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Revitalising primary healthcare requires an equitable global economic system - now more than ever
  1. David Sanders1,
  2. Fran E Baum2,
  3. Alexis Benos3,
  4. David Legge4
  1. 1School of Public Health, University of the Western Cape, Bellville, South Africa
  2. 2Southgate Institute for Health, Society and Equity, Flinders University, Adelaide, Australia
  3. 3Medical Department, Aristotle University, Thessaloniki, Greece
  4. 4School of Public Health, Latrobe University, Victoria, Australia
  1. Correspondence to Dr D Sanders, School of Public Health, University of the Western Cape, P Bag X17, Bellville 7535, South Africa; sandersdav5845{at}gmail.com

Abstract

The promised revitalisation of primary healthcare (PHC) is happening at a time when the contradictions and unfairness of the global economic system have become clear, suggesting that the current system is unsustainable. In the past two decades, one of the most significant impediments to the implementation of comprehensive PHC has been neoliberal economic policies and their imposition globally. This article questions what will be required for PHC to flourish. PHC incorporates five key principles: equitable provision of services, comprehensive care, intersectoral action, community involvement and appropriate technology. This article considers intersectoral action and comprehensiveness and their potential to be implemented in the current global environment. It highlights the constraints to intersectoral action through a case study of nutrition in the context of globalisation of the food chain. It also explores the challenges to implementing a comprehensive approach to health that are posed by neoliberal health sector reforms and donor practices. The paper concludes that even well-designed health systems based on PHC have little influence over the broader economic forces that shape their operation and their ability to improve health. Reforming these economic forces will require greater regulation of the national and global economic environment to emphasise people's health rather than private profit, and action to address climate change. Revitalisation of PHC and progress towards health equity are unlikely without strong regulation of the market. The further development and strengthening of social movements for health will be key to successful advocacy action.

  • Primary health care
  • health policies
  • social determinants
  • global economic system

https://doi.org/10.1136/jech.2009.095125

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    Introduction

    Economic and social development, based on a New International Economic Order, is of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of the developing and developed countries.

    WHO/UNICEF (1978:2)

    The 30th anniversary of the Declaration of Alma Ata1 has seen new leadership on primary healthcare (PHC), with tantalising indications that its revitalisation could finally be happening. However, this revitalisation is occurring at a time when the contradictions and unfairness of the global economic system have become clear, suggesting that the current system is unsustainable. Indeed, the past year has heralded the death of unfettered neoliberalism as banks fail, stock markets crash and many see their retirement savings slashed. In the past two decades, one of the most significant impediments to a comprehensive implementation of PHC has been the implementation of neoliberal economic policies and their imposition through such interventions as economic structural adjustment programmes. This article considers what will be required for comprehensive PHC to flourish and how the global economic order will need to be fundamentally reformed in order to support rather than undermine it. Most centrally we argue that the successful and sustainable implementation of PHC requires a new economic order, thus echoing the call of the Alma Ata Declaration 30 years ago.

    The concept of PHC evolved during the 1970s, influenced by and influencing the basic needs approach to social development.2 Informed on the one hand by the disappointments experienced in implementing the basic health services approach,3 and on the other by the remarkable progress in improving health in China in the 1960s and 1970s as well as by the achievements of many small, mostly NGO-inspired, community-based healthcare initiatives in low and middle income countries (LMICs),4 the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) elaborated the strategy of PHC as the means to achieve ‘Health for All’ by the year 2000.1

    The original PHC approach had an explicit health service focus as well as strong sociopolitical implications, outlining a strategy which would respond more equitably, appropriately and effectively to basic healthcare needs and also address the underlying social, economic and political causes of poor health. The principles of the PHC approach include universal accessibility and coverage on the basis of need; comprehensive care with the emphasis on disease prevention and health promotion; community and individual involvement; intersectoral action for health; and appropriate technology and cost-effectiveness in relation to the available resources. The 2008 World Health report reinforces each of these principles and explicitly acknowledges the centrality to PHC of the social determinants of health.5 It does not, however, question the current global economic dispensation or call for a ‘New International Economic Order’.

    This article will argue that, because most social determinants are strongly influenced by the global economic architecture and the power relations that underpin it, implementation of PHC will be considerably constrained until power and resources are far more equitably distributed at national and global levels. Such redistribution would also make the required health sector-specific changes much easier to effect.

