Alma Ata After 40 Years: Primary Health Care And Health For All—From Consensus To Complexity PDF

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Analysis BMJ Glob Health: first published as 10.1136/bmjgh-2018-001188 on 20 December 2018. Downloaded from http://gh.bmj.com/ on August 30, 2024 by guest. Protected by copyright. Alma Ata after 40 years: Primary Health Care and Health for All—from consensus to complexity Susan B Rifkin To cite: Rifkin SB. Alma Abstract Ata after 40 years: Primary Summary box Forty years ago, the 134 national government members of Health Care and Health for the WHO signed the Alma Ata Declaration. The Declaration All—from consensus to ►► The Alma Ata Declaration in 1978 expanded the ap- made Primary Health Care (PHC) the official health policy of complexity. BMJ Glob Health proach to improving health for all people from the all members countries. Emerging from the conference was 2018;3:e001188. doi:10.1136/ focus on doctors, hospitals and biomedical advanc- bmjgh-2018-001188 the consensus that health was a human right based on es to include human rights, concern for equity and the principles of equity and community participation. Alma community participation. Handling editor Stephanie M Ata broadened the perception of health beyond doctors ►► To pursue this goal, the member nations of the WHO Topp and hospitals to social determinants and social justice. In committed their governments to accept Primary the following years implementing this policy confronted Health Care as their national policy. Received 24 September 2018 many challenges. These included: (1) whether PHC should ►► Implementing this policy proved to be challenging Revised 24 November 2018 focus on vertical disease programmes where interventions Accepted 3 December 2018 focusing on issues including whether action should had the most possibility of success or on comprehensive focus on vertical disease programmes or holistic programmes that addressed social, economic and health programmes, how to define and pursue com- political factors that influenced health improvements; munity participation and equity and how to finance (2) whether primary care and PHC are interchangeable PHC programme. approaches to health improvements; (3) how equity and ►► A major concern was how to asses PHC interven- community participation for health improvements would be tions as experiences showed that implementation institutionalised; and (4) how financing for PHC would be was contextual and not generalisable in great part possible. Experiences in implementation over the last 40 because people did not behave the way profession- years provide evidence of how these challenges have been als thought they should. met and what succeeded and what had failed. Lessons ►► Evidence suggests PHC needs to be understood as a from these experiences include the need to understand process in the framework of complex interventions PHC as a process rather than a blueprint, to understand the that consider not only outcomes/impact also why process must consider context, culture, politics, economics and how an intervention works/ does not work. and social concerns, and therefore, to recognise the process is complex. PHC needs to be examined within evaluation frameworks that address complexity. Recent fulfilled only by the provision of adequate developments in monitoring and evaluation have begun to health and social measures. The people have respond to this need. They include realist evaluation and implementation research. the right and duty to participate individually and collectively in the planning and imple- mentation of their health care’ (p. 3).1 The Declaration supported by all member Introduction states of WHO put forward a new policy titled Traditionally, over the last two centuries, Primary Health Care (PHC) defined as ‘essen- health has been defined as hospitals and tial health care based on practical, scientifi- doctors. While in the past there has been a cally sound and socially acceptable methods © Author(s) (or their recognition of the importance of health as and technology made universally accessible employer(s)) 2018. Re-use a reflection of social determinants, in 1978, to individuals and families in the community permitted under CC BY-NC. No commercial re-use. See rights this recognition was formalised into policy. through their full participation and at a cost and permissions. Published by The 134 member states of the WHO declared that the community country can afford to BMJ. good health was also the result of factors that maintain at every stage of their development London School of Hygiene and included access to services, education, social in the spirit of self-reliance and self- determi- Tropical Medicine, London, UK and economic status and political and indi- nation’1 (p. 3). Raising challenges to a view Correspondence to vidual choices. The Alma Ata Declaration of health dominated by biomedicine and the Dr Susan B Rifkin; stated ‘Governments have a responsibility medical profession, the policy gave a new ​sbrifkin@​gmail.c​ om for the health of their people which can be context declaring health as a human right Rifkin SB. BMJ Glob Health 2018;3:e001188. doi:10.1136/bmjgh-2018-001188  1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2018-001188 on 20 December 2018. Downloaded from http://gh.bmj.com/ on August 30, 2024 by guest. Protected by copyright. supported by the principles of equity and