Primary health care · UHC · Health systems
Primary health care first: what the Astana Declaration still asks of health systems
Strong primary care is the most reliable route to universal coverage. What it takes to make it work in practice, from the community upwards.
Avicenna Consulting International · · 2 min read
The 2018 Astana Declaration renewed a commitment first made at Alma-Ata in 1978: primary health care (PHC) should be the foundation of every health system. Decades of evidence back this up. Where PHC is strong, people get care earlier, costs are lower, and outcomes are more equitable. Yet in many countries, hospitals still absorb the largest share of attention and funding.
What good PHC looks like
Three elements stand out:
- Integrated services that respond to a person's needs over time, rather than separate programmes for separate diseases
- Multisectoral action, because nutrition, water, sanitation, education and income shape health as much as clinics do
- Empowered people and communities who help shape, and hold accountable, the services they use
Practical foundations
A defined package, delivered at the right level. Decide which services belong at the community, basic health unit and first referral level, and make sure each level has the staff, medicines and equipment to provide them.
Community-based workers linked to facilities. Community health workers extend the system to people who rarely reach a clinic, but only when they are trained, supervised, supplied and paid reliably, and connected to a referral pathway.
A referral system that works. If patients bypass primary care because it is unreliable, hospitals become overcrowded. Clear referral rules, feedback between levels and transport options make a real difference.
Supportive supervision. Regular, constructive visits improve quality more than occasional inspections.
Financing that follows primary care. Budgets, payment methods and staffing norms should favour PHC rather than defaulting to hospital spending.
Measuring progress
Useful signals include the share of the health budget going to primary care, availability of essential medicines and staff at the first level, coverage of basic services, and the rate of avoidable hospital admissions.
Why this matters now
Pressure from outbreaks, ageing populations and rising chronic disease can pull systems towards crisis response. Strong PHC is also the best defence: it detects problems early, keeps essential services running, and builds trust.
Investing in PHC is rarely headline-grabbing. It is, however, the closest thing health systems have to a reliable strategy.
