Primary health care is not just a service delivery platform

Abstract

I congratulate Kara Hanson and colleagues on the Lancet Global Health Commission on financing primary health care (PHC).1Hanson K Brikci N Erlangga D et al.The Lancet Global Health Commission on financing primary health care: putting people at the centre.Lancet Glob Health. 2022; 10: e715-e772Summary Full Text Full Text PDF PubMed Scopus (22) Google Scholar Their focus on equity and people-focused systems is welcome, and the recommendations are excellent. However, their decision to define PHC as a service-delivery platform is a well trodden, but ultimately counterproductive shortcut. Although recasting the admittedly difficult concept of PHC in terms of health-service delivery offers tractability, it betrays the fundamental vision of the Alma-Ata and Astana Declarations and pulls focus from the relatively under-resourced, under-researched, and underdeveloped domains of multisectoral action and community empowerment. In the commissioners’ own words, “Definitions matter. They signal what is prioritised and valued”.1Hanson K Brikci N Erlangga D et al.The Lancet Global Health Commission on financing primary health care: putting people at the centre.Lancet Glob Health. 2022; 10: e715-e772Summary Full Text Full Text PDF PubMed Scopus (22) Google ScholarThe original Alma-Ata signatories recognised that clinical services make only a limited contribution to overall health outcomes. PHC is a whole-of-society approach to maximising health, empowering people and reducing inequalities that deliberately extend beyond the narrow biomedical remit of health services to engage with the wider social determinants of economic and social development.2WHOThe declaration of Alma-Ata.https://apps.who.int/iris/handle/10665/52703Date: 1988Date accessed: April 5, 2022Google Scholar, 3WHO and UNICEFDeclaration of Astana on Primary Health Care.https://www.who.int/teams/primary-health-care/conference/declarationDate: 2018Date accessed: March 23, 2022Google Scholar PHC goes far beyond primary-care services, however comprehensive they might be. Confusion is understandable, given that section VI of the 1978 Declaration states that PHC is “essential health care […] the first level of contact […] the first element of a continuing health care process.” Taken in isolation, this paragraph can be used to defend a conceptualisation of PHC that neatly aligns with clinical primary care. However, other sections of the Declaration argue that PHC performs a much broader set of functions within society. Early debates around interpretation and implementation culminated at the Rockefeller-sponsored conference in which PHC was controversially distilled into just four interventions—growth monitoring, oral rehydration, breastfeeding, and immunisation.4Walsh JA Warren KS Selective primary health care.New Engl J Med. 1979; 301: 967-974Crossref PubMed Scopus (629) Google Scholar In 2018, signatories to the Declaration of Astana reaffirmed their commitment to PHC as a wide-ranging approach to health that tackles the major challenges facing societies.3WHO and UNICEFDeclaration of Astana on Primary Health Care.https://www.who.int/teams/primary-health-care/conference/declarationDate: 2018Date accessed: March 23, 2022Google Scholar WHO defines PHC as “a whole-of-society approach to health that aims equitably to maximise the level and distribution of health and well-being”, and stresses the three synergistic components: multisectoral policy and action; empowering people and communities; and integrated health services with an emphasis on primary care and essential public health functions.5WHOA vision for primary health care in the 21st century: towards universal health coverage and the sustainable development goals.https://apps.who.int/iris/handle/10665/328065Date accessed: March 23, 2022Google Scholar WHO and major international partners are investing heavily in PHC, commonly framing it as the main vehicle for delivering Universal Health Coverage (Sustainable Development Goal 3.8).6Binagwaho A Ghebreyesus TA Primary healthcare is cornerstone of universal health coverage.BMJ. 2019; 365l2391PubMed Google Scholar Consequently, policy makers around the globe have been given new briefs to operationalise PHC. As these staff invariably sit within health ministries, there is a tendency to latch on to the familiar (integrated health services based on strong primary care) while jettisoning the trickier elements of community empowerment