PHM-Exch> Translating “Health for All” into the Present and Future

Tue May 22 03:11:55 PDT 2018

 C_o_n_s_u_l_t_a_t_i_o_n_ _s_t_a_t_e_m_e_n_t_ _o_f_ _t_h_e_ _c_i_v_i_l_
_s_o_c_i_e_t_y_ _w_o_r_k_s_h_o_p_ _“4_0_ _Y_e_a_r_s_ _o_f_
_A_l_m_a_-_A_t_a_:_ _T_r_a_n_s_l_a_t_i_n_g_ _‘H_e_a_l_t_h_ _f_o_r_ _A_l_l_’
_i_n_t_o_ _t_h_e_ _P_r_e_s_e_n_t_ _a_n_d_ _F_u_t_u_r_e_”,_ _G_e_n_e_v_a_,_
_E_c_u_m_e_n_i_c_a_l_ _C_e_n_t_r_e_,_ _1_8_ _M_a_y_ _2_0_1_8_ _

S_u_m_m_a_r_y_ _

*Translating “Health for All” into the Present and Future *

Health is a fundamental human right – enshrined in the WHO constitution and
the declaration of Alma Ata. However, after 40 years, inequality, poverty,
exploitation, violence and injustice are still keeping one Billion people
from accessing health care. To achieve health for all, inequities have to
be overcome, powerful interests to be challenged, and political and
economic priorities must be transformed to achieve health for all.

*Realising the vision of Alma Ata is more urgent than ever: *

• _Applying the principles of Primary Health Care as declared at Alma Ata
1978 is critical in achieving health for all by 2030.

• _Community engagement and ownership is the key to health for all and
essential for building resilient health systems that allow all people to
access the health care they need.

• _A skilled and motivated health workforce is at the centre of health
systems at all levels. It must be recognized that community health workers
play an essential part in realising universal health coverage and health
for all.

• _Strong people’s organisations and movements are fundamental to strong
health systems.

• _Access to essential medicines of good quality at an affordable price is
part of health for all. Policies must ensure that research costs are
delinked from the price of drugs and everyone has the right to access
essential medicines.

• _Health for all demands inter-sectoral collaboration and must provide
access to prevention, promotion, treatment, care, rehabilitation and
palliative care to everyone within a sustainable framework.

• _Health is not only a matter of human rights, it is a matter of justice
and requires a redistribution of wealth and significant changes in the
global economic order.

• _Equity in health and social justice must be the basis for all decision
making.

• _To ensure access to health services to all, service provision through
public and not-for-profit providers must be given the primacy in health
system planning and implementation. The ambiguities regarding UHC must be
resolved with health care financing policies structured to prevent the
commodification and marketisation of health care.

*Translating “Health for All” into the Present and Future *

Health is a fundamental human right – enshrined in the WHO constitution and
the declaration of Alma Ata. Realising the vision of Alma Ata and health
for all is more urgent than ever:

