In both ordinary times and during crises, strong primary health-care systems play a key role in saving lives and ensuring the continuity of health-care services. Primary health-care providers, such as general practitioners, counsellors, or pharmacists, represent the first point of contact between the health-care system and individuals, families, and communities. The role of primary care providers in providing people with the most comprehensive care possible, from prevention to treatment, is pivotal in ensuring basic health-care services and guaranteeing a health system that meets the needs of the population it serves.
The COVID-19 pandemic exacerbated pre-existing weaknesses in health-care access and delivery: primary care systems worldwide were not able to deflect the pressure from hospitals and, due to lockdown restrictions, were unable to fully support communities with maintaining essential health services. The pandemic has unequally affected many vulnerable groups, bringing the discussion around the social determinants of health and inequity to the forefront of public health. In a nutshell, access to health-care services is still not for all.
However, this is not a new issue. Heads of state across the globe met for the first time in 1978 in Alma-Ata, Kazakhstan, to commit to the ideal of health for all. The meeting recognised the existence of inequality in the access to health care between advantaged and disadvantaged individuals, both socioeconomically and geographically; acknowledged the situation as unacceptable; and endorsed primary health care as a core pillar to the attainment of health for all. The Alma-Ata declaration reinterpreted primary health care, envisioning it beyond hospitals and health services, but as a reflection of the social determinants of health. The declaration's main pillars were to build a primary health-care system close to all communities, regardless of their geographical location, to allow universal accessibility to individuals through their full participation and empowerment. In October, 2018, the commitment to health for all was reaffirmed by heads of state during the Global Conference on Primary Healthcare in Kazakhstan in the Declaration of Astana. This political re-affirmation, together with a renewed commitment globally towards universal health coverage and the development of Sustainable Development Goals, are welcome steps in the right direction. However, progress has been slow with the goal of Alma-Ata of ‘health for all’ unlikely to be met for many decades.
Joint data on access to health care released before the COVID-19 pandemic from the World Bank and WHO on Dec 13, 2017, worryingly highlighted that the trajectory to attain health for all was very far from being reached. At least half of the world's population lack access to essential health services and 800 million people spend at least 10% of their budget on health-care expenses. The same report also warned that a shortfall of 18 million health-care workers will occur by 2030, which will hamper universal health-care delivery and is likely to widen the gaps in health equity. Data from the Universal Health Coverage Global monitoring report published by WHO in 2019 reiterated these issues and warned that over 5 billion people will be unable to access health care by 2030. This report called countries for increased spending on primary care by at least 1% of the gross domestic product to close health coverage gaps and highlighted that more people were paying for services out of their own pocket, with 925 million people spending more than 10% of their household income on health-care expenses and 200 million people spending more than 25%. Although there is variation across world regions, it is evident that there is room for substantial improvement globally.
We must act now to reframe primary health care based on the Alma-Ata principles, tailoring strategies around the actual burden of diseases and the additional challenges brought about by the COVID-19 pandemic. It is time to carve policies that reflect patients’ needs to build strong primary health-care systems globally that serve the needs of all populations. It is essential that the delivery of primary health-care services is reorganised, establishing a strong link between basic practices and community services, and expanding home-based programmes and strategies to reach isolated communities. In this context, the role of community health workers should be further utilised to provide timely information and direct access to care. In addition, the leverage of remote services and use of big data that were successfully exploited during the pandemic should be further implemented as tools to help maintain continuity of care and to develop tailored interventions. Lastly, and importantly, governments should invest in modernising health-care systems and supporting the delivery of essential services, an aim that cannot be reached without a plan oriented at increasing the number of health-care workers.
Many countries are still facing major challenges posed by the COVID-19 pandemic, which has shone an uncomfortable light on the health inequities that already existed. Unfortunately, these gaps in health-care access and delivery have also widened over the past 2 years. ‘Health for all’ is certainly one of the major public health challenges of the 21st century and currently looks unlikely to be met in the next few decades. It will require input and commitment from governments at a global level, but also immediate action to reframe primary care and bring it closer to people. 43 years have passed and it is finally time to transform the Alma-Ata vision into action.