The Astana Declaration: Can Low- and Middle-Income Countries Afford Primary Care?

Date: November 29, 2018

By Daniel A. Ollendorf, PhD, Director of Value Measurement & Global Health Initiatives

The buzz from last month’s WHO Global Conference on Primary Health Care in Astana, Kazakhstan is still reverberating. The meeting’s primary purpose was to confirm a worldwide commitment to primary care as the cornerstone of universal health coverage, a commitment first made 40 years earlier with the Alma-Ata Declaration. The Astana conference endorsed a new declaration that reconfirms that original commitment, and makes strong statements about bold political choices, sustainable strategies, use of innovative technologies, education and capacity-building, and priority investments in primary care.

To be clear, there is no disagreement among global health policymakers about the intent or importance of these statements—after all, the American health care experience is too often an exemplar of the perils and pitfalls of weak primary care. But how can low- and middle-income countries (LMICs), already cash-strapped and often sites of intense political and/or military conflict, comprehensively and sustainably commit to a primary care-driven system?

Part of the answer can be found in the words of others. Five years ago, the Lancet Commission on Investing in Health published an investment framework intended to alter the way health care is delivered globally, with an ambitious goal of achieving this transformation by 2035. Among the Commission’s propositions, one is especially worth noting: to ensure population-wide delivery of an initially limited (but expandable in future) set of high-quality, cost-effective interventions that disproportionately benefit the poorest and most vulnerable in each setting. This is a compelling idea, particularly as many LMICs transition from dealing with infectious and often rapidly-fatal diseases to chronic, resource-draining, non-communicable diseases.

So, are researchers actually studying the cost-effectiveness of primary care interventions? Based on data gleaned from our Center’s Global Health Cost-Effectiveness Analysis (GH CEA) Registry, a curated, standardized dataset of published cost-effectiveness studies the answer appears to be yes. The Registry contains over 350 studies of primary prevention or other primary care interventions from 191 countries, comprising nearly 1,200 unique interventions or programs. 

The number of studies is one thing; what do we know about whether these interventions are worth their cost? Data in the GH CEA Registry again suggest they frequently are. For example, of the 402 analyses of primary care interventions reported in 2017 studies and cataloged in the GH CEA Registry, more than 80% found that the intervention evaluated was “cost-saving” (decreased costs while improving health, compared to standard practice) or favorably cost-effective – meaning that they averted a disability adjusted life year (DALY) at a cost not exceeding that country’s per capita GDP, a criterion often used to assess cost-effectiveness favorability in LMICs.

It’s possible, of course, that these impressive findings reflect some degree of publication bias, i.e., the tendency of some authors and journals to publish results that confirm expectations more often than those that clash with expectations. And an intervention that works well in one setting may not be easily transferable to another. Still, the GH CEA Registry data on primary care represents an important starting point—if policymakers need guidance on prioritizing health care investments, can we start with the accumulated cost-effectiveness evidence?

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