    Progress and context

    Since the Alma Ata Declaration, there has been significant progress in global health with an overall increase in average life expectancy. However, rapidly widening inequalities in health between and within countries—and even reversals in parts of Africa and the former Soviet bloc countries—have been aggravated by the failure to implement PHC in a way that addresses the broad social and economic determinants of health which have a greater negative impact on the poor and vulnerable.6

    Progress in implementing PHC has been greatest in respect of certain of its more medically-related elements, the narrow and technicist focus characterising what has been termed selective PHC.7 This preoccupation has at best delayed—and at worst undermined—the implementation of the comprehensive strategy codified at Alma Ata. The relative neglect of the promotive and preventive components of comprehensive care and the shift of emphasis away from equitable social and economic development, intersectoral collaboration, community participation and the need to set up sustainable district level structures suited the prevailing conservative winds of the 1980s.8 Such initiatives as UNICEF's ‘GOBI’ package for child survival, which privileged a few selected interventions, allowed donors and governments to avoid the more radical challenges of tackling inequalities and the underlying causes of ill health.3

    The Alma Ata Declaration was one of the last expressions of the development thinking of the 1970s where the non-aligned movement declared its commitment to a ‘New International Economic Order’9 and a ‘Basic Needs Approach’ to development.10 These visionary policies were buried in the 1970s debt crisis, stagflation and the increasing dominance of global economic policy by neoliberal thinking. Keynesian economics which had dominated Western governments' policies after World War II had promoted an active role for governments within the market, especially to achieve full employment. In the 1970s, government intervention in the economy came under attack by neoliberalism.2 Neoliberalism has its roots in the theories of classical economic liberalism, which promotes the freedom of markets to operate with minimal regulatory interference, including in respect of rules that may govern wage and price controls or protect the environment and public health.11

    While neoliberalism was initially directed to facilitating the maximum freedom of movement for finance capital, goods and services in the commercial sector, it came to promote a market economy in social sectors such as healthcare, education and social security which used to be the responsibility of the state. The dominance of market-orientated policies has influenced the design of health reforms that have strongly promoted privately funded health services, as is noted in the section below. Recession and neoliberal economic policies in the industrialised countries, poor country indebtedness, the political and economic collapse of the former Soviet bloc countries and the greater integration of both latter sets of countries into the global market economy have all accelerated pre-existing economic, political and social interdependence and led to what is now termed ‘globalisation’. This interdependence has been thrown into sharp relief by the financial crisis which started in the USA in September 2008 and spread rapidly to other countries.

    The combined impact of recession, deteriorating terms of trade, debt and harsh economic policies and health sector reform has had damaging effects in LMICs,12 resulting in:

    1. Declines in real public health expenditure and increasing donor dependency, including for recurrent health spending.

    2. Deterioration of health facilities and equipment.

    3. Shortages of drugs and other supplies.

    4. Dwindling patient attendance at public facilities as the quality of care worsened.

    5. Catastrophic loss of morale and motivation of public health workers as the value of their salaries plummeted and reduced spending undermined their ability to work.13 14

    In addition to the above, accelerating climate change—itself a by-product of economic activity driven by an uncontrolled and short-sighted quest for profit—is threatening the health and life of the planet and its people. Climate change is already having profound effects on health through such mechanisms as increasing temperatures resulting in deaths from hyperthermia; droughts or increased rainfall damaging agricultural systems and further threatening food supply; an increase in vector-borne diseases (especially by mosquitoes, rodents and ticks); and increasing diarrhoea from pollution of water by enteric bacteria.15 Although this is not the focus of this paper, it is clear that such challenges cannot be addressed from within the health sector alone and will require, as do the examples given below, a reassertion of key principles of PHC such as intersectoral action and especially the need to address the economic and political root causes of global warming and the impact of climate change on health.

    It is this context that shapes the implementation of PHC in the early 21st century. Below we look in detail at the impact of this context on the potential for the implementation of two of the central principles of PHC—intersectoral action and a comprehensive approach to health. We conclude by suggesting that improving health equity through PHC requires change in the global economic system—now more than ever.

    PHC for the 21st century

    Given the massive changes in prevailing values and economic and social policies globally since PHC was designed, here we consider what form PHC should take in the 21st century. Our main message is that PHC is most effective when it is implemented within a broader system in which action on the social determinants of health and health equity is systematic and truly intersectoral. Within the health sector this would see a focus on intersectoral action and comprehensive interventions which span treatment, rehabilitation, disease prevention and health promotion. While PHC cannot shoulder responsibility for most of the intersectoral action required to achieve equitable population health, it has an important role in ensuring universal access to services—itself a crucial social determinant—and catalysing social and policy action for the promotion and protection of health.

