Over 40 years ago in 1978, the world was still as unequal as it is today. There was a huge gap between the haves and the have-nots, and the majority could not access basic services including in health.
On September 6-12 of that year, the World Health Organisation and the United Nations Children’s Fund, Unicef, organised a global conference which would attempt to give people the power, dignity and the right to make decisions about their own health.
This was the first International Conference on Primary Health Care, attended by delegates from 134 governments, representatives of 67 United Nations organisations, specialised agencies and non-governmental organisations.
Held in Kazakhstan, then Kazakh Soviet Socialist Republic, Capital, Alma-Ata (today Almaty) the conference led to what came to be known as the Declaration of the Alma-Ata.
It was a forward-thinking declaration of which Kenya was one of the first nations to sign. It expressed the need for urgent action by all governments, health and development workers, and the world community to protect and promote the health of all people.
From the onset, the conference recognised and reaffirmed that health is not merely the absence of disease or infirmity, but a state of complete physical, mental and social wellbeing. As is espoused in Kenya’s 2010 Constitution, the Astana declaration recognised that health is a fundamental human right whose attainment calls for involvement from all sectors of society and not only the health sector.
The delegates declared that it was unacceptable that there was gross inequality between the health status of people within the countries and also between the developed and the developing worlds.
This, the declaration noted, can be rectified by a new ‘economic world order’. They called upon the governments to invest in adequate health and social measures.
In retrospect, the Alma-Ata was very ambitious in its call to the governments and the international community for an attainment of health for all by the year 2000.
But the delegates did not think this was unattainable. They strongly believed that Primary Health Care was the vehicle that would lead people to wellbeing, and thus economic freedom and world peace, especially in the then Cold War era.
They thus described Primary Health Care, PHC, as essential healthcare 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 could afford to maintain at every stage of their development, in the spirit of self-reliance and self-determination.
It forms an integral part, both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. PHC is the first level of contact of individuals, the family and community with the national health system, bringing healthcare as close as possible to where people live and work, and constitutes the first element of a continuing healthcare process.
In a nutshell, Primary Health Care is not treating of diseases or conditions, but its main attribute is prevention. It is personal, that is individual, but also community oriented. Today, when you walk to many health centres or hospitals, you will be tested and treated for the specific disease that took you there. But PHC envisions an integrated and comprehensive system, which is promotive, preventive, then curative with time, and rehabilitative.
The services are closer to the people, that is Level One (Kenya has six levels – Level One; community services, Level Two, dispensaries and clinics; Level Three, health centres, maternity and nursing homes; Level Four, sub-county hospitals and medium-sized private hospitals; Level Five, county referral hospitals and large private hospitals; and Level Six, national referral hospitals and large private teaching hospitals) of quality and which emphasis on early diagnosis.
In Kenya today, most people suffering from, say cancer, get diagnosed at the late stages, which call for expensive specialised care. The Alma-Ata, even 40 years ago, realised the inequity in health care, but in PHC it envisioned a scenario where everyone has access to quality health services, where the providers are efficient and motivated and working in a supportive environment.
It also called for the empowerment of communities in all areas, from food supply to nutrition to access to clean drinking water, education on family planning, immunisation, and access to safe maternal and child healthcare.
Fast forward to 2018…
In the following decades, countries launched their versions of Primary Health Care, with 191 then UN member states committing to the UN Millennium Development Goals in 2000, to run until 2015. Though the MDGs did not explicitly define PHC, three of the eight goals touched on health as envisioned in the Alma-Ata Declaration, with goals 3: Focusing to reducing child mortality; 4: To improve maternal health and 5: To combat HIV/Aids, malaria and other diseases.
In fact, goals 7 and 8 are also in a way related, as 7 was designed to ensure environmental sustainability while 8 called for partnerships and collaborations.
Primary health is preventive and promotive, so a clean environment keeps off diseases like malaria, typhoid and bilharzia. Goal one called for elimination of extreme poverty and hunger. Hunger causes malnutrition, which can lead to death. Hungry people feel undignified and thus are not mentally healthy or fit.
Between 1978 and 2015, the world made great strides against several leading causes of disease and death, increased life expectancy while reducing infant and maternal deaths. Though the cure or the ultimate vaccine against HIV is yet to be discovered, the world has turned the tide against this dangerous virus, mostly through biomedical preventive measures. In this period, the world has halved malaria deaths.
Unfortunately, health inequalities still persist. In 2015, at the cusp of MDGs, the world again went to the drawing board after reviewing the MDGs. On seeing that much remained to be done, it redesigned the goals to the current 2030 Agenda, the Sustainable Development Goals. Of this, Goal 3 captures health and well-being, with the UN member states agreeing that Universal Health Coverage is key to achieving this. Led by the World Health Organisation, most countries have committed to UHC by 2030.
At the heart of this, the nations agree that Primary Health Care must be the driving force towards achieving Universal Health Coverage. This was the reason the world again met in Kazakhstan, 40 years after the Alma-Ata Conference, this time in Astana the capital of this transcontinental country straddling Asia and Europe.
Held on October 25-26, 2018, and bringing together UN member states, health ministers and the international community, the Global Conference on Primary Health Care discussed the achievements made and renewed its commitments to primary healthcare for the 21st century, geared to achieve Universal Health Coverage by 2030.
The Ama-Ata conference gave birth to the Astana Declaration which pledged to make bold political choices for health across all sectors, build sustainable primary healthcare, empower individuals and and align stakeholder support to national policies, strategies and plans.
So, had the world achieved the Alma-Ata goals on PHC and what is the difference or similarity with the Astana Declaration?
Tedros Adhanom Ghebreyesus, the director-general of the World Health Organisation, speaking to the East African during the conference, better espoused this question. He said the Alma-Ata Declaration lacked in some areas as it came to life when the world was divided, thus some nations adopted it while others didn’t.
“Its implementation was uneven… the Alma-Ata Declaration was not “health for all” but it was “health for some”. People are saying, let us move away from that.” He added that there is confusion that primary healthcare is only for poor countries.
“Not at all; it is actually important for high income and middle-income countries as well. It is for all, for the whole world. The best and smartest investment is in Primary Health Care. Its capital investment is low and the return on investment is high.”
Later, at the WHO World Health Assembly, held in May in Geneva 2019, with the theme: Primary Healthcare as the tool for achieving #HealthForAll, Dr Tedros re-emphasised the importance of the Astana Declaration: “The world has made great progress towards Universal Health Coverage. The Declaration of Astana, endorsed by all 194 member states last year, was a vital affirmation that there will be no UHC without primary healthcare.”