Public health program in developing countries

In the late 1970s, there was a paradigm shift in the way the world thought about and responded to ‘health’ (Lerberghe, 2008) following a legacy of global governance in the early 1970s, one that Thomas and Webber (2004, p.189) describes as the “first phase” of “global governance”. Where multilateralism was fairly strong and the “UN system was the forum for the development of global governance”, including the call for a New International Economic Order (NIEO) (ibid). Commendable advances were made in the health care discourse following the Alma Ata Declaration, which deemed ‘health’ to be a “fundamental human right” (Declaration of Alma-Ata, 1978, p.1). The United Nations Children Fund (UNICEF), the World Health Organisation (WHO), and 134 participant nations asserted the goal of “Health for all by the year 2000” (Brown, Fee & Stepanova, 2016). In the context of the politics of the NIEO, the Alma Ata Declaration of 1978 was adopted at the World Health Assembly (WHA) in 1981 (ibid).

Thomas and Webber (2004, p. 190) point to the adoption of the Alma Ata Declaration that sought to provide “egalitarian health care on a global scale in accordance with a needs-based approach”, as a significantly insightful historic juncture; moving to bridge “the gap between declarative/symbolic global politics, on the one hand, and substantive policy development, on the other”. The second phase of global governance was visible through institutions like the International Monetary Fund (IMF), the World Bank, and the World Trade Organisation (WTO) and characterized by neo-liberal principles (ibid). The rise of neo-liberalism in a world shifting further from the ‘national’ to the ‘global’ offered opportunities for the broadening of “Reaganomics” in the politics and delivery of Primary Health Care (PHC). The 1980s and 1990s saw the achievement of health as a ’public good’ imagined by Alma Ata developing in neo-liberal terms by its potential for privatization (p.192).

There have been reforms in PHC and since Alma Ata, the passing decades have seen improvement in the world’s health. Despite the 2008 Wold Health report indicating that the developing country’s Primary Health Care is still not fully implemented in many health systems, many countries and regions have demonstrated commitment by continually investing in health workers’ recruitment and public education (Global Health Watch, 3, 2011).  Part of the reasons why the health systems were failing in implementation was due to inadequate preparedness in handling challenges resulting from fast global changes (Vlassoff et al., 2010). Health authorities have a narrow perception of PHC as a single health care model rather than as an essential part of reforms. Vlassoff et al. (2010) suggest that in order for PHC program objectives to be fully realized, universal coverage and equity in health services provision, service delivery centered on people, reforms to public policy that promote community health, leadership, and political reforms that empowers health authorities must first be achieved.

Thailand, Iran, Brazil, and Rwanda are some of the countries that in the recent past have made efforts to implement PHC programs nationally (Global Health Watch, 3, 2011). In all these countries, examples of common characteristics of implemented programs include involvement of communities at different levels through structures; inter sectors actions focus on addressing health problems determinants and consistent and coherent focus in efforts towards the development of health system that is integrated. Thailand, which commenced PHC programs in 1977 using Village Health Communicators and by sourcing assistance of Village Health Volunteers, saw the need for collaborating health development with other sectors such as agriculture and education. Between 1979 and 1982, the nutrition status of children in the country improved to 79% from 47%. Again, immunization centers achieved substantial success while the rate of access to clean water and sanitation increased sharply.  The population has access to indispensable drugs. In a nutshell, Thailand portrayed positive indicators towards realizing millennium development goals expected based on the set standards of a country with its size of the economy.

In Asia, several programs implemented through PHC principles before and after Alma-Ata Declaration have achieved substantial success (Global Health Watch, 3, 2011). For instance, the Deenabandhuram project and Jamkhed Comprehensive Rural Health project were initiated in the early 1980s (p.7). South America and other parts of Asia are among countries that implemented applications of CPHC that were classified as innovative in offering durable improvement services. Strong citizen participation in health provision has sustained the level of political commitment in countries such as Sri Lanka, Costa Rica, and the Indian State of Kerala, some of the countries whose investment in social sectors has been perpetually increasing with heavy bias in women’s education, health, and welfare.

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Among the world’s most successful countries in the fight against HIV/AIDS pandemic is Cuba, which is rated at the top with a transmission frequency of 0.05% (Fawthrop, 2012). The government’s quick response when the first case was reported is attributed to the success in controlling the spread of the virus within the country. Upon turning positive, patients were quarantined for life in sanatoriums and their sex partner (s) traced for testing, a move that attracted criticism from the international community. Expectant women were given drugs to prevent infecting the unborn child and were assisted to deliver by cesarean section. However, the transmission rate is shockingly high in Sub-Saharan Africa (9.0%) and the rest of the Caribbean region, for instance, Cuba’s neighboring country of Haiti, with 6.1%. Despite Cuba’s willingness to produce HIV/AIDS controlling medication for the rest of the developing nations, calls for financial support from developed countries have received minimum attention with only Britain and France showing interest to aid the initiative. Cuba’s director of the health ministry, Dr. Rigoberto Torres, states that lack of political goodwill among rich nations is the biggest constraint in combating the HIV/AIDS pandemic (Fawthrop, 2012).

