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        Forty years on from Alma Ata: present and future of Primary Health Care research
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        Forty years on from Alma Ata: present and future of Primary Health Care research
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        Forty years on from Alma Ata: present and future of Primary Health Care research
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Forty years ago, the seminal Declaration of Alma Ata triggered a global movement in support of Primary Health Care (PHC) that contributed to changing research in this field [World Health Organization (WHO), 1978]. On 25–26 October 2018 in the Global Conference on PHC, the world will come together to renew a commitment to strengthening PHC to achieve universal health coverage and the Sustainable Development Goals (WHO, 2018). This Conference will also have significant implications for PHC research, as discussed below.

PHC research: stronger than ever

In the 40 years since the declaration of Alma Ata, which characterized PHC as being ‘based on the application of the relevant results of social, biomedical and health services research and public health experience’ (WHO, 1978), research in this area has seen sustained growth and expansion from being confined within the scope of the discipline of General Practice to the breadth and depth of PHC.

There is abundant evidence on the strength of PHC research across the world. Recent research has shown that its strength seems to frequently mirror the strength of PHC practice, demonstrating how research benefits from strong practice as much as excellent care delivery benefits from a sound scientific locally relevant evidence, with some countries in Europe providing unparalleled excellence and leadership (Glanville et al., 2011).

The growth and impact of PHC research prompted the creation in June of 2011 of the subject heading “Primary Health Care” in Thomson Reuters Journal Citation Reports, which offers a systematic evaluation of the relative quality and importance of a journal within its field based on citation data and which now features over 20 such journals across the globe, including Primary Health Care Research & Development (van Weel, 2011).

Originally conducted and/or led by general practitioners or family physicians and with a narrow focus on clinical decision making in clinical settings, the multidisciplinary teams conducting PHC research now include professionals with a wide range of backgrounds and expertise. This is further evidenced by the size, scope and ambition of high impact PHC departments in very competitive environments of universities and academic centres which frequently top world rankings.

Founded in 1972, the World Organization of Family Doctors (WONCA) has also played a significant advocacy role over the years fulfilling a mission in relation to research of encouraging and supporting the development of academic organizations of primary care physicians and representing their research activities (Global Family Doctor, 2018). At global, regional and national levels meetings such as WONCA World Conference, the North American Primary Care Research Group (NAPCRG), the European General Practice Research Network (EGPRN) and the Society for Academic Primary Care (SAPC) in the United Kingdom provide fora where cutting edge PHC research is promoted and disseminated. TheEuropean Forum for Primary Care (EFPC) provides an international forum annually for the bringing together of research, policy and practice and PHCRD is its official journal where members can report their work and share position statements on all aspects of PHC.

The strength PHC research is evidenced not just in the broad scope of research for supporting PHC delivery, but also on PHC policies and organizational arrangements. From the seminal works of Barbara Starfield, a towering figure in this field, to the scope and ambition of Primary Health Care Activity Monitor for Europe (PHAMEU) and Quality and Costs of Primary Care in Europe (QUALICOPC), research on the theory and practice of the organization and delivery of PHC and Primary Care has made huge advances (Starfield, 1998; Starfield et al., 2005; Schäfer et al., 2011; Kringos et al., 2015).

A renewed PHC: challenges and opportunities

Supporting PHC research is a priority for strengthening further implementation and development of PHC across the world. In addition to pressing clinical research issues, perhaps best exemplified by the need to identify best approaches for adequately responding to multi-morbidity and polypharmacy, both in terms of their management and prevention (Academy of Medical Sciences, 2018; International Symposium Multimorbidity at the cross Roads, 2018) PHC research is facing a number of challenges related to the need: to develop capacity in broad areas of the world where delivery is still perceived as the only priority; to consolidate multidisciplinary research in terms of both methodologies and research questions; to adopt efficient models of knowledge transfer; to develop narratives of the impact of research that demonstrate the huge potential benefits of investing in research that has the potential to impact broad segments of the population; to involve patients as research partners in shaping the research agenda and the study conduct; and to reinvigorate the a focus on equity, that can also effectively address the urban rural divide.

The Global Conference on Primary Care allows a unique opportunity for developing a solid framework for responding to these challenges. The renewed vision of PHC anticipates a future where physical, mental and social well-being will be assured, where everyone will have access to the health care they needwithout fear of financial hardship (WHO, 2018). The implications of this vision for PHC research are multiple.

First of all, political commitment at all levels will be needed to allocate sufficient resources to research, evaluation and knowledge management, promoting the scale-up of effective strategies for multisectoral action, public health and, specifically, primary care.

