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Thoughts on Alma-Ata and Beyond

It is possible today to voice a proposal to take the idea of primary health care, stated in the bold language of the Alma-Ata declaration 30 years ago, forward and work towards making it a reality.


Thoughts on Alma-Ata and Beyond

Binayak Sen

It is possible today to voice a proposal to take the idea of primary health care, stated in the bold language of the Alma-Ata declaration 30 years ago, forward and work towards making it a reality.

Writing from jail, I did not have access to books and journals. This accounts for the disjointed state of some of the arguments. None of this is necessarily original or new. This article is based on earlier readings, as well as valued discussions with many friends and colleagues in Rupantar, Jan Swasthya Sahayog, the People’s Union for Civil Liberties, Shaheed Hospital, Medico Friend Circle, Jan Swasthya Abhiyan, and the National Alliance of People’s Movements. The usual disclaimers apply.

Binayak Sen, a paediatrician, public health professional and national vice-president of the People’s Union for Civil Liberties, is the recipient of the tenth annual Jonathan Mann Award for Global Health and Human Rights.

I should have done something else…… Done something else, other than going on screaming, While struggling on in this terrifying s ociety, I should have done something else. Day after day I watched a tiny hope Going into something like a huge pair of jaws Carrying around with me, in this widespread famine, The shame of having stayed alive… I should have done something.

–Raghuvir Sahay; translated by BS

he Alma-Ata declaration with its luminous promise of Health for All by 2000 AD was one such “tiny hope”. In September 1978, when the International Conference on Primary Health Care was held in what is now Almaty in Kazakhstan, and the conference declaration drafted under the charismatic leadership of the then director general of the WHO, Halfdan Mahler, the bold language of the declaration created a stir. Yet, 30 years on, the declaration as well as its guiding spirit seems rather to have fallen off the map. Paul Farmer’s Pathologies of Power: Health, Human Rights and the New War on the Poor (Berkeley, California: University of California Press, 2003) makes no reference either to Alma-Ata, or to Mahler, or, for that matter, to primary health care (PHC), the key concept that the conference elaborated. Any serious reference today to the idea of Health for All by 2000 AD would (and rightly!) cause derision. In 1978, there was no acquired immune deficiency syndrome (AIDS), no severe acute respiratory syndrome (SARS), no multi-drug resistant tuberculosis, and malaria was just coming back on the radar.

Utopian Wish List

Yet, the declaration itself commands attention, even today. It called for urgent action, in the spirit of social justice, by all governments, all health and development workers, and the “world community” (whatever that was), to promote and protect the health of all the people of the world. The conference reaffirmed that “health, which is a state of complete physical, mental, and social well-being, and not merely, the absence of disease or infirmity, is a basic human right”, required the action

of many other social and economic sectors in addition to the health sector. It also found the existence of gross inequality in the health status of people, both between countries, as well as within them, to be politically, socially, and economically unacceptable. It spoke of the need to pay the fullest attention to the reduction of the gap in the health status of the developed and the developing countries. While it held the governments primarily responsible for ensuring the health of their people, it also held that “people have the right and duty to participate individually and collectively in the planning and implementation of their healthcare. Paragraphs V, VI, and VII clarify the objectives and define the meaning of PHC, and paragraph VIII, which attempts to set out the operative part is worth quoting in full.

All governments should formulate national policies, strategies and plans of action to launch and sustain primary health care as part of a comprehensive national health system and in coordination with other sectors. To this end, it will be necessary to exercise political will, to mobilise the country’s resources and to use available external resources rationally (emphasis added).

This is the crux of what I believe was the problem with the declaration and the reason for the failure of the promise of PHC. The authors of the declaration have worked out one mighty shotgun burst of social engineering and left one lonely cowboy called “political will” to pull the trigger. Addressing an international audience under the auspices of the United Nations Children’s Fund (UNICEF) and the World Health Organisation (WHO), perhaps it was too much to expect Mahler to exhibit a sense of political process here. So instead, we get one utopian wish list and hope that deus ex machina will follow.

