How we can strengthen primary healthcare to rescue failing health systems

Health systems across the European Region are in crisis, facing existential challenges from multiple directions. This includes severe and persistent healthcare workforce shortages, which, in turn, are leading to industrial action and disruptions across Europe and Central Asia; a rapidly ageing population placing a huge strain on health systems; backlogs on everything from cancer screenings to surgeries; and, disruptions to medicine and vaccine supply chains in the wake of the COVID-19 pandemic. All the while the cost of delivering quality healthcare keeps increasing, especially for the most vulnerable, while health workers struggle to make ends meet.

Not only is this unacceptable, it’s also unsustainable. The historic post-war health gains made across the European Region over the past 75 years, when the World Health Organization was born, are being reversed right before our eyes. It’s time for a rethink and a reset and a big part of the solution lies in elevating primary healthcare to its rightful place within our health systems: at the top, not the bottom.

Often overlooked in favour of more glamorous and high-tech medical advancements, primary healthcare serves as the foundation upon which resilient and flourishing communities are built. If our health system was a tree, primary healthcare would be its roots. At its heart, it’s about the people – the doctors, nurses, therapists – who remain with you throughout your life, through complex illnesses, in good times and bad, they know you and your community intimately. They provide the kind of personal care and attention that is impossible to provide in hospitals where beds are at a premium. Crucially, they can help keep you out of hospital to begin with.

We have long known the benefits of investing in primary healthcare. We know it is the most cost-effective way to prevent the escalation of health issues, reducing the need for expensive hospitalizations and intensive treatments. By identifying and addressing health problems at an early stage, in the community, primary healthcare can save both lives and money. It is an investment that pays dividends by improving overall health while curbing healthcare expenses. Yet, primary healthcare remains unfairly sidelined across the board in the European Region, in high-income and low-income countries alike. Which begs the question, why?

We believe it’s because large-scale investments into strengthening primary healthcare demands political buy-in and rebalancing incentives in the healthcare economy, which, in turn, requires a solid business case for using public money and shifting the emphasis of investment. And, while we know primary healthcare to be cost-effective, the value it produces for our communities and societies is extremely difficult to measure and quantify, because it’s not just about gains made in biological life-years. It’s also about better mental and social well-being, which leads to thriving communities.

How can you measure the value of a relationship between doctor and patient and their families over the course of a lifetime? How can you quantify the benefits of mental healthcare in the community? How can you put a value on emotional and social support for victims of violence? It’s much easier to make the business case for a sparkling new hospital of bricks and mortar, with a certain number of beds and turnover of patients.

But herein lies the problem. If our health systems are to emerge from the myriad challenges they face, stronger and fitter for the 21^st century, we need to radically shift our mindset, from a top-down to a bottom-up approach; from a physician-led to a team-based approach; from a paternalistic to a pluralistic and inclusive approach; from a health-for-the-few to a health-for-all approach, the vision that guides WHO.

We are calling for a wholesale transformation of the way everyone involved in the health sector – policymakers, health workers, educators, suppliers, distributors, producers, administrators and managers – think about healthcare.

Our request to you all is that with every decision you make, stop and ask yourself: am I promoting the strengthening of primary healthcare? Am I contributing towards health equity and inclusion? Am I leaving anyone behind? Am I promoting a primary healthcare-led health system or is primary healthcare doomed to be siloed and left to compete with other programmes time and time again?

Many countries across the WHO European Region, covering 53 Member States in Europe and Central Asia, have already started on their transformative primary healthcare journeys and are sharing lessons with others, seeing what works and what doesn’t. There is no one-size-fits-all approach when it comes to primary healthcare and WHO Europe is playing a leading role in bringing countries and policymakers together to bring ideas and innovations to life.

In Sweden for example, digital health tools are being deployed to reach far-flung remote and rural communities. In Kazakhstan, primary healthcare teams now include mental health specialists and social workers accessible for all reducing the need for expensive travel and specialist visits. In Kyrgyzstan, a new pay-for-performance system is attracting more doctors into primary healthcare.

Ireland was one of the first countries in our region to strengthen occupational health and wellbeing structures for health workers to avoid burnout. In Tajikistan, a comprehensive health labour market analysis has helped identify primary healthcare challenges, with concrete steps taken to improve the recruitment and retention of doctors in rural areas.

Another current theme is trust – or the lack thereof. During the pandemic, the foundation of trust established through strong primary healthcare providers played a crucial role in disseminating accurate information and ensuring public compliance with safety measures. It comes as no surprise then, that the countries with strong primary healthcare rooted in communities were the ones who fared better during the pandemic.

Simply put, healthy and happy societies are more resilient, more productive and more cohesive. When individuals and communities have access to preventive care and early interventions without financial hardship, they can lead fuller lives, contribute to society and unleash their potential.

In the coming days, we will join healthcare leaders, practitioners and policymakers in the Kazakh capital Astana to mark 45 years since the Alma-Ata Declaration was signed. This landmark document was a major milestone of the 20^th century in the field of public health because it identified primary healthcare as the key to the attainment of health for all, globally. Countries committed to investing in primary healthcare on the long road towards universal health coverage. Now, nearly half a century later, with the world possibly more polarized and more unequal than ever, primary healthcare couldn’t be more relevant.

As we look to the future, it’s time to reframe health.

Primary healthcare is not an expenditure or a nice-to-have. It's a long-term investment in the wellbeing of our communities, an investment that yields substantial returns in terms of public health, economic stability and social equity, however hard they are to measure.

Let us, therefore, recognize that reframing our health systems with a primary healthcare lens is not just a choice; it’s a moral obligation, a prerequisite to the kind of society in which we all aspire to live – a society grounded in trust and empathy, where health and happiness flourish for all.