From Alma-Ata to Astana: the Declaration that shows what is in dispute13/11/2018
From Alma-Ata to Astana: the Declaration that shows what is in dispute
Undoubtedly, the proposal to bring Primary Health Care (PHC) to a forum such as the General Assembly of the United Nations (UNGA) of 2019, to give it the highest possible level of political support, sounds good. After all, after 40 years of the Declaration of Alma-Ata, we are certain of the effectiveness of the strategy and we should redouble our efforts to apply it globally in order to make the right to health a reality for all. In addition, we have absolute clarity about what was left behind, merely on paper which is a pending debt to overcome inequities (which have increased fiercely), that which spoke of establishing a new international economic order. Analyzing the process of construction and content of the Declaration of Astana that was approved at the Global Conference on Primary Health Care on October 25 and 26, 2018, starting from its very title, it becomes clear that achieving these aspirations will not be easy. Reaffirming and strengthening PHC is a necessity, but positioning a weakened version would be a step backward.
In this short analysis, I will focus on those concepts that were most discussed in the process of creating the Declaration (notably improved since its first version), either in the International Advisory Group formed by the WHO, of which I am a member, in the contributions of the general public that gave feedback to the Declaration drafts (which were limited, because in addition to opening short time periods for this process on the website created by OMS, the document was never made available in a language other than English) and finally in the negotiations of the member countries of WHO. Although the Declaration has powerful concepts, which coincide with those presented in Alma-Ata, there are elements of PHC that were frankly weakened. Without intending to make a exhaustive analysis of the Astana Declaration, I will briefly review some of its central points.
“From Alma-Ata towards Universal Health Coverage and the Sustainable Development Goals” reads the title of the Declaration. At first it seems praiseworthy, after all, the SDGs represent an opportunity to influence multiple factors that affect health. Likewise, the concept of “universal health coverage” without a deeper analysis would seem to encompass the aspirations of those who believe in health as a right. But these concepts and other aspects of the Astana Declaration must be carefully analyzed to the extent that they can undermine the definition of PHC, stripping it of some of its most essential elements.
The Declaration of Astana, takes position in some of the most critical debates we have had in the last decades in the field of health. Despite mentioning and referencing Alma-Ata, a milestone for those of us who believe in the right to health for all, the statement uses a conceptualization far from some of its central principles.
In the first place, to set “universal health coverage” as the maximum objective, ignores the strongly positioned approach in the region of the Americas of the importance of achieving universal access to health, a concept that goes beyond that of “coverage” ( and even contrasts with its tenets) in that the role of the State, is not limited to being a mere payer, and thus further opening the door to the privatization of health services that is on the way. Likewise, the term “coverage” is commonly used to define the health conditions (or diseases) that are included in health insurance schemes, and in that sense, it does not include the functions of the States that are related to achieving the health of their population, from regulation, surveillance, intersectoral action to work on the processes of social determination of health, among others.
PHC has had different interpretations throughout these decades, but if our orientation is based on achieving the right to health, it is necessary to conceive it as integral health care that incorporates health promotion, whose focus is individuals, families and communities, with a strong base in broad and deep social participation, with integrated quality health systems and States and societies that act on the social determination of health. In the Spanish version of the text, the word “sanitary” is used instead of the word “health”. In this context, the word “sanitary” in the title and body of the Declaration is a limitation that seems to rule that its maximum aspiration is to achieve universal access to basic hygienic facilities. This is the same term used in Goal 3 of the SDGs, something that has also generated debate in our region.
A risk that we run at this historic juncture is that some sectors continue to equate PHC with the first level of care exclusively. A central objective of Alma-Ata was to prioritize the first level of care in response to the hospital-centric tendency focused merely on healing. PHC proposed a first level of care with broad-based resolutive capacity, quality services, with prevention and health promotion actions, and an emphasis on social participation, endowed with sufficient financial resources and human resources formed integrally. This approach cannot be confused with a strategy of limiting the access of the population to the first level of care, or of offering health service packages based on the ability of people to pay, where the poorest access only the “basic” or “essential”. The integrality of PHC also refers to the right to access hospital services, according to the needs of the people.
The State’s regulatory role
Another aspect that deserves to be highlighted is the approach on the “need” to engage the private sector in health. Achieving health for all will undoubtedly depend on the contributions of all sectors, but it is too common that this slogan leaves aside the importance of regulating the private sector and protecting health from conflicts of interest (where commercial or lucrative interests interfere with the public interest). The Astana Declaration does not mention the regulatory role that States must have and strengthen, nor does it refer to the commercial determinants of health and it addresses conflict of interests as something that must be “managed”, not prevented or eliminated from the spaces of design and implementation of public health policy. These concepts were included in some intermediate versions of the Astana Declaration, but they disappeared from their final version. It’s not by chance. In a world in which every minute the concentration of wealth (and power) grows and in which those who concentrate it have an increasing incidence in the field of health, in which the interference of the industry is growing rapidly, talking about these issues is, in the least, uncomfortable for them.
Key elements of PHC were left out of this statement: there is talk of “getting people out of poverty” but nothing is said about a global economic system that generates it and that deepens inequities; it mentions “gender issues” and the need to be “sensitive” to them, not the need to mainstream the gender approach and combat inequalities; there is talk of “using” traditional knowledge, and traditional medicines “as appropriate”, not achieving a intercultural approach, with respect and appreciation of ancestral knowledge.
The Declaration of Astana states it reaffirms the values and principles of Alma-Ata, in particular “justice and solidarity” that we know are essential to achieving the right to health, but it is remarkable that it refers to “justice “and not “social justice” as Alma-Ata did. The difference lies in the fact that “social justice” is based on the concepts of equity and in our context, necessarily in the redistribution of wealth and social goods. Again, none of this is casual.
Influencing the language and concepts included in the PHC document that will be presented in UNGA 2019 will be limited given the asymmetry of power that exists between those who have one position versus the other. However, we cannot stop making these proposals and defending the principles, strategies, models and policies that deepen the right to health and that have positive impacts on the state of health and well-being of populations. The intentionality of making the health approach that benefits commercial interests over the public interest “hegemonic” and “normalized” cannot be countered with anything other than a well-argued and sustained position based on the right to health, solidarity, equity and social justice. The mission of ISAGS is to support efforts to achieve universal health systems, and in that sense, as long as the political will of the South American countries to have a space of this nature continues, we will continue to be active in their defense.
Read the complete version of the Declaration of Alma-Ata here.
Read the complete version of the Declaration of Astana here.
Executive Director of ISAGS -UNASUR