Alma-Ata at 40 years: reflections from the Lancet Commission on Investing in Health

Watkins, David; Yamey, Gavin; Schäferhoff, Marco; Adeyi, Olusoji; Alleyne, George A.O.; Alwan, Ala; Berkley, Seth; Feachem, Richard; Frenk, Julio; Ghosh, Gargee; Goldie, Sue J.; Guo, Yan; Gupta, Sanjeev; Knaul, Felícia Marie; Kruk, Margaret E; Nugent, Rachel; Ogbuoji, Osondu; Qi, Jinyuan; Reddy, K. Srinath; Saxenian, Helen; Soucat, Agnès; Jamison, Dean T.; Summers, Lawrence H.

doi:10.1016/s0140-6736(18)32389-4

Cited by 81 publications

(83 citation statements)

References 80 publications

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“…The impact modelling confirms the catalytic role that PHC can play for the UHC and SDG agenda. Most interventions within the SDG price tag were classified as PHC, which is consistent with Watkins and colleagues, 9 who classified 198 of 218 essential UHC interventions as PHC. Almost 75% of the health gain previously estimated as part of the SDG agenda 10 can be achieved through investing in PHC interventions under measure 1, with the caveat that many high-burden diseases, such as hepatitis, neurological and musculoskeletal disorders, and most cancers were not included in the impact analysis for the original SDG price tag on which the PHC-specific analysis draws.…”

Section: Discussionsupporting

confidence: 83%

“…8 Global PHC costs were estimated in a 2018 study based on a defined set of services delivered through selected platforms that serve as first point of contact. 9 Watkins and colleagues 9 thus estimated that total annual costs of delivering PHC interventions in lowincome countries and lower-middle-income countries, at 80% population coverage, would amount to $350 billion, or about $97 per capita (2016). However, their approach did not explicitly consider that different countries have different capacities for scale-up and did not provide details on the type of system investments needed.…”

Section: Introductionmentioning

confidence: 99%

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Guide posts for investment in primary health care and projected resource needs in 67 low-income and middle-income countries: a modelling study

Stenberg

Hanssen²,

Bertram³

et al. 2019

The Lancet Global Health

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Background Primary health care (PHC) is a driving force for advancing towards universal health coverage (UHC). PHC-oriented health systems bring enormous benefits but require substantial financial investments. Here, we aim to present measures for PHC investments and project the associated resource needs. Methods This modelling study analysed data from 67 low-income and middle-income countries (LMICs). Recognising the variation in PHC services among countries, we propose three measures for PHC, with different scope for included interventions and system strengthening. Measure 1 is centred on public health interventions and outpatient care; measure 2 adds general inpatient care; and measure 3 further adds cross-sectoral activities. Cost components included in each measure were based on the Declaration of Astana, informed by work delineating PHC within health accounts, and finalised through an expert and country validation meeting. We extracted the subset of PHC costs for each measure from WHO's Sustainable Development Goal (SDG) price tag for the 67 LMICs, and projected the associated health impact. Estimates of financial resource need, health workforce, and outpatient visits are presented as PHC investment guide posts for LMICs. Findings An estimated additional US$200-328 billion per year is required for the various measures of PHC from 2020 to 2030. For measure 1, an additional $32 is needed per capita across the countries. Needs are greatest in lowincome countries where PHC spending per capita needs to increase from $25 to $65. Overall health workforces would need to increase from 5•6 workers per 1000 population to 6•7 per 1000 population, delivering an average of 5•9 outpatient visits per capita per year. Increasing coverage of PHC interventions would avert an estimated 60•1 million deaths and increase average life expectancy by 3•7 years. By 2030, these incremental PHC costs would be about 3•3% of projected gross domestic product (GDP; median 1•7%, range 0•1-20•2). In a business-as-usual financing scenario, 25 of 67 countries will have funding gaps in 2030. If funding for PHC was increased by 1-2% of GDP across all countries, as few as 16 countries would see a funding gap by 2030. Interpretation The resources required to strengthen PHC vary across countries, depending on demographic trends, disease burden, and health system capacity. The proposed PHC investment guide posts advance discussions around the budgetary implications of strengthening PHC, including relevant system investment needs and achievable health outcomes. Preliminary findings suggest that low-income and lower-middle-income countries would need to at least double current spending on PHC to strengthen their systems and universally provide essential PHC services. Investing in PHC will bring substantial health benefits and build human capital. At country level, PHC interventions need to be explicitly identified, and plans should be made for how to most appropriately reorient the health system towards PHC as a key lever towards achieving UHC and the ...

