Country leadership and coherence among global actors are key elements to ensure health care for all
By Francisco Songane
Health for all by 2030 is quite right the central theme for this symposium now that we have already started the journey towards 2030 with the quest of addressing the inequities, the imbalances, and all elements contributing to the lack of social justice. We are living in a divided world where what is set forth in the Universal Declaration of Human Rights is enjoyed by some, with many others, particularly in the least developed countries still struggling to survive and not knowing what their children will eat the following day. As per World Bank estimates, in 2015 about 1 billion people were living on less than $1.90 a day.
It is the “Health for All” motto that will remind us about what is required to ensure that everyone everywhere will enjoy the highest attainable standard of health as stated in the constitution of the WHO, in line with article 25 of the Universal Declaration of Human Rights. This is a critical premise of always keeping the human rights lens in all the deliberations for policy decision making and programme implementation.
Health for all was the drive emerging from Alma-Ata, and it was a noble occasion where a consensus was reached to put in practice the principles of the constitution of the WHO, as it was well articulated in the declaration adopted at the end of the conference. It was a landmark, and indeed the declaration mobilized every actor dealing with health in being reminded about the right to health, and seeing the path of Primary Health Care. It was revolutionary, people put in the centre, and humanity redeemed, a moment to reorganize and strengthen the health systems to enable the fulfilment of the aspirations of all peoples. The enthusiasm generated from Alma Ata was contagious, and spontaneously turned into a movement disseminating this vision across the world.´
The Alma Ata declaration had its limitations, particularly for not devising a mechanism for accountability, and the oversimplification of the message carried through PHC. A great momentum had been created, every actor was embracing the call, but there was nothing to keep systems in check, and soon this loop hole was exploited by some, taking advantage of the tilted scale of world power, which favoured the structural adjustment policies with their well known harmful consequences. The notion of “selective primary health care” was introduced as the “quick and easy sale” encompassing only some interventions not requiring large sums of money, and yielding quick results. On the other hand, the oversimplification of PHC did pose question marks from the countries most in need, particularly their professional bodies, as there was suspicion that a framework was being set to provide “second class” health care for poor people. These two factors combined played into the hands of the large economic powers and the international financial and development institutions pushing the structural adjustment agenda.
Many countries made efforts in putting the Alma-Ata recommendations in practice, and were making strides in the improvement of their health systems, but lack of financial and technical support to invest in infrastructure and the correspondent human resources development led to stagnation, and in some instances reversal of the gains already achieved.
The call for solidarity
Nonetheless, the content of the Alma-Ata Declaration continued to be the resource to refer to whenever the World found itself at a crossroads. It is its rights approach and call for solidarity which remind us of the unacceptable situation expressed through the inequities, and compels us to act. It happened in 2000 with the Millennium Declaration, as shocking evidence was accumulating of the protracted appalling conditions 36% of the world people lived in, when the global economic throughput was of $ 33.5 trillion.
Poor health and its origins outside the health sector
In 2008, marking the 30th anniversary of Alma-Ata, WHO dedicated that year World Health Report to renew the call for “health Care for All” highlighting its pertinence, and pointing out that it was then more needed than before. The incomplete message on PHC was well dealt with, laying out the different elements and functions as integral part of the health system; another important take home message from that publication is the crucial role of leadership to move the agenda forward. In the same year, another seminal work was published, the Report on the Social Determinants of Health pointing squarely on the right to health and wellbeing as the departing premise in trying to address the inequities. Further, it clearly explained, showing evidence, that many of the manifestations of poor health have their origins outside the health sector; there could be no more doubt about the multisectoral approach articulated in the Alma-Ata Declaration. In its turn, Global Health Watch 2 discussed the politics of global health and the actions of some of the main actors, calling for a better governance of global health and minimize the harmful consequences, particularly for the least resourced countries.
Two weeks ago in Astana, delegates reaffirmed the role of PHC in achieving UHC, and in recognizing the unsatisfactory achievement of PHC committed to establish a systematic review of the implementation of the Astana Declaration.
All the elements to clarify issues and provide additional information to allow a much better understanding of the full meaning of the PHC approach are available, and emanated from authoritative publications, so it seems to be time to take a different stand. We can’t keep on learning only, as is the usual comment when a report comes out exposing the reasons of lack of progress; we need to act.
The will to act and good governance are critical to reach health for all
Right to health calls for responsibility from all sides, and requires solidarity in the actions to ensure the wellbeing of everyone, everywhere. It is a huge undertaking, and on the long run, not amenable to “quick fixes” and partial and temporary satisfaction for some results that can be shown in very short period of time, and above all not an exercise to be done in “fashion waves” as per initiatives or some stand alone appealing programmes. Well functioning health systems in the context of the overall country development are key to success, and this can only be achieved through a comprehensive investment combined with a good synchronization of all parties. The countries should be at the centre, and all the activities concerned guided by the country strategies and programmes. This is what is enshrined in the Sustainable Development Agenda to which the whole world signed up to and committed to respect. Respect, solidarity and the will is what is required to avoid failure as it has happened before; we need to make clear, we do not lack frameworks and platforms to guide our joint work. We had the Paris Declaration on Aid Effectiveness, the Accra Agenda for Action, the IHP and IHP+ and eventually the Busan Partnership for Effective Development Co-operation.
