Novice World Health Committee
Topic: Primary Health Care and the Alma Ata Declaration
Author: Joseph Granton
Statement and History of the Problem
It has been almost thirty years since the declaration of Alma-Ata (1978). This document had great potential in reformulating and reshaping health care principles across the globe, and its implementation was thought to be entirely necessary in order to achieve success in terms of Health For All by the Year 2000. The document laid out the groundwork in defining primary health care. Many saw primary health care as the key point of the Alma-Ata Declaration. PHC was inspired by and based on the practices and diverse experiences of many small struggling Community-Based Health Programs in Latin America, China and the Philippines. Essentially, the goal of Community Based Health Programs (CBHP) and PHC was to replace the predominantly Western influenced health programs with more eastern influences. Essentially, high-priced hospitals and clinics were to be augmented, and sometimes even wholly replaced. This augmentation would take the form of education of members of communities. These members of the communities would then in turn serve as health consultants for the community they represent, disseminating knowledge and healthy practices to their communities.
Many people saw the genius behind this idea, and hoped for its success. But the program also had its critics. The Alma Ata Declaration addressed not only health issues of developing nations, but also addressed the underlying social economic and political causes that lead to the poor health of communities and nations. The declarations specifically noted that a more equitable distribution of resources was necessary. This distribution of resources was mentioned not only in a national context, to ensure that the poor of a country have the same health care as the rich, but also in an international context, calling for the affluent countries to contribute more resources to ensure that the developing and especially the least developed countries have the means to implement primary health care principles.
Naturally, most of the Western nations were somewhat opposed to this declaration. It was a lose-lose situation for them: Not only would they be losing industry development by losing a market for expensive pharmaceutical sales to developing nations, the international community would be calling on them to contribute much more financially to these developing nations
PHC was ultimately seen as a liberating tool for the population. It was entirely grass roots oriented and community based, allowing people to organize themselves. Naturally some governments that were not entirely accountable to their people (that is to say most governments) were opposed to such a declaration that would put “ideas in the population’s head.” Resultantly, these countries launched many “primary health care initiatives”, however they were treated merely as extensions of traditional, western, top-down approaches. They were not implemented in the revolutionary sense as implied by the Declaration.
Now that you have a sufficient background in CBHP, PHC, and the Alma Ata Declaration, it is necessary to discuss why we are convening this meeting this November. As delegates of the World Health Organization, I would like for this committee to explore if the Alma Ata Declaration was ultimately a success or a failure. If it is either, then why was it successful or why was it a failure. If it is decided that the declaration was a failure, or if it has some key points that need to be addressed, then I would like to see some work done on updating and revamping the declaration for the modern age. Let this debate be an exploration of lessons learned and future suggestion for the future of PHC and CBHP.
Case Study
Nicaragua
Anastaisio Somoza ruled Nicaragua from 1936 – 1979. Installed by Washington as the head of a US created national militia, Somoza seized power by means of a coup, and ruled Nicaragua in a dictatorship. Community based health programs began to spring up as a result of the systematic denial of human rights. However, what started as simply nonprofit and non-governmental programs aimed solely at helping those in need turned into more politically and socially active organizations. These programs were used as organizations by which communities could be organized at a local level, and became instruments of change in many Nicaraguan communities.
Somoza would have none of this community organization and involvement, and saw these community based health programs as threats to his power. An aggressive campaign was launched by Somoza’s Ministry of Health and USAID to implement government controlled health promoters. The program was well off financially, but despite the foreign aid contributions and training, the program was not accepted at the community level. However, the spontaneous community based health programs continued to spread, and increasingly became targets of Somoza’s National Guard.
As Somoza feared, community based health programs mobilized the population of Nicaragua – particularly the very poor and very oppressed. By oppressing doctors, nurses, and community health workers, these same workers became involved in the resistance “Sandinista” that rebelled, and seized power in 1979.
Considering that many Sandinistas were doctors, nurses, and community health practitioners, it should be no surprise that the new ruling front was primarily concerned with the health of the nation. Programs created by the Sandinistas were decentralized; community oriented, and involved all sectors of the population regardless of socioeconomic status and geographic location. These organizations were not nongovernmental however, and were involved in community administration and politics. Some even served in disciplinary sections. Also, realizing the power of literacy in influencing key performance indicators in health, a national literacy campaign was launched by the Sandinista.
