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May 2007, Volume 57, Issue 5

Short Reports

Thirty years of Alma Ata pledges:Is devolution in Pakistan an opportunity for rekindling primary health care?

Babar T. Shaikh  ( Department of Community Health Sciences,Aga Khan University, Karachi. )
Muhammad Masood Kadir  ( Department of Community Health Sciences,Aga Khan University, Karachi. )
Gregory Pappas  ( Department of Community Health Sciences,Aga Khan University, Karachi. )


The 1978 Alma Ata Conference presented the manifesto to attain global health for the next century by providing basic health care aimed at the urban and rural poor of the developing world. While the goals of Alma Ata were noble, they were untenable. Today, developing countries face serious issues of equity in health care delivery and fairness in health care management with even a greater need to transform the management systems and practice. Primary health care remains a cornerstone of building the capacity of health systems. Devolution in health sector in Pakistan seems like a chance to re-exert Alma Ata agenda. To achieve the millennium development goals by 2015, revitalization and effective implementation of primary health care will be a vital reform.

The Industrial Revolution initially brought about social disruption and later intensified the burden of communicable and non-communicable diseases. Responding promptly, the 1978 Alma Ata Conference presented the manifesto of attaining by all people of the world, by the year 2000, a level of health that will permit them to lead socially and economically prolific lives.1 The conference stated that primary health care (PHC) should focus on the education and prevention of health problems, the promotion of a better choice of food, the supply of safe water and basic nutrition, the provision of child care and family planning, immunization against major infectious diseases, prevention and control of local endemic diseases, treatment of common diseases and injury and provision of basic and essential drugs. Preferably, PHC was supposed to be task-oriented when dealing with common health problems, and culturally-oriented when trying to prop up community development. Had primary health care got the chance to flourish and focus on needs of the communities, it would have been superior to hospital care in reducing suffering, waiting and cost. Au contraire, developing countries today carry a cumbersome burden of disease, of which underlying cause is poverty. While the goals of Alma Ata were noble, they are so far somehow untenable.

Issues and challenges
In most of the developing countries, PHC programmes had been dependent on donor agencies with too much emphasis and focus on disease, natural disaster and world hunger.2 Success in combating health problems through the western experts' projects and steadfast professionals from Third World countries deserve credit. However, it completely lost sight of what common people can do for their own welfare. Individual and communal action apparently was the missing link in this scenario. Introducing selective PHC, social action programs, World Bank policies for third world, and corporate agreements (WTO, GATS, TRIPS) have assaulted PHC's original spirit ruthlessly.3 Developing countries, in particular, have often agreed to such agreements without carefully examining the long term implications; a complete dearth of integration and forethought. Poor countries with low GNP, spent meager amounts on health care, in spite of the fact that their health needs are more acute, and so is the case of Pakistan.4 Inadequate health budgets are the reason why priorities are set aside. Uneven budgetary allocations in the health care system leave the urban poor and the rural people underprivileged. Healthcare delivery with a definite element of quality still remains a challenge. The government health facilities incompetently manned, focusing on curative care, operating in limited hours and distantly located are grossly under-utilized.5 Any successful PHC model is accessible in all means; comprehensive package of services; assured stock of essential supplies; structured referral system and a concerned leadership.6 Lack of permanent improvement in health sector has been ascribed to lack of political commitment and insufficient financial support.7 An unsteady poorly organized PHC in Pakistan has contributed in creating marked disparities in health status within the population. Malnutrition, for example is a major public health problem that disproportionately affects women and girls. More girls than boys die under 5 years. As for women of child bearing age, some 30,000 women die each year due to complications of pregnancy, and 10 times more women develop life-long, pregnancy-related disability, yet fertility rates continue to be high.8 The morbidity and mortality of a woman inauspiciously impinge on health of her children, household productivity and the national economy. Government's commitment here is evident from its consistently low allocation of budget to health sector.

