For
interest.
Paul
Paul Bywaters
Emeritus Professor of Social Work
Faculty of
Health and Life Sciences
Coventry University
Priory
Street
Coventry
CV1 5FB
Tel.: 02476 795945 or 795384
From: Ken
Harvey [log in to unmask]
Is
the declaration of Alma Ata still relevant to primary health care?
http://www.bmj.com/cgi/content/full/336/7643/536?
Stephen
Gillam, consultant in public health
1 Institute of Public Health,
Cambridge CB2 2SR
[log in to unmask]Thirty
years after WHO highlighted the importance of primary health
carein tackling
health inequality in every country, Stephen Gillam
reflects on the reasons
for slow progress and the implications for
today's health
systems
After years of relative neglect, the World Health Organization
has
recently given strategic prominence to the development of primary
health
care. This year sees the 30th anniversary of the declaration of Alma
Ata
(box 1). Convened by WHO and the United Nations Children's
Fund
(Unicef), the Alma Ata conference drew representatives from
134
countries, 67 international organisations, and many
non-governmental
organisations. (China was notably absent.) Primary health
care "based on
practical, scientifically sound and socially acceptable
methods and
technology made universally accessible through people's
full
participation and at a cost that the community and country can
afford"
was to be the key to delivering health for all by the year
2000.1
Primary health care in this context includes both primary medical
care
and activities tackling determinants of ill health.
Box 1
Characteristics of primary health care from Alma Ata
declaration1
* Evolves from the economic
conditions and sociocultural and
political characteristics of a country and
its communities
* Is based on the application of
social, biomedical, and health
services research and public health
experience
* Tackles the main health problems in
the community—providing
promotion, preventive, curative, and rehabilitative
services as appropriate
* Includes education on
prevailing health problems; promotion of
food supply and proper nutrition; an
adequate supply of safe water and
basic sanitation; maternal and child health
care, including family
planning; immunisation against the main infectious
diseases; prevention
and control of locally endemic diseases; appropriate
treatment of common
diseases and injuries; and provision of essential
drugs
* Involves all related sectors and aspects
of national and
community development, in particular agriculture, animal
husbandry,
food, and industry
* Requires
maximum community and individual self-reliance and
participation in the
planning, organisation, operation, and control
of
services
* Develops the ability of
communities to participate through education
*
Should be sustained by integrated, functional, and mutually
supportive
referral systems, leading to better comprehensive health care
for all, giving
priority to those most in need
* Relies on health
workers, including physicians, nurses, midwives,
auxiliaries, and community
workers as well as traditional practitioners,
trained to work as a team and
respond to community's expressed health needs
In the polarised world
of the cold war, the declaration inevitably
reflected political and semantic
compromises. Nevertheless, its ambition
resonated powerfully with a
generation of leftward leaning doctors,
plying their trade in what is often
regarded as a golden age for general
practice in the United Kingdom.
Sentimental celebration of the
anniversary alone has little meaning for later
generations, but the
visions still have relevance today.
Primary
health care eclipsed
Early efforts at expanding primary health care in
the late 1970s and
early 1980s were overtaken in many parts of the developing
world by
economic crisis, sharp reductions in public spending,
political
instability, and emerging disease. The social and political goals
of
Alma Ata provoked early ideological opposition and were never
fully
embraced in market oriented, capitalist countries. Hospitals
retained
their disproportionate share of local health economies.
In
many health systems, a medical model of primary care dominated
by
professional vested interests resisted the expansion of community
health
workers with less training. Such programmes anyway proved difficult
to
sustain, and little empirical research existed to justify them.
Many
international agencies sought early, tangible results rather than
the
fundamental, political changes implied by the original concept
of
primary health care. Selective primary health care and packages of
low
cost interventions such as GOBI-FFF (growth monitoring,
oral
rehydration, breast feeding, immunisation; female education,
family
spacing, food supplements) in some respects distorted the spirit of
Alma
Ata.2 The failure in most countries to provide even limited
packages,
coupled with the proliferation of vertical initiatives to
tackle
specific global health problems, hastened its
eclipse.
