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<B><FONT SIZE="6">Address to the 61st World Health Assembly</FONT></B><BR>
<B><FONT SIZE="5">Dr Halfdan Mahler</FONT></B>
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<B><FONT SIZE="5">Former Director-General of WHO</FONT></B>
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<A HREF="http://www.who.int/mediacentre/events/2008/wha61/hafdan_mahler_speech/en/index.html">http://www.who.int/mediacentre/events/2008/wha61/hafdan_mahler_speech/en/index.html</A><BR>
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Distinguished audience,<BR>
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My remarks will focus on "Why Alma-Ata in 1978 and Whither the Health for All Vision and Primary Health Care Strategy".<BR>
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Milan Kundera wrote in one of his books: "The struggle against human oppression is the struggle between memory and forgetfulness." So allow me to remind all of us today, of the transcendental beauty and significance of the definition of health in WHO's Constitution: "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."<BR>
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This definition is immediately followed by: "The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition." Most importantly, the very first constitutional function of WHO reads: "To act as the directing and coordinating authority on international health work." Please do note that the Constitution says "the" and not "a" directing and coordinating authority.<BR>
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So please, allow this old man in front of you to insist that unless we all become partisans in renewed local and global battles for social and economic equity in the spirit of distributive justice, we shall indeed betray the future of our children and grandchildren.<BR>
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My memory tells me that the World Health Assembly had this in mind when, in 1977, it decided that the main social target for governments and WHO in the coming decades should be the attainment of what is known as "Health for All".<BR>
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And, the Health Assembly described that as a level of health that will permit all the people of the world to lead socially and economically productive lives. The Health Assembly did not consider health as an end in itself, but rather as a means to an end.<BR>
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That is, I believe as it should be.<BR>
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When people are mere pawns in an economic and profit growth game, that game is mostly lost for the underprivileged.<BR>
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Let me postulate that if we could imagine a tabula rasa in health without having to deal with the constraints - tyranny if you wish - of the existing medical consumer industry, we would hardly go about dealing with health as we do now in the beginning of the 21st century.<BR>
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To make real progress we must, therefore, stop seeing the world through our medically tainted glasses. Discoveries on the multifactoral causation of disease, have for a long time, called attention to the association between health problems of great importance to man and social, economic and other environmental factors. Yet, considering the tremendous political, social, technical and economic implications of such a multidimensional awareness of health problems I still find most of today's so-called health professions very conventional, indeed.<BR>
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It is, therefore, high time that we realize, in concept and in practice, that a knowledge of a strategy of initiating social change is as potent a tool in promoting health, as knowledge of medical technology.<BR>
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Primary health care is indeed conditioned by its holistic framework and as such, may use different expressions. For example, in some countries health management has to be considered along with such things as producing more or better food, improving irrigation, marketing products, etc. It is not that people consider health services as unimportant, but there are things like getting food, or a piece of land, or house or an accessible source of water which are more of a life and death nature and must, in the wisdom of the people, come first to make other things meaningful. We have rarely considered these needs as falling within our expressed policies for health development and therefore, we risk being restricted, unilateral and ineffective in our action.<BR>
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Again, I am afraid that conventional or medical wisdom has done very little to provide scientific and political credibility to the alleged importance of individual, family and community participation in health promotion.<BR>
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These concerns, to which I have just alluded prompted an organizational study on "Methods of promoting the development of basic health services" by WHO's Executive Board in 1973 in which it is bluntly stated that:<BR>
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"There appears to be widespread dissatisfaction of population about their health services for varying reasons. Such dissatisfaction occurs in the developed as well as in the Third World. The causes can be summarized as a failure to meet the expectations of the populations; an inability of the health services to deliver a level of national coverage adequate to meet the stated demands and the changing needs of different societies; a wide gap (which is not closing) in health status between countries, and between different groups within countries; rapidly rising costs without a visible and meaningful improvement in service; and a feeling of helplessness on the part of the consumer who feels (rightly or wrongly) that the health services and the personnel within them are progressing along an uncontrollable path of their own which may be satisfying to the health professionals but which is not what is most wanted by the consumer".<BR>