The amount of community health workers multiplied across the country and massive campaigns called People’s Health Days were launched by the Ministry of Health. Under these programs Nicaragua successfully eradicated polio and provided anti-malarial drugs to over 80% of the population, reducing the national incidence of malaria by 62%. However, internal political fighting put an end to these early gains. Three opposing viewpoints emerged in the Nicaraguan political system. One faction wanted to further expand the community based health programs. The second wanted a health care model that featured complete nationalization and to bring government control to the primary health care system. The last faction wanted to revert to a private, westernized model of health care.
A compromise was eventually reached that ultimately lead to the distillation of the community based health programs. Nicaragua was going to proceed with a series of government operated People’s Health Clinics, staffed by both doctors and community based health promoters. The community based promoters skills were restricted to reflect the internal conservative bloc’s fear of the diminishment of the importance of the doctor role. Resultantly, attendance at council meetings declined and the health promoters became more and more inactive.
The final deathblow to the Nicaraguan experiment came in the form of the US attempt to destabilize the area by backing the Contras. Fearing the left leaning tendencies of the Sandinistas, the US government backed revolutionary forces (Contras) in the area. These contras proceeded to specifically target the institutions of the Sandinistas, one of which was the network of Health Councils throughout the nation. They specifically targeted the health programs because the dramatic increases in the nations health were the major reason for the popularity of the Sandinistas. Funds that would be used for these health councils were diverted to the more pressing National Guard effort, to defend against the guerilla warfare.
In a general election that followed, in fear of repercussion from the Contra forces, a United States funded political party called the UNO was voted into power. A nationally socialized health program was put into place, as a result of pressure from USAID, the World Bank and the IMF. All key indicators of health rose sharply. Prostitution, crime, and the divide between the rich and the poor all rose, and the health rate fell proportionally. More aid money was pouring in from the international community, but the rates still continue to stagnate or fall.
After examining this case, why do you think that the Primary Health Care model ultimately failed in Nicaragua? What could the international community have done to improve the chances of the success of a primary health care system in this nation? How did your country respond to Nicaragua’s success and the Iran-Contra affair? These questions should be an appropriate start to the rest of your research.
Note: This case study borrows heavily from chapter 20 of the book Questioning the Solution: The Politics of Primary Health Care and Child Survival, which I STRONGLY recommend that you review in order to prepare for the debate. It is available for free on the Internet. The link is posted in the web resources section.
Past WHO committee actions
Declaration of Alma-Ata
The International Conference on Primary Health Care, meeting in Alma-Ata this twelfth day of September in the year Nineteen hundred and seventy-eight, expressing the need for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all the people of the world, hereby makes the following Declaration:
I The Conference strongly reaffirms that health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that 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.
II 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.
III Economic and social development, based on a New International Economic Order, is of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of the developing and developed countries. The promotion and protection of the health of the people is essential to sustained economic and social development and contributes to a better quality of life and to world peace.
IV The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.
V Governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures. A main social target of governments, international organizations and the whole world community in the coming decades should be the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. Primary health care is the key to attaining this target as part of development in the spirit of social justice.
VI 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. It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.
VII Primary health care:
1. reflects and evolves from the economic conditions and socio-cultural and political characteristics of the country and its communities and is based on the application of the relevant results of social, biomedical and health services research and public health experience
2. addresses the main health problems in the community, providing promotional, preventive, curative and rehabilitative services accordingly;
3. includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs;
4. involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sectors; and demands the coordinated efforts of all those sectors;
5. requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources; and to this end develops through appropriate education the ability of communities to participate;
6. should be sustained by integrated, functional and mutually supportive referral systems, leading to the progressive improvement of comprehensive health care for all, and giving priority to those most in need;
7. relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community.
VIII All governments should formulate national policies, strategies and plans of action to launch and sustain primary health care as part of a comprehensive national health system and in coordination with other sectors. To this end, it will be necessary to exercise political will, to mobilize the country's resources and to use available external resources rationally.
