The community’s health can drive great economic and social progress
The Alma Alta Declaration put “health for all” centre stage as a fundamental right in 1978, with 134 countries committed to making primary health care the mainstay to achieve universal health coverage. In a tectonic shift from the existing disease-focused hospital-based treatment approach, it redefined health as physical and mental well-being of the community and essential for social and economic progress.
Over the next three decades, the declaration was dismissed as idealistic and unrealistic and the focus shifted to selective, targeted deliverables that offered low-cost and quantifiable solutions to the most common causes of death. Instead of strengthening primary healthcare, policies and public health budgets went almost exclusively to controlling communicable diseases and programmes on ‘GOBI’ (growth monitoring, oral rehydration, breastfeeding, and immunisation), and later, ‘GOBI-FFF’ (GOBI plus food supplementation, female literacy, and family planning). India, too, got on the targeted programmes bandwagon with the major chunk of its health budget going to reproductive and child health and family planning.
There is now a steady and growing support among public health experts to end this approach to health care. The Sustainable Development Goals on good health and well-being also call for making modern health care equitable and accessible to all by investing in community-based care, health centres, hospitals, and population-based interventions for prevention, early diagnosis, treatment and management.
Though people in most parts of the world enjoy better health than ever before, most countries still struggle to provide primary health care. Disease-specific policies, an unregulated private sector, overinvestment in specialised hospitals for curative treatment, and an acute workforce shortage has widened the gap in access to quality health care between the rich and the poor. Epidemics and outbreaks caused by new emerging infectious diseases, such as HIV, Ebola and influenza, further burdened the public health infrastructure in many countries already struggling to meet the growing load of non-communicable diseases, such as heart disease, diabetes, cancers and mental health diseases.
Half the world’s population still has no access to essential health services, even though 80-90% of their health needs across a lifetime can be provided by primary health care services, which range from maternity and child care, to disease prevention through vaccination, management of chronic diseases such as diabetes and hypertension, and supporting care of ageing populations, who live longer but often less healthy lives because they have more than one disease.
This week, 1,200 decision-makers and influencers, including heads of state, ministers of health, finance, education, and social welfare, not-for-profits and health professionals will meet at the Global Conference on Primary Health Care in Astana, Kazakhstan, which is co-hosting the meet with the World Health Organisation and Unicef. As in the rest of the world, much has changed in Kazakhstan since 1978. Kazakhstan is independent of the Soviet Union, Alma Ata has been renamed Almaty, and the country’s capital has shifted to Astana, best known for its glittering, sci-fi skyline that appears to have magically sprung up in Steppe wilderness. What is now being resurrected in this futuristic city is the need to rejuvenate and revitalise people-centric primary health care using newer tools, such as technology.
India, which was one of the participants in the Alma Ata conference, has made a start with the launch of health and wellness centres under Ayushman Bharat that offer health promotion, disease prevention and management, treatment of simple fever, infections and pain, and early diagnosis and timely referrals to hospitals at the community level. These will be staffed by a new cadre of technologically enabled community health officers (CHOs) trained as mid-level providers, who will work with support from auxiliary nurse midwives, community workers (Asha), and male health workers to ensure everybody in a population of around 5,000 people gets free basic medicine, diagnosis and treatment.
Around 80% of India’s 1.04 million registered doctors of modern medicine (allopathy) work is in cities, which is home to 31% of the country’s population. The rural population is heavily dependent on the public health sector, where the allopathic doctor-patient ratio is 1:11,082, against the WHO-recommended ratio of 1:1,000. These CHOs will help meet the shortfall of doctors in rural and underserved areas and strengthen health sub-centres at the village level to free up doctors for tertiary care and substantially reduce people’s out-of-pocket health spending.
Strong primary health care, rooted in community participation, builds resilience against new and existing diseases and helps governments to respond to evolving health needs, demographics, environmental challenges, and emergencies to improve outcomes and well-being at lower costs.