Magazine article New Internationalist

Elusive Promise: Whatever Happened to Health for All? [Alma Ata and the Decline of Primary Health Care]

Magazine article New Internationalist

Elusive Promise: Whatever Happened to Health for All? [Alma Ata and the Decline of Primary Health Care]

Article excerpt

THE ALMA ATA DECLARATION, Primary Health Care, back in 1978 produced a lot of optimism about working towards 'Health for All by the Year 2000'. Health was upheld as a basic human right. Primary Health Care (PHC) was to have a far-reaching, even liberating, potential. It embraced the World Health Organization's broad definition of health as 'complete physical, mental and social well-being'. It mandated universal availability of basic health services, with special concern for those in greatest need. To overcome the underlying human-made causes of ill health, it called for working toward a new economic order based on equity. Needless to say, such a comprehensive, potentially revolutionary approach was received less than enthusiastically by those with power and privilege to defend. It was not long after the world's health ministers signed on at Alma Ata that the cries of 'unrealistic' began to be heard. In 1979, a paper out of the Johns Hopkins School of Public Health insisted that Comprehensive PHC was too all-encompassing and a more limited selection of priority health problems affecting high-risk groups was needed. Low-cost, easily implemented technologies were recommended. This was the beginning of the end for the broad, social-justice approach to primary healthcare. Throughout the Third World, PHC was stripped of its social-change-seeking content and diluted into 'Selective Primary Health Care' (SPHC). Its unifying focus on equity and community participation were replaced by a few quick-fix technologies. The dream of changing the world was reduced to the doctrine of changing behaviour.

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Even UNICEF, once a strong proponent of Comprehensive PHC, caved in to US State Department accusations that it was 'too political', and jumped on the Selective PHC bandwagon. It promoted two 'simple, lifesaving technologies' - Immunization and 'ORT' - which became the 'twin engines' of UNICEF's Child Survival Revolution. (ORT, or Oral Rehydration Therapy, involves giving lots of fluids to children with diarrhea, to prevent death from dehydration.) Their global campaign did lower child mortality. But the question remains: Has it improved children's quality of life? In 1991, UNICEF reported that malnutrition contributed to 35 per cent of children's deaths. By 1996 this had jumped to 55 per cent. According to World Watch, more children are malnourished today than ever before! And despite recent record-breaking economic growth, one in five of the world's children go hungry. Hungry children are not healthy. Their minds and bodies do not develop fully. A resurgence has occurred of 'diseases of squalor' such as cholera, tuberculosis and plague. In a world of plenty, countless children remain sick with hunger. What happened to Health for All?

Make the poor pay

The next major setback for Primary Health Care was the Structural Adjustment Programmes (SAPs) pushed by the World Bank and International Monetary Fund (IMF). These 'austerity measures' are part of the demise of collective social responsibility typical of economic globalization. The SAPs were designed to make sure poor countries kept servicing their huge national debts to Northern banks. The Bank and the Fund made 'bailout loans' to indebted countries on condition they adjust their economies to free up money for debt payment. This meant slashing health and education budgets. Low-income and rural health centres were shut down or paralyzed due to lack of medicines. Public hospitals were privatized, making their services inaccessible to the poor. Food subsidies and welfare programmes were aborted.

One of the most punishing measures was a 'cost recovery' strategy that included 'user fees'. Where free healthcare and essential medicines were once provided, poor people were now required to pay. Studies in several countries show user fees decrease utilization of medical services and increase child mortality, sexually transmitted disease and tuberculosis. …

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