Primary health care and alma ata

1. Primary health care and Alma-Ata
Declaration

2. Origins of Primary Health Care
• Health care in pre, during and post colonial period
• Evidences and themes leading to PHC
• Revitalization of PHC
• Primary Health Care In The 21st Century

3. Before colonial period/19th century
• Throughout the country , traditional healers (shamans,
herbalists, witch doctors, bonesetters, etc.)have for
centuries been the major providers of health care.
• Even today, traditional healing is common in many
developing countries.

4. During Colonial Period
• Western medical services introduced
– to serve only their European employees and provided by
Western doctors linked to trading companies
• Public health activities were initiated
– either to combat diseases that affected the European
populations (e.g., malaria and sleeping sickness)
or
– as attempts to maintain a healthier work-force and so
ensure healthy profits.

5. Result of colonial period
• By the end of the colonial period, the pattern of
health care which had developed in most of the
Third World was largely modeled on the system
in the industrialized countries.
– High-technology and urban-based curative care almost
wholly confined to the larger towns, plantations and
mines
• The needs of people living in rural areas and
urban slums were largely neglected.

6. After colonial period
• The 1950s and 1960s--Independence from colonial
rule.
• Newly independent states drew up plans to expand
adequate health services into underserved areas.
However
• The public health campaigns after colonial period
tended to be quite narrow, disease specific (malaria,
smallpox etc) and vertical.
• Often these narrow campaigns absorbed more
resources than did all the rest of the country’s rural
health services.

7. Some poor countries spent over half their national health budgets
maintaining one or two huge, urban, tertiary care hospitals

8. • From these alternative approaches emerged the
concept of Community-based health
care/programs during(CBHs) 1960s and 1970s.
• Key to this concept were community health
workers or health
– Promoters --persons selected from and by their own
communities --- brief courses showing them how to
help their neighbors meet their most important health
needs
– Such participatory, awareness-raising grassroots
initiatives arose in a number of regions, including
Nicaragua, Costa Rica, Guatemala,Honduras, Mexico,
South Africa, India, Bangladesh, and the Philippines

9. Finally, It was possible…
• Scholars and developmental planners backed
by WHO and UNICEF analyzed closely CBHP
models and convinced
• A growing social consciousness that health—
and health care—was a basic human right led
to international support for a basic needs
approach to national health services

10. • In 1978 in Alma Ata, Kazakhstan (then the
Soviet Union), a grand meeting of health
ministers from around the world led to the
formulation of a plan whereby basic health
services would be available to all people.
• “An unusually progressive document with far-
reaching structural and economic implication”

12. Themes leading to Alma Ata
• Increasing reliance and effectiveness upon alternative
approaches to medical care model
• Success of CHWs and associated emphasis on community
participation
• Changing theories of health and development: shift away from
GNP as measure of development towards recognition of the
need of social development
• Revival of interest in Public Health: tackling causes of ill
health rather than symptoms

13. Actors and institutional changes
WHO Halfdan Mahler
WHO Director General. 15 years (1973-1988).
Background in TB, Ecuador & India
Charisma & Continuity.
According to a CMC member “I felt like a church
mouse in front of an archbishop.”
UNICEF
Henry Labrouisse UNICEF’s Exec. Director 1965-1979
emphasized community-work
in health and nutrition projects in rural areas and urban slums.
1975 Alternative Approaches to Meeting Basic Health Needs
in Developing
Countries. Successful PHC experiences in 9 countries
1975 28th World Health Assembly. “National Programs in
PHC, a…priority.”

14. Declaration of Alma-Ata (1978)

15. 1. Health is a fundamental human right & requires
inter-sectoral action
2. Existing gross health inequality unacceptable
3. Improved health and peace require economic and
social development based on a new international
economic order (NIEO)
4. Governments have responsibility to provide
adequate health and social measures for health

16. 5. Primary health care is appropriate, accessible,
acceptable, affordable and requires community
participation (Specifies components of PHC)
6. Governments need the will to formulate and
implement PHC policies
7. International cooperation is necessary
8. HFA 2000 requires redirecting resources from
military to social expenditures (including health)

17. Key to achieve the vision
• To achieve the Health for All vision, the world’s nations together
with WHO, UNICEF, and major funding agencies pledged to work
toward meeting people’s basic needs through a comprehensive and
remarkably progressive approach called Primary Health Care
(PHC)
• PHC was seen as “the key to achieving an
acceptable level of health throughout the world in
the foreseeable future as a part of social
development and in the sprit of social justice”

18. PHC Definition…
• “PHC is essential health care based on
practical, scientifically sound and socially
acceptable methods and technology made
universally accessible to individuals and
families in the community through their full
participation and at a cost the community and
country can afford to maintain at every stage
of their development in the spirit of self-
reliance and self-determination.”

19. • It forms an integral part both of the country's
health system, of which it is the central
function and main focus, and of the overall
social and economic development of the
community.
• It is the first level of contact of individuals, the
family and community with the national health
system bringing health care as close as
possible to where people live and work, and
constitutes the first element of a continuing
health care process

20. Four fold objective of PHC
1.To enable people to seek better health at home, in schools, in
fields and work places
2. To enable people to prevent disease and injury, and not rely
on doctors to treat illness that could have been avoided
3. To enable people to exercise their right and responsibility in
shaping the environment to bring about conditions for a
healthy life
4. To enable people to participate and exercise control in
managing health and related systems; to ensure that basic
pre-requisites for health and access to health are available

21. Four Pillars of PHC:
1. Political and societal commitment and to move
towards health for all
– role: implement programs, policies, and laws
– should have political will and budget
– follows standard protocol/things to be done
2. Community participation
– Includes mobilization of societal forces for health
development

22. 3. Inter-sectoral cooperation between the health
sector and other key development sectors
– Includes agriculture, education, communications,
industry, energy, transportation, public works and
housing
4. Systems support: scientifically sound and
affordable health technology
– Technology: equipment, drugs, and educational tools
to train health professionals/workers/medical
personnel
Four Pillars of PHC……………..

