It is possible today to voice a proposal to take the idea of primary health care, stated in the bold language of the Alma-Ata declaration 30 years ago, forward and work towards making it a reality.

Writing from jail, I did not have access to books and journals. This accounts for the disjointed state of some of the arguments. None of this is necessarily original or new. This article is based on earlier readings, as well as valued discussions with many friends and colleagues in Rupantar, Jan Swasthya Sahayog, the People’s Union for Civil Liberties, Shaheed Hospital, Medico Friend Circle, Jan Swasthya Abhiyan, and the National Alliance of People’s Movements. The usual disclaimers apply.

Binayak Sen, a paediatrician, public health professional and national vice-president of the People’s Union for Civil Liberties, is the recipient of the tenth annual Jonathan Mann Award for Global Health and Human Rights.

I should have done something else…… Done something else, other than going on screaming, While struggling on in this terrifying s ociety, I should have done something else. Day after day I watched a tiny hope Going into something like a huge pair of jaws Carrying around with me, in this widespread famine, The shame of having stayed alive… I should have done something.

–Raghuvir Sahay; translated by BS

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Utopian Wish List

Yet, the declaration itself commands attention, even today. It called for urgent action, in the spirit of social justice, by all governments, all health and development workers, and the “world community” (whatever that was), to promote and protect the health of all the people of the world. The conference reaffirmed that “health, which is a state of complete physical, mental, and social well-being, and not merely, the absence of disease or infirmity, is a basic human right”, required the action

of many other social and economic sectors in addition to the health sector. It also found the existence of gross inequality in the health status of people, both between countries, as well as within them, to be politically, socially, and economically unacceptable. It spoke of the need to pay the fullest attention to the reduction of the gap in the health status of the developed and the developing countries. While it held the governments primarily responsible for ensuring the health of their people, it also held that “people have the right and duty to participate individually and collectively in the planning and implementation of their healthcare. Paragraphs V, VI, and VII clarify the objectives and define the meaning of PHC, and paragraph VIII, which attempts to set out the operative part is worth quoting in full.

All governments should formulate national policies, strategies and plans of action to launch and sustain primary health care as part of a comprehensive national health system and in coordination with other sectors. To this end, it will be necessary to exercise political will, to mobilise the country’s resources and to use available external resources rationally (emphasis added).

This is the crux of what I believe was the problem with the declaration and the reason for the failure of the promise of PHC. The authors of the declaration have worked out one mighty shotgun burst of social engineering and left one lonely cowboy called “political will” to pull the trigger. Addressing an international audience under the auspices of the United Nations Children’s Fund (UNICEF) and the World Health Organisation (WHO), perhaps it was too much to expect Mahler to exhibit a sense of political process here. So instead, we get one utopian wish list and hope that deus ex machina will follow.

Primary Health Care Undermined

Right to the end, the Alma-Ata document exhibits a quixotic purity of intent. As we read that “an acceptable level of healthcare… can be attained ...through a fuller

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and better use of the world’s resources, a considerable part of which is now spent on armaments…”, we admire the logic, but hear sardonic laughter off stage, as the Big Boys wait to get in on the act. For almost as soon as the Alma-Ata conference was over, the idea of PHC was under attack. A new concept of selective primary health care (SPHC) that advocated the provision of PHC interventions which contributed most to reducing child (under 5) mortality was adopted, the advocates of SPHC arguing that PHC was too idealistic, expensive, and ultimately, unachievable. As John J Hall and Richard Taylor (“Health for All Beyond 2000: The Demise of the Alma-Ata Declaration and Primary Health Care in Developing Countries”, Med J Aust, 178 (1): 17-20, 2003) remind us, the argument was that by focusing on growth monitoring, oral rehydration solutions, breastfeeding, and immunisation, greater gains could be achieved at reduced costs.

In India, in addition to the above selective focus, family planning services and coercive family planning propaganda formed part of the package. The vertically integrated SPHC cost-benefit calculations conveniently relegated the area of healthcare and the relief of suffering to the private sector, which for the poorer communities translated to zero service. Our p olicymakers and planners conveniently forgot that every healthcare institution, no matter how large or how small, is not only a transaction platform on which benefits and services are traded, but a moral arena in which values such as equity and justice are reaffirmed, or – and more frequently – repudiated. The 2000 WHO report entitled Health Systems: Improving Performance places the responsibility for the failure of PHC on inadequate funding, and insufficient training and equipment for health workers at all levels. This resulted, according to the report, in absent or severely inadequate services leading to a failure of the referral system within the PHC hierarchy.

In the meantime, the World Bank, together with its Indian cohorts, was engaged in ramming the Structural Adjustment Programme (SAP) down our throats. In the health sector this took the shape of “Health Sector Reforms”. The Bank’s 1993 World Development Report:

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Investing in Health was projected onto this background. This heralded an emphasis on using the private sector to deliver healthcare services, while reducing or removing the public sector. This has resulted in a situation in which more than 80% of all expenditure in this povertystricken country is out of pocket expenditure – the biggest cause of private indebtedness today. At the same time we have moral obscenities like “medical tourism” in which hepcat Indian cardiologists and orthopaedic surgeons are taking on roles akin to resident personnel at m assage parlours.

