PHA-Exchange> Reflections on Alma Ata

[Aviva]

From: "DBanerjee" <nhpp at bol.net.in>
December 22 2002
>
REFLECTIONS ON TWENTY-FIFTH ANNIVERSARY
OF THE ALMA ATA DECLARATION
>
> The Alma Ata Declaration on Primary Health Care of 1978  which was
> endorsed
> by all the countries of the world, make a major watershed in the concepts
> and practice of public health as a scientific discipline. Expectedly, the
> vision that was endorsed at Alma Ata is the outcome of the power equations
> that had been shaping within and between countries of the world during the
> preceding
> years. India's vision in 1938 of entrusting "people's health in
> people's hands" during the anti-colonial struggle and the emergence in
> the
> course of the famous Long March of the Chinese vision of developing rural
> health cooperatives, with the `Barefoot Doctor' as the cerntrepiece, are
> instances of socio-political conditions within individual countries which
> had earlier inspired such pathbeaking endogenous thinking in public
health.
> Incidentally, the two countries contained an overwhelming majority of the
> unserved and underserved people of the world.
>
> Equally expectedly, when the power equation massively swung in favour of a
>  few rich countries of the world, the poor were made to `forget' the
> idealism contained in the solomn declarations made by them earlier.
> Significantly,
> the changes that have occured in China during the past two decades has
> virtually wiped out the rural health cooperatives, leaving vast masses of
> the poor to their fate. It is a profound irony that fearing backlash from
> the poorest of the poor, the Chinese authorities have sought assistance
from
> the World Bank to revive health cooperatives for this limited population.
> India too suffered a similar fate though, presumably because of some
degree
> of commitment to democracy, the damage to the endogenously developed
public
> health system was not as sweeping as in the case of China.
>
> HIGHLIGHTS OF THE ALMA ATA DECLARATION
>
>  1. Health is considered as a fundamental right. The state has the
> responsibility to enforce this right.
>
>  2. Instead of starting with various types of health technologies and
> considering people as almost passive recipients for them, the Declaration
> sought to reverse the relationship by considering people as the prime
movers
> for shaping their health services. It sought to straighten the capacity of
> the people to cope with their health problems which they have developed
> through ages.
>
>  3, It also visualised a wider approach to health by straightening such
> intersectoral areas as ensuring adequate supply of potable water,
> envirnmental sanitation, nutritive food and housing.
>
>  4. It called for social control of the health services that are meant to
> stregthen people's coping capacity.
>
>  5. It considered health as an intergral whole, including promotive,
> preventive, curative and rehabilitative components. Any concept of
> `selective care' was considered antithetical to the concept of Primary
> Health Care (PHC).
>
>  6. Health services ought to cover the entire population, including the
> unserved and the unserved.
>
>  7. Those aspects of traditional systems of medicine, which  are proven
> to
> be efficacious or which are the only one accessible to the people ought to
> be
> used in providing PHC.
>
> 8. Choice of Western medical technology should conform to the cultural,
> social, economic and epidemiological conditions. Particular care is to be
> taken to use only essential drugs in generic forms. Ivan Illich, in his
> book,`Limits to Medicine' had stated
> (perhaps a little exaggeratedly) how even
> in the rich countries `medicine had become a threat
> to the people' through what he called medicalisation of life,
mystification
> of medicine, professionalisaton of medicine, increasing incidence of
> medical, social and cultural iatrogeneses, among others. Later, studying
the
> rapid
> market driven technological developments, he has pointed out the
> powerful trends in making practice of medicine as a mere component of  a
> much larger `system' (systemtisation), which later turned into even bigger
> organisations in the form of `conglomerates (conglomertisation) (personal
> communication). More recently, noting that the doctor in the US have lost
so
> much of their say in the market driven
> medical practice that John McKinlay and Lisa
> Marceau, have pronounced the`end of the golden age of doctoring'.
