Interview with Dr Otmar Kloiber, WMA Secretary General, on the upcoming WHO Global Conference on Primary Health Care in Astana, Kazakhstan, 22-23 October 2018

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Interview with Dr Otmar Kloiber, WMA Secretary General,
on the upcoming WHO Global Conference on Primary Health
Care in Astana, Kazakhstan, 22-23 October 2018
In September 1978, the WHO staged the first International Conference on Primary Health Care in
Alma-Ata, Kazakhstan (at that time a part of the Soviet Union). The outcome was a document
widely known as the Alma-Ata Declaration on Primary Health Care. The conference also started a
program called “Health for All in the Year 2000” setting targets that should improve the health
status of all nations.
Forty years later, the WHO has called for a second Global Conference on Primary Health Care,
hosted this time by the government of Kazakhstan, along with WHO and UNICEF, in its new
capital Astana. Peteris Apinis, editor of the World Medical Journal talked to Otmar Kloiber,
Secretary General of the World Medical Association about the significance of this conference.
Apinis: Next month health ministers, representatives of WHO, UNICEF, the World Bank and the
International Monetary Fund will meet in Kazakhstan for the 2nd
Conference on Primary Care. Will
it be as successful as the first conference?
Kloiber: I hope it will be a much bigger success than the Alma-Ata conference.
Apinis: You sound as if you were not satisfied with the outcome of the Alma-Ata conference. Why
is that?
Kloiber: Alma-Ata was the biggest WHO event ever, however the results where patchy or mixed,
to put it kindly. The Alma-Ata Declaration reads well, but what many countries took away from it
was no more than a minimalist approach. Primary Health Care became a cheap substitute for real
care. This has led to disappointments and misunderstandings, and sometimes to a rejection of the
concept of Primary Care. This must not happen again. Primary Health Care should be at the core of
every health care system, even of the most advanced and comprehensive health care systems.
Primary Health should not be a dead-end road and should not be seen as a second-class concept for
poor people.
Apinis: Do you mean that Primary Health Care is only for affluent countries?
Kloiber: No, no it is truly for everyone. Health care systems should be organised around a solid
core of Primary Health Care providing prevention, medical treatment, dental care, rehabilitation and
palliative care. This should offer pathways to secondary and tertiary care. But when starting up a
health care system, your focus will have to be on Primary Health Care as this provides care options
for most health needs. But again: it must not be a dead-end road. When serious conditions and
trauma cannot be dealt with, frustrations will rise. Comprehensive health care systems have to be
built around the core of Primary Care.
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Apinis: Why now after 40 years?
Kloiber: Yes, this is late. In fact the WHO issued a remarkable report in 2008 entitled “Primary
Care – Now more than ever”, but obviously this advice was not taken. Now the WHO is looking
into Universal Health Coverage. This is the most ambitious WHO program ever: the desire to bring
affordable health care to everybody, not sectorial, siloed programs, not episodic care – real health
care for all people. If you want to achieve this, Primary Health Care is the first step on the delivery
side.
Apinis: What is on the other side?
Kloiber: Aiming for Universal Health Coverage means, in the first instance, tackling the Social
Determinants of Health. Without bringing justice – some people call it “social justice” – to people
Universal Health Coverage will remain wishful thinking. And yes, this must include providing the
necessary financial resources. If countries don’t understand that health care is an investment and not
an expense they will not get this done.
Apinis: What mistakes should be avoided this time?
Kloiber: It needs a comprehensive approach, starting with the Social Determinants of Health, and it
must not end with a high-quality Primary Care service – although establishing this first is a sound
idea. After Alma-Ata, countries reduced their ambitions to a minimum of care – they thought the
cheaper the better. In some places where health targets were aimed at everything else got forgotten.
The typical “window-dressing” problem: Fulfil the targets to look good, drop the rest. This can
easily turn into a fatal concept.
Apinis: What is the role of medical doctors in Primary Health Care?
Kloiber: Everybody who needs a doctor should be seen by a doctor. Medical doctors have the
highest level of competency and they should lead the primary care team. This doesn’t mean that
doctors have to direct and command everything. There are other professionals that can contribute
with their expertise, but in the end this is about health and medicine. Medical doctors should be in
charge wherever this is possible.
Apinis: This sounds very logical, why are you stressing it?
Kloiber: Firstly, doctors are a scarce resource in many countries. We must understand that in the
short run a doctor will not be available everywhere. Secondly, there are groups and donors who
again want to “save money”. At the World Health Assembly this year we heard all too often that
doctors are too expensive. Some want to focus only on Community Health Workers; others such as
the OECD prefer nurses as leaders of Primary Care teams, giving physicians more of a bystander’s
role. In my opinion these are perfect recipes for repeating the mistakes of 1978. Investment in
human resources for health must include investment in the education and employment of
physicians.
Apinis: Is there no role for nurses and Community Health Care Workers?
Kloiber: There definitely is. Nurses are desperately needed, for nursing care. Community Health
Care workers can support health professionals through outreach work, especially in rural
communities. And this again is no simple task. A lot can be done right now by well-trained
Community Health Care workers, and more will be possible in the future with better and more
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intelligent e-health tools. But this will not replace a nurse, it will not replace a dentist, it will not
replace a physiotherapist, a pharmacist or a physician.
Apinis: What do you expect from the Astana Conference – or more specifically from the
participants?
Kloiber: From the WHO: keep aspirations high and do not settle for second best. From politicians:
go for Universal Health Coverage, even if it will be a long journey. The Social Determinants of
Health have to be on the agenda of every minister in every government and quality Primary Health
Care is a sound delivery concept to start with. From donors: support sustainable solutions and not
quick fixes that don’t last. From doctors: engage for the Social Determinants of Health, for
equitable access to health, health care and medical care.
Apinis: Dr Kloiber thank you for your insights.