Check against delivery
Statement by Mr. Kul C. Gautam
Deputy Executive Director, UNICEF
The 25th Anniversary of the Alma Ata Declaration on Primary Health Care
Almaty, 23 October 2003
As the original co-sponsor of the historic Alma Ata Conference in 1978, UNICEF is proud and delighted to join WHO again at this Silver jubilee commemoration of the Declaration of Alma Ata on Primary Health Care.
And I want to thank the government of Kazakhstan for hosting this important jubilee dedicated to recapture the still unfulfilled promise of the Alma Ata Declaration.
The road from Alma Ata to Almaty has not been smooth or straight. We had the distraction of the cold war and the collapse of the Soviet Union – followed not necessarily by an era of peace and prosperity but one of painful transition in many countries of this region.
The decades following Alma Ata have seen proliferation of ethnic conflicts, the debt crisis, and the spectre of terrorism. Military expenditures are on the rise again, disappointing those of us who had hoped for a peace dividend for global health and the fight against poverty.
HIV/AIDS, a disease unknown at the time of Alma Ata has come to dominate the world’s health agenda, even as we struggle against older diseases, such as malaria and tuberculosis that have defied our efforts to tame them.
It has not been easy to keep the flame of Health for All ignited in these turbulent times. But we cannot, and will not give up. We are here to rekindle the inspiring vision of Alma Ata, duly adapted to the changing realities of the 21st century.
A revolutionary vision of “Health for All”
The historical significance of the international conference on primary health care in 1978 has been so monumental that it has turned Almaty into a city of pilgrimage – a Mecca of public health. Ten years ago at the 15th anniversary of the Alma Ata Conference, one of my predecessors, Dr. Guido Bertolaso, came here on such a pilgrimage. I would like to quote extensively from his statement at the time which still rings true today.
In the Alma Ata Declaration, he said, the nations of the world dared to define health as a fundamental human right and embraced a strategy – primary health care – and even a deadline – the year 2000 – for guaranteeing health not for a few, not for a privileged minority, not for the industrialized countries alone, but for all.
The Alma Ata Declaration took health out of the hospital – where remarkable advances of modern medicine and science were accessible only to a minority – and entrusted it to every individual, every family, every community and every State, linked in a holistic framework of caring and mutual responsibility.
The concept of Primary Health Care emphasized that health was not about curing illness, but about preventing it, by empowering people to live healthy and productive lives. The beating heart and vital centre of health systems would have to be people and communities.
Health systems, according to the Alma Ata Declaration, would have to go where people are – no matter how poor, no matter how remote their villages.
Governments and ministries of health would have to reach out in a multitude of ways through a multitude of sectors, institutions and channels, to support and involve people in their communities in their quest for primary health care.
I believe it is no exaggeration to say that the Alma Ata Declaration represented a great intellectual and moral leap forward for human kind. It paved the way for many other revolutionary ideas that later became common wisdom in international development, including Education for All, human rights based approach to programming, and other concepts espoused by the Summits and major UN conferences of the 1990s.
Child Survival and Development Revolution: a new boost to PHC
Primary health care was a wonderful idea, but in practice not much changed in the early years after Alma Ata. The decade of the 1980s saw developing countries mired in the debt crisis, and the onset of structural adjustment programmes sapped away the vitality of health systems and social development.
PHC became a dream deferred.
It took the Child Survival and Development Revolution promoted by UNICEF’s Jim Grant, and later embraced by Halfdan Mahler and Hiroshi Nakajima of WHO that gave a new boost to PHC.
Though meant to be multi-sectoral, in the early years after Alma Ata, primary health care was still generally seen as a health sector concern.
What the Child Survival and Development Revolution did in the 1980s, was to put health issues firmly onto the world’s political and social agenda, cultivating ownership by mayors and governors, parliamentarians and civil society activists, the media and the academia.