Primary Health Care Undermined

Right to the end, the Alma-Ata document exhibits a quixotic purity of intent. As we read that “an acceptable level of healthcare… can be attained ...through a fuller

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and better use of the world’s resources, a considerable part of which is now spent on armaments…”, we admire the logic, but hear sardonic laughter off stage, as the Big Boys wait to get in on the act. For almost as soon as the Alma-Ata conference was over, the idea of PHC was under attack. A new concept of selective primary health care (SPHC) that advocated the provision of PHC interventions which contributed most to reducing child (under 5) mortality was adopted, the advocates of SPHC arguing that PHC was too idealistic, expensive, and ultimately, unachievable. As John J Hall and Richard Taylor (“Health for All Beyond 2000: The Demise of the Alma-Ata Declaration and Primary Health Care in Developing Countries”, Med J Aust, 178 (1): 17-20, 2003) remind us, the argument was that by focusing on growth monitoring, oral rehydration solutions, breastfeeding, and immunisation, greater gains could be achieved at reduced costs.

In India, in addition to the above selective focus, family planning services and coercive family planning propaganda formed part of the package. The vertically integrated SPHC cost-benefit calculations conveniently relegated the area of healthcare and the relief of suffering to the private sector, which for the poorer communities translated to zero service. Our p olicymakers and planners conveniently forgot that every healthcare institution, no matter how large or how small, is not only a transaction platform on which benefits and services are traded, but a moral arena in which values such as equity and justice are reaffirmed, or – and more frequently – repudiated. The 2000 WHO report entitled Health Systems: Improving Performance places the responsibility for the failure of PHC on inadequate funding, and insufficient training and equipment for health workers at all levels. This resulted, according to the report, in absent or severely inadequate services leading to a failure of the referral system within the PHC hierarchy.

In the meantime, the World Bank, together with its Indian cohorts, was engaged in ramming the Structural Adjustment Programme (SAP) down our throats. In the health sector this took the shape of “Health Sector Reforms”. The Bank’s 1993 World Development Report:

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Investing in Health was projected onto this background. This heralded an emphasis on using the private sector to deliver healthcare services, while reducing or removing the public sector. This has resulted in a situation in which more than 80% of all expenditure in this povertystricken country is out of pocket expenditure – the biggest cause of private indebtedness today. At the same time we have moral obscenities like “medical tourism” in which hepcat Indian cardiologists and orthopaedic surgeons are taking on roles akin to resident personnel at m assage parlours.

Health Status of the People

Coming now to the current situation regarding the health status of the Indian people, this would require a whole book in itself. I will only try to highlight a few illustrative issues.

Chronic Hunger: The National Nutrition Monitoring Bureau says that a third of all Indian adults have a Body Mass Index (BMI) below 18.5. If we disaggregate the data, more than 60% of the scheduled caste population and more than 50% of the scheduled tribe population have a BMI less than 18.5. The status of povertystricken minority communities is not documented. According to WHO norms, any community which has more than 40% of its members with a BMI less than 18.5 should be treated as famine-affected. The writings of Utsa Patnaik have demonstrated a falling annual per capita availability of foodgrains in India – from 177 kg in 1991-92 to only 153 kg by 2003-04. Since the increased prosperity of the top fifth of the Indian population is well-known and well documented, all this only means that the bottom segments of our people are eating far less than they did some years ago, and are going deeper into the grip of a chronic, ongoing famine.

Widespread Anaemia, Particularly in Women: Most of this anaemia is eminently susceptible to the simplest therapeutic measures.

High Intrauterine Malnutrition and Maternal Mortality: The combination of the above facts leads to a high rate of


i ntrauterine malnutrition, manifest in low birth weight babies, and a criminally high maternal mortality rate. There are no medical interventions that could remedy the combined effects of the above two factors. Intrauterine malnutrition causes major pathologies throughout life and into the next generation. It is also responsible for a major component of neonatal mortality, and thus, also of overall infant mortality.

