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JAMA Forum: Progress in Primary Care—From Alma-Ata to Astana

By Dave A. Chokshi, MD, MSc, and Louise Cohen, MPH

Image: megaflopp/Thinkstock

At the 1978 International Conference on Primary Health Care, world leaders and health experts convened by the World Health Organization (WHO) and UNICEF (United Nations Children’s Fund) endorsed the Alma-Ata Declaration “to protect and promote the health of all the people of the world.” The declaration identified primary care as the cornerstone of healthy, thriving communities; the foundation for integrating the full spectrum of health and social services to improve health outcomes; and the key to sustainable, accessible, and equitable health systems.

Forty years later, however, despite some progress, much of this vision remains to be realized. Too many patients’ first interaction with the health system is still for catastrophic care, the disease burden continues to shift from infectious diseases to noncommunicable diseases, and there is a growing impetus to improve value in health care delivery. Primary care helps address these challenges by focusing on prevention, chronic disease management, and what matters the most to each patient.

Now is an opportune time to revitalize a commitment to primary care. As leaders reconvene in Astana, Kazakhstan, for the Global Conference on Primary Health Care, an expected focus on universal health coverage is appropriate. But 2 additional priorities are fundamental to strengthen primary care in the United States: investing in primary care infrastructure and evolving primary care around a renewed repertoire of relationships that promote health.

Investing in Primary Care
Today, as in 1978, the global community grapples with providing basic, essential health care—especially for the most underserved among us, who are often at the margins of society and the center of health tragedies. In the United States, burgeoning health care costs are increasingly recognized as untenable. At the time of the Alma-Ata Declaration, on a per capita basis, health care spending in constant dollars was $2627 in 1978 and more than tripled to $10 348 in 2016. Of this spending, primary care only receives approximately 7 cents on the dollar, according to one estimate—although part of the problem is that there is no uniform definition of primary care spending, and it is not well-studied.

Some states have taken action to enhance primary care funding. Starting in 2010, Rhode Island required that commercial plans increase spending on primary care by 1% per year, so that by 2014, 10.5% of total spending would be on primary care—through payments supporting quality and efficiency, such as incentives tied to Patient-Centered Medical Home recognition. During this period, Rhode Island was the only state in New England to increase the supply of primary care physicians per capita, while spending by commercial health insurers grew more slowly compared with other states in the region. Oregon and now Delaware have followed suit.

Shifting resource allocation to primary care would help change the core infrastructure of the health system. Fully 11% of adults in the US have gone without care because of cost, but this number is doubled for people at the lower end of the income scale. Uncertainties for community health centers and other safety-net facilities (including public health care systems) exacerbate this situation.

Reducing barriers to accessing primary care—particularly limiting out-of-pocket costs—would help ensure that no one forgoes essential care because of cost. Also, funds to incentivize physicians, nurses, and allied health professionals to enter and stay in primary care careers would invigorate the workforce and create a more stable health system.

Resources also could help expand integrated behavioral health services, linkages to public health and social service organizations, additional home-based services, and telehealth services. For instance, the Netherlands has invested in a national system of nurse telephone triage with the ability to invite a patient to visit a physician in real time, arrange a physician home visit, or call for an ambulance. The nodes of the system are organized regionally by primary care physician cooperatives, facilitating rapid clinical advice while linking patients back to more longitudinal care.

Evolving Around Relationship-Centered Care
Relationship-centered care offers a framework for the evolution of primary care. Primary care clinicians may think deeply about their relationships with patients, but a broader repertoire of relationships is at play. Mary Catherine Beach, MD, MPH, and colleagues describe 4 categories of relationships: between clinicians and patients, clinicians and other practitioners, clinicians and communities, and individual clinicians’ relationship with themselves (such as their capacity for self-knowledge).

Recentering primary care around the clinician-patient relationship would augment the value of time dedicated to forging relationships. This would also help us think about deploying human and technological resources differently. In so doing, we might more easily move away from a one-size-fits-all approach in engaging patients in the clinic. For instance, community health workers could cultivate connections based on other sources of trust—such as understanding health challenges particular to a given neighborhood.

Relationships among clinicians must evolve to recognize that primary care is the essential steward of whole-person care within the health system. It also means that primary care teams “flatten out,” so that nurses, social workers, and pharmacists take the lead on core clinical tasks like chronic disease management, counseling for depression, and medication titration. Primary care physicians, as part of their duty to manage relationships with other clinicians, should help protect patients from the harms of overdiagnosis and overtreatment.

Primary care practices are also increasingly responsive to broader community health concerns, such as food security and criminal justice involvement. The relationship between primary care and public health should be mutually reinforcing, with actions at the community level strengthened and supported by primary care clinicians for every individual who receives care. For example, a municipality may enable access to naloxone without a prescription, but primary care clinicians must ensure that patients with opioid use disorder receive medication-assisted treatment.

The final category of relationships that Beach and colleagues called attention to was clinicians’ relationship with themselves. The national conversation about burnout has particularly reverberated within primary care, as clinical responsibilities and regulatory requirements have piled up without adequate resources and support for frontline staff. Clinicians not only find themselves overworked but also find themselves spending too much time doing work that feels inconsistent with their values. If the key to healing relationships is an authentic connection, what does this look like for oneself? One promising approach is to reconnect with one’s calling, nourishing the values that led one to health care in the first place. For instance, Schwartz Rounds, Mayo Compass groups, and the Healer’s Art course (for medical students) open up interdisciplinary spaces to discuss the humanistic aspects of medicine, such as the social and emotional issues that emerge in patient care. One retrospective study of Schwartz Rounds found decreases in perceived stress and improvements in the ability to cope with the psychosocial demands of care.

The 40th anniversary of the Alma Ata Declaration is an opportune occasion to reconsider how well we are achieving the goal of making primary care foundational to the health care system. Providing adequate resources is essential. Creating durable, trusting relationships offers a path to improving outcomes and satisfaction. Both are needed for primary care to achieve its promise as a driver of health equity and community well-being.

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About the authors:

Dave A. Chokshi, MD, MSc, is the chief population health officer of New York City Health + Hospitals—the largest municipal health system in the United States. He is a primary care internist at Bellevue Hospital and clinical associate professor of population health and medicine at the New York University School of Medicine. He also serves as a member of the board of directors of the nonprofit Primary Care Development Corporation. Twitter: @davechokshi. The views expressed in this post do not necessarily reflect the position of NYC Health + Hospitals or NYU. (Image: NYU Langone Medical Center)

 

 

Louise Cohen, MPH, is the Chief Executive Officer of the Primary Care Development Corporation (PCDC), a national nonprofit organization and US Treasury–certified community development financial institution dedicated to building, expanding, and strengthening the nation’s primary care infrastructure. Previously, Cohen was vice president for Public Health Programs at a leading New York City not-for-profit, overseeing programs to improve community health through food access and nutrition, women’s reproductive health, tobacco control, and child development. Cohen also held successive leadership positions at the New York City Department of Health and Mental Hygiene, including as Deputy Commissioner of the Division of Health Care Access and Improvement. Twitter: @LouiseCohen. (Image: Ron Hester/Primary Care Development Corporation)

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.