Perspectives in Health Magazine
The Magazine of the Pan American Health Organization
Volume 8, Number 2, 2003

A call for action
 
For Mahler and others, "Health for All" was a social and political goal, but above all a battle cry to incite people to action. Its meaning, however, has been misunderstood, confused with a simple concept of programming that is technical rather than social and more bureaucratic than political.

U.S. Senator Edward Kennedy (left) made a surprise appearance at the 1978 Alma-Ata conference. At right is then WHO Director-General Halfdan Mahler.

When Mahler proposed "Health for All" in 1975, he made it clear that he was referring to the need to provide a level of health that would enable all people without exception to live socially and economically productive lives (today we would say "a minimally dignified standard of living" in a context of "truly human development"). The reference to the year 2000 meant that, as of that date, all the world's countries would have developed the appropriate political strategies and be carrying out concrete measures toward achieving this social goal, albeit within different time frames.

The process of conceptual development surrounding just what health is was also important. In 1946, the new WHO constitution incorporated a definition of health proposed by the Croatian public health pioneer Andrija Stampar. It said health was "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." This was a qualitative leap from earlier concepts, but it was difficult for many government experts of the time to fully grasp its meaning.

The Declaration of Alma-Ata repeats this definition, adding that health is "a fundamental human right and that the attainment of the highest possible level of health is a most important worldwide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector."

Perhaps because of what might be called professional deformation, it was not really understood that health is a social phenomenon whose determinants cannot be neatly separated from other social and economic determinants. Nor can it be assigned solely to one bureaucratic-administrative sector of the state. Nor was it understood sufficiently-though it was spelled out clearly-that health is, above all, a complex social and political process that requires political decision-making not only at the sectorial level but also by the state, so that these decisions are binding upon all sectors without exception.

Something else that was quite explicit, but that remains misunderstood, is that health is the responsibility of everyone-individuals, social groups and civil society as a whole. In practice, people continued to be viewed as passive recipients of health services that emphasize curative medical treatment of specific illnesses.

The conceptualization of "primary health care" was based on erroneous and biased perceptions of the experiences of Third World countries in providing health care with limited resources. In particular, the Chinese experience with "barefoot doctors" was interpreted simplistically and superficially.

As for the concept of "care," the original term in English was translated into Spanish as atención rather than cuidado. In Spanish, cuidado has a much broader connotation than atención, implying something integral that involves horizontal, symmetrical and participatory relationships. Atención, in contrast, is vertical, asymmetrical and never participatory in a social sense. El cuidado is intersectorial, while la atención is the work of a single sector, an institution, isolated programs or specific services.

The term "primary" has linguistically diverse and even contradictory meanings. In Spanish, in particular, some of these are nearly opposites. Primario can mean "primitive and uncivilized" or "principal or first in order or degree." As a result of the simplistic and biased perceptions of the experiences on which the concept was based, it was easier, more comfortable and safer to accept the former meaning, while the spirit of Alma-Ata clearly embraced the latter. The Declaration states that primary health care "forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community." It was never seen as an isolated part of the health care system, nor was it limited to marginal, low-cost treatment for the poor.

There is a fundamental difference between integral health care for everyone and by everyone-care that is multisectorial and multidisciplinary, health-promoting and preventive, participatory and decentralized-and low-cost (and lower quality) curative treatment that is aimed at the poorest and most marginalized segments of the population and, what is worse, provided through programs that are parallel to the rest of the health-care system without the direct, active and effective participation of the population.

In my academic activities I have repeatedly stressed this issue, attempting to point out what primary health care is not (regardless of its name, which can lead to mistaken assumptions), and what it indeed is. Repeatedly, while I was deputy directorgeneral of WHO, I was forced to keep a prudent silence when high-level officials from a given government would tell me with pride that they had a specific "office" or a "national program" for primary care, or that they had primary care activities only in the most peripheral health centers.

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