Saturday, October 11, 2008

Will There Be Another Alma-Ata?

What of the declaration from 1978 promising “Health for All”?

Thirty years have gone by since the “Alma-Ata Declaration” – adopted on September 12, 1978 at the end of an international conference on primary healthcare at Alma-Ata in the then Soviet Union (now, Almaty in Kazakhstan) – set the goal of “Health for All” by the year 2000, to be realised through universal, comprehensive primary healthcare.

The declaration, non-binding on the member-states of the United Nations, came at a time when the first and the second worlds were contending among themselves for advancing their respective power and influence in the World Health Organisation
(WHO), and the third world was pushing for a “new international economic order”. The world has since changed so very dramatically that one wonders if one should at all look at Alma-Ata 30 years on. Hardly had the dust in the aftermath of the declaration
settled down when neo-liberalism as an ideology and as an agenda began its hegemonic ascent. So what of Alma-Ata?

Alma-Ata happened five years after the democratically-elected Popular Unity government in Chile was overthrown in the coup d’état organised by Washington, in which president Salvador Allende was assassinated. Allende was a medical doctor who understood the social origins of disease and ill-health, just like Che Guevara, also a medical practitioner, did. Both of them saw “politics as medicine on a grand scale”.

Allende knew from his practice since the 1930s that a solution to the ill-health of the Chilean people lay not merely in the provision of healthcare but in bringing
about better conditions of work, housing, sanitation, nutrition, and so on. On its part, Cuba, a third world country that practised universal, comprehensive primary healthcare has attained health indicators corresponding to those of the developed world. Closer home, in our part of the world, Alma-Ata came at a time when the Maoist model of development in China – which had incorporated universal, comprehensive primary healthcare, among other things, as an integral part of a long-term programme – was being sought to be discarded following the third plenum of the 11th central committee of the Chinese Communist Party that announced the decision to launch “market reforms”.

The prospects of fulfilling Alma-Ata dimmed even further when conservative, right-wing governments in the United States and the United Kingdom headed by Ronald Reagan and Margaret Thatcher, respectively, took office. After all, Alma-Ata was informed by a
Weltanschauung that was wholly at odds with that of neoliberalism.

In the declaration, health “is a fundamental human right” whose attainment requires a multi pronged attack on the social determinants of ill-health and disease. Existing “gross inequality in the health status of the people is politically, socially, and economically unacceptable”. While the state is held responsible for the health of
the people, the latter “have a right and duty to the planning and implementation of their healthcare”. And, the conception and practice of primary healthcare should be informed by the understanding that social and economic relations and conditions profoundly influence health, disease and medicine (Paras VI
and VII of the declaration).

Sadly, on the ground, what was practised was selective primary healthcare, for instance, “targeting” children under age five with immunisation and oral rehydration salts (ORS), technical fixes that are useful but cannot go a long way in dealing with health problems whose roots are to be found in exploitation and oppression.

With World Bank-imposed structural adjustment programmes (SAPs) in the 1980s and the slashing of public health expenditure, poor families in the third world landed up at times spending a third of their daily earnings to buy the ORS packets that were being
promoted via “social marketing”. The SAPs adversely affected not only health expenditures, but also those related to education, food subsidy, public transport, etc, pruning a whole gamut of social welfare activity undertaken by states. User-fees, basically cost recovery measures, and the privatisation of health service functions
became the order of the day under the World Bank-mandated SAPs, even as the United Nations Children’s Fund (UNICEF) pleaded for undertaking them “with a human face”.

Whatever happened to healthcare as a “fundamental human right”?

The World Bank’s World Development Report 1993: Investing in Health, as David Werner wrote in an article in this journal 13 years ago (January 21, 1995), “put the last nail in the coffin of the Alma-Ata Declaration”. The World Bank has since pushed the
WHO into second place as the global agency influencing health policy, with a three-fold impact on the ground.

First, the responsibility for the coverage of health costs is a huge burden the poor have to bear more than ever before. Second, primary healthcare has become even more narrow and selective than it was in the 1980s. And, third, the private sector, including the insurance industry, has boomed in the “business” of healthcare. Yes, the business of healthcare – patients are now “clients” and clinical services are “product lines”.

The rights of the pharmaceutical corporations to their intellectual property precede the “fundamental right to healthcare”, which is anyway “non-binding”.

What then of Alma-Ata?

What goes around comes around. If disease is socially derived, then ill-health and disease are an indictment of the social, economic and political order. There will be many a “Sicko” (the title of the film on healthcare in the US by Michael Moore), and, sooner rather than later, the counter-movement against the market mechanism will generate its own Alma-Ata. The struggle for healthcare as a fundamental human right goes on.

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