Of Alma Ata or Almaty: Primary Health Care is everybody’s responsibility

“The International Conference on Primary Health Care, meeting in Alma-Ata this twelfth day of September in the year Nineteen hundred and seventy-eight, expressing the need for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all the people of the world, hereby makes the following Declaration…”

Next month, it would be 44 years since the most redefining moment for healthcare in history. The above were the opening words that preceded the 10 points that formed the famous “Alma Ata Declaration” – the global standard document for primary health care structuring across the globe. Those words struck me the first time I read the 77-paged report of the 1978 International Conference on Primary Health Care (PHC) held in Alma-Ata (present day Almaty), which birth the declaration. The conference, jointly sponsored by World Health Organisation (WHO) and the United Nations Children’s Fund (UNICEF), arguably remains the most significant healthcare event of the 20th century.

Contrary to what many think, the Alma Ata declaration called for urgent action by all stakeholders - not just governments of participating nations. The declaration stated clearly that contributions from government, health and development workers, and the world community were collectively needed to promote people’s health. 

For almost five decades, the Alma Ata Declaration has continued to be the basis for several discussions in the global health space, and many programs hold to appraise its core components and strategies. Despite tremendous efforts and commitments from stakeholders, we are still quite far from reaching the highlighted goals from 1987, thus necessitating reviews and re-commitments from member nations. For example, the health for all 2000 goals did not achieve the desired outcome; hence a 2030 UHC goal was set. More recently, world leaders gathered again in Astana, Kazakhstan, in 2018 for the 40th anniversary of the Alma Ata Declaration to restate their commitment to primary health care. Virtually all preventive healthcare programmes worldwide build on the principles of the Alma Ata Declaration or the Rockefeller Foundation-sponsored Bellagio Conference of 1979, which further reviewed the Alma Ata principles to curate the selective PHC model, popularly known for its GOBIFFFF strategy. 

The COVID-19 pandemic, which almost shook the world to its roots and got the whole world on lockdown, with the aftermath of economic meltdown, more than ever, exposed the deficiencies in the healthcare systems of most nations which failed hitherto in building solid and efficient PHC.

Background:

The Alma Ata Conference was the first international meeting of world health leaders to look into global health as a social issue, emphasize the importance of PHC in ensuring healthy living for all people, and design strategies for nations to pursue PHC. The organizers of the conference, notably the WHO and UNICEF, utilized history and human experience from hundreds of years which potentiate the idea that the best health system shifts focus from management to prevention and that healthcare works better by empowering people and communities as stakeholders in their health. Or who better handles health, if not those concerned?

PHC, being one of the most studied health care concepts, has several definitions, coined as per the perspectives and understanding of various researchers, countries, and organizations. One of the most popular definitions states that “PHC is an essential care based on practical, scientifically sound and socially acceptable methods and technology, made universally accessible to individuals and families in the community at a cost they can afford to maintain at every stage of their development.” 

The WHO and UNICEF, in “A vision for primary health care in the 21st century: Towards UHC and the SDGs”, defined PHC as “a whole-of-society approach to health that aims at ensuring the highest possible level of health and well-being and their equitable distribution by focusing on people’s needs and as early as possible along the continuum from health promotion and disease prevention to treatment, rehabilitation, and palliative care, and as close as feasible to people’s everyday environment.” 

The Alma Ata conference and its declaration stand out among health care innovations for many reasons. They brought the need for more focus on health care issues across the globe and worked out the ideal structure of primary health care. The conference focused on the possibilities of health care systems of people, by the people, and for the people. It established critical components of health care as highlighted in the ten focal points of the declaration. 

Firstly, the conference defined health as a state of complete physical, mental and social well-being and not just the absence of diseases and infirmities. This definition ultimately redefined the perception of healthcare across the globe. Through the definition, we know that health transcends beyond the strict medical point of view and is, in fact, a matter of everyday living and survival of people. The conference identified the inequality of health, a fundamental gap in access between developed and developing countries, and between urban and rural communities. The evident gap was declared politically and economically unacceptable, placing healthcare as a human right; everyone must have equal access irrespective of where they live or to the societies to which they belong. 

