Belgacem Sabri1
1Director, Division of Health Systems and Services Development, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondence to Belgacem Sabri:
EMHJ, 2008, 14(Supplement): S12-S14
The World Health Organization (WHO) is celebrating its 60th anniversary this year which coincides also with the 30th anni- versary of the Declaration of Alma Ata on health for all through primary health care (PHC) [1]. The double celebration will al- low countries around the world, including those of the WHO Eastern Mediterranean Region, to assess the major achievements of PHC reform, to deal with the unfinished agenda and to look to the future taking into consideration the evolving health and non- health scenarios at national, regional and global levels.
Since Alma Ata, the health status of people has improved in most countries as reflected in the trend analysis of life expect- ancy and important morbidity and mortality indicators. These health gains have been facilitated by improvements in the major social determinants of health, including literacy, economic development and access to clean water and sanitation. In addition, during this time, more evidence has been generated on the positive linkages between health and development as reflected in sev- eral global publications such as the World Development Report: investing in health and Macroeconomics and health: investing in health for economic development. Report of the Commission on Macroeconomics and Health [2,3]. Key poverty reduction strate- gies have advocated increasing investment in health and the development of pro-poor health policies and interventions. The glo- bal efforts culminated in the United Nations (UN) Millenium Summit in 2000 out of which came the Millennium Development Goals that called for actions to improve the lives of the poor and set targets to be met by 2015 [4].
The strong political commitment of policy-makers to the Goals and principles of PHC has had a positive impact on the de- velopment and strengthening of health sys- tems in the Eastern Mediterranean Region. Ministries of health have been restructured in order to accommodate the new integrated and comprehensive approach to service delivery and to focus on decentralization. Many countries have expanded their PHC networks using community health workers, who provide prevention and promotion services and supply essential medicines to treat minor health problems in the com- munity. Efforts have also been made to promote community participation and empowerment and to seek intersectoral collaboration through community-based initiatives centred on health development.
All community-based schemes use so- cial and economic determinants as entry points to comprehensive development in- cluding health. The increase in the number of countries using such approaches illus- trates the degree of ownership that communities feel of their efforts to improve individual, community and public health services. The WHO Regional Office for the Eastern Mediterranean has been active in networking between developing com- munities inside and outside countries and in trying to make objective evaluations of the integration of the various social, economic and health dimensions of community-based initiatives [5].
The launch of health for all through pri- mary health care in 1978 occurred against an unfavourable economic and political background worldwide and in our Region. The severe economic crisis in the 1980s and major macroeconomic reforms implement- ed in low- and middle-income countries constrained investment in health and public health. The economic support advocated by WHO to implement PHC, the need for which has been further highlighted by the work of the Commission on Macroeconom- ics and Health, has not fully materialized, and many health systems in the Region remain under-funded.
Inequity in health care financing has not decreased since Alma Ata as reflected in increasing out-of-pocket spending and reduction of government spending on health [6]. The limited economic and financial support to health systems has not allowed proper implementation of decentralized health systems based on PHC in some countries. Despite commendable efforts by governments, the level of social health protection remains inadequate in low- and middle-income countries of the Region. Re- cent research carried out by WHO globally and in the Region shows a worrying trend of catastrophic ill health expenditure and impoverishment following sickness of one or more household members [6].
Achievement of health goals has also been hampered by the political determi- nants of health represented by war, occupation and civil strife which exist in about a third of the countries of the Region. Man-made disasters, and also droughts and earthquakes, have also negatively affected the development and strengthening of PHC networks, particularly in rural and remote areas.
Health systems of the Region are faced with many challenges, including epidemio- logical and demographic transitions, and the challenge of globalization. Our countries are at various levels of transition and most low-income countries are facing the double burden of communicable and noncommuni- cable diseases. The health workforce is not appropriately trained to deal with the impact of this transition, particularly in relation to the promotion of healthy lifestyles and ca- tering for ageing patients and communities.
Globalization is having an impact both on lifestyles, through the promotion of un- healthy food, and on health systems, through limited access to health and biomedical technology and migration of skilled health professionals inside and between countries. At the same time some countries of the Region are striving to benefit from new opportunities offered by global economies in view of their comparative advantages in trade in health. These opportunities include health and medical tourism which is being promoted in some countries and the training of health professionals for external markets by other countries.
In view of this background and the awareness of the importance of PHC, policy- makers of the Region have reaffirmed their commitment to the values and principles of PHC, as reflected in many Regional Com- mittee resolutions [7]. They have reaffirmed health as a human right and highlighted the importance of intersectoral collaboration in health development. Their strong com- mitment to the Millenium Development Goals has focused on the need to invest in health and to direct attention to the social determinants of health. This move was also triggered by WHO’s renewed focus on so- cial determinants through the establishment of the Commission on Social Determinants of Health, a global commission that has worked for 3 years and that will provide WHO and its Member States with concrete and feasible recommendations on including the social determinants approach in health systems.
In reviving PHC, countries are building on positive achievements and are trying to mitigate the negative impact of some shortcomings in implementing PHC. Im- proved integration, out-reach programmes and community- and home-based services are now the focus of service delivery. Train- ing of health professionals is being oriented towards meeting community health needs and dealing with the implications of epi- demiological and demographic transitions. Human resources development is scaling up community health workers in some coun- tries where health systems are facing severe challenges including limited funding.
Communities are being empowered in order to contribute to their own health de- velopment by promoting healthy lifestyles and physical activity and by involving them in planning and management of health care services. This is being facilitated by the growing and active role played by social society organizations in many countries of the Region.
The celebration activities to mark the 30th anniversary of Alma Ata and the 60th anniversary of WHO offer a golden op- portunity to learn important lessons on both the factors that facilitate and those that hamper implementation of PHC in our Region. Sharing experiences and network- ing between countries and professionals will strengthen the Regional move towards better and equitable health development.
References
- Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 September, 1978 (http://www.who.int/hpr/NPH/docs/dec- laration_almaata.pdf, accessed 3 June 2008).
- World Development Report 1993: in- vesting in health. Washington DC, World Bank, 1993.
- Macroeconomics and health: investing in health for economic development. Report of the Commission on Macroeconomics and Health. Geneva, World Health Or- ganization, 2001.
- UN Millenium Development Goals (http:// www.un.org/millenniumgoals/, accessed 3 June 2008).
- Community based initiatives [website] (http://www.emro.who.int/cbi/index.htm, accessed 3 June 2008).
- The impact of health expenditure on households and options for alternative financing. Technical paper presented at the 51st Session of the Regional Com- mittee for the Eastern Mediterranean, September 2004 (http://www.emro.who. int/RC51/media/EMRC5104.doc, ac- cessed 16 June 2008).
- Resolutions of the Regional Committee (http://www.emro.who.int/governance/ resolutions.htm, accessed 3 June 2008).