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Section: Discussionsupporting

confidence: 83%

Section: Introductionmentioning

confidence: 99%

Guide posts for investment in primary health care and projected resource needs in 67 low-income and middle-income countries: a modelling study

Stenberg

Hanssen²,

Bertram³

et al. 2019

The Lancet Global Health

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show abstract

“…The survey dataset had 4601 respondents from a population of 16 323 eligible newly graduated physicians. 1 The original survey was distributed electronically to all the medical school graduates previously registered with one of Brazil's 27 Regional Medical Councils in 2015. To overcome the possible response bias from the students accepting to participate in the survey, the sample was stratified according to sex, public or private nature of the medical school, and geographic origin, as identified by the medical school attended.…”

Section: Data Set and Variablesmentioning

confidence: 99%

“…Primary health care (PHC) services are essential to improve the health of populations throughout the world. The 1979 Alma Ata declaration placed PHC at the core of those health policies aimed at reducing mortality and morbidity, as well as at maximising the impact of health spending in low-and middle-income countries (LMIC) [1]. However, shortages of primary care physicians are increasingly reported throughout the world, as fewer medical students select PHC and family medicine specialties in rich [2][3][4] as well as poorer countries [5].…”

Section: Introductionmentioning

confidence: 99%

The role of private education in the selection of primary care careers in low and middle-income countries. Findings from a representative survey of medical residents in Brazil

et al. 2020

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Background: Primary health care (PHC) doctors' numbers are dwindling in high-as well as low-income countries, which is feared to hamper the achievement of Universal Health Coverage goals. As a large proportion of doctors are privately educated and private medical schools are becoming increasingly common in middle-income settings, there is a debate on whether private education represents a suitable mean to increase the supply of PHC physicians. We analyse the intentions to practice of medical residents in Brazil to understand whether these differ for public and private schools. Methods: Drawing from the literature on the selection of medical specialties, we constructed a model for the determinants of medical students' intentions to practice in PHC, and used secondary data from a nationally representative sample of 4601 medical residents in Brazil to populate it. Multivariate analysis and multilevel cluster models were employed to explore the association between perspective physicians' choice of practice and types of schools attended, socio-economic characteristics, and their values and opinions on the profession.Results: Only 3.7% of residents in our sample declared an intention to practice in PHC, with no significant association with the public or private nature of the medical schools attended. Instead, having attended a state secondary school (p = 0.028), having trained outside Brazil's wealthy South East (p < 0.001), not coming from an affluent family (p = 0.037), and not having a high valuation of career development opportunities (p < 0.001) were predictors of willingness to practice in PHC. A low consideration for quality of life, for opportunities for treating patients, and for the liberal aspects of the profession were also associated with future physicians' intentions to work in primary care (all p < 0.001). Conclusions:In Brazil, training in public or private medical schools does not influence the intention to practice in PHC. But students from affluent backgrounds, with private secondary education, and graduating in the rich South East were found to be overrepresented in both types of training institutions, and this is what appears to negatively impact the selection of PHC careers. With a view to increasing the supply of PHC practitioners in middle-income countries, policies should focus on opening medical schools in rural areas and improving access for students from disadvantaged backgrounds.

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“…38 Understanding who is being missed, and why, requires disaggregated data, focusing attention on the root causes of exclusion, the social construction of gender, and the development of interventions that benefit impoverished populations. 39 The 2018 Astana Declaration, renewing human rights pledges from the Declaration of AlmaAta, has recommitted governments to primary health care as an essential step towards UHC. 40 "Finding that all roads lead to UHC", 41 WHO views UHC as the "best path to live up to WHO's constitutional commitment to the right to health".…”

Section: Universal Health Coverage As a Foundation For The Health Agementioning

confidence: 99%

70 years of human rights in global health: drawing on a contentious past to secure a hopeful future

Gostin

Meier

Thomas³

et al. 2018

The Lancet

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Alma-Ata at 40 years: reflections from the Lancet Commission on Investing in Health

Cited by 81 publications

References 80 publications

Guide posts for investment in primary health care and projected resource needs in 67 low-income and middle-income countries: a modelling study

Guide posts for investment in primary health care and projected resource needs in 67 low-income and middle-income countries: a modelling study

The role of private education in the selection of primary care careers in low and middle-income countries. Findings from a representative survey of medical residents in Brazil

70 years of human rights in global health: drawing on a contentious past to secure a hopeful future

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