community Ata.6 Providing a platform for neoliberal economic strate- participation. In the ensuing years, it faced the challenge gies in the health sector, the report stressed cost-effective- of implementing this policy in the light of traditional ness as key to improving health care delivery and argued view of health and by a growing acceptance of neoliberal for a reduced role for the state in health care provision. economics that moved health care from a public good to It also earmarked substantial financial support to the a consumer product. health sector to carry out its recommendations. WHO, The purpose of this paper is to trace the history of which shepherded PHC policy, responded by examining PHC policy from its inception up to the 40th anniversary costs and effectiveness in the World Health Report 200077 of the Alma Ata Declaration in 2018. It is a history that entitled ‘Health Systems: Improving Performance’. The started with a consensus of the United Nations agencies focus on health improvements became more siloed in supporting a view of health as a human right and as a 2000 with the publication of the United Nation’s Millen- result of social determinants to a narrower view defining nium Development Goals (MDGs) focusing on disease universal health coverage (UHC) as a focal point of cure and prevention.8 Global health policy could be policy implementation. This paper argues that one major seen as a shift from a comprehensive PHC approach that reason for the challenge to translate the PHC vision from included the social determinants to a vertical disease-fo- rhetoric into reality was the failure to understand and act cused agenda. These documents did not address the on the complexity of implementation. There was under- PHC values of social justice, equity and community lying but unstated assumption that PHC was a blueprint participation. rather than a process for universal health improvements. After a period of languishing in the shadow of finan- cial concerns for health focusing on service delivery, in 2008, PHC once again came to the top of the health Overview of PHC history agenda with two reports from the WHO. The first, The historical development of PHC is complicated and ‘Primary Health Care: Now more than Ever’ called for complex.2 The Alma Ata Declaration was accepted in a reforms that included: (A) UHC to improve health period that reflected the commitment of several coun- equity, (B) health service delivery reforms to make tries, including those devastated in World War II and those health systems more people centred; (C) leader- that had relinquished their former colonies, to address ship reforms to improve the accountability of health the injustices of the prewar period. Their commitment authorities; and (D) public policy reforms to promote created the United Nations and a search for social justice, and protect the health of communities.9 The second particularly in ‘developing countries’ that were gaining report published by the WHO Commission on the independence from their colonial masters. In the 1970s, Social Determinants of Health gave evidence that social the United Nations promoted the idea of a New Interna- determinants including income, education, daily living tional Economic Order to pursue this goal.3 conditions and the social, the economic and political However, implementation of the idealism of this context of countries were critical to health improve- period was sorely stretched by the existing frameworks ments. Social justice and equity prominently returned of policy and financial commitments that lacked capacity to the global health policy agenda with the statement on and will to address equity and redistribution of resources. the back cover of the report stating, ‘Reducing health These limitations were illustrated in the following period inequities is, for the Commission on Social Determi- with the 1982 oil crisis. With governments reverting to nants of Health, an ethical imperative. Social injustice debt collection from the low-income and middle-income is killing people on a grand scale’.10 countries, a policy of structural adjustments followed in However, in the same year, another global financial these countries. The reasons for the structural adjust- crisis once again prioritised the provision of health ment policies are convoluted and complex. A good inves- services and a focus on hospital curative care11 over the tigation of these factors can be found in an article by reorientation of health to pursue PHC values. In addi- Labonté and Stuckler.4 Essentially, the World Bank and tion, new actors with financial support for vertical health International Monetary Fund gave substantial loans to programmes including the Bill and Melinda Gates Foun- the ‘developing countries’ with strict conditions about dation, the Global Alliance for Vaccines and Immuniza- use and repayment. The assumption that these countries tion and the Global Fund to Fight AIDS, Tuberculosis would continue economic growth and would repay that and Malaria with much more money than WHO increas- debt proved to be unrealistic. This situation led to the ingly influenced the direction of global health policy. fear of sovereign debt defaults by debtor countries and Their concerns overrode concerns of the PHC vision a call by the lending institutions for debt reduction and of health as a human right. In face of the changing repayment. The result was reduction in social policies in