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Chapter: Sociology of Health : Health services

Relevance of Alma‐ Ata to the primary health care system

WHO has highlighted the importance of primary health care in tackling health inequality in every country but after years of relative neglect; the World Health Organization has recently given strategic prominence to the development of primary health care.

Relevance of Alma Ata to the primary health care system:


WHO has highlighted the importance of primary health care in tackling health inequality in every country but after years of relative neglect; the World Health Organization has recently given strategic prominence to the development of primary health care. This year sees the 36th anniversary of the declaration of Alma Ata. Convened by WHO and the United Nations Children’s Fund (Unicef), the Alma Ata conference drew representatives from 134 countries, 67 international organisations, and many nongovernmental organisations. (China was notably absent.) Primary health care “based on practical, scientifically sound and socially acceptable methods and technology made universally accessible through people’s full participation and at a cost that the community and country can afford” was to be the key to delivering health for all by the year 2000.Primary health care in this context includes both primary medical care and activities tackling determinants of ill health.


1. Characteristics of primary health care from Alma Ata declaration:


Evolves from the economic conditions and sociocultural and political characteristics of a country and its communities


Is based on the application of social, biomedical, and health services research and public health experience


Tackles the main health problems in the community—providing promotion, preventive, curative, and rehabilitative services as appropriate


Includes education on prevailing health problems; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunisation against the main infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs


Involves all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, and industry


Requires maximum community and individual selfreliance and participation in the planning, organisation, operation, and control of services


Develops the ability of communities to participate through education


Should be sustained by integrated, functional, and mutually supportive referral systems, leading to better comprehensive health care for all, giving priority to those most in need


Relies on health workers, including physicians, nurses, midwives, auxiliaries, and community workers as well as traditional practitioners, trained to work as a team and respond to community’s expressed health needs.


2. Essential components of effective primary health care:


·              Well trained, multidisciplinary workforce


·              Properly equipped and maintained premises


·              Appropriate technology, including essential drugs


·              Capacity to offer comprehensive preventive and curative services at community level

·              Institutionalised systems of quality assurance


·              Sound management and governance systems


·              Sustainable funding streams aiming at universal coverage


·              Functional information management and technology


·              Community participation in the planning and evaluation of services provided


·              Collaboration across different sectors—for example, education, agriculture


·              Continuity of care


·              Equitable distribution of resources


3. Progress and context


In 2008, the 30th Anniversary of AlmaAta, primary health care (PHC) was reaffirmed as the key global strategy for attaining optimal health. Celebratory meetings were held under the auspices of the World Health Organization (WHO) in all its regions. The WHO World Health Report 2008 (WHR08) was devoted to PHC (WHO 2008). In 2008 The Lancet produced a themed issue on PHC. Notwithstanding these activities and publications there remains confusion, disagreement, and controversy around PHC in terms of its content, emphasis and application.


In the thirty years since the AlmaAta Declaration there has been significant progress in global health with an overall increase in life expectancy. However, rapidly widening inequalities in health experience between and within countries – and even reversals in Africa and the former Soviet bloc countries – have led to a reexamination of the current context and content of health policies and why the AlmaAta Declaration failed to lead to health for all (Commission on Social Determinants of Health 2008). The key question is whether PHC, as originally elaborated at AlmaAta, remains a feasible option. This reexamination shows that a series of reform projects, with some key common features, driven by vested interests and shortsightedness, have perpetuated or aggravated the conditions that underpin ill health and undermined the ability of health systems to function appropriately. Key among these are selective PHC, health sector reform, and the global health partnerships. These have depoliticized health and undermined the spirit of PHC.