The facts on the ground, and the global modus operandi have shown that the happiness and the togetherness marking all these events is short living, as the countries find themselves in the same situation of having their programmes sidelined, or pushed to change the way that they are implemented due to conditions tied to funding opportunities, or due to external factors associated to geopolitical issues. There have been several global initiatives to address health problems of international concern each one with its way of channelling funds, conditions, and specific reporting requirements, but stop short of funding the country programme and have a comprehensive approach towards the strengthening of the health systems; on the contrary, the systems are further weakened and the technical staff in the ministries concerned absorbed in keeping the multiple deadlines to secure the continuity of funding. This is contrary to the agreements/frameworks mentioned above, and outside the spirit and commitment to the Sustainable Development Agenda. There has to be coherence among the global players between what is agreed and the practice of their agents, and the way they interact with countries. It is the right to health that it is at stake, and this selective approach can not be effective in building strong and well functioning health systems, the backbone of any country to face up the complexities of delivering health care to its people.
The World is undergoing many changes, some of them unexpected, and possibly outside of what could be fit for normality, and the multilateral/international institutions being gradually relegated to second plan. These institutions were created with the purpose of establishing platforms for resolution of important universal problems, and reach consensus and common understanding on how we should regulate ourselves as countries within our diversity; they provided the support and platform to the process that led to the Agenda 2030, and we have no other way for the countries, and indeed peoples from the different corners of the world, to express their concerns and points of view as we continue to nurture this movement to advance humanity.
Health for all is about people and their rights, and the action takes place in the countries where they live, therefore, leadership, and abiding by the rules of good governance are critical elements to move the agenda forward with people at the centre as direct agents for change, and not mere recipients of services. Good governance is the backbone for the moral stand that is required to effectively exert leadership in coordinating the different partners, and stay the course guided by the country programme. This characteristic has been essential in the successes registered by the countries which stood up as examples in the implementation of PHC; indeed leadership and clear sense of direction by the national authorities, complemented by consistency in the strategies and development plans are common features in countries doing well today in advancing health for their people integrated in their development plans.
We are all conscious of the magnitude of this undertaking that countries can’t address alone, and it is in this context that as we mark the 40 years of Alma-Ata we should remind ourselves of the importance of Solidarity in all the action by the development partners. It is not we and them, it is not about someone or some “outside” institution determining the standard of care or the kind of services for a particular country, but about what is needed for the country to ensure that all its citizens enjoy the “highest standard of health.”
Lack of accountability and coherence
Lack of proper accountability has been one of the main reasons for the repeated disruptions which undermine consistency in programme implementation at the country level. There is clear imbalance of power favouring considerably the counties and institutions providing support, even alleging criteria not related to the terms of the signed agreements, like geopolitical circumstances, or dislike of a particular social route chosen by the country. This area has gone unchecked, as far as human rights are concerned, and it is often a key driver of the deepening of equality gaps and reversals where progress was the order of the day. There is no coherence between what the different players sign up for and what happens in practice, and the usual excuse is to start another discussion for a new agreement or framework.
There is no coherence between what the different players sign up for and what happens in practice
Proper messaging about the right to health care seems to be where to start, so that people are informed to alley reservations in questioning the disparities, and eventually lead to a concerted action demanding change of attitude. This is one of the fronts to be pursued in close collaboration with the countries’ institutions, translating the human rights language into facts which are part of the day to day living; one concrete example is the use of disaggregated data rather than global, be national, provincial or even district. Internationally, there is already a Special Rapporteur on the Right to Health under the auspices of the UN High Commissioner for Human Rights; this is an important platform, and it seems pertinent to suggest expanding the remit of the Special Rapporteur to include the assessment of the regional, sub-regional and international actors, as well as all the signatories of the key agreements and frameworks on aid effectiveness. Certainly, it will require more staff and a good support base, but it is worth doing if we are determined to at last see the principles of Alma-Ata put in practice and the right to health fulfilled, backed by effective and responsive health systems. Again, monitoring is essential, and the different organizations can work with national and regional research institutions to generate the information to document the consequences of the disruptions caused by unilateral decisions not conforming with what has been agreed. The product could be a good input to the work of the Special Rapporteur in the efforts to address this level of denial of the right to health. The manifesto put up by MMS is timely and mostly welcome, and I am sure it will be the spark for similar action by other organizations.
The Agenda 2030 is the framework for development guiding all of us with the quest of leaving no one behind, what entails the responsibility of ensuring that everyone has good living conditions and in good health. This spirit is well captured by the question put forward for discussion in this gathering: is “Health for All” on the right track or on the verge of failing.
Let’s put “Health for All” on the right track by using the human rights approach in monitoring our actions at all levels. It is doable, and it will be a key ingredient nurturing our drive to reach the SDGs.
We should leave this place on a high note determined to refuse assembling again in 10 years to lament on the failures, but on the contrary, celebrate success.
Thank you for your attention!
Francisco Songane former Minister of Health of Mozambique has extensive involvement with the international community that has included serving as Executive Committee Member and Board Member of the Global Alliance for Vaccines and Immunization. He was also a member of Task Force 4 of the UN Millennium Project (2002 – 2004), analysing the practicalities of achieving the goals related to maternal and child health, and a Member of the Board of Trustees and the Executive Committee of the International Vaccine institute, and served in several Advisory Committees. He was the founding director of the Partnership of Maternal, Newborn and Child Health hosted at WHO, later Chair of the Forum 2012 on Research for Health organized by the Council on Health Research for Development, where he served as Senior Health Advisor. Further, he was UNICEF Representative in Angola from July 2013 to October 2016 where he was directly involved in the efforts to tackle a major yellow fever epidemic, the worst in the last decades that became a global public health threat. Dr Songane trained as a medical doctor and obstetrician/ gynaecologist at the Eduardo Mondlane University and Maputo Central Hospital in Maputo, Mozambique as well as at St. James University Hospital in Leeds, England. He has a Master of Public Health degree from Boston University and Master of Science in Financial Economics from the University of London, England. Email
40 Years of Alma Ata – It’s back to the future for Health For All
