The Alma-Ata Declaration was adopted at the International Conference on Primary Health Care (PHC) was held between September 6-12, 1978. The declaration was indeed historical, because, for the first time, elected representatives from 134 countries and 67 international organisations agreed upon a common definition of health that examined causes of ill-health to lie beyond the four walls of hospitals. This Declaration will complete 40 years in September. So, it is perhaps the right time to take a relook at and examine as to what has happened to this document. What have been the commitments of governments to the Alma-Ata Declaration? Is the Declaration still relevant?
The Alma-Ata Declaration defined health as a state of complete physical, mental and social well-being and not mere absence of diseases. This definition of health along with the concepts of primary health care formed the two core principles of this declaration. It recognised health as a human right – and to attain the same, several social and economic sectors in addition to the health sector need to be actively involved and show results. For example, female literacy is the most powerful lever to improve the health status of any community. It is well-known that achievements in the health sector of both Kerala and Tamil Nadu are attributed to better female literacy levels. In addition to education, the Declaration identified nutrition, clean water, sanitation, mother and child health, immunisation, access to treatment and availability of essential medicines as eight important components of PHC, which will enable us to achieve Health for All by 2000 (which has long gone by).
To achieve Health for All, the existing healthcare strategies will have to be vigorously transformed. First, health budgets will have to be increased. Currently, India spends just 1.2% of its GDP on health, one among the lowest in the world. Second, the scarce resources in health end up reaching only a few and leaving the vast majority without anything. Third, same level of health services should be made available to one and all, without distinction between class or caste, through primary healthcare, backed by adequate referral.
Health for All will remain a dream as long as it is formulated in purely technocratic terms – drugs, nurses, doctors, vaccines and X-ray equipment. One needs to look beyond the four walls of the hospitals where the real causes of ill-health lurk. It could be unemployment, underemployment, poor housing with overcrowding, lack of access to nutritious food and safe water, illiteracy and gender inequalities. To overcome all this, people will need to be involved in planning health programmes. And for that, a minimum understanding of health is essential. So, in essence, social awareness and health go hand in hand. Identifying this being an important component is known as community involvement.
A multi-sectorial approach was a strong pillar of Alma Ata Declaration. Further, it declared that unequal social and economic status within the country itself as well as among the countries all contribute to ill health; and pronounced the urgent need to break or at least reduce these huge gaps. Perhaps, the most important declaration was that it held the governments responsible for taking care of the health of its citizens.
Alma-Ata and its downfall
The efforts to dismantle Alma-Ata Declaration brick by brick began a year later, when in the year 1979, the Rockefeller Foundation sponsored a conference in Italy, where it was argued that Alma-Ata’s Primary Health Care concept was expensive and unrealistic. The approach by Rockefeller Foundation stripped many important key aspects of Alma-Ata, where the emphasis was on overall social and economic development. Further, the cornerstone of Alma-Ata, which was community participation, was struck down, and instead, a selective, politically sanitised version of PHC reduced to a few highly prioritised technological interventions, determined not by communities but by international health agents and experts was strongly advocated. This came under the new label as Selective Primary Health Care.
The governments that largely catered to the interests of the rich were quick enough to grab this as they had vested interests in the form of preserving status quo of the unequal economic and social conditions. It was in response to this that in the year 1983, UNICEF adapted “GOBI-FFF” – which is acronym for Growth monitoring, ORS, Breastfeeding, Immunisation, Family planning, Food supplements and Female education. Many governments just selected ORS and immunisation, which the UNICEF proclaimed as “twin engines” of child survival revolution. Several corporate-friendly countries, USAIDS and World Bank which had shown scant respect for the Alma-Ata Declaration, suddenly jumped onto the bandwagon and pledged major financial support. By mid 1980s, virtually every underdeveloped countries had launched GOBI-FFF intervention.
By 1990, many developing countries had started initiating privatisation and liberalisation processes under the duress of World Bank and IMF. Slowly, over a period of time, apart from others, the public health care sector has seen the entry of private sector in the form of Private Public Partnerships. Additionally, governments are steadily promoting private health care sectors, which is largely unregulated and is known to fleece patients. To summarise, currently, health is seen by the government as area of investment, for example, the Indian health industry is expected to touch US$ 160 billion by 2017 and US$ 372 billion by 2022. All of this goes against to the vision of the Alma-Ata Declaration.
And when ‘Health For All by 2000’ was not achieved, several health activists from all over the world sat down at Savar, in Dhaka and debated as to why the failure, unfortunately both the WHO and UNICEF shied away from this meet. Subsequently the Dhaka meet has evolved as People’s Health Movement, with its presence in 70 countries campaigning for Health Rights, through People’s Health Charter. This seems to be the only remaining hope to revive the Alma-Ata Declaration.
Dr Gopal Dabade is with Drug Action Forum, Karnataka.