<p style="MARGIN: 0in 0in 0pt"><b><font size="5"><font face="Times New Roman">Reflection on Primary Health Care 30 years after Alma Ata and the challenges ahead:</font></font></b></p>
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<p style="MARGIN: 0in 0in 0pt"><span style="FONT-SIZE: 12pt"><font face="Times New Roman">The recently released World Health Report on PHC (WHO Oct 2008) is an attempt to bring PHC again to the forefront of our priorities in global health. Good for that!</font></span></p>
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<p style="MARGIN: 0in 0in 0pt"><span style="FONT-SIZE: 12pt"><font face="Times New Roman">But the world has changed in these 30 years.</font></span></p>
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<p style="MARGIN: 0in 0in 0pt"><span style="FONT-SIZE: 12pt"><font face="Times New Roman">In 1978, we <strong>did not have</strong>:</font></span></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in"><span style="FONT-SIZE: 12pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 12pt"><font face="Times New Roman">Neoliberal globalization.</font></span></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in"><span style="FONT-SIZE: 12pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 12pt"><font face="Times New Roman">Selective, vertical health programs (many of them aggressively pushed by public-private partnerships --PPPs that started, because they did not trust WHO…).</font></span></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in"><span style="FONT-SIZE: 12pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 12pt"><font face="Times New Roman">A big health manpower crisis (only in part due to the AIDS pandemic).</font></span></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in"><span style="FONT-SIZE: 12pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 12pt"><font face="Times New Roman">The magnitude of economic impediments to access to health by poor people with increasing inequities and disparities between the haves and the have nots.</font></span></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in"><span style="FONT-SIZE: 12pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 12pt"><font face="Times New Roman">Increasing privatization and commercialization/commoditization of health services as a result of globalization *.</font></span></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in"><span style="FONT-SIZE: 12pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 12pt"><font face="Times New Roman">Intellectual property issues (patent issues) used against the interest of poor countries and poor patients.</font></span></p>
<p style="MARGIN: 0in 0in 0pt"><span style="FONT-SIZE: 12pt"><font face="Times New Roman">We also <strong>did not have</strong>:</font></span></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in"><span style="FONT-SIZE: 12pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 12pt"><font face="Times New Roman">An energetic and active civil society.</font></span></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in"><span style="FONT-SIZE: 12pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 12pt"><font face="Times New Roman">The People's Health Movement (PHM) and its global network.</font></span></p>
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<div style="MARGIN: 0in 0in 0pt"><span style="FONT-SIZE: 12pt"><font face="Times New Roman">Therefore, as a PHM member, on top of seeing PHC and Alma Ata as still alive, I think PHC-in-2008-and-beyond needs to address these (and other unmentioned) "did not have" issues as challenges at local, national and global level. </font></span></div>
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<div style="MARGIN: 0in 0in 0pt"><span style="FONT-SIZE: 12pt"><font face="Times New Roman">For this to happen, WHO is to recuperate its moral and political leadership in PHC, in health overall, and in proactively addressing the social determinants of health as per the recommendations of the ad-hoc WHO Commission that just released its report. </font></span></div>
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<div style="MARGIN: 0in 0in 0pt"><span style="FONT-SIZE: 12pt"><font face="Times New Roman">To go beyond well-meaning pronouncements, this will clearly need some internal reorganization in this UN agency. The question is whether its leadership plans such a reorientation…</font></span></div>
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<div style="MARGIN: 0in 0in 0pt"><span style="FONT-SIZE: 12pt"><font face="Times New Roman">PHM does not shy away from a political approach to PHC and is not really fighting its opponents; it is rather bringing the level of the discussion to a higher level. Therefore, it has published an alternative report to the World Health Report of 2008 --<strong>the Global Health Watch 2</strong> (being released today, see </font><a onclick="return top.js.OpenExtLink(window,event,this)" href="http://www.phmovement.org/" target="_blank"><font face="Times New Roman">www.phmovement.org</font></a><font face="Times New Roman"> ). </font></span></div>
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<div style="MARGIN: 0in 0in 0pt"><span style="FONT-SIZE: 12pt"><font face="Times New Roman">PHM challenges the concept that good health is an imperative for increased economic productivity: Instead, it insists and departs from the premise that <strong>health is an inalienable Human Right</strong>. </font></span></div>
