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CSU 41/2008: ALMA ATA, THREE DECADES ON
Those who enjoyed Halfdan Mahler’s remarks in the last CSU may want to
read this series of abstracts from a recent issue of The Lancet,
covering the follow-up to the resolutions of the Alma Ata Conference.
Alma Ata becomes more relevant as the world moves, at different rates of
speed, towards the Millennium Development Goals, especially MDG 4 and
MDG 5.
The 1978 Alma Ata Conference on Primary Health Care sought to set the
agenda for primary health care. By the early ‘80s, PHC had branched off
into the ‘health for all’ agenda of the World Health Organization and
‘selective primary health care,’ made famous by the seminal 1979 New
England Journal of Medicine article by Julia Walsh and Ken Warren,
accessible at
www.pubmed.gov (type ‘Walsh and Warren’ into the search engine).
The selective PHC approach got much of the funding. Polio eradication
has, to date, been funded for more than $4 billion, nor does anyone
claim that polio could have been eradicated by routine vaccination. The
disease specific priority continues today, as attested by the funding
for GAVI and GF, both of which fund health systems strengthening in a
bow to integration. So who was right? This series of articles from The
Lancet tries to grapple with that question. It seems that everyone was
right. No child survives without specific interventions. No child
survives without benefiting from a health system which assures cultural,
geographical and economic access to high quality preventive and clinical
services.
Readers should start with the article by Rohde and colleagues and work
their way through these abstracts; Lancet subscribers can read the full
text on the Lancet homepage.
Why has Thailand done so well? When I first went there in 1971, the
Ministry was centralized, vertical, and inequitable. Now it is
decentralized, integrated, and with an emphasis on the district
approach.
Good reading.
Bob Davis
30 years after Alma-Ata: has primary health care worked in
countries?
Rohde J, Cousens S, Chopra M, Tangcharoensathien V, Black R,
Bhutta ZA, Lawn JE.
Management Sciences for Health, Boston, MA, USA; James P Grant
School of Public Health, BRAC University, Dhaka, Bangladesh.
Lancet. 2008 Sep 13;372(9642):950-61
We assessed progress for primary health care in countries since
Alma-Ata. First we analysed life expectancy relative to national
income and HIV prevalence to identify overachieving and
underachieving countries. Then we focused on the 30 low-income
and middle-income countries with the highest average yearly
reduction of mortality among children less than 5 years of age,
describing coverage and equity of primary health care as well as
non-health sector actions. These 30 countries have scaled up
selective primary health care (eg, immunisation, family
planning), and 14 have progressed to comprehensive primary
health care, marked by high coverage of skilled attendance at
birth. Good governance and progress in non-health sectors are
seen in almost all of the 14 countries identified with a
comprehensive primary health care system. However, these 30
countries include those that are making progress despite very
low income per person, political instability, and high HIV/AIDS
prevalence. Thailand has the highest average yearly reduction in
mortality among children less than 5 years of age (8.5%) and has
achieved universal coverage of immunisation and skilled birth
attendance, with low inequity. Lessons learned from all these
countries include the need for a nationally agreed package of
prioritised and phased primary health care that all stakeholders
are committed to implementing, attention to district management
systems, and consistent investment in primary health-care
extension workers linked to the health system. More detailed
analysis and evaluation within and across countries would be
invaluable in guiding investments for primary health care, and
expediting progress towards the Millennium Development Goals and
"health for all".
Alma-Ata 30 years on: revolutionary, relevant, and time to
revitalise.
Lawn JE, Rohde J, Rifkin S, Were M, Paul VK, Chopra M.
Lancet. 2008 Sep 13;372(9642):917-27
Saving Newborn Lives/Save the Children-US, Cape Town, South
Africa.
