Introduction
Primary health care as a concept gained popularity following the 1978 International Conference on Primary Health Care jointly held by WHO and UNICEF at Alma-Ata (World Health Organization, N.d; Bryant, 2002). Although different definitions have been adopted by different people, it is the WHO’s definition that has reclaimed global acceptance which also has been used in numerous literatures. According to UNSW Research Centre for Primary Health Care (2010), World Health Organization (WHO), defined primary health care (PHC) in 1978 during the Alma-Ata declaration as one that seeks to extend the first level of the health system from sick care to the development of health, “protect and promote the health of defined communities and to address individual problems and populate health at an early stage.”
At the conference, PHC was adopted to describe the following components: “education about common health problems and what can be done to prevent and control them; maternal and child health care, including family planning; promotion of proper nutrition; immunization against major infectious diseases; an adequate supply of safe water; basic sanitation; prevention and control of locally endemic diseases; and appropriate treatment for common diseases and injuries” (Martens, 2010, p.1). Since it was adopted PHC has put more emphasis on prevention rather than cure. As the author stress, “it relies on home self-help, community participation, and technology that the people find acceptable, appropriate and affordable where also it combines modern, scientific knowledge and feasible health technology with acceptable, effective traditional healing practices” (Martens, 2010,p.1). Primary health care (PHC) plays a big and vital role in health care systems in many countries of the world (Gunn and Masellis, 2008, p.21).
PHC provides families with cost-effective services that in many cases are located close to home, thereby eliminating costly trips to specialists and hospitals. However, in most cases the coverage and effectiveness of primary care services are limited by insufficient resources and staff, erratic drug supplies and faulty equipment. On a larger scale, the functioning of primary health care has been affected by economic, socio-cultural and political aspects existing in a nation, which have direct influence on the society’s health and social environments. Therefore, this essay will investigate the above factors in accordance to the Declaration of Alma-Ata, assess, and explain the fundamental principles of Primary Health Care, the conditions that resulted into the Declaration of Alma-Ata and the possible reasons for the demise of the PHC movement. Information for the above questions will largely depend on literature review of case studies and journal analysis.
Primary Health Care: philosophy, strategy, or service?
Primary health care is believed to constitute three elements as the WHO definition of the concept may be adopted. First, PHC represents “a philosophical approach to health and health care characterized by a holistic understanding of health as wellbeing, rather than the absence of disease” (Rogers and Veale, 2000, p.11; National Primary Health Care Partnership, N.d). In this perspective, in order to experience good health, various aspects that affect human life must be taken care of, as well as ensuring that the needs of the community are addressed. Hence, “the locus of control is important in PHC; health services should reflect local needs and involve communities and individuals at all levels of planning and provision of services” (Rogers and Veale, 2000, p.11). Moreover, services and technology need to be at low cost that majority can afford after accepting them. Equity is another aspect that in great measure characterizes PHC where health services need to endeavor to address imbalance and prioritize services to the most disadvantaged.
PHC manifests a second element, which is strategic where PHC is seen to involve a set of strategies that are designed purposefully at creating health care, which is in line with the original philosophy. The “strategies include needs based planning of decentralized health services, offering management to local communities” (Rogers and Veale, 2000, p.11), and in this case, it is important to offer training to the communities in order to enhance health awareness, a program that can become successful through collective participation. To this extent, primary health care services require balance between health promotion, preventive care and illness treatment and this can be achieved through use of a team selected from various disciplines such as medical, nursing health, community work, population health, health promotion workers and educators. Therefore, primary health strategies can be summarized to include needs-based planning, decentralized management, education, intersectoral coordination and cooperation, balance between health promotion, prevention and treatment; and multi-disciplinary health workers (Rogers and Veale, 2000, p.11).
PHC also provides services within the first level of health care, thus must be strategically established in areas which are within the reach of the society. At the same time, geographical and financial obstacles, which are most likely to be present may be counteracted through ensuring that the services are easily accessible by all, both in terms of logistics and affordable rates.
On further note, PHC services should be administered through active involvement of diverse stakeholders and should include all the relevant health care services as required by the society. In summary, primary care services constitute the following characteristics: locally based, affordable and accessible, well-integrated, health care teams, health promotion, disease prevention, illness treatment and rehabilitation services (Rogers and Veale, 2000, p.12).