Decentralization: a prospect to strengthen PHC
Decentralization carries the prospects of improving participation and enhancing the capacity of local governments to put pressure on central government for greater share in national resources for local development. Many countries are reforming their health sectors and are basing these reforms on PHC. In a devolved system of government, the district health system has always been promoted as the unit within which the implementation of primary health care by the health and health-related sectors (public and private), and communities can be best organized and coordinated. District management structures were envisaged as a focus for devolution of political power and resources, increased democracy and equity. Moreover, decentralized programmes can be designed with better technical and allocative efficiency ensuring local institutional capacity building.9 The advantages are a manageable size at district level, easily obtainable information and smooth communication between different stakeholders. The district plans can be more effectively designed on systematic, epidemiological assessment of health needs of the local population. One thing is unambiguous in devolution, if community participation is allowed to thrive; human resource development and good governance would be the obvious outcomes. Community stewardship seems the only way out to achieve sustainable quality health services. PHC no doubt is the only way to ensure fair, affordable, and sustainable access to basic healthcare. The spirit of PHC can only be revitalized if the original manifesto of Alma Ata is implemented which entails local political commitment, inter-sectoral collaboration, and taking into account all social determinants of health including education of mothers, provision of clean drinking water, sanitation and housing. Today, thirty years down the road after Alma Ata congregation, there is a greater need to work on primary health care re-structuring, rationalization and management of health facilities, source and mechanisms of health care financing.

Devolution in Pakistan: the opportunity knocks
Similar initiative has evolved in Pakistan in 2001 which outlines clearly the objectives to improve technical efficiency, innovating service delivery, enhancing quality of care, ensuring equity and just allocation of resources and above all pledging community participation at all levels. Thus, the districts have become the dominant level of decision making in health sector where the administrative and financial powers have been devolved to the district health management teams. All relevant district managers can be mobilized now to work in coordination for strengthening of PHC. Under the umbrella of new structure, the district health development committees (DHDC), all managers representing education, agriculture, water and sanitation, rural development, transport, environmental sanitation, community development, law and justice, women development can participate and play their role in policy formulation and programmes implementation. Devolution in Pakistan is undoubtedly a breakthrough for the correct implementation of PHC agenda at the grass root level. A greater accent is needed on an integrated approach encompassing curative, preventive and promotive health activities. Health managers at the local level need to develop population based planning skills to deliver effective health care.

Another uphill task is achieving Millennium Development Goals by 2015. To attain these goals, effective implementation of PHC will be crucial to attract and retain competent and motivated staff, and to ensure quality of services. It has generally been accepted that the district health system is the effective unit of designing and implementing the interventions to achieve maximum health benefits.10 This revamped system with greater community participation, carries the potential of making the government institutions more responsive and accountable. Capacity building of sub-district and district personnel in advocacy, design and management and simultaneously stimulating research capacity is imperative in order to efficiently consume the meager health budget for strengthening PHC. On the eve of 60th anniversary of WHO and 30th anniversary of Alma Ata pledges of PHC, the devolution in Pakistan certainly presents an opportunity to create an enabling environment for attaining three basic goals which are indispensable for any health system: health improvement, responsiveness to expectations and fairness in financial distribution.10 Nonetheless, all of these must remain the main pillars in the health system to confirm that the pledge of 'Health for all' is still alive.


1. Declaration of Alma-Ata. International Conference on Primary Health Care. Alma-Ata, USSR, 6-12 September, 1978.

2. Shaikh BT, Kadir MM, Hatcher J. Health care and Public health in South Asia. Public Health 2006;120:142-4.

3. Hall JJ, Taylor R. Health for all beyond 2000: the demise of the Alma-Ata Declaration and primary health care in developing countries. MJA 2003;178: 17-20.

4. World Bank. Pakistan-towards a health sector strategy. Health, Nutrition & Population Unit, South Asia Region. Washington DC: 1997.

5. Government of Pakistan. Ministry of Health. An overview of the Health sector: The way forward. Multi Donor Support Unit. Islamabad: 2001.

6. World Health Organization. The challenge of implementation: district health system for Primary Health Care. Geneva: 1988.

7. Gezairy HA. The grave problems being faced by our health sector. J Pak Med Assoc 2004;54:430-3.

8. World Bank. World Development Indicators 2004. data/wdi2004. [accessed on 3rd November 2006].

9. Shaikh BT, Rabbani F. District Health System- a challenge that still remains. East Mediterr Health J 2004;10:208-14.

10. Murray CJ, Frenk J. A framework for assessing the performance of health systems. Bull World Health Organ 2000;78:717-31.

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