Inverting the “Health for All” motto to “ALL for Health”, the Child Survival and Development Revolution saw everyone, from film stars to school teachers, heads of religious organizations to heads of states, actively involved in promoting immunization, oral rehydration therapy and other health and nutrition interventions on a large scale.
The push for specific, low-cost interventions aimed at drastically reducing child mortality and morbidity was initially controversial in the international health community. A fierce debate ensued over horizontal versus vertical programmes, and selective versus comprehensive primary health care.
Time has taken the edge off the polemics, and we have learned valuable lessons. We have found that enabling a nation to deliver a few services – or even a single service – on an efficient, effective, equitable, high coverage basis can produce remarkable results.
By creating success stories, through social mobilization and political advocacy, the child survival and development interventions raised the profile of health services. By pursuing measurable goals, political leaders were held accountable. They were praised for success and shamed by comparison. Pursuit of child survival made it good politics to invest in health.
In the process, the spirit of primary health care was revived not just as an immaculate concept but by creating demand and delivering services that people cherished.
Inspired by this, UNICEF helped convene the first World Summit for Children in 1990. Its Declaration reinforced health goals related to children and women and invoked the Alma Ata Declaration on PHC as the key strategy to achieve these goals.
The Summit adopted a goal-oriented approach, bringing the international community to agreement on a common development agenda with clear targets and milestones.
Indeed many of today’s Millennium Development Goals have their origins in the health related goals of the World Summit for Children.
A decade of progress and setbacks
In May 2002, world leaders convened again at the UN General Assembly Special Session on Children, to review the progress made on the goals and targets of the World Summit for Children over the past decade.
Significant achievements were reported. Over 60 countries had achieved the target of reducing under-five mortality by one-third. Deaths due to diarrhea were cut by half. Cases of polio and guinea worm disease had been drastically reduced. Ninety million newborns were being protected from brain damage every year thanks to control of iodine deficiency disorders. A billion more people got access to clean drinking water.
Despite all the gains made, globally, almost 11 million children under the age of five still die every year. And millions more are chronically sick and malnourished.
The recently-published articles in the Lancet on child survival make it clear that there are many cost-effective interventions which could drastically reduce deaths and other burden of childhood diseases, if they were used more widely.
Many of these cost-effective interventions are not new. Indeed, breastfeeding, the single most efficient intervention for preventing childhood deaths is as old as humanity itself. Oral rehydration therapy had already been invented at the time of the 1978 Alma-Ata Conference. Simple antibiotics to cure childhood pneumonia, micronutrient supplementation and vaccines against a variety of diseases have been available for decades. And there are many examples of low cost water and sanitation measures that contribute to better health and nutrition.
Mobilizing leadership and resources to accelerate universal coverage of these and other interventions is our challenge.
The Special Session has outlined a plan of action to create a “World fit for Children” by pursuing the Millennium Development Goals in the spirit of the Alma Ata Declaration.
Challenges to realize the vision of PHC
As we look ahead, I see 5 major challenges if we are to realize the vision of PHC in the coming decade in the world:
The Challenge of mobilizing “All for Health”
The Challenge of Global Interdependence
The Challenge of Going to Scale
The Challenge of Mobilizing Resources, and
The Challenge of Leadership
Let me share with you some of the specifics under each of these 5 challenges:
1. The Challenge of Mobilising “All for Health”
It is often said that health is too important to be left entirely to the care of medical professionals. The Alma Ata Declaration had clearly recognized the importance of mobilizing support from sectors outside health as a key strategy of PHC.
From the point of view of child health, the number one health worker is the mother. The more we can do to empower her with basic knowledge, information and skills in good infant feeding practices, care and stimulation of the young child, hygiene and sanitation, better birth spacing, etc. the better the health outcomes of her child. Good maternal health and nutrition too are, of course, of paramount importance.