Socio-economic conditions that influence primary health care
Inequality experienced both in social and economic spheres have been described as harmful to the health of any society. “The effects become more harmful especially when the society appears to be diverse, multicultural, overpopulated, and undergoing fast but unequal economic growth” (Deogankar, 2004). Deogankar further notes that there exists unchallenged association between social equality, social integration, and health; and that the impact of social and economic inequality on health is great. Poverty, which is the product of social and economic inequality in society creates a lot of negative effects to health of any given population since almost all indicators of health are in one way or the other influenced by the standards of living in any particular given region (Deogankar 2004).
Amin, Shah and Becker (2010), analyzing the socioeconomic factors and how they influence accessibility to maternal and child health care services in Bangladesh, noted that various factors were responsible for the inadequacy been experienced in using maternal and child health services in most rural areas of developing nations. The factors identified included “the availability, accessibility, and quality of services as well as the characteristics of the users and communities in which the users live” (Amin, Shah and Becker, 2010). Further, these factors could be visible in instances such as distance to health services, cost of services, technical qualifications of health professionals, socioeconomic situation of the people and also the women’s’ independence in household decision making processes (Amin, Shah and Becker, 2010).
Carrying a similar study in Nigeria on the major obstacles to accessing primary health care services, Katung (2001) found out that out of 357 women interviewed, high cost of drugs which constituted 29 per cent, service charges at 19per cent, easy accessible to traditional medicine practitioners at 39per cent and problems in getting transport to a healthy facility at 30per cent. Showing how health and economy are related, Ruger, Jamison and Bloom (2001) observe that health and health care systems interrelate with the economy in many ways. For instance, their findings shows that access to higher incomes by population enables the population to experience health benefits as they are able to purchase food, have adequate sanitation, housing and education and also have incentives for fertility limitation (Ruger, Jamison and Bloom, 2001, p.2).
Central features and principles of Primary Health Care
There are five identified basic principles of PHC, which include the following.
- Equitable distribution of PHC – this principle articulates that PHC need to be provided to all people in equal amount in the community without discriminating basing on gender, age, caste, color, urban, rural, and social class (Community Health Nursing 2010).
- Community participation in order to achieve PHC – this principle states that the community needs to be given a chance to participate in decision-making process regarding policies to address their health issues. In addition, communities need to be mobilized in finding solutions to complicated social problems and there need to be “mass health campaigns and promotions to battle out health problems” (Student Nurses Community 2009).
- Self-reliance – under this principle, the community is to be empowered in order to generate support for various health programs, community to utilize local available resources, programs to train community leaders and other key management skills to be initiated and establishment of income generating projects, cooperatives and small scale industries (Student Nurses Community 2009).
- Multi-sectional approach – according to this principle, appropriate health for any community cannot be achieved in isolation of interventions that are found only in health sector but it should incorporate other sectors that are equally important in attaining proper community health and self-reliance. The key sectors that can be incorporated include agriculture, irrigation, education, housing, animal husbandry, public works, communication, rural development, industries, and voluntary organizations (Community Health Nursing 2010).
- Utilizing appropriate technology, whereby the principle outlines that technology that a community adopts should be accessible, affordable, and feasible and one that is acceptable by the culture of the community (Community Health Nursing 2010). On the other hand key features of PHC include: primary health care should be an integral part of the country’s health system; the created health system should focus on priority; the methods and technology adopted should be scientifically sound; at the same time the technology and methods adopted should be culturally sensitive; primary health care should favor and promote an element of equity; there should be community participation in provision of basic health; and the primary health care system should be sustainable and self-reliant (Marafa, n.d).
Primary Health Care Movement (PHC)
Context in which the PHC movement began
Prior to 1978 conference there were numerous evidences that the health status of poor people was deteriorating especially those living in rural villages. As such there was an urgent need to reallocate adequate health related expenditure that could be used in providing the necessary, low-cost health services to the poor people in world. Therefore, Declaration of Alma-Ata was adopted after it became evident that there was gross inequality in the health status of the people, more so considering that the gap between the developed and developing nations keeps on widening; however, efforts are necessary to bridge this gap especially in political, social and economic environments. The conviction of the participants was that, ”comprehensive approach whereby primary health care was seen as the key to achieving an acceptable level of health throughout the world in the foreseeable future as a part of social development and I the spirit of social justice” (Anon N.d). At the same time, health of individuals was seen to be a fundamental human right and any effort to achieve the right health was to be the most important world-wide social goal and in realizing it there was need for collaboration of key sectors of economy, social together with the health sector.
