Thirty years after Alma Ata: time to look back and think ahead
Friday, 08 February 2008

HTML clipboard Dr Zakir Husain

THE world health community had for long regarded widespread disparity of health status of people, among and within countries, unacceptable. In 1978 the International Conference on Primary Health Care, jointly sponsored by the World Health Organisation and the United Nations Children Fund was held in Alma Ata (in the former Soviet Socialist Republic of Kazakhstan).

The conference adopted the historic Alma Ata Declaration, which elaborated primary health care as the key strategy to attain Health for All by the year 2000. Health for All was universally accepted as the main social goal (not merely a health goal) by the world heath community.

The conference concluded with high hopes for radical reformation of national health systems and enhanced international collaboration and solidarity. Health was seen as a major contributor to world peace and security for the benefit of the entire mankind. Thirty years after Alma Ata it is time to revisit primary health care, to look back and think ahead into the future. The world has changed much since 1978.

The hope and trust in a just, more equitable and peaceful world order receded due to many unforeseen conflicts. The Cold War ended but the expected peace dividends for social advancement did not come. Thirty years after Alma Ata it is as good a time as any to look back and think ahead into the future of the PHC strategy. Perhaps it is a time not to retreat but to make a strategic shift in the light of globalisation and dominance of neo-liberal economic order.

The PHC strategy might be due for realignment and redefinition, including empowerment of people, harness their untapped resources, and strengthen their ingenuity and resilience in the face of tyranny of a dominant health care market. In that marketplace, literally everything is for sale to the highest bidder.

Yet, ideas and ideals have not lost their force nor have become extinct. The writer, even at the risk of being seen as naïve, likes to propose that the Health for All goals and the PHC strategy remain as valid as it was in 1978.

I participated in the PHC conference at Alma Ata way back in 1978. I have not lost faith in the redeeming social and economic relevance of the PHC strategy and the Health for All goals. From the global, let me turn local. What is the health picture in Bangladesh? There is a great deal of disparity in health status of population of Bangladesh – a disparity that is hidden by national aggregate statistics.

There had always been huge barriers to equitable and fair access to, and use of, available health resources. Those barriers have not been lowered, let alone eliminated. Barriers of knowledge, ability to pay, social and cultural, and geographical barriers remain.

These combine to deny essential health care to many of who need it most. Past and current investments and efforts did bring some spotty results but clearly did not prove comprehensive or adequate. Not more of the same but something different is necessary.

More specifically, and more importantly to my mind, a major strategic shift is required if the gap between the health ‘haves and have-nots’ is to be narrowed. I say this bearing fully in mind the situation of health of population and developments in national health systems during the past thirty years.

My own conclusion is that of all the barriers, the information and knowledge barrier seems to have been least addressed and acted upon. If knowledge is power and if society is knowledge-based, as it is in the world today, the knowledge of health is the trigger and pathway to empowerment of people in health matters.

That empowerment embraces political, economic, technological, social changes to break the status quo, the present set of beliefs and given truths. First, let me offer a few propositions. Good health of people is not the outcome of more hospitals and clinics or more medicines and drugs alone.

By definition, a state of good health is more than mere absence of specific illness that requires cure. A state of positive heath counts more; it gives immunity from infections and a higher quality of life. The state alone could not extend health and medical care to all people.

A healthy Bangladesh will not come about by ‘extending’ medical care to the ‘doorstep’ of households; that is something neither possible nor essential but likely will remain an empty political promise at best. It is time to move in a new strategic direction based upon real priorities and resources.

Health for All in Bangladesh remains a wish unfulfilled. However, good public health could be generated rather than extended by much stronger health promotion and disease prevention efforts. Moreover, the combined efforts and contributions by individuals, households and communities make a huge difference in population health.

Historically, however, primary health care was implemented as a ‘programme’ rather than as the overriding strategy. The systemic changes in the structure and functions of a health system at the core of the strategy were deferred. Countries have invested resources into ‘selective’ PHC elements such as child immunisation, specific disease control, nutrition and family planning but not in building up comprehensive health systems based upon primary health care.

Specific health interventions marked variable progress but overall health status of population did not mark corresponding improvement. Sustainability of short-term gains could not be assured. A strategy is dictated by and relates to priorities and resources. The choice is not always easy. One can win few battles yet lose the war.

Battles for universal child immunisation, child growth and development, or blindness prevention using specific interventions did show successes but did consume enormous resources without building up strong health systems to assure long-term sustainability. Let me add a few related propositions. Health is not just a humanitarian issue left to be addressed by charity or philanthropy. Health is a basic human right.

Health is at the heart of economic, social and political advancement. Health contributes to peace and security locally and globally. Without people in good health, economic wealth is of little value. Second, health is not the function of health services alone or of medical practitioners. People’s health status is the result of multiple factors and sectors that have direct and indirect impact on human health.

Third, governments and individuals have rights and responsibilities to promote and protect public health, to prevent and control diseases, and to work jointly for universal access to care at affordable cost. Fourth, market economics for health ruled by ability to pay proved notoriously inequitable wherever the market has been allowed unrestricted play. If equity of health care is a social good of high merit, the so-called free market shall not bring that about.

The PHC strategy stood upon four cardinal principles of which community involvement with social control of heath technologies as a major one. I would argue with all emphasis and conviction that it is time to revisit and reinvent community involvement as a tool for empowerment of people to take greater charge of their health and mobilise huge social resources otherwise not harnessed by official channels.

The aggregate health outcomes and their sustainability are enhanced manifold when people are mobilised. Empowerment and innovation, self-reliance and self-managed PHC are key sub-strategies, are powerful tools to break the present barrier to access and affordability the ‘free market’ health care has erected. Side by side, it is time for the state to demonstrate by deeds its political commitment to help generate and invest the required human, technological and financial resources in primary health care.

That political commitment was made in Alma Ata but has since been forgotten. Social control of health technologies was a key precondition. That might sound radical to many. Nevertheless, that remains a powerful strategy even more so today. People’s ownership and involvement in mobilising assets and services could multiply resources manifold and enhance sustainability so conspicuously lacking in numerous short-term donor-driven and donor-dependent project interventions.

That ownership should be restored and supported at the policy level. I wish to make a major point of departure from conventional strategy on financing primary health care. One that tinkers with cosmetic changes, attempts palliative (band aid) relief to some will not do. Nor will ‘micro-credit’ for medical care or subsidised demand generating devices will suffice.

None of the above changes the status quo or challenges what I would call ‘market anarchy’ in health care devoid of ‘social accountability’. I am thinking of loosening the grip of monopoly of privileged providers over the market of health care where the buyer has no control. Is that too ambitious or too radical?

This is an introductory essay. I hope that this might generate some interest and debate across the stakeholders of Bangladesh who wish to commit to a healthy Bangladesh. To my mind the most priority stakeholders are the local communities and their collective wisdom sharpened by experience.

People are not mere objects of mercy or charity. Indeed, in a reoriented PHC strategy the professional ‘health experts’ or the government officials have the duty to provide scientific guidance and evidence; the same goes for development partners. Having walked into what could turn into a minefield I wish to continue this debate. In my next essay on the subject, I wish to recall one notable example of self-managed PHC in a country close to Bangladesh.

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