Also, the conference highlighted health care as not just a scientific issue but a socio-economic issue. It provided that the economic and social development of any society is a requisite for quality health care, and the health of people – human resources – remains a critical factor for socio-economic growth. It emphasized the role of community participation in PHC. It posited that healthcare is better delivered in communities when the people themselves participate in the processes of health care financing and delivery since they understand the health peculiarities in their communities and have historical approaches which are socially acceptable by the community. 

The Alma Ata principles logically provided potential solutions to significant global health care challenges. However, 44 years later, many countries – especially the LMICs – still battle defective systems. The situation calls for solid reflections!

Why PHC is a trump card

PHC is the most essential and the basic functional unit of health care services worldwide. It is a good foundation upon which other levels of health care services build. It offers innumerable advantages to the people and societies it serves if carefully designed and implemented. 

Many authorities have described PHC as the most cost-effective strategy for quality health care delivery because of its focus on community participation, mobilization of local resources, including land, labour, capital, and enterprise, and an evident reduction in advanced health care needs in the long term. Since it aims to reduce the global health care burden, it adopts strategies that not only favour developed countries but equally provide a framework of health services development for the developing countries; thus, it attempts to eliminate international disparities. 

Unlike other levels of health care, PHC addresses the socio-economic determinants of health as an essential aspect of health challenges. Hence it tries to cover the inequality gaps by ensuring that everyone has access to essential care, irrespective of their social class or status. Focusing on the health services that all populations need and not those wanted by specific individuals or groups ensures that the state cheats no one in the distribution of limited resources to health. It is about a system where everyone gets access to the health services they need for survival.

More so, a health care system that prevents ill-health more than it treats illnesses – as guaranteed by PHC – ensures a healthier population for nations and raises life expectancy. Consequently, societies with well-organized PHC conserve human resources and have higher productivity, a factor necessary for economic growth. 

Furthermore, PHC empowers local communities to cultivate a sense of innovation and critical thinking through local technology and ideas for solving community problems. It promotes self-reliance and self-determination. These principles help federations achieve the devolution of powers to prioritize PHC, enabling lower units or groups within the nation to develop a sense of responsibility in other aspects of governance as it affects them.

Historical Perspective: Rural Cooperatives Medical System (RMCS) of China

As popular as the Alma Ata Declaration is, many people do not know that the Alma Ata Conference on PHC was largely influenced and motivated by earlier successes in a rural healthcare model that became popular in the wake of the Rural Reconstruction Movement of China in the 1930s. 

Known in texts as the Barefoot Doctors programme, the RCMS was a health care programme that trained local farmers and other artisans in rural areas of China in the art and practice of health promotion, disease prevention, and treatment of common ailments. It was promoted in China after the government noticed that urban and rural public health differences were massive despite the attention put into centralized healthcare. The government considered rural healthcare important, as an estimated 80-90% of the population lived in rural communities. Most of the participating barefoot doctors had no formal education, and the few who had were merely school certificate holders. Nevertheless, the government was able to design a training system that qualified them as health care workers who were skilled in the essential components of preventive health care. 

The community members usually selected the barefoot doctors to serve them and fund their activities through community-driven welfare funds and local farmer contributions. This involvement made the programme a thorough community programme since the farmers chosen in each community best understood the communities' health challenges.

The barefoot doctors often moved around in villages, attending to the rural residents from house to house, providing services that focused more on prevention than treatment; each community decided the pay of the barefoot doctors based on the peculiarities of the communities. The term barefoot comes from the fact that the program incorporated a lot of rural farmers who were known for walking barefoot - a lifestyle they took along into the barefoot doctors' programme. 

China recorded outstanding success in the RCMS years with numerous positive outcomes such as life expectancy, mortality rate, and doctor-patient ratio. The RCMS's success indicated that the health care challenges in developing countries could be tackled even in the face of scarce financial resources.

The programme was so successful that the WHO described it as "a successful example of solving shortages of medical services in rural areas" and called for global adoption of such models – hence, the Alma Ata Conference. 

