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From Alma-Ata 1978, over a modest symposium on PHC at ITM, to Astana 2018

By Bart Criel
on November 2, 2018

On 23 October, an ITM symposium, titled ’40 years after Alma Ata, Primary Health Care in 2018 and beyond, In South and North’ took place in Antwerp. The event was of course a dwarf in the company of the two Primary Health Care (PHC) conference giants, Alma Ata and Astana respectively.  We know our place, do not be mistaken. No hubris at play. Nevertheless, below I offer a few words on it, having been prominent in its design, and, foremost, having learned from it. Life-long learning, you know – even at 62!

The symposium was well attended, with around 200 people present. Somewhat unexpected, perhaps, but heart-warming and encouraging. A diverse audience, with people from North and South (to the extent that these terms still have meaning in our times); Masters and postgraduate students (making up about 2/3 of the audience) and experienced professionals; academics and practitioners. In short: a diverse public but also – unfortunately – still a bit a biased one given the dominance of people with a medical background in the room.

Let me first share the main lessons I draw from the ITM symposium. Firstly, PHC – a value and rights-based framework – is still considered as relevant, both in ‘technical’ as well as in ‘political’ terms, despite the unsatisfactory global track record when it comes to implementation and notwithstanding the dramatic changes that have taken place in our world since 1978. Secondly, there’s a consensus on the need for a pragmatic, inclusive and systemic vision on the concrete implementation of PHC. No room for rigid and dogmatic one-size-fits-all blueprints, but rather context-specific combinations of models ranging from genuine community involvement, over specific and complementary contributions by first-line professional multidisciplinary teams, to specialists at referral hospitals, and cadres from specific disease-control interventions.

With some hindsight, however, there are also three issues that would have deserved more attention, in my opinion (even if a one-day symposium of course only lasts… for one day!).

First of all, there is  a clear need for more insight into – and thus research on – how to achieve effective and sustained multi-sectoral collaboration. How to move beyond the slogan? Which approaches work and which don’t? And why? And should we per se start from the health sector? We somehow seem to take that for granted, but is that justified? For instance, in my experience with Belgian local governments, which play a growing role in the local stewardship of PHC, the social welfare sector is a more important driver for multisectoral collaboration…

Secondly, it’s important to caution for a too naïve – i.e. overly smooth – view on participation. Indeed, participation tends to go hand in hand with a tension between people and professionals, sometimes a very frank one. Social movements channeling people’s needs and expectations, via (social) media and through demonstrations or other public activities,  may indeed pressure politicians and policymakers to act. That’s when and how ‘political will’ gets created in the first place, in many settings. The case of the recent Belgian municipal elections is telling in this respect: people’s call for radically different mobility and environmental policies in our inner cities and for more clean air became, a bit unexpectedly, a central theme in the debates preceding the elections.

And thirdly, there is the elephant in the room… What about the clear and loud call in 1978 for a New International Economic Order (NIEO)? What about a NGEO (we would probably call it a New Global Economic Order nowadays) in 2018? There are doubtlessly many explanations for the relative silence on this front… I wish to share a hypothesis. A new social, economic, political and ecological order encompasses so many interlinked & intermingled issues (complexity!) that debating such an order is anything but easy. How to engage into a wider public debate on something that virtually influences all dimensions in our societies and lives? What language to use? I have no definitive answer. But I believe it would be useful to consider a ‘pedagogical’ approach – a narrative – that enables a dialogue with the general public. A suggestion? Well,  the recent book by Oxford economy professor Kate Raworth – “Doughnut Economics” – made a deep impression on me. The clarity and coherence of her analysis, and, above all, the power of the images she uses, stood out for me. In her book, the inner ring of the “doughnut” represents the “social foundation”, the situation in which everyone on the planet has sufficient food and social security. The outer ring represents the “ecological ceiling”, beyond which excess consumption degrades the environment beyond repair. The aim is to get humanity into the area between the rings, where everyone has enough but not too much – or, as Raworth calls it, “the doughnut’s safe and just space”. Perhaps the doughnut is a good starting point for a new narrative on the NGEO anno 2018?

Over to the meeting in Astana, then.

I am truly happy (and proud) that I could attend this historical conference, hosted by WHO (with a prominent role for WHO Europe), UNICEF and the government of Kazakhstan – as part of the official Belgian (federal) delegation. This landmark meeting was only possible because of the commitment of so many national governments, international and multilateral organizations. The conference was attended by 2156 delegates coming from 96 countries. The relevance of the core values and principles of the Alma-Ata declaration were explicitly reconfirmed and the vital role of PHC in Universal Health Coverage (UHC) emphasized. The Director-General of WHO, Tedros Ghebreyesus, was crystal clear: there’s no UHC without PHC. He further referred to the forthcoming United Nations General Assembly (UNGA) High-Level meeting on UHC in September 2019 “as a powerful opportunity for PHC”.

Even if the world may have become a healthier place compared to 1978 (see the increased life expectancy and the improvements in child and maternal mortality, for example), there is no room for complacency. The conference acknowledged that progress in PHC implementation is lagging behind and that for many the promise of PHC remains unfulfilled. Achievements are uneven and unfair. Social determinants of health are insufficiently addressed. And people should be at the center, not diseases. Henrietta Fore, UNICEF’s executive director, was firm: “at the current pace, we will not reach SDG 3.8”. In short, it is now time to deliver.

The two-day event was built up around six plenary sessions and some 25 parallel more specific sessions. Youth got a prominent place in Astana (120 youth delegates attended the conference!). A number of new focal areas were addressed in light of the dramatically changed (and ever faster changing) world. These ‘updates’ covered a wide range of issues and concerns: the digital revolution, connectivity, development of new technologies, disruptive innovations, quality of care, research on PHC, family medicine, social accountability, mental health (cyber bullying!), health for indigenous people, metrics for monitoring PHC implementation, the interface of health with ministries of finance, healthy cities (even healthy islands!) and the positioning on PHC by European mayors, human resources for health as an investment and not a cost, and much more…

The issue of a NGEO was also addressed in a specific session organized by the network organization Medicus Mundi International (see video), but with limited participation, unfortunately. Again that same elephant in the room…? One of the speakers in that session, a well-known academic and activist from South Africa, put it bluntly:  “people do not seem to have a clue what we are talking about”. So, still (much) work to be done, it seems.

My main take-home message? The glass is definitely half full (which, arguably, tends to be my ‘natural’ sort of perspective on things : ) )  The renewed commitment from the international community towards PHC presents a powerful opportunity and PHC does remain a pertinent and rock-solid societal program. Still, the glass is also half empty: if during the last 40 years we were not as successful as we would have liked to be, why then would we succeed now? Quoting Primo Levi’s epic book is appropriate here: “If not now, when?”

Let me conclude on a positive note.  I was pleasantly struck by the intervention of the Nuncio of Vatican City at the opening of the conference in which he explicitly blamed the “current systemic tendency in our world towards inequalities and inequities in health and health care”. And then there was the hopeful and rallying pro-PHC speech by Dr Caryssa Etienne, current PAHO Director, at the closing session of the conference. She was rewarded with a standing ovation from the audience.

Primary Health Care, here we come!



PS: on a side note, Alma-Ata means ‘father of apples’ in Kazakh. Alma-Ata claims the honor of being the birthplace of this fruit. The Kazakh Minister of Health Elzhan Birtanov in his final closing speech mentioned that… 17.000 apples were eaten during the conference!


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