Health systems in transitions: the need for transformation in primary health care
As the late Hans Rosling was fond of pointing out, the world changes at a rate we find hard to keep up with. Since the Alma Ata declaration of 1978, the global population pyramid has narrowed. The great majority of countries no longer have a population dominated by children and reproductive age adults. While the direction of change is consistent worldwide, individual countries are in very different positions with respect to this demographic transition. In Germany, the word ‘pyramid’ no longer describes the population distribution, there are about 72% more adults in the 50-54 year old bracket, as children aged 0-4. In Malawi, over 40% of the population is still under 15.
Epidemiological transition reflects these trends, as has economic development that has transformed the lifestyles of all – creating more sedentary work and diets containing more processed foods. Even COVID-19, preying in particular on those with pre-existing chronic conditions, reinforces rather than undermines the trend for the largest burdens of disease to have underlying chronic disease explanations. The global economic and political system has also played a part – the influence of multinational corporations constrains regulatory capacities with respect to critical components of disease processes such as food systems.
Among a host of implications is the need for a new vision of primary health care in the 21st century. Alma Ata’s provisions responded to a world of ubiquitous poverty, a burden of disease dominated by infectious disease and nutritional deficiencies, with effects concentrated in children, and health problems associated with reproduction that were exacerbated by high fertility rates. This is not of course to argue that such conditions are now unimportant – severe, concentrated problems associated with infectious disease, nutritional deficiency and reproduction persist, particularly among some of the world’s poorest.
Among the neglected elements of the primary health care vision, as relevant in 2021 as in 1978, concerned building the economic, social and political conditions that produce good health reaching far beyond the ‘medical model’ focused on the resolution of disease. That emphasis distinguishes the broader primary health care movement from the mere building of primary care systems. In 2021, building the economic, social and political conditions that produce good health more clearly needs to address the drivers of growing economic inequalities and the shapers of natural and urban environments that are inimical to good population health.
We also need to reconfigure the character of primary care systems. Those that emerged before, during and in the decades after the Alma Ata declaration were influenced by the understanding most clearly expressed in article (VII, 3) ‘primary health care contains at least….’ . The need to respond to populations requiring protection from infectious disease exacerbated by water and sanitation conditions and nutritional deficiencies and offering support to women and newborns before, during and immediately after births. There are very few countries in which adult men consider public primary care as offering any response to the health conditions that they may seek to avoid, manage, and treat.
The health of adult women (whether pregnant or not) and men is essential to the well-being of their households and communities and to economic development writ large. The effects of infectious disease, nutritional deficiency, and maternal mortality on a poor child’s chances in life, are now added to by the toll imposed on their household by a chronic condition in a breadwinner, or from the impoverishing effects of any household member’s succumbing to a chronic illness. Our current research in India is underlining the importance of this last issue. In order to respond to the ever-larger proportion of population disease burdens, and to avoid such impoverishment, a public (or at least heavily subsidised) primary care system needs to be trusted to manage the health problems of adults. Trust is critical – not only because a system that isn’t used is useless. Messages about the long-term nature of conditions and the joint production of the needed responses, involving the service user and provider, for example via lifestyle modification, cannot occur without it.
There are many elements of primary care systems required for this transformation. A critically important one is rehabilitation. Rehabilitation was recognised by the broader primary health care movement: “curative, rehabilitative” but less by those who developed systems based on the ‘at least’ provisions and influenced by the controversial ‘selective primary health care’ vision. Intentions to extend from this narrow view and according to regional need have failed largely to materialise in the intervening half century, and instead rehabilitation emerged outside the health sector in the form of Community Based Rehabilitation which has provided a critical resource especially for (and by) people with disabilities. Nevertheless, this left a yawning rehabilitative gap in the response to those with chronic illness. Recent prevalence estimates based on GBD data describe high and growing unmet needs for rehabilitation, due both to changing disease patterns and a growing, ageing population.
A great deal of work has been done over the last decade or so by many parties, including WHO, to specify the characteristics of the needed rehabilitation and assistive technology services and to consider questions about how they can be financed, the required workforce and how to build the trust required. At the Nossal Institute, we are co-leading with Johns Hopkins University and working with a host of other partners, a program supported by USAID concerning learning about how better to integrate rehabilitation into health systems, ReLAB-HS. We plan for it to support a sea-change in the extent to which health systems in its four focus countries respond to the challenge of extending the remit of primary care services in the required direction, and offer guidance to the rest of the world to follow suit.
It’s a big challenge but a response that I think the Alma Ata Conference participants would consider long overdue.
This article was written by Professor Barbara McPake and Dr Wes Pryor
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Professor Barbara McPake, Director, Nossal Institute for Global Health