segunda-feira, fevereiro 18, 2008

30th Alma Ata

The 30th anniversary of the declaration of Alma-Ata at the International Conference of Primary Health Care will be on Sept 12, 2008.1 This non-binding declaration stated that primary health care was the key to the attainment of a level of health sufficient to permit people to lead a socially and economically productive life by the year 2000. The use of appropriate technology (ie, relevant to the needs of the population, affordable, and scientifically justified) was emphasised, perceived medical elitism was opposed, and a commitment was made to use health as an engine of development. The panel shows the description of primary health care in the declaration. The boundaries of primary health care can be debated, partly because there are international differences in the way health systems are organised, but generally they can be considered to encompass the spectrum of care from that delivered in the patient's home (eg, by community health workers) to care delivered in facilities that represent the first point of contact with the health system.
Panel: Description of primary health care from Alma-Ata declaration1

1. Reflects and evolves from economic conditions and sociocultural and political characteristics of the country and its communities, and is based on application of relevant results of social, biomedical, and health-services research and public-health experience

2. Addresses main health problems in the community, providing promotive, preventive, curative, and rehabilitative services accordingly

3. Includes at least: education about prevailing health problems and methods of preventing and controlling them; promotion of food supply and proper nutrition; adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunisation against major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs

4. Involves, in addition to health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications, and other sectors; and demands coordinated efforts of all those sectors

5. Requires and promotes maximum community and individual self-reliance and participation in planning, organisation, operation, and control of primary health care, making fullest use of local, national, and other available resources; and to this end develops, through appropriate education, ability of communities to participate

6. Should be sustained by integrated, functional, and mutually supportive referral systems, leading to progressive improvement of comprehensive health care for all, and giving priority to those most in need

7. Relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries, and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as health team and to respond to expressed health needs of the community

