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Role of the World Health Organisation

The Alma-Ata Declaration of 1978 on Primary Health Care together with the slogan of Health for All by 2000 AD is considered one of the most significant public health initiatives of the 20th century. The 30th anniversary of the declaration provides an opportune time to revisit its history and arrive at some fresh perspectives. This article examines the role of World Health Organisation in developing countries as a directing and coordinating authority on international health, and in providing impartial, evidence-based technical information.

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Role of the World Health Organisation

Indira Chakravarthi

The Alma-Ata Declaration of 1978 on Primary Health Care together with the slogan of Health for All by 2000 AD is considered one of the most significant public health initiatives of the 20th century. The 30th anniversary of the declaration provides an opportune time to revisit its history and arrive at some fresh perspectives. This article examines the role of World Health Organisation in developing countries as a directing and coordinating authority on international health, and in providing impartial, evidencebased technical information.

Indira Chakravarthi (indira.chakravarthi@ yahoo.co.in) is a public health researcher based in Delhi.

Economic & Political Weekly

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november 22, 2008

T
he World Health Organisation (WHO), the specialised health agency of the United Nations (UN), is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical information, and monitoring and assessing health trends (http:// www.who.int/about/en/). Of late there has been plenty of critical writing about the WHO, such as about its transformation/marginalisation in international health (Brown et al 2006; Ollila and Koivusalo 2002; Navarro 2001), its internal problems, the need for it to refocus (Katz 2007; Levine 2006), and how it generates its evidence-based guidelines (Cheng 2007). The 30th anniversary of the Alma-Ata Declaration of September 1978 by the World Health Assembly (the governing body of WHO) provides an opportune time to revisit its history and come up with some fresh perspectives. Against this background this article examines how the WHO has been fulfilling its role as a directing and coordinating authority on international health, and of providing impartial, evidence-based technical information.

1 The Idea of Primary Healthcare

The Alma-Ata Declaration of 1978 on P rimary Health Care, together with the slogan of Health for All by 2000 AD (HFA) proposed at the 1976 World Health

30TH ANNIVERSARY OF ALMA-ATA

Assembly, is considered to be the major public health initiative of the 20th century. It was made at the International Conference on Primary Health Care, jointly sponsored by two UN organisations, the WHO and the United Nations Children’s Fund (UNICEF), and held at

Alma-Ata, Kazakhstan, in the erstwhile Union of Soviet Socialist Republics (USSR). Alma-Ata has since come to be identified with certain basic tenets of public health, such as those of primary health care (PHC), universal access to healthcare, and of health for all.

There are several explanations of the emergence of the concept of primary health care in the 1960s and 1970s, and its subsequent adoption by the WHO. The emphasis on PHC in the Alma-Ata Declaration was an outcome of the failures of the traditional vertical programmes concentrating on specific diseases, as well of the criticism of the assumption that “western medical systems” would meet the needs of the common people in developing countries. The 1960s and 1970s was a period of social ferment, of several movements, including the radical science movement in the west. Radical political critiques arose from several quarters, such as from the anti-war movement, from the organised left, and from the women’s health movement. There were calls and movements for alternative technologies, for “appropriate” technology, “intermediate” technology, as also opposition to ideologies propounding a “technological imperative”. This was also the time of McKeown’s much-cited thesis relating the improved health of p opulations to better living standards and Illich’s discourse on the negative effects of modern medicine. There was questioning of the hospital-centred bio-medical model

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of healthcare services from many quarters. In the developing countries, the 1950s to 1970s witnessed the adoption of population control programmes and the transfer of technology from the developed countries (scientific and technological a ssi stance as instruments to resolve world poverty).

In the same period, Christian medical missionaries trained villagers as health workers, and the Cultural Revolution in China implemented the concept of “barefoot doctors”, with large-scale expansion of rural medical services there. In India, too, villagers were trained as community health volunteers and birth attendants, and indigenously formulated programmes were implemented.

The priority of the WHO in the 1950s and 1960s was the eradication of malaria (advocated by the US government), and control of certain other diseases. Criticism of the malaria eradication programme began in the 1960s from those who felt that the development of health services was suffering due to the attention being given to malaria. The Soviets took the lead in calling for a review, which took place in 1969 and essentially led to the abandonment of the eradication programme.

