The importance of having a strong primary care sector in every country was highlighted by the World Health Organization (WHO) in 1978 at an international conference at Alma-Ata, in what is now known as Uzbekistan.1 The Alma-Ata declaration set out the aspiration of providing health for all by a primary care-led service. Here is its definition of primary care:
Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of selfreliance and self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.
Article VI, Alma-Ata Declaration, WHO, 19781
The aspirations of the Alma-Ata declaration have not yet been fully realised, but many countries are attempting to improve the health care that they offer their citizens by building a stronger base in primary care. China, for example, aims to train a further 300 000 GPs over the next 10 years, so that there will be 1 GP for every 3000–5000 people.2
The last 2 decades have seen the publication of a lot of evidence suggesting that countries which have a strong primary care sector have better health care outcomes. Professor Barbara Starfield, from the Johns Hopkins School of Public Health in the USA, published a seminal paper on this topic in 1994,3 in which she ranked developed countries according to their health care outcomes and the strength of their primary care services. Countries which had the most developed primary care services had the best health care outcomes. The USA, which had the least developed primary care system at the time, had the worst health care outcomes. In the same paper, Professor Starfield showed that the countries which spent the least per capita on health care were the countries which had the most developed systems of primary care.
A more recent analysis of data from 31 European countries4 has confirmed that health care outcomes are better in those countries which have a strong primary care base, as measured by the density of primary care providers and the quality of their environment. However, this analysis has not confirmed that these better outcomes are provided more cheaply. Today, countries in Europe which have well-developed primary care services tend to spend a larger proportion of their gross domestic product (GDP) on health than countries with less robust primary care services. According to the World Bank, in 1995 the UK spent 6.8% of its GDP on health; by 2012, it was spending 9.4%.5