One of the best ways to promote this is actually through action in the education sector. As we know, girls' education is probably the most effective of all health interventions. An educated girl marries later. She can better protect herself from diseases, including HIV/AIDS. She has reduced fertility, lower infant and maternal mortality. Her children are likely to be better nourished and healthier. They are more likely to go to school and perform better. And as they become adults, they help break the intergenerational cycle of ill health and poverty.
The high priority UNICEF attaches to girls education, is therefore, a direct contribution to PHC.
Teachers are another group of potential health workers. Most children spend many years as a captive audience of their teachers. If teachers had the basic knowledge of nutrition, hygiene and sanitation, and if they were empowered to impart such knowledge to their students, they could make an enormous contribution in bringing about good health outcomes.
It is said that the greatest reductions in infant and child mortality in the 19th century in Europe were attributable, not to medical breakthroughs but to dramatic progress in potable water and sanitation. Collaboration with actors in the water sector can therefore produce great results in promoting good health.
And in today's world, mass media and communication can be a great provider of good health information or a promoter of unhealthy life-styles. The communications media, both public and private, can therefore be the greatest ally of ministries of health in their mission of health promotion.
So let us mobilize “all for health”, not just promote “health for all”
2. The Challenge of Global Interdependence:
We cannot be healthy in an unhealthy world. Unlike people, diseases do not need a passport or visa to travel.
We must, therefore, promote international cooperation to combat diseases and to promote health as a global public good.
Programmes to eradicate or eliminate polio and measles, to fight HIV/AIDS, malaria and tuberculosis, and to promote epidemiological surveillance must increasingly be considered global public goods.
In this age of globalization and massive movements of people across borders, diseases can be weapons of mass destruction, but health can be a bridge to peace.
Solidarity for promotion of global health is, therefore, in the enlightened self-interest of every nation, and every society in this era of global interdependence.
3. The Challenge of Going to Scale:
The health development map of the world is littered with small scale pilot studies and demonstration projects.
To be really useful, development programmes should attempt to take action on a scale commensurate with the problems that they are trying to tackle.
Fortunately, we already have globally approved goals and targets, and agreed strategies. Now we need to scale up actions with simple and focused plans, strong partnerships, competent and motivated human resources, essential supplies, strong monitoring and evaluation, and sufficient funds.
The PHC revolution led to a stream of health sector reforms in many developing countries. Some of these helped strengthen district health services with a network of first-level and referral health facilities. The Bamako Initiative launched in 1987, for example, pioneered provision of essential drugs through revolving funds managed at the community level.
However, far too many of these health system reforms tended to focus on elaborate “processes” rather than on outcomes and impact in significant scale.
Let us make sure that the second generation of health sector reform is much more results-oriented rather than process-driven. Let us influence poverty reduction strategy papers to give priority to health goals. Let us engage in sector-wide approaches to get donors to provide better coordinated support for health. Going to scale should be our mantra if health for all is our ultimate goal.
4. The Challenge of Finance:
The WHO Commission on Macroeconomics and Health estimates that the financial resources required for a set of essential interventions against infectious diseases and nutritional deficiencies that could potentially save 8 million lives per year in low income countries would cost around $34 per person per year.
The total additional resources needed for low income countries would amount to an additional 1 to 2 percent of their GNP, and for the donor community an additional 0.1 percent of their GNP in the form of ODA. These amounts are certainly affordable for both developing countries and for donors.
Given the extraordinary benefits of investment in health - in terms of lives saved, sicknesses averted, and productivity raised – investment in health, and education, is the best guarantee for achieving the broader millennium development goal of poverty eradication.
We must craft debt relief schemes for the highly indebted poor countries, and debt swaps for middle income countries to generate additional resources for PHC. And we must press for donors and developing countries to follow the internationally agreed target of allocating 20 per cent of ODA and 20 percent of national budgets for basic social services, which would go a long way towards sustainable funding for all key health goals.
