Viviana Martinez-Bianchi, M.D.: 40 Years after Alma Ata: My Experience at the WHO/UNICEF Global Conference on Primary Health Care

Thursday, December 27, 2018

Viviana Martinez-Bianchi
Viviana Martinez-Bianchi, M.D., FAAFP

While living in Argentina, back in 1978, I was 14 years old when my father, a vascular surgeon, showed me a newspaper article that highlighted the Declaration of Alma-Ata. “This,” my father said, citing the call to action to develop primary health care with an emphasis on health equity and health for all, “will make a difference in the health and lives of people of the world.” I read it with attention, and told my dad I wanted “a career that would involve primary care, taking care of babies, children and adults together with teaching and policy making at the world stage.” “What specialty should I go into?” I asked. “That specialty has not been created,” my dad said. “You will find your own path.”

Forty years later, I find myself at the Global Conference on Primary Health Care hosted by the WHO, UNICEF and the Ministry of health of Kazakhstan, an Argentina and U.S.-trained family physician, a clinician and educator representing the World Organization of Family Doctors together with the WONCA Leadership team. Having spent the last year involved in inputs to the Declaration of Astana and collating the collective responses of family doctors from around the world, I have a sense of responsibility to represent, to engage, to collaborate, to listen and to advocate for health for all. In this role, I am making the case for health systems and governments investing in the training of family doctor leaders and members of teams to meet the health care needs of communities worldwide.

The conference emphasized how the world failed to meet the dream of Alma Ata. Even though there has been progress on global health, with life expectancy now 10 years more than in 1978, and a 2/3 decrease in the risk of dying before the age of 5 years old, preventable child and maternal mortality remain high. In addition, chronic non-communicable diseases such as coronary artery disease, stroke, and COPD have replaced acute infections as major causes of morbidity and mortality. That beautiful declaration did not meet many of its goals due to a milieu of issues, from lack of political will, to lack of investment in primary health care, to market-driven health systems that failed to put communities and people at the helm of their lives, and devoid them of any decision making power. The conference highlighted that lack of access to healthy foods, safe and healthy environments, or even clean water cause disease worldwide; and that over 100 million people are pushed into extreme poverty each year because of out-of-pocket health expenses. In addition, it informed how the underdevelopment of primary health care worldwide, has led to health systems emphasizing sick care, without coordination, continuity, or preventive measures in place. 

The Declaration of Astana aspires to be a vision for PHC in the 21st century. It serves as guide and shows a commitment by countries around the world to make concerted efforts to build health systems with strong PHC to accelerate progress on universal health coverage and really improve health for all and the health-related Sustainable Development Goals. Members of the WONCA delegation and other family doctors present in Astana were encouraged to see an emphasis on

  • “meeting people’s health needs through comprehensive promotive, protective, preventive, curative, rehabilitative and palliative care throughout the life course, strategically prioritizing key health care services aimed at individuals and families through primary care and the population, with essential public health functions as the central elements of integrated health services”
  • “systematically addressing the broader determinants of health (including social, economic and environmental factors, as well as individual characteristics and behaviour) through evidence-informed policies and actions across all sectors;
  • empowering individuals, families and communities to optimize their health, as advocates of policies that promote and protect health and well-being, as co-developers of health and social services, and as self-carers and caregivers”.

This part of the vision document, in many ways described what we do as family doctors. Our concern is that the actual members of the primary health care team were never named in the declaration, thus not providing enough guidance and support for a well-defined PHC workforce. Until a few weeks prior, the public draft had included family doctors and nurses in the declaration. Our concern is that in many countries, the primary health care team is not trained to meet the complexity, diversity and variety of health care needs that present for care at primary health centers, and having postgraduate-trained family doctors working in multidisciplinary teams with nurses, community health workers, midwives, technicians, and assistants would answer these needs.

The conference showcased best practices and opportunities for success. Ministers and secretaries of health, government representatives and many other organizations (non-government collaborating actors with the WHO) highlighted ways to improve, practice and invest in Primary Health Care. WONCA leaders participated as lecturers in side events, panel discussions, with passionate participation during Q&A sessions, and with a strong presence in networking. We are family doctors; we are specialists in Primary Health Care, and understand its values, its comprehensiveness, and its potential.

As a director of the Duke Family Medicine Residency Program, I had special pride when I learned that one of our own Duke residents, Clayton Cooper, M.D., MBA, had been selected by WHO out of 2,000 applicants, to attend the Global Conference, and to be trained as part of a network of young global leaders. It was special to be in Astana with Clay during such an important global moment.

The more I listened and participated in the conference, the more I am convinced, that the answer for well run and managed primary health care systems worldwide is to strengthen family medicine working in interdisciplinary teams within the community, providing comprehensive health care that can truly resolve most problems. Family medicine should be engaged in cross sector partnerships with the community, academia, all health professionals’ schools, public health, private sector, NGOs, hospitals and narrow focus specialty clinics, business and policymakers to improve health.

Read More: First-year resident Clayton Cooper, M.D, MBA, blogs about his experience attending the conference.

Viviana Martinez-Bianchi is program director of the Duke Family Medicine Residency Program. Email with questions.
Editor’s note: A member of the Duke Family Medicine Residency Program leadership team guest blogs every month. Blogs represent the opinion of the author, not the Duke Family Medicine Residency Program, the Department of Community and Family Medicine or Duke University.