Our consultation on the 2nddraft of the Astana Declaration with our global network of PHC practitioners and activists has been limited, due to the short time frames set by WHO to receive feedback. The following comments are submitted on behalf of the Global Steering Council and some country circles and build upon our comments on the 1st draft. Comments We welcome the second draft, and recognise the difficult task in pulling together this draft, and trying to include extremely conflicting views. PHM has a number of concerns about the current draft and have highlighted a few specific areas of concern: While recognising the importance of having a declaration arising from the Astana conference, which reaffirms the importance of Primary Health Care (PHC), we would like to state upfront, that for PHM, the Alma Ata declaration has defined PHC and continued to guide and inform PHM’s work (and indeed that of many member states) on PHC. The definition and principles enshrined in the Alma Ata are ones we have not achieved and that we should still be striving to achieve. This declaration should upfront state this, and reaffirm the Alma Ata declaration. A fundamental concern for PHM is the continuing framing of PHC as a means to achieve UHC. Our understanding is that PHC, which includes actions to address social determinants of health as well as community participation, is broader and indeed subsumes UHC. UHC on the other hand is narrowly defined in most literature as financial protection for a package of services. The whole of the draft declaration, including the heading, assumes that Primary Health Care is a means to achieve UHC, which completely undermines the significant role that PHC can play in health systems [ref heading, point 3 of the principles behind the AA40 Declaration text] 3rd para starting “To address the health and development challenges of the modern era, we need PHC that:” Point 2 should include reference to the political determinants of health (in addition to social, economic and commercial). The paragraph should also highlight that governments have prime responsibility for health and health service delivery. Section “We are more likely to succeed than ever before. Our success will be driven by:” PHM earnestly hopes for greater success “than ever before”; however, the current global economic system has failed to satisfy the basic needs of much of humanity or to operate within the confines of environmental sustainability. The system is characterised by extreme inequality and poorly regulated markets, and dominated by the interests of a small rich minority in the corporate and financial sectors. If we want to achieve social goals such as health for all, and do so while simultaneously tackling climate change and achieving true environmental sustainability, then we need to redesign the global economic system to realise these aims. That increasing inequalities within and between countries is real and is a stark feature of our current world has been acknowledged in the SDG slogan ‘leave no one behind’. Phrases such as ‘..we acknowledge remarkable progress in health outcomes and are encouraged by new opportunities that propel us toward the goal of health and well-being for all’ fail to take into account that those health outcomes are unevenly distributed, due to inequitable policies and political choices. This issue, the challenges it poses and its fundamental economic and political cause need to be more clearly stated. These challenges were pointed out by the Commission on the Social Determinants of Health (http://www.who.int/social_determinants/thecommission/en/ ) in its report to WHO some ten years ago and its messages regarding health equity are still highly relevant to the PHC agenda in 2018. Subsection: Political will: The first sentence reads “We will have more partners and more stakeholders, both public and private, working towards common goals in the SDGs…..”.PHM is unconvinced that public and private are “working towards common goals in the SDG’s”. Partnerships with the private sector generally lead to private extraction of profits at the expense of public health. Unfortunately, the achievement of the SDG’s is dependent on high levels of GDP growth based on a profit-maximising, extractivist, economic model, which is both economically and environmentally unsustainable. Moreover, “political will” needs to be evidenced by a stronger role for democratic and accountable national and global government in prioritising health equity. Subsections: Knowledge and technology: PHM strongly agrees that we possess sufficient knowledge and technology to greatly improve health and narrow inequities, but their dissemination and use remains highly inequitable; even simple yet effective technologies such as vaccination and oral rehydration therapy remain inaccessible to large swathes of populations, especially in Sub-Saharan Africa and South Asia; and the digital divide has still not been bridged. Additionally, the global Intellectual property regime prevents the dissemination of new health products to large parts of the world. We strongly agree with the paragraph beginning “Reflecting on the last 40 years…”, which stresses the remaining challenges of ill health, marginalisation and inequality. This paragraph should come earlier so that it precedes and provides a framework for the section titled “We are more likely to succeed than ever before”. PHM aligns itself with the subsections falling under “To address today’s challenges…..” , however as stated earlier, we understand PHC to go well beyond UHC and are concerned that resolving to “Put public health and primary care at the centre of UHC” limits these to serving selected health service components. Additionally, it is already the case that UHC is, in many countries, manifesting as limited “packages of care” for public sector dependents and more comprehensive services for those who can afford private insurance. Page 2, under section “To Address today’s challenges……” subsection “Put public health and primary care…..” – the term non-professional should be removed before community health workers (line 4). This term is demeaning. Conclusion Throughout the document, we note that primary health care is being translated as “public health and primary care”. While we welcome the focus on public health (preventive and promotive actions), we are concerned that aspects of comprehensive PHC e.g. rehabilitative and palliative components are absent. We are concerned that there is insufficient reference to the responsibilities and role of governments and the declaration as currently worded risks placing most responsibility on the shoulders of individual citizens. We would also like to reaffirm the Alma Ata declaration statement that better health for all the people of the world 2000 can be attained through a fuller and better use of the world's resources, and the recognition that a considerable part continues to be spent on armaments and military conflicts. And that as stated in the Alma Ata Declaration, “A genuine policy of independence, peace, détente and disarmament could and should release additional resources that could well be devoted to peaceful aims and in particular to the acceleration of social and economic development of which primary health care, as an essential part, should be allotted its proper share.” We would like to emphasise a point made in our response to the first draft “The whole document fails to provide a critique of the corporate private sector and the evidence that a high level of private sector involvement is inimical to PHC and the achievement of UHC in particular. UHC should be defined as universalist, based on social solidarity and built mainly on a unified public funded system, with most service provision through public institutions. The problems of privatisation of health systems need to be highlighted – and the benefits of publicly funded and publicly provided and comprehensive services, free at the point of use stressed.”