An interesting account of “the role of influential individuals and their political and health ideologies in the events leading up to the Alma-Ata Conference in 1978” is provided by Litsios, who held official positions in WHO from 1967 to 1980 (Litsios 2002). According to him, the Alma-Ata agenda began to unfold at the 1970 World Health Assembly, where the Soviets proposed and the Assembly adopted a resolution, WHA 23.61, “Basic Principles for the Development of Health Services”. The Soviet delegate to the WHO is considered to have “played a prominent part in pushing for WHO to give high priority to health services” (Litsios 2002: 710). In 1974 he proposed that an international conference be organised under WHO auspices “for the exchange of experiences as regards the development of national health services”, and in 1975 pushed the adoption of a resolution, which considered an international conference desirable. The WHA passed a resolution to hold an International Conference on Primary Health Care to exchange experiences on the development of primary healthcare within the framework of comprehensive national health systems and services, especially as regards the aspects of planning and evaluation. The resolution 28.88 defined primary healthcare as the point of entry for the individual to the national healthcare system and as an integral part of that system, related closely to the life patterns and needs of the community it serves and fully integrated with the other sectors involved in community development.

As early as in the 1969 World Health Assembly there was a call to develop rural health systems and to integrate malaria control into general health services. Between 1971 and 1975 several activities were initiated within WHO around the issue of development of Basic Health Services (BHS). In 1973 the WHA called upon WHO to concentrate upon programmes that would assist countries in developing their healthcare systems for their entire populations, and for furthering of nationalhealth service goals, as also to pursue research on the role that other sectors can play in the delivery of primary healthcare. A 1975 report entitled “The Promotion of National Health Services” proclaimed that the development of primary health care services at the community level was the only way in which health services could develop rapidly and effectively. It laid down seven guiding principles for this development, such as shaping PHC around the life patterns of the population, involvement of the local population, reliance on available community resources within cost limitations, an integrated approach to preventive, curative and promotive services for both the community and the individual, and design of other services to support the peripheral level. Thus many of the concepts and ideas related to PHC (as part of BHS) were being given shape within the WHO.

Litsios also writes about “the time and effort spent on deciding what words to use in position papers”, the discussions about “how PHC differed from BHS”, “drafting definitions and descriptions of PHC” and “how pressure mounted to define PHC”. According to Litsios, there was “tension bet ween advocates of a community-centred and a health-services-centred vision of PHC, which continued into and beyond the Alma-Ata”. PHC meant different things to different people (Venediktov 1978). The question arises as to why there should have been such uncertainty and confusion regarding PHC, given that a tractable c oncept of PHC as part of basic health s ervices had been articulated in the e arlier meetings and resolutions. It was possibly related to the attitude of the then director-general of WHO, Halfdan Mahler, who is credited with the Alma-Ata Declaration on Primary Health Care and the goal of HFA.

According to Litsios, Mahler did not want the conference and took steps to block the idea from the moment it was put forward. Mahler found “the Soviet model totally inappropriate – it was highly centralised and over-medicalised; there was little to be learned from the Soviet system that could be used by the developing world” (Litsios 2002: 718). He began proposing a blueprint of health for all, which included PHC as a frontline activity to ensure essential health for all in any s ociety, and had to form part of a broader health system.

Attenuated Version

While WHO strived to give direction to the all-around disillusionment and discontent with vertical health programmes, with existing biomedical models and ways of providing health services, at the same time it allowed other considerations – such as personal preferences, and the politics of the Cold War – to creep in. It ended up with an attenuated version of PHC. In the Alma-Ata Declaration, PHC came to include all the essential elements for HFA identified by Mahler, such as adequate food and housing, safe drinking water, immunisation, and prevention and control of locally endemic disease. PHC became the key to HFA, and the location where all related sectors and aspects of national and community development were to be involved. Thus as remarked by Litsios, “to many it seemed that almost by a sleight of hand the basic health services had given way to primary healthcare” (p 720), and the Decla ration carried the anti-medical positions held by many at that time, including the director-general Mahler, as against the earlier views within WHO regar ding develop ment of basic health services.