*Primary Health Care and Universal Health Coverage *

*“P_r_i_m_a_r_y_ _h_e_a_l_t_h_ _c_a_r_e_ _i_s_ _e_s_s_e_n_t_i_a_l_
_h_e_a_l_t_h_ _c_a_r_e_ _b_a_s_e_d_ _o_n_ _p_r_a_c_t_i_c_a_l_,_
_s_c_i_e_n_t_i_f_i_c_a_l_l_y_ _s_o_u_n_d_ _a_n_d_ _s_o_c_i_a_l_l_y_
_a_c_c_e_p_t_a_b_l_e_ _m_e_t_h_o_d_s_ _a_n_d_ _t_e_c_h_n_o_l_o_g_y_
_m_a_d_e_ _u_n_i_v_e_r_s_a_l_l_y_ _a_c_c_e_s_s_i_b_l_e_ _t_o_
_i_n_d_i_v_i_d_u_a_l_s_ _a_n_d_ _f_a_m_i_l_i_e_s_ _i_n_ _t_h_e_
_c_o_m_m_u_n_i_t_y_ _t_h_r_o_u_g_h_ _t_h_e_i_r_ _f_u_l_l_
_p_a_r_t_i_c_i_p_a_t_i_o_n_ _a_n_d_ _a_t_ _a_ _c_o_s_t_ _t_h_a_t_ _t_h_e_
_c_o_m_m_u_n_i_t_y_ _a_n_d_ _c_o_u_n_t_r_y_ _c_a_n_ _a_f_f_o_r_d_ _t_o_
_m_a_i_n_t_a_i_n_ _a_t_ _e_v_e_r_y_ _s_t_a_g_e_ _o_f_ _t_h_e_i_r_
_d_e_v_e_l_o_p_m_e_n_t_ _i_n_ _t_h_e_ _s_p_i_r_i_t_ _o_f_
_s_e_l_f_-_r_e_l_i_a_n_c_e_ _a_n_d_
_s_e_l_f_-_d_e_t_e_r_m_i_n_a_t_i_o_n_._“ _(_D_e_c_l_a_r_a_t_i_o_n_ _o_f_
_A_l_m_a_-_A_t_a_)_ _*

The Primary Health Care (PHC) principles affirm health as a human right
based on equity and social justice, implemented through community
engagement, health promotion, the appropriate use of resources, and
inter-sectoral action based on a “New International Economic Order” with
the vision of health for all by the year 2000.

The Declaration, however, came at a time of major global economic changes
including the economic slow-down of the 1970ies, the debt crisis and
structural adjustments. Shortly after Alma Ata UNICEF and the Rockefeller
Foundation declared “Selective Primary Health Care” instead of
“Comprehensive Primary Health Care”, which under structural adjustments
became the dominant paradigm and model of PHC. Structural adjustment
programs led to a reduction of staff, narrow benefit packages and a lack of
resources in the public sector and weakened already weak health systems.

The advent of the HIV epidemic led to isolated but impressive community
based responses even before the advent of antiretrovirals. These were
applying PHC principles dealing with HIV prevention, home based care,
destigmatisation, treatment literacy a.o. addressing the challenges of HIV.

Global health initiatives such as the GFATM or Gavi contributed to a
considerable increase of funding but these have been mainly earmarked for
vertical programmes especially in the area of HIV, Malaria or TB. Besides
all the positive effects that were achieved, this has been associated with
a migration of resources and personnel from public primary care systems to
globally funded programs.

In 2010, WHO introduced the concept of Universal Health Coverage (UHC),
which was defined as access to health services without financial hardship.
While in general, the notion of UHC seems consistent with WHO’s concept of
Health for All in Primary Health Care, a key issue that remains unresolved
is the primacy provided to public or non-for-profit services under PHC and
conversely the larger role envisioned to private for-profit providers while
implementing UHC. Hence, in many countries public services are being
replaced by private for-profit providers. Especially concerning is the
increase of corporate chains of providers, mainly supported by private
insurance.

While impressive medical and technological advances have taken place around
the world, improvements in the health status of the people have been
moderate and inconsistent between and within countries. The biomedical and
technical approach to health has its limitations in actually improving
health especially among marginalised and poor populations and has
contributed to a neglect of other determinants of health.

Health systems must be built on the principles of comprehensive primary
health care that includes community engagement, adequate healthcare
infrastructure, skilled, supported and motivated health workforce, access
to essential drugs of good quality that are rationally used in addition to
new advancements and technologies that must be accessible to all.

*Communities: From objects of health care to full participation and
ownership *

*“T_h_e_ _p_e_o_p_l_e_ _h_a_v_e_ _t_h_e_ _r_i_g_h_t_ _a_n_d_ _d_u_t_y_
_t_o_ _p_a_r_t_i_c_i_p_a_t_e_ _i_n_d_i_v_i_d_u_a_l_l_y_ _a_n_d_
_c_o_l_l_e_c_t_i_v_e_l_y_ _i_n_ _t_h_e_ _p_l_a_n_n_i_n_g_ _a_n_d_
_i_m_p_l_e_m_e_n_t_a_t_i_o_n_ _o_f_ _t_h_e_i_r_ _h_e_a_l_t_h_ _c_a_r_e_._”
_(_D_e_c_l_a_r_a_t_i_o_n_ _o_f_ _A_l_m_a_-_A_t_a_)_ _*

