Elsevier

The Lancet

Volume 392, Issue 10156, 20–26 October 2018, Pages 1461-1472
The Lancet

Review
Revisiting Alma-Ata: what is the role of primary health care in achieving the Sustainable Development Goals?

https://doi.org/10.1016/S0140-6736(18)31829-4Get rights and content

Summary

The Sustainable Development Goals (SDGs) are now steering the global health and development agendas. Notably, the SDGs contain no mention of primary health care, reflecting the disappointing implementation of the Alma-Ata declaration of 1978 over the past four decades. The draft Astana declaration (Alma-Ata 2·0), released in June, 2018, restates the key principles of primary health care and renews these as driving forces for achieving the SDGs, emphasising universal health coverage. We use accumulating evidence to show that countries that reoriente their health systems towards primary care are better placed to achieve the SDGs than those with hospital-focused systems or low investment in health. We then argue that an even bolder approach, which fully embraces the Alma-Ata vision of primary health care, could deliver substantially greater SDG progress, by addressing the wider determinants of health, promoting equity and social justice throughout society, empowering communities, and being a catalyst for advancing and amplifying universal health coverage and synergies among SDGs.

Introduction

The Sustainable Development Goals (SDGs) are now steering the global development agenda and are key drivers of international action on social and environmental determinants of health. The 17 goals cover poverty reduction, hunger, health, education, inequalities, sanitation, energy, social justice, the environment, and climate change. Like their predecessors, the Millennium Development Goals, the SDGs include specific targets, but additionally emphasise broader interlinked aspects, such as sustainability and social justice, promoting a more integrated development agenda. Notably, the SDGs contain no mention of primary health care (PHC)1—one of the principal strategies for reshaping health care, promoting health-enhancing policies across sectors, and developing more equitable and fairer societies. Sept 12, 2018, marked 40 years since the Alma-Ata declaration, the bold and ambitious statement that proposed PHC as a platform for improving global health.2, 3

The 1978 Alma-Ata declaration's vision for societal health included reorienting health systems towards primary care and addressing the social and environmental determinants of health and inequality (panel 1). It emphasised social justice and equitable access to health-care services, key elements of the modern universal health coverage (UHC) agenda (panel 2), and advocated for empowering communities to participate in health-care planning and delivery. In October, 2018, the international community will commemorate Alma-Ata in Astana, Kazakhstan, with an updated declaration which reiterates PHC's indispensability in improving health, and emphasises the need for strengthening and sustaining health systems, and achieving UHC.

Nevertheless, will the Astana declaration succeed in advancing the implementation of PHC against a backdrop of 40 years of lacklustre uptake? Despite efforts to revitalise Alma-Ata in 2008, with WHO's World Health Report on PHC29 and a Lancet Series on Alma-Ata,23 global action remains disappointing. This disappointing uptake stemmed from misinterpretation of Alma-Ata, minimal political motivation for societal reform, and constrained finances.14, 23 Confusion between primary care and PHC (panel 1) led to criticism that Alma-Ata was too broad,23 with the misinterpretation arising from the perspective that primary care should be responsible for addressing broader determinants of health and advancing social justice, far beyond the remit of health services. The proposal of selective PHC in the 1980s, focusing on vaccination, growth monitoring, oral rehydration therapy, and breastfeeding, was viewed as a pragmatic approach to implement primary care in resource-constrained settings, but diverged from Alma-Ata's defining principles.1, 30

In the past decade, attention to PHC's broader principles has gained pace (panel 3). This attention builds on efforts in some countries to embrace elements of comprehensive PHC, including community engagement and participation—eg, in Costa Rica,77 Brazil,78 Chile,79 and as part of family medicine or general practice in many European countries.56 Building on this momentum, the current focus on UHC is welcome (panel 2), but it is crucial that this focus on UHC does not create a narrow focus on health services, diverting attention away from broader PHC principles and the potential to advance many of the SDGs.

The draft Astana declaration25 identifies PHC as a driving force for achieving the SDGs. However, a clear articulation of how PHC contributes to the SDG agenda is absent. In this Review, we argue that reorienting health systems towards primary care can accelerate achievement of SDG3 (figure 1).56, 79, 80, 81, 82 We then build a case for why both primary care and an even broader PHC approach could make essential contributions to achieving many of the non-health SDGs (figure 2), and advocate for countries to engage with the Alma-Ata's vision of PHC as a mean to maximise efforts towards achieving their SDG targets and to capitalise on the synergies among them.

Section snippets

How could reorienting health systems towards primary care contribute to the SDGs?

Reorienting health systems towards primary care will not only deliver major health gains, but also promote wider sustainable development. In their most basic role, primary care services contribute to achievement of SDG 3 (health), with preventive interventions and treatments, such as vitamin and nutritional supplements, vaccinations, and therapeutic drugs, which can avert many causes of illness and death, especially for children (figure 1).83, 84 Indeed, most basic cost-effective essential

How might embracing a more comprehensive PHC approach contribute to the SDGs?

Beyond re-orienting health systems to primary care, the Alma-Ata vision of PHC supports the achievement of the SDGs. The PHC and SDG agendas are linked because they both address the broader determinants of health, through intersectoral action and Health in All Policies, the promotion of equity and social justice, and the empowerment and participation of communities and individuals. Furthermore, PHC and UHC are strongly aligned (panel 2). However, little robust evidence exists on the effect of

Promising opportunities and challenges for PHC in the SDG era

The absence of PHC in the SDG documents and policies remains a crucial oversight. The evidence base for PHC's potential contribution to many of the SDGs is stronger than ever. Countries with prioritised investments in primary care are better placed to achieve the SDGs than those with hospital-focused systems or limited investments in health. Those countries adopting a broad PHC approach can deliver substantially more—namely through actions to address the wider determinants of health, promoting

Conclusions

The SDGs provide a unique opportunity to make the case for renewed attention and investment in PHC as envisaged in the Alma-Ata declaration. As the global community considers its future direction for the coming decades, Alma-Ata's 40th anniversary is the time to reaffirm commitments to PHC and recognise its importance across societies. The Alma-Ata declaration stated that PHC “reflects and evolves”,2 hence its vision is relevant today and has great potential to contribute to the SDGs and other

Search strategy and selection criteria

Data for this Review were identified by searches of PubMed, Google Scholar, and references from relevant articles. Search terms included combinations and synonyms of “primary care” and “primary healthcare”, relevant Sustainable Development Goal terms (eg, “poverty”, “education”, “income”), and key concepts (eg, “social determinants”, “community”, “universal health coverage”, “health and human rights”). We supplemented the data with our knowledge of existing publications. Particular attention

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