However, the Chinese government abolished the programme after a political restructuring that saw the end of the communal system in China. The government reworked barefoot doctors into a new model of 'village doctors.' Over the following years, China witnessed a steep drop in the rural public health status; the healthcare crises of poor people increased substantially afterward – proving that health is indeed a socio-economic issue with strong interconnections to politics and economics. Many barefoot doctors took further training to qualify as medical practitioners after the abolition of RCMS. Interestingly, China's former minister of Health, Chen Zhu, was a product of the barefoot doctors programme. 

The Nigerian Story

There is no gainsaying that a lot is wrong with the Nigerian Healthcare system. Although I have always been interested in our public health system and had read several papers on the issues in the system, I was still unprepared for the accurate picture. In less than two months of medical practice, I realized much more than I did through books and conferences that our current healthcare system is on a long road to failure. Our structure has technically collapsed and would take a total overhaul to change the story. 

The question of our health care systems planning in Nigeria has been controversial for too long. Despite our participation and theoretical commitment to the Alma Ata principles, we are far from doing the things recommended by the declaration. Our health system has revolved for a lengthy period around tertiary healthcare, with the Federal Government and the State Governments focusing on establishing several tertiary centres without a clear focus on what the centres hope to do. The current system commits the bulk of our funding to those centres that serve less than 10% of the population and are not easily accessible by people who do not live in the urban centers. More so, the lack of an efficient health finance plan for our exponentially growing population makes it difficult for people to willingly use those tertiary centres where they have to pay out of pocket. 

Our shift from primary health care puts us in a quagmire as there are not so many preventive healthcare strategies. Poor people who are the majority and who mostly live in rural areas depend on charlatans that are more accessible for care. Those people exist as charlatans because we have failed to organize a proper system to optimize the opportunities of their existence with the provision of training programs as was obtainable in Ethiopia under the leadership of Dr. Tedros Adhanom, who was health minister from 2005-2012. Our health system discards traditional resource persons' ideas. It outrightly rules them out of the plans, even when we have no clear strategies to get qualified medical and health care professionals to work in rural areas. The few who work in those rural centers go there from the urban centers daily and do not live in the communities; hence they have no connections with the grassroots - a condition that is core in the Alma Ata principles. Rural communities that are privileged to have their indigenes become successfully trained as healthcare workers do not enjoy the benefits. Those indigenes usually do not dream of serving the communities since they do not earn much there.

We have on our hands, a total breakdown of preventive strategies across the five levels of prevention. People in disadvantaged communities have no access to information and resources due to poor road networks, the disparity in technological access, and the lack of commitment of healthcare workers to rural communities. There is a concomitant lack of specific protection due to the same reasons. So many communities remain unreached. The lack of efficient primary health care centres and lack of capacity at the rural level also prevent the early diagnosis of health problems. In most tertiary hospitals, most patients present with complications of diseases and not the disease entity itself. By the time they present, they are usually already at advanced stages of the disease, with a worse prognosis, and need even more expensive resources to manage the complications. Their complications are still not well managed at the tertiary centers because of financial constraints since the hospitals only exist without much attention to how people get funds to obtain proper care. So even at those centers with sophisticated apparatus and well-qualified health care workers, including specialists, patients waste away because they do not have funds. 

To put it into perspective, the first time many Nigerians know that they have hypertension is when they come down with heart failure or stroke. They then need more funds to treat the complications of a disease condition ordinarily managed in most cases with essential lifestyle modifications or relatively cheaper medications. Most of those who suffer a stroke end up spending days on the hospital wards without a definite diagnosis because they have no finances to get a Computed Tomography scan done. Moreover, it is not peculiar to hypertension only. The first time many Nigerians get diagnosed with peptic ulcer disease is after presenting with gastrointestinal bleeding or perforations. 