In this paper, we revisit the revolutionary principles-equity,
social justice, and health for all; community participation;
health promotion; appropriate use of resources; and
intersectoral action-raised by the 1978 Alma-Ata Declaration, a
historic event for health and primary health care. Old health
challenges remain and new priorities have emerged (eg, HIV/AIDS,
chronic diseases, and mental health), ensuring that the tenets
of Alma-Ata remain relevant. We examine 30 years of changes in
global policy to identify the lessons learned that are of
relevance today, particularly for accelerated scale-up of
primary health-care services necessary to achieve the Millennium
Development Goals, the modern iteration of the "health for all"
goals. Health has moved from under-investment, to single disease
focus, and now to increased funding and multiple new
initiatives. For primary health care, the debate of the past two
decades focused on selective (or vertical) versus comprehensive
(horizontal) delivery, but is now shifting towards combining the
strengths of both approaches in health systems. Debates of
community versus facility-based health care are starting to
shift towards building integrated health systems. Achievement of
high and equitable coverage of integrated primary health-care
services requires consistent political and financial commitment,
incremental implementation based on local epidemiology, use of
data to direct priorities and assess progress, especially at
district level, and effective linkages with communities and
non-health sectors. Community participation and intersectoral
engagement seem to be the weakest strands in primary health
care. Burgeoning task lists for primary health-care workers
require long-term human resource planning and better training
and supportive supervision. Essential drugs policies have made
an important contribution to primary health care, but other
appropriate technology lags behind. Revitalisng Alma-Ata and
learning from three decades of experience is crucial to reach
the ambitious goal of health for all in all countries, both rich
and poor.
Community participation: lessons for maternal, newborn, and child
health.
Rosato M, Laverack G, Grabman LH, Tripathy P, Nair N, Mwansambo
C, Azad K, Morrison J, Bhutta Z, Perry H, Rifkin S, Costello A.
Lancet. 2008 Sep 13;372(9642):962-71.
Centre for International Health and Development, Institute of
Child Health, University College London, UK.
Primary health care was ratified as the health policy of WHO
member states in 1978.(1) Participation in health care was a key
principle in the Alma-Ata Declaration. In developing countries,
antenatal, delivery, and postnatal experiences for women usually
take place in communities rather than health facilities.
Strategies to improve maternal and child health should therefore
involve the community as a complement to any facility-based
component. The fourth article of the Declaration stated that,
"people have the right and duty to participate individually and
collectively in the planning and implementation of their health
care", and the seventh article stated that primary health care
"requires and promotes maximum community and individual
self-reliance and participation in the planning, organization,
operation and control of primary health care". But is community
participation an essential prerequisite for better health
outcomes or simply a useful but non-essential companion to the
delivery of treatments and preventive health education? Might it
be essential only as a transitional strategy: crucial for the
poorest and most deprived populations but largely irrelevant
once health care systems are established? Or is the failure to
incorporate community participation into large-scale primary
health care programmes a major reason for why we are failing to
achieve Millennium Development Goals (MDGs) 4 and 5 for
reduction of maternal and child mortality?
(Embedded image moved to file: pic14709.jpg)(Embedded image moved to
file: pic27956.jpg)(Embedded image moved to file: pic22421.jpg)
(Embedded image moved to file: pic15945.jpg)1: Lancet. 2008 Sep 13;372
(9642):972-89.(Embedded image moved to file: pic13465.jpg) (Embedded
image moved to file: pic16016.jpg)Links
Alma-Ata: Rebirth and Revision 6 Interventions to address
maternal, newborn, and child survival: what difference can
integrated primary health care strategies make?
Bhutta ZA, Ali S, Cousens S, Ali TM, Haider BA, Rizvi A, Okong P
, Bhutta SZ, Black RE.
Department of Paediatrics & Child Health, The Aga Khan
University, Karachi, Pakistan.
Several recent reviews of maternal, newborn, and child health
(MNCH) and mortality have emphasised that a large range of
interventions are available with the potential to reduce deaths
and disability. The emphasis within MNCH varies, with skilled
care at facility levels recommended for saving maternal lives
and scale-up of community and household care for improving
newborn and child survival. Systematic review of new evidence on
potentially useful interventions and delivery strategies
identifies 37 key promotional, preventive, and treatment
interventions and strategies for delivery in primary health
care. Some are especially suitable for delivery through
community support groups and health workers, whereas others can
only be delivered by linking community-based strategies with
functional first-level referral facilities. Case studies of MNCH
indicators in Pakistan and Uganda show how primary health-care
interventions can be used effectively. Inclusion of
evidence-based interventions in MNCH programmes in primary
health care at pragmatic coverage in these two countries could
prevent 20-30% of all maternal deaths (up to 32% with capability
for caesarean section at first-level facilities), 20-21% of
newborn deaths, and 29-40% of all postneonatal deaths in
children aged less than 5 years. Strengthening MNCH at the
primary health-care level should be a priority for countries to
reach their Millennium Development Goal targets for reducing
maternal and child mortality.
