PHA-Exch> Halfdan Mahler's address to the 61st World Health Assembly

[Wim De Ceukelaire]

Address to the 61st World Health Assembly
Dr Halfdan Mahler

Former Director-General of WHO

http://www.who.int/mediacentre/events/2008/wha61/hafdan_mahler_speech/en/index.html

Distinguished audience,

My remarks will focus on "Why Alma-Ata in 1978 and Whither the Health
for All Vision and Primary Health Care Strategy".

Milan Kundera wrote in one of his books: "The struggle against human
oppression is the struggle between memory and forgetfulness." So allow
me to remind all of us today, of the transcendental beauty and
significance of the definition of health in WHO's Constitution: "Health
is a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity."

This definition is immediately followed by: "The enjoyment of the
highest attainable standard of health is one of the fundamental rights
of every human being without distinction of race, religion, political
belief, economic or social condition." Most importantly, the very first
constitutional function of WHO reads: "To act as the directing and
coordinating authority on international health work." Please do note
that the Constitution says "the" and not "a" directing and coordinating
authority.

So please, allow this old man in front of you to insist that unless we
all become partisans in renewed local and global battles for social and
economic equity in the spirit of distributive justice, we shall indeed
betray the future of our children and grandchildren.

My memory tells me that the World Health Assembly had this in mind when,
in 1977, it decided that the main social target for governments and WHO
in the coming decades should be the attainment of what is known as
"Health for All".

And, the Health Assembly described that as a level of health that will
permit all the people of the world to lead socially and economically
productive lives. The Health Assembly did not consider health as an end
in itself, but rather as a means to an end.

That is, I believe as it should be.

When people are mere pawns in an economic and profit growth game, that
game is mostly lost for the underprivileged.

Let me postulate that if we could imagine a tabula rasa in health
without having to deal with the constraints - tyranny if you wish - of
the existing medical consumer industry, we would hardly go about dealing
with health as we do now in the beginning of the 21st century.

To make real progress we must, therefore, stop seeing the world through
our medically tainted glasses. Discoveries on the multifactoral
causation of disease, have for a long time, called attention to the
association between health problems of great importance to man and
social, economic and other environmental factors. Yet, considering the
tremendous political, social, technical and economic implications of
such a multidimensional awareness of health problems I still find most
of today's so-called health professions very conventional, indeed.

It is, therefore, high time that we realize, in concept and in practice,
that a knowledge of a strategy of initiating social change is as potent
a tool in promoting health, as knowledge of medical technology.

Primary health care is indeed conditioned by its holistic framework and
as such, may use different expressions. For example, in some countries
health management has to be considered along with such things as
producing more or better food, improving irrigation, marketing products,
etc. It is not that people consider health services as unimportant, but
there are things like getting food, or a piece of land, or house or an
accessible source of water which are more of a life and death nature and
must, in the wisdom of the people, come first to make other things
meaningful. We have rarely considered these needs as falling within our
expressed policies for health development and therefore, we risk being
restricted, unilateral and ineffective in our action.

Again, I am afraid that conventional or medical wisdom has done very
little to provide scientific and political credibility to the alleged
importance of individual, family and community participation in health
promotion.

These concerns, to which I have just alluded prompted an organizational
study on "Methods of promoting the development of basic health services"
by WHO's Executive Board in 1973 in which it is bluntly stated that:

"There appears to be widespread dissatisfaction of population about
their health services for varying reasons. Such dissatisfaction occurs
in the developed as well as in the Third World. The causes can be
summarized as a failure to meet the expectations of the populations; an
inability of the health services to deliver a level of national coverage
adequate to meet the stated demands and the changing needs of different
societies; a wide gap (which is not closing) in health status between
countries, and between different groups within countries; rapidly rising
costs without a visible and meaningful improvement in service; and a
feeling of helplessness on the part of the consumer who feels (rightly
or wrongly) that the health services and the personnel within them are
progressing along an uncontrollable path of their own which may be
satisfying to the health professionals but which is not what is most
wanted by the consumer".

It was this organizational study by WHO's Executive Board that led to
the decision by WHO in co-sponsorship with UNICEF to convene "The
International Conference on Primary Health Care" in the city of Alma-Ata
in 1978.

