PHA-Exch> Is the declaration of Alma Ata still relevant to primary health care?

[Claudio Schuftan]

From: Ken Harvey k.harvey at medreach.com.au

Is the declaration of Alma Ata still relevant to primary health care?

http://www.bmj.com/cgi/content/full/336/7643/536?

Stephen Gillam, consultant in public health

1 Institute of Public Health, Cambridge CB2 2SR

sjg67 at medschl.cam.ac.uk

Thirty years after WHO highlighted the importance of primary health
carein tackling health inequality in every country, Stephen Gillam
reflects on the reasons for slow progress and the implications for
today's health systems

After years of relative neglect, the World Health Organization has
recently given strategic prominence to the development of primary health
care. This year sees the 30th anniversary of the declaration of Alma Ata
(box 1). Convened by WHO and the United Nations Children's Fund
(Unicef), the Alma Ata conference drew representatives from 134
countries, 67 international organisations, and many non-governmental
organisations. (China was notably absent.) Primary health care "based on
practical, scientifically sound and socially acceptable methods and
technology made universally accessible through people's full
participation and at a cost that the community and country can afford"
was to be the key to delivering health for all by the year 2000.1
Primary health care in this context includes both primary medical care
and activities tackling determinants of ill health.


Box 1 Characteristics of primary health care from Alma Ata declaration1

    * Evolves from the economic conditions and sociocultural and
political characteristics of a country and its communities

    * Is based on the application of social, biomedical, and health
services research and public health experience

    * Tackles the main health problems in the community—providing
promotion, preventive, curative, and rehabilitative services as appropriate

    * Includes education on prevailing health problems; promotion of
food supply and proper nutrition; an adequate supply of safe water and
basic sanitation; maternal and child health care, including family
planning; immunisation against the main infectious diseases; prevention
and control of locally endemic diseases; appropriate treatment of common
diseases and injuries; and provision of essential drugs

    * Involves all related sectors and aspects of national and
community development, in particular agriculture, animal husbandry,
food, and industry

    * Requires maximum community and individual self-reliance and
participation in the planning, organisation, operation, and control of
services

    * Develops the ability of communities to participate through education

    * Should be sustained by integrated, functional, and mutually
supportive referral systems, leading to better comprehensive health care
for all, giving priority to those most in need

    * Relies on health workers, including physicians, nurses, midwives,
auxiliaries, and community workers as well as traditional practitioners,
trained to work as a team and respond to community's expressed health needs


In the polarised world of the cold war, the declaration inevitably
reflected political and semantic compromises. Nevertheless, its ambition
resonated powerfully with a generation of leftward leaning doctors,
plying their trade in what is often regarded as a golden age for general
practice in the United Kingdom. Sentimental celebration of the
anniversary alone has little meaning for later generations, but the
visions still have relevance today.

Primary health care eclipsed

Early efforts at expanding primary health care in the late 1970s and
early 1980s were overtaken in many parts of the developing world by
economic crisis, sharp reductions in public spending, political
instability, and emerging disease. The social and political goals of
Alma Ata provoked early ideological opposition and were never fully
embraced in market oriented, capitalist countries. Hospitals retained
their disproportionate share of local health economies.

In many health systems, a medical model of primary care dominated by
professional vested interests resisted the expansion of community health
workers with less training. Such programmes anyway proved difficult to
sustain, and little empirical research existed to justify them. Many
international agencies sought early, tangible results rather than the
fundamental, political changes implied by the original concept of
primary health care. Selective primary health care and packages of low
cost interventions such as GOBI-FFF (growth monitoring, oral
rehydration, breast feeding, immunisation; female education, family
spacing, food supplements) in some respects distorted the spirit of Alma
Ata.2 The failure in most countries to provide even limited packages,
coupled with the proliferation of vertical initiatives to tackle
specific global health problems, hastened its eclipse.

Geographic and financial inaccessibility, limited resources, erratic
drug supply, and shortages of equipment and staff have left many
countries' primary care services disappointingly limited in their range,
coverage, and impact. Primary health care was hardly mentioned in the
millennium declaration.3

Challenges facing health systems

Low and middle income countries, like high income ones, face an
increasing prevalence of non-communicable illness. This shift has
already led to the coexistence of persisting infectious disease,
undernutrition, and reproductive health problems alongside emerging
non-communicable disease and related risk factors (such as smoking,
hypertension, obesity, diabetes, stroke, and cardiovascular disease).
This epidemiological transition poses considerable challenges to health
systems. Most systems are oriented to maternal and child health and the
care of acute, episodic illness. Primary healthcare services appropriate
to future needs will have to be able to deliver effective management of
chronic disease.

