The Astana Declaration: the future of primary health care?

The Lancet
Oct 20, 2018 Volume 392 Number 10156 p1369-1486  e12

The Astana Declaration: the future of primary health care?

The Lancet
Primary health care is in crisis. It is underdeveloped in many countries, underfunded in others, and facing a severe workforce recruitment and retention challenge. Half the world’s population has no access to the most essential health services. Yet 80–90% of people’s health needs across their lifetime can be provided within a primary health-care framework—from maternity care and disease prevention through vaccination, to management of chronic conditions and palliative care. As populations age, and multimorbidity becomes the norm, the role of primary health-care workers becomes ever more important.

In 1978, the Declaration of Alma-Ata was ground-breaking in uniting health leaders behind the importance of primary health care as key to delivering better health for all, and to the value of social justice, health equity, and the social determinants of health. But 40 years later, this vision has not been realised. Instead, the focus has been on individual diseases with variable results. Now the Sustainable Development Goals provide new impetus to reach universal health coverage via strengthened primary health care.

This week, on Oct 25 and 26, the Global Conference on Primary Health Care will be co-hosted by the Government of Kazakhstan, WHO, and UNICEF. 1200 leaders (including heads of state; ministers of health, finance, education, and social welfare; non-governmental organisations; researchers; health practitioners; and youth leaders) will meet in Astana, Kazakhstan, to endorse the Astana Declaration. The aim is to renew political commitment from member states and global organisations to developing people-centred primary health care, building on the principles of the Alma-Ata Declaration.

A renaissance in primary health care is essential to provide health for all, including the most vulnerable. An example is Pakistan, where the provision of universal primary health care is likely to be the only route to address the country’s abysmal health indicators. Include, invest, innovate—the themes of the Tallinn Charter in 2018—put primary health care at the heart of sustainable health systems.

Investing in primary health care through four delivery platforms (community-based care, health centres, first-level hospitals, and population-based interventions) is one of the messages from the Lancet Commission on Investing in Health. The Commission’s proposed package of primary health-care interventions provides a blueprint for what should be available in each of the platforms. In Ethiopia, a diagonal investment approach has led to strengthened primary health-care capacity and improved health status. The Lancet Commission on Primary Health Care in China, which will be presented in Astana and Beijing, outlines many opportunities for the Chinese government, such as integrating primary health-care and public health services.

The health workforce is a key contributor to the performance and sustainability of health systems—no more so than in primary health care. The World Organization of Family Doctors (WONCA) has strengthened efforts to train doctors in developing countries, but there has been insufficient investment in primary health-care staff in the past 30 years. Interprofessional teams focusing on the needs of the patient are one important way of introducing innovation. Teams in which nurses provide much of the care, including health promotion and the management of non-communicable diseases, is one possible model.

Recruitment and retention of community health workers, nurses, and doctors must improve in most regions of the world. Making primary health care a more attractive working environment is crucial to recruit and retain the best staff. Evidence presented at the European Health Forum Gastein, Austria, on Oct 3–5, documented the need for new curricula, multiprofessional settings, and more organisational support. In most European countries, there is a shortage of general practitioners (family doctors), especially in rural areas. General practice is often seen as low status, with low prestige for doctors, linked with a high administrative workload and lack of peer support. Despite some innovation, such as new roles for nurses and pharmacists in primary care, there is a need to offer more professional development and more infrastructure support, including technological innovations. Primary care clerkships, and exposing students to working in rural areas, can help to recruit into the most remote areas.

The joy depicted in the photographs in this issue illustrates just some aspects of primary health care at its best. The Astana Declaration marks the beginning of a better future for primary health care. Leadership after the Astana meeting is essential to rejuvenate and revitalise all aspects of primary health care.