Let me then repeat with awe and admiration, the consensus concept of
primary health care as contained in the Declaration of Alma-Ata 1978:

"Primary Health Care is essential health care based on practical,
scientifically sound and socially acceptable methods and technology made
universally accessible to individuals and families in the community
through their full participation and at a cost that the community and
the country can afford to maintain at every stage of their development
in the spirit of self-reliance and self-determination. It forms an
integral part, both of the country's health system, of which it is the
central function and main focus, and of the overall social and economic
development of the community.

"It is the first level of contact of individuals, the family and
community with the national health system bringing health care as close
as possible to where people live and work, and constitutes the first
element of a continuing health care process."

Let me also quote from the Declaration of Alma-Ata, that primary health
care includes at least: education concerning prevailing health problems
and the methods of preventing and controlling them; promotion of food
supply and proper nutrition; an adequate supply of safe water and basic
sanitation; maternal and child health care, including family planning;
immunization against the major infectious diseases; prevention and
control of locally endemic diseases; appropriate treatment of common
diseases and injuries; and provision of essential drugs. In my opinion,
an admirable summation of key priorities.

Are you ready to address yourselves seriously to the existing gap
between the health "haves" and the health "have-nots" and to adopt
concrete measures to reduce it?

Are you ready to ensure the proper planning and implementation of
primary health care in coordinated efforts with other relevant sectors,
in order to promote health as an indispensable contribution to the
improvement of the quality of life of every individual, family and
community as part of overall socio-economic development?

Are you ready to make preferential allocations of health resources to
the social periphery as an absolute priority?

Are you ready to mobilize and enlighten individuals, families and
communities in order to ensure their full identification with primary
health care, their participation in its planning and management and
their contribution to its application?

Are you ready to introduce the reforms required to ensure the
availability of relevant human resources and technology, sufficient to
cover the whole country with primary health care within the next two
decades at a cost you can afford?

Are you ready to introduce, if necessary, radical changes in the
existing health delivery system so that it properly supports primary
health care as the overriding health priority?

Are you ready to fight the political and technical battles required to
overcome any social and economic obstacles and professional resistance
to the universal introduction of primary health care?

Are you ready to make unequivocal commitments to adopt primary health
care and to mobilize international solidarity to attain the objective of
health for all by the year 2000?

Alma-Ata was, in my biased opinion, one of the rare occasions where a
sublime consensus between the haves and the have-nots in local and
global health emerged in the spirit of a famous definition of consensus:
"I am not trying to convince my adversaries that they are wrong, quite
to the contrary, I am trying to unite with them, but at a higher level
of insight."

The Alma-Ata primary health care consensus also reflects a famous
truism: "The Health Universe is only complete for those who see it in a
complete light, it remains fragmented for those who see it in fragmented
light!"

In conclusion, my personal view is that the Alma-Ata primary health care
consensus has had major inspirational and operational impacts in many
countries having a critical mass of political and professional
leadership combined with adequate human and financial resources to test
its adaptability and applicability within the local realities through a
heavy dose of systems and operations research.

Mind you, it is much easier to be rational, audacious and innovative
when your are rich! But, please, let us not forget that the
inspirational energies and the evidence base came from the developing
countries themselves, be they governmental or non-governmental sources.

For a majority of these countries, financial support from so-called
donors was essential to carry out a broad array of studies, in
appropriate technology, human resources development, infrastructure
development, social participation, financing etc. in order to integrate
the Alma-Ata vision into heavily constrained local contexts.

Most donors, after an initial outburst of enthusiasm quickly lost
interest or distorted the very essence of the Alma-Ata Health for All
Vision and Primary Health Care Strategy under the ominous name of
selective primary health care which broadly reflected the biases of
national and international donors and not the needs and demands of
developing countries.

But in spite of these brutal impediments many developing countries have
shown, before and after the Alma-Ata happening, courageous adhesion to
its health message of equity in local and global health. Civil society
movements have also been prime shakers and movers in these admirable
efforts.

And so, being an inveterate optimist I do believe that the struggle
between memory and forgetfulness can be won in favour of the Alma-Ata
Health for All Vision and its related Primary Health Care Strategy. Let
us not forget that visionaries have been the realists in human
progression.

And so, distinguished audience, let us use the complete light generated
by WHO's Constitution and the Alma-Ata Health for All Vision and Primary
Health Care Strategy to guide us along the bumpy, local and global
health development road.

Thank you.

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