PHA-Exch> PHM and PHC in 2008

[Claudio Schuftan]

Primary Health Care remains the Best Tool to Achieve "Health for All"

*Interim Position of the People's Health Movement
(PHM)[*]<http://mail.google.com/mail/?ui=2&view=js&name=js&ver=WWJlcMdYu-w&am=T-E8hUTDR0lX#_edn1>
*May 2008.

*The comprehensive Primary Health Care (PHC)  approach articulated at Alma
Ata remains as relevant today as it was 30 years ago. It was never really
implemented to reflect its true spirit, i.e., the basic intent of the Alma
Ata Declaration which highlighted the need for a new international economic
order to ultimately solve inequities in health. A PHC policy for 2008 and
beyond needs  renewed commitment, which, while affirming the fundamental
positions of thirty years back, also takes into account the new realities of
this age.*

In its renewed commitment to PHC, in 2008, PHM vies to address the obstacles
that have blocked PHC's implementation so far and is furthermore committed
to incorporate into it the new challenges that have emerged since 1978.

*PHM is committed to promote* *the still unshaken basic principles of the
Alma Ata Declaration* --way beyond its original eight technical components*.
*

*PHM insists that PHC is to be embedded in the social and political
processes in each specific context where it is applied.* For that, it* *must
:

-   be neither limited to just the primary level of care, nor be considered
merely as a "basic" package of care for the poor, but include public health
interventions, health promotion and a working referral system to secondary
and tertiary levels of care;

-   be financed through public sources, so as to ensure universal and
equitable access;

-   address the socio-economic injustice underlying a system of health care
that does not provide equitable access and care according to need;

-   resolutely address the social, political, economic and environmental
determinants of health and not just be limited to health care;

-   address the issues of global warming, the current international economic
order and the militarization the latter has brought about.

-   empower communities, especially, the most disadvantaged, so that they
can act as protagonists in improving their health and their livelihoods;

-   use technology* *in a manner that is sensitive to local needs and
contexts;

-   combine traditional and modern medicine to maximize benefits to
patients; and

-   embed policies and interventions in the human rights framework, i.e.,
recognising and supporting the role of beneficiaries as *claim holders* with
an internationally sanctioned right to hold to account *duty bearers* in
bringing about needed changes in the provision of health care services.

PHM takes the new challenges that have emerged in the last 30 years, as
challenges that must be incorporated in a renewed vision for PHC. In this
context, *PHM strongly believes that:*

-   Neoliberal globalisation presents us with new threats to health such as,
among other, an increase in trade in unhealthy commodities, international
trade agreements that are promoting the penetration of transnational
corporations into the health sector, patent rights being used against the
dire health needs of poor people, and unfair rules in the international
trade of agricultural products that devastate the livelihood and health of
poor peasants.  All of them seriously undermine the ability of poor
countries to adequately support PHC systems. Global inequities also result
in poor countries being left with too few resources to sustain funding for
health systems overall, thereby becoming reliant on external sources of
funding. PHM posits that *the negative aspects of globalization are the
major obstacle to Health For All.* Outside the present neoliberal framework,
certain aspects of globalization can and should be used to address the
social, economic and political determinants of health.

-   After over 25 years, selective, vertical health care programs remain
dominant, not only fragmenting wider health systems, but also drawing away
scarce resources, treating patients as passive recipients of care and
ignoring the ever-present social, economic and political determinants of
health. PHM recognizes that, while there may be a need for focused
programmes, the same need to be integrated into a comprehensive PHC
approach.

-   The planning and execution of PHC activities must be genuinely
community-driven and community-centered.

-   Both in light of the looming health manpower crisis, and as a core PHC
principle, there must be a renewal of the role of community health workers
to not only extend coverage at the local level, but also to give them a
concrete role as social mobilizers in the right to health-based empowerment
of communities, particularly in relation to the social determinants of
health. PHM thus strongly emphasizes the training of health workers, not
only in clinical and preventive health skills, but also in skills that make
them effective agents of social change.

-   Significant investments in PHC *do* bring about important changes --as
the example of Brazil has demonstrated. PHM advocates for similar
initiatives being actively pursued by countries across the globe.

-   For a good PHC policy to succeed and to make a real difference in *
access* and in *equity*, it must have sufficient resources specifically
allocated to it. PHM thus lobbies states to invest more in public
health,  particularly
in PHC. At the same time, PHM strongly feels that WHO should lead this
effort: it simply cannot consider itself as just a technical agency.

