HEALTH FOR ALL BY THE YEAR 2OOO THROUGH PRIMARY HEALTH CARE A CHALLENGE TO NATIONAL LEADERSHIP
Remigio D. Mercado, M.D., MPH
Professor of Public Health
UPM - College of Public Health
HEALTH FOR ALL BY THE YEAR 2OOO - CONCEPTS AND ISSUES
In May 1977, the Thirtieth World Health Assembly adopted resolution WHA 3O.43. This resolution decided that the main target of governments and of WHO should be the attainment by all the people of the world by the year 2OOO a level of health that will permit them to lead a socially and economically productive life. This is popularly known as " Health for the year 2OOO".
While by and large, this concept has been accepted by authorities throughout the world, many may have expressed reservations. They expressed doubts about the feasibility of its achievement. They contended that no matter what the national and international agencies do, there will always be people who will get sick, become disabled, and eventually die. They are of course correct. But such pronouncements are based on lack of
understanding of the health - for - all goal. On the other hand, there are a good number of leaders who believe in the goal but are appalled by the magnitude of the task in the face of limited resources that can be mobilized for health improvement.
MAGNITUDE OF THE CURRENT HEALTH PROBLEMS
Leaders of the health sector realize that the achievements of the health for all goal is going to be an arduous task. One must be aware of millions of people living in conditions of abject deprivation. Their incomes are too low to ensure basic nutrition. They also have no access to essential health care.
According to the WHO Global Strategy for Health for All by the Year 2OOO, the average infant mortality rates in 198O in the developed countries ranged from 1O to 2O for every 1OOO infants. On the other hand, the infant mortality rates in most developing countries ranged from 9O to 2OO per thousand. Whereas the average life expectancy at birth is about 72 years in developed countries, it is about 55 in the developing countries. In Africa and Southern Asia, it is only about 5O years. The death rate among children between 1 and 5 years old is only 1 per 1OOO in most developed countries, while in the developing countries it is between 2O and over 3O. Of every 1OOO children born into poverty in the least developed countries, 2OO die within a year, another 1OO die before the age of 5 years, and only 5OO survive to the age of 4O years.
Safe water supply is taken for granted in the developed countries where coverage is 1OO%. In the least developed and developing countries on the other hand, the coverage is not even 5O% causing considerable suffering in terms of parasitic diseases, diarrhea and skin diseases. The acute communicable diseases are still principal causes of illness and death in the least developed and developing countries. These diseases have
been reduced to a mere nuisance level in the developed countries.
Against this gloomy picture of the health status in developing countries is also a pessimistic forecast of the economic situation. It is estimated in 1981 that the per capita income of people living in the least developed countries is likely to grow only by no more than 1% a year- an average of only US$ 2 or 3 per individual. In terms of the health budget, this means that one cannot expect significant increase. This, plus the high inflation rate, the rising cost of essential imports, and the declining price of major agricultural exports, are enough to discourage even the toughest administrator.
POLICY BASIS OF THE HEALTH-FOR-ALL GOAL
The task of the national and international leadership is how to alleviate the conditions of nearly one billion people trapped in the vicious circle of poverty, malnutrition, disease and despair that saps their energy, reduces their work capacity and limits their ability to plan for the future. In effect the problem that is being contended with is not health. It is survival. And no matter how great the barriers maybe, there is no alternative except to keep trying to overcome them if the human race is to survive with honor. Those who now lead a good and comfortable life should not think that the problem will not affect them. The same message should be appreciated by people in the developed countries. One must realize that progressive increase in the proportion of poor and unhealthy people who feel neglected would eventually lead to political instability which will affect the whole nation and the whole world.
It is because of their awareness of the very poor state of health in the least developed and developing countries, and the strong conviction that so much can be done to improve them, even with the resources on hand, that the Member States in the World Health Assembly in 1977 decided to act as the conscience of the world and passed resolution WHA 3O.43 which started the health-for-all movement. This resolution was given further substance in 1978 at the International Conference on Primary Health Care held in Alma Ata, USSR, which stated that primary health care is the key to attaining the health-for-all goal. In 1979, the World Health Assembly launched the Global Strategy for Health for All, which was subsequently adopted by the Thirty-fourth World Health Assembly in 1981. Following this, all 6 regions of WHO prepared their respective regional health strategy. The global strategy was first monitored in 1983, is to be monitored every years up to the year 2OOO.
