ALMA-ATA at 40: Insights from Canada
Martha Roberts, Baijayanta Mukhopadhyay, Anne-Emanuelle Birn, Farah Shroff, Smita Pakhale, and Lori Hanson
As an engaged participant in the 1978 International Conference on Primary Health Care, which issued the Alma-Ata Declaration, Canada affirmed that:
The existing gross inequality in the health status of the people particularly between developed and developing countries as well as within countries is politically, socially and economically unacceptable and is, therefore, of common concern to all countries.
Since that time Canada has had an abiding, if sometimes fraught, connection to the Alma-Ata legacy and the Health for All movement. The Declaration of Alma-Ata, endorsed by the World Health Assembly, reiterated WHO’s definition of health as “a state of complete physical, mental, and social well-being and not merely the absence of disease”, calling for universally available, technologically and culturally appropriate healthcare integrating biomedical and traditional approaches and incorporating community-based participation. The follow-up International Conference on Health Promotion in 1986, sometimes critiqued as “Alma-Ata for rich countries,” took place in Canada’s capital, Ottawa. Through the Ottawa Charter, participating states reaffirmed their commitment to Health for All and identified the prerequisites for health as: peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity.
While health inequities between Canadians persist, there has been some progress towards a goal of better healthcare access for all Canadians. At the time Canada was involved in these momentous global gatherings, its domestic healthcare policies were taking their most progressive turn in history. In 1978, Canada’s system of publicly-funded universal health insurance had been fully instituted for just a few years. By 1984, two years before the Ottawa Charter, the Canada Health Act enshrined five principles that enacted some of the world’s strongest protections against a two-tiered system, heavily disincentivizing healthcare delivery in the private sector (for any and all services covered by the public sector). Access to medical care was no longer determined by ability to pay, and a wide array of services were delivered free at the point of care. This victory was an important step in a vision of healthcare as a right.
Since 1984, however, much has changed under Canada’s Medicare system, with multiple assaults on equity and the public basis for the system, even as it remains a model for other countries. Furthermore, this public investment in physician-centred healthcare no longer addresses today’s realities of the challenges to health equity.
Cracks in the foundation of the Canadian system
Prior to the mid 19th century official formation of ‘Canada’—superimposed on unceded Indigenous lands—various systems of Indigenous health care co-existed on Turtle Island (also known as North America) in delicate balance with sensitive ecologies. Genocide and ecocide by French and English colonisers—coupled with sustained colonial systems that alienated Indigenous people from their lands and their communities—threatened these pre-existing health approaches and practices.[1] The Canadian state outlawed ceremonies such as pow-wows and socially redistributive potlatches; Canadian authorities created residential schools and other oppressive institutions that wreaked havoc on Indigenous communities and health. In buttressing Western medical practice as the sole state-legitimised healing system, the Canadian government also displaced a range of folk healing and midwifery practices of impoverished Asian, African-origin, and European settlers.[2] As a result, physician-centred care became the dominant mode of healthcare across Canada, even as it was often inaccessible both financially and geographically.
After World War II, coalitions of progressive social movements rejected the meek social welfare measures offered by the main political parties, channelling their support to the socialist Co-operative Commonwealth Federation (CCF). The intense struggle for public provision and equitable access to healthcare reached a climax in Saskatchewan in 1961, where the CCF provincial government under Premier Tommy Douglas advanced a proposal for universally funded and publicly provided healthcare services, building on earlier province-wide hospital insurance efforts. After a polarizing three-week doctors’ strike in July 1962, the public plan became law, albeit watered down. Within a decade, following other doctors’ strikes, provincially-organized Medicare systems swept the nation. The “politics of compromise” meant that the initial vision of publicly funded, universal, and comprehensive care still allowed physicians to engage in private practice though they would bill only the government for services they provided. Though Medicare prevailed in Canada, strongly supported by the public, it remains marked by idiosyncrasies and gaps in coverage.
Profiteering in a not-for-profit system
Since the 1980s, Canada has compromised its attainment of the Alma-Ata vision of health for all in various ways. For example, Canada remains the only high-income country with universal healthcare that lacks universal drug coverage. And essential services such as outpatient physiotherapy allowing people with disabilities to maintain independence and mobility have been delisted from many provincial insurance programmes, which now require payment for these services.
Indigenous people, in particular, are subject to fragmented and arcane healthcare arrangements, with bureaucratic hurdles generating shocking barriers to care. The continuing inequities in health outcomes between Indigenous and other people in Canada is not simply the result of the healthcare system. The enforced loss of land and livelihood during the colonial period, coupled with intense racism within and outside healthcare, have led to significant unmet health and social needs.[3] To redress these and other problems Canada needs to use the Alma-Ata’s principles of people’s participation, inter-sectoral action, intra-sectoral collaboration, and a political willingness to address the rights of Indigenous communities together with restorative/reparative social justice for all oppressed groups.
