Policy bite: Making a global declaration

Making a global declaration – how to influence and advocate?

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I hope all WONCA members reading this will know that in July there was a very short period when the final draft of the “Astana Declaration on Primary Health Care: From Alma-Ata towards Universal Health Coverage and the Sustainable Development Goals” allowed people to comment on this version. At least three of our Executive – myself as President through being invited onto an International Advisory Group for WHO, Anna Stavdal through her involvement in the WHO Europe Advisory group, and Viviana Martinez-Bianchi, as WHO Liaison had seen the previous versions, and were relieved to see the words ‘family physicians’ appear for the first time in the recent one! We can consider this a small victory, but the process remains a curious one – open to all, with an online survey: so will it be the number of comments that will count or the status of the submitters? The quantity? Or the quality?

Faced with this dilemma, we submitted a formal response on behalf of WONCA after gathering as many views as we could via Member Organisation, Executive, and Working Party inputs. We got more than 80 inputs, and are grateful to all. But we also encouraged others to reply in their own right, hoping that our many key messages and communications in the past would enable you to use these as you saw fit.

On the whole the draft met with conditional approval, especially because it did have the words ‘family physicians’ in the text. Much of the commentary addressed the following big issues:

Terminology –There were requests for definitions, and concern that the term family physicians would not be interpreted as meaning specialist family doctors. Similarly, a debate about whether primary health care was adequately defined, and whether the message on the necessary workforce was clear.

Implementation – concerns that the Declaration does not hold countries and governments to account, and that its ideals will not be implemented in practice: also that, because it is short and general in its terms, there is room for misinterpretation of its goals towards a minimal model. In addition, many said that the ‘how to do it’ was not adequate, both in financial and practical terms.

Equity issues – although the draft does claim a global aim, there were major concerns that key inequities were not addressed – a particular omission being rural health and health service inequities; also gender, poverty, and vulnerable communities such as victims of violence. The need to help the disempowered was also emphasised by our members.

Absence of explicit commitment to training and research capacity as core to a fit-for-purpose workforce and health system.

Level of detail – this was a recurrent theme, but there was also acknowledgement that the Declaration might need to be short and in ‘plain English’: respondents varied on this.

Overall ethos – person centredness, efficiency, avoiding overpayment and overmedicalisation, an absolute societal commitment to address social determinants of health, and the caring / interpersonal nature of professional motivation and trust should all be made more visible.


Our messages back to WHO have reflected the areas of comment you have sent, and a draft summary on which our online submission has been based is shown here.

1. “WONCA welcomes the overall emphasis of the Declaration on the central importance of effective primary health care to achieve universal health coverage. We fully support the inclusion of family physicians in the document, as we know our medical speciality is central to integrated person-centred care that can bring together all aspects of preventive, acute and ongoing care for individuals and their communities.

2. We want to see even more emphasis on the key elements of effective equitable health care – accessible and high quality, as well as available and affordable, and also culturally and linguistically appropriate care provided in a timely manner.

3. Our organization has consistently asked for recognition that the biggest equity challenges for health care are poverty and rurality; and we know that women, children, those in poor health, and displaced persons often have even greater challenges in accessing care than the rest of the population. We want to see these dimensions explicitly mentioned in the Declaration’s commitments.

4. We also note that, while empowerment and partnership are really key areas, illness and neediness can make us all powerless for a period – and that good health care should protect and support us in these vulnerable periods of our life. This includes the right to care in all stages.

5. We want to strengthen the commitment to implement changes – too often a Statement like this becomes a paper exercise. We understand that W.H.O. aims to build momentum across its members and partners for an implementation cycle following the launch of the Declaration in Astana, and will seek to ensure this occurs – for the good of our patients.

6. We recognise the need to make a bold clear statement, but many members sought further detail and were concerned that technical guidance and even definitions were lacking. We urge W.H.O. to pursue its stated commitment to providing further detail, and our experts will support review of this to ensure that the details of ‘who can’ and ‘how to’ achieve truly great PHC are useful.

7. In particular, many urged a further statement on the PHC workforce, and government commitment to training, developing academic capacity, effective recruitment and retention policies, and an investment in the status and sector of PHC. Too often this sector has not had effective workforce development: without family doctors, primary care nurses and other community-based staff, PHC for UHC cannot become a reality.

8. Finally, we know that good health care at all levels cannot exist without the right values and motivation driving the healthcare workers, the public, and all citizens. Strong PHC needs to be driven by a real commitment to the needs of others. This comes above technology and knowledge – which should be servants of the people, not masters”.

We have suggested some rewording and reordering in the Declaration, in line with these views. Things are changing minute by minute – We are submitting this to the July deadline of 19/7/18, and many waters will have run under bridges by the time you read it in August! But we reiterate here that WONCA welcomes the declaration, looks forward to its final version, and even more to seeing strong PHC delivering UHC on a global basis. The family doctor workforce will play its major part, and we shall aim to hold others to do the same.

Amanda Howe, WONCA President
Viviana Martinez-Bianchi, WONCA-WHO Liaision