PHA-Exch> The story of primary health care: From Alma Ata to the present day ( Id21)

[Claudio Schuftan]

From: ashenafi waktola awaktola at yahoo.com


This is from www.id21.org . The 30th anniversary of the Alma Ata Declaration
( http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf )
is in less than 2 months.

Where are we now? Where do we need to be?
The story of primary health care From Alma Ata to the present day

The idea of primary health care (PHC) emerged in the 1960s, in recognition
of the shortcomings of the health systems inherited by developing countries
after independence. Such urban, centralised and curative-oriented health
systems were poorly matched to the needs of their people.
Health for all

By the time of the Alma Ata conference in 1978, a consensus had emerged
placing fresh emphasis on preventive, rural, peripheral and 'appropriate'
services, integration and inter-sectoral collaboration, and participation of
local communities. The conference itself affirmed the right to health – and
its definition as a state of complete, physical, mental and social
wellbeing.

The Conference demanded 'an acceptable level of health for all the people of
the world by the year 2000' or 'Health for All 2000', implying an emphasis
on equity as well as effectiveness and efficiency.

Fissures in the consensus appeared almost immediately. In 1979, the paper
'Selective Primary Health Care' proposed a limited list of cost-effective
interventions to respond to most health needs in low-income countries,
especially those of children. It prompted a host of critical responses which
argued that cost-effectiveness did not ensure a universal health system or
give sufficient space to equity, and that the holistic notion of health
espoused in the Alma Ata declaration had given way to one of avoiding
disease. They argued that the strategy provided a short-term fix rather than
a long-term solution and that this implicitly medical notion ignored the
need for collaboration and integration.
Affordable primary health care?

A cornerstone of the initial consensus was that a PHC system would be
affordable to low-income countries. The Rockefeller Foundation published the
'Good Health at Low Cost' case studies in the mid 1980s, which showed that
some places such as China, Costa Rica, Sri Lanka and the Indian state of
Kerala, had achieved affordable and effective health systems. All had
dramatically improved health outcomes, despite economic constraints within
widely differing political systems, but all emphasised PHC within an overall
social welfare-oriented development model.
PHC delivery system ignored

However, others argued that PHC is not cheap and that simple interventions
require a delivery system that is frequently lacking in practice and ignored
in the debate. The realities of PHC delivery systems failed to match up to
the ideal. Services intended for poor people were often perceived as cheap
and second class. Governance issues affected the delivery of services in a
number of settings. Political commitment voiced at Alma Ata was often not
followed up through implementation.

By the 1990s, proposals looking for alternatives to over-stretched public
sector budgets emerged from international agencies. Increased debt levels
were undermining the credibility of increasing public expenditure and there
was a growing emphasis on markets as the basis of public sector reform. The
World Bank's Agenda for Reform promoted centralised user fees, insurance
mechanisms and greater involvement by the private sector. And the Bamako
Initiative proposed local revenue-generating mechanisms alongside measures
to strengthen the delivery of PHC.

These approaches, however, undermined access by the poorest people,
threatening the universal principle enshrined in Alma Ata. User fees were
widely implemented and equally widely maligned: evidence emerged, for
example from Ghana, which resulted in reduced use of health services and
exclusion of poor people.

Several new approaches have emerged in the last decade, whilst those of the
1980s and 1990s continue to inform current thinking. Conflict between new
aid modalities, most notably the sector-wide approach – where aid effort in
each sector is brought under a single management framework governed by
national government and bilateral and international agencies – and
international mechanisms with specific disease focus, such as the Global
Fund to fight Aids, TB and Malaria, has similarities with the dispute
between selective and comprehensive PHC.

   - Should local ownership, integrated service provision and system
   development be emphasised, or measurable outcomes, specific objectives, and
   short-term efficiency?
   - 'Essential packages' itemising a limited set of priority cost-effective
   interventions, are now everywhere in aid dependent countries, but raise the
   same questions that selective PHC did 30 years ago. How does a health system
   based on an essential package respond to a patient with a condition not
   covered by the package? What are the equity implications of allowing the
   private sector to fill the less cost-effective gap?

It is possible to argue that PHC 'failed', in the sense that 'Health for All
2000' was not achieved. Advocates of comprehensive PHC have critiqued
advocates of more selective approaches for their tendency to prioritise
'technical fixes' over larger social development processes. Nevertheless, if
it is recognised that a more comprehensive PHC vision is more than a longer
list of technical fixes, PHC failure can only be addressed in the same terms
as those that evaluate wider development processes.

These in turn perhaps can also be seen to have largely failed over the same
period, owing to global economic and political forces and national failures
of governance. These are likely to be the critical factors that determine
success with PHC and other elements of social development over the coming
decades.

*Barbara McPake*
Institute for International Health and Development, Queen Margaret
University, Queen Margaret University Drive, Musselburgh, East Lothian, EH21
6UU, UK
bmcpake at gmu.ac.uk<bmcpake at gmu.ac.uk?subject=Re+id21+piece+%22+The+story+of++primary+health+care+%22,+insights+health+12&bcc=editor at ids.ac.uk>

See also

'Selective Primary Health Care: an Interim Strategy for Disease Control', *New
England Journal of Medicine*, 301, pages 967-74, by J Walsh and K Warren,
1979
http://content.nejm.org/cgi/content/abstract/301/18/967

*Good Health at Low Cost*, Conference report, Bellgaio Conference Centre,
Rockefeller Foundation, by SB Halstead, J Walsh and K Warren, 1985
www.popline.org/docs/0862/271533.html

'A Price to Pay: The impact of User Charges in Ashanti-Akim District Ghana',
*International Journal of Health Planning and Management*, 4, pages 17- 47,
CJ Waddington and KA Enyimayew, 1989

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