Interaction between Nutrition and Infection: My colleagues in the Jan Swasthya Sahayog, Bilaspur have found that almost all their cases of lung tuberculosis (who do not have AIDS or diabetes) have a BMI less than 18.5. In other words, malnutrition is a major cause of lung tuberculosis, due to reduced immune resistance.

Numerous Infectious Diseases: Persistence of high rates of numerous infectious diseases, including malaria, a large part of which is chloroquine resistant f alciparum malaria, tuberculosis, respiratory infections, kala-azar and other infectious diseases.

Poor Sanitation and Unhygienic Water Supply: These remain major causes of disease and death. It is not only the traditionally recognised viral and bacterial waterborne infections that are worthy of note, important as they are. Increasing parts of the country are now becoming susceptible to arsenic contamination of drinking water supply. Colleagues in Vellore, Tamil Nadu, have found that the largest single cause of the adult onset of epilepsy is n eurocysticercosis – not as traditionally taught, a disease of pork eaters, but also found in strict vegetarians, because of e ating vegetables grown with contaminated shitty water.

Abysmal Health Infrastructure and Corruption: The condition of the health infrastructure can be understood with reference to an illustrative story. The Chhattisgarh government carried out a survey/evaluation of government healthcare infrastructure under prodding from the European Union, which was the major funder for their “Health Sector Reforms” package. The performance of emergency Caesarean sections


was taken as an index of capability, and it was found that there were only three g overnment centres, including the m edical colleges, which were performing Caesarean section in a state with a population of 24 million. C orruption is a major problem in drug purchase and supply. Chhattisgarh, which has no legitimate facilities for the m anufacture of drugs, patronises a major industry in the production of fake drugs, mostly for purchase and use in government facilities.

Wither Public-Private Partnerships: The same state of Chhattisgarh spent Rs 12 crore to set up the Escort/Aayushman Heart Care and Endosurgery Centre at the Raipur Medical College, under the management of the Escorts Hospital. Both enterprises took off with much fanfare and ground to a halt within three years in a brilliant display of public-private partnership.

Dependence on Import of Vaccines:

Meanwhile, the union government has just succeeded in destroying our existing vaccine manufacturing capability – one of the most advanced in the world. One-sixth of mankind that is resident in India is now entirely dependent on imported vaccines for their immunisation programmes.

Towards an Alternative

How then do we see the future, especially in India? If we take the present structure and limitations of the state, whose hospitality I currently enjoy, as a given, is there any scope for the directed induction for change in the matter of the right to health and healthcare? Or are we condemned forever to endless karmic cycles of the adoption and unworkability of admirable protocols like the Alma-Ata declaration? In recent times, in the Mitanin programme developed in Chhattisgarh, there was an attempt to create an empowered woman activist at the village level who would articulate the community’s right to healthcare and pressurise the system from the “demand” end to deliver what were basic healthcare entitlements. The National Rural Health Mission, which adopted and extended this concept nationally through the ASHA (accredited rural health activist) diluted the concept considerably, and today’s ASHA is a pale shadow of her i magined self, an unpaid assistant to the health department trying to fulfil and take responsibility for all kinds of tasks that the department is incapable of doing.

Depressing as all this may sound, I do believe that there are certain resources that we have which can help us to work towards an alternative. One of them is the collective experience of public litigation and legislation towards the achievement of certain human rights, principally the right to food in the People’s Union for Civil Liberties (PUCL) Right to Food case and the campaigns for the National Rural Employment Guarantee Act and Right to Information. A second resource is the UN Covenant on Economic, Social and C ultural Rights, especially articles 11 and 12 which recognise the right of everyone to an adequate standard of living and medical attention, and the directive to signatory state parties to take appropriate steps to ensure the realisation of this right. The Universal Declaration of Human Rights, in particular, article 25 and a s ection of article 27 should be read along with this, which together lay down the rights of every individual to adequate, appropriate healthcare, as well as their claim to share in scientific advancement and its benefits.