> The PHC approach ensures that such anomalies do not creep in  the practice
> of medicine.
>
> It may be underlined that PHC is a PROCESS. Even the most rudimentary
forms
> of home remedies or use of a village bone setter could form the starting
> point of  development of PHC. Mahatma Gandhi had recognised such
limitations
> of the deprived sections of the population. In his programme of
> `Constructive
> Work', he had included very simple but effective methods of rural
sanitation
> and use of naturopathy to protect and promote the health of rural
> populations in India.
>
> EVOLUTION OF THE ALMA ATA DECLARATION
>
> Overthrow of colonial rule and rising aspirations of the liberated people,
> starting of democratic forms of government in some of the newly
independent
> countries, initiation of the cold war and formation of the Non Aligned
> Movement (NAM), have been some of the major factors which contributed to
> creation
> of conditions which tended to impel the new rulers in these countries and
> the newly formed international organisations to pay attention to some of
the
> urgently needed problem facing them. International organisations such as
WHO
> and UNICEF  bilateral agencies came forward to contribute to improvement
> of health status of the people in the needy countries. Availability of the
> so-called silver bullets tempted these organisation to launch special
> `vertical' or `categorical' programmes against some of the major scourges
> such as malaria (DDT and synthetic antimalarials), tuberculosis (BCG
> vaccination), leprosy (dapsone), filaraisis (hetrazan) and trachoma
> (aureomycin). It took them quite some time to realise that these vertical
> programmes were not only very expensive but they also failed to provide
the
> expected results. These programme also hindered the growth of integrated
> health services.This impelled them to advocate integration of health
> services, then promotion of basic health services, then going to
individual
> countries
> to promote country health planning and later, country health programming.
In
> the mid-1970s WHO got together with the World Bank to link health
activities
> with poverty reduction programmes. A World Health Assembly resolution in
> 1977, aiming for a programme of Health For All through PHC by 2000AD
> (HFA2000/PHC), set the stage for the calling of the International
Conference
> for PHC at Alma Ata in 1978.
>
> POST ALMA ATA SCENARIO
>
> There were exponential changes in the power equations between and within
the
> countries of the world from the early 1980s. Events such as the end of the
> cold war, enfeebling of the NAM, rapidly increasing influence of the
Bretten
> Woods institutions, brought about a sea change in the national and
> international
> commitment to HFA-2000/PHC. As early as in 1979, the rich countries
launched
> what
> they called Selective Primary Health Care (SPHC) on the basis of virtually
> no
> scientific data. Apparently to rub in the power of the syndicate of the
> rich
> countries and the ruling elite of the poor countries, the two sponsors of
> the Alma Ata Conference - WHO and UNICEF - were made to tow the line laid
> down by it. An active effort was made to thoroughly wash out the ideas
> generated by the Declaration to make `space' for patently unscientific
> market
> driven agenda for health for the poor countries of the world. It was a
> massive assault on the intellect of public health workers; those who
> conformed to the laid down line were rewarded and those who dared to
> disagree were simply ostracised. Public health was
> once again put on its head, with people once again becoming hapless
> recipients
> of pre-fabricated, market driven, technoentric and scientifically very
> questionable programmes imposed by international agencies.
>
> The International Monetary Fund demanded and got compliance for
fundamental
> structural
> adjustments in the economy of dependent countries . Their impact on health
> and health services for the poor was
> devastating. It meant drastic cuts on the already pathetically inadequate
> public supported health budgets. They created space for rapid growth of
the
> private sector in magical care. There was also pressure for cost recovery
> for services provided by some of the publicly funded health agencies.
Their
> pressure to globalise poor countries on grossly unequal and inequitous
terms
> turned them
> into bonded labourers in the global village dominated by the syndicate.
> The World Trade Organization (WTO) added its bit by forcing patent laws in
> many poor countries to subseve the interests of the drug manufacturing
> giants.
