PS006 - Primary Healthcare Revival: Beyond Declarations

From a historical perspective, the Alma Ata Declaration for Primary Health Care (PHC) was the "most promising event of 1978" and a "major turning point in International Health". But according to Elisabeth Fee (History of Medicine Division, National Library of Medicine, Bethesda, United States) "it simply has not happened", because the world has changed since the planning phase in the 1970's. It was influenced by important world events such as the decolonization of African nations, the non-aligned movement, successful mass primary health care models in China and Cuba and the end of the cold war. The implementation of Primary Health Care in the 1980's was later challenged by new political and economic developments, such as the restructuring of the World Health Organization (WHO), selective Primary Health Care programs using extra-budgetary funding controlled by donors often without community participation, the dominance of International Monetary Fund economic policies linked to debt relief, as well as the concomitant increase in petrol prices and reduced commodity prices. The result of these changes in many developing countries, especially in Africa, was a complete fragmentation of the health systems. In fact, by the late 1990's, the health systems lacked infrastructure and human resources to deliver even the well funded vertical programs against malaria, diarrhea, immunization and recently the "3 by 5" ART program.

In an effort to revitalize Primary Health Care the Prince Mahidol Award Conference was organized in 2008 in Thailand.   A summary of the conference was reported by Dr. C. Kanchanachitra ( Prince Mahidol Confernce, Mahidol University, Institute for Population and Social Research, Thailand) during which the many lessons and challenges to the implementation of PHC over the past 30 years were discussed. While affirming that many changes have occurred in the global and national contexts three "unfinished agendas" related to financing, human resources and health information and disease surveillance need to be overcome. Particular reference was made to low spending on child and maternal mortality when compared to HIV/AIDS and high out of pocket payments by the poor for private health care leading to catastrophic poverty. Inappropriate skill mix and poor retention of health professionals are important human resource constraints. A clearer definition of roles, task shifting, incentive packages and enabling community health care workers are recommended actions. Although the important roles of volunteers was acknowledged it is firmly believed that  this is not the solution. The paucity of good national data  leading policy is of major concern and the potential application of new technologies such as ICT and GST and networked surveillance are possible solutions. 

Dr. Frank Nyonator (Director, Policy Planning Monitoring and Evaluation, Ghana Health Service) stressed the fact that although there is strong political commitment among African countries for Primary Health Care, the problem is "how do we get the issues down to the ground?" The Ouagadougou Declaration is yet another affirmation of the Alma Ata declaration which "expressed the need for accelerated action by African governments" to improve health. The mood today is clearly set by the "need for action", documenting best practices, innovation and sharing those ideas that work.

Dr. John Martin (Advisor, Office of the Director General, World Health Organization) had no doubt that "Primary Health Care is very much alive", citing recent examples of Brazil's family health teams, Thailand's voluntary health workers, and Jamaica's lowered costs for health care among the poor. Primary Health Care is a process that involves governments, civil societies and other partners, but it should be owned by countries and set according to their needs and demands. To affirm this the audience was specifically asked to share their views with the rest of the panel and  a number of issues where raised by participants:

·        The lack of health professionals to deliver health care even at the district level in India.

·                    The dominant role of global partners which is dictating the agenda to technical bodies such as WHO and influencing the policies of many countries. Notable exceptions are Malaysia, Thailand and Sri Lanka.

·                    The exact meaning of community participation, this definition may vary from one context to the other.

·                    The political basis of the policy incoherence that is observed even sometimes within WHO.

·                    Primary Health Care depends on both technical and political elements; however the "right to health" is often forgotten. Health policies should be aimed at poverty alleviation and no longer take the simplistic" Pro Poor" approach.

·                    There is a disconnect between strengthening the health system and strengthening community health.

·                    Primary Health Care must not remain an issue only for Ministries of Health but must involve also Ministries for Development.. 

·                    There is a tendency for Primary Health Care to be interpreted as the first level source of health care delivery, but in fact it should encompass a more holistic approach towards health.

·                    Primary Health Care can be a misnomer as it is sometimes regarded as a "primitive" form of health care. Perhaps it is time to re-label it as "Essential Health Care".