The covid-19 pandemic has reminded us of the critical role that primary healthcare has in keeping our communities safe and healthy, say Orin Levine, Atul Gawande, Gina Lagomarsino, Edward Kelley, Lu Wei Pearson, and Muhammad Ali Pate

The covid-19 pandemic has been the most disruptive event for health systems across the world in a century. It’s forced them to tackle a new infectious disease, protect health workers and patients, and figure out how to still deliver essential health services. The virus has preyed especially on the vulnerable, setting back global efforts to ensure that everyone everywhere has access to equitable, high quality care whenever they need it. 

But we know how to get back on track.

Two years ago, world leaders endorsed the Declaration of Astana, marking their commitment to strengthening primary healthcare as the cornerstone of resilient health systems and the most effective pathway towards health for all. The global community united behind high quality primary healthcare, where person centered, comprehensive frontline services are capable of meeting the majority of people’s health needs at every stage of life. It provides the foundation for strong health systems that can prevent, detect, and respond to infectious disease outbreaks; improve health outcomes for the world’s most vulnerable people; and strengthen a broad and inclusive movement for universal healthcare. 

The covid-19 crisis has highlighted what happens when resilient, high quality primary healthcare is not in place: not only do people face a deadly virus without frontline support, but they also suffer collateral damage to their health from a dramatic drop in access to, availability of, and demand for the essential health services they rely on.

The consequences of not investing in primary healthcare are severe—and we’ve seen them before. During the 2018-2019 Ebola outbreak in the Democratic Republic of the Congo (DRC), disruptions in essential health services became an even bigger crisis than the outbreak itself: plummeting vaccination rates led to the world’s largest measles outbreak, which by November of last year had killed more than twice the number of people who died of Ebola. 

Today, 90% of countries are experiencing wide ranging interruptions to essential health services, with low and middle income countries hit hardest. Early models predicted an additional 1.2 million children and 50 000 mothers could die from interrupted maternal and child health services alone, with new data from the Global Financing Facility and World Health Organization (WHO) confirming fears about the scale of these disruptions. 

Strong health systems grounded in primary healthcare are able to maintain essential health services even during emergencies, including treatment for reproductive, maternal, newborn, and child healthcare; noncommunicable diseases; malnutrition; HIV/AIDS, TB, and malaria services; and more. With smart investments in primary healthcare, countries can ensure they have a robust and capable health workforce, which operates in efficient and well equipped facilities bolstered by strong supply chains and disease surveillance networks, responsive to the people and communities they serve. 

When primary healthcare is strong, these same systems also become a robust first line of defense against disease outbreaks and global health security threats. From testing to contact tracing, to treating and referring those who fall ill, the frontline health workers who deliver primary care every day are also the backbone of pandemic response efforts.  Effective testing and tracing depends on people’s trust and confidence that the health system is there to serve them, and that recommended public health measures can keep them safe. This trust relies on the people centered orientation that primary healthcare providers show in their daily work. Once safe and effective vaccines and therapeutics are available, this same trust will be key to building demand and distributing these resources equitably. 

Achieving high quality primary healthcare is a whole of society commitment. Policy makers and health workers need more and better data on the state of their primary healthcare, using tools like the Primary Health Care Performance Initiative’s Vital Signs Profiles, to understand where their gaps are and how to close them. Governments and development partners should use such data to drive policies and investments that make services more resilient and equitable. Civil society and private sector organizations must be full partners in these efforts, helping to drive a cycle of accountability for better health for all.  

As countries and global institutions decide how to allocate limited resources in the wake of covid-19, the commitments made at Astana remind us of the critical role that primary healthcare has in keeping our communities safe and healthy—in times of both crisis and calm. By placing strong primary healthcare at the core of our approach to global health security, countries can emerge from this pandemic stronger and more resilient to future disease threats. 

Covid-19 calls on us to urgently recommit to what we have collectively recognized is the key to delivering care that is equitable, accessible, and comprehensive under all circumstances: a foundation of strong primary healthcare at the core of our approach to global health security. The road to recovery, readiness, and resilience runs through Astana. 

Orin Levine is the director of global delivery programs at the Bill & Melinda Gates Foundation. Before joining the foundation, Dr Levine was a professor of international health and executive director of the International Vaccine Access Center at Johns Hopkins University’s Bloomberg School of Public Health. Twitter @OrinLevine

Atul Gawande is the chairman of Ariadne Labs, Haven Healthcare, and the global surgery charity Lifebox. He is a general and endocrine surgeon at Brigham and Women’s Hospital and a professor in the Department of Health Policy and Management at the Harvard T H Chan School of Public Health. Dr Gawande is also a staff writer for The New Yorker magazine and has written four New York Times bestsellers. Twitter @Atul_Gawande

Gina Lagomarsino is the president and CEO of Results for Development, which supports change agents around the world who are working to build strong health systems. Gina previously helped design and launch the Joint Learning Network for Universal Health Coverage. Twitter @LagomarsinoGina

Edward Kelley is the director of the Department of Service Delivery and Safety at the World Health Organization. Before joining WHO, he served as director of the National Healthcare Reports for the US Department of Health and Human Services in the Agency for Healthcare Research and Quality. Twitter @etkelley419

Luwei Pearson is the acting associate director and chief of Health Programme, at UNICEF’s New York Headquarters. Dr Pearson has worked with UNICEF for over 20 years at HQ, regional, and country levels and received a special recognition from the government of Ethiopia for contributions to strengthening primary healthcare in 2013. Twitter @PearsonLuwei

Muhammad Ali Pate is the global director of health, nutrition, and population global practice of the World Bank and the director of Global Financing Facility for Women, Children, and Adolescents. Dr Pate previously held several senior global health and development positions, including the chief executive officer of Big Win Philanthropy and the minister of state for health in the Federal Republic of Nigeria. Twitter @muhammadpate

Competing interests: None declared.