Interview for Astana Conference, 23 October 2023 with Katie Dain, CEO of NCD Alliance

This year marks the 45^th anniversary of the Alma Ata declaration, and the 5^th anniversary of the last Astana Conference in 2018. The NCD Alliance was present at that one as well, we saw the momentum, the energy, the renewed commitments of everyone there, and so it is great to be here this year and reflect on progress made in strengthening primary health care since then. I think this is what makes this year’s conference so important – especially important in the aftermath of the COVID-19 pandemic. It’s a chance to take a look at what has worked and where the gaps still need to be closed.

Now, just a few weeks after the second UN High-Level Meeting on UHC, there are plenty of lessons learnt from the pandemic that are so relevant to PHC.

The pandemic both reinforced the importance of PHC, and set back progress towards it, and towards universal health coverage. Data from the World Health Organization and World Bank that was launched at the HLM on UHC showed that more than half of the global population – 4.5 billion people – are not fully covered by essential health services. Among them, 2 billion people face severe financial hardship when paying out-of-pocket for the services and products they need, and 1.3 billion are being pushed or further pushed into poverty just trying to access basic health care. This is a stark reality which shows widening health inequities and a trajectory that is taking us directly away from where we are aiming to go. It shows that health systems globally are failing billions of people, particularly the most vulnerable and marginalised populations. Investment in PHC is integral to changing this.

Why is primary health care central to the healthcare today and for the future?  

Our health systems today are in a transition, moving from episodic disease-specific treatment to long-term integrated health management. For noncommunicable diseases like diabetes, cardiovascular disease, and mental health disorders, this kind of PHC-based person-centred care is a huge opportunity. This is because – with integrated PHC and NCD care – every consultation can be used as an opportunity to promote healthy behaviours, and to screen for and detect conditions early or before symptoms appear.

Most NCDs can be prevented – up to 80% – and nurses, primary care physicians, and community health workers play a critical role in this aspect of care. They can increase health literacy among patients; help with smoking cessation; advise on weight, nutrition, and physical activity; provide alcohol counselling. NCDs that are not prevented can usually be managed with fairly simple treatment if they are diagnosed early. Most of the care needed – not all, but most – can be managed at primary care level, but only with early diagnosis. That is why investment in NCDs at PHC level is so critical for health systems – because prevention is far better than treatment. Prevention and early diagnosis save money as well as lives.

Furthermore, the sheer scale of the NCD burden means that it is just not feasible to manage these diseases mainly through specialists or in hospitals – it requires a shift to multidisciplinary, team-based care, and entails health workers across doctors, specialists, nurses, and community health workers, all working collaboratively to meet patient needs. This is essentially about optimisation of the health workforce – improving efficiencies, ensuring the time of all health professionals is being maximised, task shifting of key duties to community health workers or nurses.

We have seen through many initiatives now in all regions of the world and especially in low- and middle- income countries that community health workers can detect, treat and refer people with NCDs like hypertension, mental health conditions, and diabetes. They can support people living with NCDs and associated co-morbidities across the population, by promoting healthy lifestyles and preventive measures, and focusing on risk factors and patients in pre-disease stages. And they can also act as a bridge between health decision makers and communities, helping to ensure that people who use health systems are represented and having their true needs met.

Primary healthcare is the critical first level of care, the entry point into the health system. It has to be the foundation, but with secondary and tertiary levels working in conjunction – this of course is essential. Take complex NCDs like cancer – CT, MRI, and PET scanning facilities are required for diagnosis and monitoring of cancers, but are lacking in many countries.  Immunotherapy demands hospital-based services and a more specialised workforce. Many people living with cancer today would not be alive if they didn’t have specialist treatment and tertiary level care, and the same goes for many people with cardiovascular disease. PHC is extremely important, but we do need all levels of the health system functioning together to improve health outcomes as much as possible.

That being said, we have the evidence that investing in PHC will improve health outcomes for NCDs. Evidence from many WHO Euro countries shows that reductions in cause-specific premature mortality from asthma, cancer, and CVD are attributed to treatment and improvements in primary care. And we know what to do – we have the WHO package of essential non-communicable disease interventions (WHO-PEN) for primary healthcare, which has been adapted in about 30 countries, as a set of cost effective and action-oriented interventions feasible in all settings.

