Audrey R. Chapman
The fortieth anniversary of the Declaration of Alma-Ata comes at a time when primary health care is once again receiving some well-deserved attention.[1] Target 3.8 of the Sustainable Development Goals to achieve universal health coverage has energized many countries to make a greater effort to progress toward that goal.[2] Four decades ago the Declaration of Alma- Ata identified primary health care as key to the attainment of health for all. It still is. Unlike tertiary health care, comprehensive primary health care is both pro-poor and pro-rural. Comparative studies have shown that primary health care is a central feature of national health systems delivering high quality care at an affordable cost.[3]
At a time when there is a great deal of interest in achieving universal health coverage, it is relevant to note that there is historical evidence of the importance of primary health care as a foundation for the transition toward universal health coverage. The 2002 Thai health system reform that led to universal health coverage was preceded by, and able to leverage, 15 years of health center development that established primary health centers in rural areas.[4] Brazil is another country in which the development of primary health care has been central to efforts to provide universal access and comprehensive health care as well as to coordinate and expand coverage to more comprehensive levels of care.[5] The early development of a comprehensive network of rural primary health care clinics during the colonial period also played an important role in enabling Sri Lanka to show the possibilities of a poor country providing good health at a low cost.[6] Its strong primary health care network has also been central in Sri Lanka’s movement toward universal health care.[7]
The Declaration of Alma-Ata strongly affirms that health is a fundamental human right and that governments have a responsibility for the health of their people.[8] It set a goal of the attainment by all peoples of the world of a level of health that would permit them to lead socially and economically productive lives by the year 2000 and identified primary health care as key to attaining this target.[9] While this goal was not achieved, primary health care is still central to the progressive realization of the right to health.
The visionary approach to primary health care in the declaration includes attention to the social determinants of health as well as to providing basic health services. It characterises primary health care as including at least a minimum education regarding the prevailing health problems affecting a community and the methods of preventing and controlling them; promotion of food supply and proper nutrition; and an adequate supply of safe water and basic sanitation.[10] Twenty two years later the UN Committee on Economic, Social and Cultural Rights re-conceptualized the right to health, defined in Article 12 of the International Covenant on Economic, Social and Cultural Rights, in its General Comment 14 “as an inclusive right extending not only to timely and appropriate health care but also to the underlying determinants of health.”[11] The list of the underlying determinants of health in General Comment No 14 reflects the influence of the Declaration of Alma-Ata. The discussion of the importance of the social determinants of health in the declaration also anticipated WHO’s Commission on Social Determinants of Health’s 2008 report on achieving health equity through action on the social determinants of health.[12]
Given the importance of primary health care, what is needed to invigorate efforts to provide universal primary care as envisioned by the declaration? It would be helpful for the human rights community, particularly those working on the right to health, to recognize the importance of comprehensive primary health care and actively promote efforts towards its achievement. Unfortunately, General Comment 14 did not adopt the Declaration of Alma-Ata’s primary care approach. The Committee on Economic, Social and Cultural Rights’ earlier General Comment 3 had identified primary health care as a minimum core obligation required to implement the International Covenant on Economic, Social and Cultural Rights, and the only one relating to health.[13] Although the paragraph in General Comment 14 preceding the enumeration of the core obligations related to the right to health references General Comment 3 and the Alma-Ata Declaration, the lists of the core obligations and the obligations of comparable priority do not.[14] In contrast, the article in the Convention on the Rights of the Child dealing with the right to health links “the provision of necessary medical assistance and health care to all children with emphasis on the development of primary health care.”[15]
To achieve the vision of primary health care in the declaration there is a need to define an agreed upon detailed list of the health services and essential medicines that all primary care facilities should be expected to provide. The Declaration of Alma Ata identifies this list of health services as essential to primary health care: maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs.[16] While the list is a beginning, greater specificity is still needed. Which types of maternal and child health care should be provided? How inclusive should the treatment of common diseases be? Should all medications on the government’s essential drugs list be available at all primary health centers all of the time, as WHO recommends? Now that noncommunicable diseases constitute the leading cause of global mortality, should primary health centers be expected to offer treatments for these diseases even though some require advanced equipment and the medications for many are expensive? In 2015 the World Health Assembly adopted a resolution identifying emergency and essential surgical care as a component of universal health coverage and urged member states to integrate a core set of emergency surgical procedures into primary health care.[17] Is this feasible, particularly in low- and lower-middle income countries?