At the halfway stage, progress towards the millennium development goals
is least impressive where the neediest populations live, notably in
sub-Saharan Africa.4 Global initiatives tackling priority diseases like
AIDS, tuberculosis, and malaria may undermine broader health services
through duplication of effort, distortion of national health plans and
budgets, and particularly through diversion of scarce trained staff.5
Holistic care is often neglected in favour of the technicalities of
controlling disease.

Ironically, Alma Ata highlighted the limitations of top-down, single
issue programmes. Primary health care and the horizontal integration of
health programmes is integral to attainment of the millennium
development goals.6 For example, efforts to integrate preventive
chemotherapy programmes targeting five of the so called neglected
tropical diseases are projected to result in cost savings of up to 47%.7

Primary health care is also the key interface linking, on the one hand,
ambulatory care with hospital and specialty services and, on the other,
individual clinical care with community-wide health, nutrition, and
family planning programmes. Failure to recognise the inter-relationship
between components of a district health system has resulted in great
inefficiency.8 In low income countries this first level of care could
deal with up to 90% of demands.9 Evidence suggests that health systems
that are oriented towards primary health care are more likely to deliver
better health outcomes and greater public satisfaction at lower costs.10

No single system of primary health care can be universally applicable.11
A major challenge is to establish the most effective combinations of
interventions that can target multiple conditions and risk factors
affecting key groups (children, women, and older adults, for example)
and that are appropriately adapted to local epidemiological, economic,
and sociocultural contexts. Clustering of interventions can achieve
comprehensiveness despite resource constraints. Such clusters are likely
to include the integrated management of childhood illnesses; maternal
and reproductive health services; clinic and community based management
of tuberculosis, HIV and AIDS, and other sexually transmitted
infections; management of malaria; management of hypertension and other
cardiovascular risk factors, stroke, and cardiovascular disease; mental
illness and substance misuse.12

Not only does primary care constitute the first point of patient or
family contact, it is also a critical base for extending care to
communities and vulnerable groups. Outreach services may focus on
individual preventive measures (such as immunisation, vitamin A, or oral
rehydration therapy) or community-wide health promotion (such as
education on child nutrition or adult diet and exercise). These services
depend substantially on community support and mechanisms for
identifying, training, and supporting village or community health
workers.13 14

However, the empirical evidence on large scale and routine primary
healthcare programmes is scant.6 There is plenty of evidence for cost
effective interventions that could vastly improve maternal and child
health,15 for example, but less evidence on how to ensure these services
reach the most vulnerable populations to lasting effect16—and without
the detrimental concomitants of vertical approaches. A community focused
operational research agenda has been neglected in favour of research on
individual interventions. Evaluations of new ways of organising primary
healthcare services in specific settings are required. Such research is
complex because it is context specific and dependent on local capacity
and commitment. Translation of the evidence into coherent, operational
strategies at district level and below will be an equally big challenge.

Affordability remains the over-riding and universal challenge. What
services can realistically be provided free at the first point of
contact and what mix of financing mechanisms should be promoted to do
so? The place of user charges for primary health care remains contested
for they have repeatedly been shown to deter those most likely to
benefit from preventive activities.17 Indeed, one way to reach poorer
people is to provide them with financial incentives to visit services.
Many countries are piloting schemes that give money or vouchers to
increase access to particular services such as maternity care.18 19
Other ways to improve equitable access include monitoring delivery of
service and health outcomes in separate population groups and provision
of incentives to service providers to deliver services to vulnerable
groups.20 The reality in low and middle income countries is that most
primary medical care will continue to be provided by private and
non-governmental organisations. How can independent providers be
encouraged to deliver centrally determined priorities? (The UK's
quasi-independent general practitioners provide some instructive
experience.)

