Nearly a year into the societal transformations of the COVID-19 pandemic, it is now inarguable that health and economics are not only connected but that they are existentially interdependent. More than four decades ago, a global blueprint was drafted for a future in which primary care would act as the front line and beating heart of that interdependence. The current crisis could provide the catalyst for that transformation.

 

Gillian Bartlett and Laurette Dube

In September 1978, the International Conference on Primary Health Care in Kazakhstan adopted the Declaration of Alma-Ata, arguably one of the most important milestones for public health of the 20th century. With the current global pandemic, economic crisis, and daily headlines highlighting the strains and deficits of health care systems, it is worth revisiting the Alma-Ata, over 40 years later, as a basis for much-needed health system innovation.  The major tenet of the Alma-Ata, adopted by the World Health Organization (WHO) as key to achieving “health for all”, was the critical role of primary care. Section IX of the Declaration stated:

Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system, bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.

Primary care in the Canadian context is provided predominantly by family physicians who often work with other health and social service professionals to provide health care services. This approach does not differentiate by age, gender, disease or organ system, and by doing so, develops long-term therapeutic relationships. Primary care puts into practice the notion that a person is greater than the sum of their parts. The primary care providers’ distinct advantage for contributing new information related to patient-level care has its locus in their direct experience with both healthy and ill people in every stage of disease, long-term follow-up, and the obligation to adopt a multidisciplinary approach to care. 

Currently, primary care is situated as an extension of our hospital-oriented health care system with fragmentation of information and challenges with sufficient and equitable access. The COVID-19 pandemic and ensuing crisis in care has provided an opportunity to flip the orientation of our health care system to ensure that primary care is at the hub as an anchoring point for provision of care as originally envisioned by the Alma-Ata.

Much like an engineering stress test, the COVID-19 pandemic has pushed health care systems to the limit and clearly identified areas of failure. The current model of health care is still—more than 50 years after introduction of universal health care in Canada in 1966—fundamentally organized around hospital care with a focus on disease diagnosis and treatment. While health promotion and disease prevention receive some attention, only a small fraction of funding for research and care has ever been attributed to these areas. Most funds and efforts have been concentrated in university teaching hospitals. That is not to diminish the important work being done in these institutes—we have had many impressive successes in cancer, cardiometabolic disease, respiratory, neurological and other areas where certain diagnoses are no longer the death sentences they would have been even 10 years ago. Given that  great deal of research published in high-impact journals supports the tenets of the Alma-Ata Declaration on the key role of primary care in improving the performance and sustainability of a health care system and the health of the population, primary care must be more centrally located and emphasized. As noted in the concluding statement of the Alma-Ata, there is a need for an “urgent and effective national and international action to develop and implement primary health care throughout the world.” 

This is particularly critical as early research indicates that people with stronger immune systems and no underlying conditions are less likely to get COVID-19, and if they do, they suffer a milder version with a lower likelihood of being hospitalized and intubated. Keeping the population as healthy as possible as long as possible is the essence of primary care. Primary care providers serve as partners in managing chronic disease, as gatekeepers to successive tiers in the health care system, and as health educators. Importantly for our current situation, primary care is often a critical intermediary between medicine and public health, thereby contextualizing patient needs against the sociocultural backdrop of the world in which they live. This degree of personalization—unique to primary care—rests on an intimate understanding of a community’s social and cultural fabric. Given that COVID-19 is impacting people and communities differently, these defining characteristics of primary care need to be supported and strengthened.  

Some of the technology-enabled care that the pandemic has forced to the forefront can help manage access and routine care through embedding innovations into everyday life as we have seen with virtual clinical visits. The instant uptake in rates of telehealth both by phone and video, however, has highlighted deficits in our digital infrastructure. There is an urgent need to increase accessibility to hardware, software and Wifi so that this does not become another contributor to increasing health inequities. 

Far in advance of its time, the Alma-Ata stated that primary health care needs to focus on all the dimensions of a person’s well-being, including access to affordable healthy water, air, and food, decent housing, and other facets of the surrounding environment. Clearly, this transcends health system boundaries, even primary care, at least with its still prevailing clinical focus. In a full convergence economy, health, social, and commercial sectors all partake in creating resilience for individuals, economies and society. We would argue that a key post-COVID-19 health system innovation is for primary care (and not just the medical doctor on the team) to move beyond what have become fairly restrictive health domains to serve as catalyst in key areas such as climate, environment, food distribution and technology to create a human-centered, digitally powered approach to health and economics. This will more closely embrace the WHO statement that, “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” In fact, the large-scale application of smart digital technology that has accelerated telehealth in response to the pandemic may play a vital role in giving Alma-Alta the full wings that it has not achieved to-date. 

This approach incorporates health and economic convergence as the overriding principle at the centre of the evolution of preventive health care. While nobody would have wished for the COVID-19 pandemic, its role in revealing the existential importance of convergence has helped focus public policy attention and private intellectual capital on the need for innovation in health and economic policy that better incorporates the relationship between health care—especially primary health care—and economic well-being. We would argue that lens of convergence thinking that anchors on primary care but goes outside of typical health domains to combine in a way that strongly aligns with the Alma-Ata is a way to give life to this still-
relevant Declaration.

It is now possible to gather, structure, and analyze more significant quantities of data with greater efficiency than ever to support solution-oriented health care systems strongly grounded in primary care, thereby enabling performance and resilience for individuals and populations as well as for our economy and society. Keeping the ‘past’ of the Alma-Ata firmly in mind, we need to re-imagine the connections among all of the industrial inputs that affect health outcomes, from agriculture to transportation to urban planning to the definition of work—so that innovation better serves our transforming world. 

This is where we move beyond the typical focus of health systems to provide a much-needed update and re-integration of the principles of the Alma-Ata to a digitally-adapted convergence approach that is moored in complexity science and societal transformation. The impact would be a robust system of economically, environmentally and culturally integrated solutions to support the sustainability and resilience of the individuals, institutions and organizations that make up our society, including our interdependent health and economic systems—an Alma-Ata blueprint for the 21st century.  

Gillian Bartlett was the Research and Graduate Program Director in Family Medicine at McGill University and is now a Professor of Family and Community Medicine and the Associate Dean for Population Health and Outcomes Research at the School of Medicine, University of Missouri.

Laurette Dubé is the James McGill Chair in Consumer and Lifestyle Psychology at the Desautels Faculty of Management; Chair and Scientific Director, McGill Centre for the Convergence of Health and Economics (MCCHE).