Malaria, one of our leading health challenges, and by now, we should have built massive capacity against even among rural dwellers, still kills children. Many Nigerian children whose caregivers live below a dollar per day are not diagnosed with malaria when it is uncomplicated and requires less than a dollar to treat. Instead, they present as severe malaria (often cerebral) with complications that eventually require hundreds of dollars to manage. Our health sector is an endless cycle of self-perpetuating calamity with no clear solution in sight. The list goes on. I project that the situation will get worse in the coming years, given the alarming rate of our export of health care workers (the brain drain), another impending doom that health care leaders seem not to be bothered about yet. 

The problems ravaging our healthcare sector stem from many factors, including a lack of political will to change the narratives. There is an evident infrastructure deficiency, little or no focus on human capital development and capacity building, unimpressive funding plan, neglect of culturally-driven and locally available solutions, and a phenomenon of over-reliance on foreign aid and support. The National Health Insurance Scheme (NHIS) and the National Health Act, which both sought to solve significant health care challenges, have not been many success stories. Our annual budgetary commitment to health is disgracefully below 5% despite the agreement between African nations to do a minimum of 15% for health - a pact signed right on our soil. Many stakeholders argue that changing the face of healthcare in the country is only possible by upscaling the budgetary provisions for health. I, however, strongly disagree.

While it is true that our health sector has not enjoyed funding as it should, I believe that the little we get is not optimized. We can do much better with deliberate efforts to reorganize our health care services to do more primary health care. We must prioritize by focusing on the role of community participation and local innovations in the promotion of health and prevention of diseases. We spend too much of the little we have, providing infrastructure and services that most of our people cannot afford to use when we need more commitment to services that can reduce the size of those who need sophisticated healthcare to the barest minimum. State and Local governments should have no business in tertiary health care when there is no available primary health care. These governments, in most instances, leave the duty of primary health care delivery to private practitioners whose target is mainly profit and are usually not altruistic in their care of patients. It is an aberration that certain states with next to zero success in primary health care own up to two, three, or four tertiary centers. A healthcare system run in such a manner cannot develop. 

Nigeria was once on that path to prosperity in health care under the leadership of late Prof. Olikoye Ransome-Kuti. He was a phenomenal minister of health who understood the importance of primary health care. He dedicated his leadership to structuring the Nigerian primary health care system based on the Alma Ata principles. He was bold and fierce in his resolve to commit more resources to primary health care components than tertiary health care. Although his reforms in health services delivery met with resistance from some quarters, he remained focused and insisted that there was no reason why 90% of the health budget should serve less than 10% of the population. The successes achieved through his reforms are said to be yet unmatched. As obtained in all other politically-driven sectors, his reforms were thrown away with a change in government, and the rest is history. 

What we must do

The most crucial strategy to eliminate our current health care challenges is to return to the communities. We must imbibe lessons on PHC from nations working and from our short stint in the Ransome-Kuti days. Health care leaders and administrators have to return to the basic principles of the Alma Ata declaration to enable a system that promotes health and prevents diseases. To do this, I opine that the following agenda is necessary.

1. Healthcare Services Organisation:

We must urgently commit to reorganizing the current structure of our healthcare services. The stratification of health services into primary, secondary, and tertiary has to move from being merely theoretical to practical. To do this, the Federal Government (FG) must devolve power and policy-making to the State Governments (SGs) and Local Governments (LGs). The SGs should be charged with designing PHC models that the LGs under them can implement and maintain. The SGs should be responsible for running secondary healthcare services and providing monitoring for the LGs. The FG should be left to focus strictly on providing technical support for the SGs and LGs in terms of capacity building, research, development, and innovations.

2. Private sector involvement:

Anecdotal evidence proves that the private sector does well in managing advanced healthcare solutions. The private sector has the full complement of staffing, resources, and finances, and we will benefit from collaboration between the FG and private sector to manage our tertiary healthcare services. Of course, many would argue that involving the private sector would make advanced healthcare less affordable for the poor. It would not matter much if we fix our health services first. Maintaining a prevention-oriented PHC system would eventually mean that only a few people would need advanced healthcare, and we will be able to cater to them from our national health finance plans.