context, WHO began to focus on a single programme affected countries and a major decrease in funding for that reflected concerns of equity, that of UHC. Starting the health and education sectors.5 with the World Health Report for 201012 by 2017 with a The World Bank’s 1993 World Development Report new director-general, Tedros Ghebreyesus, UHC became entitled ‘Investing in Health’ further challenged the the mantra for WHO with equity and human rights as financing of health programme that came out of Alma its foundation. This focus was reflected in Goal 3 of the 2 Rifkin SB. BMJ Glob Health 2018;3:e001188. doi:10.1136/bmjgh-2018-001188  BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2018-001188 on 20 December 2018. Downloaded from http://gh.bmj.com/ on August 30, 2024 by guest. Protected by copyright. Sustainable Development Goals and in Tedros’ vision for health services at the primary care level (though that was the future of WHO.13 important), but rather a health system model that acted also on the underlying social, economic and political caus- es of poor health (p. 33).10 Challenges to implementing PHC The reality, however, is that in industrial countries, The search for a standard implementation protocol as Starfield described, primary health is often equated The broad definition of PHC in Alma Ata provoked an with PHC. This situation continues to challenge the way almost immediate challenge.14 In an article in the New health care is conceived and delivered both in these England Journal of Medicine in 1979, Walsh and Warren countries and in low-income and middle-income coun- put forward the idea of Selected Primary Health Care tries where industrial countries provide substantial (SPHC). It stated that PHC was clearly a compel- monetary aid and thus influence for developing health ling view about how health improvements should be care systems. pursued. However, it was too visionary to be practical. To address the concerns put forward in Alma Ata, the Evaluation of health care interventions article argued that a SPHC approach was more appro- Rooted in the health care system, policy planners, priate. This approach focused on tackling the diseases managers, service providers and intended beneficiaries that had the highest prevalence, the greatest risk of often see PHC programme as solely interventions to mortality and the highest possibility of control in terms improve health status. As a result, their successes and of cost effectiveness. It challenged the view of Compre- failures are assessed using the same framework used for hensive Primary Health Care (CPHC) that highlighted assessing biomedical interventions—the randomised health as wholistic based on the original definition of control trials (RCTs). However, research studies have health by WHO (health is a ‘state of complete phys- highlighted the weaknesses in this approach.20–22 The ical, mental and social well-being and not merely the assessment of intervention using RCTs is based defining absence of disease or infirmity’15)and the importance a linear process that is generalisable and predictable. of equity, community participation and multisectoral As PHC is people centred and people do not behave collaboration.16 This debate remains a point of conten- the way planners think they should, outcomes are not tion among health policy planners and managers today. predictable and generalisable. They are contextual, It focuses on whether services should be delivered in based in history and experiences outside health care and a vertical manner focusing on specific diseases or in the result of a change of attitudes and behaviours over a horizontal manner to include concerns about social time. For this reason, identifying replicable outcomes determinants.17 One way that has been put forward to has been difficult and has challenged funders of health resolve this apparent conflict is the call for diagonal care programmes who depend on RCTs to justify their programmes to integrate both approaches.18 support. The following sections explore this challenge in terms of evaluating the contribution of equity and PHC versus primary care community participation to health improvements and The term used for the Alma Ata vision for global health in justifying financing for PHC programmes. improvements was PHC. Accepted by those who signed the Alma Ata Declaration, it quickly caused confusion The search for equity among those who sought to implement this approach. While accepting equity as a key principle of PHC, Universally supported in theory, in practice, mainly in assessing its impact has proved elusive. Evaluators use the industrial countries, the vision was translated as a default measurement of inequality to investigate how primary, or first line, provision of health services. In the impact of health provision affects different popula- the USA, Dr Starfield from Johns Hopkins University tions. However, inequality is not the same as inequity. advocated an approach to ‘provide entry into a health Inequity is an ethical concept based on social justice service that addresses all new needs and problems by and linked to human rights.23 Inequality is only descrip- giving person focused care over time, by providing tive of which groups have better health disregarding care for all but unusual problems and by coordinating factors such advantages people have due to their place care provided outside the service where the person was in