“Primary health care: back

to Alma-Ata in early 21st

century"

Dr Jean-Jacques BERNATAS, MD, MSc – Medical Regional Coordinator

– Institut Pasteur/SISEA Project.

jjbernatas@gmail.com

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Plan

1. Definition – Declaration of Alma-Ata

2. 2008 vision of PHC

3. PHC in practice

4. Conclusion

5. References

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1. Essential health care, based on:

1. Evidence-based approach

2. Social acceptability

3. Accessibility of technology

4. Participatory approach involving communities

5. Affordability of services

2. Integration in the national health systems,

3. Integration in the social and economic development of the community

4. Bringing services a close as possible to the people

5. First contact with health care system as the main point of entry

DEFINITION – Declaration of

Alma-Ata (Sept. 1978): core

principles.

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DEFINITION – Declaration of Alma-

Ata (Sept. 1978): content (1)1. Relevance: soco-economic context, sound scientific

content (EB-M/PH)

2. In line with the existing local situation

3. Providing:

Health promotion services

Preventive services

Curative services

Rehabilitation services

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DEFINITION – Declaration of Alma-

Ata (Sept. 1978): content (2)

4. Including:

Education for health (prevention and control)

Promotion of better nutrition

Safe water and “watsan”

MCH

Immunization

Prev&control of endemic diseases

Appropirate TTT of common diseases&injuries

Essential drugs supply

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DEFINITION – Declaration of Alma-

Ata (Sept. 1978): content (3)5. Involving all related sectors: agriculture, animal

husbandry, education, industry, communication, …

6. Community and individual self-reliance& participation

from planning to implementation of PHC activities

7. Comprehensive health care services:

Integration

Referral system

Best offer (quality) for all

Prioritizing those most in need

8. Wide range of health workers (physicians to community

worker; including traditional practitioners)

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DEFINITION – Declaration of Alma-

Ata (Sept. 1978): content (4)9. Government leadership in implementing national policies

strategies, and plans of actions, …

10. International cooperation: bilateral, multilateral, NGOs.

Strong support from WHO/UNICEF

11. “Health for all by year 2000” …..

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DEFINITION – Declaration of Alma-

Ata (Sept. 1978): achievements

and limitation (1)1. Awareness of political leaders and stakeholders in putting

people at the centre of health care

2. People are healthier

Longer life expectancies

Lower infant mortality rate

Better access to safe water

Etc …

BUT: what is the PHC’s

input? Global economic

develoment could also

(mainly?) explain these

achievements …

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DEFINITION – Declaration of Alma-

Ata (Sept. 1978): achievements

and limitation (2)BUT …..same problems remains active + discrepancies between

high-income and low-income countries, and within countries

More financial resources available now than never before even if health

financing comes at the top of political agenda

Human resources for health comes up as a key issue everywhere,

Common shortcomings in health care delivery: inverse care,

impoverishing care, fragmented and fragmenting care, unsafe care,

misdirected care ….

New paradigms tighly linked with health issues: new communication

(web), climate change, ageing and growing demography …

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2008 vison of PC – 2008 WHO

report. Change of questionning health issues

From : « simple technology for volunteer, non-professional

community health workers »

To: « teams of health workers facilitating access to and appropriate

use of technology and medicines »

From : « focus of small number of selected diseases, primarily

infectious and acute »

To: « A comprehensive response to people’s expectations and

needs, spanning the range of risks and illness

From : « concentration on mother and child health »

To: « dealing with the health of everyone in the community »

And so on …

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2008 vison of PC – 2008 WHO

report. The 4 sets of PHC reforms

1. Universal coverage reforms to improve health

equity

2. Sevice delivery reforms to make health

systems people-centred

3. Public policies reforms to promote and protect

the health of communities

4. Leaderships reforms, to make health

authorities more reliable

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PHC in practice - Thailand

1.Health promotion as a key activity

2.Huge health volunteers commitment,

especially the Buddhist monks

3.Universal coverage scheme providing

health care for its 64 million people.

4.Strong government involvement, f.i.

supporting the Thailand’s health

promotion Temple project from 2003.

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PHC in practice – Emerging

diseases in SEA

1. Consequence of the « famous » changing

world.

2. Typical obvious exemple of the inefficiency of a

vertical fragmented approach.

3. Multisectoral response came up as a part of an

evidence-based plan of action.

4. Key of the success related to the community

participation and appropriation of this long-

term issue.

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PHC in practice – TB control

1. Began early as a typical vertical approach of

disease control but in line with PHC’s

principles (free and afordable high-quality

services, essential drugs, community

involvement, …)

2. Was included at the vey beginning in the PHC’s

« package »

3. Had to face with unexpected issues (HIV/AIDS;

health financing; MDR-TB) that force this

vertical approach to strenghten multisectoral

and transversal links

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CONCLUSION

1. PHC is definitely not an old and ineffective

bureaucratic concept …

2. On the contrary, it is a modern, comprehensive

and updated tool, providing drafts of plans for

actions for improving health for all, through a

holistic (individual and people-centred) and

realistic (addressing financial and political

issues)

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REFERENCES

1. The World Health Report 2008 - primary Health Care (Now More

Than Ever). http://www.who.int/whr/2008/en/index.html

2. Declaration of Alma-Ata, International Conference on Primary

Health Care, Alma-Ata, USSR, 6-12 September 1978.

www.who.int/hpr/NPH/docs/declaration_almaata.pdf

3. Carol Perks,a Michael J Toole,b & Khamla Phouthonsyc. District

health programmes and health-sector reform: case study in the

Lao People’s Democratic Republic