Friday, September 12, 2008

Renaissance of Primary Health Care? Fact or Fiction?

A renaissance in primary health care

30 years ago, in the midst of the Cold War, health experts and policy makers from 134 WHO member states convened in the former USSR to attend a conference on international primary health care. On Sept 12, 1978, the Alma-Ata Declaration was signed, with the ambitious target of achieving “Health for All by 2000”.

In 1978, 2000 million people were estimated to have no access to adequate health care. There were vast inequalities between rich and poor countries, and between rich and poor populations within countries. The Alma-Ata Declaration revolutionised the world's interpretation of health.

Its message was that inadequate and unequal health care was unacceptable: economically, socially, and politically. Unfortunately, the goal of “health for all”, while a rallying call to action, was not met.

Theories for this failure abound: the vision for primary health care was politically unacceptable to some nations and so was marginalised; emerging health threats took precedence (no one imagined the global disease burden that HIV/AIDS would bring); and health priorities shifted (to the Millennium Development Goals [MDGs]).

30 years on, what is the relevance of the Alma-Ata Declaration in 2008? In short, primary health care is now offering global health a lifeline. Progress towards the MDGs has stalled. Weak health systems have restricted the success of efforts to improve maternal, newborn, and child health, and to reduce the disease burden from malaria and tuberculosis.

New epidemics of chronic disease threaten to reverse what small gains have been achieved. To get back on track, and to meet the MDGs by 2015, countries need to strengthen their health systems through the implementation of effective primary health care.

Now is the right moment to proclaim the urgent need for a renaissance in primary health care.

The continuing relevance of this 30-year-old Declaration is remarkable. Many of the challenges faced in 1978 remain, such as infectious diseases (eg, the ongoing threat of H5N1 avian influenza and HIV/AIDS), political instability and conflict (most recently seen in Iraq and Zimbabwe), and worsening poverty (the World Bank last month estimated that 1·4 billion people now live in poverty).

In recognition of this timely reawakening of interest in primary health care, this week's Lancet revisits, updates, and relaunches the key messages from Alma-Ata.

A series of eight papers begins with an analysis of modern primary health care, and issues such as implementing cost-effective interventions in low-resource settings and tackling the growing burden of chronic diseases. We publish an analysis of individual country progress since 1978, with possible lessons for those who have shown the least advance.

Involvement of communities in planning and implementation of health care (one of the main tenets of the Alma-Ata Declaration) is explored in the context of maternal, newborn, and child health, as are the roles of national policies and effective service integration, all foundations of a successful primary health care service. The final paper in the series looks to the future and provides a series of action points to revitalise primary health care,both nationally and globally.

WHO's vision for health—complete physical, mental, and social wellbeing—is the key to achieving Alma-Ata's prime goal of “health for all”. This week's research articles also focus on these three principles.

Stephen Tollman and colleagues discuss the challenges in managing chronic diseases in primary health care and the importance of providing adequate services to ensure physical wellbeing.

Atif Rahman and co-workers tackle mental health in Bangladesh, with a psychological intervention that can be delivered within communities to treat mothers with perinatal depression. And the importance of social development is shown by Luis Huicho and authors who present data from four countries highlighting the importance of health workers with shorter durations of training in providing vital care to people in low-resource settings.

Importantly, WHO, under Margaret Chan's effective leadership and together with her regional directors, has reaffirmed its commitment to primary health care. This revisioning of the principles of Alma-Ata is welcome and illustrates a new unity of purpose across global health institutions.

Political progress is also encouraging. Following the G8 meeting earlier this year, Japan has announced its own commitment to lead international initiatives to strengthen health systems.

Such renewed global interest in primary health care is promising. The need remains great and there are no shortcuts to success. But with refined international relationships, new and emerging technologies, and 30 years of experience, “health for all” need not be a dream buried in the past.

The right to the highest attainable standard of health can be a reality within our grasp.
The Lancet

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