|Plenary session PL09, Wednesday, May 28 2008, 15:45-17:00, Room 2|
|Chair(s): Claude Le Coultre, Professor Emeritus, Faculty of Medicine, University of Geneva, Switzerland, Louis Loutan, President of the Organizing Committee, Geneva Health Forum, Switzerland|
|Everyone Contributes to Strengthening Health Systems|
|Ruth Dreifuss, Former President of the Confederation of Switzerland|
|Maintaining Progress Towards Global Access to Health|
|Bruno Gryseels, Director, Institute of Tropical Medicine, Belgium|
Contributors: Irene Amodei (ICVolunteers)
After recalling the importance of the call for health equity and primary health care policies in the Alma Ata Declaration, seen as a "pact between Society and health workers", Mrs. Ruth Dreyfuss, former President of the Confederation of Switzerland, listed the current challenges humanity has to face: the old ones, still there, unsolved; and the new ones, such as drug-resistance; new "civilization" diseases affecting the poor of developed countries as well as developing countries; and chronic diseases.
Ms. Dreyfuss stressed the government's former acceptance of responsibility for the health of their population. "In the last thirty years, however, she said, States, worried by the balancing of the public finance, have abdicated a part of their responsibility." New priorities must be put in place, and these must not vary depending on "the trends of the moment" nor by the availability of resources.
New mechanisms and structures are needed for coordinating more efficiently between the different stakeholders, and the population must be democratically involved in choosing these priorities and structures.
Ms. Dreyfuss supported empowerment of health workers and health authorities in budget decisions, and highlighted the unavoidable role of the World Health Organization (WHO), whose mandate is to assure that all initiatives at the international level are complementary and not in competition. The WHO must offer its experience and its commitment in the global debate on public health in order to avoid an exclusively economical-oriented definition of health policies.
Dr. Sania Nishtar, named International Health Professional of the Year 2007, was invited to share her experience as a cardiologist in Pakistan and founder of the non-governmental organization Heartfile. She described the beginning of her career, when she decided to start an awareness creation campaign to combat heart disease, and to commit her time to the government, helping to develop the public-private partnership program on non-communicable diseases (NCDs). "I soon learned," she pointed out, "that plans could not be cascaded on a country if systems were not robust enough to implement them". Therefore, she focused her attention on health systems reform. "Health reform within developing countries is not an isolated phenomenon. Without government reform, without attention to broader social sector systems, without institutional strengthening and broader structural changes, health reform can not be an achievable objective", she continued. Dr. Nishtar identified four crucial issues aimed at reconfiguring and reorienting health systems that need to be addressed:
- In developing countries, governments must pay due attention to macroeconomic reforms within the context of health, in order to have additional resources to allocate for health. A wide range of measures should be considered, such as taxation reform or increasing foreign direct remittances. Economic growth is one of the strongest determinants of health system achievements, but it must be seen not in terms of capital market, but in terms of pro-poor redistribution of growth benefits.
- Health is not an isolated phenomenon. Social conditions deeply impact health status. Food security, water and sanitation, conflicts, natural disaster and post-conflict situations have a huge bearing on health conditions.
- Governance impacts on the health sector. Civil service reforms, measures to build integrity and enhance transparency in the procurement chain may enable governments to run more efficiently and effectively, saving resources and better targeting services and subsidies.
- Many health system designs are prevalent in the world, such as the social welfare model, the social health insurance model. But for more than 95 percent of the population, the existing health system is a mixed private-public health system, generally unregulated (or poorly regulated), characterised by a lack of equity and transparency, and by distortions, which ultimately lead to high out-of pocket expenditures. The answer to this is a fundamental reform of the mixed health system itself.
"We have to make an incremental plan to make these things happen. It is important that through collaborative efforts we set our sights on the right course, which will ultimately cascade into appropriate changes at the country level", concluded Dr. Nishtar.
Professor Bruno Gryseels, Director of the Institute of Tropical Medicine, Belgium, wrapped up the Forum conclusions. "Where do we come from and where do we go from here?" he asked. The prior Geneva Health Forum came to the conclusion that Global Access to Health is a comprehensive expression for a wide range of things: access to determinants of health, to prevention, to basic health care, to hospitals, to disease control. It concerns individuals, communities and countries, and has physical, financial and socio-cultural components. "Healthcare is first and foremost a fundamental human right. It is not an intervention, not a commodity, not a socio-economic choice", stated Mr Gryssels, pointing out that twenty-eight years later, "Alma Ata is still very much alive, not as an ideological pamphlet, but really as a practical instrument for organising healthcare". Accessible quality and sustainable healthcare services are crucial for disease control to be effectively implemented. Furthermore, "accessible healthcare is a motor for social, economic and political development, and is the main and overarching health Millennium Development Goal."
Prof. Gryssels continued by highlighting the core messages of the 2008 meeting, on which there was clear consensus:
- The need for a reaffirmation of Alma Ata as a basis for the future: the Primary Health Care model is a functional one that meets the demands and needs of the population and that WHO has adopted as its basic strategy.
- Weak health systems cannot deliver: we are at a new inflection moment in history, demanding a new balance between disease-specific programs and broader systems.
- The gap between needs and resources is political. Decision-makers must be informed and mobilised.
- The context has changed (new drug-resistance, chronic diseases, emerging powers in developing countries, stronger international interference in national and local policies, the Information and Communication Technology (ICT) revolution, the human resources crisis, food and oil crises). But this does not fundamentally affect Primary Health Care (PHC), which can also tackle new problems.
- There is evidence of many interesting examples of PHC in action, from a bottom-up and community-based perspective as well as from a top-to-bottom perspective (ministerial initiatives).
- It is a fact that there is an inadequacy in health system research.
- Much more is needed in terms of funding. Who should pay? User fees, community health insurance, tax-based redistribution, international solidarity? Who is eligible to handle the system costs?
- The final responsibility remains with the country which must take care of its citizens. The State does not have merely a regulation role: it has to have a health policy and to implement it. And it has to be accountable to the population.
- The WHO should show stronger and more coherent leadership. They should take the side of the healthcare recipient and the poor countries.
Where do we go? Alma Ata took place thirty years ago, but it is not too late to implement its recommendations. "Maybe now is the time to start. Maybe now we have the right conditions, the resources, the global attention to really implement the Alma Ata principles", concluded Prof. Gryssel.
According to the last speaker, Louis Loutan, Medicine Internationale, Geneva University Hospital, "The very strength of this Forum is not only to be policy-oriented but to have people coming from the field and sharing with us what they have been doing".
Mr. Loutan highlighted the common commitment that arose from the Forum: "We have to move forward according to the holistic view and global direction that began with the Alma Ata Declaration".