"The attainment of the highest possible level of health is a most important worldwide social goal. … Primary health care is the key to attaining this target."
-- Declaration of Alma Ata, 1978
Cynthia Haq, M.D.
Commemorating the 40th anniversary of the signing of the Declaration of Alma-Ata,(www.who.int) the United States and 193 other members of the United Nations gathered in Astana, Kazakhstan, this week(www.who.int) to review progress and challenges and renew their commitments to the never-ending quest to provide primary care for 7.5 billion people.
What led to this watershed declaration? What were the key elements? Why should this matter to U.S. family physicians and the patients and communities they serve?
The Evolution of Primary Care
In 1978, a historic international meeting to define and promote primary care was held in Alma-Ata (known today as Almaty) in the former Soviet Union. The meeting, which was sponsored by the World Health Organization (WHO) and the United Nations Children's Fund, resulted in a declaration that was signed by 134 member nations.
International organizations and most world governments already had affirmed access to basic medical care as a fundamental human right as early as 1948. Subsequently, countries began experimenting with methods and components of services to improve the health of populations. Health was recognized as both a prerequisite for economic growth and an outcome of development. Small-scale pilot programs began to accumulate evidence about what worked and what might be considered essential health care services. The Alma Ata Declaration was the culmination of decades of work.(www.who.int)
The Declaration defined primary care as both a level of service and a philosophy of care. Essential features included first-contact, personal, continuous, comprehensive, coordinated care for acute, chronic, preventive and community-oriented health issues. Primary care was considered the hub of the health system, with services to be equitably distributed according to the needs of the population in a manner that was scientifically sound, cost-effective, culturally acceptable, affordable and accountable.
Sound familiar? It should; these are also the key principles of family medicine.
The Declaration inspired nations, organizations and thousands of individuals -- including me -- to contribute to the goal of achieving health for all by the year 2000. This vision inspired me to pursue medical school and family medicine residency, as well as to work where I perceived the needs were greatest.
My husband, three children and I moved to rural Uganda for my first job in 1986. The country was recovering from a protracted civil war, the economy and infrastructure had collapsed, and one out of three children died before the age of 5, mostly from preventable causes. My job was to train village health workers to improve child survival. I was full of hope, loaded with tropical disease textbooks, and supported by a grant from the U.S. Agency for International Development. Within a few years, Uganda renewed its efforts to promote primary care services and reduced under-5 child mortality by more than 50 percent. The immense rewards of this work fueled my desire to develop family medicine training programs in rural and urban areas of the United States and low-income countries, and to work with the WHO and Wonca (the World Organization of Family Doctors) to promote primary care.
Progress and Challenges
Globally, average human life expectancy has more than doubled during the past century,(ourworldindata.org) more than in any other period in recorded history.
Additionally, the quality of human life has improved dramatically, with more people living better and longer. Improvements in living conditions, public health practices and primary care measures such as immunization and treatment of common conditions have saved millions of lives.
But this astounding progress in human health is unequally distributed, both within and between countries. For example, life expectancy is 56 years in Somalia, compared to 84 in Japan, because the conditions that promote health and prevent disease are unevenly distributed.
Most high-income countries, some middle-income countries and a few low-income countries have been able to implement primary care. Yet more than half of the world's population -- more than 3 billion people -- still lack access.
In the United States, millions still lack access to primary care. More than half our counties and large populations within urban communities face shortages of family physicians and other primary care professionals.(data.hrsa.gov) Life expectancy and years of healthy life can differ drastically -- by as much as 35 years -- between the healthiest and wealthiest and the sickest and poorest neighborhoods in the United States. In many areas, the situation is worse than in some low-income nations.
What have we learned during the 40 years since Alma-Ata? It has been a wild, bumpy ride with uneven progress. Evidence from countries that have implemented primary care successfully point to several vital components: leadership; health in all public policies; community-based services; universal health insurance coverage; and adequate human, physical and financial resources.
Family Physicians as Champions of Primary Care
Skilled health professionals who are trained to manage most common problems and distributed according to the needs of the population are essential for primary care delivery. Dozens of studies have confirmed that family physicians and their teams improve the quality and lower the costs of health care.(www.healthaffairs.org)
Family physicians serve as quarterbacks of primary care teams to prevent crises, manage complexity, improve the quality and expand the scope of teams. Family physician leaders know they need others, such as community health workers, nurses, therapists, pharmacists, oral and behavioral health specialists, and support staff to round out the skills of the care team. Family physicians are the only physicians who provide whole-person, first-contact, comprehensive continuity of care across the entire lifespan, coordinating services and referring patients to community and/or subspecialty and hospital-based resources as needed.
Forty years after Alma-Ata, the nations of the world have gathered in Astana, Kazakhstan, for the Global Conference on Primary Health Care Oct. 25-26 to renew their commitment to primary care(www.healthaffairs.org). What has changed? People are more engaged and have more information and higher expectations for health. An explosion of medical information and technology has broadened the range of available health services. We have more evidence, more stakeholders, more resources and more opportunities to achieve health for all.
Although we celebrate this remarkable progress, we know that uneven conditions contribute to persistent health inequities. People living in poverty and/or in rural areas are more likely to experience limited access to primary care. Therefore, we need to redouble our efforts to provide universal health coverage to ensure that all people, even those who are disadvantaged or vulnerable, have access to high-quality health services without financial hardship.
The Astana Declaration(www.who.int) calls for nations to put public health and primary care at the center of universal health coverage. During the past 40 years, most countries have come to recognize the value of well-trained generalists and are now training family physicians. Although family physicians were not named in the original Declaration, the Astana document specifically identifies family physicians as vital members of the primary care workforce.
AAFP Commitment to Health Care for All
AAFP members have been major contributors to the primary care movement. The AAFP has been a steadfast advocate of health care for all and recently renewed its commitment through robust policy recommendations.
Through The EveryONE Project, the Academy has launched a national program to promote health equity. The AAFP Center for Global Health Initiatives is fostering global collaborations and recently celebrated a successful summit highlighting new partnerships, progress and innovations. The Robert Graham Center for Policy Studies in Family Medicine and Primary Care has developed vital signs by which to measure a nation's primary care performance.(phcperformanceinitiative.org)
U.S. leaders of family medicine are calling for reinforcements to advocate for health care for all and to expand and reinvigorate our specialty. We need more students, residents and family physicians to bring fresh perspectives and new skills and tools and to become leaders of the next generation of champions of primary care. What will we accomplish in the next 40 years?
- societies and environments that prioritize and protect people's health;
- health care that is available and affordable for everyone, everywhere;
- health care of good quality that treats people with respect and dignity;
- people engaged in their own health."
-- Astana Declaration on Primary Health Care, 2018
Cynthia Haq, M.D., is professor and chair of the Department of Family Medicine at the University of California, Irvine. Her career is focused on health equity and preparing health professionals to serve patients and communities that are medically underserved and/or disadvantaged. She has provided full-scope family medicine and medical education for more than 30 years.