Has PHC become a global orphan?

With progress towards quality primary health care still slow some thirty years after Alma-Ata, Anthony Seddoh writes that an effective global alliance of global and country actors needs to set positive and realistic paths to implement the declaration’s intentions. In light of the continuing absence of a conceptual framework for addressing longstanding debates and organisational issues, the author considers whether primary health care represents a global orphan in need of fresh guardianship.

Thirty years after the 1978 Declaration of Alma-Ata, it seems the world is still at odds on how best to implement the principles of primary health care. The slow progress in improving health outcomes for all raises questions about the effectiveness of current ways of doing business. A concerted global alliance of global and country actors needs to set positive and realistic paths to implement the intentions of Alma-Ata.

Sixty years ago, the World Health Organization (WHO) stated in its constitution that health is ‘a state of physical, mental and social wellbeing, not only the absence of disease or infirmity.’ Thirty years later, the Alma-Ata declaration on Primary Health Care (PHC) declared among other things that ‘health is a fundamental right’ and created a thirteen-point outline to ensure this right. This outline captured concepts of essential care, universally accessibility and affordability for individuals and families within communities, who would be able to participate fully in a spirit of self-determination. It located PHC as an integral part of a country’s health system involving all related sectors and aspects of national and community development.

The WHO constitution’s definition of health and the Alma-Ata declaration together prompt a diametrical but complementary state to be addressed concurrently in the promotion of good health. The first deals with the clinical determinants of health, pushing for the absence of disease in individuals. The second addresses the determinants of health that predispose or prevent individuals from attaining a state of mental, physical and social wellbeing as a fundamental right. These include appropriate governance, the absence of war, economic and infrastructure development, adequate infrastructure and aid policies. A unique moment occurred in 1978 to bring these complementary understandings together.

Even before the ink could dry on the Alma-Ata declarations it had however already generated polarised antagonism. From a capitalist standpoint, it was a ridiculous proposition, both too costly and defying economic reasoning, and too socialist in its excessive emphasis on state-managed intervention. The conservative duo of J.A. Walsh and K.S. Warren launched the Selective PHC debate, arguing that it would probably more be efficient to save children and limit population growth, while the two main PHC proponents, WHO and UNICEF, soon drifted apart, with UNICEF promoting a selective package of low cost interventions. With resource flows following Selective PHC, Primary Health Care translated in most countries into a basic collection of services to be delivered at district and community levels based on a select number of interventions with some outreach services, with an accompanying watered-down district health package.

Why nobody asked at the time whether there was any moral significance to be attached to a person’s life or pointed out that choices based on state preferences for total health gain can be justified over financial resource allocation efficiency is difficult to comprehend. Aside from efficiency-based arguments being ridiculous propositions founded on utility-based preferences or embodying unattractive equity assumptions, the economic bargain in a healthy population should at least have also appealed to responsible international choice.

Much has since been achieved from the advance in technology in dealing with specific clinical determinants of specific diseases. It could be argued that a saturation point has been reached, where increases in financial and human investments in existing technologies are yielding less than proportional gains. Despite this the selective interventions approach continues to define health and health services delivery. It was given a new lease on life by the World Bank through its 1993 World Development Report, entitled ‘Investing in Health’. This report, which scarcely acknowledged PHC, commoditised and de-linked health from development and moved the world closer to an interventionist approach to health; intervening at a selective point in the epidemiology of a disease or health system.

This approach has since had wide global appeal. Currently there are over thirty WHO resolutions on AIDS, TB or Malaria alone; more than all other subjects. The Millennium Development Goals (MDGs) have further entrenched this disease-specific approach to resource mobilisation. There are over 80 major global health initiatives linked to the health MDGs, providing over US$100 million annually. The Italian Global Health Watch reported in 2008 that the Global Fund has allocated approximately US$3.5 billion to countries for interventions on AIDS, TB and Malaria, mainly in Africa. Together, these initiatives have thrown billions of dollars at addressing diseases and improving clinical health conditions and made up a significant part of health sector budgets.

PHC is hardly mentioned in these initiatives, seldom highlighted by member states outside of anniversaries of the initiatives or occasional references to district health system strengthening. For various reasons the world assumed an emergency mode to address what are considered new and urgent public health issues. Single disease interventions that lend themselves to easily recognisable financial accountability, quantitative monitoring and evaluation held greater appeal for funders, especially when twinned with arguments of weak domestic governance and public policy failures and capacity limitations.

While these initiatives on clinical determinants hummed with measurable outcomes on specific diseases, the nexus of poverty and ill health was exacerbated. On the back of a growing trend in urban slum development, decline in state services, market failures in privatised economies, growing food insecurity and massive deprivation of rights to health care, inequalities in health have deepened to a significantly greater level over the past 30 years.

Hence while a lot has been done to deal with disease in individuals, the unique opportunity provided by the Alma-Ata Declaration to also address the determinants of health have largely been lost. Thirty years later we see the costs of this omission in levels of poverty which belie the levels of knowledge and technological advance achieved globally.

As we approach another anniversary for PHC expectations are high. People expect that their physical and mental health will be promoted in a safe social, economic and political environment. They expect to have quality health systems that provide preventive services, and which diagnose, treat and manage disease injury and reduce the severity and repeated occurrence of disease. They do not expect to see wide social and economic disparities in these basic entitlements. In Africa, the region furthest from delivery on these expectations, the Ouagadougou declaration on Primary Health Care issued on April 30 2008 called for a renewal of the Principles of Primary Health Care and its implementation in developing countries and by the international community.

Such declarations are encouraging, yet their implementation calls for resolution of longstanding debates of the past 30 years. These debates are not academic. In choices made over policy measures, relative allocation of institutional, social and financial resources and complementary systems for dealing with the social determinants of health (mostly dealt with by actions outside the health sector), they present social and economic inequalities that arise due to the burden of disease (mostly dealt with within the health sector). There are no clear answers for how a conceptual framework of Primary Health Care in 2008 will address this.

And while there is a massive coalition of global initiatives dealing with diseases, there is no clear coalition of global institutions supporting or funding the determinants of health, the second factor in the PHC equation. At a global level, the Bretton Woods institutions and OECD initiatives for debt relief and poverty reduction have in some African countries led to short-lived increases in spending on health and education, with no global initiatives so far adequately addressing the determinants of health.

This leaves PHC as an orphan with no global guardian. The WHO’s attempt to foster PHC is inadequate given the pluralistic global environment. The state of poverty and the winds of change in international health resource priorities will make rational choices among the various dimensions impossible and predispose countries to the dictate of new interventions and their implementation. While debates over the conceptual understanding of PHC will not end in 2008, this year could at least mark the turning point for a new institutional response, one that builds a global alliance to generate the momentum and support for countries to implement PHC and that provide policy learning based on practice from the bottom up, reminiscent of another basis for the Alma-Ata declaration.

A WHO or UN resolution creating such a global alliance would be a befitting PHC birthday gift for the millions of people seeking more than another conference. It will squarely put implementation right at the doorstep of a recognisable entity that can mobilise the needed funds and offer effective support to individual countries.

World Health Organization Africa region inter-country support team, Harare, Zimbabwe

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