the social hierarchy and access to good health based being treated’ (p. 9).19 She noted that this approach on factors such as income, education, environment reflected the provision of health care delivery in the and health services and health care. While inequality industrial countries where hospital care and technology can tell which groups have worse health conditions, it had a firm basis and where there was little experience does not answer the reason for these conditions. The in community-based care. Commission on the Social Determinants of Health In an attempt to clarify the relationship of PHC to (2008) in its third recommendation highlighted for the primary care, the Commission on the Social Determi- need to measure and understand the causes of poor nants of Health included this statement in its 2008 report: health beyond health services and health care and to The Alma Ata declaration promoted PHC as its central correct the recognised problems (p. 2).10. Causes of means towards good and fair global health—not simply inequity are not easily identified and often need proxy Rifkin SB. BMJ Glob Health 2018;3:e001188. doi:10.1136/bmjgh-2018-001188 3 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2018-001188 on 20 December 2018. Downloaded from http://gh.bmj.com/ on August 30, 2024 by guest. Protected by copyright. measures. WHO made available in 2013 a handbook a challenge. Much of financing concerns have focused using the measurement of health inequalities as an on approaches in the low-income and middle-income indirect means by which to assess health inequities. It countries most often dependent on donor aid and published a list of factors to consider. Referred to by on expanding access to health care to a large popula- the acronym PROGRESS, these factors include Place tion that has been underdeveloped economically and of residence (urban, rural and so on), Race/ethnicity, underserved. In the period following Alma Ata, an Occupation, Gender, Religion, Education, Socioeco- immediate response from WHO members was to estab- nomic status and Social capital or resources.24 lish Community Health Workers (CHW) programmes. The Chinese experience of ‘barefoot doctors’ inspired The contribution of community participation these programmes. Here local people received training Providing data that support the contribution of commu- to deal with minor health care problems in the commu- nity participation to health proved to be even more nity and promote improved health behaviours.32 CHW challenging. First, there are no standard definitions for programmes have been equated with PHC giving meat either ‘community’ or ‘participation’. In the health liter- to the skeleton of new health care approaches.33 Several ature ‘community’ is often defined within geographic countries including India, Colombia and Sri Lanka borders assuming a homogeneity of share interests. Yet created CHW programmes. The early programmes did common sense and experience confirms people living not last long. Although seen as a way to provide cheap in the same area most often have different backgrounds, health care to mainly rural people, in fact, the cost of views and commitments.25 ‘Participation’ has often training, supervision and medical supplies proved to be been defined on a spectrum that ranges from having expensive.34 In addition, governments were unable to community people turn up at a meeting for a discus- ensure safety and quality when CHWs were mainly volun- sion of health topics to community people becoming teers. Because of prohibitive costs, governments balked at part of the decisions about how health programmes are incorporating CHW programmes.35 By 2006, however, it created, implemented and financed (empowerment).26 was clear that the depletion of health providers, particu- Second, participation in health programmes has been larly in Africa due to the HIV/AIDs epidemic was a based on a number of unproven assumptions. These crisis.36 From that time, governments often with the help include: programmes can be created and implemented of international donors have vastly increased resources to without clearly defining ‘community’ and ‘participa- train and support CHWs. tion’; the provision of information ensures that people However, the financing for CHW programmes and information will change their attitudes and behaviours; for other PHC programmes in the low-income and people want to be involved in decisions about their own middle-income countries has continued to be a chal- health care; and participation will empower people to lenge to PHC’s principle of equity. Compared with act in the way professionals know will bring about health the industrial high-income countries, these countries improvements.27 28. Third, the evidence to support the have not allocated as much funding to health. Many contribution of participation to development projects including health has not been robust. The World Bank of these countries are dependent on aid from foreign commissioned a review to investigate the contribution donors. Between 2000 and 2009, donor aid increased of participation in development projects including at a rate of 11.3% annum. Yet between 2010 and 2015, health. The conclusion was that the money which the annual contribution of donor aid dropped to 2% Bank invested in participation, over $85 billion over the annually.37 As a result, there has been increasing pres- period 2003–2013, was ‘arguably still