In My View ... Prof Chris van Weel


Introduction by the President:
As I mention in this month’s ‘From the President’ column, we in WONCA need to be alert to the undermining of family medicine and its key role in delivering comprehensive primary care to communities globally. At the same time, we need to be proactive to ensure better understanding within our health systems of the benefits of adopting a qualified, doctor-led, primary care team. My guest this month, Past President Professor Chris van Weel, has been involved with WONCA for more than forty years! He has long been an advocate of WONCA speaking out on the benefits of effective, professional primary care teams as the basis for health systems. We welcome his reminder – and take on his challenge to WONCA, to advocate at every possible opportunity.

Prof Chris van Weel writes:

On October 27, 2018, the World Health Organization (WHO) Conference in Astana, approved a declaration to strengthen primary health care [1]. It acknowledges the importance of primary health care, as a core function in health systems, to attain universal health coverage [2]. This declaration is a welcome support for health reforms around the world particularly now it has been endorsed by the World Health Assembly [3] . With the unanimous backing of all 196 member countries of WHO, the stated ambitions provide guidance for national governments to invest in primary health care and in the improvement of the quality of and access to health care for their populations. For WONCA and its member organizations ‘Astana’ should therefore be seen as a major landmark and frame of reference for the coming years.

From Alma Ata to Astana

The Astana declaration may evoke memories of Alma Ata and 1978, when WHO had adopted, for the first time, a stated policy on primary health care [4].’Alma Ata’ came at a time when family medicine and primary health care were internationally still in their infancy. WONCA had only been founded six years previously by 18 member organizations. ‘Alma Ata’ was a visionary statement that never lost its conceptual attractions, but never fulfilled its political potential.

In that respect, Astana is in all probability better timed: it relates to the concerns of global sustainable development and the planned actions to address this [5]. WONCA, on a global scale, and its member organizations in their jurisdictions, should actively engage in this broader field. Working with other sectors will create new opportunities for health reforms and find new allies to change existing power structures.

Between system structures and professional positions

In engaging in the implementation of Astana, it is essential that family doctors, together with nurses, midwives, and other allied health professionals, present their perspectives and competencies [6]. After all, the quality and effectiveness of primary health care, and with it the ability to realize universal health coverage, is determined by their professionalism [6, 7]. However, here lies the great disappointment of Astana [1]. As in 1978, in Alma Ata, the Astana declaration failed to acknowledge the professionals who should undertake much of the implementation action – suggesting that the mere provision of health care structures would do the trick. And given the strong development in family medicine and primary health care in relation to service delivery and academia, the disappointment in 2018 is more dramatic than in 1978.

WONCA has been expeditious in redressing this through a Memorandum of Understanding (MOU) with WHO [8] that stresses the collaboration needed to realize Universal Health Coverage; delivery of primary care with a central role for family doctors; and development of cross-disciplinary education and training to improve professional quality. The realization of this MOU is a jewel in the crown of WHO-WONCA collaboration for which the WONCA President and leadership should receive lots of praise.

The World Health Assembly resolution WHA62.12 (2009) as a learning experience

The failure to include professionals in the Astana declaration should also cause some self-reflection for WONCA leaders and representatives of WONCA Member Organizations (MOs). In 2009 WONCA, together with The Network: Towards Unity for Health [9], did lead the presentation and subsequent acceptance of a resolution by the WHO World Health Assembly (WHA) of a resolution that, even then, outlined the ambitions of ‘Astana’. It provided a key role for primary health care to realize universal health coverage; stressed the importance of people at the centre of health systems; and urged governments to support the position and education of primary health care professionals – in the wording of the resolution:
‘…. to train and retain adequate numbers of health workers, with appropriate skill mix, including primary health care nurses, midwives, allied health professionals and family physicians, able to work in a multidisciplinary context, in cooperation with non-professional community health workers in order to respond effectively to people’s health needs’ [10].

Although this was celebrated at the time, WONCA only occasionally revisited or referred to this text in its own publications and presentations – assuming that what was on paper would be part of the action. That was, sadly, not the case.

Operating in post-Astana international primary health care

Astana has taught us a different lesson – that of the importance of continuously informing and educating other stakeholders of the, for us, well-known facts about primary health care and family medicine. It would have been much more difficult for the participants at the Astana table to ignore reference to the role of primary health care professionals had their attention been drawn more intensively during the preceding years to the text of resolution WHA62.12 of 2009. It was, after all, a statement of governments of 196 countries around the world, not the private assumptions of WONCA and its leadership.

Now, post Astana, WONCA is in an even stronger position than before. We need to use the lessons learnt from previous years and regularly remind partners and stakeholders of the values of primary health care and family medicine. And, in this context, WONCA and its Member Organizations should frequently and explicitly refer to statements, data, evidence and information that may seem well-established in our professional eyes. We should also refer to primary health care nurses, midwives, allied health professionals and family physicians as professionals – with a professional and academic frame of reference in its own right – and not as ‘workers’. We must capitalise on the opportunities presented by ‘Astana’ to build effective, professional primary care teams.

1. World Health Organisation. Astana declaration from Alma-Ata towards universal health coverage and the sustainable development goals 25–26 October 2018. Astana, Kazakhstan: WHO. 2018.
2. Universal Health Coverage. Sustainable Developmental Goal 3: Health. Geneva: World Health Organization; 2017. Available: (accessed 2019 March 06).
3. Binagwaho A, Ghebreyesus TA. Primary healthcare is cornerstone of universal health coverage. BMJ 2019; 365 doi:
4. World Health Organisation. Declaration of Alma Ata 1978. Geneva: WHO, 1978. (accessed 2019 March 06)
5. Sustainable development goals: 17 goals to transform our world. Geneva: United Nations; 2015. Available: -goals/ (accessed 2019 March 06).
6. Muijsenbergh M van den, Weel C van. The essential role of Primary Care professionals in achieving Health for All. Ann Fam Med 2019; 17: 293-95
7. Weel C van, Kidd MR. Why strengthening primary health care is essential to achieving universal health coverage. CMAJ 2018 April 16;190:E463-6. doi: 10.1503/cmaj.170784
8. WHO-WONCA Memorandum of Understanding. 2019 more here
9. The Network: Towards Unity for Health. (accessed 2019 March 06).
10. Primary health care, including health system strengthening. Proceedings of the sixty-second World Health Assembly. Resolution WHA62.12; 2009 May 22. Geneva: World Health Organization. Available: (accessed 2019 March 06).