Many places, and particularly sub-Saharan Africa, have crippling
shortfalls in human resources, partly as a result of international and
internal migration; hence the renewed interest in the possible
contribution of community workers. Ironically, poor countries that
emulated training standards in industrialised countries have been most
vulnerable to poaching by them.21 One of the greatest challenges is to
overcome the loss of motivation and sense of resignation of many primary
healthcare workers who work in understaffed settings. They lack
consistent managerial support and have grown accustomed to a norm of
inadequate service.22

In most developing countries jobs in primary health care are regarded as
low status, and are less valued than those in hospital medicine by both
the public and policymakers. Only high level political commitment and
adequate governance and funding will raise the status of primary care
and attract suitable workers. Various bodies have recently proposed that
15% of the budgets of disease oriented programmes be invested in
strengthening primary healthcare systems by 2015 ("15 by 2015").23

Past and future threats

Many industrialised countries have extensively improved their primary
tiers, influenced to varying degrees by Alma Ata. For others, including
the UK, the rhetoric of Alma Ata was of mostly symbolic importance.
Pivotal turning points in the postwar development of general
practice—notably the Family Doctor Charter of 1966—were already yielding
benefits. The UK already boasted some of the best primary medical care
in the developed world. British general practice has been one of the
main reasons for the relative efficiency of the National Health Service.
But moves under the current Labour government to create a market for
these services threaten to fragment health care and erode the public
support that holds the NHS together.24 Experience from North America
suggests that dividing the care of chronic diseases between different
commercial companies principally concerned to increase profit margins
results in less efficient (higher transaction costs) and more
inequitable (excluding patients at higher risk) care.25

Effective primary health care is more than a simple summation of
individual technological interventions (box 2). Its power resides in
linking different sectors and disciplines, integrating different
elements of disease management, stressing early prevention, and the
maintenance of health. A patient centred approach—a striking feature of
family medicine in northern European countries but barely reflected in
the medical curriculums of most developing countries—strives to tailor
interventions to individual need.26 On the other hand, the concept of
the empowered consumer engaged in shared decision making is far from
what was implied by the term community participation. Health
professionals can be supported and rewarded for roles that promote
social mobilisation. Support for intersectoral action should come from
ministerial level downwards.


Box 2 Essential components of effective primary health care

    * Well trained, multidisciplinary workforce

    * Properly equipped and maintained premises

    * Appropriate technology, including essential drugs

    * Capacity to offer comprehensive preventive and curative services
at community level

    * Institutionalised systems of quality assurance

    * Sound management and governance systems

    * Sustainable funding streams aiming at universal coverage

    * Functional information management and technology

    * Community participation in the planning and evaluation of
services provided

    * Collaboration across different sectors—for example, education,
agriculture

    * Continuity of care

    * Equitable distribution of resources


Health systems are part of the fabric of social and civic life.27 They
both signal and enforce societal norms and values through the personal
experiences of providers and users. The declaration of Alma Ata helped
to entrench the idea of health care as a human right. This anniversary
provides a salutary reminder of what we are placing at risk.

Summary points

    The declaration of Alma Ata defined primary health care 30 years ago
    Although it had huge symbolic importance, its effect in practice
was more limited

    Community participation and intersectoral action remain challenges
for those working to reduce health inequalities

    The changing global burden of disease and workforce shortages make
effective integration of existing vertical programmes essential

    Primary health care is key to providing good value for money and
enhancing equity

    Alma Ata remains relevant for effective healthcare systems today


Editorial, doi: 10.1136/bmj.39496.444271.80

I thank Jennifer Amery for comments.

Contributors and sources: SG also works as a general practitioner.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

