ALMA ATA DECLARATION ‘The main goal of Governments and World Health Organization in the coming decades should be the attainment by all people of the world by the year 2000, a level of health that would permit them to lead a socially and economically productive life’ 51ST WHA in 1998 reaffirmed the declaration for the 21st century

By Dr Arshad Usmani Lahore, Paksitan Primary Health Care By Dr Arshad Usmani Lahore, Paksitan

Themes Leading to Alma Ata Changing theories of health & development: shift away from GNP as measure of development towards recognition of the need of social development Concerns about poverty & population control Increasing reliance upon alternative approaches to medical care model Success of CHWs & associated emphasis on community participation Revival of interest in public health; tackling causes of ill health rather than symptoms

PRIMARY HEALTH CARE PHC is essential health care based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford… It forms an integral part of the country's health system, of which it is the central function and the main focus, and of the overall social and economic development of the community

PRINCIPLES OF PHC Health Prevention & Promotion Equity Appropriate Technology Community Participation Intersectoral Coordination Decentralization*

COMPONENTS OF PHC Education concerning prevailing health problems & the methods of preventing & controlling them Promotion of food supply and proper nutrition An adequate supply of safe water and basic sanitation MCH including FP Immunization against major infectious diseases Prevention and control of locally endemic diseases Appropriate treatment of common diseases and injuries Provision of essential drugs

PHC: EXTENDED ELEMENTS IN THE 21st CENTURY Expanded options of immunization Reproductive health needs Provision of essential technologies for health Health promotion as defined in Ottawa Charter and endorsed by resolution (WHA 42.44) Prevention and control of non-communicable diseases Food safety and provision of selected food supplements0

PHC: Global Targets 1. All people in every country will have ready access at least to essential health care & to first-level referral facilities 2. All people will be actively involved in caring for themselves & their families, as far as they can, in community action for health 3. Communities throughout the world will share government’s responsibility for the health care of their members 4. All governments will assume the overall responsibility for the health of their people 5. Safe drinking water & sanitation will be available to all people (Cont …)

PHC:Global Targets (Cont …) 6. All people will be adequately nourished 7. All children will be immunizes against the major diseases of childhood 8. Communicable diseases in the developing countries will be of no greater public health significance in the year 2000 than they were in the developed countries in the year 1980 9. All possible ways will be applied to prevent & control non-communicable diseases & promote mental health through influencing the life styles & controlling the physical & psychological environment 10. Essential drugs will be available to all

GLOBAL HEALTH TARGETS Health equity: childhood stunting Survival: MMR, CMR, life expectancy Reverse global trends of five major pandemics Eradicate and eliminate certain diseases Improve access to water, sanitation, food and shelter Measures to promote health Develop, implement and monitor national HFA policies Improve access to comprehensive essential, quality health care Implement global and national health information and surveillance systems Support research for health

Obstacles to the Implementation of PHC Strategy Misinterpretation of the PHC Concept Misconception that PHC is a 2nd rate health care for the poor Selective PHC Strategies Resistance to Change Lack of political will Centralized Planning & Management Infrastructure

SELECTIVE PRIMARY HEALTH CARE PHC implies that if one cannot afford to offer universal coverage for even the most basic of health care, one could would offer treatment & preventive strategies for the few diseases identified as having the greatest threat to mortality, & which are amenable to prevention / cure at low cost.

Comprehensive PHC ADVANTAGES DISADVANTAGES Looks at total health care Involvement of community Covers all elements of PHC Ensures equitable distribution of resources Facilitates effective referral system Government goal DISADVANTAGES More costly to implement Takes long time to see impact Long time to process Lack of specialized treatment Expensive Inefficient referral system ???-- misuse

Selective PHC ADVANTAGES DISADVANTAGES Donor friendly Elimination of selected disease Easy to plan & implement Is focused & have more impact Easy to manage & measure output Require limited resources Improve quality of services DISADVANTAGES Disease rather than health oriented Doesn’t ensure equity Top down decision making Neglect other problems Leads to outbreak Resources (tight) might not be available for urgent needs (emergencies) Less community involvement– donor priority

EVALUATION OF HFA: 1979 - 1996 Reasons for slow progress towards HFA 1. Insufficient Political commitment to implementation of HFA 2. Failure to achieve equity in access to all PHC elements 3. The continuing low status of women 4. Slow socioeconomic development 5. Difficulty in achieving intersectoral action for health 6. Unbalanced distribution of, and week support for, human resources

Reasons for slow progress towards HFA (Cont….) 7. Widespread inadequacy of health promotion activities 8. Weak health information systems and no baseline data 9. Pollution, poor food safety, and lack of safe water supply and sanitation 10. Rapid demographic and epidemiological changes 11. Inappropriate use of, and allocation of resources for, high cost technology 12. Natural and man-made disasters

PHC: FROM ALMA- ATA TO 21st CENTURY PHC as an approach has provided impetus and energy to progress towards HFA Some progress has been made in ensuring access to the original eight PHC elements PHC remains valid as the point of entry into a comprehensive health care system Intersect oral action for health has not been fully achieved Reorientation of health services and personnel to PHC principles remains elusive Community participation takes time and dedication by all

New Trends that Will Influence Health in the 21st Century Widespread absolute and relative poverty Demographic changes: aging and growth of cities Epidemiological changes: continuing high incidence of infectious diseases; increasing incidence of non- communicable diseases, injuries and violence Global environmental threats to human survival New technologies: information and telemedicine services Advances in biotechnology Globalization of trade, travel and spread of values and ideas

GOALS AND TARGETS OF HFA An increase in life expectancy and in the quality of life for all Improved quality in health between and within countries Access for all to sustainable health systems and services   An initial set of targets will guide the implementation of the HFA policy and define priorities for action for the first two decades of the 21st century

THE PRINCIPALS OF HEALTH PROMOTION IN THE OTTAWA CHARTER (1986) Building a healthy public policy Creating supportive environment Developing personal skills Strengthening community action Reorienting health services  

PHC in the 21st Century: Policy Objectives to Reinforce the PHC Approach Make health central to development and enhance prospects for intersect oral action Combat poverty as a reflection of PHCs concern for social justice Promote equity in access to health care Build partnerships to include families, communities and their organizations Reorient health systems towards promotion of health and prevention of disease

Sustainable Health Systems: Some Essential Components   Attach greater emphasis to comprehensive quality health care throughout the life span Ensure equitable access to the original eight PHC elements Expand PHC elements in response to identification of new threats of health, and opportunities to tackle these threats

Essential Health System Functions that Complement and Support PHC Provide sustainable financing of PHC Invest in human and institutional capacity for health Optimize private and public sector support for PHC through appropriate regulations Strengthen research to support and advance PHC Implement global, national and local surveillance and monitoring systems