Effective universal primary care will also require many countries to infuse more money into funding the health system and to rebalance priorities so that a larger share goes to primary care. Most low-income and many middle-income countries consider health to be a low priority sector and do not devote sufficient resources to develop an effective and equitable health system. In addition, primary health care often receives very little money compared with secondary and tertiary health care. In this regard, it is disappointing that the draft Astana Declaration on Primary Health Care that will be considered for adoption by WHO in October 2018 affirms the importance of primary health care and the need to put primary care at the center of universal health care, but does not deal with the resource issue satisfactorily. The draft text states, “We will allocate sufficient resources to research, evaluation and knowledge management, promoting the scale up of effective strategies for multi-sectoral action, public health and primary care.”[18] The text needs to be forthright asking for a commitment to invest sufficient resources in primary health care to make essential medicines and a full range of needed health services available to every person as the grounding for universal health care.
Audrey R. Chapman is Healey Professor of Medical Ethics, UConn Health. Please address correspondence to achapman@uchc.edu.
References
[1] Declaration of Alma-Ata, International Conference on Primary Health Care (1978). Available at: http://www.who.int/publications/almaata_declaration_en.pdf.
[2] United Nations, Transforming our World: the 2030 Agenda for Sustainable Development, Resolution adopted by the General Assembly on 25 September 2015, UN Doc. A/RES/70/1.
[3] S. Rawaf, J. De Maeseneer, and B. Starfied, “From Alma Ata to Almaty: A New Start for Primary Health Care,” The Lancet 372 (2008) pp. 1367-1375.
[4] A. Sengupta, “Universal Health Coverage: Beyond Rhetoric,” Municipal Services Project, Occasional Paper No. 20 (2013), pp. 15-16.
[5] J. Paim, C. Travassos, C. Almeida, et al., “The Brazilian Health System: History, Advances and Challenges” The Lancet 277 (2011): p. 1788.
[6] P. Gottret, G. J. Schieber, H. R. Waters, eds. Good Practices in Health Financing: Lessons for Reforms in Low- and Middle-Income Countries (2008) Washington, D.C.: the International Bank for Reconstruction and Development/the World Bank.
[7] A. Chapman, “Sri Lanka and the Possibilities of Achieving Universal Health Coverage in a Poor Country,” Global Public Health forthcoming 2018.
[8] See note 1, Section I.
[9] See note 1, Section V.
[10] See note 1, Section V11, 3.
[11] Article 12, International Covenant on Economic, Social and Cultural Rights, General Resolution 2200 (XXI) 21 UN GAOR Supp. No. 16 at 49, UN Doc. A/6316, 1966; Committee on Economic, Social and Cultural Rights, General Comment 14, The Right to the Highest Attainable Standard of Health, UN Doc. E/C.12/2000/4 (2000).
[12] Commission on Social Determinants of Health, Closing the gap in a generation: Health equity through action on the social determinants of health (Geneva: World Health Organization, 2008).
[13] Committee on Economic, Social and Cultural Rights, General Comment 3: The nature of States parties obligations (Art. 2, para.1), United Nations Human Rights Website, Treaty Database, http://www.unhcr.ch/tbs/doc.nsf/(Symbol)94bdbaf59b43a43c12563ed0052b664?Opend…
[14] See note 11, Committee on Economic, Social and Cultural Rights, paras. 43 and 44.
[15] United Nations General Assembly, Convention on the Rights of the Child, adopted on 20 November 1989, U.N.Doc. A/RES/44/25.
[16] See note 1, VII, 3.
[17] World Health Assembly 2015, resolution 68.15, Strengthening Emergency and Essential Surgical Care as a Component of Universal Health Coverage.
[18] WHO, Astana Declaration on Primary Health Care: From Alma-Ata towards Universal Health Coverage and the Sustainable Development Goals. 28 June 2018. Available at http://www.who.int/primary-health/conference-phc/DRAFT_Declaration_on_Primary_Health_Care_28_June_2018.pdf.