    Intersectoral action in the current global environment

    The current challenge to implementation of PHC is shown by the example of nutrition, a continuing and major determinant of health status and one which has been particularly affected by the processes of globalisation.16

    Effects of neoliberal globalisation on implementation of a PHC approach to nutrition

    Since the 1980s the globalisation of food and agriculture has accelerated, with many countries opening up their markets by lowering barriers to trade and investment, reducing subsidies on inputs to agricultural production such as fertilisers, and dismantling state food marketing monopolies, including the public holding of food stocks. A series of international agreements, notably the multilateral Agreement on Agriculture, have accelerated this trend. The Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPs) has further strengthened private property rights on food products, including through patents on seeds.17 The combination of global trade liberalisation and strengthened property rights has given increasing power to the corporate food industry and undermined national food security in many countries.17 Between 1990 and 2001, the foreign sales of food-related transnational corporations (TFCs) within the world's largest 100 transnational corporations rose from US$88.8 billion to US$234.1 billion, with total foreign assets rising from US$34.0 billion to US$ 257.7 billion.18 These TFCs dominate the whole food supply chain—including seeds, fertilisers and pesticides, the production, processing and manufacturing of foods, and the way they are sold and marketed to consumers. TFCs are now leading traders of food; 40% of food imports and exports are between and within TFCs.19 These trends, together with the recent sharp increase in the proportion of US maize being used for biofuels and the increasing impact of climate change, are primarily responsible for the recent critical food shortages in many poor countries.20

    In LMICs between 1970 and 2001 food imports grew by 115% compared with 45% in rich countries, and in LMICs food import bills as a share of GDP more than doubled between 1974 and 2004.21 Food price increases in the last 2 years threaten the reductions achieved in poverty and hunger over the past two decades. The Food and Agriculture Organization (FAO) index of food prices rose by 51% in the last 2 years. In 2008 this was projected to increase by more than 40% the import costs of low-income food-deficit22 countries and to have pushed at least 100 million people back into poverty and erased at least 4 years of progress towards the Millennium Development Goal (MDG) 1 target for the reduction of poverty.23 FAO estimates that food price rises have resulted in at least 50 million more people becoming hungry in 2008.24

    Such food insecurity has contributed to continuing widespread nutrition as evidenced by high stunting rates and micronutrient malnutrition, with an estimated 854 million undernourished people worldwide in 2001–3.25 Simultaneously, because of the increasing reliance on imported processed foods, there is the rapid emergence globally of chronic non-communicable diseases such as diabetes and hypertension fuelled by growing obesity. Already 22 million children worldwide are overweight; by 2015 approximately 2.3 billion adults will be overweight and more than 700 million obese.26

    These global changes in food production and trade have significantly altered the context for PHC nutrition programmes. The efficacy of health and nutrition interventions to reduce undernutrition has been established for decades.27 As a result of this evidence, national or large-scale programmes were established in several countries. Detailed reviews have shown that, to be effective, interventions must include a range of activities relating to health and nutrition with intersectoral actions being common, often as part of PHC, well illustrated by Tanzania's Iringa Nutrition Programme (INP).28 29 By their very nature such programmes are local, yet their chances of success are undermined by the impact of these changes in food production and supply.

    Given that PHC includes an imperative to also promote health, documenting the impact of broader political and economic forces on the health of the population served, raising local awareness of these issues, working cooperatively with other sectors and advocating for policy change in relation to them is an increasingly essential aspect of comprehensive PHC. There are many other areas in which neoliberal globalisation is having an impact on population health and calls for a response from PHC services. Table 1 provides some examples of how a PHC approach would develop a comprehensive response to selected key health issues.

    View this table:
    Table 1

    Spectrum of interventions for primary healthcare (PHC) in the 21st century

    Comprehensive PHC in the current global environment

    Neoliberal policies have informed an approach to health sector reform that now dominates in most countries. While there is no blueprint for healthcare reform, it essentially involves restructuring of national health agencies; planning more cost-efficient implementation strategies and monitoring systems; introducing user fees for public health services; introducing managed competition between service providers; involving the private sector through contracting, regulating and franchising different private providers; and decentralising management.30

    These reforms, especially cost containment and deregulation, have had an adverse impact on the potential for PHC to be implemented effectively.6 Although there is increasing evidence that privatisation of healthcare is undermining the achievement of equity in coverage31—another of the fundamental principles of PHC—here we focus on the quest for efficiency through ‘rationalisation’ of essential interventions (in the form of a ‘core package’), and its impact on the ‘comprehensiveness’ of services.

    Effects of health sector reform and new funding mechanisms on comprehensive PHC

    Cost-effectiveness analysis (CEA) is increasingly employed to define priority interventions, which then are grouped as costed ‘packages’ of care.32 This approach, it is suggested, enables governments to make rational economic choices and prioritise interventions and services. For example, hygiene promotion (especially hand washing) has been promoted over improved water supply and sanitation as a much more cost-effective means of reducing diarrhoea.33 However, the many other indirect effects of improved water and sanitation on health and nutrition are excluded as benefits as they are difficult to cost. This use of CEA inevitably narrows the scope of PHC to a set of technical interventions, reminiscent of selective PHC, ignoring the determinants of ill health and thus negating comprehensive approaches.34 Health interventions other than those specified in the essential ‘package’ are increasingly funded ‘out of pocket’ and provided by the private sector, thus commercialising healthcare. For example, by the late 1990s only 9% of healthcare transactions studied in Tanzania were found to be provided free of charge.35 The promotion of limited ‘packages’ of care represents a drive towards multi-tiered healthcare with package-based safety nets for the poor, social insurance for employed workers and private insurance for the rich.