The public sector alone need not bear the burden of investment in health. In recent years we have seen commendablee examples of generous corporate contributions to such initiatives. The Global Alliance for Vaccines and Immunization (GAVI), the Global Fund for AIDS, Tuberculosis and Malaria (GFATM), and the support to the development efforts of UNICEF, WHO and others by private sector donors such as the Bill and Melinda Gates Foundation, the Ted Turner-funded UN Foundation, Rotary International, the Kiwanis and the Acumen Fund, are some shining examples.
The pharmaceutical industry can also be a more enlightened partner in such public health efforts. The public sector can encourage this by providing tax and other incentives.
5. The Challenge of Leadership:
Finally, we need strong leadership at the local, national and international level to promote health for all.
Health issues are now commanding the interest and support of many world leaders ranging from the Kofi Annan to Nelson Mandela, and from Bill Gates to Bono.
I know WHO, UNICEF, UNFPA, the World Bank, and regional Development Banks are all deeply committed to giving health a high priority as are many bilateral donors.
The presence here of so many ministers and other leaders at this meeting is a testimony to our own determination to provide strong leadership for primary health care.
If collectively we can further mobilize leadership at the highest levels of governments, civil society and the private sector, health for all need not be a dream delayed for too long.
Future of PHC in the backyards of Alma Ata
Before concluding, let me say a few words about the countries of the region assembled at this jubilee meeting.
The former USSR played a key role in convening the Alma Ata Conference. Following the demise of the Soviet Union, your countries are engaged in an unprecedented transition amidst extraordinary difficulties. While getting rid of what was bad and unfair in the old order, you are struggling to preserve the best aspects of the prior health care system, with its generally high coverage and care for the most vulnerable.
Please do not throw away health and wellbeing of your people to the vagaries and cold calculus of the market place.
We are happy to see many positive developments in the region. All the countries you represent have achieved and sustained a high level of immunization coverage. The region has been certified as polio-free.
Many countries are now working on issues related to improving the quality of immunization including safe injection practices, and self sufficiency in vaccine procurement and funding. We commend your efforts in these areas.
Micronutrient deficiencies are a big problem in this region. More needs to be done to achieve Universal Salt Iodization by 2005. Vitamin A supplementation and flour fortification to combat iron deficiency anemia are other areas where we need increased efforts by countries in this region. International help is available to support your efforts.
This region has a chance to avoid the worst impact of HIV/AIDS if preventive actions is taken now aggressively before it is too late, as we have witnessed in the regions.
UNICEF’s Innocenti Research Centre in its latest report “Social Monitor 2003” has brought to our attention the fact that infant mortality rates in several countries of the region seem to be much higher than previously reported.
The figures are based on household surveys and show under-reporting by health establishments in these countries, partly because they continue to use the old Soviet era definition of live births, whereas the rest of the world is now using a different WHO definition.
Flawed statistics are a danger to children. They inspire complacency. They perpetuate the legacy of the past, when hospitals and medical staff could be penalized for failure to reach infant mortality targets set by central health ministries.
I would encourage countries in the region to accelerate the implementation of the WHO definition, and I would encourage WHO to provide the necessary technical assistance.
A related problem in compiling accurate child mortality statistics is in the weaknesses in the system of birth registration. A recent UNICEF study estimated that around 10 per cent of births in this region go unregistered. If the birth of a baby is not registered, it is hardly likely that the baby’s death will be recorded. This perpetuates under-reporting of infant mortality.
Let us make sure that we have the right baseline figures for monitoring progress towards the Millennium Development Goals.
The challenges that lie ahead to achieve health for all and related MDGs in this region, and in the developing world, may seem daunting.
But we at UNICEF believe that they are not insurmountable. If we face the 5 challenges I outlined earlier with creativity and tenacity, I have no doubt that the vision of Alma Ata can be realized in our life time.
Distinguished delegates, I am here to assure you that UNICEF stands shoulder-to-shoulder with you in this noble effort to pursue Health for All as part of our common effort to create a world truly fit for children.