A vision for primary health care in the 21st century

The Declaration of Alma-Ata in 1978 was a landmark in the history of global health. Forty years later, the Global Conference on Primary Health Care and its associated Declaration renew a commitment to PHC in pursuit of health and well-being for all, leaving no one behind.

Primary health care, or PHC, refers to “essential health care” that is based on scientifically sound and socially acceptable methods and technology. This makes universal health care accessible to all individuals and families in a community. PHC initiatives allow for the full participation of community members in implementation and decision making. Services are provided at a cost that the community and the country can afford at every stage of their development in the spirit of self-reliance and self-determination.

The focus on PHC is critical at this moment for three reasons:

1. The features of PHC allow the health system to adapt and respond to a complex and rapidly changing world.

2. With its emphasis on promotion and prevention, addressing determinants, and a people-centred approach, PHC has proven to be a highly effective and efficient way to address the main causes of, and risk factors for, poor health, as well as for handling the emerging challenges that may threaten health in the future.

3. UHC and the health-related SDGs can only be sustainably achieved with a stronger emphasis on PHC.

The concept of PHC has been repeatedly reinterpreted and redefined in the years since 1978, leading to confusion about the term. This document elaborates a modern concept of PHC, including how it is aligned with and contributes to the SDGs and UHC.

PHC is a whole-of-society approach to health that aims equitably to maximize the level and distribution of health and well-being by focusing on people’s needs and preferences (both as individuals and communities) as early as possible along the continuum from health promotion and disease prevention to treatment, rehabilitation and palliative care, and as close as feasible to people’s everyday environment.

PHC has three inter-related and synergistic components:

1. Meeting people’s health needs through comprehensive promotive, protective, preventive, curative, rehabilitative, and palliative care throughout the life course, strategically prioritizing key health care services aimed at individuals and families through primary care and the population through public health functions as the central elements of integrated health services;

2. Systematically addressing the broader determinants of health (including social, economic and environmental factors, as well as individual characteristics and behaviour) through evidence-informed policies and actions across all sectors; and

3. Empowering individuals, families, and communities to optimize their health, as advocates for policies that promote and protect health and well-being, as codevelopers of health and social services, and as self-carers and caregivers.

This vision places people, as individuals and communities, as the central focus of all efforts towards PHC. People’s fundamental right to the highest attainable standard of health and well-being, and the world’s renewed commitment to social justice, are expressed through adequate social protection and concerted efforts to address the needs of those who are most disadvantaged.

People are protected from adverse health outcomes through population-based measures, planned and delivered with consideration for the needs of those served. These include prevention and control of locally endemic diseases and disease outbreaks, prevention of noncommunicable diseases, and information and education concerning prevailing health problems, including major risks, and how to prevent and control them.

In the context of individual care, a trusted multidisciplinary primary care team supports patients in prioritizing and identifying care goals. Teams approach individual patient care, taking into consideration the patient’s cultural preferences and stage of life, across a wide range of problems (mental and physical, chronic and acute, communicable and noncommunicable). Teams are responsible for assessing the health needs of the patient, providing safe, evidence-based, cost-efficient management through appropriate use of health technologies and information technology, and coordinating additional or specialized services for patients who need them through wider PHC networks.

The broad determinants of health, including social, economic, environmental determinants, and associated commercial factors are addressed through action involving multiple sectors of government, civil society, and the private sector, which sustain societies and environments that foster health and well-being. Close collaboration among sectors, such as social protection, housing, education, agriculture, finance, and industry, enables people to live in health-promoting neighbourhoods that combine clean air, walkability and accessibility, green spaces, road safety and effective public transit options.

Efforts to advance health and well-being are anchored in and informed by the community. People have access to the knowledge, skills and resources needed to care for themselves and their loved ones, leveraging the full potential of health technologies as well as information and communications technologies (ICT).

To achieve this ambitious vision of PHC in the 21st century, transformational action is required. The specifics of this action will vary considerably from country to country; for example, the types of activities required in a fragile setting still grappling with the unfinished Millennium Development Goals agenda will differ significantly from what a middle-income country confronted with a rising prevalence of noncommunicable diseases needs to do. Therefore, a flexible set of thirteen “levers” has been identified that countries can employ as they move towards PHC.

The choice of specific actions should be informed by evidence, both local (e.g. the social, economic, and environmental situation and trends in the country, the disease burden, and the strengths and weaknesses of the health system) and global (e.g. what has been shown to work in improving PHC and what does not). To assist with this, lessons learned from the past four decades of research into PHC are summarized here.

Through the SDGs, the world has committed to an ambitious development agenda aimed at improving the health and well-being of all people. Forty years after the Declaration of Alma-Ata, equipped with evidence and inspired by the renewed global commitment, it is time for the global community to take humanity closer to health and well-being for all through bold steps. A bold new approach to primary health care is central to achieving the SDGs and UHC. Progress will require courage and determination. Clearly the time is now. The world has never been better positioned for success.