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It was this organizational study by WHO's Executive Board that led to the decision by WHO in co-sponsorship with UNICEF to convene "The International Conference on Primary Health Care" in the city of Alma-Ata in 1978.<BR>
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Let me then repeat with awe and admiration, the consensus concept of primary health care as contained in the Declaration of Alma-Ata 1978:<BR>
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"Primary Health Care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the 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.<BR>
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"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."<BR>
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Let me also quote from the Declaration of Alma-Ata, that primary health care includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs. In my opinion, an admirable summation of key priorities.<BR>
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Are you ready to address yourselves seriously to the existing gap between the health "haves" and the health "have-nots" and to adopt concrete measures to reduce it?<BR>
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Are you ready to ensure the proper planning and implementation of primary health care in coordinated efforts with other relevant sectors, in order to promote health as an indispensable contribution to the improvement of the quality of life of every individual, family and community as part of overall socio-economic development?<BR>
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Are you ready to make preferential allocations of health resources to the social periphery as an absolute priority?<BR>
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Are you ready to mobilize and enlighten individuals, families and communities in order to ensure their full identification with primary health care, their participation in its planning and management and their contribution to its application?<BR>
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Are you ready to introduce the reforms required to ensure the availability of relevant human resources and technology, sufficient to cover the whole country with primary health care within the next two decades at a cost you can afford?<BR>
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Are you ready to introduce, if necessary, radical changes in the existing health delivery system so that it properly supports primary health care as the overriding health priority?<BR>
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Are you ready to fight the political and technical battles required to overcome any social and economic obstacles and professional resistance to the universal introduction of primary health care?<BR>
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Are you ready to make unequivocal commitments to adopt primary health care and to mobilize international solidarity to attain the objective of health for all by the year 2000?<BR>
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Alma-Ata was, in my biased opinion, one of the rare occasions where a sublime consensus between the haves and the have-nots in local and global health emerged in the spirit of a famous definition of consensus: "I am not trying to convince my adversaries that they are wrong, quite to the contrary, I am trying to unite with them, but at a higher level of insight."<BR>
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The Alma-Ata primary health care consensus also reflects a famous truism: "The Health Universe is only complete for those who see it in a complete light, it remains fragmented for those who see it in fragmented light!"<BR>
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In conclusion, my personal view is that the Alma-Ata primary health care consensus has had major inspirational and operational impacts in many countries having a critical mass of political and professional leadership combined with adequate human and financial resources to test its adaptability and applicability within the local realities through a heavy dose of systems and operations research.<BR>
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Mind you, it is much easier to be rational, audacious and innovative when your are rich! But, please, let us not forget that the inspirational energies and the evidence base came from the developing countries themselves, be they governmental or non-governmental sources.<BR>
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For a majority of these countries, financial support from so-called donors was essential to carry out a broad array of studies, in appropriate technology, human resources development, infrastructure development, social participation, financing etc. in order to integrate the Alma-Ata vision into heavily constrained local contexts.<BR>
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Most donors, after an initial outburst of enthusiasm quickly lost interest or distorted the very essence of the Alma-Ata Health for All Vision and Primary Health Care Strategy under the ominous name of selective primary health care which broadly reflected the biases of national and international donors and not the needs and demands of developing countries.<BR>
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But in spite of these brutal impediments many developing countries have shown, before and after the Alma-Ata happening, courageous adhesion to its health message of equity in local and global health. Civil society movements have also been prime shakers and movers in these admirable efforts.<BR>
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And so, being an inveterate optimist I do believe that the struggle between memory and forgetfulness can be won in favour of the Alma-Ata Health for All Vision and its related Primary Health Care Strategy. Let us not forget that visionaries have been the realists in human progression.<BR>
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And so, distinguished audience, let us use the complete light generated by WHO's Constitution and the Alma-Ata Health for All Vision and Primary Health Care Strategy to guide us along the bumpy, local and global health development road.<BR>
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Thank you.<BR>
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