A third resource is the infrastructure of local self-government/panchayati raj institutions (PRIs) that we have already built up across the country. Despite their unevenness in terms of empowerment, and in spite of the utter inadequacy of financial devolution to them, these remain the only institutions through which people can potentially exercise control over their own governance. Apart from the allocation of larger parts of our gross domestic product to the healthcare sector, means will need to be found to enable the utilisation of these funds at the local level through the PRIs.

Other resources exist in the physical and human infrastructure in the health and social sectors, the nucleus of which already exists and that we need to build upon and strengthen across the country in order to make healthcare for the ordinary Indian a reality. The development of information technology in recent years can be used to strengthen and equip this infrastructure in a way that would not have been possible even 10 years ago. With all these resources at hand, it is possible today to voice a proposal to take the idea of PHC forward in the first place, and to work towards making it a reality in a lived and shared future.

Realising the Right to Health

To come to the details of the proposal itself, our proposal is for a national campaign for the passage of a law to implement the right to health and healthcare. Since health is a state subject in the Indian Constitution, this will require the passage of a model central law which the states could adopt. The elements of the law would include the following:

Mandated Diagnostic and Treatment Algorithms: All interventions for healthcare are based on a generally agreed body of knowledge. These algorithms would make explicit the process of ap plication of that knowledge to the health problems of the individual or community, and give those algorithms the authority of legal mandate. The creation of this mandate would serve the following functions:

  • (1) Standardise the process of diagnosis and treatment of health problems at appropriate institutional levels from community-based first contact care onwards, at least up to the level of secondary care. (These algorithms would be available in vernacular languages as well as English, and they would be accessible online.)
  • (2) At entry level of therapeutic intervention, these mandated algorithms would make explicit the entitlements that would subsist for individuals and communities accessing the healthcare system, along with remedies that would accrue for a breach of entitlement.
  • (3) Records of Intervention: Through the use of virtual records as well as patient retained media, records of all transactions as well as investigations and treatment would be maintained. Any rights-based system requires a system of records to document the fulfilment of that entitlement or, in the alternative, its breach. The mandated algorithms would form the background of such a system both at the level of individual transactions as well as for purposes of monitoring and social audit. The records would also, of course, provide the obvious benefit of continuity
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    and integration of diagnostic/therapeutic interventions across different levels of care – something hard to come by even in relatively sophisticated settings today.

    Certification for Healthcare Professionals and Institutions: This process can be thought of at the level of healthcare professionals who would require certification in order to practise their profession, as well as for institutions (public, as well as private, or any combination of the two) that would serve as care-giving centres. In both cases the process of certification would include a process of mapping skills, knowledge and practice that are put to use, as well as the societal obligation fulfilled, perhaps through a mapping of the categories of patients treated on a cashless basis or with single payer payment (whether by the government, private party, or insurance company). Medical insurance programmes, as and when they become a significant reality, would also require certification, and subsidised insurance programmes would thus make healthcare equally available to all sick people.

    Other Prerequisites for Health: Universally applicable schedules of access and



    entitlements to public distribution of food, healthcare, health facilities, nutrition and other prerequisites for health. The Supreme Court directives issued from time to time in the PUCL Right to Food case may serve as a model for other areas where no such directives exist. As Paul Farmer puts it, it is necessary to recognise the state order as a guarantee of rights:

    “It can be said with certainty that the liberties of citizens are better protected by their own institutions than by the well meaning interventions of outsiders. State failure cannot be rectified by human rights activism on the part of NGOs” (M Ignatieff, 2001, quoted in Paul Farmer, op cit, 2003).






    Economic & Political Weekly

    november 22, 2008

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