthening primary health care. The event began with Dr Hans Kluge, Director of the Division of Health Systems and Public Health at WHO/Europe, welcoming delegates to Astana.
The opening plenary paid tribute to the revolutionary Declaration of Alma-Ata from 1978, which was the first to underline the importance of primary health care and put health equity on the international agenda. In her address, Dr Zsuzsanna Jakab, WHO Regional Director for Europe, reminded the audience of how the Declaration continues to provide direction to our work today. She underlined to the global leaders gathered that “it is our responsibility to ignite a new era of primary health care – one that accelerates implementation and collective action to realize a primary health care approach once and for all.”
Erbolat Dossaev, Deputy Prime Minister of Kazakhstan, emphasized in his plenary address that investing in primary health care is as important today as it was 40 years ago. Prevention and early detection of a disease in primary health care is more cost-effective than the treatment of a disease in hospital, he said.
European Region leading the way in primary health care innovation
The opening session was followed by a panel discussion with participants from the 6 WHO regions, representing government, civil society, youth and intergovernmental bodies to ensure inclusivity in discussions.
In his remarks, panellist Rifat Atun, Professor of Global Health Systems at Harvard University encapsulated the messages from the report “From Alma-Ata to Astana: Primary health care – reflecting on the past, transforming for the future”, developed by WHO/Europe as background documentation for the Conference. Professor Atun explained that Europe has been leading the way in innovation in primary health care because the region has invested in people, partnerships, platforms and political will.
Also, in the session, Yana Panfilova, from Ukraine, spoke on behalf of adolescents living with HIV, about their needs related to access to health services and people-centred care. Yana is the founder of Teenergizer, an organization of adolescents and youth with and without HIV that also offers peer-to-peer trainings.
Adoption of the Declaration of Astana
A high-level ministerial plenary explored the whole-of-government approach to advancing primary health care. The session, moderated by Minister of Health of Kazakhstan, Dr Yelzhan Birtanov, included Prime Minister of Kazakhstan, Bakytzhan Sagintayev; WHO Director General, Dr Tedros Ghebreyesus; United Nations Children’s Fund (UNICEF) Executive Director, Henrietta Fore; Prime Minister of Samoa, Tuilaepa Aiono Sailele Malielegaoi; Deputy Prime Minister of Nepal, Upendra Yadav; and European Commissioner for Health and Food Safety, Dr Vytenis Andriukaitis.
The plenary looked at lessons learned over the past 40 years and sought to create a movement, with the Declaration of Astana as a starting point, for the strengthening of primary health care as the foundation of universal health coverage and to achieve the Sustainable Development Goals.
The Declaration of Astana was then adopted unanimously by Member States. It makes pledges in 4 key areas:
- make bold political choices for health across all sectors;
- build sustainable primary health care;
- empower individuals and communities;
- align stakeholder support to national policies, strategies and plans.
“Today, instead of health for all, we have health for some,” said Dr Ghebreyesus. “We all have a solemn responsibility to ensure that today’s declaration on primary health care enables every person, everywhere to exercise their fundamental right to health.”
Integrating primary health care-based service delivery
A ministerial parallel session, organized by the WHO European Centre for Primary Health Care, explored how primary health care can effectively integrate the delivery of health services to ensure that populations receive the right care, at the right time, in the right place, in accordance with their needs and local context.
In the session, the Minister of Health of Lithuania, Aurelijus Veryga, spoke of the new system of incentives in the country. Mirella Minkman, Professor of Innovation, TIAS School for Business and Society, the Netherlands, stressed the importance of rethinking and reorganizing the system to put the person at the centre, with primary health care teams around them, creating professional networks of care.
Eric de Roodenbeke, Chief Executive Officer, International Hospital Federation, Switzerland, spoke of the need to re-assign the image of hospitals as a place of population health and as a place that supports a primary health care approach.
Primary health care for the health of migrants – the economic argument
This side event, co-organized by WHO/Europe and the International Organization for Migration, provided an opportunity to share evidence and country experiences that addressed the socioeconomic aspect of improving migrant access to health services. Governments in many regions have acknowledged the need to address the health needs and vulnerabilities of refugees and migrants to enhance health equity and security. Excluding migrants from health services not only results in health risks for the individual and violations of migrants’ rights, it also puts at-risk the broader attainment of public health objectives. Participants at the event underlined that primary health care is the minimum package of services that should be made available for all refugees and migrants.
The joint press conference was well attended by both national and international print reporters, wire services and broadcasters based in Kazakhstan. The speakers – Dr Yelzhan Birtanov, Dr Tedros Ghebreyesus, Dr Zsuzsanna Jakab and Henrietta Fore – announced to the press the signing of the Declaration of Astana and welcomed the commitment by all parties to primary health care as the foundation of strong health systems and universal health coverage. The event generated good media coverage and reached beyond the host country.
