All Roads Lead to Astana

Grace is very worried. Her seven-month-old baby boy has a raging fever and chills. She lives in the Mbarara district in Western Uganda. Sheepa, a continent away in Rangpur, Bangladesh is also very anxious. She’s seven months pregnant and has been having cramps and some bleeding. For both Grace and Sheepa, the interventions they seek are different—Grace’s baby most likely has malaria, while Sheepa requires skilled maternal care. Regardless, they need access to primary health care, whether it be from the community health worker who serves Grace’s village, or the primary health clinic in Rangpur where a trained medical practitioner will ensure Sheepa is healthy and safe.

In 1978, primary health care was declared the model for global health policy at a meeting of health ministers and experts from around the world. This month marks the 40th anniversary of the International Conference on Primary Health Care (PHC), sponsored by WHO and UNICEF, and held in Alma-Ata, Kazakhstan, USSR. As global leaders led by WHO and UNICEF convene again in Astana, the capital city of the Republic of Kazakhstan, the world reflects on the journey from the ideals codified in the Alma-Ata Declaration to the embrace of universal health coverage (UHC) as part of the Sustainable Development Goals (SDGs).

Lessons from the last 40 years are reflected in the updated Astana Declaration on Primary Health Care, linking primary health care (PHC) as a key foundation of UHC in the context of 21^st century health systems. The Declaration describes PHC as a system that

1. empowers people and communities as owners of their health, as advocates for the policies that promote and protect it, and as architects of the health and social services that contribute to it;
2. addresses the social, economic, environmental, and commercial determinants of health through evidence-based policies and actions across all sectors; and
3. ensures strong public health and primary care throughout people’s lives, as the core of integrated service delivery.

The Declaration is noteworthy, in that it highlights two ideas that we at The Rockefeller Foundation believe are the bedrock of 21^st century health systems—that digital technologies are key to enabling access to health and empowering individuals to drive their health, and that community health cadres have a critical role to play in extending primary health access to households. The latter is particularly salient, given the disproportionate role that community health systems play in delivering basic services for maternal, newborn, and child health—not to mention responding to disease outbreaks, notably the 2014 Ebola outbreak in West Africa and most recently in the DRC. With increasing awareness and a growing evidence base, there has been an emergence of political commitment and support toward community health systems, though this commitment is rife with fragmentation in delivery and financing.

The vision for the Community Health Roadmap is that it will elevate national priorities and create a common agenda for investments in community health.

To elevate these emerging national priorities in community health, The Rockefeller Foundation joined a group of other global organizations that include USAID, UNICEF, the Bill and Melinda Gates Foundation, and the World Bank. Together, these organizations are developing a Community Health Roadmap with political leaders from an initial set of countries to prioritize and highlight investment opportunities that enable a harmonized and sustainable model for community health delivery. The vision for the Roadmap is that it will elevate national priorities and create a common agenda for investments in community health.

Six countries so far have engaged in the Roadmap process—Burkina Faso, Liberia, Malawi, Mozambique, Niger, and Uganda—with key themes resonating across contexts. Among others, these themes include linking community health to broader primary health systems to create a continuum of care; harmonizing financing to eliminate redundant parallel investments and enable sustainability; and the expanding digital health and health information systems to drive transparency and data-enabled decision making. These points highlight a convergence of community health, primary healthcare, health systems strengthening, and disease elimination efforts, while leveraging digital technologies to realize impact.

The increasing alignment between countries and global health actors gives hope that Grace’s baby will receive quick diagnosis and proper medication. That Sheepa will see a medical professional who treats her with dignity and gives quality care. And that not only infants and mothers, but entire communities, have access to care that is appropriate and affordable. That is the promise that community health can fulfill in the SDG era—health for all.