23. PHC is a blend of
• A set of Activities—What to do?
– 8 components of PHC/Essential care/Basic care---
Emphasis more on public health rather than medical
care.
• A level of Health Care– Where to do?
– Emphasis on Primary level (first level of contacts with
health system/gatekeeper) but linked with secondary
and tertiary level car through referral.
• Approach or strategy or principle-- How to do?
– The central theme is ensuring Equity and social justice
(Affordable, Accessible, Acceptable)

24. Principles Of PHC
1. Universal coverage:
– Accessible to all, more to needy ones
2. Community Participation:
– Taking care of their own health, self-reliance and
social awareness Fundamental concept of PHC
3. Inter-sectoral Approach:
– For overall social and economic development

25. • 4. Appropriate Technology:
– Cost effective methods and equipments for the
level of care, locally available and cheap if
possible
• 5. Health Promotion and Prevention:
– Multi-sectoral public health interventions as well
as facility based health services

26. In the other way…….
Principles of Primary Health Care (PHC)
1. Focus on lifestyle and the needs of the population.
2. Integration in the National Health System
3. Consider other sectors relevant for health like agriculture,
education and public services
4. Participation of the population in the search for solutions
5. Use of locally available resources considering their scarcity
6. Integrate and coordinate promotional, preventive, curative
and rehabilitative measures
7. Decentralize services

27. “Essential components” (Essential/Basic Health
Care) of Primary Health Care
1. Health education
2. Environmental sanitation, especially food and water
3. The employment of community or village health workers
4. Maternal and child health programs, including
immunization and family planning
5. Prevention of local endemic diseases
6. Appropriate treatment of common diseases and injuries
7. Provision of essential drugs
8. Promotion of nutrition
9. Traditional medicine
.
Source: Alma-Ata Conference documents

28. A primary health care approach
• Meeting people’s health needs throughout their
lives
• Addressing the broader determinants of health
through multi-sectoral policy and action; and
• Empowering individuals, families and
communities to take charge of their own
health.

29. WHAT IS THE REASON BEHIND
FAILURE?

30. • LACK OF COMMUNITY PARTICIPATION:
– A result of conviction that the state is responsible for providing the
totality of health services.
– In addition, the civic infrastructure and civic organizations are not well
developed.
• LACK OF INTERSECTORAL COLLABORATION:
– limited inter-sectoral cooperation for health development.

31. • MISMANAGEMENT.
– A major reason was weaknesses of national health systems with respect to
policy analysis and formulation, coordination and regulation.
– Weak managerial capabilities at all levels of care have hindered the
effective and efficient implementation of health programmes.
– Weak management also caused poor organization and delivery of health
services at all levels including ineffective referral systems.
– The weakness of health information systems at central and peripheral
levels has resulted in difficulties in collecting and using information to
measure performance of health facilities.
• Lack Of Inter Country Collaboration And Lack Of
Operational Research.

33. Why torevitalize
• PHC values
– Equity
– Prevention
– Universal Coverage
– The only effective and affordable strategy (community
health workers, community participation, self-
reliance….)
• Importance of Health System and role of PHC
• Achieving MDGs—Revitalize PHC
– Primary Health Care matters to all Goals, revitalizing
– PHC will definitely catalyze MDGs achievements

34. How to revitalize?
• Clarify Misperceptions about PHC
• Address changed scenario and new challenges
• Attitude changing and innovative ways

35. Misperceptions about PHC
• Misperceptions:
• PHC is only for poor developing countries
• PHC is cheap and low quality care
• PHC is only for the rural populations
• PHC is primary care or first point of contact
• Needs for better partnership with the private
sector. Alma-Ata did not specifically address it
• There is misperception also:
– in the year 2000 the health professionals provided health
care for everybody or that nobody would be sick or
disabled.

36. Proposed new definition:
• “A stage of health development whereby
everyone has access to quality health care or
practice self-care protected by financial
security so that no individual or family is
experiencing catastrophic expenditure that may
bring about impoverishment”
Regional Conference on “Revitalizing Primary Health Care” Jakarta, Indonesia 6-8 August 2008

37. PRIMARY HEALTH CARE IN
THE 21ST CENTURY

38. • The principles of PHC were first outlined in
the Declaration of Alma-Ata in 1978, a seminal
milestone in global health.
• Forty years later, global leaders ratified
the Declaration of Astana at the Global
Conference on Primary Health Care which took
place in Astana, Kazakhstan in October 2018

39. • It explains how PHC aligns with and contributes
to the Sustainable Development Goals (SDGs)
and universal health coverage (UHC).
• It highlights some of the lessons learned over
the past 40 years with regard to successful
implementation of PHC and describes the
challenges faced.

41. The focus on PHC is critical at this moment
for three reasons
1. The features of PHC allow the health system to adapt and
respond to a complex and rapidly changing world.
2. With its emphasis on promotion and prevention, addressing
determinants, and a people-centred approach, PHC has proven to
be a highly effective and efficient way to address the main
causes of, and risk factors for, poor health, as well as for
handling the emerging challenges that may threaten health in the
future.
3. Universal health coverage (UHC) and the health-related
sustainable development goals (SDGs) can only be sustainably
achieved with a stronger emphasis on PHC.