<div style="MARGIN: 0in 0in 0pt"><span style="FONT-SIZE: 12pt"><font face="Times New Roman">Health is not <i>either</i> a technical or a political issue: it is both…and pro-poor health interventions mean nothing if not concomitantly accompanied by poverty reduction actions that are pro-health. <span> </span></font></span></div>
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<div style="MARGIN: 0in 0in 0pt"><span style="FONT-SIZE: 12pt"><font face="Times New Roman"><span></span>Based on patients registers at health facilities, statistics want to make us believe that 50% of the poor choose to seek private health care. Such a fallacy hides the real fact that 50% of the poor do not seek <u>any</u> care (and thus escape facility-based statistics!). So, let us stop using the slogan "those who can pay should pay" without carefully weighing its meaning. </font></span></div>
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<div style="MARGIN: 0in 0in 0pt"><span style="FONT-SIZE: 12pt"><font face="Times New Roman">I am a perennial optimist. I hope recent developments mean a real new window of opportunity for PHC. But WHO/member states/civil society interactions will have to become more of a 'two-way street'. I am sure PHM will play its role in achieving this.</font></span></div>
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<p style="MARGIN: 0in 0in 0pt"><span lang="IT" style="FONT-SIZE: 10pt"><font face="Times New Roman" size="1">Claudio Schuftan, Ho Chi Minh City</font></span></p>
<p style="MARGIN: 0in 0in 0pt"><span lang="IT" style="FONT-SIZE: 10pt"><a onclick="return top.js.OpenExtLink(window,event,this)" href="mailto:cschuftan@phmovement.org" target="_blank"><font face="Times New Roman" size="1">cschuftan@phmovement.org</font></a><font face="Times New Roman" size="1"> </font></span></p>
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<p style="MARGIN: 0in 0in 0pt"><font face="Times New Roman" size="5"> <font size="1">______________</font></font></p>
<p style="MARGIN: 0in 0in 0pt"><span style="FONT-SIZE: 10pt"><font face="Times New Roman">*: The myth that private health providers are more efficient has to be broken once and for all. Without trying to generalize, it is still true that, in the private sector, the following facts are prevalent:</font></span></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in"><span style="FONT-SIZE: 10pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 10pt"><font face="Times New Roman">An irrational use of drugs, of polypharmacy and an overuse of antibiotics, vitamins and steroids.</font></span></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in"><span style="FONT-SIZE: 10pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 10pt"><font face="Times New Roman">An overuse of injectables.</font></span></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in"><span style="FONT-SIZE: 10pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 10pt"><font face="Times New Roman">A veritable 'ultrasound epidemic'.</font></span></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in"><span style="FONT-SIZE: 10pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 10pt"><font face="Times New Roman">An excessive numbers of cesarean sections and tonsillectomies performed.</font></span></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in"><span style="FONT-SIZE: 10pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 10pt"><font face="Times New Roman">Private insurance companies cherry picking the healthier patients and leaving the others for the public sector to care for (or offering minimum coverage packages to the poor that end up in 1<sup>st</sup>, 2<sup>nd</sup> and 3<sup>rd</sup> class medicine).</font></span></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in"><span style="FONT-SIZE: 10pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 10pt"><font face="Times New Roman">A penetration of transnational health corporations in developing countries using GATS provisions (that PHM denounces).</font></span></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in"><span style="FONT-SIZE: 10pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 10pt"><font face="Times New Roman">Public hospitals opening private wards 'that will (allegedly) generate income to subsidize the public wards', but most of the times ending up being subsidized by the public sector since they undercharge private patients.</font></span></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in"><span style="FONT-SIZE: 10pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 10pt"><font face="Times New Roman">Health tourism springing up in many countries with the consequent internal brain drain.</font></span></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in"><span style="FONT-SIZE: 10pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 10pt"><font face="Times New Roman">A conspicuous absence of private practitioners in remote and poor areas.</font></span></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in"><span style="FONT-SIZE: 10pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 10pt"><font face="Times New Roman">A very limited role of this sector in preventive and promotive health actions and a minimal role in TB and in AIDS, and</font></span></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in"><span style="FONT-SIZE: 10pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 10pt"><font face="Times New Roman">A resistance of medical associations to any measures directed at regulating private practice.</font></span></p>
<p style="MARGIN: 0in 0in 0pt"><span style="FONT-SIZE: 12pt"><font face="Times New Roman"><span> </span></font></span><span lang="IT"><font face="Times New Roman" size="5"> </font></span></p>