Primary Health Care: More Action Less Words please! (2)
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25 years anniversary Alma-Ata
Political assumptions. Limits of the proposal. Local contexts and ap-
plication.
1. A quarter of a century after the Declaration of Alma-Ata, we might
legitimately ask whether and to what extent its principles were cor-
rect, the hopes on which it rested reasonable, and the ensuing pro-
gramme realistic. Personally I do not believe that "health for all" was
or is a utopia. It was - and remains - an obligation of humanity and an
attainable goal. The status review which I am proposing should be un-
derstood as a prospective analysis, not a lamentation. In this brief
exposition, in these few lines, I will attempt a) first of all to sum-
marise succinctly the international context and the spirit of the
original Declaration; b) to continue by pointing out the major differ-
ences between the situation then and now, and c) to finish with an out-
line of the future.
2. Unless I am mistaken, the Declaration of Alma-Ata was, like all in-
ternational agreements, the result of both a complex intersection of
interests among those actors with global decision-making power, and the
relative autonomy of the international organisations. The various mod-
els of development in vogue at the time found a point of confluence in
the Primary Health Care strategy. In retrospect, it is striking how far
the Declaration succeeded in capturing with total clarity the tension
between the two parallel and dominant conflicts of the day: the East-
West conflict, and the North-South conflict. A striking result, above
all, was the fact that the World Health Organization, though suscepti-
ble to political instrumentalisation, did wish to see itself as an ap-
propriate authority for articulating desires and possibilities. Obvi-
ously, WHO's problem then, which is not that much different to its
problem now, was its lack of power. Yet despite this weakness, it did
know how to raise the Declaration into a legitimate platform for the
claims of the least well protected, calling for the principle of compe-
tition to be replaced by that of solidarity.
3. The Declaration of Alma-Ata was thus based on a normative postulate:
the need for a New International Economic Order. This was its fundamen-
tal precondition: recognition of the compelling right to development as
an inalienable human right.
4. Nonetheless, the really innovative aspect of the Declaration of
Alma-Ata was the structural relationship established between economic
growth and the health of the population. The New International Economic
Order was not just a hypothesis, but was to be understood above all as
an objective. The basic concept, then, was health as an instrument of
growth and development.
5. The Declaration of Alma-Ata thus marked a conceptual revolution in
health by introducing the notion that: the object of medical sciences
is not the body of the individual, but the spiritual and physical well-
being of the community. At the time, this shift in focus from the indi-
vidual to the social, from a purely physical to a holistic understand-
ing of the human being, was incorporated into the design of a new
health methodology: Primary Health Care.
6. The principles for this methodology proposed by the Declaration of
Alma-Ata were few, but sound:
* health sector coordination at the international level (resource
transfer, support, exchange)
* health sector coordination at the national, regional and local levels
(coherent resource management and joint planning of measures)
* community participation (active involvement of the population in the
planning, implementation and evaluation of health programmes)
* self-reliance (yes to cooperation, no to dependence)
* globality, continuity and integration of all health systems, at all
levels: promotive, preventive, curative and rehabilitative
* recovery of traditional medical knowledge (sound management of all
indigenous resources)
7. The wisdom of this vision, and the difficulties involved in imple-
menting it, are familiar to us. Yet they cannot be evaluated without
taking into account the enormous changes that came about in the two
decades which followed. It is indisputable that the two key conflicts -
East/West, North/South - which prefigured the Declaration subsequently
became dissipated in various ways: on the one hand through the collapse
of the Soviet Union and of authoritarian socialism in Central Europe,
and on the other through the structural changes in the global economy.
Yet the new international economic order envisaged did not materialise.
What did emerge was the controversial phenomenon of "globalisation".
This frequently discussed process has often been defined as a univer-
salisation of the marketplace, a relative collapse of the nation state,
and a process of cultural homogenisation. As we know, there is no
shortage of either apologists or critics of globalisation. For some,
the opening-up of world trade represents a unique opportunity for de-
velopment by the poor countries, whilst others produce figures demon-
strating that the only result has been a widening of the gap. It is
striking that, whilst the term "globalisation" does not appear in the
Declaration - and therefore goes unacknowledged, the call for a New In-
ternational Economic Order did not imply leaving development to the
fate of the market, but implied placing it in the responsible hands of
the nation state. Yet this is not the only point where contrasts become
evident. The Declaration also devotes little attention to environmental
problems. It should not be forgotten that it predated Chernobyl. This
relative indifference to the ecological dimension of human health is
also reflected in the absence of the notion of "sustainability". It did
of course speak of self-reliance and self-determination, but this em-
phasis on horizontal solidarity seemed to obscure the importance of the
social contract between the generations. Equally pallid was the image
of civil society, which the Declaration put across. Though it called
for community participation, it insisted above all that governments
were responsible. Finally, whilst the Declaration did not discuss forms
of government, it goes without saying today that health work is
inseparably linked to democratic growth.
8. Other marked differences -like the incorporation of gender issues in
health - between the visions of the Declaration and our present-day
world could also be listed. I would like to conclude my thoughts by re-
flecting on what I consider to be the future challenges. During these
25 years we learned both how difficult it can be to effect positive
changes, and how rapidly negative changes can spread. I am thinking for
instance of HIV/AIDS, another phenomenon which came after the Declara-
tion, impacting at both the epidemiological and the public awareness
levels. And we do not know what awaits us (SARS). To sum up, I would
speak of three axes along which we should re-orient programmes.
9. The right to health. Also addressed in the Declaration, this remains
a basic instrument of health work to empower those most in need. The
Declaration contained an everlasting idea, that health is such an im-
portant right as self-determination and respect for the human being.
This right must be articulated through the responsibility accountabil-
ity and transparency of the Governments together with civil society and
community participation and responsibility.
10. Sustainability. This is another word, which we have incorporated,
using it to denote both the ecological challenge, and an integral as-
pect of strategic planning for health. As a result, I would say - tau-
tologically - that health must not be produced at the expense of
health.
11. Coordination. I believe this is a key word. It was included amongst
the Declaration's aims. Our globalised world has perfected technologies
such that we are now able to achieve significant synergistic effects
using fewer resources.
Dr. Nina Urwantzoff
10. April 2003
Misereor, Germany
mailto:Urwantz@misereor.de
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