driven by ideology sure on WHO and international donors to provide and optimism more than by systematic analysis, either health care to a majority of people living in poverty theoretical or empirical’ (p. 3).29 Finally, it has been in these countries. Responding to global concerns shown that community participation in health has not coming from the 2008 financial crisis as well as uneven addressed questions around power and control, a key to evidence about the direct relationship between PHC the emphasis on the importance on empowering people and specific health improvements, policy makers in order to make health interventions sustainable and began to focus on a limited intervention where clear cost-effective. Much of the literature has focused on the evidence could support its value.11By 2018, WHO had mechanisms of community participation rather than made UHC its prime policy focus based on the call context and process.30 It was only in 2016 the Bulletin of for equity and community participation. However, the the World Health Organization31 published an article that ways in which equity and participation would support concluded power must be identified in communities if UHC remained vague. This focus has raised concerns the transformation to sustainable health actions and from economists who are unable to figure out how programmes is to succeed. governments of poor countries will raise funds. It also raised concerns among those who saw the call as Financing PHC policy a siloed programme with little room to address the As discussed in the Introduction of this paper, financing social determinants of health and community involve- of PHC policies and programmes has continually been ment in specific ways.38 4 Rifkin SB. BMJ Glob Health 2018;3:e001188. doi:10.1136/bmjgh-2018-001188  BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2018-001188 on 20 December 2018. Downloaded from http://gh.bmj.com/ on August 30, 2024 by guest. Protected by copyright. Lessons from 40 years of PHC PHC policy implementation is a process that develops over The last four decades has seen the move of a consensus time and with experience on a global health policy based on the Alma Ata Decla- This process involves trial and error learning from ration to a wide range of experiences in successes mistakes and responding with flexibility meeting prob- and failures of policy implementation. These experi- lems and needs. Seeing the implementation of PHC as a ences have highlighted the complexity of translating process highlights the dynamics of the application of the a visionary policy into practical applications. Based on intervention. It highlights the factors that encourage or the research presented in this paper, here are the most limit the its acceptance or rejection. It demands a recog- important lessons from the 40 years of PHC experi- nition and investigation into both intended and unin- ences: tended outcomes. It demands a continual monitoring of what works and why and how it works. It also demands a continual interaction between policy makers, programme There is no ‘blue print’ for universal implementation of PHC managers, health providers, intended beneficiaries and policy other stakeholders such as non-government organisa- PHC is not a biomedical intervention that is linear tions and community people. Where programmes have and generalisable for the following reasons. Unlike made achievements health outcomes have not only been programmes to eradicate specific diseases focusing seen in statistics about health improvements. They are on the need for specific personal behaviours such as also seen in sustainable health programmes particularly accepting immunisations or accessing clean water, at the community level that have been able to address PHC addresses a range of approaches that support a issues around equity and community acceptance, involve- change of both opinions and behaviours that only ment and support for health improvements and health happen over a long period of time and reflect a specific care delivery.2 context amenable to these changes. It depends on the ability of governments to raise funds, on the availability The process is complex of funds for the health sector and competing inter- It must be examined within assessment frameworks ests for their allocation. It depends the availability of designed to investigate complex health interventions. human resources to support health programmes and Complexity research is a growing field that responds on the structures to allocate and apply these resources to this need. This type of research highlights a way in to specific programmes. It depends on the organisa- which science can be used to solve the relevant problem tion and management of health care delivery in both using the relevant method. It comes from a realisation government and non-government programmes. Criti- that to apply science is to confront the challenge that its cally it depends on politics.39 application to society is not predictable and manageable National governments that have established PHC with accuracy and precision. Traditional reductionist as a policy focus and implemented this policy do approaches that take apart a complex problem and try to not have the same programmes. For example, Thai- deal separately with each component part fail to account land40 has pursued PHC focused on UHC. India41 for the interconnection of those parts to each other. and Ethiopia 42 have