References

   1. WHO. Declaration of Alma Ata. International conference on primary
health care, Alma-Ata, USSR, 6-12 September 1978. Geneva: WHO, 1978.
www.who.int/hpr/NPH/docs/declaration_almaata.pdf.
   2. Tejada de Rivero D. Alma-Ata revisited. Persp Health 2003;8:1-6.
   3. Travis P, Bennett S, Haines A, Pang T, Bhutta A, Hyder N, et al.
Overcoming health systems constraints to achieve the millennium
development goals. Lancet 2004;364:900-6.[CrossRef][ISI][Medline]
   4. UN. The millennium development goals report 2007. New York: UN, 2007.
   5. De Maeseneer J, Willems S, De Sutter A, Van de Geuchte I,
Billings M. Primary health care as a strategy for achieving equitable
care. Centre for Health Policy, 2007.
www.wits.ac.za/chp/kn/De%20Maeseneer%202007%20PHC%20as%20strategy.pdf.
   6. Doherty J, Govender R. The cost-effectiveness of primary care
services in developing countries: a review of the international
literature. Washington, DC: World Bank, 2004.
   7. Brady M, Hooper P, Ottesen E. Projected benefits from integrating
NTD programs in sub-Saharan Africa. Trends Parasitol
2006;22:285-91.[CrossRef][ISI][Medline]
   8. Unger J-P, De Paepe P, Ghilbert P, Soors W, Green A, et al.
Disintegrated care: the Achilles heel of international health policies
in low and middle-income countries. Int J Integr Care 2006;6:1-20.[Medline]
   9. World Bank. Better health in Africa: experience and lessons
learned. Washington, DC: World Bank, 1994.
  10. Macinko J, Starfield B, Shi L. The contribution of primary care
systems to health outcomes within organization for economic cooperation
and development (OECD) countries, 1970-1998. Health Serv Res
2003;38:831-65.[CrossRef][ISI][Medline]
  11. Meads G. Primary care in the twenty-first century. An
international perspective. Oxford: Radcliffe, 2006.
  12. Bryce J, Victora C, Habicht J-P. Programmatic pathways to child
survival: results of a multi-country evaluation of integrated management
of childhood illness. Health Policy Plan 2005;20:15-7.
  13. Wagstaff M, Claeson M. Improving service delivery. In: The
millennium development goals for health: rising to the challenges.
Washington, DC: World Bank, 2004:111-31.
  14. Haines A, Sanders D, Lehmann U, Rowe A, Lawn J, Jan S, et al.
Achieving child survival goals: potential contribution of community
health workers. Lancet 2007;369:2121-31.[CrossRef][ISI][Medline]
  15. Bryce J, El Arifeen S, Pariyo G, Lanata C, Gwatkin D, Habicht J,
et al. Reducing child mortality: can public health deliver? Lancet
2003;362:159-64.[CrossRef][ISI][Medline]
  16. Victora C, Hanson K, Bryce J, Vaughan J. Achieving universal
coverage with health interventions. Lancet
2004;364:1541-8.[CrossRef][ISI][Medline]
  17. NHS Centre for Reviews and Dissemination. Evidence from
systematic reviews of the research relevant to implementing the wider
public health agenda. York: University of York, NHS Centre for Reviews
and Dissemination, 2000.
  18. Skoufis E. Progress and its impact on the welfare of rural
households in Mexico. Research report 139. Washington, DC: IFPRI, 2005.
  19. Standing H. Understanding the "demand side" in service delivery.
London: Department for International Development, 2004.
  20. Gilson L, Doherty J, Loewenson R, Francis V. Challenging inequity
through health systems. Geneva: WHO Commission on the Social
Determinants of Health, 2007.
  21. Blanchet H, Dussault G, Liese B. The human resource crisis in
health services. Washington, DC: World Bank, 2003.
  22. Narasimhan V, Brown H, Pablos-Mendez A, Adams O, Dussault G,
Elzinga G, et al. Responding to the global human resource crisis. Lancet
2004;363:1469-72.[CrossRef][ISI][Medline]
  23. De Maeseneer J, van Weel C, Egilman D, Mfenyana K, Kaufman A,
Sewankambo N, et al. Strengthening primary care: addressing the
disparity between vertical and horizontal investment. Br J Gen Pract
2008;58:3-4.[CrossRef][Medline]
  24. Pollock A, Price D, Viebrock E, Miller E, Watt G, et al. The
market in primary care. BMJ 2007;335:475-7.[Free Full Text]
  25. Weiner J, Lewis R, Gillam S. Lessons for a small island from a
lost continent. London: King's Fund, 2002.
  26. Unger J-P, Van Dormael M, Criel B, Van der Vennet J, De Munck P.
A plea for an initiative to strengthen family medicine in public health
care services of developing countries. Int J Health Services
2002;32:799-815.[CrossRef]
  27. Freedman L. Achieving the MDGs: health systems as core social
institutions. Development 2005;48:19-24.[CrossRef]

(Accepted 14 January 2008)

Related Articles

Finding meanings
    Jane Smith
    BMJ 2008 336: 0. [Extract] [Full Text]

Funding for primary health care in developing countries
    Jan De Maeseneer, Chris van Weel, David Egilman, Khaya Mfenyana,
Arthur Kaufman, Nelson Sewankambo, and Maaike Flinkenflögel
    BMJ 2008 336: 518-519. [Extract] [Full Text]

The market in primary care
    Allyson M Pollock, David Price, Elke Viebrock, Emma Miller, and
Graham Watt
    BMJ 2007 335: 475-477. [Extract] [Full Text]
_______________________________________________
All mailing list
All at lists.haiap.org
http://lists.haiap.org/mailman/listinfo/all
-------------- next part --------------
An HTML attachment was scrubbed...
URL: <http://phm.phmovement.org/pipermail/phm-exchange-phmovement.org/attachments/20080311/4073cef1/attachment-0001.html>