Abstract
Since the historic Declaration of Alma-Ata (World Health Organization (WHO), 1978), over 50 years ago, there have been dramatic changes in the global patterns of disease, population ageing, and economic, social and cultural environment. All of these have inevitably presented new challenges to primary care (GBD 2019 Diseases and Injuries Collaborators, 2020; Head et al., 2021; Kingston et al., 2018;). Primary care also faces challenges around access issues, workforce shortages and operational weaknesses (Langlois et al., 2020; Majeed, 2017; Petterson et al., 2015). Transcending national borders, these ubiquitous challenges highlight the commonalities, rather than dissimilarities, between countries and settings. These are important challenges for all of us working in primary care.
Unpacking global primary care
Primary care is a term used frequently in discussions of medical care, and the concept of ‘primary care’ is central to government efforts to increase the accessibility of comprehensive health care. Despite this there are a surprising number of imperfect and overlapping definitions of primary care. Most are grounded in Barbara Starfield’s seminal work describing primary care as: ‘first-contact, continuous, comprehensive, and coordinated care provided to populations undifferentiated by gender, disease, or organ system’ (Starfield, 1994). The WHO has defined primary care as ‘a model of care that supports first-contact, accessible, continuous, comprehensive and coordinated person-focused care. It aims to optimise population health and reduce disparities across the population by ensuring that subgroups have equal access to services’ (WHO, 2023). Finally, the National Academies of Sciences, Engineering, and Medicine has defined primary care as ‘the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community’ (Molla et al., 1996).
How should we think about global primary care? It may be easy to think about global primary care similarly to the concept of global health, which has been widely defined as ‘an area for study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide’ (Koplan et al., 2009). Common criticisms of global health include that it is merely a collection of problems (Farmer et al., 2013) rather than a discipline, that perspectives on global health are largely determined and advocated for by people or institutions in high-income countries (HICs)(Ranchod and Guimarães, 2021), and it takes place only in low-income and middle-income countries (LMICs) (King and Koski, 2020). We want to avoid global primary care leaning towards a disease-focused orientation, perpetuating power asymmetries that overwhelmingly favour HICs, and fly-in, fly-out work. A concerted effort is required to practice whole-person or holistic care, which characterises general practice and was developed in critique of the biomedical model’s reductionist framework (Checkland et al., 2008). This should be present and apparent throughout training, research and service delivery. It is time to reflect on whether we think we in high-income countries (so-called Global North) who work in LMICs (so-called Global South) really know what is best for people whose backgrounds and health and illness experiences are unlike our own. Embedding cultural sensitivity in global primary care is a basic prerequisite to ensure good quality care for all patients (Napier et al., 2014). There is also a great need for global primary care to do more than just reflect technical assistance delivered largely by the Global North to the Global South. Knowledge flow needs to be reciprocal, with contributions from the Global South driving discussions and practice for primary care reform in these settings (Büyüm et al., 2020).
The notion of using primary care to advance health equity gained substantial support in 1978 at the International Conference on Primary Health Care, world leaders and health experts convened by the WHO and United Nations Children’s Fund (UNICEF) endorsed the historic Alma-Ata Declaration (WHO, 1978). This advocated primary health care as the key to the attainment of the goal of health for all. The more recent Declaration of Astana (WHO, 2018) reaffirms the historic 1978 Declaration of Alma-Ata to strengthen primary health care systems. The declaration includes the emphasis on jointly understanding the influence and context of the community in the health care of the person. We are uniquely poised to champion the Astana Declaration, due to the critical role we have in the community, serving generations of families and following patients through different life stages.
The term ‘primary health care’ derives from WHO core principles describing an approach to health policy and service provision that includes both services delivered to individuals (primary care services) and population-level ‘public health-type’ functions (Muldoon et al., 2006). Therefore, an integral part of bringing good health for all or pursuing health equity (striving for the highest possible standard of health for all people and giving special attention to the needs of those at greatest risk of poor health, based on social conditions (Braveman, 2014)) is primary care. Primary care attributes (first contact access, greater focus on prevention, provision of person-focused comprehensive care, with greater continuity and coordination) are key to health equity reduction as the socially disadvantaged benefit more from a comprehensive, coordinated, person-focused (rather than a specialty driven disease-focused) view of morbidity (Kringos et al., 2010; Kruk et al., 2010; Shadmi et al., 2014). Evidence demonstrates that primary care (in contrast with specialty care) is associated with a more equitable distribution of health in populations, both cross-nationally and nationally (Starfield et al., 2005). Because health is needed for functioning in every sphere of life, primary care should not be considered as a commodity service (such as live-in chefs and housekeepers) but rather as a global common good and distributed according to need (Braveman, 2014).
Where to from here?
Global primary care refers to the scope of challenges not their location, and therefore, can be anywhere. Addressing primary care challenges wherever they occur, will help to inform genuinely global primary care. The discipline of global primary care must include training, research and service delivery that places a priority on the needs of individuals and communities, their overall health and achievement of health equity. Fully integrating global primary care into the feedback loop between training, research, and service delivery will advance equitable health and greater equity in health. These three actions must consistently be aligned, otherwise progress will undoubtedly stall, and the value realised will be just a small fraction of its potential.
GPs (along with other primary care providers) are ultimately the torchbearers for health equity globally, because GPs focus on primary care and often provide whole-person care in diverse and disadvantaged communities in ways that secondary care cannot. This role allows us to identify patient- and community-level specific factors that contribute to and sustain health inequities. Achieving health equity will require truly whole-person care—that is, individualised care by GPs/family medicine doctors who understand patients’ culture, behaviours, and socio-economic circumstances, as well as their community throughout patients’ lives.
We believe it is time to assert that achieving health equity is a common defining feature of global primary care and to begin important conversations about the nature of training, research and service. Global primary care advocates must challenge questionable priorities and take action to promote change that improves primary care globally.