Communities are at the heart of PHC and must be the *owners and partners *in
making health for all a reality. People and communities own their health
and therefore health planning, promotion and provision need to be carried
out by people and with people, rather than for people. They must not be
reduced to mere consumers of health services and health systems must be
accountable to people and the communities they serve. However, communities
are changing rapidly and in many settings new ways in which community
ownership is expressed need to be developed. Strong people’s organisations
and movements are fundamental to more democratic, transparent and
accountable decision‐making processes in health.

Community health workers are an important link between communities and the
formal health system. They play an essential role in order to strengthen
local health services and make them accessible to all. Therefore, community
health workers must be recognised in their specific role, supported,
trained and remunerated accordingly.

Community health workers must become part of a skilled and motivated health
workforce. In the light of changing demographics globally, global health
worker migration and a gap in trained health work force, health systems
must ensure an environment that will be enable and retain skilled and
motivated health workers at all levels.

*Justice, cooperation and solidarity *

*“T_h_e_ _e_x_i_s_t_i_n_g_ _g_r_o_s_s_ _i_n_e_q_u_a_l_i_t_y_ _i_n_ _t_h_e_
_h_e_a_l_t_h_ _s_t_a_t_u_s_ _o_f_ _t_h_e_ _p_e_o_p_l_e_
_p_a_r_t_i_c_u_l_a_r_l_y_ _b_e_t_w_e_e_n_ _d_e_v_e_l_o_p_e_d_ _a_n_d_
_d_e_v_e_l_o_p_i_n_g_ _c_o_u_n_t_r_i_e_s_ _a_s_ _w_e_l_l_ _a_s_
_w_i_t_h_i_n_ _c_o_u_n_t_r_i_e_s_ _i_s_ _p_o_l_i_t_i_c_a_l_l_y_,_
_s_o_c_i_a_l_l_y_ _a_n_d_ _e_c_o_n_o_m_i_c_a_l_l_y_
_u_n_a_c_c_e_p_t_a_b_l_e_ _a_n_d_ _i_s_,_ _t_h_e_r_e_f_o_r_e_,_ _o_f_
_c_o_m_m_o_n_ _c_o_n_c_e_r_n_ _t_o_ _a_l_l_ _c_o_u_n_t_r_i_e_s_._”
_(_D_e_c_l_a_r_a_t_i_o_n_ _o_f_ _A_l_m_a_-_A_t_a_)_ _*

Health is not only a matter of human rights, but also of justice.
Governments who are not making provision for decent health care are denying
justice to their people.

The Alma Ata declaration recognised the need to restructure the global
economic order to address inequalities and enable countries to generate
resources for decent health care and tackle the root causes of poor health.
This still remains a critically important task today.

In contrast to the New International Economic Order referred to in the
Declaration the dominant contemporary paradigm of export led development
has contributed to loss of tax receipts at country level because of the
competition for investment which drives reduced tax rates and constant
pressure to reduce the cost of production or extraction. These have led to
a deterioration of people’s living circumstances and contributed to ill
health, instability or even war.

It is vital that we build solidarity between people within and across
nations and regions. The existing system of international aid and the
associated charity narrative legitimise an unfair economic framework which
prevents national self-determination and weakens the building of strong and
resilient local health systems. Health for all requires the redistribution
of wealth nationally and globally.

Public financing is essential for health for all. This requires tax justice
that will clamp down on tax avoidance and control tax competition between
countries. The regulation of transnational corporations through appropriate
agreements is essential.

Trade justice for health will require trade agreements that protect from
extortionate drug prices and not provide corporate impunity through
investor state dispute settlements.

A reform of research and development financing is required which enables
the delinking of research costs from profits from drug sales. Drug policies
must support production capacity in low and medium income countries.

