From Alma-Ata to Astana: Primary health care – reflecting on the past, transforming for the future Interim Report from the WHO European Region 1 2 From Alma-Ata to Astana: Primary health care – reflecting on the past, transforming for the future Interim Report from the WHO European Region 3 Abstract The Global Conference on Primary Health Care, taking place on the occasion of the 40th anniversary of the Declaration of Alma-Ata, aims to commemorate and reaffirm the original principles of the declaration while renewing political commitment to placing primary health care (PHC) at the foundation of achieving universal health coverage and the sustainable development goals. This interim report, is one of the six reports developed by each WHO regional office as background documentation for the conference. It analyses PHC progress made in the European region over the past four decades and makes projections for the future of PHC. To develop the report, all 53 European Member States were invited to submit input based on their experiences in PHC innovations, enablers and barriers. By examining the main challenges and opportunities for PHC in the European region since 1978, and taking stock of the lessons that have been learned at both national and regional levels, the report identifies key innovations of PHC models for the 21st century. This provides a base guidance for strengthening health systems around PHC to achieve health for all and ultimately transform the vision set out in the 1978 declaration into a practical reality. Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest). Keywords 1. PRIMARY HEALTH CARE 2. PRIMARY CARE 3. DELIVERY OF HEALTH CARE – ORGANIZATION AND ADMINISTRATION 4. HEALTH SERVICES 5. HEALTH CARE SYSTEMS 6. EUROPEAN REGION © World Health Organization 2018 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. 4 Contents Foreword 7 Preface 9 Acknowledgements 11 1. Primary health care: achieving health for all 13 2. Fostering PHC in Europe: the evolution of regional health policies 19 3. Translating policies and strategies into reality: innovations in PHC in the European Region 25 4. Transforming for the future: accelerating innovation in PHC 43 5. Conclusions 51 6. References 53 5 List of Boxes Box 1. The Declaration of Alma-Ata 14 Box 2. The need to adopt evidence-based policies and innovations to improve the health and well-being of women and children 16 Box 3. Health 2020: a European policy framework and strategy for the 21st century 21 Box 4. People-centred health systems through integrated and coordinated health service delivery 22 Box 5: Understanding innovation in health systems: hard and soft innovations 26 Box 6. PHC Innovation in the Netherlands 34 Box 7. Innovation in PHC in Scotland to reduce alcohol consumption 35 Box 8. Transforming individual health services towards integrated, multidisciplinary PHC 36 Box 9. Developing fit-for-purpose human resources 37 Box 10. Health financing strategies to support the scale-up of core interventions and services for NCDs 39 Box 11. Developing and applying health system information solutions for NCDs 40 Box 12. Foundational conditions for large-scale transformation in health systems 48 6 Foreword I am pleased to present the interim European regional report From Alma-Ata to Astana: primary health care – reflecting on the past, transforming for the future, prepared as background documentation for the 40th anniversary of the Declaration of Alma-Ata. In 1978, delegates from 134 countries adopted the declaration, the first international declaration to launch a primary health care (PHC) approach as the key to achieving health for all. Today, the world is a different place. Though great progress has been made in PHC, conditions beyond and within the health sector have limited the full realization of the vision set forth in the declaration. Still, its guiding principles and values remain as pertinent now as when they were first iterated in 1978. Moreover, we have deepened our understanding of what is necessary to bring this vision forward. Across the WHO European Region, we have renewed our commitment to uphold the principles established in the declaration. In 2012, European Member States recognized strengthening people-centred health systems as one of four priority areas in Health 2020, the European policy framework for health and well-being. A PHC approach is also at the core of the WHO European Framework for Action on Integrated Health Services Delivery, adopted in 2016. Yet we still face an unfinished agenda to provide universal access to quality care through a PHC approach. The 40th anniversary of the Declaration of Alma-Ata provides an opportunity we must take advantage of to reaffirm and commit to the values we still hold today. This is especially important in the new context of the 2030 Agenda for Sustainable Development, as a people-centred PHC approach accelerates progress towards the established targets – particularly Sustainable Development Goal 3.8 to achieve universal health coverage as a means of ensuring healthy lives and promoting well-being for all individuals at all ages in all places around the world. This report advances the European Region’s achievement of this goal by taking stock of achievements and failures over the course of the past 40 years so that we may apply the lessons we have learned as we create a future where health systems meet the needs of their communities. Ultimately, it moves us forward by providing key guidance for ensuring that all individuals – in Europe and around the world – have access to the quality PHC services they need while protecting them from health threats and exposure to related financial hardship. Dr Zsuzsanna Jakab WHO Regional Director for Europe 7 8 Preface On the occasion of the 40th anniversary of the Declaration of Alma-Ata, the Government of Kazakhstan, the United Nations Children’s Fund and WHO co-organized the Global Conference on Primary Health Care on 25–26 October 2018 in Astana, Kazakhstan. The conference aims to commemorate the 1978 declaration, reaffirm its original principles and renew political commitment to placing primary health care (PHC) at the heart of achieving universal health coverage and the SDGs. To inform the conference’s processes and products, a series of background documents have been completed by each WHO regional office. From Alma-Ata to Astana: primary health care – reflecting on the past, transforming for the future is one of six regional reports that provide perspective by looking both back and forward through a PHC lens. They highlight the progress that has been made over the past four decades, consider challenges and opportunities, and provide policy analysis to project what is needed for the future of PHC to achieve health for all by 2030. In the true spirit of PHC, WHO Regional Director for Europe Dr Zsuzsanna Jakab invited all 53 European Member States to submit their experience of PHC innovations as well as enablers and barriers to improving the health outcomes, equity and efficiency of their health systems. By considering both the challenges and opportunities countries have faced in advancing PHC towards the achievement of health for all, this report offers pragmatic and actionable policy lessons for the European Region and beyond. This report identifies key innovations of PHC models for the 21st century, guiding principles for transforming PHC, foundational conditions for the large-scale transformation of health systems, and guidance for policy-makers to achieve strategic change. Through the cross-cutting themes of investment, innovation and inclusion, this report makes clear how Europe can transform PHC to realize the vision set in the Declaration of Alma-Ata, building responsive and resilient health systems that deliver equitable health and financial protection, drive economic growth, and generate wealth for sustainable development for all. Dr Hans Kluge Director of the Division of Health Systems and Public Health WHO Regional Office for Europe 9 10