4. Four Assaults on Primary Health Care:



1. Selective Primary Health Care – introduced in the late 70’s. The comprehensive approach to PHCwith its emphasis on equity and its call for a model of socioeconomic development conducive to Healthfor All,was quickly undermined by experts at John Hopkins School of Public Health, who claimed it wastoo complex and too costly. Instead, they advocated Selective Primary Health Care, focusing on a few “cost effective”, topdown technological fixes “targeting” high risk groups. UNICEF quickly adopted this selective approach, which in practice focused mainly on oral rehydration therapy and immunization. While these socalled “twin engines” of the Child Survival Revolution did succeed in somewhat reducing child mortality, they did discouragingly little to reduce poverty, hunger, or children’s quality of life. For this, a comprehensive approach is needed that confronts the root causes. While progress inimplementing the PHC strategy in most low and middle income countries (LMICs) has been greatest in respect of certain of its more medicallyrelated elements, the narrow and technicist focus characterizing what has been termed the ‘selective PHC’ approach (Walsh and Warren 1979) has at best delayed, and at worst undermined, the implementation of the comprehensive strategy codified at AlmaAta. The latter insisted on the integration of rehabilitative, therapeutic, preventive and promotive interventions with an emphasis on the latter two components. Selective PHC (SPHC) took the form in many LMICs of certain selected medical – mostly therapeutic and personal preventive – interventions, such as growth monitoring, oral rehydration therapy (ORT), breastfeeding and immunisation (GOBI). These constituted the centrepiece of UNICEF’s 1980s Child Survival Revolution, which, it was argued, would be the ‘leading edge’ of PHC, ushering in a more comprehensive approach at a later stage (Werner and Sanders 1997). The relative neglect of the other PHC programme elements and the shift of emphasis away from equitable social and economic development, intersectoral collaboration, community participation and the need to set up sustainable district level structures suited the prevailing conservative winds of the 1980s (Rifkin and Walt 1986). It gave donors and governments a way of avoiding the fuzzier and more radical challenges of tackling inequalities and the underlying causes of illhealth. Some components of comprehensive PHC, especially the promotive interventions, have remained marginalised ever since AlmaAta. These require for their operationalisation the implementation of such core principles of PHC as ‘intersectoral action’ and ‘community involvement’, and, increasingly with economic globalisation, intersectoral policies to address the social determinants of health (SDH) (Sanders et al. 2009). PHC has been defined (even in the AlmaAta Declaration) as both a ‘level of care’ and an ‘approach’. These two different meanings have persisted and perpetuated divergent perceptions and approaches. Thus, in some rich countries and sectors, PHC became synonymous with first line or primary medical care provided by general doctors, and simultaneously PHC has been viewed by many as a cheap, low technology option for poor people in LMICs. The AlmaAta Declaration was one of the last expressions of the development thinking of the 1970s where the nonaligned movement declared its commitment to a ‘New International Economic Order’ (Cox 1997) and a ‘Basic Needs Approach’ to development. These visionary policies were buried in the 1970s debt crisis, stagflation, and the dominance of global economic policy by neoliberal thinking. This, together with rising unemployment and changes in the labour market, changes in demographic and social trends, and rapid technological advances with major cost implications for health services, has, over the past two decades, driven a process of ‘health sector reform’ in industrialized countries and LMICs.




·  Structural Adjustment Programs introduces in the early 1980s. In the 1960s and 70s thegovernments and banks of the North loaned a vast amount of money to poor countries in the South to promote a model of development that replaced rural peasants and urban workers with fossil fuel consuming machines. This brought large profits for foreign investors and massive joblessness and increased poverty for the many. When poor countries began to default on their loans, the World Bank and IMF stepped in with bailout loans. There were tied to structural adjustment programs (SAPs). These required debtburdened countries to reduce public spending, including that for health and education, to free up money to keep servicing their debts to the Northern Banks. Whereas the Alma Ata Declaration has called for increased government spending on health, SAP’s pressured the poor countries to reduce and privatize public services. “Cost recovery” schemes (with introduction of “user fees”) placed health services out of reach for many poor families. As a result in some countries child mortality, sexually transmitted diseases and rates of tuberculosis drastically increased. In terms of the pursuit of Health for All, this was a giant step backwards.


3.World Bank’s takeover of Third World Health Policy – in the 1990s. Prior to the 1990s the WorldBank invested almost nothing in health. But in the 1990s the Bank discovered that poor health reduces worker productivity, thus impeding economic growth (of big industry). So over a few years the Bank increased its investment in health to where, by the late 1990s, it was spending on the health sector three times as much as the entire WHO Budget. In terms of guiding Third World health policy, this has relegated WHO to second place, not only because of the Bank’s greater spending, but because it can tie its health reform “recommendations” to urgently needed (or strongly desired) loans. In its 1993 World Development Report, titled Investing in Health, the Bank spells out its health policy recommendations. These are essentially a free market version of selective health care. Governments should determine which health interventions to support according to their cost effectiveness in terms of keeping workers on the ob. Persons who cannot contribute to the economy – such as elderly and severely disabled persons – are ranked as of lower “value” and therefore merit little or no public assistance. Another dehumanizing step backwards in terms of Health for All!



· The Mcdonaldization of WHO and UNICEF –in the 2000’s. Partly because of shortage of funds,and partly because of influence of corporate gifts, in the last few years both WHO and UNICEF have entered into an increasing number of “partnerships” with transnational corporations, including drug and junk food companies. An example is UNICEF’s recent plan with fast – food giant, Mcdonalds. On its promotion McDonalds will include UNICEF public helth messages and boost sales of Big Macs by announcing that part of the purchase price goes to UNICEF. In Nigeria UNICEF has made a similar agreement with Coca Cola. Such compromises with industries that promote conducive to obesity, heart disesases, stroke and diabetes are not conducive for Health for ALL. Partnerships with other pre packaged massproduced food with endorsement by WHO or UNICEF. Even if these costly foods have improved nutritional content, they are still a threat to health. If poor families spend their limited money to buy them rather than cheaper staple foods (like Maize and beans), the end result is more undernourished children. The Alma Ata declaration called for combating the underlying social and structural causes of poor health. To the contrary, these new partnerships by UNICEF and WHO with transnational corporations further entrenches and legitimizes the forces that put healthy profits before people.