The provision of health care is costly in any society. A health system
based on primary health care principles will be able to achieve health for
all at a reasonable cost even while countries develop the capacity for more
technological intensive health care.

*Beyond the health sector: Addressing root causes and determinants of
health inequity *

*“T_h_e_ _a_t_t_a_i_n_m_e_n_t_ _o_f_ _t_h_e_ _h_i_g_h_e_s_t_
_p_o_s_s_i_b_l_e_ _l_e_v_e_l_ _o_f_ _h_e_a_l_t_h_ _i_s_ _a_ _m_o_s_t_
_i_m_p_o_r_t_a_n_t_ _w_o_r_l_d_-_w_i_d_e_ _s_o_c_i_a_l_ _g_o_a_l_
_w_h_o_s_e_ _r_e_a_l_i_z_a_t_i_o_n_ _r_e_q_u_i_r_e_s_ _t_h_e_ _a_c_t_i_o_n_
_o_f_ _m_a_n_y_ _o_t_h_e_r_ _s_o_c_i_a_l_ _a_n_d_ _e_c_o_n_o_m_i_c_
_s_e_c_t_o_r_s_ _i_n_ _a_d_d_i_t_i_o_n_ _t_o_ _t_h_e_ _h_e_a_l_t_h_
_s_e_c_t_o_r_._” _(_D_e_c_l_a_r_a_t_i_o_n_ _o_f_ _A_l_m_a_-_A_t_a_)_ _*

The WHO’s Commission on Social Determinants of Health in 2008 demonstrated
that poor health is not randomly distributed, but rather follows a
predictable pattern with systematic differences among social groups (i.e.
gender, class, race/ethnicity) caused by unequal exposure to, and
distribution of, social determinants of health (SDH). Social justice is a
matter of life and death. Addressing root causes of health inequity and
investing in society, is the only way that health for all and sustainable
development can be achieved.

The broader context, shaped since the late 1980s by neoliberal economic
globalization has profoundly influenced our health situation today. This
can be seen in the impact of globalization on social justice, the effect of
climate change on livelihoods; the loss of biodiversity, the detrimental
effects of agribusiness on peasant farmers and small-holder farmers, who
provide most of the world’s food; the impact of land grabbing and the
grabbing of water bodies by big business; the influence of patriarchy on
society; tax evasion leading to the lack of public funds; the unbridled
growth of the arms trade; and the effects of migration to name only a few.
All these issues require collaboration across sectors and policies that
will address the root causes of illness and the determinants of health
inequity.

The current global economic order has become dominated by a greatly
expanded financial sector leading to price instability due to speculation
and reduced policy space because of the reach of market sentiment. It has
seen the deregulation of corporations and of trading relations and the
commodification and marketization of services which should be based in
human relationships and handled as public goods.

As in the Alma Ata Declaration, we are calling for a new global economic
order (NGEO) to facilitate a safe and just space for humanity. This NGEO
would be a means for securing global common goods. The NGEO would guarantee
a social foundation for all while at the same time an ecological ceiling so
that planetary boundaries are respected. This embedded economy would follow
a human rights based approach. It would regulate global public “bads”,
economic externalities that damage the living environment and drive
poverty. It would redistribute the enormous wealth and capital available in
the world ensuring essential public services and social protection. The
NGEO would be regenerative and circular in nature as to remain within the
ecological ceilings that planet earth provides while providing a dignified
living for all.

Today, we have a clear vision on how to overcome these challenges through
transformative policies; through the building of people’s movements; and
the facilitation of people-to-people connections and solidarity. Examples
of such movements include the Women’s March; the tax justice movement, the
Global Network for the Right to Food and Nutrition; the Treaty Alliance,
the Treatment Action Campaign and others. They are positive examples of a
way forward. It is only with the mobilization and convergence of people’s
movements and a process of dialogue on national, regional and international
level that health equity can become a reality.

We call upon governments and people from across the globe to take forward
the principles of Primary Health Care that are so clearly articulated in
the Alma Ata Declaration.
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