    Finally, when healthcare is viewed as a commodity, either because of privatisation or because of the use of a narrow form of accounting to assess health service activity, then the functions of community mobilisation, intersectoral action and advocacy are unlikely to be rewarded or encouraged by the broader health system. In LMICs, narrowness of health programmes is becoming more prevalent. Most donor funding for health in LMICs up to the early 1990s was provided in two ways: from the World Bank in the form of loans and credits; and earmarked project and programme support to LMICs from bilateral donors. The past 10 years has seen the dramatic growth of global health partnerships (GHPs) or global health initiatives (GHIs) as a new mechanism for channelling donor funds to LMICs. These include the Global Alliance on Vaccines and Immunisations (GAVI), the Global Fund to Fight AIDS, TB and Malaria (GFATM), the World Bank Multicountry AIDS Program (MAP) and the US President's Emergency Plan for AIDS Relief (PEPFAR) which all have massive budgets and are now the major sources of health financing in the poorest countries, especially for HIV, tuberculosis and malaria. Although their advent has resulted in an exponential increase in funding for certain programmes (especially HIV/AIDS), they have reinforced the selective approach to PHC through countrywide disease-specific funding mechanisms which are usually vertically implemented and managed and which privilege therapeutic interventions and (in selected cases) personal prevention, with little funding to promotive interventions to address ‘upstream’ determinants, community mobilisation or care.36 The emphasis of GHIs on treatment and products to address diseases has the effect of deflecting the focus from environmental and social determinants and from effective prevention activities and thus from comprehensive PHC.37 GHIs are also fragmenting and undermining country-led approaches and increasing the opportunity costs for already overstretched Ministries of Health.6 38 There is very little coordination between different GHIs and they are seldom integrated into the health systems of the recipient countries. This has major implications for the sustainability of programmes after the funding from a particular GHI declines or ends.

    Conclusion

    Here we have outlined some of the profound challenges to the implementation of comprehensive PHC, especially in poor countries, imposed ultimately by neoliberal globalisation, notably macroeconomic policies, market-friendly healthcare reforms and climate change. There are many examples—especially from the 1970s and 1980s—that demonstrate the positive impact of comprehensive PHC, particularly when programmes also address the social determinants that underlie common health problems.39 More recently, significant gains have been achieved in countries such as Brazil and Thailand, both of which have successfully pursued relatively autonomous economic development and implemented national social—including health—policies that differ markedly from those promoted as part of ‘mainstream’ health sector reform.40 41

    Replication of these and other positive experiences will be extremely difficult—if not impossible—for the poorest countries and sectors without radical changes in the dominant neoliberal economic paradigm and its accompanying health reforms, funding modalities and donor policies. While the likelihood of any form of new economic order seemed extremely unlikely before September 2008, the combined effect of the global financial crisis and the election of a new US administration has opened a new policy space in which the necessity to change the current system towards a more equitable dispensation is being openly debated. Although unlikely, if such re-thinking were to result in radically different economic policies that promote equity and address climate change, it would be much more possible to implement a comprehensive form of PHC. PHC must include both action on the social determinants of health that are within its control (mainly at a local level) and advocacy on the broader determinants which are increasingly global.

    Even well-designed health systems based on PHC have little control over the broader economic forces that shape their operation and their ability to improve health. Reforming these economic forces will require, at a minimum, greater regulation of the national and global economic environment to emphasise people's health rather than private profit. As we have argued, the promised revitalisation of PHC is unlikely without concerted advocacy by supranational institutions, including the WHO, for a radically-changed more equitable global economic dispensation which also urgently addresses climate change. The history of major public health advances should remind us that securing healthy public policies invariably involves a strong organised demand by citizens for government responsiveness and accountability to social needs.42 Recognition of this dynamic informed the call at the Alma Ata Conference for strong community participation. A process of social mobilisation involving broad civil society, which may take different forms in different contexts, is essential to achieve and sustain such political will. In recent years it has mainly been civil society groups such as the People's Health Movement43 that have taken on this advocacy role.

    This article has argued that such mobilisation is necessary at both national and global levels to challenge current power imbalances that underpin the current dominant economic order, and thus ameliorate the social determinants of health inequity and attain the elusive goal of ‘Health for All’. The implementation of comprehensive PHC can assist in this process.

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    Footnotes

    • See Commentary, p 653

    • Linked articles 93914, 102780

    • All authors are members of the Global Steering Council of the Peoples' Health Movement.

    • Competing interests None.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    Linked Articles