Alma-Ata 40th birthday celebrations and the Astana Declaration on Primary Health Care 2018

BACKGROUND

Primary care is positioned by the World Health Organization (WHO) as one important pillar of UHC. The three main principles of UHC are equity of access; ensuring health services are of sufficient quality to improve the health of recipients; and protection of patients from financial-risk resulting from healthcare access. The WHO Global Action Plan to achieve the 2030 Sustainable Development Goals³ promotes alignment of financing and resources; accountability for healthcare delivery; and accelerated progress to collectively bring together resources and expertise.

Alma-Ata 40th anniversary celebrations coincide with the 70th birthday of the NHS. Both have striven to promote PHC delivery which is universal (open to all); comprehensive (patients can present any problem or illness); and free at the point of access. Both celebrations, however, mark an important point in history at which the success and development of PHC might either flourish or perish.

ARTICULATING PRIMARY HEALTH CARE IN 2018

We know from many studies following the work of Barbara Starfield⁴ that effective primary care enables efficient, cost-effective, and high-quality healthcare delivery to those in need. Iona Heath has developed the concept of ‘gatekeeping’ in primary care at two levels, reflecting not only the interface at which a referral is made to another service, but also the process of negotiation and differentiation during patient consultations: navigating with patients between stressful experiences, illness, and medicalised disease.⁵ This highlights the balance required between identifying and treating patients’ biomedical needs, while avoiding overdiagnosis, investigation, and treatment, ultimately prioritising patients’ above commercial needs.⁶ This approach aims to maximise health and wellbeing across global society, rather than aiming to detect and treat all disease. Richard Wilkinson and Kate Pickett⁷ have pioneered examination of the impact of social inequalities on both physical and mental wellbeing across all individuals in society, highlighting the impact of inequality on both rich and poor in relation to the existence of social and economic disparity.

CONTEMPORARY CHALLENGES TO PRIMARY HEALTH CARE

Alma-Ata states that, ‘Primary health care ... reflects and evolves from the economic conditions and sociocultural and political characteristics of the country and its communities ...’. The influence of policy is crucial to consider here in relation to both international and national acceptance and implementation of the Alma-Ata principles and more recent Astana Declaration recommendations.

Astana includes both service and healthcare education priorities. Across both, the importance of collaboration and sharing of expertise and knowledge is emphasised, at both national and international levels. Many countries are, however, currently trying to deliver increasingly compartmentalised (and often privatised) PHC systems, and promoting individualisation rather than collective responsibility for health. In combination with a global rise in nationalism, this provides significant challenges for the effective exchange and delivery of knowledge at local, national, and international levels.

PATIENT PERSPECTIVES AND PARTICIPATION

The Alma-Ata 1978¹ states that the ‘... people have the right and duty to participate individually and collectively in the planning and implementation of their health care’, already hinting at ways in which patient involvement might contribute to research and delivery of care. The more recent Astana² refers to supporting ‘people in acquiring the knowledge, skills and resources needed to maintain their health or health of those for whom they care, guided by health professionals’. This guidance and support is crucial to attend to, in order to ensure that ‘empowerment’ is not about distributed accountability to vulnerable patient groups, but rather authentic shared involvement in the organisation, enquiry, and delivery of health care.

FUTURE HEALTHCARE PROFESSIONALS

While the Astana declaration refers to information rather than personal continuity of care and the use of technologies in surveillance and delivery of care, it does also prioritise capacity building of healthcare professionals. Astana explicitly calls on the international community to minimise the existing ‘international migration’ phenomena. This requires significant work to maximise communication of globally relevant principles of PHC delivery, but also to make visible the variety of ways in which these are adapted and applied in different contexts. Healthcare professional training institutions need to attend not only to the social accountability of each school in relation to their own local patient population, but also the distribution and exchange of knowledge across borders.

Astana calls for a commitment to health ‘across all sectors’, referring to a ‘Health in All Policies’ approach. This has important implications for the design and delivery of PHC service and education, to ensure that relevant knowledge is connected across disciplines, and both work and curricula is designed to enable fluidity across disciplinary boundaries.

CONCLUSION

In summary, the global collaboration of individuals and countries represented within the Astana Declaration, and the reaffirmation of many Alma-Ata principles underpinning international PHC delivery, has to be encouraged as a positive step. However, careful consideration is required to negotiate many of the ideological tensions which exist between ambitions towards comprehensive and equitable PHC, within today’s political and social contexts. Finding ways to maximise patient- and inter-professional connectivity at local, national, and international levels, will help support opportunities for both the development and exchange of knowledge both within service delivery and the development of healthcare professional education.