Geographic and financial inaccessibility, limited resources,
erratic
drug supply, and shortages of equipment and staff have left
many
countries' primary care services disappointingly limited in their
range,
coverage, and impact. Primary health care was hardly mentioned in
the
millennium declaration.3
Challenges facing health
systems
Low and middle income countries, like high income ones, face
an
increasing prevalence of non-communicable illness. This shift
has
already led to the coexistence of persisting infectious
disease,
undernutrition, and reproductive health problems alongside
emerging
non-communicable disease and related risk factors (such as
smoking,
hypertension, obesity, diabetes, stroke, and cardiovascular
disease).
This epidemiological transition poses considerable challenges to
health
systems. Most systems are oriented to maternal and child health and
the
care of acute, episodic illness. Primary healthcare services
appropriate
to future needs will have to be able to deliver effective
management of
chronic disease.
At the halfway stage, progress towards
the millennium development goals
is least impressive where the neediest
populations live, notably in
sub-Saharan Africa.4 Global initiatives tackling
priority diseases like
AIDS, tuberculosis, and malaria may undermine broader
health services
through duplication of effort, distortion of national health
plans and
budgets, and particularly through diversion of scarce trained
staff.5
Holistic care is often neglected in favour of the technicalities
of
controlling disease.
Ironically, Alma Ata highlighted the
limitations of top-down, single
issue programmes. Primary health care and the
horizontal integration of
health programmes is integral to attainment of the
millennium
development goals.6 For example, efforts to integrate
preventive
chemotherapy programmes targeting five of the so called
neglected
tropical diseases are projected to result in cost savings of up to
47%.7
Primary health care is also the key interface linking, on the one
hand,
ambulatory care with hospital and specialty services and, on the
other,
individual clinical care with community-wide health, nutrition,
and
family planning programmes. Failure to recognise the
inter-relationship
between components of a district health system has
resulted in great
inefficiency.8 In low income countries this first level of
care could
deal with up to 90% of demands.9 Evidence suggests that health
systems
that are oriented towards primary health care are more likely to
deliver
better health outcomes and greater public satisfaction at lower
costs.10
No single system of primary health care can be universally
applicable.11
A major challenge is to establish the most effective
combinations of
interventions that can target multiple conditions and risk
factors
affecting key groups (children, women, and older adults, for
example)
and that are appropriately adapted to local epidemiological,
economic,
and sociocultural contexts. Clustering of interventions can
achieve
comprehensiveness despite resource constraints. Such clusters are
likely
to include the integrated management of childhood illnesses;
maternal
and reproductive health services; clinic and community based
management
of tuberculosis, HIV and AIDS, and other sexually
transmitted
infections; management of malaria; management of hypertension and
other
cardiovascular risk factors, stroke, and cardiovascular disease;
mental
illness and substance misuse.12
Not only does primary care
constitute the first point of patient or
family contact, it is also a
critical base for extending care to
communities and vulnerable groups.
Outreach services may focus on
individual preventive measures (such as
immunisation, vitamin A, or oral
rehydration therapy) or community-wide
health promotion (such as
education on child nutrition or adult diet and
exercise). These services
depend substantially on community support and
mechanisms for
identifying, training, and supporting village or community
health
workers.13 14
However, the empirical evidence on large scale
and routine primary
healthcare programmes is scant.6 There is plenty of
evidence for cost
effective interventions that could vastly improve maternal
and child
health,15 for example, but less evidence on how to ensure these
services
reach the most vulnerable populations to lasting effect16—and
without
the detrimental concomitants of vertical approaches. A community
focused
operational research agenda has been neglected in favour of research
on
individual interventions. Evaluations of new ways of organising
primary
healthcare services in specific settings are required. Such research
is
complex because it is context specific and dependent on local
capacity
and commitment. Translation of the evidence into coherent,
operational
strategies at district level and below will be an equally big
challenge.
Affordability remains the over-riding and universal challenge.
What
services can realistically be provided free at the first point
of
contact and what mix of financing mechanisms should be promoted to
do
so? The place of user charges for primary health care remains
contested
for they have repeatedly been shown to deter those most likely
to
benefit from preventive activities.17 Indeed, one way to reach
poorer
people is to provide them with financial incentives to visit
services.
