International Seminar on Primary Health Care
25 Years of Alma-Ata
Distinguished Ministers, Ladies and Gentlemen,
I am happy to be with you here in Brasilia to mark the 25th Anniversary of the Declaration of Alma-Ata on Primary Health Care. I would like to thank Dr Humberto Costa and the many others involved for organizing this important event. It is very encouraging to see so many key countries and organizations represented in these discussions. It is a unique opportunity to learn from the past and present activities and make bold plans for the future.
At this seminar, the main reference point is a milestone for global public health in the last century. The Declaration made in 1978 launched what became known as the health-for-all movement.
Health for all is not just an idea or a slogan. It is an all-important fact of life: health is for all people. Everyone needs it and has the right to the best health possible. Every society has the duty to ensure that every one of its members receives the health care they need.
This was a clear understanding shared by the 134 countries and 67 organizations who met in what is now Kazakhstan to discuss primary health care 25 years ago. Their call for action included specific guidance on how to proceed by applying the principles of primary health care. It inspired the world and brought out the best in many people, many health systems, and many countries. It led to many achievements, and represents a period of great hope in the history of public health.
Its work remains unfinished, however, and has been followed by setbacks and uncertainties. It is time for renewed commitment to the health of all people.
The man who did most to define and promote the notion of health for all was Halfdan Mahler. He was the Director-General of WHO from 1973 to 1988. I am delighted that he too is with us here today, and that you could hear some of his knowledge, memories and ideas first-hand yesterday.
The millennium we are now in seemed far away in 1978. At that time the cold war was in full swing, and controversy raged over socialism versus capitalism, public versus private financing, vertical versus integrated health care, and other major issues. But the vision and methods of primary health care cut through those arguments with a practical agenda that everyone could support and participate in. That agenda needs rethinking for today's conditions, but the principles of universal coverage, intersectoral support, and community participation, so clearly set out 25 years ago, remain as valid as ever. Now as then, we do not have to wait for the political differences to be settled before taking action.
In the last quarter of a century, we have achieved a lot and learnt a lot through unprecedented global cooperation. What we learnt from eradicating smallpox we are applying to eradicating polio. Earlier this year we stopped a global outbreak of SARS. Immunization programmes have saved very large numbers of children from infectious killers.
But great challenges lie ahead. The world has changed significantly, and global health needs have become even more complex than they were in 1978.
First, health systems have changed. Some of them are failing because of economic crises and conflicts. Different approaches to financing health care have been tried, with mixed results, while costs for individuals' out-of-pocket health expenses continue to rise. The private sector is playing a prominent part in health care provision, and the growth of NGOs is producing new ways of organizing and carrying out health work.
Second, the burden of disease has changed. No one had heard of AIDS in 1978, yet it is now the number one health threat worldwide. Tuberculosis has made a comeback; cardiovascular diseases are increasing; as are mental health problems.
Third, some diseases are more responsive to our control efforts than others. We have made progress in controlling several communicable diseases, such as leprosy, onchocerciasis and guinea worm, but half a million women still die every year in childbirth and pregnancy.
Fourth, the world's demographic situation has changed, and with it the distribution of health problems. There are two billion more people alive today than there were in 1978. Migration and ageing populations are putting new pressures on health systems. Health workers also naturally move to wherever they can find the best conditions of service, leaving the neediest places shorter still of staff.
Fifth, globalization changes the world's health situation. Back in 1978, few would have imagined the interconnectedness we now have. It brings rapid access to life-saving technology, but it also brings new health challenges in areas such as food safety and bio security.
The most unexpected event of all has been HIV/AIDS, which has now claimed nearly 30 million lives. The number of deaths and new infections is still rising. This disease is destroying individuals, their families and communities, and whole societies. It is the worst social and health disaster the world has seen for several centuries. Eight thousand people are dying of AIDS every day, despite the availability of effective treatment.
On September 22, responding to repeated calls from the World Health Assembly of our 192 Member States, I declared the treatment gap for HIV/AIDS to be a global health emergency.
That AIDS still kills almost everyone infected with it in poor countries is unacceptable both morally and by any standard of public health. I have committed WHO to assisting the world to get three million people onto ARV therapy by the end of 2005. In this way we will demonstrate that the situation can and must be changed. That is our target. Our goal is universal access to AIDS treatment.
