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With progress towards primary health care still slow
three decades after the Alma-Ata declaration, an
effective alliance of global and country actors is needed to set
positive and realistic paths to implement the declaration’s intentions, argues Anthony Seddo.
6th October 08 - Anthony Seddo, Pambazuka News
Thirty years after the 1978 Declaration of Alma-Ata, it seems the world
is still at odds on how best to implement the principles of primary
health care. The slow progress in improving health outcomes for all
raises questions about the effectiveness of current ways of doing
business. A concerted global alliance of global and country actors
needs to set positive and realistic paths to implement the intentions
of Alma-Ata.
Sixty years ago, the World Health Organization (WHO) stated in its
constitution that health is ‘a state of physical, mental and social
wellbeing, not only the absence of disease or infirmity.’ Thirty years
later, the Alma-Ata declaration on Primary Health Care (PHC) declared
among other things that ‘health is a fundamental right’ and created a
thirteen-point outline to ensure this right. This outline captured
concepts of essential care, universally accessibility and affordability
for individuals and families within communities, who would be able to
participate fully in a spirit of self-determination. It located PHC as
an integral part of a country’s health system involving all related
sectors and aspects of national and community development.
The WHO constitution’s definition of health and the Alma-Ata
declaration together prompt a diametrical but complementary state to be
addressed concurrently in the promotion of good health. The first deals
with the clinical determinants of health, pushing for the absence of
disease in individuals. The second addresses the determinants of health
that predispose or prevent individuals from attaining a state of
mental, physical and social wellbeing as a fundamental right. These
include appropriate governance, the absence of war, economic and
infrastructure development, adequate infrastructure and aid policies. A
unique moment occurred in 1978 to bring these complementary
understandings together.
Even before the ink could dry on the Alma-Ata declarations it had
however already generated polarised antagonism. From a capitalist
standpoint, it was a ridiculous proposition, both too costly and
defying economic reasoning, and too socialist in its excessive emphasis
on state-managed intervention. The conservative duo of J.A. Walsh and
K.S. Warren launched the Selective PHC debate, arguing that it would
probably more be efficient to save children and limit population
growth, while the two main PHC proponents, WHO and UNICEF, soon drifted
apart, with UNICEF promoting a selective package of low cost
interventions. With resource flows following Selective PHC, Primary
Health Care translated in most countries into a basic collection of
services to be delivered at district and community levels based on a
select number of interventions with some outreach services, with an
accompanying watered-down district health package.
Why nobody asked at the time whether there was any moral significance
to be attached to a person’s life or pointed out that choices based on
state preferences for total health gain can be justified over financial
resource allocation efficiency is difficult to comprehend. Aside from
efficiency-based arguments being ridiculous propositions founded on
utility-based preferences or embodying unattractive equity assumptions,
the economic bargain in a healthy population should at least have also
appealed to responsible international choice.
Much has since been achieved from the advance in technology in dealing
with specific clinical determinants of specific diseases. It could be
argued that a saturation point has been reached, where increases in
financial and human investments in existing technologies are yielding
less than proportional gains. Despite this the selective interventions
approach continues to define health and health services delivery. It
was given a new lease on life by the World Bank through its 1993 World
Development Report, entitled ‘Investing in Health’. This report, which
scarcely acknowledged PHC, commoditised and de-linked health from
development and moved the world closer to an interventionist approach
to health; intervening at a selective point in the epidemiology of a
disease or health system.
This approach has since had wide global appeal. Currently there are
over thirty WHO resolutions on AIDS, TB or Malaria alone; more than all
other subjects. The Millennium Development Goals (MDGs) have further
entrenched this disease-specific approach to resource mobilisation.
There are over 80 major global health initiatives linked to the health
MDGs, providing over US$100 million annually. The Italian Global Health
Watch reported in 2008 that the Global Fund has allocated approximately
US$3.5 billion to countries for interventions on AIDS, TB and Malaria,
mainly in Africa. Together, these initiatives have thrown billions of
dollars at addressing diseases and improving clinical health conditions
and made up a significant part of health sector budgets.
PHC is hardly mentioned in these initiatives, seldom highlighted by
member states outside of anniversaries of the initiatives or occasional
references to district health system strengthening. For various reasons
the world assumed an emergency mode to address what are considered new
and urgent public health issues. Single disease interventions that lend
themselves to easily recognisable financial accountability,
quantitative monitoring and evaluation held greater appeal for funders,
especially when twinned with arguments of weak domestic governance and
public policy failures and capacity limitations.
While these initiatives on clinical determinants hummed with measurable
outcomes on specific diseases, the nexus of poverty and ill health was
exacerbated. On the back of a growing trend in urban slum development,
decline in state services, market failures in privatised economies,
growing food insecurity and massive deprivation of rights to health
care, inequalities in health have deepened to a significantly greater
level over the past 30 years.
Hence while a lot has been done to deal with disease in individuals,
the unique opportunity provided by the Alma-Ata Declaration to also
address the determinants of health have largely been lost. Thirty years
later we see the costs of this omission in levels of poverty which
belie the levels of knowledge and technological advance achieved
globally.
As we approach another anniversary for PHC expectations are high.
People expect that their physical and mental health will be promoted in
a safe social, economic and political environment. They expect to have
quality health systems that provide preventive services, and which
diagnose, treat and manage disease injury and reduce the severity and
repeated occurrence of disease. They do not expect to see wide social
and economic disparities in these basic entitlements. In Africa, the
region furthest from delivery on these expectations, the Ouagadougou
declaration on Primary Health Care issued on April 30 2008 called for a
renewal of the Principles of Primary Health Care and its implementation
in developing countries and by the international community.
Such declarations are encouraging, yet their implementation calls for
resolution of longstanding debates of the past 30 years. These debates
are not academic. In choices made over policy measures, relative
allocation of institutional, social and financial resources and
complementary systems for dealing with the social determinants of
health (mostly dealt with by actions outside the health sector), they
present social and economic inequalities that arise due to the burden
of disease (mostly dealt with within the health sector). There are no
clear answers for how a conceptual framework of Primary Health Care in
2008 will address this.
And while there is a massive coalition of global initiatives dealing
with diseases, there is no clear coalition of global institutions
supporting or funding the determinants of health, the second factor in
the PHC equation. At a global level, the Bretton Woods institutions and
OECD initiatives for debt relief and poverty reduction have in some
African countries led to short-lived increases in spending on health
and education, with no global initiatives so far adequately addressing
the determinants of health.
This leaves PHC as an orphan with no global guardian. The WHO’s attempt
to foster PHC is inadequate given the pluralistic global environment.
The state of poverty and the winds of change in international health
resource priorities will make rational choices among the various
dimensions impossible and predispose countries to the dictate of new
interventions and their implementation. While debates over the
conceptual understanding of PHC will not end in 2008, this year could
at least mark the turning point for a new institutional response, one
that builds a global alliance to generate the momentum and support for
countries to implement PHC and that provide policy learning based on
practice from the bottom up, reminiscent of another basis for the
Alma-Ata declaration.
A WHO or UN resolution creating such a global alliance would be a
befitting PHC birthday gift for the millions of people seeking more
than another conference. It will squarely put implementation right at
the doorstep of a recognisable entity that can mobilise the needed
funds and offer effective support to individual countries.
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