In 1978 the Alma Ata Declaration affirmed health as a human right with health being defined as a state of complete physical, mental and social wellbeing. The Declaration proclaimed that communities should adopt the principles of primary health care to achieve better health for all (WHO 2008). The principles of primary health care are based on a social justice approach where community health focuses on empowering individuals enabling them to make informed health decisions (Green 2004).
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The aim of this essay is to discuss primary health care in the Alma-Ata Declaration and how attitudes towards primary health care have changed over time. Furthermore, it will discuss the relevance of primary health care today according to the WHO report, Primary Health Care ? Now more than ever, focusing on Australian Indigenous children?s health in the Western region of Melbourne.
In the Alma-Ata declaration, primary health care is essentially healthcare based on practical, evidence based and socially acceptable methods that are made accessible to all individuals within a community through full participation. The principles form the integral part of the health system, providing health care at the first level with an overall focus on the communities and countries socio-economic development (Awofeso 2004).
Primary health care was criticised as soon as the Alma-Ata conference concluded, politicians did not accept that communities would be responsible for planning and implementing health care services. As a result, political commitment was not sustained nor was it backed with necessary reforms (Hall & Taylor 2003).
Government agencies lacked any provisions for ensuring equity to accessing services especially for the poorer and disadvantaged communities. Furthermore, experts and politicians refused the principle of primary health care which allowed communities to plan and implement their own health care services (McMurray & Param 2008).
Internationally, resources for public health were diverted from primary health care to aid with the management of high-mortality emergencies. This included the resurgence of tuberculosis, increases in malaria and the emergence of HIV/AIDS (WHO 2008).
World events impacted on the development of primary health care, an oil crisis, a global recession and the introduction of structural adjustment programs by development banks shifted governments? budgets away from health and social services (WHO 2008).
Inadequate funding and training for healthcare professionals resulted in a lack of services for communities with people choosing to by-pass the primary level of services being provided. Inaccessibility, limited resources and poor equipment left primary health care services limited in coverage and quality (Hall & Taylor 2003).
Inaccessibility, limited resources and poor equipment left primary health care services limited in coverage and impact. Due to poor levels of service, primary health care workers lost motivation and resigned as a result of under-staffed centres and inadequate delivery of service.
In some countries primary health care continues to be inadequately supported and resourced due to lack of structure and investment within health organisations leading to poor coverage and quality of services (Hall & Taylor 2003).
In 1994, the World Health Organisation (WHO) review of world changes in health development since Alma-Ata bleakly concluded that the goal of health for all by 2000 would not be met (WHO 2008).
The principles of primary health care cannot be rejected however there is a need to find new ways of adapting the principles and applying them to present contexts (Macdonald 2004). A case study published by the Rockefeller Foundation ‘Good Health at low cost’ found countries such as China, Costa Rica and Sri Lanka managed to achieve an affordable and effective health system by placing a strong emphasis on overall social welfare developments despite their differing economic constraints and political systems (McPake 2008).
In 2008, the Commission on Social Determinants of Health report called on all government policies to pay close attention to health for all as gaps in health outcomes are indicators of policy failure. The report further states primary health care to be used as a model for health systems that act on underlying social, economic and political causes of ill health (WHO 2008).
The World Health Organisation (WHO) Report, Primary Health Care-Now More Than Ever (2008) reports an increased demand for primary health care knowledge among policy makers to develop health systems that are equitable, inclusive and fair. Furthermore, demonstrating the need for comprehensive policies ensuring adequate performance of health systems as a whole.
The report revisits the vision of primary health care as a set of values and principles for guiding the development of health systems. However, it addresses lessons learnt from the past and Alma-Ata, potential challenges ahead with a particular focus on narrowing intolerable gaps within health systems (WHO 2008).
WHO recognises four key reforms that need to take place in order for primary health care to be embraced, they reflect a convergence between primary health care values, equity, solidarity, social justice and community expectations of a globalised society with the principles forming the integral part of the health system focusing on community and country socio-economic development (WHO 2008).
Service delivery reforms include people centred health systems ensuring people’s needs are met, socially relevant service and adaptable to an ever changing world. Universal coverage reforms to improve health equity primarily through universal access and social health protection. Leadership reforms to ensure health authorities are more reliable by pursing healthy public policies by promoting and protecting the health of communities through participation negotiation-based leadership that is required due to the complexity of contemporary health systems (WHO 2008).
In many countries the management of national resources to support primary health care reforms requires considerable attention and action from both social and political aspects. International collaboration and acceptance of primary health care reforms can stimulate a rapid adaptation to ensure equitability, efficiency and cost-effectiveness for health systems (WHO 2008). Furthermore, primary health care reforms must be supported by initiatives that focus on ensuring people who are predisposed to lower socio-economic backgrounds or disabilities are given equal access to health services, in Australia these are Indigenous communities.
