We Still Need a Grand Vision

The WHO defines health as a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity. The Declaration of Alma-Ata cited this definition of health to emphasize the right to health for all and, thus, urge governments to implement comprehensive national health systems. As we discussed during lecture and section, the broad scope of this declaration was greatly criticized. The declaration set unrealistic expectations because it posed immeasurable, and seemingly unattainable, goals to achieve better health for all around the globe. In spite of all these criticisms, primary health care has set the standards for today’s expectations for health systems precisely because it encompasses a grand vision: health as a fundamental right.

The Declaration of Alma-Ata was a great tool for setting the framework around global health; it incited all countries to consider the health of their people and how these people were accessing the health care system. As broad as the overarching mission to implement primary health care was in scope, it served as the foundation for the “Primary Health Care movement,” which has trickled into today’s ambitions. For example, the WHO’s World Health Report of 2008 emphasized placing people and their health needs at the forefront of health care. In addition, the Bill & Melinda Gates Foundation, World Bank Group and WHO just came together in September to form a new partnership, the Primary Health Care Performance Initiative (PHCPI). The PHCPI’s aim is “to support [low- and middle-income] countries in improving the performance of primary health care.” It will help countries monitor, track, and share their key vital signs, which include information about the health system as a country’s priority, service delivery, and the delivery of better outcomes. In this manner, primary health care will continue to address the social determinants of health, but on a country-by-country basis. However, I wonder how exactly these three powerful organizations will work with other countries’ community values instead of imposing their own values.

In addition to addressing social determinants of health, primary health care also focuses on the need to improve value for patients, “where value is defined as the health outcomes achieved that matter to patients relative to the cost of achieving those outcomes.” (HBR) In this manner, we should be able to improve outcomes without increasing associated costs or decrease costs without worsening the outcome, thereby obtaining better health for all. The overall aim is ensure that everyone is achieving the best outcomes at the lowest costs, that we are offering a ‘ preferential option for the poor’. Yet, to what extent is this ‘preferential option for the poor’ influenced by and idealized in Western settings? Primary health care is supposed to avoid the elements of paternalism that are so prevalent among the “magic bullets,” like antiretroviral drugs and regional and global vaccination campaigns.

Magic bullets have the benefit of being simpler and more cost-effective than longer-term goals, but also distal to the social determinants of health. The global eradication of smallpox, for example, failed to address the more pressing concerns that the last communities with smallpox were facing. Further, it raised questions about the ethical implications of taking a vertical approach: How important is it to vaccinate all resistant individuals? Will this actually benefit all global citizens? Should we be more concerned with hazards, like smoke accumulating in houses when someone cooks or water contamination? These more narrow, yet measurable goals that are characteristic of vertical approaches and selective primary health care often detract from the social determinants of health, thereby ignoring the “causes of the causes” that negatively impact health.

Interestingly enough, other kinds of “magic bullets” dealing with HIV/AIDS don’t necessarily avoid social determinants of health altogether, but rather create what Dr. Adia Benton calls “methodological horizontality.” In this way, we do not place our sole focus on the disease and targeted clinical interventions or only promote evidence-based interventions to obtain funding. This combination of vertical and horizontal programmatic approaches allows us to address HIV/AIDS diagnosis, treatment, and follow-up while also conducting other health programming. Would this approach work for all diseases? Can we simultaneously work toward providing truly accessible, affordable, and coordinated primary health care and also address problems that require specialized care?

Discussion Questions:

  1. Do we need a global framework for primary health care? Or can other countries interpret primary health care as they see fit for their needs and, thus, develop nation-specific primary health care?
  2. Can we ever truly eliminate elements of paternalism from our (American) international health efforts?
  3. How can all nations work toward providing truly accessible, affordable, and coordinated primary health care to then be able to address problems that require specialized care?

 

Sources:

Benton, Adia. HIV Exceptionalism: Development Through Disease in Sierra Leone. U of Minnesota, 2015.

Bryant, J. H., and J. B. Richmond. “Alma-Ata and Primary Health Care: An Evolving Story.” Health Systems Policy, Finance, and Organization. By Guy Carrin. Amsterdam: Elsevier/Academic, 2009. 59-81.

Cueto, M. “The Origins of Primary Health Care and Selective Primary Health Care.” American Journal of Public Health, 2004. 94(11)1864-74.