and multisectoral action. It is true that primary-care systems can and should engage with communities and work with other sectors;7Allen LN Barkley S Maeseneer JD et al.Unfulfilled potential of primary care in Europe.BMJ. 2018; 363k4469PubMed Google Scholar however, this microcosmic version of PHC is an imperfect representation, a blurred fractal. Primary-care platforms are poorly equipped to lead national health-in-all-policies approaches, convene public and private stakeholders, or empower people to meaningfully contribute to societal transformation. Unfortunately, the conflation of primary care and PHC is being perpetuated by major international partners including the Bill & Melinda Gates Foundation,8Bill & Melinda Gates FoundationPrimary health care is exactly that.https://www.gatesfoundation.org/ideas/articles/coronavirus-jean-kagubare-phcDate accessed: April 5, 2022Google Scholar the Organisation for Economic Co-operation and Development,9Organisation for Economic Co-operation and DevelopmentRealising the potential of primary health care.https://www.oecd.org/health/realising-the-potential-of-primary-health-care-a92adee4-en.htmDate: 2020Date accessed: April 5, 2022Google Scholar and the World Bank.10Barış E Silverman R Wang H Zhao F Pate MA Walking the talk: reimagining primary health care after COVID-19. World Bank, Washington, DC2021Google Scholar In their accompanying Comment, Kutzin and colleagues11Kutzin J Dalil S Barroy H et al.An assertive, practical, and substantive agenda to catalyse meaningful change.Lancet Glob Health. 2022; 10: e606-e608Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar note that interpreting PHC as primary care is familiar ground, “appealing because it is measurable”.11Kutzin J Dalil S Barroy H et al.An assertive, practical, and substantive agenda to catalyse meaningful change.Lancet Glob Health. 2022; 10: e606-e608Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar Although it is true that contemporary global health accounting systems are poorly mapped to PHC,1Hanson K Brikci N Erlangga D et al.The Lancet Global Health Commission on financing primary health care: putting people at the centre.Lancet Glob Health. 2022; 10: e715-e772Summary Full Text Full Text PDF PubMed Scopus (22) Google Scholar this is a weak justification for perpetuating biomedical reductionism. Given the scale, remit, and prestige of the Commission, I cannot help but feel that this was a missed opportunity to fill a crucial gap; the world needs a robust economic approach to capture the tricky and chronically overlooked aspects of PHC. I want to reaffirm that the content of the Commission report is first class, but the scope is disappointingly safe and narrow. Until we develop financing models to advance full-blooded PHC, we risk selling our communities short of the radical social and economic change required to truly advance health for all. I am a practising family physician. I worked as a WHO consultant for the Global Conference on PHC. I led and contributed to several supporting documents for the Declaration of Astana, including the Vision for PHC in the 21st century. Since moving to the the London School of Hygiene & Tropical Medicine in 2021, I have joined, and now co-lead, the school-wide team that is developing a PHC seminar series. I am also a PHC consultant for the World Bank, and have previously worked with PHC teams at the Bill and Melinda Gates Foundation and the OECD. The Lancet Global Health Commission on financing primary health care: putting people at the centreThe COVID-19 pandemic has brought the need for well-functioning primary health care (PHC) into sharp focus. PHC is the best platform for providing basic health interventions (including effective management of non-communicable diseases) and essential public health functions. PHC is widely recognised as a key component of all high-performing health systems and is an essential foundation of universal health coverage. Full-Text PDF Open AccessPrimary health care is not just a service delivery platform – Authors' replyWe are grateful to Luke Allen for highlighting the importance of definitions and challenging our Commission's1 choice to operationalise the definition of primary health care (PHC) as a service delivery platform. This is an issue that we revisited continuously during our deliberations as we were committed from the outset to the encompassing, and purposively political, vision of Alma Ata and Astana as health for all. Full-Text PDF Open Access