A renaissance in primary health care

Abstract

30 years ago, in the midst of the Cold War, health experts and policy makers from 134 WHO member states convened in the former USSR to attend a conference on international primary health care. On Sept 12, 1978, the Alma-Ata Declaration was signed, with the ambitious target of achieving “Health for All by 2000”. In 1978, 2000 million people were estimated to have no access to adequate health care. There were vast inequalities between rich and poor countries, and between rich and poor populations within countries. The Alma-Ata Declaration revolutionised the world's interpretation of health. Its message was that inadequate and unequal health care was unacceptable: economically, socially, and politically. Unfortunately, the goal of “health for all”, while a rallying call to action, was not met. Theories for this failure abound: the vision for primary health care was politically unacceptable to some nations and so was marginalised; emerging health threats took precedence (no one imagined the global disease burden that HIV/AIDS would bring); and health priorities shifted (to the Millennium Development Goals [MDGs]). 30 years on, what is the relevance of the Alma-Ata Declaration in 2008? In short, primary health care is now offering global health a lifeline. Progress towards the MDGs has stalled. Weak health systems have restricted the success of efforts to improve maternal, newborn, and child health, and to reduce the disease burden from malaria and tuberculosis. New epidemics of chronic disease threaten to reverse what small gains have been achieved. To get back on track, and to meet the MDGs by 2015, countries need to strengthen their health systems through the implementation of effective primary health care. Now is the right moment to proclaim the urgent need for a renaissance in primary health care. The continuing relevance of this 30-year-old Declaration is remarkable. Many of the challenges faced in 1978 remain, such as infectious diseases (eg, the ongoing threat of H5N1 avian influenza and HIV/AIDS), political instability and conflict (most recently seen in Iraq and Zimbabwe), and worsening poverty (the World Bank last month estimated that 1·4 billion people now live in poverty). In recognition of this timely reawakening of interest in primary health care, this week's Lancet revisits, updates, and relaunches the key messages from Alma-Ata. A series of eight papers begins with an analysis of modern primary health care, and issues such as implementing cost-effective interventions in low-resource settings and tackling the growing burden of chronic diseases. We publish an analysis of individual country progress since 1978, with possible lessons for those who have shown the least advance. Involvement of communities in planning and implementation of health care (one of the main tenets of the Alma-Ata Declaration) is explored in the context of maternal, newborn, and child health, as are the roles of national policies and effective service integration, all foundations of a successful primary health care service. The final paper in the series looks to the future and provides a series of action points to revitalise primary health care, both nationally and globally. WHO's vision for health—complete physical, mental, and social wellbeing—is the key to achieving Alma-Ata's prime goal of “health for all”. This week's research articles also focus on these three principles. Stephen Tollman and colleagues discuss the challenges in managing chronic diseases in primary health care and the importance of providing adequate services to ensure physical wellbeing. Atif Rahman and co-workers tackle mental health in Bangladesh, with a psychological intervention that can be delivered within communities to treat mothers with perinatal depression. And the importance of social development is shown by Luis Huicho and authors who present data from four countries highlighting the importance of health workers with shorter durations of training in providing vital care to people in low-resource settings. Importantly, WHO, under Margaret Chan's effective leadership and together with her regional directors, has reaffirmed its commitment to primary health care. This revisioning of the principles of Alma-Ata is welcome and illustrates a new unity of purpose across global health institutions. Political progress is also encouraging. Following the G8 meeting earlier this year, Japan has announced its own commitment to lead international initiatives to strengthen health systems. Such renewed global interest in primary health care is promising. The need remains great and there are no shortcuts to success. But with refined international relationships, new and emerging technologies, and 30 years of experience, “health for all” need not be a dream buried in the past. The right to the highest attainable standard of health can be a reality within our grasp. Return to Alma-Ata30 years ago, the Declaration of Alma-Ata articulated primary health care as a set of guiding values for health development, a set of principles for the organisation of health services, and a range of approaches for addressing priority health needs and the fundamental determinants of health. Full-Text PDF Implications of mortality transition for primary health care in rural South Africa: a population-based surveillance studyMortality from non-communicable disease remains prominent despite the sustained increase in deaths from chronic infectious disease. The implications for primary health-care systems are substantial, with integrated chronic care based on scaled-up delivery of antiretroviral therapy needed to address this expanding burden. Full-Text PDF Open AccessCognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomised controlled trialThis psychological intervention delivered by community-based primary health workers has the potential to be integrated into health systems in resource-poor settings. Full-Text PDF Open AccessHow much does quality of child care vary between health workers with differing durations of training? An observational multicountry studyIMCI training is associated with much the same quality of child care across different health worker categories, irrespective of the duration and level of preservice training. Strategies for scaling up IMCI and other child-survival interventions might rely on health workers with shorter duration of preservice training being deployed in underserved areas. Full-Text PDF Alma-Ata 30 years on: revolutionary, relevant, and time to revitaliseIn this paper, we revisit the revolutionary principles—equity, social justice, and health for all; community participation; health promotion; appropriate