focused on CHW programmes. What is needed is an alternative way of understanding Brazil created Family Health Teams composed of one the problem using alternative tools, techniques and doctor, one nurse, one nurse assistant and between approaches.44 This approach is necessary to understand four and six CHWs. 43 Countries choose and develop how why and where PHC policy has been effective and programmes that best suit their context and needs. where it has failed. Despite obstacles and limitations, these programmes Recent years have seen the creation of evaluation have been sustainable and have been noted as frameworks that respond to this need. The Medical successes in getting health care to poor populations Research Council in the UK has developed a frame- over a long time period. They do share common work for assessment of complex interventions that it characteristics. The political leadership that came defines as those with many interacting components to govern and implement PHC policy replaced the that require some flexibility to implement and which previous leadership either by an elective process or a allow for a wide range of possible outcomes relating coup. The new leadership has been committed in both to a variable target population.45 However, it has been words and actions to address issues around health criticised because complex interventions are not equity through creating access to health services for predictable and cannot be reduced to a static and often the most marginalised members of the country. They mathematical model.46 More promising is realist eval- also support participation of the intended beneficia- uation based on the work of Pawson and Tilley.47 This ries in choices about health care mainly through the approach uses theory-driven models that examine the creation of CHW programmes and/or health centre context and mechanisms that underlie the interven- committees. They have kept the flexibility to change tion and produce processes and outcomes that can be and address challenges that arise in the implementing observed. More recently in the field of health, imple- the programme. mentation research has gained credence for examining Rifkin SB. BMJ Glob Health 2018;3:e001188. doi:10.1136/bmjgh-2018-001188 5  BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2018-001188 on 20 December 2018. Downloaded from http://gh.bmj.com/ on August 30, 2024 by guest. Protected by copyright. complexity. It is defined as investigating ‘any aspect of 4. 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The 'diagonal' approach future understanding, how this approach is best devel- to Global Fund financing: a cure for the broader malaise of health oped and used is critical both for its implementation systems? Global Health 2008;4:6. and for resources to support expansion. 19. Starfield B. Primary care: balancing health needs, services and technology. Oxford, UK: Oxford University Press, 1998. Acknowledgements Meredith Fort, one reviewer whose suggestions improved 20. Rifkin SB. Examining the links between community participation and health outcomes: a review of the literature. Health Policy Plan the presentation. 2014;29(suppl 2):ii98–ii106. Contributors I am the sole contributor to this article. 21. Atkinson JA, Vallely A, Fitzgerald L, et al. The architecture and effect of participation: a systematic review of community participation Funding The authors have not declared a specific grant for this research from any for communicable disease control and elimination. Implications for funding agency in the public, commercial or not-for-profit sectors. malaria elimination. Malar J 2011;10:225–55. Competing interests None declared. 22. Mubyazi G, Hutton G. Rhetoric and reality of community participation health planning, resource allocation and service Patient consent for publication Not required. delivery: a review of the reviews, primary publications and grey literature. Rwanda Journal of Health Sciences Provenance and peer review Not commissioned; externally peer reviewed. 2012;1:51–65. Data sharing statement No additional data are available. 23. Whitehead M. The concepts and principles of equity and health. Int J Health Serv 1992;22:429–45. Open access This is an open access article distributed in accordance with the 24. World Health Organization. Handbook on health inequality Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which monitoring. Geneva, Switzerland, 2013. permits others to distribute, remix, adapt, build upon this work non-commercially, 25. MacQueen KM, McLellan E, Metzger DS, et al. What is community? and license their derivative works on different terms, provided the original work is An evidence-based definition for participatory public health. Am J properly cited, appropriate credit is given, any changes made indicated, and the Public Health 2001;91:1929–38. use is non-commercial. See: http://​creativecommons.​org/l​ icenses/​by-​nc/​4.0 26. Rifkin S,B. Health planning and community participation: case studies in Southeast Asia. London: Croom Helm, 1986. 27. Rifkin SB. Lessons from community participation in health programmes: a review of the post Alma-Ata experience. Int Health 2009;1:31–6. References 28. Rifkin SB, 2012. Translating rhetoric to reality: a review of community 1. World Health Organization. Primary health care: report of the participation in health policy over the last 60 years. 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