VARIOUS WAYS OF VIEWING HFA / 2OOO
When dealing with something very important, difficult, and time consuming in the face of scarcity of resources, resort has to be made to long-term planning. The plan must reflect what the societal image should be in so far as health is concerned by the final year of the plan. In the case of the Global Health Strategy, the time frame has been arbitrarily decided as 2O years. Within the framework of the societal image, the health sector should develop medium-term plans of 4-5 years span, the incremental achievements of which would lead to the realization of the long-term objective. This is one way of interpreting health for all by the year 2OOO - an exhortation to engage in long-term planning.
Health-for-all may also be viewed as a different approach by which health is considered in the broader context of its contribution to social and economic development. It also means that health is a fundamental human right. It is concerned with the just distribution of health resources in quantity and quality, aiming at all people whatever their present level of social and economic development but demands that greatest attention be paid to the underprivileged and underserved.
In more specific terms, one can consider health for all as a moving target. As a starting point, the health - for - all goal envisions that no country will have an infant mortality rate of over 5O per 1OOO and a life expectancy of less than 6O years by the year 2OOO. Many poor countries will need help to achieve these targets. On the other hand, there are those which have already achieved such targets, and there are those which will be
able to reach the targets before the year 2OOO.
The concept of a moving target is that as a certain health status is reached, people should try to aim for a higher level.
" Health - for - all does not mean that in the year 2OOO, doctors and nurses will provide medical care for everybody in the world for all their existing ailments; nor does it mean that in the year 2OOO nobody will be sick or disabled. It does mean that health begins at home, in schools and in factories. It is there, where people live and work that health is made or broken. It does mean that people will use better approaches than they do now
for preventing diseases and alleviating unavoidable disease and disability and have better ways of growing old and dying gracefully. It does mean that there will be an even distribution among the population of whatever resources for health are available. It does mean that essential health care will be accessible to all individuals and families in an acceptable and affordable way, and with their full involvement. And it does mean that people will realize that they themselves have the power to shape their lives and the lives of their families; free from the avoidable burden of disease and aware that ill - health is not inevitable."
PRIMARY HEALTH CARE - THE KEY TO THE ATTAINMENT OF THE HEALTH - FOR - ALL GOAL
Since the International Conference on Primary Health Care in Alma - Ata in 1978, primary health care has become the main thrust for the improvement of world health. The Conference came up with what is now known popularly as the Alma - Ata Declaration, which represents a global ideal, a new vision about how to achieve world health. But as experience is gained in translating this ideal into reality, it becomes necessary to
clarify the definition of PHC.
The Alma - Ata Declaration itself provides the basis for avoiding confusion. Between the lines, one can deduce that primary health care can be viewed at least in three different dimensions - as a service or minimum of health activities that must be provided, as a structure of the health system, and as an approach/philosophy.
Primary health care as an approach emphasizes equity and justice, believing strongly that health is a basic right of every individual and not just of those who can afford to pay for their own health care. It is thus very much concerned with the reduction in the gaps between those who have good health and those who have not by giving priority to the latter in the allocation of resources so as to meet the health needs of those whose needs are greatest.
Primary health care further believes that people must be given an opportunity to exercise control over their own lives and their environment and take responsibility for their own health. This partnership in health development between the government, and the individual and his community is an expression of a very important component of the philisophy of primary health care - that of individual and collective responsibility for health in the spirit of self - reliance.
Primary health care recognizes that health is the outcome of a complex set of socio - cultural and economic, as well as physical and biological factors. This leads to the need for making health goals a higher priority in the overall development process and of the importance of ensuring that many sectors in addition to the health sector take the necessary action to promote health.
An important component of the PHC approach is the use of appropriate health technology. The word technology means an association of methods, techniques and equipment which, together with the people using them, can contribute significantly to solving a health problem. " Appropriate " means that besides being scientifically sound, the technology is also acceptable to those who apply it and to those for whom it is used. This implies
that technology should be in keeping with the local culture. It must be capable of being adapted and further developed if necessary. In addition, it should preferably be easily understood and applied by community health workers, and in some instances even by individuals in the community.
The cost of the technology is an important consideration. There are those who would consider " affordability " by the community as part of the meaning of the world " appropriate ", and there are those who don't. Regardless of such conflict of interpretation, the point to keep in mind is that the technology must be available to a cost that the community can afford.
The call for greater community involvement, intersectoral collaboration and the use of appropriate technology will need more flexible approaches and styles of management. These, plus the concern for equity in the face of scarce resources requires the strengthening of health planning and management. They also require the use of appropriate health manpower.
In summary, one can define PHC as an approach which aims to reduce the inequity in health status by giving priority to the underserved population, advocating the use of appropriate technology, promoting intersectoral action for health, developing the community as an important base for health activities, and exhorting the authorities to make changes in the health system to make this responsive to the tasks given to it, starting with the
improvement of planning and management and the development and use of appropriate health manpower.