3. Increased welfare in healthcare practice and incentivization of rural healthcare services:

The government has a duty on its hands to urgently work out a national strategy to reduce the brain drain and retain the healthcare professionals whose education and training it subsidizes. Losing such professionals to other countries is a waste, and no serious country should look on as things worsen. In addition, the government must work out a new scheme to make rural healthcare services more attractive to practitioners to ensure the presence of a few expert collaborators in the PHC plan.

3. Integration of local and cultural care providers into PHC:

We must begin to have focused discussions on the possibility of implementing an integration programme for local care providers in traditional settings into the various components of PHC with a focus on prevention, early diagnosis, first aid care, early recognition of danger signs and complications as well as appropriate and prompt referrals to qualified experts. Some of the local care practices in the country have existed for ages, and attempts to eradicate them have proven abortive since the practices are inherited culturally. Instead of eradicating them, it may be better to commence programmes that seek to train and equip them with the needed knowledge and skills. Since we cannot stop people in rural places from patronizing the local caregivers, it is necessary that we at least train them to do no harm and to build relationships with them to enable them to refer their patients as appropriate. Caregivers of focus in this category include traditional birth attendants, traditional bone setters, herbalists, traditional mental healers, spiritual healers, patent medicine sellers, and health assistants. 

4. New approach to financing:

Given the inadequate coverage of our current NHIS plan, which mainly covers those in the formal sector, there is an urgent need to focus on covering gaps through community-based and community-driven financing plans to sustain PHC. 

5. Encouraging indigenous solutions and technology:

Our government must commit more to promoting indigenous research, locally available technology, and locally-driven innovations for healthcare. The era of depending on foreign support for everything should be gone. Local solutions are poised best to solve local problems. We must be able to adopt our cultural and age-long health solutions (including traditional medicine), which are socially acceptable and are proven to have no adverse effects on the PHC plan. We also have to recruit local technology to strengthen all healthcare apparatus, especially the cold chain system.

6. Health as a socio-economic issue:

We must develop a more deliberate attitude towards including health as a critical component of our national economic discourse. Healthcare financing, planning, and economics experts must be involved in every national table or discussion on economic development.

7. Policy-making for health:

We must do better with our policy-making for health. Several health challenges are correctable with policies aimed at food security, lifestyle modifications, environmental safety, and the direct elimination of risk factors. Legislation for health must be a focal point in the National Assembly and all state parliaments. Parliaments across the country must establish regular engagements with healthcare professionals to formulate strategic health policies.

8. Fostering inter-professional collaboration:

For a country with so many gaps to cover in healthcare, inter-professional rivalry and unnecessary competition reduce the efficiency and productivity of our already inadequate health workforce. Healthcare leaders across all professions must be able to come together to foster collaboration and prescribe a permanent solution to rivalry. To achieve UHC, we need collaboration, not competition.

9. Positive attitude:

The first step in redefining PHC delivery in Nigeria is for everyone to develop a positive attitude towards health. All population members have a vital role to play in the public health of that population. Healthcare professionals and non-professionals must be ready to play their part in enabling a healthy society. Our people must be willing to take responsibility by paying attention to all details of their health and those around them. We must all be advocates of healthy living. More importantly, those of us in healthcare must see the improvement of healthcare delivery as our collective responsibility and commit to fixing the problems in whatever way we can and from wherever we may be.

The Almaty Focus

To conclude this issue of the newsletter, The Almaty Focus (TAF) as an organization, is my initiative and contribution to PHC development in Nigeria and Africa. Through the organization, other young healthcare professionals and I intend to promote public health in our immediate environment using preventive strategies based on a multi-targeted approach. 

TAF newsletter is one such strategy. Using the newsletter, I hope to drive thought-provoking conversations, intensive conversations, and debates among the younger generation – the future of healthcare – on the most crucial management issues affecting healthcare delivery in countries like Nigeria, focusing on PHC. 

"The Almaty Focus" continues to remind us of the intentions and principles of global healthcare leaders who converged on 12th September 1978, at Almaty, Kazakhstan, to give us the most effective strategy for healthcare. 

Thank you, and I hope you enjoyed reading this.

Till next time,

DSA