IX All countries should cooperate in a spirit of partnership and service to ensure primary health care for all people since the attainment of health by people in any one country directly concerns and benefits every other country. In this context the joint WHO/UNICEF report on primary health care constitutes a solid basis for the further development and operation of primary health care throughout the world.
X An acceptable level of health for all the people of the world by the year 2000 can be attained through a fuller and better use of the world's resources, a considerable part of which is now spent on armaments and military conflicts. A genuine policy of independence, peace, détente and disarmament could and should release additional resources that could well be devoted to peaceful aims and in particular to the acceleration of social and economic development of which primary health care, as an essential part, should be allotted its proper share.
The International Conference on Primary Health Care calls for urgent and effective national and international action to develop and implement primary health care throughout the world and particularly in developing countries in a spirit of technical cooperation and in keeping with a New International Economic Order. It urges governments, WHO and UNICEF, and other international organizations, as well as multilateral and bilateral agencies, non-governmental organizations, funding agencies, all health workers and the whole world community to support national and international commitment to primary health care and to channel increased technical and financial support to it, particularly in developing countries. The Conference calls on all the aforementioned to collaborate in introducing, developing and maintaining primary health care in accordance with the spirit and content of this Declaration.
The United Nations has also consistently affirmed the idea of Primary Health Care and Community Based Health Programs, but has failed to turn policy into action.
Please review the United Nations TRIPS Agreement and the Doha Declaration regarding prescription drug distribution and patent laws in the third-world nations.
Questions a Resolution Must Answer
1) Was the Alma Ata Declaration a failed experiment or partially successful?
2) Should Primary Health Care and Community Based Health Practices be revitalized?
3) What went wrong with the first declaration and what steps can we take to correct those
4) Do pharmaceuticals have a place in any primary health care strategy and if so, what safeguards can be put into place to ensure that they are not too heavily relied upon.
5) Can we implement any of the proven strategies utilized in the TRIPS Agreement and the Doha Declaration
Bloc Positions
United States and the European Union and other Western Pharmaceutical Producing Nations:
As primary health care in its traditional sense emphasizes the basic elements of health, and not the dispensing of and sale of pharmaceuticals, you stand to lose big if Primary Health Care and Community Based Health Projects become a reality. Furthermore, expect to be called on to “share the wealth” and to contribute to an equitable distribution of resources. You would be expected to argue for new alternatives to primary health care.
Sub-Saharan African nations:
Many of your countries desperately require primary health care. China would be your biggest support, Do not look to South Africa for help, as they have been responsible for destabilization campaigns in the past. South Africa utilizes a Western model of health care that appears to be working for it.
Latin America
Looking at the Nicaraguan case study, we can see that these countries can directly benefit from a very grass-roots oriented primary health care strategy. Again, China has in the past utilized something similar in the past and would be willing to back you in an attempt to revitalize PHC principles
As always, existing pacts, trading agreements, and informal ally situations should affect your debating strategy.
Web Resources
www.who.org
http://www.healthwrights.org/books/QTSonline.htm
http://www.hain.org/PUBLICATION/HEALTH%20ALERT%20NEWSLETTER.htm
Further Suggested Bibliography.
Questioning the Solution: The Politics of Primary Health Care and Chilid Survival. 1997 D Werner et al. Note: Please read this whole book. If you are pressed for time, please focus on chapters 2, 3, 4, 5, 12, 13, 14, 15, and 20. Case studies focusing on Zimbabwe, Mexico and Nicaragua are also available.
The appendix focuses specifically on the roles of UNICEF and WHO
This book provides a solid foundation in the principles of Primary Health Care and the politics surrounding it. Large portions of this study guide used it as its basis and inspiration. It is available for free from
http://www.healthwrights.org/books/QTSonline.htm
The Life and Death of Primary Health Care, or, The McDonaldization of Alma Ata. 1993 D. Werner
To a lesser degree, please try to review as much as possible as listed in the Health Alert Asia Pacific Newsletter (Issue 1) Resource List. This is available at
http://www.hain.org/PUBLICATION/HEALTH%20ALERT%20NEWSLETTER.htm