Category Archives: Alma Alta, Primary Health Care, and Selective Primary Health Care

Alma Alta, Primary Health Care, and Selective Primary Health Care, Section 3, Unit 2 - Trying to Help

Forgotten: Emergency Care in the Context of Public Health Care Frameworks

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In the 1970s and 1980s, discussion around what and how health systems should be implemented sparked a heated debate. In 1978, the Alma-Ata declared that ‘Health for All’ should be the international goal of countries through Primary Health care. Unfortunately, the Alma-Ata failed, likely due to not specifying where how it was to be funded and the inability to hold countries to their commitment. After this, the concept of selective primary health care emerged, a way to package health services in a cost effective manner. Although both of these approaches aim to improve health, neither of them specifically mention emergency care, and where it belongs in the context of these frameworks and life.

Ziad Obermeyer conducted a study in low-and middle-income countries (LMICs) about the emergency care available. In “Rethinking emergency Care is key to ‘Health for All,’” he summarized his findings. He shed light on the fact that people in LMICs still get pneumonia, diarrhea, heart attacks and asthma. Something I think most people don’t realize is that studies consistently put emergency conditions at the top of list of causes of death and disability worldwide. The number 1 cause of death in LMIC is Ischaemic heart disease at 11.5% of deaths in LMIC, while HIV/AIDS was the 4th cause of death at 6.1% (Razzak & Arthur). Despite this, LMICs tend to have a lack of emergent care facilities, leading to an average of 10 times the caseloads of primary care doctors in the region. I believe that because of this, emergency health care should be a part of any country’s health system, even if it wasn’t in the plans of health care in the 1970s and 80s.

In the Alma-Ata Declaration, statement V says that all people should be at a level of health “that will permit them to lead a socially and economically productive life” by 2000. It then explained that the key to this target is primary health care. While I do agree that primary health care is necessary to track and prevent diseases and should be implemented around the globe, Obermeyer states that 10-15% of deaths in Nigeria occur in emergency care facilities. Most of these people are young and generally healthy, so they lose the most productive years of their lives. If primary health care and emergency health care both support preserving a productive, healthy life, then why didn’t Alma-Ata include emergent care?

Included in the principles of selective primary health care is the idea the main disease problems of poor countries can be solved through low-cost technical inventions, as Cueto explains. In this is the philosophy that “international agencies had to do their best with finite resources and short-lived political opportunities” (12). Though emergent health care was not originally discussed when it came to selective primary health care, I believe that these philosophies are very similar to what Obermeyer observed. In higher income countries, a small portion of the national medical expenditures helped emergency care providers focus on improving quality and training. As many providers in emergent care facilities in LMICs don’t have specific training, select LMICs have benefited from this training too.

The end of the Alma-Ata and the Cueto article on selective primary health care both focus on cost-effectiveness and the reallocation of resources. Investing in emergency care could relieve the burden of primary care doctors, allowing them to better serve their community. Emergency care could also alleviate some of the death and disability in LMICs, allowing for a more productive workforce, possibly boosting the country’s economy. Though the Obermeyer article doesn’t suggest a specific intervention, it does mention the opportunity for low cost, quality education of providers. This, along with a possible creation or renovation of an emergency care facility, could be perceived at a cost-effective strategy. As such, emergency health care would be a valuable addition to health care around the world, even if it’s philosophy is the only thing that might line up with other health care strategies.

  1. Should emergency care systems be thought of as separate of primary health care and selective health care, or are they already integrated into this framework? Are emergency care systems necessary if a strong public health care system is in place?
  2. Would implementing an emergency care facility in rural areas be feasible due to the lack of access to them and the number of providers that would be needed? How could communities be involved in the implementation of an emergency care facility or practices?
  3. Would you consider emergency care a magic bullet?
Alma-Ata Declaration. USSR. 6-12 Sepetember 1978.
Cueto, M. “The Origins of Primary Health Care and Selective Primary Health Care.” American Journal of Public Health, 2004. 94(11)1864-74.
Obermeyer, Ziad. “Rethinking Emergency Care Is a Key Part of ‘Health for All'” Brookings. N.p., 25 Aug. 2015. Web. 20 Oct. 2015.
Obermeyer, Ziad, Samer Abujaber, Maggie Makar, Samantha Stoll, Stephanie R. Kayden, Lee A. Wallis, and Teri A. Reynolds. “Emergency Care in 59 Low- and Middle-income Countries: A Systematic Review.” Bulletin of the World Health Organization Bull. World Health Organ. 93.8 (2015): n. pag. Web. 20 Oct. 2015.
Razzack, Junaid, and Arthur Kellermann. Emergency Medical Care in Developing Countries: Is It Worthwhile? (n.d.): n. pag. Web. 21 Oct. 2015.
Alma Alta, Primary Health Care, and Selective Primary Health Care, Section 1, Unit 2 - Trying to Help

We Still Need a Grand Vision

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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/.

