ALMA-ATA at 40: From Siloes to Synergy—Linking Primary Health Care to Human Rights

Gillian MacNaughton and Diane F. Frey

In the 1970s, two international milestones emerged to advance health for all. In 1978, the International Conference on Primary Health Care—a joint project of the World Health Organization (WHO) and UNICEF—adopted the Declaration of Alma-Ata. The Declaration called “for urgent and effective national and international action to develop and implement primary health care throughout the world and particularly in developing countries.”^[1] It also reaffirmed that health is a fundamental human right as stated in the preamble to the WHO Constitution. Nonetheless, it did not explain the meaning of the right to health or precisely how it is related to primary health care. Essentially, the right to health was merely a label or slogan. Two years earlier, the International Covenant on Economic, Social and Cultural Rights (1976) had come into effect, elevating the right to health from an aspiration in the WHO Constitution (1946) and the Universal Declaration of Human Rights (1948) to a binding international legal obligation. Yet, the Alma Ata Declaration did not signal the importance of this transformation or recognize the newly elaborated content of this right.

In October 2018, WHO and UNICEF will host the Second International Conference on Primary Health Care in Astana, Kazakhstan. The Draft Declaration of Astana again reaffirms health as a fundamental human right.^[2] Yet, the right to health remains a slogan in the draft, despite the robust content of the right to health that has developed over the past 42 years and despite the commitment of UNICEF to the Convention on the Rights of the Child (1989), which recognizes primary health care as a component of the right to health.^[3] Today, there is no less urgency than in 1976 to advance health for all. “Every day, approximately 830 women die from preventable causes related to pregnancy and childbirth.”^[4] And it is not just health care that is needed. There are 2.3 billion people who do not have basic sanitation facilities such as toilets or latrines, and 155 million children who are stunted from malnutrition.^[5] In emerging and developing countries, 300 million workers live in extreme poverty, and 430 million more live in moderate working poverty.^[6] Human rights and primary health care both address these challenges—but could do so more effectively by recognizing the potential of working more closely together.

The meaning of “primary health care” in the Declaration of Alma-Ata

Although coined “primary health care,” the concept is defined broadly to extend beyond the health care system. The Declaration states: “Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families through their full participation.”^[7] It explains the meaning of primary health care:

• it addresses the main health problems in the community, and provides promotive, preventative, curative and rehabilitative services
• includes at least: health education, nutrition and food security, safe water and basic sanitation, maternal and child health care, including family planning, immunizations, control of local endemic diseases, treatment for common illnesses and injuries and essential medicines
• requires community participation in planning and operation of primary health care and full use of available resources
• involves not simply the health sector but also agriculture, food, education, housing, public works, communications and other sectors.^[8]

The World Health Report 2008 explains the concept of primary health care as integrating conventional medical care and public health into a people-centered community-based system in which “[p]eople are partners in managing their own health and that of their community.”^[9] Table 1 highlights the differences between a conventional approaches to health care and the primary health care approach.

Table 1: Comparison of Conventional Health Care and Primary Health Care

Modification of World Health Report 2008 Table 3.1

This concept of primary health care contrasts with the narrow concept of primary health care in General Comment 14 of the Committee on Economic, Social and Cultural Rights (CESCR), which states: “primary health care typically deals with common and relatively minor illnesses and is provided by health professionals and/or generally trained doctors working within the community at relatively low cost” and is contrasted with secondary health care provided in hospitals at comparatively higher cost and tertiary health care in relatively few centers and relatively expensive.^[10]

Synergy between the right to health and primary health care

There are, however, many common threads between the Alma-Ata vision of primary health care and the right to health. Indeed, General Comment 14 defines the right to health as an expansive right that includes health care and the underlying determinants of health, thus extending obligations for realizing this right beyond the health care system. Also, General Comment 14 draws on the Declaration of Alma-Ata to define the core content of the right to health, including safe and nutritionally adequate food, basic shelter, safe water and sanitation, essential medicines, a national public health plan.^[11] Additionally, they both highlight the importance of non-discrimination, participation, and international assistance and cooperation. Yet, as Audrey Chapman points out, the General Comment falls short of adopting the Declaration’s primary health care approach, which calls for a transformation of the economic and social system to reduce gross inequalities between the haves and have-nots and ensure quality of life for all.^[12] The CESCR should embrace this more transformative approach to health for all as the practical means to realize the right to health.

Similarly, the Second International Conference on Primary Health Care to be held on 25-26 October 2018 should take advantage of the detailed elaboration of the right to health to improve upon its draft Declaration of Astana. For example, the draft refers to the right to health in the preamble of the WHO Constitution but should also acknowledge that every country in the world has ratified at least one human rights treaty that recognizes the right to health as an international legal obligation. Second, the Declaration should recognize the rights to food, water, sanitation, housing, education, social security, and the benefits of science as social determinants of health and therefore essential components of primary health care. Third, the Declaration should call upon the human rights treaty bodies and the Human Rights Council to monitor implementation of primary health care as aligned with these rights, rather than relying solely upon the voluntary monitoring system for the Sustainable Development Goals. Finally, health officials and human rights practitioners should pull down the siloes of primary health care and the right to health, recognize their synergy, and work collaboratively to achieve health for all.

Gillian MacNaughton, is Assistant Professor, School for Global Inclusion and Social Development, University of Massachusetts Boston

Diane F. Frey, is Lecturer, Labor and Employment Studies Department, San Francisco State University

References

[1] Declaration of Alma-Ata, in Report of the International Conference on Primary Health Care (RICPHC) (1978), p. 6. Available at: https://www.unicef.org/about/history/files/Alma_Ata_conference_1978_report.pdf.

[2] Draft Astana Declaration on Primary Health Care: From Alma-Ata towards Universal Health Coverage and the Sustainable Development Goals, 28 June 2018. Available at http://www.who.int/primary-health/conference-phc/DRAFT_Declaration_on_Primary_Health_Care_28_June_2018.pdf.

[3] Convention on the Rights of the Child, Article 24(2)(b) and (c).

[4] World Health Organization, Maternal Mortality, Key Facts, http://www.who.int/news-room/fact-sheets/detail/maternal-mortality.

[5] World Health Organization, Sanitation, Key Facts, http://www.who.int/news-room/fact-sheets/detail/sanitation; World Health Organization, Malnutrition, Key Facts, http://www.who.int/news-room/fact-sheets/detail/malnutrition.

[6] International Labour Organization, World Employment and Social Outlook: Trends 2018, Geneva: International Labour Office (2018), p. 1, https://www.ilo.org/wcmsp5/groups/public/—dgreports/—dcomm/—publ/documents/publication/wcms_615594.pdf

[7] Declaration of Alma-Ata (see note 1), p. 3.

[8] Declaration of Alma-Ata (see note 1), p. 4.

[9] World Health Organization, Primary health care – Now more than ever: World health report 2008 (Geneva: World Health Organization 2008), pp. 43.

[10] Committee on Economic, Social and Cultural Rights, General Comment No. 14: The Right to the Highest Attainable Standard of Health, UN Doc. E/C.12/2000/4 (2000), fn. 9.

[11] Ibid., para. 43.

[12] A.R. Chapman, “ALMA-ATA at 40: Revisiting the Declaration,” Health and Human Rights Journal Blog, September 10, 2018. Available at https://www.hhrjournal.org/2018/09/alma-ata-at-40-revisiting-the-declaration/; Declaration of Alma-Ata (see note 1), p. 2-3.