-   Global public private partnerships (PPPs) are seen as a way to bring new
financial resources to address global health challenges. However, in
reality, they have further reinforced selective programs by focusing on
non-sustainable, techno-centric solutions to single issues, and are not
addressing the social determinants of health or many of the burning needs of
health systems to deliver such services. PPPs need to be seriously
reoriented towards more horizontally-integrated, sector-wide approaches that
have the explicit commitment to strengthen health systems, to respond to
local needs and to build new alliances with civil society, people's
organisations and social movements --thus reasserting the central place of
democratic, participatory decision-making in all health services. PHM
purports that there is a need to carry out a proper audit of existing global
PPPs, in order to arrive at the basic principles and rules that such PPPs
need to abide by, among other making them build upon existing public systems
and embedding them in a PHC structure.

-   The last thirty years have seen increasing privatisation and
commercialisation of health systems across the world. The new market economy
in health has undermined public sector health systems and has eroded the
ethical standards among health workers, as well as the trust between
communities and the health system. The result has been exacerbated inequity
and growing disparities in access to health care. PHM thus thinks that there
is a profound need in most countries to strengthen the public health sector
and the 'public ethic' of service provision and that the private medical
sector needs to be regulated as a matter of priority.

-   PHC in 2008 and beyond must address the critical problems of the global
health workers' labour market and must ensure an adequate human resource
base for the health systems of all countries --including compensating poor
countries for the losses suffered by their health systems as a consequence
of migration of health humanpower.

-   Intellectual property issues are increasingly used against the interests
of poor countries. The development of technology for the treatment of
diseases is oligopolistic and ignores the research needs for diseases of
poverty.. Moreover, many useful technologies already available in 1978 are
still unavailable to most people. Intellectual property rules cannot be
allowed to continue to make new life-saving medications unavailable and
unaffordable to the people who need them the most. PHC requires universal
access to essential medicines, with most of them made available as generics.
PHM will confront patent regimes that are primarily market-oriented; it will
support countries to make full use of the flexibilities in TRIPS that make
necessary drugs available to all who need them.

-   The institutions involved in PHC will need to change their focus. But it
is not a time to blame; it is a time to move forward.

Three decades have passed since Alma Ata and the situation is worse than
what it was in 1978. Our ability to support human health is now at greater
risk from an unjust and unsustainable process of development; inequities
have increased between and within countries; access to food, education,
water, shelter, sanitation and employment are still greatly inadequate for
many; *the challenges of globalization, poverty, gender inequity and social
exclusion continue*; both communicable and non-communicable disease
epidemics challenge health systems already stretched to the limit; and war,
violence and conflict abound.

Today, 30 years after Alma Ata, PHM looks at WHO to provide not only the
technical, but also the moral and political leadership in this entire
process. It has to reclaim its legitimate position as the global leader in
promoting policies that lead to a world with healthy populations.
Specifically, PHM expects WHO to support member countries to adopt policies
that promote PHC as an integral part of their national policies.  This
support is not just to be given in the area of health systems development,
but also in promoting policies that more resolutely address the issues
related to the social determinants of health. WHO should also take the lead
in promoting alternate models of research that promote the development of
health products that address the critical needs of people in developing
countries.

ð *For PHM, while THE PRIMARY HEALTH CARE OF 2008 AND BEYOND reiterates the
core principles of Alma Ata, it must, in addition, address these new
challenges at local, national, regional and global levels. This is PHM's
commitment, i.e., to put the health of marginalised groups at the center of
its commitment to 'Health for All Now' --a commitment already espoused by
the PHM in 2000 as the core principle of its People's Health Charter (
www.phmovement.org).*

------------------------------

[*]<http://mail.google.com/mail/?ui=2&view=js&name=js&ver=WWJlcMdYu-w&am=T-E8hUTDR0lX#_ednref1>PHM
is working on a more elaborate position to be released later this
year;
it includes a critical analysis of WHO's shortcomings in defending the
principles of Alma Ata over the years and how WHO is profiling its role to
support PHC in 2008 and beyond. It also addresses difficult questions such
as whether WHO and member states are ever going to bring health to poor and
marginalized groups in society ---and if not, who will and who should PHM be
engaging more closely with.
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