It may seem that the goal of universal primary health care - in which state capacities are strengthened to ensure the rapid expansion of free publicly-provided health services - is further away than ever before. But there are many signs that the ideal of 'health for all' is making a second resurgence, writes Adam Parsons.
As many developing countries begin to reel from the impacts of a global recession, the possibility of achieving ‘health for all' may seem an unlikely prospect. Following a recent warning from the United Nations that its Millennium Development Goals are likely to be jeopardised by the economic meltdown, it has since declared the targets on health to be the most ‘elusive'. The rich world has never met the UN development assistance target of 0.7 percent of GNI, and promises made by the G8 to double aid to sub-Saharan Africa by 2010 were not even mentioned at the latest summit in Canada. In spite of this pessimistic outlook, however, there are signs that the United Nations and civil society are re-embracing the health approach developed in the 1970s known as Primary Health Care - and the vision of a new international health strategy could be making a welcome comeback.
The year 2008 marked the 60th anniversary of the World Health Organisation as well as 30 years since the Alma-Ata Conference, an international gathering that sparked the rise and fall of Primary Health Care (PHC) as both a philosophy and practice. More than just the provision of basic services, PHC was a revolutionary concept infused with the spirit of social justice and universal equality. Not only did it involve guaranteeing access to essential healthcare at a community level for all people of the world, but PHC services were to work closely with health-related sectors responsible for other essential needs including education, safe water, sanitation and food security. According to the vision of PHC, addressing the socio-economic determinants of health, not just the medical consequences of sickness and disease, is fundamental to reducing the global inequities in healthcare provision. In 1978, when ministers from 134 countries gathered in Alma-Ata, Kazakhstan, and signed a declaration calling on nations to reduce the gap between the health status of the developing and developed countries, ‘Health for All by the Year 2000' was seen as a laudable and achievable goal.
The sense of optimism amongst health policymakers was unfortunately short-lived. Alongside the rise from the late 1970s of the prevailing economic model commonly known as neoliberalism, public health joined other social services in being recast within a market framework. As the neoliberal discourse in public health policy became dominant from the 1980s onwards, the new buzzword became ‘Selective Primary Health Care', derided by critics as ‘Health for Some by the Year 2000'. The social democratic ideal of government-funded programs to meet the essential needs of society, guided by the goal of universal coverage as enshrined in the Universal Declaration of Human Rights, became superseded by the neoliberal philosophy of an austere state. As such, the balancing of financial accounts was prioritised over the government provision of basic services - leaving little room for ambitious public health programs.
Health for 'some' by the year 2000
No sooner than the Alma-Ata declaration was signed by the World Health Organisation and its member states, the debate over Selective PHC created a schism in the global health community; WHO and UNICEF - the two main proponents of PHC - soon drifted apart, and UNICEF switched to promoting a selective package of low cost interventions. This ‘selective interventions' approach was similarly adopted by the World Bank, as epitomised in its 1993 World Development Report on health investment that hardly mentioned PHC. Instead of viewing health as an integral part of development, the Bank placed emphasis on intervening at a selective point in the epidemiology of a disease or health system - thus focusing on the clinical determinants of health, rather than the social, political and economic determinants of health that are largely beyond the control of health ministries. Alma-Ata was a landmark moment in bringing together these two complementary understandings of health, although the disease-specific, vertical approach to resource mobilisation has since been reinforced by governments and UN agencies through the Millennium Development Goals, and is now the de facto norm in global health initiatives.
The consequences of neoliberal policies in many developing countries have long been documented; structural adjustment programmes, which included the rapid privatisation of many state enterprises and the incorporation of competition into the provision of social services, led to the slashing of health budgets in many poor countries. In the management of debt crises by the International Monetary Fund and World Bank since the 1980s, cost-recovery strategies such as user fees were introduced in the healthcare sector. For the poor, this often meant making hard choices between food, education, or healthcare. The social impacts of this economic model are recorded in any number of statistics; sharp increases in global poverty levels by the late 1980s, an increase in the number of hungry people by almost 60 million between 1992 and 2000. And between 1985 and 2005, the gap between average life expectancy at birth in low-income countries and in the OECD actually widened, by nine months.
