The Concept of Primary Health Care (PHC) was formalized in 1978 when The World Health Organization and UNICEF convened a major conference in the then Alma Ata in Kazakhstan. The resulting Alma Ata Declaration resulted in advocacy for Health for All, which had evolved into Universal Health Coverage. The Declaration outlined important principles such as community participation in health care planning and delivery, promotion of scientifically sound and acceptable health interventions, the use of community-based health workers (CHWs), and addressing the common endemic health problems in each community. One of those endemic problems common to a majority of communities in Africa is malaria. Now in 2018, 40 years after the Alma Ata Declaration we explore how malaria has progressed within the context of PHC.
The Roll Back Malaria Partnership (RBM) began in 1998, 20 years after Alma Ata. When RBM convened a meeting of African Heads of State in 2000 the resulting Abuja Declaration set targets for major malaria interventions of 80% coverage by 2010. The Abuja Declaration reflected principles of Alma Ata when it called on all member states to undertake health systems reforms which will:
- Promote community participation in joint ownership and control of Roll Back Malaria actions to enhance their sustainability.
- Make diagnosis and treatment of malaria available as far peripherally as possible including home treatment.
- Make appropriate treatment available and accessible to the poorest groups in the community.
By 2011 reality intervened. WHO reported that “In the 10 years that has passed since the Abuja Declaration, there has been progress towards increasing the availability of financial resources for health at least in terms of dollar values. However, there has not been appreciable progress in terms of the commitments the Africa Union governments make to health, or in terms of the proportion of GNI the rich countries devote to Overseas Development Assistance.” Since that time funding from international and bilateral donors has leveled, such that there is even greater need for malaria endemic countries to step forward and guarantee access to malaria prevention and treatment services are available through PHC at the grassroots. Such access needs to move beyond removing barriers to making malaria interventions attractive to the community.
Christopher and colleagues looked to the community and examined how response to malaria and other childhood illnesses were faring 30 years since Alma Ata. After they reviewed seven studies of community health workers they concluded that “CHWs in national programmes achieved large mortality reductions of 63% and 36% respectively, when insecticide-treated nets and anti-malarial chemoprophylaxis were delivered, in addition to curative interventions.” (They found little evidence of the effectiveness of these community interventions on pneumonia and diarrhoea.) The challenge they saw was the ability of countries to move beyond successful studies to scale up and sustain community malaria control interventions to the national level and thereby reap the full promises and benefits of PHC.
Others continue to advocate for a community role in achieving malaria goals through PHC. Malaria Consortium has looked at the position of malaria control within the context of Community Based PHC (CBPHC) and the use of CHWs as a means for revisiting Health for All.
Ghana’s community-based health planning and services (CHPS) program aims to make primary care accessible at the grass roots. CHPS compounds are small clinics in space usually donated by the community, staffed by community health officers who oversee community based agents (CBAs) and other community volunteers who treat and prevent malaria through integrated community case management. Countries have also build on the community directed intervention approach pioneered by the African Program for Onchocerciasis Control to ensure malaria interventions are delivered through community community planning and action.
Controlling and eventually eliminating malaria will certainly go a long way toward helping achieve Health for All. On this 40th Anniversary year of Alma Ata it is time to ensure that all malaria endemic countries and malaria donors revisit the basic philosophy of community action and participation and ensure that these principals guide us to accessible and sustainable malaria programming by the community “Through their Full Participation.”
(This posting has been extracted from a full article appearing in the April 2018 Issue of Africa Health. Also please join the discussion about Alma Ata at 40 on the forum created by colleagues at the Johns Hopkins Bloomberg School of Public Health.)