Brazil has shown the world that this is possible, and other countries are following your example. They need all the support the international community can give them in order to obtain the necessary medicines, diagnostics and expertise.
Experience shows that ARV treatment is a powerful means not only of restoring AIDS patients to active life but of preventing HIV transmission. Where people know that effective treatment is available, they come forward for testing and counselling. When they know their HIV status, the transmission rates go down. Stigma is thereby reduced, and with it the social fear and secrecy which help the infection to spread invisibly.
As you may have noted yesterday with Dr Mahler, the Alma-Ata Declaration described primary health care as "essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families within the community". In many places ARV therapy is the most essential form of health care, and the most urgent task is to make it accessible.
In these ways the 3-by-5 Initiative is designed as a catalyst to reactivate health systems based on the principles of primary health care. It compels us to focus more sharply on results, work with more speed and determination, mobilize more resources, and coordinate more effectively the activities of the many different providers now involved in health care.
The biggest challenge in all these activities will not be the cost of drugs. Thanks to the impressive efforts made in this country and others, the prices of the essential medicines have fallen and are continuing to fall. Meanwhile, the money being made available to purchase them is increasing.
It is human resources that are in much more critically short supply. For the 3-by-5 Initiative to succeed, we have to train 10 000 new health providers and community treatment supporters in the next six months, and 100 000 in the next two years. When I say "we" have to do it, fortunately I do not just mean WHO. I mean all of the countries and organizations represented here today, and all of the others, many of whom are already hard at work on it.
The principles of primary health care can unlock that door as well. Early on in the PHC campaign many of the doctors and nurses involved started saying it was not just about health for all but health by all. They saw that everyone could help to provide the care and the many different services that were needed, including community and family members of patients. They can be trained as necessary. Once trained people have experience they can train others. Once they have mastered some of the necessary skills they can acquire more. It is this process that will rebuild and strengthen health systems more than any other.
We will present a report on Primary Health Care at the next World Health Assembly. It will take into account your findings at this meeting and other recent ones such as those held in Madrid and Almaty in October. The purpose is not to dwell on the past but to use what we can learn from it as our guide to the future.
At this point we know that some principles should get more emphasis than they did in the Alma-Ata report. These include:
- the need for international action on some of the current determinants of health that cannot be controlled by countries acting on their own (such as infectious disease outbreaks and food safety);
- the need for governments to maintain full responsibility for the health of all while working as necessary with the private sector and civil society;
- the need for full recognition that prevention and care are complementary: one cannot replace the other or be seen as an alternative to it. This has become self-evident with all the current major disease threats.
The Millennium Development Goals provide some clear indications of what today's health systems must aim for. Reduction of the suffering, illness and death associated with poverty, together with living and working environments that make health possible, are achievable with strong partnerships.
But there is a danger with long-term goals. 2015 is the deadline for the Development Goals, and to some that still seems a long way off. The health for all goals were to be achieved by the year 2000. That too was a long way off in 1978. At first it seemed too soon for an all-out push, but then by about 1990, it seemed too late. Let us not make the same mistake with the MDGs. At present they have the strong support of the global community, they are achievable, but only if we seize the present opportunity.
Simón Bolívar, known to many on this continent as the Liberator, is famous for having said: "Let us do the impossible today, and leave what is difficult till tomorrow." It was a great approach, but with things changing so quickly in our own time, we might need to update it a little and say, "Let us do both what is impossible and what is difficult today", and just leave what is easy till tomorrow.
Business as usual is not an option. At current rates of progress some of the MDGs will take 150 years to reach instead of the 15 planned. Our hope for the 3-by-5 Initiative is that its short time frame will convey the necessary sense of urgency in one area, and thereby trigger action in the others as well.
The principles of primary health care, revised in the light of current realities, provide the specific framework within we can all do our part in strengthening national health systems. Our gathering here today, from many parts of the world provides a great opportunity to find out more exactly what we need to do.
It may very well be that the presentations and discussions of yesterday and today will also mark a new beginning in many situations for health systems designed to meet the needs of all people.
I wish us all every success.
Thank you.