What we need now is leadership from the very top of governments to implement these interventions and make the investments in PHC and integrated care that are needed.

How would you assess the progress of countries since the Astana Conference in 2018 where the Astana Declaration was adopted? What positive experiences do you see in other countries in transforming primary health care? 

I think political leadership on PHC and UHC has grown over the last 5 years, and this is very promising. I’d mention in particular that we are seeing greater political recognition for social participation as a key part of UHC. Leaders are now really starting to accept and embrace the importance of engaging civil society organisations and people living with NCDs and other conditions in health policy making and governance, as well as in health service design and delivery. This changes the whole health landscape quite dramatically, because it becomes people-centred, and this is a huge achievement.

But at the same time, COVID-19 has resulted in some backsliding, with health systems still reeling in many countries, still dealing with backlog of screening and treatment and late diagnoses. This has presented a massive public health challenge, and it’s also put a spotlight on many weaknesses in health systems, particularly at PHC level. Big challenges remain in regard to NCDs specifically.

One has to do with health governance. Historically, in many countries, the PHC system has focused on responding to acute conditions, primarily infectious diseases like HIV/AIDS and tuberculosis, and maternal and child health services, which were the priorities in global health for many years – and they still are very important ones. But consequently, NCDs have remained less prioritised over the decades and many PHC systems are just not equipped to deal with chronic care and to detect and treat NCDs. They are based on a vertical, disease specific model, and there is a lack of recognition that NCDs are part of the essential PHC package.

Second, we can talk about PHC all day long, but unless we have the sufficient health workforce to manage and deal with NCDs at primary care level, we are not going to make any progress. There is a severe shortage of health workers, especially in low- and middle-income countries but in high-income countries too. In addition to numerical shortages there is uneven distribution, retention and performance. This is coupled with a lack of sufficient and accessible training for the health workforce. Investment in the health workforce, including community health workers, is absolutely essential.

Third – and we are making progress on this – is transitioning to patient-centred rather than disease-centred approaches. We need to put the patient at the centre of PHC. People living with NCDs require long-term or lifelong care that is proactive, community-based and sustainable. We need a transformation of service provision to make the day-to-day management and care of a chronic condition as easy as possible for the patient– and this is the crux of it, this is currently where we are falling down. Fixing this means for example reducing the distance people have to travel to their local health services, and ensuring the care provided is integrated and joint up. And in order to do this, governments should be involving people living with NCDs and civil society organisations in how they develop policies and design services. People living with NCDs are experts in their own right, and they need to be at the table.

And the last major challenge I’ll mention ishow to bring in sustained financing. We are starting to see some progress on this as well.

But despite these challenges, I think we should be optimistic because there have been a lot of positive experiences in countries around the world, as well as a lot of lessons learnt that can inform future interventions. All countries have different starting points, different challenges and epidemiology, different approaches. So there is no blueprint or silver bullet, but general principles that can be applied in diverse countries.

It’s also important to remember that PHC is as much a political issue as a technical one – it requires top level leadership and the political will to bring together governance; human and financial resources; data; cross-sectoral collaboration; and civil society engagement. Knowing what to do is not enough, countries need the political will to actually make it happen. And as I mentioned before, any political planning or action needs to be people-centred and community led. This is so important to ensuring that PHC is designed and delivered based on needs of people, for integrated approaches that make living with chronic conditions as easy as possible for them.

And while we are maintaining a focus on service delivery, we can’t take our attention off of the broader determinants of health. Action is needed beyond health sector – health and NCDs are an equity issue and a rights issue, and this requires an all-of-society and all-of government approach.

How would you assess Kazakhstan’s role in promoting PHC?  

The political leadership of Kazakhstan has been so important on PHC, both within the WHO Euro region and globally. They have been the leader on PHC for decades, starting with Alma Ata back in 1978, the first Astana Conference in 2018, and now in 2023 again. As with all health issues, sustained political leadership and champion governments are key to making progress. Their leadership goes well beyond hosting conferences, and having the WHO European Centre for PHC hosted in Almaty. Kazakhstan is a European reference point on contextualised PHC policies, and their technical assistance and policy advice has been invaluable to many countries.

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