Many countries are piloting schemes that give money or vouchers
to
increase access to particular services such as maternity care.18
19
Other ways to improve equitable access include monitoring delivery
of
service and health outcomes in separate population groups and
provision
of incentives to service providers to deliver services to
vulnerable
groups.20 The reality in low and middle income countries is that
most
primary medical care will continue to be provided by private
and
non-governmental organisations. How can independent providers
be
encouraged to deliver centrally determined priorities? (The
UK's
quasi-independent general practitioners provide some
instructive
experience.)
Many places, and particularly sub-Saharan
Africa, have crippling
shortfalls in human resources, partly as a result of
international and
internal migration; hence the renewed interest in the
possible
contribution of community workers. Ironically, poor countries
that
emulated training standards in industrialised countries have been
most
vulnerable to poaching by them.21 One of the greatest challenges is
to
overcome the loss of motivation and sense of resignation of many
primary
healthcare workers who work in understaffed settings. They
lack
consistent managerial support and have grown accustomed to a norm
of
inadequate service.22
In most developing countries jobs in primary
health care are regarded as
low status, and are less valued than those in
hospital medicine by both
the public and policymakers. Only high level
political commitment and
adequate governance and funding will raise the
status of primary care
and attract suitable workers. Various bodies have
recently proposed that
15% of the budgets of disease oriented programmes be
invested in
strengthening primary healthcare systems by 2015 ("15 by
2015").23
Past and future threats
Many industrialised countries
have extensively improved their primary
tiers, influenced to varying degrees
by Alma Ata. For others, including
the UK, the rhetoric of Alma Ata was of
mostly symbolic importance.
Pivotal turning points in the postwar development
of general
practice—notably the Family Doctor Charter of 1966—were already
yielding
benefits. The UK already boasted some of the best primary medical
care
in the developed world. British general practice has been one of
the
main reasons for the relative efficiency of the National Health
Service.
But moves under the current Labour government to create a market
for
these services threaten to fragment health care and erode the
public
support that holds the NHS together.24 Experience from North
America
suggests that dividing the care of chronic diseases between
different
commercial companies principally concerned to increase profit
margins
results in less efficient (higher transaction costs) and
more
inequitable (excluding patients at higher risk) care.25
Effective
primary health care is more than a simple summation of
individual
technological interventions (box 2). Its power resides in
linking different
sectors and disciplines, integrating different
elements of disease
management, stressing early prevention, and the
maintenance of health. A
patient centred approach—a striking feature of
family medicine in northern
European countries but barely reflected in
the medical curriculums of most
developing countries—strives to tailor
interventions to individual need.26 On
the other hand, the concept of
the empowered consumer engaged in shared
decision making is far from
what was implied by the term community
participation. Health
professionals can be supported and rewarded for roles
that promote
social mobilisation. Support for intersectoral action should
come from
ministerial level downwards.
Box 2 Essential components
of effective primary health care
* Well trained,
multidisciplinary workforce
* Properly equipped
and maintained premises
* Appropriate technology,
including essential drugs
* Capacity to offer
comprehensive preventive and curative services
at community
level
* Institutionalised systems of quality
assurance
* Sound management and governance
systems
* Sustainable funding streams aiming at
universal coverage
* Functional information
management and technology
* Community
participation in the planning and evaluation of
services
provided
* Collaboration across different
sectors—for example, education,
agriculture
*
Continuity of care
* Equitable distribution of
resources
Health systems are part of the fabric of social and civic
life.27 They
both signal and enforce societal norms and values through the
personal
experiences of providers and users. The declaration of Alma Ata
helped
to entrench the idea of health care as a human right. This
anniversary
provides a salutary reminder of what we are placing at
risk.
Summary points
The declaration of
Alma Ata defined primary health care 30 years
ago
Although it had huge symbolic importance, its
effect in practice
was more limited
Community
participation and intersectoral action remain challenges
for those working to
reduce health inequalities
The changing global
burden of disease and workforce shortages make
effective integration of
existing vertical programmes essential
Primary
health care is key to providing good value for money and
enhancing
equity
Alma Ata remains relevant for effective
healthcare systems today
Editorial, doi:
10.1136/bmj.39496.444271.80
I thank Jennifer Amery for
comments.
Contributors and sources: SG also works as a general
practitioner.
Competing interests: None declared.
Provenance and
peer review: Not commissioned; externally peer
reviewed.
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(Accepted 14 January 2008)
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