A renewed focus on primary health care: reflections from Astana

PCI’s Jonathan Winter (CEO) and Adam Sandell, (Clinical Advisor), recently attended the Global Conference on Primary Health Care 2018 in Astana, Kazakhstan. Here, Jonathan and Adam reflect on the conference and the key points emerging from it for the PCI team.

This conference marked the fortieth anniversary of the Alma Ata Declaration, a milestone of the twentieth century in the field of public health, which identified primary health care as the key to attainment of the goal of ‘Health for All’.

“Do you have roses like this in (your country)?” asked Jonathan, stooping to look more closely at the flower arrangement next to the podium. It was an unusual question to open a conversation with a minister of health, but it fitted a quiet moment. “Flowers are important” she said. “Put them in a clinic or hospital and it makes a real difference”.

The conversation was symbolic of this historic conference that set out a better-integrated vision of Health for All, calling on countries to ‘prioritise essential public health functions’ of Primary Health Care and to promote multisectoral action. ‘We can no longer underemphasize the crucial importance of health promotion and disease prevention’.

Integration, working across sectors, and working in multi-disciplinary teams became recurring themes in this event that was both celebrating and updating the Declaration of 1978 in the city of Alma Ata.

This focus on collaboration included: multidisciplinary teams involving greater responsibility for nurses and community health workers; collaboration within health, especially between health and social care; and synergies and collaboration beyond health, especially needed to address the social determinants of health.

There was a sense of a growing acceptance of, and belief in, the importance of primary care and in particular primary care for NCDs — and that more investment is needed in primary care globally in order to achieve the SDG goals for 2030. There was confidence expressed that primary care is on a strongly upward trajectory in the global health economy, towards the goal of UHC.

The point was made repeatedly that that investing more in primary care saves money, gets more and better healthcare for the money, and helps secondary care too (partly by reducing the demand for it). There was also a widespread view that investment in primary care leads to, and is necessary for, economic growth. Ministers were called upon both to convince their finance ministries to invest more in health, and to shift spend from secondary to primary care.

Mental health, palliative care and cancer came up repeatedly as vital areas within NCD primary care – subjects that PCI is progressively including in its standard NCD package. However it was also clear that NCDs have not yet become a priority for some key actors. There is still work to be done in communicating the evidence and demonstrating impact from effective primary care interventions.

The role of the private sector was also acknowledged. In a workshop we attended academics presented valuable insights into the role of the private sector in achieving Universal Health Coverage (in short: it’s best to engage vigorously with the private sector – it delivers 50% of healthcare worldwide).

We were involved in several discussions about how to measure the results of investment in primary health care, something we have been working towards at PCI. Most people were of the view that it’s difficult. The conference included the launch of the PHCPI ‘vital signs’ dashboard of indicators at country level, to drive improvements.

As the conference closed, we were inspired by the positive energy of the event. A few things puzzled us however. Near the top of the list was the fact that we had just witnessed an historic and confident re-statement of the importance of primary care, yet there didn’t seem universal agreement on what primary care is. Practical questions were left unanswered. How can aspirational public health goals be combined with delivering essential clinical services? There were hints (about cross-sector collaboration) but fewer examples.

Astana is a city only 20 years old, built from scratch on the left bank of the Ishim river. The president moved the capital from Almaty in 2008 and the result is impressive – the palace, parliament, government buildings and works of art carry messages of power, unity and peace. You can view them from the Beyterek tower. At the top you find the president’s handprint, impressed in a gold bar. You can put your hand in it and make a wish.

At times, the conference itself seemed like an exercise in wishing too. Progress since the original Alma Ata declaration in 1978 has been significant but patchy. The aspiration of ‘Health for All by 2000’ was obviously not achieved. It was not clear how a renewed declaration would make a difference. But as the meeting progressed, the high level and often genuine passion of speakers conveyed something beyond the words; it conveyed a sense of real belief in the value of Primary Health Care. We hope that this means real action beyond the conference and we can all contribute to making a difference each and every day to the health and well-being of individuals, families, communities and nations.