CSU 41/2008: ALMA ATA, THREE DECADES ON
| Friday, 17th of October 2008 |
 |
 |
Those who enjoyed Halfdan Mahler’s remarks in the last CSU may want to
read this series of abstracts from a recent issue of The Lancet,
covering the follow-up to the resolutions of the Alma Ata Conference.
Alma Ata becomes more relevant as the world moves, at different rates of
speed, towards the Millennium Development Goals, especially MDG 4 and
MDG 5.
The 1978 Alma Ata Conference on Primary Health Care sought to set the
agenda for primary health care. By the early ‘80s, PHC had branched off
into the ‘health for all’ agenda of the World Health Organization and
‘selective primary health care,’ made famous by the seminal 1979 New
England Journal of Medicine article by Julia Walsh and Ken Warren,
accessible at
www.pubmed.gov (type ‘Walsh and Warren’ into the search engine).
The selective PHC approach got much of the funding. Polio eradication
has, to date, been funded for more than $4 billion, nor does anyone
claim that polio could have been eradicated by routine vaccination. The
disease specific priority continues today, as attested by the funding
for GAVI and GF, both of which fund health systems strengthening in a
bow to integration. So who was right? This series of articles from The
Lancet tries to grapple with that question. It seems that everyone was
right. No child survives without specific interventions. No child
survives without benefiting from a health system which assures cultural,
geographical and economic access to high quality preventive and clinical
services.
Readers should start with the article by Rohde and colleagues and work
their way through these abstracts; Lancet subscribers can read the full
text on the Lancet homepage.
Why has Thailand done so well? When I first went there in 1971, the
Ministry was centralized, vertical, and inequitable. Now it is
decentralized, integrated, and with an emphasis on the district
approach.
Good reading.
Bob Davis
30 years after Alma-Ata: has primary health care worked in
countries?
Rohde J, Cousens S, Chopra M, Tangcharoensathien V, Black R,
Bhutta ZA, Lawn JE.
Management Sciences for Health, Boston, MA, USA; James P Grant
School of Public Health, BRAC University, Dhaka, Bangladesh.
Lancet. 2008 Sep 13;372(9642):950-61
We assessed progress for primary health care in countries since
Alma-Ata. First we analysed life expectancy relative to national
income and HIV prevalence to identify overachieving and
underachieving countries. Then we focused on the 30 low-income
and middle-income countries with the highest average yearly
reduction of mortality among children less than 5 years of age,
describing coverage and equity of primary health care as well as
non-health sector actions. These 30 countries have scaled up
selective primary health care (eg, immunisation, family
planning), and 14 have progressed to comprehensive primary
health care, marked by high coverage of skilled attendance at
birth. Good governance and progress in non-health sectors are
seen in almost all of the 14 countries identified with a
comprehensive primary health care system. However, these 30
countries include those that are making progress despite very
low income per person, political instability, and high HIV/AIDS
prevalence. Thailand has the highest average yearly reduction in
mortality among children less than 5 years of age (8.5%) and has
achieved universal coverage of immunisation and skilled birth
attendance, with low inequity. Lessons learned from all these
countries include the need for a nationally agreed package of
prioritised and phased primary health care that all stakeholders
are committed to implementing, attention to district management
systems, and consistent investment in primary health-care
extension workers linked to the health system. More detailed
analysis and evaluation within and across countries would be
invaluable in guiding investments for primary health care, and
expediting progress towards the Millennium Development Goals and
"health for all".
Alma-Ata 30 years on: revolutionary, relevant, and time to
revitalise.
Lawn JE, Rohde J, Rifkin S, Were M, Paul VK, Chopra M.
Lancet. 2008 Sep 13;372(9642):917-27
Saving Newborn Lives/Save the Children-US, Cape Town, South
Africa.