>
> Substituting scientific reasoning and well researched conclusions, for use
> of brute force, the syndicate  let loose a virtual torrent of
> international health initiatives on the poor countries. As admitted even
by
> the
> government of India in its Health Policy pronouncement of 2002, these
> initiatives have not
> only been highly expensive, but they have also further decimated the
general
> health services. Worse still, they have fallen far short of the objective
> for which they were launched. The Universal Imminization Programme, the
> Global Programme for AIDS, the Global Tuberculosis Control Programme, the
> Pulse Polio Programme for polio eradication and the Leprosy `Elimination'
> Programme, are examples
> of the major initiatives taken during the last decade and a half. Despite
> pouring billions of dollars, the syndicate-inspired initiatives
> are becoming a menace to the health and health services of the world's
poor.
>
> In what has turned out to be a desperate bid to regain some credibility
for
> itself, WHO managed to interest some of the top economists of the world to
> join a Commission on Macroeconomics and Health (CMH) to study
macroeconomics
> of health services for the poor people
> of the world and make its recommendations. Interestingly, it included
> the former finance minister of India and the present leader of the
> opposition in the upper house of the Parliament, Dr Manmohan Singh and the
> President of the Mitsubishi Bank. The Report is being analysed at some
> length as it provides a documentary evidence of the poor level of
> the scholarship of the members and the secretariat. The Report of the
> Commission is ahistorical, apolitical and atheoretical.
> It has adopted a selective approach to conform to a preconceived ideology.
> It has ignored the earlier work done in this field. It has pointedly
> ignored such major developments in the health services as the Alma Ata
> Declaration. This of attitude of developing massive blindspots in their
> vision has brought the quality scholastic work to almost the rock-bottom
> level. It is not surprising that the CMH has developed a tube vision in
> making recommendations on so important a subject. Their emphatic
> recommendation for perpetuating vertical programmes against major
> communicable diseases like Tuberculosis, AIDS and Malaria on the grounds
> that vertical programmes have proved to be convenient in a number of ways
to
> the `donors' lets out the real motivations for undertaking such an almost
> openly ideology driven agenda. This is a serious danger signal for
> scholars of the world who would like to have a scientific attitude towards
> programme formulations for the poor to get the maximum returns from the
> limited resources.
>
> WHAT IS TO BE DONE?
>
> A struggle for HFA-2000/PHC has to be a part of the long and very
formidable
> struggle to have a just world order. The focus of the struggle has to be
in
> individual countries. Like minded groups from individual countries will
have
> to join together to form a global movement. Some first, very tentative
steps
> have already been taken:
>
> 1. After having their own National Health Assemblies, delegates from a
large
> number of countries got together at Dhaka in December 2000 to form the
> People's Health Assembly to adopt a People's Health Charter. To carry
> forward
> the struggle for health it has formed People's Health Movement which has
set
> up branches at continental, national and sub-national levels.
>
>  2. The inaugural meeting of a World Social Forum (WSF) was held in Brazil
> in 2002. Concern for health of the poor is an important component of the
> activities of the WSF. As a prelude to the Second WSF, a meeting of the
> European Social
> Forum which was attended by two or three hubdred thousand delegates was
> recently held at
> Florence. An Asian Social Forum will be held at Hyderabad during January
2-7
> 2003.
>
>  3. A great deal of credit is due to anti-capitalist activists for
> organising sustained demonstrations against extremely heavy odds to
register
> their protest at major conclaves of rich countries in different parts of
the
> world - starting
> from Seattle and then covering cities like Gothenburg, Barcelona, Davos,
> Calgary, Doha, Genoa and
> Melbourne.
>
>  4. Another line of struggle will be to use scientific critiques as a
weapon
> to
> resist imposition of the syndicates' agenda on the poor and to offer an
> alternative one.
> To `remind' them about the Alma Ata Declaration is one such example.

> Debabar Banerji
> Emeritus Professor,
> Jawahrlal Nehru University,