Greenough, P. “Intimidation, Coercion, and Resistance in the Final Stages of the South Asian Smallpox Eradication Campaign, 1973-1975.” Social Science and Medicine, 2005. 41(5): 633-645.

Lerberghe, Wim Van, Tim Evans, Kumanan Rasanathan, and Abdelhay Mechbal. The World Health Report 2008. Geneva, Switzerland: World Health Organization, 2008. http://www.who.int/whr/2008/whr08_en.pdf.

Porter, Michael E., and Thomas H. Lee. “The Strategy That Will Fix Health Care.” Harvard Business Review. 01 Oct. 2013. https://hbr.org/2013/10/the-strategy-that-will-fix-health-care.

World Health Organization. “New Partnership to Help Countries Close Gaps in Primary Health Care.” World Health Organization. 26 Sept. 2015. http://www.who.int/mediacentre/news/releases/2015/partnership-primary-health-care/en/.

11 thoughts on “We Still Need a Grand Vision”

  1. Hi Natalie,

    Thanks for your post – I think the ideas you brought up are very important to keep in mind when having these conversations about global health and I enjoyed reading the questions you posed.

    I am interested to learn more about the Primary Health Care Performance Initiative and their progress so far, as well as your thoughts on how we can increase organizations like these to work with the community values of a region instead of imposing their own, like you mentioned.

    To answer your first question, I don’t know whether implementing a global framework will ever be possible. I wonder whether the U.S. and other countries like ours (ones that have not put too much of an effort into primary healthcare for all) would have signed onto the Alma Ata if it had been binding and had imposed strict deadlines of infrastructure and other quantitative changes by a certain date. I also believe that a community will almost always be better at developing their own primary care system and understanding the most important needs of their people. I think it is therefore the role of global organizations to work on partnering with the communities to develop not just nation-specific but community-specific goals and implementation of health care.

  2. Natalie,

    I really liked your article. I think it’s important to note that even though the Alma Ata Conference wasn’t exactly a success, it did set the stage for primary healthcare in years to come.

    In response to your first question, I’m not sure we do need a global framework for primary health care. If there is a global framework, who would decide what it entailed? Would it be representatives of each of the countries, and if so, what if they had differing opinions on the most important health issues. I think it is the most pragmatic to allow each country to decide for itself how their particular primary health care will be set up and implemented because only the community itself can decide its own most pressing concerns. In this way, no society is imposing its own views and culture on another.

    However, one risk of having each country decide their own primary health care is the fact that each country may decide either not to implement primary health care at all or may devote few resources to it. If countries are allowed to decide their own form of primary health care, I think it is necessary that some global system is developed that makes the countries accountable. For example, countries could state their goals of primary health care and then periodically report to other countries their progress toward those goals.

    Another risk involved in nation-specific healthcare is the fact that there may be less cooperation among nations. In order for many countries to be able to implement their primary health care, they may need assistance and resources from wealthier countries. If the goal of primary health care is too separated between countries, it may discourage financial assistance.

  3. Hello Natalie,

    I agree with you assertion that we still need a grand vision to propel our efforts towards achieving better health care. Like Methma, I too am curious to hear about PHCPI and its performance so far.

    The questions you pose are complex and give us a lot to think about. In response to the first, I think it is terribly difficult to impose any kind of global framework on every country for many reasons, the most commonly cited ones being differing political priorities and lack of infrastructure and resources. Our best bet, is to make a coordinated effort to work with governments/organizations, who know their citizenry’s needs best, and take measured steps towards achieving better health outcomes for everyone. The question you pose about paternalism also figures into this. I feel that given the existence of a power hierarchy in the world at present, it is very difficult to eliminate all elements of paternalism. I say this (and feel free to disagree with me) because power dynamics are reinforced not only by those in positions of power but also by those in relatively weaker positions. I find this to be especially true in circumstances where development aid (which encompasses health related funding and aid) is in play. However, I do think that while this paternalism cannot be discounted entirely, conscious efforts can be made to minimize it and empower the people who know the local context better in a manner that will have better outcomes.

    To address the last of your questions, I feel that the first step in this direction would be to help governments realize that by improving primary health care, they can prevent more people from developing diseases and conditions that need more specialized care. As I say this though, I realize, that this is in some ways a Utilitarian argument that to some extent does not address the dimension of suffering and puts the needs of the many before the needs of the few. What do you think of this?