Health Status of the People

Coming now to the current situation regarding the health status of the Indian people, this would require a whole book in itself. I will only try to highlight a few illustrative issues.

Chronic Hunger: The National Nutrition Monitoring Bureau says that a third of all Indian adults have a Body Mass Index (BMI) below 18.5. If we disaggregate the data, more than 60% of the scheduled caste population and more than 50% of the scheduled tribe population have a BMI less than 18.5. The status of povertystricken minority communities is not documented. According to WHO norms, any community which has more than 40% of its members with a BMI less than 18.5 should be treated as famine-affected. The writings of Utsa Patnaik have demonstrated a falling annual per capita availability of foodgrains in India – from 177 kg in 1991-92 to only 153 kg by 2003-04. Since the increased prosperity of the top fifth of the Indian population is well-known and well documented, all this only means that the bottom segments of our people are eating far less than they did some years ago, and are going deeper into the grip of a chronic, ongoing famine.

Widespread Anaemia, Particularly in Women: Most of this anaemia is eminently susceptible to the simplest therapeutic measures.

High Intrauterine Malnutrition and Maternal Mortality: The combination of the above facts leads to a high rate of

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i ntrauterine malnutrition, manifest in low birth weight babies, and a criminally high maternal mortality rate. There are no medical interventions that could remedy the combined effects of the above two factors. Intrauterine malnutrition causes major pathologies throughout life and into the next generation. It is also responsible for a major component of neonatal mortality, and thus, also of overall infant mortality.

Interaction between Nutrition and Infection: My colleagues in the Jan Swasthya Sahayog, Bilaspur have found that almost all their cases of lung tuberculosis (who do not have AIDS or diabetes) have a BMI less than 18.5. In other words, malnutrition is a major cause of lung tuberculosis, due to reduced immune resistance.

Numerous Infectious Diseases: Persistence of high rates of numerous infectious diseases, including malaria, a large part of which is chloroquine resistant f alciparum malaria, tuberculosis, respiratory infections, kala-azar and other infectious diseases.

Poor Sanitation and Unhygienic Water Supply: These remain major causes of disease and death. It is not only the traditionally recognised viral and bacterial waterborne infections that are worthy of note, important as they are. Increasing parts of the country are now becoming susceptible to arsenic contamination of drinking water supply. Colleagues in Vellore, Tamil Nadu, have found that the largest single cause of the adult onset of epilepsy is n eurocysticercosis – not as traditionally taught, a disease of pork eaters, but also found in strict vegetarians, because of e ating vegetables grown with contaminated shitty water.

Abysmal Health Infrastructure and Corruption: The condition of the health infrastructure can be understood with reference to an illustrative story. The Chhattisgarh government carried out a survey/evaluation of government healthcare infrastructure under prodding from the European Union, which was the major funder for their “Health Sector Reforms” package. The performance of emergency Caesarean sections

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was taken as an index of capability, and it was found that there were only three g overnment centres, including the m edical colleges, which were performing Caesarean section in a state with a population of 24 million. C orruption is a major problem in drug purchase and supply. Chhattisgarh, which has no legitimate facilities for the m anufacture of drugs, patronises a major industry in the production of fake drugs, mostly for purchase and use in government facilities.

Wither Public-Private Partnerships: The same state of Chhattisgarh spent Rs 12 crore to set up the Escort/Aayushman Heart Care and Endosurgery Centre at the Raipur Medical College, under the management of the Escorts Hospital. Both enterprises took off with much fanfare and ground to a halt within three years in a brilliant display of public-private partnership.

november 22, 2008 Economic & Political Weekly

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and integration of diagnostic/therapeutic interventions across different levels of care – something hard to come by even in relatively sophisticated settings today.

Certification for Healthcare Professionals and Institutions: This process can be thought of at the level of healthcare professionals who would require certification in order to practise their profession, as well as for institutions (public, as well as private, or any combination of the two) that would serve as care-giving centres. In both cases the process of certification would include a process of mapping skills, knowledge and practice that are put to use, as well as the societal obligation fulfilled, perhaps through a mapping of the categories of patients treated on a cashless basis or with single payer payment (whether by the government, private party, or insurance company). Medical insurance programmes, as and when they become a significant reality, would also require certification, and subsidised insurance programmes would thus make healthcare equally available to all sick people.

Other Prerequisites for Health: Universally applicable schedules of access and

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entitlements to public distribution of food, healthcare, health facilities, nutrition and other prerequisites for health. The Supreme Court directives issued from time to time in the PUCL Right to Food case may serve as a model for other areas where no such directives exist. As Paul Farmer puts it, it is necessary to recognise the state order as a guarantee of rights:

“It can be said with certainty that the liberties of citizens are better protected by their own institutions than by the well meaning interventions of outsiders. State failure cannot be rectified by human rights activism on the part of NGOs” (M Ignatieff, 2001, quoted in Paul Farmer, op cit, 2003).

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