Implementation and its demise
During the Alma-Ata conference, access to basic health services was affirmed as key fundamental human right that was not supposed to be denied to any individual. But when evaluation of the Declaration is done today, it is a bitter reality that almost more than 30 years later, many people in developing countries still do not have equitable access to basic health services (Hall and Taylor, 2002, p.1); and in other places, the gap is even widening at an alarming rate. PHC has not realized its goals for a number of reasons that range from the fact that key promoters in first world countries denied to accept the involvement of communities in first-hand decision-making process in health care programs. Also, changes in economic ideology resulted into the replacement of PHC by ‘Health Sector Reforms’ that were largely designed based on forces of the market and the economic benefits of better health (Hall and Taylor 2002, p.1). Further Hall and Taylor (2002) note that as soon as the Alma-Ata conference was over, PHC was under attack whereby “Politicians and aid experts from developed countries could not accept the core PHC principle that communities in developing countries would have responsibility for planning and implementing their own healthcare services.”
According to Stephen Gillam, the PHC failed in its initial stages of formation when early efforts at primary health care expansion I the late 1970s were overtaken in mot parts of the developing world by major factors that included economic crisis, sharp reductions in public spending, political instability and emerging disease (Gillam 2007, p.1). Further, the author observes that the social and political goals of Alma-Ata spurred early ideological opposition hence were never fully accepted in market-oriented, capitalist nations. Moreover, in many health systems, a medical model of primary care dominated by professional stakes resisted attempts to expand community-level health workers with poorer training. “Selective primary health care and packages of low cost interventions such as GOBI-FF(growth monitoring, oral rehydration, breast feeding, immunization, female education, family spacing, food supplements) in some way distorted the spirit of Alma Ata” (Gillam 2007, p.1).
Other factors identified to have hastened the demise of PHC include failure in most nations to provide even limited packages, together with explosion of vertical initiatives to tackle the particular world health problems contributed to death of PHC; geographical and financial inaccessibility. In addition, limited resources, erratic drug supply, and faulty equipment have influenced many countries’ PHC services to be largely limited in their availability, accessibility and even impact (Gillam 2007, p.1).
According to Lawn et al (2008), the major setbacks to the Alma-Ata declaration came from the Cold War politics, which stifled the Alma-Ata momentum. On the same measure during that period the global development policy was largely dominated by neoliberal macroeconomic and social policies, for instances the developing countries had to accept the harsh reality of the structural adjustments programs (SAPs) which resulted to reduction in budget deficits through devaluations of the local currency and cuts to public spending in the sectors of health, education and transport. These policies affected the performance of health systems in negative ways such as inadequate supply, chronic under funding of key public health infrastructure, reductions in the number and quality of health personnel and the worsening access to health care for the poor. These situations denoted negatively to the Alma-Ata goals (Lawn et al. 2008, p.4).
Conclusion
The declaration of Alma Ata helped to entrench the thought of providing health care as being a sign of enhancing human right, with its goals being to reduce health inequalities especially for the poor people since concerns have been that people affected by poverty are disadvantaged as they live in deplorable conditions. In addition, their economic status cannot allow them to enjoy the benefits of the basic services on offer. Various factors have acted as barrier to the attainment of key goals of the declaration but as the recent trends indicate primary health care goals will be achieved in future if key stakeholders come together and pursue common goals. For instance, what is evident today is the fact that governments, donors, and even private organizations are in a positive way talking about working together and major health agencies who in the past have acted in competition are now grouped together in a new outfit known as Health 8 and from this cooperation and coordination is seen to be increasing. Moreover, funding is gradually increasing and is shifting from selective global funds towards health system strengthening through sector-wide approaches. Therefore, as a result of recent numerous programs and policies, there is wide hope that health care will reach many of the poorest families and this will be achieved more easily by revitalizing the principles of Alma-Ata.
Reference List
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