Understanding primary health care

The PHC approach is regarded as the most inclusive, effective, and efficient way to enhance people’s physical and mental health over their lifetime, as well as their social well-being. Organizing services through the PHC prism can improve the level and distribution of health and well-being among populations.

Primary care can be understood in terms of the core functions it is expected to fulfill: first-contact accessibility, comprehensiveness, continuity, and coordination for person-centred services. Investing in strong primary care in every community and country is both a moral and a strategic imperative.

In calm times, health systems built on the tenets of the PHC approach are well-positioned to comprehensively address the day-to-day needs of people and communities, supporting the goals of universal health coverage (UHC) and the Sustainable Development Goals (SDGs). In times of crisis, health systems built on these principles can respond more resiliently. 

The landmark 1978 Declaration of Alma-Ata affirmed health as a fundamental human right and put social justice at the heart of public health policy for the first time. World leaders made a historic commitment to the PHC approach, marking a major milestone towards achieving the goal of “Health for All”. The 2018 Astana Declaration renewed this commitment, recognizing its continued relevance for the health and well-being of populations.

At the Global Conference on Primary Health Care on 23 October 2023 in Astana, Kazakhstan, policy-makers, advocates, health-care professionals and providers, patients and people that are committed to a healthier world will launch a renewed movement for PHC in the 21st century.

Countries have made remarkable progress towards improving the health and well-being of their populations since 1978, thanks to increased investment in their health systems, continuous research and innovation, and the tireless efforts of health-care professionals. 

Major achievements encompass the eradication of smallpox, almost complete eradication of polio, reduced burden of the HIV/AIDS epidemic, and drastic improvements in maternal survival rates and the ability of families to raise their children in good health.

The interrelated commitments to the PHC approach, UHC, and the SDGs forge a bold new consensus that everyone, everywhere, should have access to quality health services without financial hardship.

The challenges impeding progress towards adopting the PHC approach stem from inadequate investments in health systems, specifically the neglect and underfunding of robust primary care and public health services. Unfortunately, primary care often receives insufficient attention and resources within national health systems, disproportionately affecting the poorest and most marginalized communities. As a result, primary care remains inaccessible, unaffordable, fragmented, and ill-suited to local needs in many cases, or even non-existent.

Further pressures come from escalating health-care costs that arise from factors, such as population ageing, and also from the impacts of urbanization and shifting lifestyles, mounting inequalities and the growing prevalence of noncommunicable diseases, along with advancements in medical technologies that prolong the lives of people afflicted by these conditions. 

New conflicts, migration crises, and the ongoing COVID-19 pandemic have placed even greater demands on health systems in recent years. These unforeseen circumstances have also highlighted the importance of strong and resilient primary care systems and the broader PHC approach in responding to health crises.

Many countries in the WHO European Region have been successful in translating their commitment to the PHC approach into national strategies and concrete policies, often in innovative ways. Some country examples include the following.

• Türkiye established migrant health centres in areas heavily populated by Syrian refugees to provide effective and efficient preventive care and essential health care services, remove language and cultural barriers to access, and improve the overall accessibility of services.
• In 2013, Georgia introduced a national UHC programme that aims to protect citizens from catastrophic health expenditures and gives all citizens access to a basic benefits package. As a result, the utilization of outpatient services has increased and out-of-pocket payments have declined, thereby improving financial protection.
• Kazakhstan introduced a PHC model of care based on multidisciplinary teams that include not only family doctors and nurses with an expanded scope of practice, but also psychologists and social workers. This allowed the transition from a biomedical and doctor-centred PHC service delivery approach towards a more holistic, biopsychosocial one.
• Azerbaijan applied a participatory approach to assess its rural health system, involving a diverse group of PHC workers and community representatives. This approach was instrumental in improving understanding of the social determinants of health, health priorities, and changes needed to the PHC model.
• The Health Service Executive in Ireland adapted its structures to implement interventions critical to employee safety, health, and well-being, in order to build working environments in which health-care workers felt mentally safe during the COVID-19 pandemic.
• North Macedonia introduced a refreshed PHC model, which expands the roles of PHC physicians and nurses, and implemented a national eHealth system to improve the accessibility and quality of care.
• The Russian Federation’s new outpatient clinic model, driven by lean management methods, has improved the efficiency of its health-care services. The new model of care sets out actions for 9 areas, enabling better PHC responsiveness for patients and improved conditions for health-care workers.
• Slovenia’s contextualized community-based approach is instrumental to a prompt and structured response to the needs of vulnerable and marginalized populations during emergencies.
• 3 regions of Spain – Catalonia, Castile & Leon, and Asturias – reconfigured their multidisciplinary primary care teams and broke down professional silos to provide effective emergency response while maintaining a dual-track response to non-COVID-19 patients.
• With a patient-centred focus, Sweden transformed its health-care policy and practice by capitalizing on the potential of telemedicine services alongside traditional face-to-face service delivery. The new approach addressed resource constraints in the publicly funded health-care system, better meeting the health needs of ageing populations in rural and sparsely populated areas.

The 1978 Declaration of Alma-Ata launched a revolutionary movement, but one that has not yet fulfilled its promise. The 2018 Declaration of Astana built a foundation for action, advocacy, and accountability on the journey toward health for all, defining 3 components of the PHC approach. These were later translated into 4 core strategic and 10 operational levers, with a monitoring framework put in place to help countries to evaluate progress.

Now is the time to take stock of progress and demonstrate concrete results. Governments must make bold policy choices and investments to make progress towards the PHC approach, addressing the underlying determinants of health and putting equity at the heart of all policies.

Communities should actively participate in decisions on their health and health care and hold decision-makers accountable for delivering results. Health professionals must advance quality, safe, comprehensive, people-centred, and equitable primary care that is core to integrated services for all people across the life course.

Global health and development partners and donors should support and align with local and national policies and strategies to strengthen the PHC approach, and the delivery of primary care as a core component of this approach.