The Alma Ata Symposium
Hi there! Sorry it has been a wee while since I was last in touch. There has been a lot happening. This week’s issue of The Lancet is a very special one. It focuses on 30 years of Alma Ata- the declaration for health for all- and Joy Lawn from Save the Children explains the origins and current progress in international health since the signing of the Alma-Ata Declaration here. Vanessa Jessop, a medical student from Edinburgh University was fortunate enough to be able to go the Alma Ata Symposium in London last week and reports for us below-Rhona
Health for all? Photo courtesy of Oxfam
Last week the School of Oriental and African Studies (SOAS) played host to the Alma Ata Symposium. Supported by the London School of Hygiene and Tropical Medicine, the Symposium on Primary Health Care assessed the legacy of the Alma Ata declaration 30 years after its creation in 1978. The potential for primary care to address current and emerging global health priorities was also discussed.
The International Conference on Primary Health Care was convened in Alma Ata, Kazakhstan, in 1978 and was attended by almost all member states of the WHO and UNICEF. The creation of the Alma Ata Declaration constitutes a key event in public health history, identifying primary health care as the key to attaining Health for All.
The Symposium began by reflecting on the past, with lectures outlining the social determinants of health and health equity since Alma Mata. Professor Lucy Gilson identified rising economic inequality both within and between countries as a key social determinant underlying health inequities, with global gains in life expectancy and health status often serving to mask these inequities. Professor Gilson suggested health care development policies associated with globalisation exacerbated exisiting inequalities, and presented primary health care as a strategy for the reorientation of health systems. However, she stressed the need for political will to tackle social injustice both locally, by national governments, and globally by organisations such as WHO.
Professor Gilson also made reference was made to the recent report ‘Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health’ published earlier this month by the World Health Organization’s Commission on the Social Determinants of Health. /You can read Sarah Walpole’s blog about the report here.
Speakers from India, South Africa, Ghana and Geneva, delivered their thoughts on the role of community health workers (CHWs) in primary healthcare development, and stressed the importance of community participation in achieving improvements in health. Among them Dr. Ravi Narayan from the People’s Health Movement, discussed how social movements in the global south have redefined the concept of participation in development. From participation in programmes at community level, participation is being redefined as a social process that enables ‘globalisation of health solidarity from below, to counter health inequities and policy distortions, resulting from a technology driven globalisation of health system development from above’.
Professor David Saunders focused on the value of community health workers to render certain basic health services to their communities. He stressed the advantages of community selection and training of health workers, and their special aptitude for health promotion and community mobilisation. However, he did take time to point out that community health workers are not ‘a panacea for weak health systems’, and to dispel the misconception that CHW programmes are easy and cheap to implement. Infrastructure is a necessity, and CHWs should be trained and supported in such a way as to supplement, not substitute, existing health services.
Support for this was offered by Professor Fred Binka, who outlined the findings of an experimental study in Ghana comparing the effectiveness of community based care delivered by community health nurses and village volunteers. Whilst posting nurses to community locations substantially reduced child mortality rates over eight years, community volunteer approaches had no additional impact on mortality.
In the afternoon, focus shifted to health systems, and the tensions between disease specific (vertical) and health systems (horizontal) approaches. Professor Francis Omaswa defined primary health care as the foundation of health systems. He described how the eradication of small pox in 1978 marked the beginning of disease specific programmes, and how, subsequently, economists and financial institutions had adopted a ‘return on investment approach’, resulting in loss of solidarity and compassion. He referred to a ‘parasitic approach’, with vertical programmes infecting health systems and weakening them until they are too weak to survive. Please visit the Medsin Website to find out more about the Health Systems Campaign.
He also talked about the ‘NGOnisation’ of primary health care. NGOs often lack accountability and in situations where they provide primary care services this allows governments to also escape accountability for the provision of PHC. He stressed the need for the international community to recognise governments’ responsibilities and to ensure they are ‘not let off the hook’. Professor Omaswa went on to outline the challenges of Global Health Initiatives (GHIs), including duplication of planning and accounting, and displacement of government health funds.
The Uganda Reform Model seeks to overcome the problems inherent in GHIs and the resurgence of vertical programmes. Vision 2025 is a new national constitution, involving the decentralisation of government and a Strategic Poverty Eradication Action Plan (PEAP). Within the constitution, donor support is only accepted for programmes within PEAP. A memorandum of understanding is drawn up between the donor and the government to prevent dictatorship and encourage government ownership of programmes, as part of an integrated health systems approach. Professor Omaswa attributes Uganda’s success in reaching the WHO 3 by 5 initiative targets six months early to the Reform Model.
Finally, Dr. Laurent Yameogo, Coordinator of the Office of the Director of the African Programme for Onchoceriasis Control (APOC), highlighted the efficiency of vertical approaches in disease eradication and the potential for success, with ‘concrete results’, in health and development. He acknowledged the frustration with vertical programmes expressed by Professor Omaswa, including lack of capacity building of health staff. He agreed that there was ‘no real synergy’ between GHIs, and that without policies on integration Ministries of Health are often lost in a spaghetti junction of ineffective aid.
Dr. Yameogo offered a solution to the power struggle between vertical and horizontal programmes: Community Directed Treatment (CDT). A multi-country study concluded that CDT was feasible, effective, replicable and likely to be sustainable. Despite being a vertical programme, community involvement in drug collection and distribution, with feedback to health services, served to strengthen the local health system. In April this year the WHO/AFRO meeting in PHC urged all countries to implement the CDT approach and for health personnel to better accept the empowerment of communities to take care of their own health. Vanessa Jessop: vanessaannjessop@gmail.com
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