The ambitious vision of Health for All by the year 2000, with primary health care at the centre, was a powerful motivating idea for people concerned about continuing inequities and injustices in global health. However, some argued that to start with selective primary health care for a few cost-effective interventions would be best, especially where delivery systems were weak.2 This view led to the UNICEF GOBI (growth monitoring, oral rehydration, promotion of breastfeeding, immunisation) strategy that focused on four inexpensive interventions.3 Although the selective approach to primary health care did not directly seek to undermine the vision of Alma-Ata, tensions between the two approaches were inevitable, with some individuals regarding the selective approach as complementary and others believing it to be contradictory to the spirit of Alma-Ata.4 The charismatic Halfdan Mahler, who had done so much to champion the Alma-Ata declaration, Health for All by the year 2000, and a comprehensive approach to primary health care, finished his term in office as WHO Director-General in 1998. Under his successor primary health care did not have the same prominence.
Countries' experience of including community-health workers in primary health care varied but many programmes proved difficult to sustain,5–7 especially if they used unpaid volunteers. The retention of community-health workers was often poor, and their performance was frequently inadequate, leading to low uptake of services.8 Professional opposition by powerful medical and nursing associations to the handing over of tasks to inadequately qualified health workers was instrumental in stalling progress in some countries.4 The lack of investment in good-quality research led to difficulties in developing solid counter-arguments against those who argued that little empirical evidence existed to back up the audacious vision. The Alma-Ata declaration might have also been a victim of the ideological clash at the time between communism and capitalism,9 and in retrospect, a declaration emerging from a conference in the former USSR would clearly never be accepted fully in the West.
By the 1990s the emphasis had moved away from primary health care, as exemplified by the world development report: Investing in Health,10 which advocated minimum packages of care and health-care reforms. The Millennium Development Goals (MDGs) of 2000 set ambitious international targets, including in the health sector, but said little or nothing about delivery.11 New and powerful organisations, such as The Global Fund to fight AIDS, Tuberculosis and Malaria, have achieved much to address the needs of people with priority diseases, as has the GAVI Alliance (formerly the Global Alliance for Vaccines and Immunisation), but these bodies have only a limited remit to address the general problems of weakened and fragmented health systems.
Nevertheless, the idea of primary health care is attracting renewed interest for several reasons. Progress towards the MDGs is uneven and only one of eight regional groupings of nations is on track to achieve all MDGs. The shortfall is especially pronounced in sub-Saharan Africa.12 WHO has drawn attention to the human-resource crisis in many parts of the world and suggests that 57 countries presently have severe shortages equivalent to a global deficit of 2•4 million doctors, nurses, and midwives.13 The problems of international and internal migration, together with the limited capacity for training additional health professionals, have led to renewed interest in the possible contribution of community-health workers and midlevel cadres. Additionally, recognition is growing that many of the barriers to delivering effective interventions for a range of health problems are shared.14 Many vertical programmes that address specific diseases can interact adversely with each other and lead to inefficient use of limited resources. China was an early exponent of primary health care through so-called barefoot doctors;15 however, the collapse of the health-care system—especially in rural areas—after market reforms has left hundreds of millions of poor people without access to basic health care.16,17 The Chinese Government has now begun to look at ways to finance and deliver access to health care for the population, and this quest will necessitate the revival of primary health care.
There is growing research evidence about the cost-effectiveness of at least some components of primary health care. For example, community participation has been assessed with rigorous designs and has been shown to improve neonatal and maternal mortality in Nepal.18,19 Robust evidence shows that community-health workers can deliver several interventions,20 especially for conditions such as acute respiratory infections, malaria, perinatal care, and neonatal sepsis21–26 and, at least in some settings, these interventions are cost effective.27 Some programmes, especially in Asia, have been scaled up to reach large populations.28,29
Non-governmental organisations concerned about health, most notably the People's Health Movement,30 have become galvanised around prospects for revitalising primary health care, to address pervasive health inequalities, poor coverage of basic health care, and lack of engagement by communities in health systems. WHO is once again giving priority to the development of primary health care and in a speech to the World Health Assembly in 2006, Margaret Chan, then the Director-General Designate, emphasised that she intended to build on the legacy of Halfdan Mahler.31 She also mentioned that she had heard from many sources in her visits to Latin America, Africa, Europe, and Asia about the importance of primary health care at the national level. The World Health Report in 2008 will focus on the role of primary health care in strengthening health systems.
Several middle-income countries have successfully extended coverage of primary care. One example is Brazil, where the Family Health Programme now reaches more than 60% of municipalities, with primary-care teams incorporating many of the elements of primary health care as envisaged at Alma-Ata.32 Each family-health team consists of one family physician, one nurse, two auxiliary nurses, and four to six community-health workers, and is responsible for a catchment area of 600–1000 families.
In many industrialised countries (with the notable exception of the USA) that have adequate numbers of doctors and nurses, primary medical care, influenced to varying degrees by Alma-Ata, has made major gains. Much of the European Union has improved the coverage and quality of such care over recent decades. For example, in Spain an outmoded system staffed by doctors without postgraduate training was transformed into a modern primary-care system staffed by trained general practitioners and nurses.33
Many questions remain to be addressed including: what is the relevance and meaning of a comprehensive approach to primary health care in settings with highly constrained resources? How best should scarce resources be prioritised? How should sufficient health workers be recruited, trained, and retained? How should medical and public-health approaches be integrated? What is the appropriate contribution of the private sector in view of its prominent role in health-care delivery in many countries? Is engaging other sectors at the community level feasible, and what will be the effects? How should effective referral systems and the roles of medical and nursing professionals in primary health care be developed? In particular, scaling up primary health-care programmes is a continuing challenge, as is showing that effectiveness can be maintained outside research settings. In high-income countries, questions remain about how to cope best with challenges such as the ageing population, changing expectations of patients, and poor integration with hospital care. Engagement of the academic community in research and training will be of paramount importance if we are to successfully build on the lessons of the past.
In recognition of the historical importance of Alma-Ata, and of the abiding interest in primary health care from a range of stakeholders, The Lancet will be publishing a special issue on this subject. This special issue will marshall the available evidence to address both the promise and the pitfalls of primary health care from a range of perspectives and discuss the continuing relevance of such concepts to improvement of world health. We invite the submission of papers documenting original research relevant to primary health care and policy-oriented papers that take the debate forward. Please submit relevant papers by Feb 1, 2008.
We declare that we have no conflict of interest.
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