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– by Barbara Kühlen, Susanne Schmitz
© PIES occidente
Traditional midwife in Guatemala.
In 1978, a conference held by the World Health Organisation (WHO) in Alma-Ata (the Kazakh city now called Almaty) demanded health care for all people and spelled out principles accordingly. The declaration that was adopted by the World Health Assembly back then was revolutionary. It defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. It also stated that this is a fundamental human right.
The ambitious goal was expressed in the slogan “Health for all by 2000”. Then (as now), poor segments of African, Latin American and Asian societies did not have access to health-care systems. Therefore, the WHO’s focus was on primary health care as a strategy to improve matters.
Primary health care is about prevention, cure and rehabilitation. The concept takes into account locally specific ways of life, cultural attitudes and local resources. It emphasises people’s involvement and responsibility in health matters. Of course, the causes of diseases must be researched and health measures taken accordingly.
Right from the start, primary health care focussed on grassroots-level care, but contrary to later interpretations, it did not limit itself to this level. Rather, the idea was always to involve all levels of health care, from rudimentary health posts through to hospitals with the goal of improving cooperation at all levels.
Lack of political will, institutional opposition and unfavourable economic and socio-political conditions, however, hampered the implementation of primary health care, and so did misinterpretations of the concept. Many governments resisted what was intended to result in a “democratisation of health”. Primary health care was soon deemed to be too expensive. International organisations like the World Bank considered so called vertical programmes that focus on single health issues such as HIV/AIDS or malaria much more efficient.
Governments increasingly withdrew from the health sector in waves of privatisation in the 1980s. Budgets for health-care systems fell steadily, and were mostly spent on high-profile projects in urban centres. Large sections of society, in particular in rural areas, were excluded from health care. The spirit of Alma-Ata appeared to be dead.
But it isn’t. The WHO’s 2008 World Health Report, which was published on the 30th anniversary of Alma-Ata, repeated the call for primary health care for all. Ever since, the Alma-Ata objectives have once again attracted much attention. This is especially true in Latin America.
In June 2012, action medeor, a Germany-based non-governmental organisation that specialises in pharmaceutical and medical aid, held a meeting with partner organisations from Mexico, Guatemala, Haiti, Bolivia, Ecuador and Colombia. Their outlook on health and health care, their experiences and demands were reflected in the meeting’s final declaration, the contents of which we outline in this essay.
Latin America has come up with a new development model. “Buen vivir” is about much more than the mere pursuit of material prosperity. The term literally means “good” or “fulfilled living”. The notion is based on indigenous traditions and values of the Andean region and promotes a balance of culture and nature.
The Andean languages Quechua and Aymara do not have a word for “health”. The closest term would be “buen vivir” in Spanish. This notion not only includes medical aspects, it also covers the determinants of health in any specific cultural, social, political and economic context.
Ecuador and Bolivia have made “buen vivir”
a principle of their constitutions. Bolivia, moreover, has come up with a new policy called “Salud Familiar Comunitaria Intercultural” (SAFCI – Family, Community and Intercultural Health). Well-being of this kind is considered a fundamental right that must be guaranteed by the state. Key objectives are:
- the integration of all health-related action in a coherent system,
- the relevance of both science-based and traditional medicine, and
- cooperation between all actors at all levels in the health-care system.
Admittedly, SAFCI remains an ambition that must yet become practice (see interview on p. 27). The progressive objectives of President Evo Morales’ health policy are far from being widely understood and accepted in Bolivia. Only a few decision makers actively try to enforce them entirely.
However, many NGOs in Latin America welcome the policy. They understand and appreciate the buen-vivir philosophy. In their eyes, the principles of primary health care, that were defined in Alma-Ata, never ceased to be an important reference. To bear fruit, however, the policy approach must involve all levels, including the one of traditional practitioners and voluntary workers.
Village health workers and traditional midwives play a very important role. In Latin America, most of their work is done on a voluntary basis. They are sometimes remunerated in kind, but their voluntary work always affects their livelihoods adversely. At the same time, the volunteers make valuable contributions to community life. They help to prevent illness through health education. They typically provide basic medical care at the primary level. Without these people, medical care would be even worse for large segments of Latin American society.
Village health workers are generally from the same indigenous or mestizo group as their patients. They identify with the people, so there is a strong sense of solidarity and a much greater willingness to do voluntary work than in Europe. Indigenous health workers know their patients, speak their language and appreciate their culture. They use traditional knowledge, apply alternative treatments and rely on local resources. Their approach is holistic. The guiding principle is respect for traditions, people and nature. They have considerable authority and legitimacy.
Nonetheless, voluntary health workers’ attempts to cooperate with the science-based health-care system often fail. Formal agencies seldom have much regard for them because they lack formal education and vocational training. Matters must change. Voluntary health workers must be appreciated, and their skills and qualifications must improve. Traditional healers deserve support in terms of vocational training, feedback and supervision. Their important role must be acknowledged, Unfortunately, they still are marginalised in many places. The result is untapped medical potential. Involving them would strengthen the health-care system as a whole. Most important, however, the volunteers need to be appropriately compensated for their time, effort and travel expenses, either in cash or in kind. For instance, they should be given some kind of stipend or grants or means for more effective income generation. The price they pay for doing life-saving work must not be jeopardising their own livelihoods.
For the sake of long-term motivation, however, health workers need official recognition, in the form of certificates, references and personal ID cards. Moreover, they must be involved in decision making. State agencies and local NGOs should have to regard them as partners with equal standing, involve them in institutional procedures and give them a say.
Primary health care depends on steps to counteract the profit-driven privatisation of health-care systems. Governments must assume responsibility for all citizens, rather than discriminating against particular groups. Accordingly, governments must make available adequate budgets for health care at the primary level, make sure that local communities participate and inform people of their rights.
More than white garb
What is needed are alliances that include the private and public sectors as well as national and international NGOs. All parties must cooperate at eye-level, without reducing non-governmental agencies to mere service providers or even stop-gaps. All involved must examine the extent to which their work actually helps to create a primary health system in the sense of buen vivir and as demanded by the Alma-Ata Declaration. Donor governments and international civil-society organisations should not only invest in health programmes that promise fast results.
Civil-society organisations, moreover, must re-assess their own role. Those that are based in developing countries must not only focus on their own health-care programmes, but also keep an eye on government policy, checking how health budgets are used. Internationally active NGOs from rich countries, on the other hand, must support southern partners’ efforts to raise awareness and influence policy making, with both advice and funding. Otherwise, health for all will never be achieved.
It is worth heeding what one of our partners from Ecuador said at the end of our meeting in June: “It must be clear to everyone that health care is about more than people wearing white doctor’s coats.”
Declaration del “Buen Vivir”, joint declaration by action medeor and Latin American partner organisations (Spanish and German versions)