Second, it will be critical to ensure that measures of physical, mental and social well-being are appropriately identified as core outcomes of PHC interventions in the design and conduct of research, in particular through the use of patient reported outcomes [a priority already highlighted by the Organization for the Economic Co-Operation and Development (2018), which is aiming at developing patient reported of health system performance for Primary Care patients with multi-morbidity].

Third, the renewed vision supports reinvigoration of research on access to high-quality care and on economic evaluation of policies and interventions that is comprehensive and considers not only the financial implications to the payers and insurers, but also financial implications for individuals. Further research priorities should include effective approaches, including system redesign, interventions, and tools for empowering people and communities; the evaluation of the impact on Primary Care of policies and actions across all sectors aimed at addressing the broad determinants of health, while also, more generally, to have a broad perspective to scoping research that takes into consideration the social, economic, environmental and commercial determinants of health.

Finally, research addressing a number of key levers will be instrumental in providing the critical evidence to support policy decision making (Akman, 2017) for ensuring that people have access to high-quality and strong public health and primary care throughout their lives, as the core of integrated service delivery, including: measuring and evaluating the impact of policies and interventions on adequate funding and resource allocation; the development and implementation of new models of care, including refining purchasing and payment systems; measurement of quality and safety of care and evaluation of initiatives aimed at improving it; supporting the further training and development of the Primary Care workforce and thedevelopment and evaluation of new professional roles; the evaluation of necessary facilities and equipment; appropriate access to medicines; and use information and communication technology. The systematic evaluation and monitoring of efforts by country and global partners in delivering the renewed vision of PHC should be based on reliable data and support for their interpretation and use for improved decision making at all levels, from local to global levels, from the policy arena to individual patient outcomes.

Conclusion

Forty years ago, the Declaration of Alma Ata made research a core feature of PHC and stimulated and unprecedented growth and expansion of Primary Care research worldwide. The Global Conference on Primary Care 2018 offers a unique opportunity for academia to play a leading role by providing a firm evidence base for PHC while addressing a wide ranging and exciting research agenda. PHCRD offers a significant opportunity to publish cutting edge PHC research in a special issue commemorating Alma Ata (see https://www.cambridge.org/core/journals/primary-health-care-research-and-development).

Let us all make the most of this unique opportunity for the benefit of populations and communities through PHC research like never before.

References

Academy of Medical Sciences (2018) Multimorbidity: a priority for global health research. Retrieved 3 August 2018 from https://acmedsci.ac.uk/file-download/82222577
Akman, M (2017) Primary health care from the global perspective: lessons learned from current research. Primary Health Care Research & Development 18, 209211.
Glanville, J, Kendrick, T, McNally, R, Campbell, J Hobbs, FD (2011) Research output on primary care in Australia, Canada, Germany, the Netherlands, the United Kingdom, and the United States: bibliometric analysis. BMJ 342, d1028.
Global Family Doctor (2018) Retrieved 3 August 2018 from www.globalfamilydoctor.com
International Symposium Multimorbidity at the Crossroads (2018) Lessons learned. Retrieved 3 August 2018 from http://www.multimorbidity2018-stockholm.se/lessons-learned
Kringos, DS, Boerma, WG, Hutchinson, A Saltman, RB (2015) Building primary care in a changing Europe. WHO Regional Office for Europe.
Organization for the Economic Co-Operation and Development (2018) PaRIS: Patient Reported Indicators Survey. Retrieved 3 August 2018 from http://www.oecd.org/health/health-systems/PaRIS-Booklet.pdf
Schäfer, WL, Boerma, WG, Kringos, DS, De Maeseneer, J, Greß, S, Heinemann, S, Rotar-Pavlic, D, Seghieri, C, Švab, I, Van den Berg, MJ Vainieri, M (2011) QUALICOPC, a multi-country study evaluating quality, costs and equity in primary care. BMC Family Practice 12, 115.
Starfield, B (1998) Primary care: balancing health needs, services, and technology. USA: Oxford University Press.
Starfield, B, Shi, L Macinko, J (2005) Contribution of primary care to health systems and health. Milbank Quarterly 83, 457502.
van Weel, C (2011) The impact of research in primary care and family medicine: the Thomson Reuters Web of Science Subject Category ‘Primary Health Care’. Family Practice 28, 239240.
World Health Organization (WHO) (1978) The Declaration of Alma Ata. Presented at the International Conference on Primary Health Care, Alma Ata.
World Health Organization (WHO) (2018) Global Conference on Primary Health Care. Achieving Universal Health Coverage and the Sustainable Development Goals. Retrieved 3 August 2018 from http://www.who.int/primary-health/conference-phc/en