In this paper, we revisit the revolutionary principles-equity,
social justice, and health for all; community participation;
health promotion; appropriate use of resources; and
intersectoral action-raised by the 1978 Alma-Ata Declaration, a
historic event for health and primary health care. Old health
challenges remain and new priorities have emerged (eg, HIV/AIDS,
chronic diseases, and mental health), ensuring that the tenets
of Alma-Ata remain relevant. We examine 30 years of changes in
global policy to identify the lessons learned that are of
relevance today, particularly for accelerated scale-up of
primary health-care services necessary to achieve the Millennium
Development Goals, the modern iteration of the "health for all"
goals. Health has moved from under-investment, to single disease
focus, and now to increased funding and multiple new
initiatives. For primary health care, the debate of the past two
decades focused on selective (or vertical) versus comprehensive
(horizontal) delivery, but is now shifting towards combining the
strengths of both approaches in health systems. Debates of
community versus facility-based health care are starting to
shift towards building integrated health systems. Achievement of
high and equitable coverage of integrated primary health-care
services requires consistent political and financial commitment,
incremental implementation based on local epidemiology, use of
data to direct priorities and assess progress, especially at
district level, and effective linkages with communities and
non-health sectors. Community participation and intersectoral
engagement seem to be the weakest strands in primary health
care. Burgeoning task lists for primary health-care workers
require long-term human resource planning and better training
and supportive supervision. Essential drugs policies have made
an important contribution to primary health care, but other
appropriate technology lags behind. Revitalisng Alma-Ata and
learning from three decades of experience is crucial to reach
the ambitious goal of health for all in all countries, both rich
and poor.
Community participation: lessons for maternal, newborn, and child
health.
Rosato M, Laverack G, Grabman LH, Tripathy P, Nair N, Mwansambo
C, Azad K, Morrison J, Bhutta Z, Perry H, Rifkin S, Costello A.
Lancet. 2008 Sep 13;372(9642):962-71.
Centre for International Health and Development, Institute of
Child Health, University College London, UK.
Primary health care was ratified as the health policy of WHO
member states in 1978.(1) Participation in health care was a key
principle in the Alma-Ata Declaration. In developing countries,
antenatal, delivery, and postnatal experiences for women usually
take place in communities rather than health facilities.
Strategies to improve maternal and child health should therefore
involve the community as a complement to any facility-based
component. The fourth article of the Declaration stated that,
"people have the right and duty to participate individually and
collectively in the planning and implementation of their health
care", and the seventh article stated that primary health care
"requires and promotes maximum community and individual
self-reliance and participation in the planning, organization,
operation and control of primary health care". But is community
participation an essential prerequisite for better health
outcomes or simply a useful but non-essential companion to the
delivery of treatments and preventive health education? Might it
be essential only as a transitional strategy: crucial for the
poorest and most deprived populations but largely irrelevant
once health care systems are established? Or is the failure to
incorporate community participation into large-scale primary
health care programmes a major reason for why we are failing to
achieve Millennium Development Goals (MDGs) 4 and 5 for
reduction of maternal and child mortality?
(Embedded image moved to file: pic14709.jpg)(Embedded image moved to
file: pic27956.jpg)(Embedded image moved to file: pic22421.jpg)
(Embedded image moved to file: pic15945.jpg)1: Lancet. 2008 Sep 13;372
(9642):972-89.(Embedded image moved to file: pic13465.jpg) (Embedded
image moved to file: pic16016.jpg)Links
Alma-Ata: Rebirth and Revision 6 Interventions to address
maternal, newborn, and child survival: what difference can
integrated primary health care strategies make?
Bhutta ZA, Ali S, Cousens S, Ali TM, Haider BA, Rizvi A, Okong P
, Bhutta SZ, Black RE.
Department of Paediatrics & Child Health, The Aga Khan
University, Karachi, Pakistan.
Several recent reviews of maternal, newborn, and child health
(MNCH) and mortality have emphasised that a large range of
interventions are available with the potential to reduce deaths
and disability. The emphasis within MNCH varies, with skilled
care at facility levels recommended for saving maternal lives
and scale-up of community and household care for improving
newborn and child survival. Systematic review of new evidence on
potentially useful interventions and delivery strategies
identifies 37 key promotional, preventive, and treatment
interventions and strategies for delivery in primary health
care. Some are especially suitable for delivery through
community support groups and health workers, whereas others can
only be delivered by linking community-based strategies with
functional first-level referral facilities. Case studies of MNCH
indicators in Pakistan and Uganda show how primary health-care
interventions can be used effectively. Inclusion of
evidence-based interventions in MNCH programmes in primary
health care at pragmatic coverage in these two countries could
prevent 20-30% of all maternal deaths (up to 32% with capability
for caesarean section at first-level facilities), 20-21% of
newborn deaths, and 29-40% of all postneonatal deaths in
children aged less than 5 years. Strengthening MNCH at the
primary health-care level should be a priority for countries to
reach their Millennium Development Goal targets for reducing
maternal and child mortality.
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