The Workshop on Universal Health Coverage Partnership and Primary Care and the International Conference on Primary Health Care Policy and Practice were held on 22 and 23 October 2023, respectively. Both jointly organised by the World Health Organization (WHO), United Nations Children's Fund and the Government of Kazakhstan, they were held to celebrate the 45th anniversary of the 1978 Alma Ata declaration and the fifth anniversary of the 2018 Astana declaration. In this article, I will share three key insights I had as a participant in both events.
45 years of PHC development
Primary health care (PHC) as a term was not in widespread use in the mid – 20th century. The 1978 Declaration of Alma Ata states that "PHC is essential health care" and an "integral part both of the country's health system... and of the overall social and economic development of the community".1
It is easy to forget the progress made in the field of PHC when we are focused on the challenges of tomorrow and the limitations of today. The 2018 Global Conference on Primary Health Care held in Astana, Kazakhstan provided a useful platform to take stock of the remarkable achievements of the preceding 40 years, and it reaffirmed the importance and need to continue investing in reorienting health systems towards strengthening PHC. The statements made by the heads of state and government at the conference came to be known as the Declaration of Astana.2
The effects and impact of such global meetings and conferences may not be immediately felt by practitioners and patients. Nevertheless, the power of convening to provide leadership on global health matters, shaping the health research agenda, and setting normative standards is crucial in influencing and guiding countries and states to place PHC as a key priority on their long list of development agendas.3 Policy developments such as these have a long lag time before showing their effects – a quick search on PubMed for the term "primary health care" shows that the number of publications in the field barely rose the years preceding 1978, and only visibly rose about 15 years after 1978.
PHC is well placed to manage complex care
During the two days of high-level discussions on PHC, health sector leaders and experts helped unpack the history of PHC developments over the past half-century, and they uncovered an insightful discovery. The growth and development of hospital care and specialist care in the post-war developments of the 20th century greatly advanced the field of medicine and surgery, and had a powerful impact on the lives of people around the world. Hospitals became an important place and nidus for the health system to manage complicated care and complex care. This had the unfortunate effect of eclipsing the strengths of PHC in managing the health needs of people with both simple and complex care. The workload of managing complex care shifted away from primary care and became sited in hospitals, even though hospitals are expensive places to manage complex care.
There is now recognition and acknowledgement of this phenomenon and a renaissance to correctly site complex care with the PHC sector. This involves re-prioritisation and committed investment into PHC. Apart from the economic argument in favour of siting complex care with PHC, there is also the matter of trust. A robust PHC system leads to an enhanced provider-patient relationship, thus engendering trust, leading to better health outcomes.
Continued measures of our investments in PHC
The workshop and conference provided insightful conversations by world leaders and experts, making the case that health systems around the world need to be better structured to develop policy and dedicated resourcing plans for PHC. Leading by example, the WHO established the Special Programme on Primary Health Care in 2020,4 following the Global Conference on Primary Health Care in 2018 and the United Nations high-level meeting on universal health coverage in 2019.5
One good practice discussed is the dedicated measurement and monitoring of inputs and investments in PHC. The quote by Peter Drucker that "what gets measured gets improved" is instructive, but as sociologist William Bruce Cameron says, ""Not everything that counts can be counted, and not everything that can be counted counts"; we thus acknowledge that the returns of investments into PHC are hard to measure. An overly narrow view of measuring outcomes to guide future resourcing and investments may in fact have dysfunctional consequences,6 though progress has been made by developing the PHC measurement framework and indicators.7
Another feature of the complexity of health ecosystems is that a healthy population contributes to the overall social and economic development of the community – meaning that the benefits of a strong health system accrue in the form of human, social and economic capital, and the returns on investments manifest in other sectors. This is similar to investment in education as a public good, where such investments increase productivity and economic growth.
As not everything in PHC that matters can be measured, and not everything that we currently measure matters, policymakers and health sector planners will need to be strategic in measuring the levers that will help to maintain and accelerate progress towards PHC and universal health coverage.
Strengthening PHC
The secret sauce to a strong and efficient PHC sector and system is in its service delivery design and models of care, along with the financing arrangement around them. Simply put, this is akin to the engine, or the code of the system. Many health systems around the world are running on "old technology". Imagine driving a 20-year-old car or using a washing machine that is more than ten years old – it works, but it is no longer considered efficient because new technology has been developed. What are the features of the new "technology" and approach for PHC?
Firstly, the connectedness with and of the overall health system. Care that is integrated and people-centred, with clear connections, pathways, and transfer and referral protocols between care providers in the system, means a stronger and more effective primary care system.8 The connections here are not just with the hospitals, but also with the community care and social care providers. Such a system places strong emphasis on multidisciplinary team-based care, with strong alignment of purpose and values. Digital health technology can help with connectedness and integration, but it is important to let the care model drive the technology and not the converse.
Secondly, enabling features of empanelment and a way to establish a formal relationship between the person, the community and the provider, so that there is accountability around the health outcomes of individuals. Their work is to keep people healthy, rather than only treating the sick.
Lastly, if we want a health system and health services that are proactive rather than reactive – comprehensive and continuous rather than episodic and disease-specific – we need to anchor them based on sustainable person-provider relationships instead of incidental, episodic and provider-led care. Relationship-based care will help mitigate the undesirable fragmentation that many health systems experience due to over-medicalisation and siloed specialised care, as well as lay the foundation for stronger continuity of care.