Today, privatisation and market principles remain at the centre of the global health agenda, despite health inequalities becoming far greater than they were 30 years ago. In recent statistics, the WHO reported that the difference in life expectancy between the richest and poorest countries still exceeds 40 years, and about 100 million people are being pushed into poverty each year as a result of paying for healthcare. Besides this, as many as 5.6 billion people in low and middle-income countries have to pay for more than half of their health expenditure themselves. Furthermore, the WHO estimates that an additional 400,000 child deaths per year could be caused as a direct consequence of the financial crisis. Despite the continued deterioration of health in many less developed nations, however, the World Bank and a growing number of international donors continue to promote an expansion of private-sector healthcare delivery in poor countries.
On the surface, it may seem that the ideals of universal PHC, in which state capacities are strengthened to ensure the rapid expansion of free publicly-provided healthcare, are further away than ever before. But there are also many signs that the principles of primary health care are making a second resurgence. In December 2000, when governments were originally due to meet the Alma-Ata vision of ‘health for all', the People's Health Assembly took place in Bangladesh with over 1,400 participants from civil society movements and non-governmental organisations. After 18 months of preparation and over a hundred sessions during the five-day gathering, civil society groups formulated The People's Charter for Healththat soon became the most widely endorsed consensus document on health since the Alma-Ata Declaration.
Health For All Now!
In calling for ‘Health For All Now!', the Charter describes the social and economic conditions that have undermined people's access to healthcare and other social services, summarised in terms of neoliberal political and economic policies together with "the unregulated activities of transnational corporations". Governments and international bodies, it states, are "fully responsible" for the failure of ‘Health for All by the Year 2000'. In response, participants called for a "people-centred health sector" that prevents "the exploitation of people's health needs for purposes of profit", outlined with a comprehensive list of recommendations to reform trade and the governance of the global economy. Spelling out its vision, the Charter states: "Equity, ecologically-sustainable development and peace are at the heart of our vision of a better world - a world in which a healthy life for all is a reality... There are more than enough resources to achieve this vision."
In 2008, on the thirtieth anniversary of the Declaration of Alma-Ata, the Peoples Health Movement again called for governments, the WHO and the international community to renew the commitment to achieving health for all as articulated in 1978. It is an "achievable goal", they reiterated, that governments could meet within a generation. Around the same time, the WHO released its World Health Report 2008 titled ‘Primary Health Care: Now More Than Ever', shortly before publishing the final report by the WHO'sCommission on Social Determinants of Health (CSDH) called ‘Closing the Gap in a Generation'. Following a three year investigation, the CSDH reported that increased national wealth alone does not necessarily increase national health - in fact, economic growth can even exacerbate poor health unless there is a fairer sharing of its benefits. The structural drivers of health inequality, stated the Commission, are focused in the inequitable global distribution of power, money and resources, which demands a redistributive role of governments to secure the social contract of public health. The CSDH final report's analysis, peppered with stinging criticisms of globalisation and trade liberalisation policies in poorer countries, was considered by some analysts to be little short of revolutionary.
While these prominent UN reports were a positive sign of a shift in the right direction, there is still a long way to go before a PHC strategy can be put into practice. Although the WHO is again attempting to foster PHC, there are no adequate global initiatives and no sufficient coalitions of global institutions to address the social and economic determinants of health. The WHO itself is long criticised by civil society for being too ‘disease-focused' and supportive of selective, vertical interventions that undermine its own PHC vision. In a health policy landscape dominated by the more powerful World Bank, IMF and WTO, the WHO was conspicuously silent during the market-driven health sector reforms of the past few decades, and is often lambasted by analysts for its lack of transparency and accountability.
