PHM-Exch> [PHM NEWS] People’s Health Movement comments on WHO's Draft Declaration for the upcoming Second International Conference on Primary Health Care

[Claudio Schuftan]

*People’s Health Movement comments on the Draft Declaration for the Second
International Conference on Primary Health Care: Towards Universal Health
Coverage and the Sustainable Development Goals*

*Preamble:*

The People’s Health Movement (PHM) is a global network bringing together
grassroots health activists, academics, policymakers and practitioners,
civil society organizations and academic institutions from around the
world, particularly from low and middle income countries (LMIC). PHM
currently has a presence in over 80 countries.

Our consultation on the 2nddraft of the Astana Declaration with our global
network of PHC practitioners and activists has been limited, due to the
short time frames set by WHO to receive feedback. The following comments
are submitted on behalf of the Global Steering Council and some country
circles and build upon our comments on the 1st draft.

*Comments*

We welcome the second draft, and recognise the difficult task in pulling
together this draft, and trying to include extremely conflicting views. PHM
has a number of concerns about the current draft and have highlighted a few
specific areas of concern:

While recognising the importance of having a declaration arising from the
Astana conference, which reaffirms the importance of Primary Health Care
(PHC), we would like to state upfront, that for PHM, the Alma Ata
declaration has defined PHC and continued to guide and inform PHM’s work
(and indeed that of many member states) on PHC. The definition and
principles enshrined in the Alma Ata are ones we have not achieved and that
we should still be striving to achieve. This declaration should upfront
state this, and reaffirm the Alma Ata declaration.

A fundamental concern for PHM is the continuing framing of PHC as a means
to achieve UHC. Our understanding is that PHC, which includes actions to
address social determinants of health as well as community participation,
is broader and indeed subsumes UHC. UHC on the other hand is narrowly
defined in most literature as financial protection for a package of
services. The whole of the draft declaration, including the heading,
assumes that Primary Health Care is a means to achieve UHC, which
completely undermines the significant role that PHC can play in health
systems [ref heading, point 3 of the principles behind the AA40 Declaration
text]

3rd para starting “To address the health and development challenges of the
modern era, we need PHC that:” Point 2 should include reference to the
*political
determinants of health *(in addition to social, economic and commercial).
The paragraph should also highlight that *governments *have prime
responsibility for health and health service delivery.

Section “We are more likely to succeed than ever before. Our success will
be driven by:”

PHM earnestly hopes for greater success “than ever before”; however, the
current global economic system has failed to satisfy the basic needs of
much of humanity or to operate within the confines of environmental
sustainability. The system is characterised by extreme inequality and
poorly regulated markets, and dominated by the interests of a small rich
minority in the corporate and financial sectors. If we want to achieve
social goals such as health for all, and do so while simultaneously
tackling climate change and achieving true environmental sustainability,
then we need to redesign the global economic system to realise these aims.
That increasing inequalities within and between countries is real and is a
stark feature of our current world has been acknowledged in the SDG slogan
‘leave no one behind’. Phrases such as ‘..we acknowledge remarkable
progress in health outcomes and are encouraged by new opportunities that
propel us toward the goal of health and well-being for all’ fail to take
into account that those health outcomes are unevenly distributed, due to
inequitable policies and political choices. This issue, the challenges it
poses and its fundamental economic and political cause need to be more
clearly stated. These challenges were pointed out by the Commission on the
Social Determinants of Health (
http://www.who.int/social_determinants/thecommission/en/ ) in its report to
WHO some ten years ago and its messages regarding health equity are still
highly relevant to the PHC agenda in 2018.

Subsection: Political will:

The first sentence reads “*We will have more partners and more
stakeholders, both public and private, working towards common goals in the
SDGs…..”.*PHM is unconvinced that public and private are “working towards
common goals in the SDG’s”. Partnerships with the private sector generally
lead to private extraction of profits at the expense of public health.
Unfortunately, the achievement of the SDG’s is dependent on high levels of
GDP growth based on a profit-maximising, extractivist, economic model,
which is both economically and environmentally unsustainable. Moreover,
“political will” needs to be evidenced by a stronger role for democratic
and accountable national and global government in prioritising health
equity.

Subsections: Knowledge and technology:

PHM strongly agrees that we possess sufficient knowledge and technology to
greatly improve health and narrow inequities, but their dissemination and
use remains highly inequitable; even simple yet effective technologies such
as vaccination and oral rehydration therapy remain inaccessible to large
swathes of populations, especially in Sub-Saharan Africa and South Asia;
and the digital divide has still not been bridged. Additionally, the global
Intellectual property regime prevents the dissemination of new health
products to large parts of the world.

We strongly agree with the paragraph beginning “Reflecting on the last 40
years…”, which stresses the remaining challenges of ill health,
marginalisation and inequality. This paragraph should come earlier so that
it precedes and provides a framework for the section titled “We are more
likely to succeed than ever before”.

PHM aligns itself with the subsections falling under “To address today’s
challenges…..” , however as stated earlier, we understand PHC to go well
beyond UHC and are concerned that resolving to “Put public health and
primary care at the centre of UHC” limits these to serving selected health
service components. Additionally, it is already the case that UHC is, in
many countries, manifesting as limited “packages of care” for public sector
dependents and more comprehensive services for those who can afford private
insurance.

Page 2, under section “To Address today’s challenges……” subsection “Put
public health and primary care…..” – the term non-professional should be
removed before community health workers (line 4). This term is demeaning.


*Conclusion *Throughout the document, we note that primary health care is
being translated as “public health and primary care”. While we welcome the
focus on public health (preventive and promotive actions), we are concerned
that aspects of comprehensive PHC e.g. rehabilitative and palliative
components are absent.

We are concerned that there is insufficient reference to the
responsibilities and role of governments and the declaration as currently
worded risks placing most responsibility on the shoulders of individual
citizens.

We would also like to reaffirm the Alma Ata declaration statement that
better health for all the people of the world 2000 can be attained through
a fuller and better use of the world's resources, and the recognition that
a considerable part continues to be spent on armaments and military
conflicts. And that as stated in the Alma Ata Declaration, “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.”

We would like to emphasise a point made in our response to the first draft
“The whole document fails to provide a critique of the corporate private
sector and the evidence that a high level of private sector involvement is
inimical to PHC and the achievement of UHC in particular. UHC should be
defined as universalist, based on social solidarity and built mainly on a
unified public funded system, with most service provision through public
institutions. The problems of privatisation of health systems need to be
highlighted – and the benefits of publicly funded and publicly provided and
comprehensive services, free at the point of use stressed.”
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