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In any case, there remains the question of how “new” or original the Alma-Ata recommendations actually were. Two earlier reports on health and medicine in the underdeveloped world, in 1972 by the Office of Health Economics,1 and in 1975 by the World Bank, made similar recommendations. They talked of change of priorities within healthcare services with more emphasis in resource allocation to primary healthcare services, nutrition, water and sanitation; shift from highly sophisticated to less sophisticated medical technology; emphasis on self-care and self-reliance; and encouragement of community participation in planning and implementation of health programmes (both reports cited in Navarro 1984).

How the proposals of the Alma-Ata Declaration were never seriously implemented and how the PHC approach got diluted into the selective PHC approach are all well-documented. Similarly, the onslaught of the neoliberal ideology in terms of worsening health status and decreased access to health services in the developing countries, are all extensively written about and discussed. Since the late 1990s, international development institutions have drawn atten tion to increasing disparities, and the members of the UN and a number of international organisations have agreed to achieve eight millennium development goals by 2015. We also have the WHO Commission on Social Determinants of Health and the latest WHO report of 2008 talks of a return to PHC.

Interestingly, while there is lamentation about failure and talk of alternatives and solutions, in all these discussions, involving both academic and development institutions, including the WHO, a working viable alternative has been either ignored or sidelined. There is, however, one low income/developing country, Cuba, that has recorded excellent health indicators that are the best in the third world and among the finest in the world, proving that it is possible for such countries to provide free and good quality public health services. The Pugwash Conference, while nominating Cuba’s National Immunisation Programme for the 2001 Gates Award for Global Health states, “Despite the obstacles faced by all developing countries, as well as some unique to itself, Cuba has established an incredibly comprehensive

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november 22, 2008

30TH ANNIVERSARY OF ALMA-ATA
public healthcare system for its people… Medical Services are provided to 98%
(which) easily surpasses those of almost of the population (surpassing that of the
all other developing countries, and in US and all of Latin America) while 95% is
many respects is comparable to, or even attended to by local family doctors (Pug
better than those of many industrialised wash Conference 2001). According to a
nations” (Pugwash Conference 2001). The public health consultant of Medecins Sans
next section summarises few distinctive Frontieres (MSF), “Doctors and nurses con
features of the health status of the Cuban tinue to work towards the goal of health
people and the quality of health services for all Cubans, even though their salaries
in Cuba, and considers the implications of are minimal. Signs of negligence or cor-
WHO ignoring such evidence. ruption often found in other socialist
countries are unknown... All the health
2 Cuba Shows the Way workers we met stand for their job, their
In every area of public health – such as principles and their people” (Veeken
infectious diseases, poor maternal and 1995). The Cuban health system consists
child health, and routine immunisation – of a three-tier system, with family physi
in which developing countries such as cians providing frontline care (doctor:
India are “struggling”, and are receiving population ratio of 1:170), supported by a
aid and advice from a whole host of devel large number of polyclinics, and finally,
opment institutions apart from the WHO, hospitals at the third-tier. Tertiary medi-
Cuba has achieved remarkable success. cal facilities lack the amenities and high-
After the 1959 revolution, the Cuban tech found in the industrialised countries
situation was not dissimilar to that of and in large numbers in developing coun
countries like India at the time of their tries like India; only recently ultrasound,
independence – a heterogeneous health endoscopy, magnetic resonance imaging,
sector comprising a single university hos and interventional cardiology have
pital and medical school, a dominant pri been made available to polyclinics and
vate sector and a rudimentary public referral hospitals.
health system. By the mid-1960s, a few Cuba’s record in the area of infectious
thousand physicians had left for the USA. diseases is particularly noteworthy – they
Primary care for the poor and rural popu are not a major cause of death there as in
lation was weak or non-existent. In the so many developing countries. A number
early stages, emphasis was placed on basic of common infectious diseases have been
public health improvements, such as sani eliminated altogether, often for the first
tation and immunisation, and medical time in any country – poliomyelitis in 1962
care was extended to the rural areas. Cuba (Lago 1999), neonatal tetanus in 1972,
spends around 16% of its gross national diphtheria in 1980, measles in 1993, per
product directly on the health system, tussis in 1994, rubella and mumps in 1995
roughly $320 per year per person (Cooper (Cooper et al 2006). In 1962, “vaccination
et al 2006). It is reported to have a high days” were established to reach the entire
degree of income equality; the slums and population, against the advice of external
shanties so characteristic of India and health officials. This method proved to be
other developing countries are not to be effective in eliminating polio and became
found in Cuba. With genuine commitment the basis of the global polio eradication
on the part of healthcare workers and the initiative. Malaria has been eradicated,
government, the country has put in place and dengue fever successfully reduced by
a comprehensive public healthcare system an immense campaign with popular par
despite widespread material shortages. ticipation. Cuba has a well-functioning
Healthcare in Cuba is exclusively in the surveillance system and publishes exten
hands of the public sector, and free for all sive vital statistics, and mortality and
Cubans. Several accounts indicate that it morbidity data by cause and province
is of high quality. Privatisation is not an since 1970.
option. Private practice is prohibited by During the economic crisis in 1991-94,
law. As quality services are available free following the collapse of the Soviet Union,
of charge, there is no significant demand the incidence of low birth weight increased
for private medicine (De Vos 2005). and was accompanied by a slight increase
43