5. Corporate rule as a threat to world health.


All of these four “assaults” on Primary Health Care as conceived in Alma Ata are manifestations of the dominant “free market” paradigm of development. As undemocratic as it is unsustainable, it promotes economic growth of the rich regardless of the human and environmental cost. That the current model of economic development driven by a deregulated market system is dangerous to health is evident when we consider the impact of its biggest industries. In economic terms, the world’s three biggest industries are:



·              Military/arms.


·              Illicit drugs, and


·              Oil.



All three of these colossal industries poses farreaching dangers to the sustainable well being of humanity and the planet. Yet because the money proffered by these industries strongly influences who gets elected to public office, it undermines democratic process. It impedes humanity from taking decisive steps to rein in the biggest emerging global threats to human health such as global warming, the pending Third World War, the deepening poverty of one third of humanity, the global pandemic of crime and violence and the disempowerment that leads to terrorism. Rather than confront the underlying causes of these globalized threats to health, the world’s chieftains – with their ties to the arms, drugs and the oil industries – use the current crises as a pretext to systematic roleback of civil rights, public services and rein in on corporate greed. In sum, far from progressing toward Health for All, humanity may currently be on a collision course toward Health for no one. It is time to collectively wake up and change course.




6. Primary health care: 36 years since AlmaAta:


The 1978 Declaration of AlmaAta was groundbreaking because it linked the rights based approach to health to a viable strategy for attaining it. The outcome document of the International Conference on Primary Health Care, the declaration identified primary health care as the key to reducing health inequalities between and within countries and thereby to achieving the ambitious but unrealized goal of “Health for All” by 2000.


Primary health care was defined by the document as “essential health care” services, based on scientifically proven interventions. These services were to be universally accessible to individuals and families at a cost that communities and nations as a whole could afford. At a minimum, primary health care comprised eight elements: health education, adequate nutrition, maternal and child health care, basic sanitation and safe water, control of major infectious diseases through immunization, prevention and control of locally endemic diseases, treatment of common diseases and injuries, and the provision of essential drugs.



The declaration urged governments to formulate national policies to incorporate primary health care into their national health systems. It argued that attention be given to the importance of communitybased care that reflects a country’s political and economic realities.


This model would bring “health care as close as possible to where people live and work” by enabling them to seek treatment, as appropriate, from trained community health workers, nurses and doctors.



It would also foster a spirit of selfreliance among individuals within a community and encourage their participation in the planning and execution of healthcare programmes. Referral systems would complete the spectrum of care by providing more comprehensive services to those who needed them most – the poorest and the most marginalized.


AlmaAta grew out of the same movement for social justice that led to the 1974 Declaration on the Establishment of a New International Economic Order. Both stressed the interdependence of the global economy and encouraged transfers of aid and knowledge to reverse the widening economic and technological divides between industrialized countries and developing countries, whose growth had, in many cases, been stymied by colonization.


Examples of communitybased innovations in poorer countries after World War II also provided inspiration. Nigeria’s underfive clinics, China's barefoot doctors and the Cuban and Vietnamese health systems demonstrated that advances in health could occur without the infrastructure available in industrialized countries.



The International Conference on Primary Health Care was itself a milestone. At the time, it was the largest conference ever held devoted to a single topic in international health and development, with 134 countries and 67 nongovernmental organizations in attendance.



Yet there were obstacles to fulfilling its promise. For one thing, the declaration was non-binding.



Furthermore, conceptual disagreements over how to define fundamental terms such as ‘universal access’, which persist today, were present from the beginning. In the context of the cold war, these terms revealed the sharp ideological differences between the capitalist and communist worlds, discord perhaps heightened by the fact that the Alma-Ata conference took place in what was then the Union of Soviet Socialist Republics.



As the 1970s gave way to a new decade, a tumultuous economic environment contributed to a diversion away from primary health care in favour of the more affordable model of selective health care, which targeted specific diseases and conditions.





Insufficient progress towards the Millennium Development Goals, coupled with the threats posed to global health and human security by climate change, pandemic influenza and the global food crisis, have led to renewed interest in comprehensive primary health care.



Yet the many challenges that prevented Alma-Ata’s implementation have evolved and must be confronted to achieve its goals now. Drawing on the growing body of evidence about cost-effective initiatives that integrate household and community care with outreach and facility-based services – such as those for maternal and child health.

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