With controversy still raging over national health reform in the United States, the media is paying little attention to an international debate on global health policy that is of major importance to the world’s poorest people. Both debates revolve around a similar theme, which President Barack Obama neatly summarized in his recent landmark address to Congress as “the appropriate size and role of government” in the provision of health services.
In the late 1970s, long before the U.S. House of Representatives introduced the bill “Medicare for All” (H.R. 676), the World Health Organization (WHO) and its member states (including the United States) embraced the greater goal of “health for all.” The approach to achieve this universal target, termed Primary Health Care (PHC), encompassed a vision of a new international health strategy that is today gaining renewed attention from policymakers, health professionals, civil society, and the United Nations.
While the healthcare discussion in the United States is framed by the objective of universal coverage, the debate on PHC has long been guided by the same aspiration for developing countries. Global health care reform is again on the agenda of the international community, though it faces some of the same challenges that Obama’s initiatives have encountered in the United States.
Origins of PHC
According to the PHC vision, addressing the socioeconomic determinants of health, not just the medical consequences of sickness and disease, is fundamental to reducing the global inequities in healthcare provision. In 1978, when ministers from 134 countries gathered in Alma-Ata, Kazakhstan, and signed a declaration calling on nations to reduce the gap between the health status of the developing and developed countries, they considered the slogan “Health for All by the Year 2000” as a laudable and achievable goal. Not only did it involve guaranteeing access to essential health care at a community level for all people of the world, but PHC services were to work closely with health-related sectors responsible for other essential needs including education, safe water, sanitation, and food security.
The sense of optimism amongst health policymakers was unfortunately short-lived. The late 1970s saw the rise of the neoliberal economic model along with the recasting of public health and other social services within a market framework. As the neoliberal discourse in public health policy became dominant from the 1980s onwards, the new buzzword became “Selective Primary Health Care.” Critics derided this new approach as “Health for Some by the Year 2000.” The Washington Consensus doctrine of an austere state rapidly superseded the social democratic ideal of government-funded programs to meet the essential needs of society. There was little room for ambitious public health programs.
No sooner did the WHO and its member states sign the Alma-Ata declaration than the debate over Selective PHC created a schism in the global health community. WHO and UNICEF — the two main proponents of PHC — soon drifted apart, and UNICEF switched to promoting a selective package of low-cost interventions. The World Bank adopted the selective approach for disease control in developing countries based on the rationale of cost efficiency. Instead of viewing health as an integral part of development, the Bank emphasized intervening at a selective point in the epidemiology of a disease or health system — thus focusing on the clinical determinants of health rather than the social, political, and economic determinants of health that are largely beyond the control of health ministries.
During this period of structural adjustment programs, governments rapidly privatized many state enterprises and incorporated competition into the provision of social services. Many poor countries slashed their health budgets and introduced user fees in the healthcare sector. The poor often had to make hard choices between food, education, or health care. As a result, global poverty levels increased sharply from the late 1980s. Between 1992 and 2000, the number of hungry people increased by almost 60 million. And between 1985 and 2005, the gap between average life expectancy at birth in low-income countries and in the major industrialized countries actually widened by nine months.
Global Health Today
Today, although global health inequalities have become far greater than they were 30 years ago, privatization and market principles remain at the center of the international health agenda. In recent statistics, the WHO reports that the difference in life expectancy between the richest and poorest countries still exceeds 40 years, and the cost of health care has pushed about 100 million people into poverty each year. As many as 5.6 billion people in low- and middle-income countries have to pay for more than half of their health expenditure themselves. Furthermore, the WHO estimates that an additional 400,000 child deaths per year could be caused as a direct consequence of the financial crisis.
In other words, the ideals of universal PHC, in which state capacities are strengthened to ensure the rapid expansion of free, publicly provided health care, appear to be further away than ever before. But the principles of PHC are, in fact, making a second resurgence.
Alongside the opening up of intellectual space in the United States on the government role in providing health care, a number of civil society groups are exerting a push for PHC on the international level. In December 2000, when governments were originally slated to meet the Alma-Ata vision of “health for all,” the People’s Health Assembly took place in Bangladesh with over 1,400 participants from civil society movements and non-governmental organisations. After more than a hundred sessions, the participants formulated The People’s Charter for Health, which soon became a common tool of a worldwide citizen’s movement committed to making the Alma-Ata dream a reality.
