Wednesday, October 15, 2008

Reflections on Primary Health Care 30 years after Alma Ata and the Challenges Ahead

The recently released World Health Report on PHC (WHO Oct 2008) is an attempt to bring PHC again to the forefront of our priorities in global health. Good for that!

But the world has changed in these 30 years.

In 1978, we did not have:
· Neoliberal globalization.
· Selective, vertical health programs (many of them aggressively pushed by public-private partnerships -- PPPs that started, because they did not trust WHO…).
· A big health manpower crisis (only in part due to the AIDS pandemic).
· The magnitude of economic impediments to access to health by poor people with increasing inequities and disparities between the haves and the have nots.
· Increasing privatization and commercialization/commoditization of health services as a result of globalization *.
· Intellectual property issues (patent issues) used against the interest of poor countries and poor patients.

We also did not have:
· An energetic and active civil society.
· The People's Health Movement (PHM) and its global network.

Therefore, as a PHM member, on top of seeing PHC and Alma Ata as still alive, I think PHC-in-2008-and-beyond needs to address these (and other unmentioned) "did not have" issues as challenges at local, national and global level.

For this to happen, WHO is to recuperate its moral and political leadership in PHC, in health overall, and in proactively addressing the social determinants of health as per the recommendations of the ad-hoc WHO Commission that just released its report.

To go beyond well-meaning pronouncements, this will clearly need some internal reorganization in this UN agency. The question is whether its leadership plans such a reorientation.

PHM does not shy away from a political approach to PHC and is not really fighting its opponents; it is rather bringing the level of the discussion to a higher level. Therefore, it has published an alternative report to the World Health Report of 2008 --the Global Health Watch 2 (being released today, see ).

PHM challenges the concept that good health is an imperative for increased economic productivity: Instead, it insists and departs from the premise that health is an inalienable Human Right.
Health is not either a technical or a political issue: it is both…and pro-poor health interventions mean nothing if not concomitantly accompanied by poverty reduction actions that are pro-health.

Based on patients registers at health facilities, statistics want to make us believe that 50% of the poor choose to seek private health care. Such a fallacy hides the real fact that 50% of the poor do not seek any care (and thus escape facility-based statistics!). So, let us stop using the slogan "those who can pay should pay" without carefully weighing its meaning.

I am a perennial optimist. I hope recent developments mean a real new window of opportunity for PHC. But WHO/member states/civil society interactions will have to become more of a 'two-way street'. I am sure PHM will play its role in achieving this.

Claudio Schuftan, Ho Chi Minh City
*: The myth that private health providers are more efficient has to be broken once and for all. Without trying to generalize, it is still true that, in the private sector, the following facts are prevalent:
· An irrational use of drugs, of polypharmacy and an overuse of antibiotics, vitamins and steroids.
· An overuse of injectables.
· A veritable 'ultrasound epidemic'.
· An excessive numbers of cesarean sections and tonsillectomies performed.
· Private insurance companies cherry picking the healthier patients and leaving the others for the public sector to care for (or offering minimum coverage packages to the poor that end up in 1st, 2nd and 3rd class medicine).
· A penetration of transnational health corporations in developing countries using GATS provisions (that PHM denounces).
· Public hospitals opening private wards 'that will (allegedly) generate income to subsidize the public wards', but most of the times ending up being subsidized by the public sector since they undercharge private patients.
· Health tourism springing up in many countries with the consequent internal brain drain.
· A conspicuous absence of private practitioners in remote and poor areas.
· A very limited role of this sector in preventive and promotive health actions and a minimal role in TB and in AIDS, and
· A resistance of medical associations to any measures directed at regulating private practice.

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