Translating "Health for All" into the present and the future

Patrick Kadama at the Civil society meetings ahead of the 71st World Health Assembly, 18 May 2018, Geneva. Photo: © MMI

Realising the vision of Alma-Ata is more urgent than ever:

• Applying the principles of Primary Health Care as declared at Alma-Ata 1978 is critical in achieving health for all by 2030.

• Community engagement and ownership is the key to health for all and essential for building resilient health systems that allow all people to access the health care they need.

• A skilled and motivated health workforce is at the centre of health systems at all levels. It must be recognized that community health workers play an essential part in realising universal health coverage and health for all.

• Strong people’s organisations and movements are fundamental to strong health systems.

• Access to essential medicines of good quality at an affordable price is part of health for all. Policies must ensure that research costs are delinked from the price of drugs and everyone has the right to access essential medicines.

• Health for all demands inter-sectoral collaboration and must provide access to prevention, promotion, treatment, care, rehabilitation and palliative care to everyone within a sustainable framework.

• Health is not only a matter of human rights, it is a matter of justice and requires a redistribution of wealth and significant changes in the global economic order.

• Equity in health and social justice must be the basis for all decision making.

• To ensure access to health services to all, service provision through public and not-for- profit providers must be given the primacy in health system planning and implementation. The ambiguities regarding UHC must be resolved with health care financing policies structured to prevent the commodification and marketisation of health care.

Translating “Health for All” into the Present and Future

Health is a fundamental human right – enshrined in the WHO constitution and the declaration of Alma-Ata. Realising the vision of Alma-Ata and health for all is more urgent than ever:

Primary Health Care and Universal Health Coverage

“Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self- reliance and self-determination.“ (Declaration of Alma-Ata)

The Primary Health Care (PHC) principles affirm health as a human right based on equity and social justice, implemented through community engagement, health promotion, the appropriate use of resources, and inter-sectoral action based on a “New International Economic Order” with the vision of health for all by the year 2000.

The Declaration, however, came at a time of major global economic changes including the economic slow-down of the 1970ies, the debt crisis and structural adjustments. Shortly after Alma-Ata UNICEF and the Rockefeller Foundation declared “Selective Primary Health Care” instead of “Comprehensive Primary Health Care”, which under structural adjustments became the dominant paradigm and model of PHC. Structural adjustment programs led to a reduction of staff, narrow benefit packages and a lack of resources in the public sector and weakened already weak health systems.

Susana Barria at the civil society meetings ahead of the 71st World Health Assembly, 18 May 2018, Geneva. Photo: © MMI

The advent of the HIV epidemic led to isolated but impressive community based responses even before the advent of antiretrovirals. These were applying PHC principles dealing with HIV prevention, home based care, destigmatisation, treatment literacy a.o. addressing the challenges of HIV.

Global health initiatives such as the GFATM or Gavi contributed to a considerable increase of funding but these have been mainly earmarked for vertical programmes especially in the area of HIV, Malaria or TB. Besides all the positive effects that were achieved, this has been associated with a migration of resources and personnel from public primary care systems to globally funded programs.

In 2010, WHO introduced the concept of Universal Health Coverage (UHC), which was defined as access to health services without financial hardship. While in general, the notion of UHC seems consistent with WHO’s concept of Health for All in Primary Health Care, a key issue that remains unresolved is the primacy provided to public or non-for-profit services under PHC and conversely the larger role envisioned to private for-profit providers while implementing UHC. Hence, in many countries public services are being replaced by private for-profit providers. Especially concerning is the increase of corporate chains of providers, mainly supported by private insurance.

While impressive medical and technological advances have taken place around the world, improvements in the health status of the people have been moderate and inconsistent between and within countries. The biomedical and technical approach to health has its limitations in actually improving health especially among marginalised and poor populations and has contributed to a neglect of other determinants of health.

Health systems must be built on the principles of comprehensive primary health care that includes community engagement, adequate healthcare infrastructure, skilled, supported and motivated health workforce, access to essential drugs of good quality that are rationally used in addition to new advancements and technologies that must be accessible to all.

Communities: From objects of health care to full participation and ownership

“The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.” (Declaration of Alma-Ata)

Communities are at the heart of PHC and must be the owners and partners in making health for all a reality. People and communities own their health and therefore health planning, promotion and provision need to be carried out by people and with people, rather than for people. They must not be reduced to mere consumers of health services and health systems must be accountable to people and the communities they serve. However, communities are changing rapidly and in many settings new ways in which community ownership is expressed need to be developed. Strong people’s organisations and movements are fundamental to more democratic, transparent and accountable decision-making processes in health.

Community health workers are an important link between communities and the formal health system. They play an essential role in order to strengthen local health services and make them accessible to all. Therefore, community health workers must be recognised in their specific role, supported, trained and remunerated accordingly.

