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Improving standards for primary care for children and adolescents in Europe, Central Asia and beyond: the WHO Pocket Book of Primary health care for children and adolescents
  1. Susanne Carai1,2,
  2. Sophie Jullien1,
  3. Martin W. Weber1
  1. 1WHO Athens Quality of Care and Patient Safety Office, WHO Regional Office for Europe, Athens, Greece
  2. 2Global Paediatrics, University Witten Herdecke Faculty of Health, Witten, Germany
  1. Correspondence to Dr Susanne Carai, WHO Athens Quality of Care and Patient Safety Office, WHO Regional Office for Europe, Athens 10675, Greece; carais{at}

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Primary healthcare has been a global priority since the 1978 Alma Ata Declaration when it was identified as the most inclusive, effective, and efficient approach to promoting physical and mental health.1 The Astana Declaration of 2018 reaffirmed the central role of primary care as a cornerstone for achieving universal health coverage for all, including children.1

Less consensus exists on what primary healthcare concretely entails and which are the health services that can and should be delivered safely at the primary healthcare level for children and adolescents.

With the Integrated Management of Childhood Illness (IMCI), launched in the 1990s, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) set standards for the management of the most frequent causes of preventable mortality in children under 5 years.2

However, many important areas of child health are missing from IMCI, for example, non-communicable diseases and adolescent health. In addition, the quality of existing primary healthcare is not always optimal. Health professionals in primary care do not always have the appropriate training, evidence-based information, and resources required for holistic and good quality care.

To help solve these problems, the WHO European Regional Office has recently published the WHO Pocket Book of Primary health care for children and adolescents for the European region—based on evidence-based guidelines for health promotion, disease prevention and management (figure 1).

Figure 1

The WHO Pocket Book of Primary health care for children and adolescents.

It implements the shift in thinking about child and adolescent health required to attain the sustainable development goals: moving from a focus on survival of children under 5 years to a holistic view of child health that also includes health promotion, disease prevention, early risk factor management and management of chronic conditions.3 It includes guidance for major causes of morbidity and mortality in children from 0 to 18 years of age, considering the epidemiological and demographic changes affecting child health since the launch of IMCI. Guidance is provided for the differential diagnosis and management of frequent presenting complaints and conditions to ensure relevance and usefulness for primary care providers, as well as rarer but important conditions responsible for a significant loss of healthy life years, such as childhood cancer and chronic diseases. With a dedicated chapter on well-child visits and a section on promotion of early childhood development, it puts a focus on disease prevention and health promotion. It also includes information to enable the primary healthcare provider to coordinate the continued care of children and adolescents with long-term conditions and diseases managed by other specialists. With a chapter dedicated especially to adolescent health, the scope is extended beyond the care of children under 5 years of age (figure 1).

The Pocket Book is available in a handy format and stands out by being user-friendly with visual features such as colour coding, illustrations, charts and algorithms, similar to its successful sister, the WHO Pocket Book of Hospital care for children.4 Translation into other languages is underway as well as the development of a mobile phone application. The Pocket Book is intended for use by all—doctors, nurses and other health workers—who are responsible for the care of newborns, children and adolescents at the primary healthcare level and can be used as basis for medical training. It sets standards for services to be delivered at this level including the required equipment and diagnostic tools. The guidelines are evidence based and developed to meet the requirements, realities and needs of the European region. They can easily be adapted by any country to take into account their specific circumstances and to promote ownership and uptake.

Primary healthcare is often distrusted by patients and bypassed to directly access hospitals or other specialist services, which are perceived—rightly or wrongly—to provide better care.5 Resources are allocated predominantly to hospitals and curative services in many settings. Actual government spending on primary healthcare is meagre, at $3 per capita in low-income countries and $16 in lower middle-income countries, which falls short of the WHO cost estimate of around $60.6 The share of government spending on primary healthcare in relation to their Gross Domestic Product (GDP) is lower in lower-income countries than in high-income countries. This prioritisation is reflected in the equipment available at primary healthcare facilities, which have often little more to offer than a desk and a pen 5. It is also reflected in the salaries of the health workers staffing these facilities, which in some countries are lower than the average salary in the general population.7

The Pocket Book of Primary health care for children and adolescents aims to bring quality primary care to all children and adolescents. It intends to end the persistent problem of non-evidence-based practices, particularly the indiscriminate use of antibiotics and inappropriate medicalisation (ie, preferring invasive or active treatment over conservative or watchful management, intravenous treatment over oral rehydration therapy and multiple drugs over just one), and unnecessary hospitalisation.8 The lack of mental health services and the insufficient focus on prevention and promotion of healthy growth and development can also be tackled by implementing these guidelines.

The newly established WHO Athens Quality of Care and Patient Safety Office is working with countries to support the implementation, awareness, and promotion of the Pocket Book through national adoption, alignment of existing standards and making available required medicines, equipment, and other resources. While training materials to support the implementation of the Pocket Book in the context of continuous education are being developed, the focus is put on integration into university curricula to ensure sound training and sustainability.

Four decades after the historic Declaration of Alma Ata, the foundation of primary healthcare and a global call for health for all, barriers and challenges remain that prevent primary healthcare from reaching its full potential of delivering health services that are of high quality, safe, comprehensive, integrated, accessible, available, affordable and acceptable for everyone, everywhere.

The Pocket Book of Primary health care for children and adolescents will help to make quality primary healthcare a reality for children and adolescents in the European region, however, it will not be able to do so alone: health systems and community aspects will need to be strengthened, which in turn will require adequate investments.

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The authors gratefully acknowledge support of the editorial group of the WHO Pocket Book of Primary Health Care for Children and Adolescents in Europe, particularly Julia Mutevelli.



  • Twitter @SusanneCarai

  • Contributors SC wrote the first draft of the manuscript. MWW and SJ provided critical appraisal of the manuscript. SC made subsequent revision.

  • Funding The development of the Pocket Book and related activities were partially funded by the Federal Ministry of Health of Germany.

  • Disclaimer The authors alone are responsible for the opinions expressed in this publication and they do not necessarily reflect the policies and positions of the WHO.

  • Competing interests MWW is a staff member of the WHO.

  • Provenance and peer review Not commissioned; internally peer reviewed.