In 1978, the Declaration of Alma-Ata at the International Conference on Primary Health Care launched primary health care as a route to better health for all. The ambition was bold. The Declaration of Alma-Ata responded to a world characterized by vast and largely avoidable differences in the health status of populations, and mapped out a strategy for reducing these gaps through fundamental changes in the way health systems were organized and care delivered. As the Declaration of Alma-Ata argued, enlightened policy that made fair access to health care an explicit objective could raise the level of health within populations, enabling people to lead socially and economically productive lives, and thus driving overall development.
The primary health care approach broadened the medical model of health to include social and economic dimensions, since the health of disadvantaged populations was often compromised by low rates of literacy, poor nutrition, substandard housing, contaminated water, and lack of sanitation. In line with this broad public health approach, primary health care sought population-wide solutions that emphasized prevention, as well as cure. The approach placed particular emphasis on local ownership and community participation. In doing so, it honoured the resilience and ingenuity of the human spirit and made space for solutions created, owned and sustained by communities.
The approach was almost immediately misunderstood. It was a radical attack on the medical establishment. It was utopian. It was confused with an exclusive focus on first-level care. For some, it looked cheap: poor care for poor people, a second-rate solution for the developing world.
Nor could the visionary thinkers of 1978 have foreseen world events: an oil crisis that hit hard in 1979, a subsequent economic recession, and the introduction by development banks of structural adjustment programmes that shifted national spending away from the social services, including health.
As resources for health shrank, selective approaches using packages of interventions gained favour over the intended aim of fundamentally reshaping health care. The emergence of HIV/AIDS, the associated resurgence of tuberculosis, and a deterioration of the malaria situation moved the focus of international public health away from broad-based programmes and towards the urgent management of high-mortality emergencies. In 1994, a World Health Organization (WHO) review of world changes in health development since Alma-Ata bleakly concluded that the goal of health for all by the year 2000 would not be met.
What can be gleaned from the experiences of a movement that failed to reach its goal? Apparently, quite a lot. Today, primary health care is no longer so deeply misunderstood. In fact, several recent trends and events have clarified its relevance in ways that could not have been imagined thirty years ago. More and more, primary health care looks like a smart way to get health development back on track.
BREATHING NEW LIFE
The Millennium Development Goals breathed new life into the values of equity and social justice, this time with a view towards ensuring that the benefits of globalization do not bypass the poor. Taken together, the eight Millennium Development Goals represent the most ambitious attack on human misery in history. They acknowledge the contribution of health to the overarching goal of poverty reduction. Like the primary health care approach, they address root causes of ill health that arise in other sectors.
In the drive to reach the health-related goals, multiple global health initiatives were formed to tackle priority diseases and increase childhood immunization coverage. In the past ten years, commitments of official development assistance for health rose more than three-fold, from $6.5 billion in 2000 to more than $21 billion in 2007.
While much has been achieved, these efforts have brought home a fundamental reality: powerful interventions and the money to purchase them will not produce better health outcomes in the absence of fair and efficient systems for service delivery. As the international community now recognizes, health systems, weakened by decades of neglect, are the fundamental obstacle to better health.
Renewed concern about the performance of health systems coincides with several alarming trends that are making the values, principles, and approaches of primary health care more relevant today than ever before. Worldwide gaps in income, opportunities and health outcomes, which motivated the quest for greater fairness in 1978, are actually greater today than at any time in recent history. Life expectancy between the richest and poorest countries differs by more than forty years. Annual government expenditure on health ranges from as little as $20 per person to more than $6,000.
All around the world, the costs of health care are escalating. Aided by the revolution in information and communication technologies, the demands of consumers for quality health care that is also fair and affordable are growing.
Health in all regions is increasingly shaped by the same powerful forces. Phenomenal increases in international air travel have made emerging and epidemic-prone disease a much larger menace. Trade agreements influence the global availability and prices of commodities, including food and pharmaceutical products, often with little regard for the impact on health.
Universal trends, like urbanization, demographic aging, and the marketing of unhealthy lifestyles have sparked a sharp increase in chronic diseases like heart disease, stroke, cancer, and diabetes. Long considered the close companions of affluent societies, these diseases now impose around 80 per cent of their burden on low- and middle-income countries. The requirements of life-long treatment strain already weak systems of care and add to the costs. Growing numbers of the frail elderly further increase the demands on health systems, the health workforce, and for social welfare.
Efforts to prevent diseases have become more complex. Chronic diseases, for example, are largely caused by a limited number of lifestyle-related factors, yet these factors lie beyond the direct control of the health sector. Although better health has long depended on the collaboration of multiple sectors, efforts to shape the determinants of health increasingly pit the interests of public health against those of powerful industries with powerful marketing strategies.
Taken together, these trends help explain recent calls from leaders in all regions of the world for a renewal of primary health care. Health systems will not automatically gravitate towards greater efficiency or greater equity in access to care. Unless deliberate steps are taken, steady advances in the biomedical sciences will continue to benefit a privileged minority, the poor will continue to be excluded from basic essential care, and the gaps in health outcomes will grow wider, both within and between countries.
Above all, as experience during the previous decade so clearly shows, all the cash, commitment, and caring in the world will not improve health in the absence of well-functioning systems for service delivery. As a platform for strengthening health systems, primary health care makes fairness in access to quality health care an explicit policy objective. The Millennium Development Goals promote health as a route to poverty reduction. To put it bluntly, if we miss the poor, we miss the point.
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