30TH ANNIVERSARY OF ALMA-ATA

in the infant mortality rate (IMR). How-impact on health indices was short-lived ever, within two years the health of and healthcare continues to be free. Evi-

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women of child-bearing age and infants recovered, and there continued to be a decline in IMR. Cuba now has the second lowest infant mortality in the Americas –

5.8 per 1,000 live births (LBs) in 2004, comparable to that of Canada (5.4), and the US (7.1) – whereas in terms of GNP per capita, Cuba compares with countries like Bolivia and Brazil. The prevalence of low birth weight in 2004 was 5.4%. In 2005 the MMR was 29 per 100,000 LBs (Cooper et al 2006; De Vos 2005). There was a reduction of tuberculosis infections from around 30 to 5 per 100,000 from the 1970s to 1991, when it increased to 15 per 100,000 because of difficult living conditions. Unlike in other countries, the increased incidence was not related to drug resistance or AIDS. However, the trend has been reversed since then (De Vos 2005).

Another distinctive component of Cuba’s health system is its human resource-based international medical assistance activity. For decades Cuba has been sending medical teams during emergencies, such as hurricanes and volcanic eruption, to Central America, to Indonesia and Sri Lanka after the tsunami, to Pakistan after the 2005 earthquake. It also has Integrated Health Programmes with many African and Latin American countries where medical teams work in places where there is no medical care. It has a special programme for Venezuela; there is also an international medical training programme where students from Africa and Latin America study medicine in Cuba at no expense (De Vos et al 2007; Cooper et al 2006). While it is easy to dismiss such support as a political ploy, one needs to remember that all these countries being supported, except Venezuela, have nothing much to offer Cuba, as discussed by Cooper et al (ibid). The value of providing medical care to marginalised communities and where nothing exists should not be undermined.2

Decades of aid and technical assistance to the developing countries have failed to achieve what has been attained by a small island country over the same decades without such aid, and despite a 45-year old US-imposed commercial, economic, and financial embargo. In spite of its economic crisis and reforms during the 1990s, the dently, Cuba has made great strides in the direction of health for all through giving political priority to health, addressing from the start the now fashionable concept of “social determinants of health”, as well as through a comprehensive and effective public health approach that meets WHO definitions of primary care. Without undermining the achievements of the socialist revolution in the country, in this context, the fact that Cuba has had such a social-political revolution is beside the point. Certainly, we do not need a revolution in order to provide adequate food, sanitation, clean drinking water, and good health facilities by the state!

The lack of objective evaluation, and discussion of the significance of the Cuban experience, and not attempting to learn from it, by institutions such as WHO raises questions about its non-partisan role, and to what it extent it provides evidencebased policy options. On the contrary, we find that the WHO has joined the league of other development institutions such as the World Bank, and is promoting policies – such as “verticalisation”, public-private partnerships, immunisation specifically through the GAVI3 – that undermine the functioning of comprehensive public health systems (Puliyel and Madhavi 2008).