  4. Natalie

    Thank you for posting! I think you did an amazing job summarizing our class readings and discussion. I also think you propose some new intriguing ideas and great questions. In response to your last question, Primary Health Care is difficult to implement. Although well intended, the goals of PHC are so large they can become abstract. Individual governments (especially countries that are often paternalized) can become overwhelmed by these abstract goals and end up discarding the ideas of Primary Health Care.

    This is unfortunate because Primary Health Care principles have a lot to offer. However, these Primary health care standards should be offered as guidelines rather than strict obligations. Individual governments should be encouraged to review and adjust primary health care standards and then to create their own health care programs to fit their specific countries needs. This flexibility will create a sense of self-reliance and autonomy and will make governments more likely to implement health care models. This is not to imply that all health care programs within a country should all be government regulated. Many international countries still need external support but this aspect of autonomy is also important.

    Hopefully, these concepts may also reduce the prevalence of paternalism. Paternalism may never be completely removed from global health efforts but it definitely can be reduced. Countries providing aid can initially do this by regulating their international health programs to make sure they are not overly imposing. Additionally, agency can also give nations more confidence to voice their health care opinions and practices.

    Hopefully, this act of minimizing paternalism will overall make nations more motivated to work together, more likely to actively partake in global health initiative and more likely to implement programs on their own.

  5. Hi Natalie,
    I really enjoyed your post, you brought up a lot of good questions about primary care and vertical programs that are key to global health. You mentioned the dangers of developed countries imposing their own ideas of primary health care on other lower and middle income countries. I think its also important to address the flaws of the primary health system in the “first world” countries that claim to have such a good system that it should be replicated elsewhere. Taking the primary healthcare in the United States as an example, we can see that although one of the main goals is to address the social determinants of health, physicians do not always do this. For instance, during a clinic visit a doctor will (for the most part) ask the patient about things like pain, the family’s health history, etc. but will not ask if they have enough money to purchase food, have a stable home, etc. These socio-economic factors that play a major role in health are not usually ignored by primary care physicians, thus illustrating the flaws in the very systems that believe themselves to be good enough to be replicated abroad.

    In response to your third question, I think that the only way for all countries to create, sustainable, cost-effective, and quality health systems are through the proper allocations of government funds towards the medical institutions. In order to keep quality sustainable programs, huge amounts of financial investment will be needed and if the own country’s government does not do it, other countries will intervene, but bring with them their own preconceived notions of a good healthcare system (which would begin to look much like the paternalism that you spoke about in your post).

  6. Hi Natalie,

    It was interesting to read your perspective of global health care and primary care in context of each country.

    It is important to have baseline policies that are applicable to the global community but as far as individual nations and individual communities are concerned, each one has to have a few policies and requirements based on its needs. For example, it is acceptable to have a global policy about vaccinations to limit and eradicate the spread of preventable infections, especially in this day and age as the world gets smaller and global travel becomes easier and faster. This is global health and primary care. However, enforcing people in non-endemic areas to take a prophylactic antibiotic like ivermectin every six months to prevent river blindness is inconsistent with these goals and irrelevant as the infection in endemic to mostly sub-Saharan Africa. This is a primary care policy that should be applicable regionally. On the other hand, another example that is a bit complicated is travel immunization requirements. Saudi Arabia requires everyone traveling to their country to be immunized against meningitis regardless of their country of origin. This is a policy that is directed towards prevention of spread of meningitis to their local population and is therefore a primary care policy; however, it is achieved by imposing rules on outside travelers, making it a global healthcare issue/ policy. So there is a clear crossover. It is therefore important to understand that every country and every region needs to have its own health care policies and interventions while conforming to global health care standards and needs as the situation arises. No country has a right to impose changes on anyone else unless it is done with complete collaboration and cooperation for the betterment of the recipient society.

  7. Hello Natalie,
    I appreciated the fact you considered the Alma Ata important as a grand vision; I think many people overlook the fact that a declaration is in fact nothing more than an announcement of beliefs and intents. The fault of the Primary Care Movement is not that it declared ideals of global health—declarations by nature are grand—but rather that it never had a follow-up conference of plans of action. Historically, declarations, such as the Declaration of Independence, do not set out a plan but rather plant the seed of an ideal. After such, the Primary Care Movement, for the sake of comparison, needed something like an Articles of Confederation to set out rules and constitutions of action to reach the declared goal.

