Primary Health Care Matters.

Abstract

In 1978, at the International Conference of Primary Health Care (PHC) held in Alma-Ata (Kazakhstan), a historic declaration was adopted. This expressed the need for action by all governments, all health and development workers and the world community to protect and promote the health of all the people of the world (World Health Organization 1978). The Alma Ata Declaration was a visionary step as it defined and promoted PHC as the central means towards good and fair global health not simply health services at the primary care level (although that was important) but rather a health system model that acted also on the underlying social, economic and political causes of poor health (Commission on the Social Determinants of Health 2008). In 2008, the World Health Organization (World Health Organization 2008) released ‘Primary Health Care – Now More than Ever.’ Reflecting on the Alma-Ata Declaration, this report argued that moving towards health for all involves substantial reorientation and reform of the ways health systems operate. Yet despite the vision and commitments given, the reality in many countries is that progress has been extremely slow. In fact, the failure to sufficiently invest in PHC, the dominance of medical models and the hospital-centric approach to healthcare delivery, combined with a lack of political leadership, all mean that there is still much work to do to deliver on the ground change. This year, 2018, marks the 40-year anniversary of the Alma-Ata Declaration and the WHO, supported by many global health organisations, have grasped this as an opportunity to renew and refresh the Declaration and to inspire new generations of leaders to go further and implement a truly primary health care and people-centred and led healthcare system. In October, more than 1000 government and health leaders will meet in Astana in Kazakstan to renew the Declaration but also, and importantly, to address the critical issues of how to operationalise and implement changes in healthcare delivery. ICN, working with the Nursing Now campaign, has been advising on and shaping the agenda and working papers for this event. This is because we know that nurses sit absolutely at the centre of the revolution that is required if we are to successfully meet the global health challenges that we all face. The world has seen dramatic changes over recent years. There is disillusionment with political establishments that seem distant and unresponsive to the issues ordinary people face in their everyday lives. There are fluctuating currencies, unstable economies, prolonged conflicts, widening inequalities, ethnic tensions and horrific acts of violence. Not only is society rapidly changing, but so is the environment in which we live; global temperatures are rising, antibiotics are failing, inequalities in income levels are increasing, and healthcare costs are rapidly escalating (International Council of Nurses 2017). Whilst progress is being made achieving the United Nations’ Sustainable Development Goals (SDG), new and re-occurring infectious diseases are impacting on advances that have been made and the rise of non-communicable diseases (NCDs) has been described as a global health disaster happening in slow motion. Today, NCDs have overtaken infectious diseases as the leading causes of mortality across the world and modern living has widened the entry point for the spread of unhealthy lifestyles (Forouzanfar et al. 2016). Whilst many health systems have been designed to meet the needs of acute infections, the challenges in improving health prevention, enhancing PHC and ensuring genuinely people-centred approaches across the world is profound and pressing. Now is the time that we must make that seismic shift in not only how we think about health care but how we deliver health. For progress to be made in the achievement of the SDGs, PHC must be on the agendas of all governments and healthcare policy makers. PHC plays a critical function in supporting the broader health system to deliver quality care, with key roles in ensuring continuity of care, integration between different components of the healthcare and social care system and coordination of the many functions that combine to create a quality care environment. As nurses, we have both a role and responsibility to speak up and educate word leaders and policy decision-makers about the importance of public health and prevention and to advocate for healthcare policies and systems to be truly centred around the individual. PHC extends beyond the biomedical model of care to a social model of health, based on the philosophy that for health improvement to occur, the social, political, environmental and economic determinants of illness must all be addressed. I truly believe that a comprehensive approach to PHC that takes into account the social determinants of health requires a multi-disciplinary approach to health that includes inter-sectoral collaborations and partnerships and places a much greater emphasis on population health and prevention strategies. Many countries still have a medically dominated approach to health care and are set up with the hospital at the centre, rather than the person. If we stop seeing people just as a disease or condition and support people to lead the decision-making about their health care, we need different health systems and changes in how the health professionals work. Shifting resources and services closer to people's home, the use of technology to receive information, manage treatments and care, staff supporting the coordination of care and navigation of people and their families along a care pathway are just some of the fundamental elements of a system driven by people's needs rather than vice-versa. However, it is true these are huge changes to achieve in practice and require brave and visionary leadership to make sure that more money is going into public health and primary healthcare budgets, and not simply continuing with traditional spending patterns that favour hospital-based services. Very deliberately WHO and ICN are also working to ensure that there is a much stronger voice and representation from younger people. The changes we need in health care are the result of factors that will be with us for generations to come, and the options and solutions to these are being driven by the ideas, values and innovation of younger people. It is important to recognise there is an umbilical relationship between PHC and the importance of achieving universal health coverage (UHC) and ensuring that health really is a human right for all. UHC delivers many benefits. It means that workers are more productive, children are less absent from school, poverty and inequality decreases, societies are more harmonious, and economic growth is robust and sustained. Economically, UHC is a good investment. The WHO estimates that in developing countries, for every US$1 invested in health, between US$9-20 of growth is returned (WHO 2015). UHC has become the internationally agreed objective of health and development policy. UHC aims to ensure that all people can access promotion, prevention, curative, rehabilitative and palliative health services that are of high quality, whilst also ensuring that the use of these services does not cause financial hardship. To this end, it is important to remember that PHC is the preferred and most effective means of delivering essential health services at a cost which governments and communities can afford. A national healthcare system is more effective when it is based on PHC encompassing a range of publicly funded essential, universally accessible and equitable health services to the population. The nursing profession has for a long time been a strong supporter of UHC and an advocate for Health as Human Right. The ICN Code of Ethics for Nurses calls for nurses to advocate ‘for equity and social justice in resource allocation, access to healthcare and other social and economic services’ (International Council of Nurses 2015, p.2.). Nurses are committed to UHC, and we are aware of the trends in health care, the costs and the added demands on the daily practice of nursing work. This year's ICN International Nurses Day resources, ‘Nurses Voice to Lead, Health is a Human Right’, contain powerful case studies of nursing practice from right around the globe that demonstrate how our profession is bridging the gap between policy and practice. To turn the Astana Declaration from vision to reality requires putting nurses into key leadership positions in health systems at both country and global levels. The 40th anniversary of the 1978 Declaration of Alma-Ata is a seminal milestone in global health. ICN is proud to be working in collaboration with the WHO on the review of the 1978 Declaration of Alma-Ata. ICN strongly supports the recognition of the role of the PHC workforce in the Astana Declaration and are pleased to see the wording about putting public health and primary care at the centre of UHC, with reference to both nurses and midwives. We have been working hard to ensure that the new declaration recognises the importance of investing into the Nursing and PHC workforce with a focus on improved education, recruitment and retention. ICN will remain steadfast in our efforts to increase investment in the nursing workforce to ensure that there are not only enough nurses, but that their practice is supported through ongoing professional development and learning, that barriers to expanded roles and working at full scope of practice are removed, and that there is assurance of decent working conditions and fair pay. We say this not just because it is the right thing for our profession, but such efforts will deliver changes to health care and the health and well-being of people and populations. Without nurses there would be no PHC and without PHC, we will not move beyond health care to Health for All.