PHA-Exch> Alma Ata then and PHC in 2008 and beyond

[Claudio Schuftan]

>
>
>  A juxtaposition of the original text of the Alma Ata Declaration and what
> is deemed necessary for a PHC framework 30 years later makes for an
> interesting discussion topic:
>
> * *
>
> *Declaration of Alma-Ata*
>
> **
>
> *International Conference on Primary Health Care, Alma-Ata, USSR, *6-12
> September 1978
>
> * *
>
> Primary Health Care remains the Best Tool
>
> to Achieve "Health for All"
>
> *Position of the People's Health Movement (PHM)*[i]<http://mail.google.com/mail/?ui=1&view=page&name=gp&ver=sh3fib53pgpk#_edn1>
> *,** *June 2008.
>
> * *
>
> "The International Conference on Primary Health Care, meeting in Alma-Ata
> this twelfth day of September in the year Nineteen hundred and
> seventy-eight, expressing the need for urgent action by all governments, all
> health and development workers, and the world community to protect and
> promote the health of all the people of the world, hereby makes the
> following Declaration:
>
> * *
>
> [A PHC policy for 2008 and beyond needs renewed commitment which, while
> reaffirming the fundamental positions of thirty years back, also takes into
> account the new realities of this day and age. 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 (iii) to ultimately solve
> inequities in health.              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]. (Numbers in Roman
> numerals cross-reference the issues in the Alma Ata Declaration with those
> in the current position of PHM towards PHC in 2008 and beyond).
>
> **
>
> *The Alma Ata Declaration:*
>
> *I*
>
> The Conference strongly reaffirms that health, which is a state of complete
> physical, mental and social wellbeing, and not merely the absence of disease
> or infirmity, is a fundamental human right (i) and that the attainment of
> the highest possible level of health is a most important world-wide social
> goal whose realization requires the action of many other social and economic
> sectors in addition to the health sector.
>
> **
>
> *II*
>
> The existing gross inequality in the health status of the people
> particularly between developed and developing countries as well as within
> countries is politically, socially and economically unacceptable and is,
> therefore, of common concern to all countries. (ii)
>
> **
>
> *III*
>
> Economic and social development, based on a New International Economic
> Order (iii), is of basic importance to the fullest attainment of health
> for all and to the reduction of the gap between the health status of the
> developing and developed countries. The promotion and protection of the
> health of the people is essential to sustained economic and social
> development and
>
> contributes to a better quality of life and to world peace. (iv)
>
> **
>
> *IV*
>
> The people have the right and duty to participate individually and
> collectively in the planning and implementation of their health care. (v)
>
> **
>
> *V*
>
> Governments have a responsibility for the health of their people which can
> be fulfilled only by the provision of adequate health and social measures
> (v-a). A main social target of governments, international organizations
> and the whole world community in the coming decades should be the attainment
> by all peoples of the world by the year 2000 of a level of health that will
> permit
>
> them to lead a socially and economically productive life. Primary health
> care is the key to attaining this target as part of development in the
> spirit of social justice. (vi)
>
> **
>
> *VI*
>
> Primary health care is essential health care based on practical,
> scientifically sound and socially acceptable methods and technology (vii)made universally accessible to individuals and families in the community
> through their full participation and at a cost that the community and
> 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.
>
> **
>
> *VII*
>
> Primary health care:
>
> 1. reflects and evolves from the economic conditions and socio-cultural and
> political characteristics of the country and its communities and is based on
> the application of the relevant results of social, biomedical and health
> services research (viii) and public health experience;
>
> 2. addresses the main health problems in the community, providing
> promotive, preventive, curative and rehabilitative services accordingly;
>
> 3. includes at least (*): (1)education concerning prevailing health
> problems and the methods of preventing and controlling them (ix);
> (2)promotion of food supply and proper nutrition (x); (3)an adequate
> supply of safe water and basic sanitation (xi); (4)maternal and child
> health care, including family planning; (5)immunization against the major
> infectious diseases; (6)prevention and control of locally endemic diseases
> (xii); (7)appropriate treatment of common diseases and injuries (xii-a);
> and (8)provision of essential drugs (xiii);
>
> 4. involves, in addition to the health sector, all related sectors and
> aspects of national and community development, in particular agriculture,
> animal husbandry, food, industry, education, housing, public works,
> communications and other sectors; and demands the coordinated efforts of all
> those sectors (xiv);
>
> 5. requires and promotes maximum community and individual self-reliance and
> participation in the planning, organization, operation and control of
> primary health care, making fullest use of local, national and other
> available resources; and to this end develops through appropriate education
> the ability of communities to participate (v, xiv);
>
> 6. should be sustained by integrated, functional and mutually supportive
> referral systems (xv), leading to the progressive improvement of
> comprehensive health care for all, and giving priority to those most in
> need;
>
> 7. relies, at local and referral levels (xv), on health workers, including
> physicians, nurses, midwives, auxiliaries and community workers as
> applicable, as well as traditional practitioners as needed, suitably trained
> socially and technically to work as a health team and to respond to the
> expressed health needs of the community. (xvi)
>
> **
>
> *[PHM is committed to promote* *the still unshaken basic principles of the
> Alma Ata Declaration* --way beyond its original eight technical components
> *. (*)*
>
> *PHM reiterates 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 (xvi);
>
> -   be financed through public sources, so as to ensure universal and
> equitable access (v-a);
>
> -   address the socio-economic injustice underlying a system of health
> care that does not provide equitable access and care according to need
> (vi);
>
> -   resolutely address the social, political, economic and environmental
> determinants of health and not just be limited to health care (xiv);
>
> -   address the issues of global warming (xiv), the current international
> economic order and the militarization (iv) 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
> (v);
>
> -   use technology* *in a manner that is sensitive to local needs and
> contexts (vii);
>
> -   combine traditional and modern medicine to maximize benefits to
> patients (xii-a) since PHC has to be open to different health systems, not
> only to the allopathic system (xvi).