3 Immunisation and Pulse Polio

We now draw attention to the role of WHO in the immunisation and pulse polio programme in India and the pernicious effect the latter has had on the already emasculated health services of many states. That there has been a decrease in the coverage of routine immunisation across the country is now an established and accepted fact. It is acknowledged in official circles that this decrease is due to the concentration on the pulse polio programme.4

Since its inception in 1996, a disproportionately large amount of human and material resources have gone for a single disease – polio.5 How big a public health problem was it to begin with as far as India is concerned was not addressed by WHO and other international institutions. It had to be implemented as part of the Global Polio Eradication Initiative (GPEI) (Sathyamala et al 2005). In fact the National Commission on Macroeconomics and Health records that before the benefits of the national immunisation programme could be realised, this polio eradication initiative was launched. The National Polio Surveillance Project (NPSP) and a network of 148 polio laboratories were set up solely for identification and surveillance of polio. Tens of thousands of workers have been trained to investigate cases of polio and manage pulse polio immunisation activities. However, apart from such extreme “verticalisation”, there are other extremely serious problems with the polio eradication initiative.

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There have been repeated changes in the definition of polio cases – out of the thousands of cases of acute flaccid paralysis (AFP) now reported only those with wild polio virus detected in their stools are classified as polio cases. This leaves out a large number of cases of paralysis that would qualify to be classified as polio by the older definition based on clinical signs (Sathyamala et al 2005). Secondly, there has been an unacceptably large increase in the number of AFP cases in the country since 2000. It has steadily increased from 8,103 in 2000 to 41,401 in 2007 (35,552 up to October 2008). The non-polio AFP rate had increased from

1.99 to 9.40 in this period6 (all figures from www.npspindia.org). The government of India and WHO are ignoring these increasing numbers of AFP cases, and the fact that a significant proportion of children with confirmed wild poliovirus paralysis are immunised children who have received 12-15 doses of OPV.7 Such an epidemic of paralysis while there is an ongoing “elimination programme”, is being “explained away” by WHO to be due to “excellent surveillance”, instead of undertaking a comprehensive epidemiologic investigation into the steady increase. Thirdly, it has also been found that bulk of the cases of AFP is not being followed up, unless the wild polio virus was detected in the stools.8 Fourthly, untested monovalent oral polio vaccine (mOPV) was introduced in 2005, flouting all ethical norms (Grassly et al 2007; Puliyel et al 2007). Lastly, none of the IEC materials on pulse polio referred to intramuscular injections as a key risk factor for paralysis with poliovirus. F urther, parents are not informed that

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november 22, 2008

they should not allow intramuscular injections in children with fever during the poliovirus season or after receiving OPV (Wyatt 2003a, 2003b).

The pulse polio initiative raises grave concerns about the role and technical assistance of WHO in India. WHO has not responded to these issues raised with it by concerned sections of the public health community, for a review of this eradication programme, and to re-integrate the polio immunisation programme into the Universal Immunisation Programme. Instead it has only been intensified – over the past two years there have been 10-12 rounds of pulse polio immunisation in a year in the country. The original concept of pulse polio immunisation as a supplementary immunisation activity has been lost sight of by NPSP-WHO.

WHO is also promoting vaccines such as hepatitis-B vaccine and now Haemophilus influenzae type b (Hib) in the routine immunisation (Puliyel and Madhavi 2008), even though they are not needed, justifying the doubts and concerns raised by the pulse polio programme about its “technical assistance”. One finds that currently GAVI is the “leader” in immunisation, with WHO facilitating GAVI entry into developing countries such as India. Proposals are under consideration by the Ministry of Health and Family Welfare to introduce other non-essential vaccines such as pneumococcal vaccine and a pentavalent vaccine, and WHO is assisting in compliance with GAVI conditions, by preparing Multi-Year Plans for Immunisation in India and setting up immunisation monitoring systems (see www.whoindia.org).