Alma Alta, Primary Health Care, and Selective Primary Health Care, Section 2, Unit 2 - Trying to Help

Vertical vs. Horizontal Approach: The drawbacks of each and a need for a merging or “diagonal” approach

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When thinking about how to address health problems around the world there were two ideas that seem to arise, vertical and horizontal approaches. The vertical approach being a disease specific top-down approach that makes it easier to obtain funding and measure results and the horizontal approach being a more comprehensive approach that seeks to treat all the underlying issues a population that cause various diseases and health problems but that is more abstract.

These approaches are also intrinsically related to the debate of Magic Bullets vs. Primary Care and even in the debate of Comprehensive Primary vs. Selective Primary Care. The vertical model relies on the use of magic bullets, simple and fast acting biomedical advances, in order to implement their programs. When a so-called magic bullet is available and completely effective a vertical approach would be successful as you can reach many people give them a one-time treatment and solve the specific health problem.

The issue arises because there doesn’t exist a magic bullet for the vast majority of diseases that developing countries face, therefore when global health organizations come into these countries with specific disease approaches they are overlooking the structural factors that give rise to health concerns. Comprehensive Primary Care aims to be the opposite of this; it is basically a horizontal approach. The issue there, of course are concerns over cost-effectiveness. Quick-fix and Magic bullet programs come out with a much better ranking in regards to cost-effectiveness which favors downstream medical interventions and finds upstream interventions, such a school-based programs largely ineffective, because it will take several years for the health effects to take place and even when they do it is not easily measurable.

You see this sort of idealistic approach and mentality at the Alma-Ata conference in 1975, with the desire of “Health Care for all by year 2000”. But this model was ultimately unsuccessful and the Selective Primary Care Model that emphasized GOBI (growth monitoring, oral rehydration therapy, breast feeding and Immunizations) triumphed. Selective Primary Care operates more as a vertical approach even primary care in the name because it emphasized only specific issues. While it was an “interim” strategy there were never plans of shifting to more comprehensive primary care.

These two approaches seem like they would have to be competing ideologies, where only one can be correct. I believe that this is not necessarily true. Because both of these approaches have considerable drawbacks and unintended consequences of implementation, the merging of both these approaches would actually increase the benefits while minimizing the risks and drawbacks. In an article by Gorik Ooms, he addresses this as a need for a “diagonal” approach. He suggests that we should be aiming for “disease-specific results but through improved health systems”. This is an interesting idea and definitely important to consider when planning and designing interventions. I believe it is possible to create a new approach that will be more effective; it will however require funding and commitment. Tore Godal suggests the shifting to a Global Health fund that would “consolidate towards a global health fund with one health sector funding channel”. He argues that with an increase in funding and supplies it is possible through a unified effort to simultaneously achieve disease-specific success while strengthening the health system.

Gijs Elzinga also discusses this in an editorial piece titled “Vertical-horizontal synergy of the health workforce” in which he states that while certain components of vertical programs are vertical in nature there is an interface when it comes to the delivery of interventions. Because intervention delivery requires the greatest number of workforce involvement, there is some room for the interventions to be more integrated into a horizontal system, in which health care workers seek to address all the issues. I think vertical approaches can enhance vertical horizontal collaborations and attempt to decrease the polarization of the vertical vs. horizontal debate. The use of more of the existing personnel of healthcare workers is one way this can be achieved.

I believe the strength in this idea of a “diagonal approach” comes from not shifting to a horizontal approach overnight and the integration of the benefits of each. It is important to change the mentality around our approach as only being able to fit into these categories. Although pragmatism is important when it comes to implementation, we need to think about the long-term results and the programs sustainability. We need to implement programs that have the ability to change over time, shifting its goals with increasing resources.

Sources from Class:

Paul Farmer, e. A. (2013). Reimagining Global Health An Introduction.

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

Outside sources:

“Vertical–horizontal Synergy of the Health Workforce.” WHO. N.p., n.d. Web. 22 Oct. 2015.

“The ‘diagonal’ Approach to Global Fund Financing: A Cure for the Broader Malaise of Health Systems?” Globalization and Health. N.p., n.d. Web. 22 Oct. 2015.

Discussions Questions:

  1. Do you think merging the different approaches that we have discussed will yield successful outcomes? Do you think it is possible to implement programs like this?
  2. Do you think the idealism of the Alma-Ata Declaration was influential in making change by getting people to talk about health, or did its lack of pragmatism and ability to be implemented render it basically useless?