In recent years, an alternative world health report has been created by an alliance of civil society organisations working in the health sector in order to highlight the root causes of poor health and to critically appraise the actions of key institutions and governments (see the Global Health Watch 2008). What the alternative report makes clear is that sweeping reform of the UN agencies, in particular to free the UN from the influence of big business whilst giving it a stronger mandate to monitor the practices of transnational corporations, is a prerequisite to achieving ‘health for all'. In calling for the WHO to act in its proper capacity as a ‘global health conscience', the first Global Health Watch report stated; "Radical changes are needed within the organization - a wider variety of health professionals, more social scientists, economists, pharmacists, lawyers, and public policy specialists, more representation from developing countries, stronger regional offices run by experienced professionals, and greater transparency and accountability leading to a more collaborative way of working." Uncertainties therefore remain on how the WHO can transform its operations and build coalitions with other development agencies, and thus work towards the colossal reforms of the global economy that are envisioned by its Commission on Social Determinants of Health.
Various country-specific examples are often cited to show that good health can be achieved, even in the absence of economic growth and with only modest financial investment. Thanks to the documentary Sicko by Michael Moore, Cuba is now well known for having a population as healthy as those of the wealthiest countries at a fraction of the cost, and for enabling any citizen to see a doctor in their own neighbourhood, as well as being the only country with a permanent medical corps on standby for overseas aid. Sri Lanka, Costa Rica and the Indian state of Kerala are further case studies that reveal how poorer countries with less inequity can have better health indicators than wealthier countries with higher levels of inequality. By focusing on the PHC common rules of socio-economic and health policy measures combined with public health and medical interventions, these countries have shown that redistributive and pro-equity policies are the foundation for health improvements. Kerala, for example, combined its curative and preventative health services with strategies on land reform, education, universal access to housing and sanitation, and effective social safety nets. The promotion of social and economic equity, as both the WHO Commission and civil society organisations have made clear, is central to respecting human rights obligations in health.
Inequitable distribution of resources
At the heart of the comprehensive approach of PHC is a commitment to redress the inequitable distribution of world resources that has increased over the past few decades of economic globalisation. In the last 15 years, as the WHO Commission reported, the poorest quintile in many low-income countries has shown a declining share in national income. If the World Bank and WHO had promoted a true form of socio-economic development through a transfer of resources from rich to poor countries, as opposed to reinforcing the privatised and medical-technical approach to healthcare favoured by transnational corporations, it is unlikely that the health catastrophe in many developing countries would have assumed such tragic proportions since the 1980s. With the WHO's renewed commitment to PHC has come a reinvigorated notion of the public sector's redistributive function, and it's ultimate responsibility for shaping national health systems. Yet still the dominant global discourse frames healthcare as a commodity rather than a basic human right, with the role of governments limited to supporting safety nets for those left outside a selective coverage of healthcare benefits.
For many, the WHO's attempt to foster PHC is inadequate given the prevailing macro-economic order, in which private actors like the Gates Foundation spend more than double the core budget of the WHO on healthcare in developing countries. Despite a renewed interest in PHC that spans the United Nations, academia, civil society and professional associations, there are also a wide range of different perspectives on its conceptual framework, with many questions remaining on how it can be developed into a long-term international strategy. In calling for a new world health order, however, many proponents of PHC together argue that a global alliance is needed to challenge the commercialisation and privatisation of healthcare in both the developed and developing world.
To achieve these aims, and to prevent PHC from again being dropped from the international policy radar, it is clear that civil society has a crucial role to play in educating public perceptions in favour of ‘health for all'. As argued by the People's Health Movement, only a coordinated international campaign can recast all global and national health sector reform initiatives in the light of the framework of ‘health as a right', including the reforms being pursued to achieve the Millennium Development Goals. They reason that the neoliberal model is unchecked by either national or global mechanisms of social regulation and redistribution, and universal norms need to be established in terms of minimum standards of essential health services - to all persons of all nationalities in all countries. In a political climate that is already questioning the ‘markets good, state bad' rhetoric following the stock market collapse of 2008, and in light of the renewed push for primary health care in the WHO, the time is ripe for a global civil society movement to turn ‘health for all' into an international priority.