[Interview] 40 years after the Declaration of Alma Ata, a congress in Astana confirms the commitment that was made at that time: every human being is entitled to decent basic health care. Glo.be met public health expert prof. Bart Criel.
In 1978, a conference held in Alma Ata (the then Soviet Union) resulted in a strong political declaration on the right to basic or “Primary Health Care”. 40 years later, in October 2018, international health professionals returned to what is now Kazakhstan to take stock of the situation. The World Health Organisation (WHO) and the UN Children’s Fund (UNICEF) organised a conference in the capital Astana. Prof. Bart Criel (Institute of Tropical Medicine) was present.
What does basic health care mean?
Basic health care stands for accessible and thorough primary health care for everyone, for which purpose multiple disciplines are available. In Belgium, general practitioners form the pivot of the system, in close cooperation with (homecare) nurses, physiotherapists, psychologists, dieticians, social workers, informal carers, etc.
In the South, especially in low-income countries, this is usually the role of primary care centres. These are often run by paramedics, in collaboration with village health workers (Community Health Workers) who are embedded in the local community.
Provided that solid basic health care is available, 80 to 90 percent of the health problems can be treated. The remaining cases are referred to a hospital.
What exactly did the Declaration of Alma Ata imply?
The Alma Ata Declaration of 1978 placed social justice and solidarity at the centre. Everyone is entitled to high-quality basic health care and both individuals and communities should be involved in the decision-making process. The human being is central - not the disease.
Basic health care therefore goes beyond mere 'medical' care. The Alma Ata Declaration clearly stated that although decent primary care is essential, it is still insufficient to improve people's health. This can only be achieved by working together with other sectors such as food, education, housing, public hygiene, transport and social assistance. The psychological state and living conditions of people must also be taken into account.
The Alma Ata declaration was an important reference framework for the health sector and a guideline for policy, also in the rich North. The ambition was considerable: "Health for All" would be realised by 2000.
A decent primary care can only be achieved by working together with other sectors such as food, education, housing, public hygiene, transport and social assistance. The psychological state and living conditions of people must also be taken into account.
How far have we got today?
The glass is barely half full. Half of the world population still does not have access to essential health services. Every year, health costs force 100 million people into extreme poverty. At the current pace, we will not be able to achieve Sustainable Development Goal 3 (SDG3): 'Ensure healthy lives and promote well-being for all at all ages'.
Where are the difficulties?
Alma Ata introduces a radical approach that not everyone agrees with. It advocates, among other things, that, proportionately, more resources and personnel should go to primary care and less to high-tech medicine in specialised hospitals. The first line should be the central pivot in the health system, and the hospital should be at its service, not vice versa. This obviously requires radical changes in health care.
The training of health professionals must also be adapted. They need to learn more than to care for the sick. Prevention and promotion are equally fundamental, besides consultation and cooperation with professionals from other sectors.
In our country, life expectancy for 25-year-old men without a diploma is 7.5 years shorter than for men with a higher education diploma. The difference can go up to 18 years for the life expectancy in good health. In developing countries, these differences are even more pronounced.
This is unacceptable and indicates that health care is not equally accessible to everyone. Besides, the social position of people in society and unhealthy living conditions at home and at work play an important role. Such barriers must be tackled. This should also be addressed in the training of health professionals.
Are there any success stories?
Yes, but they remain too often exceptions to the rule. For example, the state of Tamil Nadu in India is doing noticeably better than most other Indian states. After all, Tamil Nadu made a clear political choice for basic health care. Costa Rica has strong and publicly funded primary care and can show off health indicators that a number of richer countries can only dream of. Thailand has made the courageous choice to develop universally accessible health care, largely with public money. The country serves as an international model.
Ghana and Ethiopia have a growing network of Community Health Workers who are well embedded in the local community. They listen to the people, pay them a visit, offer care and contribute to prevention, promotion and awareness raising. Well-being is given a lot of attention.
Change is therefore possible. In all the cases mentioned, a strong government took the lead.
Alma Ata advocates, among other things, that, proportionately, more resources and personnel should go to primary care and less to high-tech medicine in specialised hospitals.
What is the Institute of Tropical Medicine (ITM) doing to spread the ideas of Alma Ata? And the Belgian Development Cooperation?
In 2001, the ITM and the Belgian government already organised an international conference on the right to health care (Health Care for All). In 2008 and 2018, international symposia took place on the occasion of the 30th and 40th anniversary of the Alma Ata Declaration.
The Alma Ata philosophy has a central place in our postgraduate training programmes for health professionals from South and North. Basic health care is also an important part of our field research and in the numerous collaborations with institutions in Africa, Asia and Latin America. In my field of expertise, public health, Alma Ata remains a great source of inspiration. We try to 'translate' the principles that underpin basic health care into today's context.
The Belgian Development Cooperation is on the same wavelength. We must continue to insist on the same message in order to make younger generations enthusiastic as well.
How was the atmosphere at the congress '40 years after Alma Ata' in Astana? What are the main points of the resulting statement?
History was written in Astana. More than 2000 enthusiastic delegates from almost 100 countries came together to express their full support to the principles of Alma Ata. I find it heartwarming that Alma Ata's philosophy remains fully intact.
Of course, the new text was updated to reflect the reality of 2018. The world has changed substantially since 1978. Just think of the growing urbanisation, the increasing role of the private sector in the supply of health care, the advance of HIV/AIDS and chronic diseases such as diabetes, the rise of the Internet and new forms of communication, the increased empowerment of citizens worldwide, climate change...
But there was a lot of criticism as well. In Astana, for example, it was openly admitted that we have not sufficiently succeeded in achieving the target over the past 40 years. The director of UNICEF, Henrietta Moore, put it crystal clear: at the current pace, we will never be able to achieve the objectives. Today, far too many people are still deprived of basic health care. This is and remains unacceptable and requires a clear political commitment. We now have to walk the talk.
Basic health care is also an important part of our field research and in the numerous collaborations with institutions in Africa, Asia and Latin America.
To what extent will governments take the Astana statement into account?
The conference in Astana has created momentum. The new declaration on basic health care is an important political fact. The Director-General of the World Health Organisation, Tedros Ghebreyesus, will table it during the General Assembly of the United Nations in September 2019. Civil society also plays an important role. It must put pressure on governments from the bottom up and thus create the necessary political will.
What about primary health care in Belgium?
I graduated as a doctor in Leuven in 1981. Since then, a lot has changed for the better. The first line has gained a solid place in our health system. Today, general practitioners have grown into a fully-fledged academic discipline, gaining great respect in the public opinion. General practitioners also work much more closely with other primary care workers such as nurses and physiotherapists. The municipal councils do significantly more to promote health and prevention.
On the other hand, our health system remains far too strongly focused on 'curative care' (= care that is provided to patients who are consulting a health worker on their own initiative). In addition, specialised care in hospitals is rewarded much better financially than the low-threshold, global approach to health problems in the first line. This encourages the overconsumption of expensive specialised care, resulting in the waste of valuable resources. Moreover, health problems resulting from social disadvantage are still too often viewed through medical spectacles.
The health gap in our country between low- and high-skilled groups remains inexcusable. This problem requires a visionary, far-reaching approach and a guiding role for our governments. So there is still work to be done.