Moreover, as the worldwide retreat of the welfare state continues, Canadian hospitals are sliding into models that facilitate profit-making within the publicly financed system. When the province of British Columbia passed the Health and Social Services Delivery Act in 2001, the collective agreements of ancillary hospital workers were unilaterally rescinded, leading to the largest mass firing of health care workers in Canadian history, 85% of whom were women, the majority racialised. The legislation allowed corporations such as Sodexo, Aramark, and Compass to provide hospital ancillary services, making profit from limited health resources for their shareholders.[4]
The underfunding of home care for the elderly and for people with disabilities has led to fragmented care and is an example of the undermining of Canada’s not-for-profit, public model. Financially advantaged households can use the temporary foreign worker Caregiver Program to provide care for elderly family members, or those with disabilities. This scheme brings about 7,000 caregivers on temporary work visas per year into Canada, the majority of whom are women from the Philippines.[5] The Canadian government’s increasing reliance on the Labour Export Policy of the Philippines, which oversees the migration of highly-trained and skilled Filipino workers, contributes to the global trend of states outsourcing welfare needs to vulnerable workers, with little public oversight and little regard for the home country impact.[6] Furthermore, Canadian households for whom this option is not financially viable have to struggle with an under-resourced public system to meet their care needs.
Participation and popular movements
People’s participation in health is one of the core principles of Alma-Ata. In Canada, as access to public care has retreated, communities have often resorted to addressing health crises themselves. Responding to spikes in overdose deaths across Canada, groups such as the Vancouver-Area Network of Drug Users and the Toronto Overdose Society have been exemplars of community-based care. Indigenous communities throughout Canada are also creating care systems that respond to their own needs, reviving traditions of healing that have been long suppressed. Meanwhile, some providers have challenged and resisted government attempts to cut back healthcare for people claiming refugee status.
These efforts address Canada’s mis-steps in its journey to meet the vision of Alma-Ata, but much more is needed to redirect public policies for people’s health. Contemporary priorities in Canadian politics continue to pose serious challenges to the goal of health for all. For example, the federal government’s ongoing arms deal with Saudi Arabia, even as that country’s military intervention in Yemen has provoked the world’s worst humanitarian crisis, and the Canadian government’s backing of the environmentally-destructive Kinder-Morgan pipeline, highlight the need to put a socially just vision of health at the centre of policymaking.
The global challenges of climate change, deepening inequalities, and rising social violence call for an urgent return to the values and principles of the Alma-Ata Declaration in Canada and elsewhere. People’s movements that struggle for economic, social, political, and environmental justice, must continue to lead the way.
Martha Roberts, Baijayanta Mukhopadhyay, Anne-Emanuelle Birn, Farah Shroff, Smita Pakhale, and Lori Hanson are all members of People’s Health Movement, Canada
References
[1] Shroff, F (2011). Power Politics and the Take over of Holistic Health in North America: an exploratory historical analysis. Journal of Indigenous Wellbeing, Pimatsawim, 9(1): 129-152; Benoit, C. & Carroll, D. (1995). Aboriginal Midwifery in British Columbia: A narrative untold. In, A Persistent Spirit: Toward Understanding Aboriginal Health in British Columbia, Stephenson, Elliot, Foster & Harris, Eds. Pp. 223-248. Victoria, BC: Canadian Western Geographical Series 331.
[2] Strong-Boag, V. & McPherson, K. (1992). The Confinement of Women: Childbirth and hospitalization in Vancouver, 1919-1939. In, British Columbia Reconsidered: Essays on Women, Creese & Strong-Boag, Eds.,pp. 143-171. Vancouver: Press Gang Publishers.
[3] Truth and Reconciliation Comission of Canada (2015). Calls to Action (specifically 18-24). Winnipeg: Truth and Reconciliation Commission of Canada.
[4] Camfield, D. (2006). “Neoliberalism and Working-Class Resistance in British Columbia: The Hospital Employees’ Union Struggle, 2002-2004,” Labour/Le Travail, 57, pp. 9-41.
[5] Schnabel, C. (2018). OFW cash remittances start 2018 strong at $2.37 billion. Rapper on-line news: https://www.rappler.com/business/198243-philippines-ofw-remittances-january-2018
[6] Longhurst, A. (2017). Privatization & Declining Access to BC Seniors’ Care: An urgent call for policy change. Vancouver, BC: Canadian Centre for Policy Alternatives.