By Isaac Florence
Over the past year, particularly since Dr Tedros’ election as the Director-General of the World Health Organisation, there has also been a large focus on the development of countries’ Primary Healthcare (PHC) systems. PHC put simply is a “whole-of-society approach to health that aims to ensure the highest possible level of health and well-being”. This was highlighted by the Astana Conference on PHC, co-hosted by WHO, UNICEF and the Kazakhstani Government. As one of the ten-yearly sequels to the original Alma-Ata declaration, many of the original declaration’s ideologies were brought to the fore, highlighting that few of the ideas from 40 years ago had been brought into reality. Notable areas of the declaration that weren’t achieved in the majority of signatory countries were access to clean water, attendance of midwifery personnel at births and access to child care for children under one year old.
The Astana conference and subsequent declaration were intended to be more technical and a prelude to September 2019’s UN General-Assembly high-level meeting on Universal Health Coverage (UHC). The Astana Declaration can be summarised as an agreement by governments to protect and promote health through ensuring “PHC and health services that are high quality, safe, comprehensive, integrated, accessible, available and affordable for everyone and everywhere”. Progress will be periodically reviewed, and coordination is the responsibility of governments, WHO and UNICEF.
The Astana declaration is made up of a vision document and several technical documents, ranging from digital technologies to the PHC workforce, including one on PHC and health emergencies. The document itself was written by a team from an academic institute, overseen by WHO’s Department of Service Delivery. Much of the writing of WHO’s (and other UN agencies) documents are outsourced to academic institutions, often due to the huge degree to which WHO staff – especially in the health emergencies department – are overstretched and underfunded as well as to increase the pool of knowledge and perspectives that inform the document.
The background technical document on PHC and health emergencies notes, “In emergency situations, primary care can provide essential routine health services, identify and manage emergency cases, prevent disease outbreaks with effective public health measures and play a key role in disease surveillance. While vague suggestions are made on ways to increase epidemic preparedness, such as innovative financing mechanisms in emergency situations and maintaining PHC for civilians in conflict zones and ensuring the quality of care, no direction is provided as to how they can be improved, and what WHO tools and guidelines are already available, or how WHO country offices can assist them. The document also misses discussing the increased onus on decentralisation of expertise to regional and country offices (a centrepiece of the WHO Director-General’s election manifesto), as well as the work of the WHO-World Bank Global Preparedness Monitoring Board, the World Bank Pandemic Emergency Financing Facility, and International Health Regulations integration and implementation of the early warning, alert and response system.
Using the Astana conference as a forum for discussing and prioritising health emergency preparedness within PHC would have been a logical and sensible step. It should have included the launch of a detailed, evidence-based and implementable strategy template for health emergencies and PHC. This document should have integrated with the new WHO emergencies programme and be built on recommendations from experts from the WHO UHC and health systems departments.
Preparing and responding to health emergencies is one of the most pressing issues in global health. Last week the WHO Director-General Dr Tedros and head of UN Peacekeeping Jean-Pierre Lacroix visited the active conflict zone in the Democratic Republic of Congo where efforts to contain the Ebola outbreak is looking ever more precarious as fighting hampers contact tracing and vaccination efforts. As the 2014 West Africa Ebola outbreak highlighted, diagnostic capacity, management of initial cases, provision of effective infection control measures and vaccination of contacts are just some of the measures effective PHC systems are required to deliver in outbreak and emergency situations.
There is currently strong support for both UHC and health emergency preparedness. Capitalising on this to generate substantial progress and funding quickly must be paramount. The former President of Liberia and Nobel Peace Prize winner, Ellen Johnson Sirleaf, who navigated her country through the 2014 West Africa Ebola outbreak wrote a rallying call to world leaders to increase epidemic preparedness in all countries, saying “Investing in primary healthcare is the best way to detect and stop local outbreaks before they become global pandemics”. The crucial point, however, about the global need to improve primary care and emergency preparedness for our collective safety is that “the world’s health system is only as strong as its weakest link”.
References and Reading List
WHO Newsroom – DRC Ebola reports http://www.who.int/csr/don/archive/country/cod/en/
WHO Newsroom – WHO DG – UN Peace Keeping chief in DRC http://www.who.int/news-room/detail/08-11-2018-new-measures-and-strong-partnership-having-positive-impact-on-ebola-response-in-the-democratic-republic-of-the-congo
UN Security Council Resolution 2439 – Peace and Security in Africa http://undocs.org/S/RES/2439(2018)
Global Health Security Agenda https://www.ghsagenda.org/
Astana Global Conference on Primary Care http://www.who.int/primary-health/conference-phc/background-documents
Astana Declaration background Documents http://www.who.int/primary-health/conference-phc/background-documents
Astana Declaration PHC and health emergencies technical document http://www.who.int/docs/default-source/primary-health-care-conference/emergencies.pdf?sfvrsn=687d4d8d_2
WHO-Country Cooperation http://www.who.int/country-cooperation/en/
WHO-World Bank GPMB http://www.who.int/news-room/headlines/24-05-2018-who-and-world-bank-group-join-forces-to-strengthen-global-health-security
World Bank Pandemic Emergency Financing Facility http://www.worldbank.org/en/topic/pandemics/brief/pandemic-emergency-financing-facility
WHO International Health Regulations http://www.who.int/ihr/en/
WHO Early warning, alert and response system http://www.who.int/emergencies/kits/ewars/en/
Ellen Johnson Sirleaf – The Guardian article https://www.theguardian.com/global-development/2018/oct/25/ebola-has-shown-global-health-system-strong-as-weakest-link-ellen-johnson-sirleaf
Innovation for Pandemics – Bill Gates in NEJM https://www.nejm.org/doi/full/10.1056/NEJMp1806283