    Achieving this goal of “health for all,” of course, leads to the very complex and interesting interplay between a set vision and paternalism. Like Harsh, I propose that it would be very difficult to eliminate paternalism in international health because power hierarchies are inherent in the act of helping. Foreign aids that coalesce in the Primary Care Movement already have a set idea of what success in a health system should look like. I predict that such a paternalistic struggle would be inherent in partnerships such as PHCPI.

    However, I think models of success are also important to the Primary Care Movement. Therefore, I propose that the idea of paternalism be reinvented as a dynamic model of contemporary health ideals. At some extent, governments providing help need to agree on what success in health might look like. But that consensus of good health needs to be geographically malleable and modified in partnership with local health officials. The great thing about a health constitution is that it can always be amended.

  8. I really enjoyed reading your thoughts on primary health care and the declaration of Alma-Ata. I think you have targeted some key issues central to global health.
    In response to your first question, I think that while conferences like Alma-Ata where nations discuss and decide health priorities are important, nations must specifically create their own primary health programs. I love how you brought up the power of having a shared vision. The idea of “health as a fundamental right,” has definitively shaped our worldview. While I do think that establishing a global framework may not be practical, I think that it is important for nations to create a shared vision, especially due to our increasingly globalized society.

    However, like you, I am wary of paternalism and how “this shared vision” may be influenced by nations in position of power. An example is Bolivia, where aid from the World Bank was only given when water was privatized by the U.S Company Betchel. I am worried that a global framework would perpetuate existing inequities and place certain nations at a disadvantage. I do not think it is possible to truly eliminate paternalism, but I do think that we can work towards being more aware of the cultural context and voices of the people we provide aid to.

    With regards to your third question, I think primary health care is the first baseline step towards improving human health. When strong primary health care facilities are established, specialized health care will automatically improve as a result.

  9. Hi Natalie,

    Thank you for your very well-written post on the Alma Ata, Primary Health Care, and Selective Primary Health Care. I agree that although the Alma Ata was vague in its actual plan of action, it was necessary to create a moral structure for future standards of care.

    I appreciate the fact that you marked your description of the ways in which PHC lives on in today’s interventions with a question about how exactly that PHC framework is imposed on the cultural context of a place. In many ways, primary health care is a wonderful vision to have and has the potential to create a lot of change, but it is definitely worthwhile to consider the fact that it is a movement that was created within one cultural framework and a certain type of health care system. How will it translate elsewhere? In answer to your first question though, I do think we need a global framework for primary health care. In many ways, I think the Alma Ata could still serve as that framework, though it could of course be updated. Specific goals must rise underneath it however, in order for it to have any effect, as we have already see. Those goals must be more location and culture-specific.

  10. Hi Natalie,

    Your blog post is very interesting and informative. I was unaware of the new partnership of the three organizations creating the PHCPI. I think this partnership is a step in the right direction. Addressing health inequalities in low and middle-income countries will be beneficial global health, but you bring up an interesting point in that it is possible that these groups will impose their own values, as opposed to working with these countries.
    I think it is important for these organizations to recognize the significance of being culturally sensitive, as that is how they will better understand the causes of these health disparities. To answer your second question, I think it is possible to eliminate elements of paternalism from America’s international health efforts. As I mentioned, being culturally sensitive when dealing with such issues will be important not only for eliminating this patriarchal view, but also in resolving the issue. With the right efforts, I think it is possible to eliminate these elements.

  11. Hi everyone,

    Thanks for your thoughts!

    Some of you commented that you would like to hear more about PHCPI’s progress, so here is their website: http://phcperformanceinitiative.org/. Their approach and activities are based on the following areas of work: 1) Strengthen Performance Measurement, 2) Generate and Share Knowledge, 3) Promote Country-level Improvement, and 4) Engage Partners to Build Momentum.

    Like many of you, including Harsh and Methma, pointed out, I also think that it would extremely difficult to create a global framework for primary health care because of the logistics of its creation. If the US and/or other developing nations were involved in this framework, would their vote inherently hold greater value? Would these voices be the loudest in the room? This hierarchal structure is not only reinforced among countries, but within them. As Harsh stated, to some extent, some in weaker positions relative to power uphold the status quo. Thus, how we address the questions that Sierra brought up? If there are only country representatives, how does this larger global framework account for the varying narratives and priorities within the country?

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