Cuba conducted only two National Polio Eradication Drives, in February and April 1962, and eradicated polio within four months, a world record; there have been no reported cases of poliomyelitis since then. The Pugwash nomination states that “Cuba’s public healthcare system through which the vaccination programme is implemented is itself a model of advancing health in low-income societies”. What a contrast with the experience in India that has “achievements” like a “fastgrowing economy”, nuclear capabilities, Chandarayan, and lakhs of doctors, but a weak public health system. Thousands of children are paying a heavy price for the

30TH ANNIVERSARY OF ALMA-ATA

GPEI, and many more are dying of diseases that can be traced to poverty. In this situation there is an urgent and pressing need to evaluate what is being offered by WHO and other international institutions in the name of “technical information and assistance” in public health. One finds a large gap between lofty statements by WHO and what it actually promotes and implements in developing countries like India. Clearly, WHO is “saying one thing and doing another”. It is high time that this is acknowledged, only then can things begin to be remedied.

Notes

1 The office of Health Economics UK is a research body supported by the British Pharmaceutical Industry, to support healthcare policies through research, advisory and consultancy services and economic and policy issues in the pharmaceutical, healthcare and biotech sectors (see www.ohe. org).

2 A Cuban government representative rightly told a visiting MSF consultant, “Cubans were the first medicos sin fronteras (Doctors without Borders). We have always exported doctors to places where they are needed ” (quoted in Veeken 1995).

3 GAVI – the Global Alliance for Vaccines and Immunisation – was announced at the 2000 World Economic Forum in Davos. The founding partners of GAVI are WHO, UNICEF, World Bank, Bill & Melinda Gates Foundation, Rockefeller Foundation, the International Federation of Pharmaceutical Manufacturers’ Association, and some national governments. GAVI aims to reduce under-5 mortality in the poor countries by making available new and underused vaccines, and strengthening delivery systems for immunisation. This is to be achieved by giving long-term financial support to “eligible” countries. The biggest contributors to GAVI are the Gates Foundation, US, Norway, the Netherlands and the UK. GAVI is touted as a major public-private partnership of all the “stakeholders” in immunisation. It is governed by a 16-member board, including five permanent members – the Gates Foundation, the World Bank, WHO, UNICEF, and the Vaccine Fund. The remaining 11 will include developing and developed countries and industry from each of these, NGOs, foundations, research and academia, and technical health institutes (see www.vaccinealliance.org). A close ally of GAVI is the International Finance Facility for Immunisation (IFFI), a new “international development institution” designed to make funds available for GAVI projects. In October 2006 the IFFI launched a supranational bond to raise funds from potential investors, with the World Bank as its treasury manager. This is being projected as a new way of funding international development, and addressing “the seemingly intractable problems of poor nations with a tried and true model from the world of business” (see www.iff-immunisation.org).

GAVI conditions for support include a guarantee for “reasonable prices”, support for a credible and sustainable market, advanced market commitments for vaccines, safeguards against re- export of products from developing countries to higher-priced markets, and prohibition on c ompulsory licensing. GAVI did not support provision of the six basic EPI vaccines, DTP, polio, measles, and BCG, unless DTP was combined with hepatitis-B and/or Haemophilus influenzae

30TH ANNIVERSARY OF ALMA-ATA

type B vaccines (Hardon and Blume 2005). India has so far taken GAVI support for introduction of the hepatitis-B vaccine in the routine immunisation in several states.

4 According to the National Commission on Macroeconomics and Health, “The immunisation staff in UP relate their failure to achieve any of their Programme goals under RCH, TB, UIP or FP to the overbearing emphasis given to polio, which not only commands better resources and better visibility in the media, but also consumes nearly one-third of the time, costs 30 times more than routine immunisation and exhausts their staff” (p 48).

The Common Review Mission of the NRHM in November 2007 records that in Bihar “health officials complained that the pulse polio programme drained a lot of their human resources for a substantial proportion of time every month or two. It had adverse effects on all other work”. The RCH-II review in January 2007 for Uttar Pradesh notes that “All staff still spent a substantial part of their time and effort towards the pulse polio programme. The focus shifted completely to polio immunisation during pulse polio rounds and routine immunisation shut down completely during the polio week”.