>
> -   embed policies and interventions in the *human rights framework*,
> i.e., recognizing 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 (i)].**
>
> **
>
> *VIII*
>
> All governments should formulate national policies, strategies and plans of
> action to launch and sustain primary health care as part of a comprehensive
> national health system and in coordination with other sectors. To this end,
> it will be necessary to exercise political will, to mobilize the country's
> resources and to use available external resources rationally. (xvii)
>
> **
>
> *IX*
>
> All countries should cooperate in a spirit of partnership and service to
> ensure primary health care for all people since the attainment of health by
> people in any one country directly concerns and benefits every other
> country. In this context the joint WHO/UNICEF report on primary health care
> constitutes a solid basis for the further development and operation of
> primary health care throughout the world.
>
> **
>
> *X*
>
> An acceptable level of health for all the people of the world by the year
> 2000 can be attained through a fuller and better use of the world's
> resources, a considerable part of which is now spent on armaments and
> military conflicts (iv). A genuine policy of independence, peace, détente
> and disarmament could and should release additional resources that could
> well be devoted to
>
> peaceful aims and in particular to the acceleration of social and economic
> development of which primary health care, as an essential part, should be
> allotted its proper share.
>
> The International Conference on Primary Health Care calls for urgent and
> effective national and international action to develop and implement primary
> health care throughout the world and particularly in developing countries in
> a spirit of technical cooperation and in keeping with a New International
> Economic Order (iii). It urges governments, WHO and UNICEF, and
>
> other international organizations, as well as multilateral and bilateral
> agencies, nongovernmental organizations, funding agencies, all health
> workers and the whole world community to support national and international
> commitment to primary health care and to channel increased technical and
> financial support to it, particularly in developing countries.
>
> The Conference calls on all the aforementioned to collaborate in
> introducing, developing and maintaining primary health care in accordance
> with the spirit and content of this Declaration".
>
> *[PHC Beyond Alma Ata or The PHC of 2008 and Beyond:*
>
> 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 (v).
>
> -   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* (i), *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 (xvi).
>
> -   Significant investments in PHC can and *do* bring about important
> positive changes in people's health --as the example of Brazil has
> demonstrated. PHM advocates for similar investments/initiatives being
> actively pursued by countries across the globe, because 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: WHO
> simply cannot consider itself as just a technical agency.
>
> -   Global public private partnerships (PPPs) are seen by the
> Establishment 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, technocentric solutions
> to single issues that are neither addressing the *social determinants of
> health* nor addressing many of the burning needs of national health
> systems to deliver such services. PPPs need to be seriously questioned since
> they have proven to be a) unable to promote horizontally-integrated,
> sector-wide approaches with an explicit commitment to strengthen local
> health systems, b) unable to respond to locally felt needs, and c) unable 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 expose the
> basic flaws and rules that such PPPs apply ongoingly --among other making
> them not to build upon existing public systems and not to embed themselves
> in a genuine 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 (ii). PHM thus thinks
> that there is a profound need in most countries to strengthen the *public*health sector
> (v-a) 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 (xvi) --including
> compensating poor countries for the losses suffered by their health systems
> as a consequence of outmigration of their 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 (vii). 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 (xiii). 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 (xvii)].
>
> *[PHC and WHO:*
>
> 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 (ii); access to food (ix),
> education (x), water and sanitation (xi), shelter 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 (xii); and war, violence and conflict abound (iv).
>
> 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.* WHO simply 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 prompt and support member
> countries to adopt policies that promote PHC as an integral part of their
> national policies (v-a).-
>
>                                                  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*.
>
>
> Last Last, but not least, 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 (viii)].
>
>
> 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 marginalized groups at the center of
> its commitment to 'Health for All Now' --a commitment already espoused by
> the People's Health Movement in 2000 as the core principle of its People's
> Charter for Health (www.phmovement.org).*
>
> *Epilogue*: PHC in 2008 and beyond is to empower communities to counter
> the current negative trends in globalization, in trade patent regimes that
> favor market strategies over people's health needs and in all the other
> social ills depicted above.
>
> This renewal of PHC thus is the core of a social movement we simply have to
> build towards Health For All Now, a movement based on equity, human rights
> and solidarity --which should have actually started in 1978. This is the
> vision PHM has when calling for the revitalization of PHC as articulated in
> Alma Ata and adapted to a changed world. PHM will continue to empower
> communities *and* have them coalesce into wider regional and global
> movements.
>
> ------------------------------
>
>  [i]<http://mail.google.com/mail/?ui=1&view=page&name=gp&ver=sh3fib53pgpk#_ednref1>
> : PHM is working on a more elaborate position paper (widely discused by
> our constituency) to be released later this year; it  will include a
> critical analysis of how WHO is profiling its role to support PHC in 2008
> and beyond. It will also address 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 with more
> closely.
>
>
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