A contemporary primary health care policy needs renewed commitments, which, while affirming the fundamental positions of 40 years ago, also takes into account today’s realities. We have to address the obstacles that have blocked implementation of primary health care since the Alma-Ata Declaration in 1978.
Therefore, to embed primary health care in today’s social and political processes it must:
- include public health interventions, a working referral system to higher secondary and tertiary levels of care based on need, as well as health prevention and promotion, that is, it is more than a basic package of care for people rendered poor
- be financed through public sources to ensure universal and equitable access
- address the socio-economic injustices underlying a system of health care that does not provide equitable access
- address the social, political, economic, and environmental determination of health including climate change
- address international economic inequalities including the far reaching effects of military conflicts
- empower communities, especially the most disadvantaged, so that they can act as protagonists in improving their health and their livelihoods
- use technology in a manner that is sensitive to local needs and contexts
- combine traditional and modern medicine to maximize benefits to patients
- embed policies and interventions in the human rights framework, recognizing and supporting the role of beneficiaries as claim holders with an internationally sanctioned right to hold to account duty bearers in bringing about changes needed in the provision of health care services.
Neoliberal globalization presents threats to health such as increases in the trading of unhealthy ultra-processed foods. International trade agreements are enhancing the role of transnational corporations within the health and nutrition sector, and intellectual property rights attached to medicines restrict their use by people rendered poor. Unfair trade terms in agriculture devastate the livelihood and health of subsistence farmers. These pro-wealthy policies seriously undermine the ability of low-income countries to develop and maintain primary health care or functioning health systems. It also leaves them dependent on overseas development assistance. These negative aspects of globalization are major obstacles to the achievement of Health For All—Now.
Privatization and commercialization of health systems are increasing globally. The new market economy in health undermines public sector health systems, exacerbates inequalities, and brings about growing disparities in access to health care. Strengthening the public health sector and the ‘public ethic’ of service provision is urgently needed.
The development of technology for the treatment of diseases is oligopolistic and ignores diseases affecting those rendered poor. Moreover, many of the technologies around in 1978 still remain unavailable to the poorest people 40 years later, because of unfair intellectual property rights rules. Primary health care cannot be conceived without universal access to essential medicines—with most of them made available as generics. Patent regimes that are primarily market-oriented must be challenged; countries must be supported to make full use of the flexibilities in international treaties to ensure essential medicines are available to all who need them.
Vertical health care programs continue to dominate and fragment health care systems. They draw scarce resources away from primary health care and treat patients as passive recipients of care, ignoring the social, economic, and political determinants of health. When focused programs are needed, they must be integrated into comprehensive primary health care.
The planning and execution of primary health care must be genuinely community-driven and community-centered. Crucially, the role of community health workers must be re-invigorated so they can address the looming health worker crisis. Community health workers can be key in meeting core human rights principles, that is, involving people in their communities and encouraging them to claim their right to health entitlements, particularly in relation to the social determinants of health.
The critical shortage of health workers must be addressed urgently and low- and middle-income countries need to be compensated for the losses suffered by their health systems as a consequence of the migration of their health workers to high-income countries.
Significant investments in primary health care do bring about important changes—Brazil and other countries are evidence. But significant investment is necessary for primary health care policy to succeed. WHO has a serious important role to play in urging states to invest in their health systems.
Forty years since Alma-Ata and we are still a long way off from Health for All. Health for many remains threatened, because of an unjust, unfair, and unsustainable process of development. Inequalities have increased between and within countries; access to food, education, water, shelter, sanitation, and employment are still grossly inadequate for too many. The challenges of globalization, poverty, gender inequality, and social exclusion continue. Finally, communicable and non-communicable disease epidemics challenge health systems already stretched to the limit while war, violence, and conflict abound.
We must look to WHO to provide not only the technical, but also more decisively the moral and political leadership needed to lead a call for change. It has to reclaim its legitimate position as the global leader in promoting policies that lead to a healthy world. Specifically, WHO must support states to adopt policies that promote primary health care as an integral part of their human rights duties—and fulfillment of the right to health includes fulfilling rights to the social determinants of health and to all other interdependent rights. But states must also up their financial contributions to fund WHO and must resist the influence of encroaching public-private partnerships and multi-stakeholder platforms.
The commemoration of the 40th anniversary of Alma-Ata is not a time to blame, point fingers and focus on failings; it is a time to move forward, to raise our hands, and be heard. With founded worries I am looking towards the forthcoming Astana meeting on primary health care in October.
Claudio Schuftan, an organzing member of the People’s Health Movement, is based in Saigon. The views here expressed do mirror those of PHM.