5 While the general impression sought to be created is that the eradication programme receives generous external funds, in reality it is only partially true. External contributions have been matched by national resources from governments, NGOs and private sector, at the national, state, district and local community levels to cover petrol, social mobilisation, training and other costs. In fact, of the expenditure so far of $4.5 billion at the global level, a conservative estimate based on the time of volunteers and health workers during the NIDs (the most labour-intensive part of the programme) indicates that the countries would have contributed at least $2.35 billion in volunteer time alone. For instance, the Indian government pays 46% of the total costs incurred on the polio eradication campaigns by a combination of bilateral grants, domestic budgetary allocations, and loans from World Bank.

6 Non-polio AFP rate is defined as number of cases of paralysis per 100,000 population which is not due to polio. It is between one and two in most countries, whereas it is the highest in India (8.5 in 2008 followed only by Afghanistan with 8.2) (www.polioeradication.org).

7 There has been excessive dosing of children in India with OPV, at times exceeding more than 25 doses in the first five years of age. This is unheard of in the history of polio eradication in the west.

8 NPSP-WHO maintains that the increase in AFP cases is due to “excellent surveillance’’ and detection of all cases of paralysis cases. If this were so then the number of cases should have reached a plateau after a point when the surveillance system would have been in place. However, it has only steadily increased, indicating that other factors could be responsible. However NPSP says it is concerned only with polio! In 2005 of the 10,264 cases of AFP, 209 were confirmed or compatible with polio. Of the remaining 10,055 only 2,553 were followed up. Such findings cast a shadow over the claims to “excellent surveillance” and detection of polio cases. Among those followed up 898 had residual paralysis, which would qualify them to be diagnosed as polio using the old definition, and 217 had died. Projecting these figures on those not followed up shows that approximately 4,800 cases either had residual paralysis (polio) or died in UP after acquiring non-polio AFP in 2005. This figure must be compared to the all- India figure of 4,793 cases of polio in 1994, before the start of this eradication programme (Puliyel et al 2007). In 2006 out of the 10,879 cases of AFP only 2043 were followed up, of which 48.4% had residual paralysis and 11.9% had died. By the same

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c alculations in all there were 5,265 cases of polio and 1,294 had died, indicating that the problem had worsened in these two years (Sathyamala 2007). NPSP-WHO has not given any explanations for the lack of follow-up of the AFP cases, for these increases or for the high death rates among the “non-polio” AFP children.

References

Brown, T M, M Cueto, and E Fee (2006): “The World Health Organisation and the Transition from International to Global Public Health”, American Journal of Public Health, 96(1), pp 62-72.

Cheng, M (2007): “Press Report: WHO Criticised for Neglecting Evidence”, International Journal of Health Services, 37(4), pp 783-85.

Cooper, R S, J F Kennelly and P Orduñez-Garcia (2006): “Health in Cuba”, International Journal of Epidemiology, 35, pp 817-24.

De Vos, P, W D Ceukelaire, M Bonet, and P Van der Stuyft (2007): “Cuba’s International Cooperation in Health: An Overview”, International Journal of Health Services, 37(4), pp 761-76.

De Vos, P (2005): “‘No One Left Abandoned’: Cuba’s National Health System since the 1959 Revolution”, International Journal of Health Services, 35(1), pp 189-207.

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Post-Doctoral Fellowship in Economics

The Centre de Sciences Humaines (CSH), New Delhi, invites applications for a Post-Doctoral Fellowship:

The candidate should hold a PhD in economics from a recognised university/institute in India or abroad. The candidate is expected to conduct a research project relevant for the Indian or South Asian context and produce original results. Preference will be given to the following fields: development & growth; political economy; poverty, inequalities & redistribution; urban economics; environmental economics. Strong qualifications in applied econometrics would be an asset.

Fluency in English is a prerequisite. For conditions of the fellowship and application procedures, please see www.csh-delhi.com The deadline for submission of applications is 2nd January 2009. Preselected candidates will be called for an interview in the second week of January.

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