Imperial researchers have shown that more attention to primary health care could help to tackle some of the world’s biggest challenges.

In 1978, the World Health Organization set out a plan for improving health and well-being around the world.

Its proposal, the Alma Ata declaration, called on governments and international organisations to back primary health care as a platform to improve lives.

Now, forty years on, researchers have revisited the WHO’s proposal, considering how primary care could help to meet the UN’s Sustainable Development Goals – a set of targets aimed at tackling global challenges linked to everything from healthcare and poverty, to climate change and food security.

In a review, published in a special edition of The Lancet this month, Dr Thomas Hone, Research Fellow at Imperial’s School of Public Health, highlights how primary care can help to address much more than health issues.

Here he talks about the need to be clearer about the language we use when talking about health, what still needs to be done, and how putting primary health care at the forefront of global policy will help tackle the world’s biggest problems head-on.

Q - Primary health care is a term that we see commonly used, but what does it actually mean and why is it important?

People often use the terms ‘primary care’ and ‘primary health care’ interchangeably, but they are not the same.

Primary care is one part of primary health care and focuses on the delivery of community-focused frontline healthcare services, such as family doctors or GPs.

However, primary health care embeds health in the bigger picture, including the wider context around improving health. This includes the environment, sanitation, education and other sectors of society, which help promote equity and improve health and empower communities.

When the World Health Organization originally set out its vision for primary health care 40 years ago with its Alma-Ata declaration, it aimed to move away from expensive high-tech solutions that benefit only a few individuals, and move towards broader and more equal approaches that empower people and communities to improve their health and well-being.

Q - You recently looked at what has changed in the last four decades and highlighted the need for putting primary health care first. Why is this particularly relevant now?

We felt there was a need to draw sharper attention to these broader approaches and revisit why they are important within the current global agenda, which is driven by the United Nations’ Sustainable Development Goals – a collection of 17 goals aimed at addressing the global challenges we face today, including issues around poverty, climate and health.

I think the disappointing uptake of the WHO’s Alma Ata declaration was partly caused by confusion over what it actually means.

People assume primary health care is about healthcare services and, when the Alma-Ata declaration was proposed, many felt that GPs and primary care workers would be burdened with achieving these huge social goals.

However, this isn’t what was meant. Primary health care does aim to orientate health systems towards primary care services, but bigger changes need to be brought about through political, institutional and other channels as well.  

We hoped some academic thought and clarity could help to clear up the confusion, so people could see the true value that a primary health care approach could bring and so international policy makers could once again embrace the concept.

Q - How does your recent work help to clarify things?

Rather than focus on Alma-Ata we decided it would be better to see how primary health care fitted with a more recent and relevant concept – the UN’s Sustainable Development Goals (SDGs), which were set out in 2015 and now steer the global health and development agendas.

In our recent paper in The Lancet we reviewed academic publications and major reports from organisations such as WHO, the UN, and the World Bank to analyse how a primary health care approach can help achieve each of the 17 SDGs.

Firstly, we looked at the possible contribution of developing stronger primary care services in health systems, for example increasing access to GPs, opening new clinics, or shifting care out of hospitals.  We then analysed how a more comprehensive ‘deeper’ primary health care approach could help achieve the SDGs. 

As one of the goals is specifically focussed on health and wellbeing we analysed this in more depth, breaking it down into its component targets.

Q - And what does your research tell us?

We showed that a primary health care approach can make major contributions to achieving the targets associated with goals for health and wellbeing (SDG3) and that this happened both at the level of primary care provision and at the level of a more broad primary health care approach.

For example, in terms of combatting infectious diseases such as HIV, tuberculosis and malaria, there are many primary care actions that can help to reduce their burden such as antiretroviral therapies, prophylactic medicines, treatment, and education about risks and protection.

However, a broader more comprehensive primary health care approach that includes action on the wider social elements of health and community participation can tackle the underlying determinants of these infectious diseases, such as housing quality, sanitation, and controlling how the diseases spread.

We also showed how a primary health care approach can contribute to achieving the other sustainable development goals. For example, a primary care level approach can contribute to achieving the goal of ‘zero hunger’ through nutrition interventions, education, and growth monitoring. However, a wider primary health care approach would contribute substantially more to reducing hunger by calling for action within agriculture and the food industry to produce sustainable food systems and more equitable distribution of production and consumption. 

Q - Are there any messages for policy makers to take away from the paper?

Firstly, I think we need to stress that primary health care is not just about primary care services but is a much wider package that encompasses many other sectors of policy. This is related to the wider debate on Universal Health Coverage (UHC) and it is important to ensure the discussion does not purely focus on services and access as a way of improving health.

Secondly, we should engage with and resource these ‘deeper’ reforms around equity and the right to access good health that a primary health care approach would require.

And lastly, there is a real need to develop community engagement and involvement in order to make these approaches work and to do this we must foster accountability and trust in our political institutions.

Dr Hone will be presenting at the Global Conference on Primary Health Care (25 – 26 October 2018), which will mark the fortieth anniversary of the Alma-Ata Declaration.

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‘Revisiting Alma-Ata: what is the role of primary health care in achieving the Sustainable Development Goals?’ Hone, T., Macinko, J. & Millet, C. is published in The Lancet. DOI: 10.1016/S0140-6736(18)31829-4