A Manifesto for Universal Healthcare: Reconstituting Primary Care Through Digital Innovation, Microbial Technologies and Empowered Citizenship.

Despite unprecedented medical advances, global healthcare systems are failing to deliver universal, equitable and quality care. Many systems also have low resilience to surges in demand, are highly fragmented, or suffer from unsustainable funding models. The crisis of poor accessibility of healthcare services, which includes both lack of availability and unacceptably long waiting times, stems from systemic failures: inadequate provision of primary healthcare, suboptimal deployment of human and non-human healthcare assets, metric- and profit-centric models that exacerbate inequality, fragmented and siloed services, unsustainable costs and a reactive focus on treatment over prevention. Climate change and demographic shifts threaten to overwhelm already strained systems. In this discourse we argue that achieving the fundamental human right to healthcare requires a radical reconstitution of primary healthcare, centred on unlocking previously un- and under-exploited resources, capacities and productivity, governed by the principle of 'Networked Agency with a Safety Net'. We propose a holistic transformation that increases accessibility, resilience, integration, sustainability and, crucially, equity, centred on three synergistic pillars. First, a digital and patient-agency revolution, designed to radically increase access to, and the productivity of, primary healthcare. This involves creating self-care ecosystems such as Do-It-Yourself Digital Medical Centres and Home Clinics, supported by a National Clinical Informatics Centre. By enabling patients to manage routine care, this system frees highly trained healthcare professionals to focus on the complex clinical work that demands their full expertise. This enables and fosters patient empowerment while ensuring continuous clinical oversight (to prevent any misunderstanding: clinical oversight means that all clinical recommendations/decisions are made by healthcare professionals; patient agency involves inter alia implementing such recommendations/decisions). Second, acceleration of the strategic exploitation of microbial technologies-frugal, sustainable tools for diagnostics, prophylactics and therapies, including and especially mental health interventions, and environmental health (One Health). Third, a decisive shift towards disease prevention and health creation, integrating 'Health in All Policies', targeted comprehensive health education, and a comprehensive and systematic dismantling of healthcare accessibility barriers-such as transport impediments-and legacy forms of discrimination like restricted sexual/reproductive healthcare and failure to adequately care for the most chronically underserved, including the ageing population. This model is inherently sustainable and designed to drastically reduce the healthcare sector's carbon footprint and environmental impact through service consolidation, transport-oriented siting and green infrastructure. The measures constitute a technical upgrade and also a fundamental recasting of the primary healthcare system and mindset. This is also a moral imperative. Governments, while increasingly delegating service provision to commercial actors, hold a non-delegable duty of care. Fulfilling this duty necessitates a covenant that transitions healthcare from a market commodity to a publicly-accountable system sustainably designed for long-term resilience, equity and dignity. The roadmap we provide-encompassing governance, infrastructure, innovation and education-charts a course from crisis to a sustainable future where universal access to quality healthcare can finally be realised.