Making the economic case for primary health care
Building a business case for increased investment in primary health care, through increased and effective dialogue with finance ministries, was the theme of the opening plenary on the second day of the Conference. In opening remarks, Dr Hans Kluge highlighted 4 key points that should interest finance ministries:
- In low, middle and high-income countries, health systems organized with a primary health care approach have been shown to improve overall population health, which in turn has macroeconomic benefits.
- Increased access to primary care services and continuity of care are associated with reductions in avoidable hospitalizations, hospital readmissions and health-care costs.
- Multimorbidity is a challenge in all countries and primary health care is the best line of defence against its rise.
- Primary health care offers a platform for many highly cost-effective preventive services.
In the same session, Søren Brostrøm, Director General of the Danish Health Authority, noted that in Denmark, the total annual health-care spending is €27.5 billion, most of which comes from public funding. Arguing for more public spending is not viable, he emphasized, and therefore the argument must be for better spending. Brostrøm shared 3 arguments to use when negotiating with ministries of finance for investing in primary health care:
- Getting more health care for the money: hospital services will always be more expensive than similar services provided outside.
- Better health care for the money: hospitals are meant for treating people who need specialized treatment, and may over-diagnose and over-treat. Community care is a much better investment, particularly when it comes to noncommunicable diseases and mental health.
- Shifting services outside of hospitals, into primary health care can help hospitals work better: hospitals should be geared towards higher specialized services. If people go to hospitals with common conditions that can be safely and effectively treated in primary health care, hospitals will be unable to develop and update their competencies to treat complex cases.
Mental health in primary health care: illusion or inclusion?
Despite evidence around the need and mechanisms for including mental health as a core element of primary health care, it remains a largely unrealized goal in the majority of countries, contributing to the current treatment gap for people with mental disorders and psychosocial disabilities. Speakers at this session included 2 Kazakh youth with lived experience of mental health challenges, and national perspectives from Chile, Sri Lanka, Bosnia and Herzegovina, and Kazakhstan, as well as perspectives from international nongovernmental organizations on mental health and disability. Participants reflected on successes with (and barriers to) integrating mental health into primary health care, identifying critical levers for appropriate and scaled-up integration, and highlighted innovative practices that can enhance system design and service delivery in the future.
In the closing session, the Deputy Mayor for Health of the city of Rennes, Charlotte Marchandise, presented the Almaty Acclamation of Mayors and expressed the commitment of the WHO European Healthy Cities Network to the Declaration of Astana. “When it comes to health, we need local governments. We must help people who live, work, love and play in our cities to live a healthy life,” she said.
Dr Zsuzsanna Jakab also spoke at the closing, saying, “The Declaration of Astana is a call to step up action, which should empower us to make primary health care a reality in all our countries. Our shared goal to pursue universal health coverage depends on our commitment and ability to put this Declaration into practice”.
Special issue of the Lancet puts primary health care in focus
The Lancet published a special issue devoted to primary health care, which launched at an event held on the second day of the Conference in Astana. The special issue features a commentary on primary health care for the 21st century, co-written by Dr Tedros Ghebreyesus, Dr Zsuzsanna Jakab, Henrietta Fore and Dr Yelzhan Birtanov.
They write: “Strong primary health care, rooted in community participation and action, is the foundation of every health system, and no country can achieve health for all without it”. The special issue also includes commentaries from WHO authors that examine how primary health care can make universal health coverage a reality and the importance of placing nursing and midwifery at the heart of the Alma-Ata vision. The full issue can be viewed via the link below.
Preconference events in Almaty, Kazakhstan
Scientific conference: crossroad of policy, research, education and practice in primary health care
Two days prior to the Global Conference on Primary Health Care, health professionals, researchers, managers and experts from across the European Region gathered in Almaty to explore the multiple facets of primary health care. This scientific conference took stock of achievements during the 4 decades since the Declaration of Alma-Ata and explored connections between policies, research and education in primary health care in order to improve clinical practice, quality of care and overall health outcomes.
WHO European Healthy Cities Network Summit of Mayors
Mayors and city political leaders gathered in Almaty on 23–24 October to discuss the role of cities in taking forward the legacy of the Declaration of Alma-Ata, including primary health care and universal health coverage. Acknowledging that the Declaration of Alma-Ata was a key factor in the foundation of WHO Healthy Cities 30 years ago, Dr Zsuzsanna Jakab said: “Healthy cities and primary health care are inextricably linked. Your work as healthy cities to strengthen health literacy and strive to create empowered and resilient communities that encourage increased individual and community ownership and responsibility for their health and well-being is essential for primary health care”. The Almaty Acclamation of Mayors, articulating strong political commitment to ensure that healthy cities are best placed to support primary health care, was adopted at the Summit.