Community health workers must become part of a skilled and motivated health workforce. In the light of changing demographics globally, global health worker migration and a gap in trained health work force, health systems must ensure an environment that will be enable and retain skilled and motivated health workers at all levels.

Baba Aye at the civil society meetings ahead of the 71st World Health Assembly, 18 May 2018, Geneva. Photo: © MMI

Justice, cooperation and solidarity

“The existing gross inequality in the health status of the people particularly between developed and developing countries as well as within countries is politically, socially and economically unacceptable and is, therefore, of common concern to all countries.” (Declaration of Alma-Ata)

Health is not only a matter of human rights, but also of justice. Governments who are not making provision for decent health care are denying justice to their people.

The Alma-Ata declaration recognised the need to restructure the global economic order to address inequalities and enable countries to generate resources for decent health care and tackle the root causes of poor health. This still remains a critically important task today.

Consultation Statement “40 Years of Alma-Ata” Geneva, Ecumenical Centre, 18 May 2018

In contrast to the New International Economic Order referred to in the Declaration the dominant contemporary paradigm of export led development has contributed to loss of tax receipts at country level because of the competition for investment which drives reduced tax rates and constant pressure to reduce the cost of production or extraction. These have led to a deterioration of people’s living circumstances and contributed to ill health, instability or even war.

It is vital that we build solidarity between people within and across nations and regions. The existing system of international aid and the associated charity narrative legitimise an unfair economic framework which prevents national self-determination and weakens the building of strong and resilient local health systems. Health for all requires the redistribution of wealth nationally and globally.

Public financing is essential for health for all. This requires tax justice that will clamp down on tax avoidance and control tax competition between countries. The regulation of transnational corporations through appropriate agreements is essential.

Trade justice for health will require trade agreements that protect from extortionate drug prices and not provide corporate impunity through investor state dispute settlements.

A reform of research and development financing is required which enables the delinking of research costs from profits from drug sales. Drug policies must support production capacity in low and medium income countries.

The provision of health care is costly in any society. A health system based on primary health care principles will be able to achieve health for all at a reasonable cost even while countries develop the capacity for more technological intensive health care.

Manoj Kurian at the civil society meetings ahead of the 71st World Health Assembly, 18 May 2018, Geneva. Photo: © MMI

Beyond the health sector: Addressing root causes and determinants of health inequity

“The attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.” (Declaration of Alma-Ata)

The WHO’s Commission on Social Determinants of Health in 2008 demonstrated that poor health is not randomly distributed, but rather follows a predictable pattern with systematic differences among social groups (i.e. gender, class, race/ethnicity) caused by unequal exposure to, and distribution of, social determinants of health (SDH). Social justice is a matter of life and death. Addressing root causes of health inequity and investing in society, is the only way that health for all and sustainable development can be achieved.

The broader context, shaped since the late 1980s by neoliberal economic globalization has profoundly influenced our health situation today. This can be seen in the impact of globalization on social justice, the effect of climate change on livelihoods; the loss of biodiversity, the detrimental effects of agribusiness on peasant farmers and small-holder farmers, who provide most of the world’s food; the impact of land grabbing and the grabbing of water bodies by big business; the influence of patriarchy on society; tax evasion leading to the lack of public funds; the unbridled growth of the arms trade; and the effects of migration to name only a few. All these issues require collaboration across sectors and policies that will address the root causes of illness and the determinants of health inequity.

The current global economic order has become dominated by a greatly expanded financial sector leading to price instability due to speculation and reduced policy space because of the reach of market sentiment. It has seen the deregulation of corporations and of trading relations and the commodification and marketization of services which should be based in human relationships and handled as public goods.

As in the Alma-Ata Declaration, we are calling for a new global economic order (NGEO) to facilitate a safe and just space for humanity. This NGEO would be a means for securing global common goods. The NGEO would guarantee a social foundation for all while at the same time an ecological ceiling so that planetary boundaries are respected. This embedded economy would follow a human rights based approach. It would regulate global public “bads”, economic externalities that damage the living environment and drive poverty. It would redistribute the enormous wealth and capital available in the world ensuring essential public services and social protection. The NGEO would be regenerative and circular in nature as to remain within the ecological ceilings that planet earth provides while providing a dignified living for all.

Today, we have a clear vision on how to overcome these challenges through transformative policies; through the building of people’s movements; and the facilitation of people-to-people connections and solidarity. Examples of such movements include the Women’s March; the tax justice movement, the Global Network for the Right to Food and Nutrition; the Treaty Alliance, the Treatment Action Campaign and others. They are positive examples of a way forward. It is only with the mobilization and convergence of people’s movements and a process of dialogue on national, regional and international level that health equity can become a reality.

We call upon governments and people from across the globe to take forward the principles of Primary Health Care that are so clearly articulated in the Alma-Ata Declaration.