Primary health care as a service or minimum set of health activities that must be provided or enjoyed by the population is very well explained by the Declaration of Alma - Ata (Declaration No. VII, Article 3 ). This in effect is a modified listing of the basic health services of earlier times. The Alma - Ata report outlined eight essential elements to be included in the content of PHC comprising the initial and continuing care at the point of entry into the health system. But these are broad headings, each of which can be broken down into a hierarchy of tasks and activities to be performed at different levels within the total system.
Primary health care as a structure refers to that part of the health system where contact is first made with the people. This view of PHC has dominated the way PHC has been defined by countries where it has frequently become synonymous with community health workers ( non- professional community members performing health tasks on a part - time or full - time basis ), with " low cost " community health care programmes or simple health activities that the community does, as distinct from the formal health system of a country. This has given rise to the erroneous view that PHC is a second - class medicine for the poor.
Primary health care as the most peripheral level of the health system has sometimes been erroneously seen as an alternative to basic health services rather than as a complimentary or more peripheral level. Basic health services tended to stop at the health centre or sub - centre level while PHC extends further into the community and homes, providing the link between the more formal health system and the community. It is in connection with this definition of PHC that so much confusion has arisen.
The Alma - Ata Declaration states that PHC forms an integral part of the national health care system of which it is the central function and main focus. To avoid confusion, it maybe more productive if attention is refocussed on the totality of the health system which is based on the principles of primary health care, functioning as a comprehensive interlinked system which effectively meets the priority health needs of the population. This involves meeting needs at the level of the community or home as well as ensuring access to higher technical levels as necessary. This clarification is essential to avoid unfortunate experiences of some countries who began implementing PHC as a separate vertical programme with its own organizational structure becoming an entity distinct from the rest of the health system.
In summary,PHC can be defined as a philosophy, or approach, as a level of the health care system and as a set of activities. It is all of these. Understandsing what PHC means today, in the light of the experience of trying to implement it, does not mean that new perspectives will not emerge over the next few years.
We must be constantly reviewing the concept with the fresh insights gained from experience. But it is the understanding and acceptance of the underlying philosophical principles or values, outlined earlier in this paper, which will determine what PHC really means in countries.
Political will and commitment to PHC on the part of governments first and foremost requires acceptance of these values. Commitment, however, is itself a process and shades or levels of commitment are usually the reality rather than political commitment existing or not. Furthermore, governments are by no means homogeneous in their shades of commitment and several different shades may exist in countries simultaneously.
Some countries already have policies, and are pursuing patterns of development in conformity with this principles. Some political systems are more favorable to PHC precisely because they emphasize these values and are concerned with a broad attack on poverty and inequality and on the socio - economic structures which maintain them. Even for the health sector, the pattern of existing health systems and opportunities for change reflect wider socio-political values.
It will be easier to effect the kinds of changes discussed above, in countries where the overall development policy gives priority to equity and social justice, than in countries where economic growth is being pursued regardless of the human consequences. It has to be clearly understood at the outset that commitment to PHC is a commitment to a political goal which will have to be fought for against opposition forces and progress is
likely to be slow. This is why PHC is a political issue.
CONCLUSION
The experience over the past 2O to 3O years has brought home two important lessons. First is that society has experienced rapid socioeconomic transformations in directions which have proved to be neither wholly acceptable nor comprehensible. The second is that we are not in control of these changes and we have not learnt how to manage change. These lessons are as true and valid for national and political leaders
and economic managers as for those who are in the field of health.
We, in health, have dwelt too long on the notion that technology can adequately address the problems of human development. We have lived too long with the assumption that society is willing to pay any price, take any risk to support the belief that there can be quick solutions to complex problems. The morbidity patterns described earlier and the health situation we can project for the future do not speak well of our performance.
It is time to change the way health professionals perceive the world. They must take an active role in the political and economic decisions that directly affect the health and welfare of their communities, and, finally, they must get involved in rethinking how they can manage the health care institutions they are responsible for in order to address the changing health needs of the community.
The unique characteristics of the present time is rapid change - changing societies, changing environment, changing lifestyles. Change has long been recognized for its ability both to disturb and stimulate conditions affecting man, which include among others the economy, the ecology, the social and cultural traits, the technology and the state of health. It is this dual nature of change, in both its negative and positive aspects, the lends a particular urgency to the need to improve understanding of the focus of change at work in the cities, in the rural areas, and in the world today.
In order to bring about improvement in the community so that it can lead a socially and economically productive life, one has to understand the positive as well as the negative forces of change at work in the community. To put the matter as simply as possible, primary health care is a strategy to harness these forces so that the end result is change for the better and not change for the worse.
ROJ@17may12