use of resources; and intersectoral action—raised by the 1978 Alma-Ata Declaration, a historic event for health and primary health care. Old health challenges remain and new priorities have emerged (eg, HIV/AIDS, chronic diseases, and mental health), ensuring that the tenets of Alma-Ata remain relevant. We examine 30 years of changes in global policy to identify the lessons learned that are of relevance today, particularly for accelerated scale-up of primary health-care services necessary to achieve the Millennium Development Goals, the modern iteration of the “health for all” goals. Full-Text PDF Supporting the delivery of cost-effective interventions in primary health-care systems in low-income and middle-income countries: an overview of systematic reviewsStrengthening health systems is a key challenge to improving the delivery of cost-effective interventions in primary health care and achieving the vision of the Alma-Ata Declaration. Effective governance, financial and delivery arrangements within health systems, and effective implementation strategies are needed urgently in low-income and middle-income countries. This overview summarises the evidence from systematic reviews of health systems arrangements and implementation strategies, with a particular focus on evidence relevant to primary health care in such settings. Full-Text PDF Improving the prevention and management of chronic disease in low-income and middle-income countries: a priority for primary health careThe burden of chronic diseases, such as heart disease, cancer, diabetes, and mental disorders is high in low-income and middle-income countries and is predicted to increase with the ageing of populations, urbanisation, and globalisation of risk factors. Furthermore, HIV/AIDS is increasingly becoming a chronic disorder. An integrated approach to the management of chronic diseases, irrespective of cause, is needed in primary health care. Management of chronic diseases is fundamentally different from acute care, relying on several features: opportunistic case finding for assessment of risk factors, detection of early disease, and identification of high risk status; a combination of pharmacological and psychosocial interventions, often in a stepped-care fashion; and long-term follow-up with regular monitoring and promotion of adherence to treatment. Full-Text PDF 30 years after Alma-Ata: has primary health care worked in countries?We assessed progress for primary health care in countries since Alma-Ata. First we analysed life expectancy relative to national income and HIV prevalence to identify overachieving and underachieving countries. Then we focused on the 30 low-income and middle-income countries with the highest average yearly reduction of mortality among children less than 5 years of age, describing coverage and equity of primary health care as well as non-health sector actions. These 30 countries have scaled up selective primary health care (eg, immunisation, family planning), and 14 have progressed to comprehensive primary health care, marked by high coverage of skilled attendance at birth. Full-Text PDF Community participation: lessons for maternal, newborn, and child healthPrimary health care was ratified as the health policy of WHO member states in 1978.1 Participation in health care was a key principle in the Alma-Ata Declaration. In developing countries, antenatal, delivery, and postnatal experiences for women usually take place in communities rather than health facilities. Strategies to improve maternal and child health should therefore involve the community as a complement to any facility-based component. The fourth article of the Declaration stated that, “people have the right and duty to participate individually and collectively in the planning and implementation of their health care”, and the seventh article stated that primary health care “requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care”. Full-Text PDF Interventions to address maternal, newborn, and child survival: what difference can integrated primary health care strategies make?Several recent reviews of maternal, newborn, and child health (MNCH) and mortality have emphasised that a large range of interventions are available with the potential to reduce deaths and disability. The emphasis within MNCH varies, with skilled care at facility levels recommended for saving maternal lives and scale-up of community and household care for improving newborn and child survival. Systematic review of new evidence on potentially useful interventions and delivery strategies identifies 37 key promotional, preventive, and treatment interventions and strategies for delivery in primary health care. Full-Text PDF Integrating health interventions for women, newborn babies, and children: a framework for actionFor women and children, especially those who are poor and disadvantaged, to benefit from primary health care, they need to access and use cost-effective interventions for maternal, newborn, and child health. The challenge facing weak health systems is how to deliver such packages. Experiences from countries such as Iran, Malaysia, Sri Lanka, and China, and from projects in countries like Tanzania and India, show that outcomes in maternal, newborn, and child health can be improved through integrated packages of cost-effective health-care interventions that are implemented incrementally in accordance with the capacity of health systems. Full-Text PDF Primary health care: making Alma-Ata a realityThe principles agreed at Alma-Ata 30 years ago apply just as much now as they did then. “Health for all” by the year 2000 was not achieved, and the Millennium Development Goals (MDGs) for 2015 will not be met in most low-income countries without substantial acceleration of primary health care. Factors have included insufficient political prioritisation of health, structural adjustment policies, poor governance, population growth, inadequate health systems, and scarce research and assessment on primary health care. Full-Text PDF The Astana Declaration: the future of primary health care?Primary health care is in crisis. It is underdeveloped in many countries, underfunded in others, and facing a severe workforce recruitment and retention challenge. Half the world's population has no access to the most essential health services. Yet 80–90% of people's health needs across their lifetime can be provided within a primary health-care framework—from maternity care and disease prevention through vaccination, to management of chronic conditions and palliative care. As populations age, and multimorbidity becomes the norm, the role of primary health-care workers becomes ever more important. Full-Text PDF