The Aboriginal community accepted the primary health care approach due to their holistic view of human nature and health (Macdonald 2004). By planning and implementing health worker home visits and helping people in their own environment has proved successful particularly in maternal and child health services (Flahive 2009). This is visible in the period 1996-2001, where the life expectancy for an Indigenous Australian child had a difference of approximately 17 years. In 2009, the Australian Bureau of Statistics (ABS) reported the life expectancy of Indigenous Australian children to be approximately 10 years lower than for non-Indigenous Australians (ABS 2009) while the gap is still significant, the disparity is being reduced.
The Western region of Melbourne has one of the highest Indigenous populations in Victoria with 57% being under the age of 25 in 2001 (Department of Health and Aging 2005).
The Aboriginal Services Plan key indicators 2006/07 Report identifies potential indicators for significant improvement to reduce Indigenous disadvantage for; early childhood development, early school attendance and performance and positive childhood transition into adulthood (Department of Health 2008).
Social, cultural and economic factors influence a child?s health especially within the first three years, along with the child?s health, education, development and growth during this period influences the level of health and education in adulthood (Department of Health 2008).
In 2003-04, 1666 Koorie children were registered with the Metropolitan Maternal and Child Health Service (Department of Health 2008).
The Aboriginal Best Start Program is a service co-ordinated with the Victorian Aboriginal Community Service Association designed to focus on the health, development, learning and well being of all Aboriginal children aged upto 8 years (Department of Health 2008). The program supports communities and local services in order for families to receive improved child and family support by ensuring and promoting Koorie children are given the best possible start for their future.
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The NorthWest Metropolitan region Indigenous Child Protection Program is a service that aims to improve cultural awareness within the community and enhance partnerships between Aboriginal services providers. The program has enabled the North West to provide a high level of culturally appropriate services ensuring that children placed in protective care remain connected with their family and wider Aboriginal community (Department of Health 2008).
The Aboriginal community controlled health organisation based in Fitzroy has a program that focuses on increasing knowledge and awareness on maternal and child health through health promotion activities and services provided for families with children upto 8 years old to improve overall health outcomes. The program has increased immunisation rates amongst Aboriginal children (Department of Health and Aging 2005).
Primary health care reform in Australia ? Report to support Australia?s first national primary health care strategy draws on ten elements for an enhanced primary health care system to improve and strengthen service deliveries in response to current and future health issues, the elements are;
In our future primary health care system all Australians should have access to primary health care services which keep people well and manage ill-health by being:
- Accessible, clinically and culturally appropriate, timely and affordable,
- Patient-centred and supportive of health literacy, self-management and individual
- More focussed on preventive care, including support of healthy lifestyles,
- Well-integrated, coordinated, and providing continuity of care, particularly for those
with multiple, ongoing, and complex conditions
Service delivery arrangements should support:
- Safe, high quality care which is continually improving through relevant research and innovation,
- Better management of health information
- Flexibility to best respond to local community needs and circumstances through sustainable and efficient operational models.
Supporting the primary health care workforce are:
- Working environments and conditions which attract, support and retain workforce,
- High quality education and training arrangements for both new and existing
Primary health care is:
- Fiscally sustainable, efficient and cost-effective? (Department of Health and Aging 2009).
Four key priority areas developed from the strategy include ?improving access and reducing inequity, better management of chronic conditions, increasing the focus on prevention and improving quality, safety, performance and accountability? (Department of Health and Aging 2009).
The basis of these priority areas are the combination of person-centred care, improved management of health information and development of an educated workforce. The strategy also recognises community encouragement in relation to health status and access to services, the increased use of multi-disciplinary teams and performance accountability along with disease prevention rather than temporary illness treatment through health promotion activities (Department of Health and Aging 2009).
Countries with dedicated and resourceful primary health care systems demonstrate efficient and affordable health care is achievable with research finding improved overall health outcomes, lower hospitalisations and fewer health inequalities (Department of Health and Aging 2009).
The first element of the enhanced primary health care system for Australian?s is to ensure that all Australian?s have access to clinical services that are culturally appropriate, are delivered promptly and essentially affordable. Certain population groups, Indigenous Australians, face significant health care access gaps; however effective implementation and collaboration would eliminate these gaps (Department of Health and Aging 2009).
In order to eliminate the health gap between Indigenous and non- Indigenous Australians, the strategy recognises health issues and gaps associated with Indigenous populations having higher rates of disease, disability and exposure to drug misuse. All Australian governments have allocated funds to improve Indigenous Australian health outcomes especially for the children as they are the future (Department of Health and Aging 2009).
Further commitment from the government to eliminate health disparities is through person-centred approaches where Indigenous Australians will be able to access mainstream health services (Department of Health and Aging 2009).
These focused activities will greatly influence Indigenous children in prevention of chronic diseases, management of chronic illnesses and most importantly ensuring they are the centre of the care being provided (Department of Health and Aging 2009).
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