The director-general of the World Health Organisation Tedros Adhanom Ghebreyesus spoke to Edmund Kagire and Elizabeth Merab after the signing of the Astana Declaration about what is to be done scale up health for all.
If you could give us a quick recap of the discussions here in Astana... what do we take home? What next after signing the declaration?
We all agree that it is a good declaration and now it is the time to walk the talk. It gives me confidence that all the people who participated are serious about the implementation of the declaration.
They even gave some ideas on how we can proceed, combining it with what is being done with the Primary Health Care Improvement Initiative, the Bill and Melinda Gates Foundation, who are the trailblazers.
We have already assessed primary health care and we know what the status is, based on some factors we considered while doing the analysis and to help them address the gap so that we can together build strong primary healthcare systems.
So we know where the gaps are and we know what needs to be done. People are saying let’s go to the ground quickly and start working with those countries already. That is very important and that is what I want to take home. We need to get things done starting now.
At the same time, discussions should continue. The commitment should really be strengthened. The other thing people are now asking is, how do we use the next World Health Assembly, the next UN General Assembly in September and other high level meetings at the global level to advance the Astana Declaration?
We need to use these opportunities to reinforce the declaration but at the same time start getting things done.
How will you get things done?
We need to agree on the practical issues, for instance, to make primary healthcare happen, we will need human resources.
How do we address the human resource gap? The discussion should continue. We have the financing issue, the technology issue, capacity building issue.
We all know that the focal point for all these is the financing part. While we encourage countries to increase use of their domestic resources, how can we also globally increase the envelope to support countries to fill some of the gaps they have in terms of financing? We want to use these platforms, the World Health Assembly and the UN General Assembly, to address the financing issue.
Forty years ago, there was the Alma Ata Declaration on Primary Health Care, today we are talking about the Astana Declaration, still on the same, so what difference does it make?
The Alma Ata declaration had something lacking because it was a divided world when it was signed. Some countries took it on, others didn’t.
Its implementation was uneven. That is why in my speech I said that the Alma Ata declaration was not “health for all” but it was “health for some”. People are saying let us move away from that.
There is also some confusion that primary healthcare is prescribed for developing countries only. Not at all –it is actually important for high income and middle income countries as well.. It is for all, for the whole world. The best and smartest investment is in primary health care. Its capital investment is low and the return on investment is high.
Most of the problems of non-communicable diseases, be it in high, middle or low income countries, can be addressed through primary healthcare. There is some consensus now the primary healthcare is for everybody.
It starts from the individual and community. PHC has to operate in a way that empowers individuals and families to take care of their own health.
We should break the “provider-receiver model”. We have to transfer the knowledge, the skills and the means to the individuals, families and communities so that they can control their own lives and health in order to lead healthy lives.
While community health workers are an integral part of the healthcare system, many countries do not remunerate them accordingly. What challenges exist in terms of bringing them fully on board to achieve the desired levels of primary healthcare?
Having full-time staff especially at the level of primary healthcare, is very important because if we are to have only voluntary workers who are also preoccupied with their own lives and supporting their families, it will be a problem because nobody is going to volunteer at the expense of their own family. Therefore, we are saying those health workers, including community health workers, that we want to operate full time, based on the services they provide, should be remunerated. But it does not mean that we should not have volunteers.
In Ethiopia, for example, we proposed that all extension workers, who are like community health workers, be paid. These are high school graduates, from the same village, trained for one year on different service packages, which include health promotion, prevention and some curative services, serving in health posts in their respective communities.
Two extension workers per 5,000 people in their communities are remunerated because we need them full time. But in addition to that, we have volunteers. These do not need any remuneration because they are contributing to their own communities in kind.
They also receive in kind contributions from others in the village. You will find some contributing to construction of roads, others to security, others in health and others in provision of water. In my own experience, this has worked.
However, I emphasise that we also need those in full time service, who are remunerated for the work they do, in order for us to get good services.
You talked about financing and the different platforms to push for improved financing, but as we speak, some donors are pulling out from supporting different initiatives especially in sub-Saharan Africa, while some projects have stalled and others have failed. Is it time to rethink how we finance primary healthcare?
We may need, first of all, to re-energise. If we show the same donors that investment pays and give them reasons to invest, they may still be convinced.
That way we can still keep the base, but at the same time we can broaden the base, meaning that we need to look for additional sources of revenue itself. When we focus on select donors only, there will definitely be donor fatigue. Broadening the base is very important.
In addition to that, innovative financing mechanisms should be considered. A combination of these should help. But the most important aspect is domestic resources. Whatever comes from outside, the country should consider it as a supplement. The bulk of the resources should come from the countries themselves.
The declaration talks about countries making bold political choices. Beyond signing the agreement, what are you going to do to ensure that countries implement the Astana declaration?
We expect countries to implement it but we have to continue to promote it and speak about it. We must ensure that we get things done as we have agreed here.
From our experience, we can learn from the practical action taken by some countries and understand what doesn’t work and what works. We will advocate for countries to really move into action.
Primary healthcare is not a big deal to ask countries to implement because it does not require a lot of investment. All we need is the political will. Action and implementation is the next phase.
The Declaration of Astana, adopted at the October 25-26 Global Conference on Primary Health Care in Astana, Kazakhstan, makes pledges in four key areas:
(1) Make bold political choices for health across all sectors;
(2) Build sustainable primary health care;
(3) Empower individuals and communities; and
(4) Align stakeholder support to national policies, strategies and plans.
Among the participants were ministers of health, finance, education and social welfare; health workers and patient advocates; youth delegates and activists; and leaders representing bilateral and multilateral institutions.