On the 30th anniversary of the Declaration of Alma-Ata in 2008, the People’s Health Movement again reiterated its call. Meanwhile, in April 2008 the Ouagadougou Declaration also called for a renewal of the principles of PHC and its implementation in developing countries. A further impetus was given to the concept of PHC by the publication of three prominent reports in 2008: the WHO’s World Health Report 2008, the WHO’s Commission on the Social Determinants of Health (CSDH), and the Global Health Watch II.
Of these, the final report of the CSDH is of particular note. Following a three-year investigation, the CSDH reported that increased national wealth alone does not necessarily increase national health. In fact, economic growth can even exacerbate poor health unless there is a fairer sharing of its benefits. The structural drivers of health inequality, stated the Commission, are focused in the inequitable global distribution of power, money and resources, which demands a redistributive role of governments to secure the social contract of public health. Some analysts considered the Commission’s findings, peppered with stinging criticisms of globalization and trade liberalisation policies in poorer countries, to be little short of revolutionary.
The U.S. Debate
The divisive debate over national healthcare reform in the United States reflects the longstanding debate over “Health for All” on the international level. Critics on the U.S. right fear that universally provided medical care — which could eliminate the role of private insurance companies in favor of a government-only plan — would be a radical intrusion of government into basic health services. On the other side of the U.S. debate, advocates of a greater public role in health care argue that socialized medicine has long existed in the form of Medicare, Medicaid, and the Veterans Administration — all examples of government-funded single-payer systems that could be extended into a universal program. As outlined in countless media commentaries over recent months, the fully privatized U.S. health care model has led to poor health outcomes compared to other advanced countries. The system boasts the highest administrative costs, yet leaves 46.3 million Americans without access to health insurance.
The public-versus-private debate on health care is similarly divisive on the international stage. With the WHO’s renewed commitment to PHC has come a reinvigorated notion of the public sector’s redistributive function and its ultimate responsibility for shaping national health systems. Yet still the dominant global discourse frames health care as a commodity rather than a basic human right, with the role of governments limited to supporting safety nets for those left outside a selective coverage of healthcare benefits. The World Bank in particular continues to encourage and fund the expansion of private-sector health care, despite a wide body of evidence showing that only scaling up the public sector provision of services is likely to deliver health benefits for poor people. Just as Republicans in the United States staunchly oppose a strong central government role in health services, so do many global health professionals continue to support private health systems over a tax-funded public delivery of health care in developing countries.
The United States is destined to play a pivotal role in the outcome of these debates both on the domestic and international scene. Many health professionals worry that the same neoliberal thinking that contributed to the decimation of health systems in the 1980s will still prevail through U.S.-influenced institutions like the World Bank, IMF, and WTO. The U.S. Agency for International Development is well known for supporting these same structural adjustment programs, and today still leans toward market-based health systems and privatization policies. U.S. foreign aid also continues to support only disease-based initiatives that ultimately hinder the comprehensive health systems development central to PHC, despite Obama recently calling his increased funding for combating HIV/AIDS, tuberculosis, and malaria “a new comprehensive global health strategy.”
While the three prominent reports released by the UN and civil society in 2008 signal a shift in the right direction, a PHC strategy is still far from implementation. Although the WHO is again attempting to foster PHC, there are no adequate global initiatives and no sufficient coalitions of global institutions to address the social and economic determinants of health. Civil society has long criticized the WHO itself for being too “disease-focused” and supportive of selective, vertical interventions that undermine its own PHC vision.
For many, the WHO’s attempt to foster PHC is inadequate given the prevailing macroeconomic order, in which private actors like the Gates Foundation spend more than double the core budget of the WHO on health care in developing countries. A basic criticism of the Foundation’s work also concerns its bias toward biomedical and technological solutions, and its business-oriented approach to health improvement that has fragmented health systems and diverted resources away from the public sector. As the WHO’s CSDH report concluded, technocratic solutions cannot resolve global health problems unless combined with the political and power structure changes needed to redistribute economic and social resources more equitably.
If the World Bank and international donors had tackled the structural causes of ill-health by adopting a comprehensive PHC strategy, as opposed to reinforcing the privatized and medical-technical approach to health care favored by the United States, the health catastrophe in many developing countries would not likely have assumed such tragic proportions since the 1980s. Still, we are at a different political point at this moment, when the stock market collapse of 2008 has led many to question “markets good, state bad” rhetoric. In light of both the renewed push for Primary Health Care and the crucial U.S. debate over healthcare reform, the time is ripe for a global civil society movement to turn “health for all” into an international priority.