Rwanda, which had a fragile economic base, saw its health infrastructure constructed for about 15 years get destroyed alongside a large share of its human capital following the 1994 genocide (Global Health Watch, 3, 2011). However, the country’s progress in reintegrating ex-combatants and the reconciliation process has received global applause. More than a third of the country’s entire population who were exiled and sought refuge in other countries have been repatriated and assisted to resettle. Rwanda has enjoyed sharp economic growth accompanied by the remarkable improvement in primary health care (p.9). As one of the Sub-Saharan African countries under the mercy of the high infection rate of the HIV/AIDS pandemic, Rwanda has established several measures to deal with congestion in hospitals, especially as a result of terminally ill patients. A male and female volunteer is elected by each village with between 100 and 150 households to serve as community health workers (CHWs). The CHWs are trained to offer moral and health support to people living with HIV/AIDS, monitor children’s development, and distribute family planning supplies. Furthermore, they treat other conditions such as pneumonia and malaria in addition to referring serious conditions to health facilities (Global Health Watch, 3, 2011).

Immediately after rolling a comprehensive PHC program in 1984, Iran integrated health care services and medical education that was to help in dealing with the country’s shortage of health workers (Global Health Watch, 3, 2011). To extend basic health services to underprivileged areas, the CHWs program was expanded to cover the 65,000 villages in Iran. Since 1974, a remarkable range of health indicators realized include the increase in life expectancy from 55.7% to 71.6% in 2003 and a decrease in maternal mortality rate (p.10). The disparity in mortality rate between rural and urban areas which stood at 120 per 1000 birth in rural areas and 62 per 1000 birth in urban areas decreased to 23.7 and 27.7 deaths in urban and rural areas respectively in 2003.

Despite experiencing political problems due to rulers’ dictatorships, Brazil and Thailand were not left behind in the implementation of PHC programs. In 1994, Brazil initiated ProgramaSaude da Familia (PSF) which by 2013 had 33,000 health workers consisting of physicians, nurse assistants, nurses, and CHWs. The initiative saw the country’s infant mortality decrease from 114 per 1000 births in 1970 to 19.3 per 100 births in 2007. The life expectancy improved from 40 to 72.8 by 2008 (Global Health Watch 3, 2011). These changes are attributable to more than just health reforms. During the same period, Brazil’s domestic gross income doubled while the rate of adult illiteracy shrank from 33.7 to 10 %. Social policies and legal minimum wages regulations are among the factors that led to a decrease in income disparities between the people’s living conditions. In Thailand, the formation of the Rural Doctors Society in 1978 developed many innovative activities, leading to the formation of the Rural Doctor Foundation with the objectives of funding health programs (Global Health Watch, 3, 2011).

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Amidst all the accolades that developing nations may receive from their keen implementation of PHC programs, the world is still a threat due to the outbreak of deadly viral diseases in a number of countries. For instance, the Ebola outbreak in West African countries of Sierra Leone, Guinea, and Liberia triggered shivers among the western countries prompting severe screening measures in airports of travelers from these countries (Wenham, 2016). When the Zika virus was detected in Brazil, the world health board organization declared the virus a global health challenge, despite the inadequacy of information available about its health implication. Wenham (2016) states that the approach taken to tackle the Zika virus was inspired by fear of the Ebola virus notwithstanding that the two health hazards are not related in any way. Zika is spread through infected mosquito bites and leads to mild flu that does not necessitate hospitalization. The emergence of these viruses is an indication that the public healthcare battle in developing countries is far from being won.

Moreover, Malaria, a disease prevalent in almost 100 countries all over the world, is still a significant killer and burdensome to both the economy and individual productivity of a person, especially in the developing countries in South Asia and Sub-Saharan Africa (Bills and Melinda Gates Foundation, 2016). Approximately 207 million people contracted and suffered from Malaria with 627,000 succumbing to it in 2012. Sub-Saharan Africa contributed about 90% of all deaths were 77% involved children under 5 years old. Three years later, more than 348,000 people lost their lives to malaria out of 217 million people who suffered from Malaria in 2015 (World Health Organization, 2015). WHO (2015) reports that about half of the world’s population is under exposure to malaria with over 400 million being under more than average risk of contracting the disease. While the cost to economic growth resulting from sick people is highly technical to determine, Centres for Disease Control and Prevention (2016) approximate the direct costs associated with malaria treatment, illness, and premature death to be more than US$ 12 billion per annum. Since 2000, malaria treating and controlling costs amount to US$ 300 billion, which is believed to have consumed more than 1.2% of the entire African GDP (Unicef, 2016).

In the recent past, projects aimed at combating malaria in the third world have received over-whelming financial support from all over the world, particularly the United States through the Bills and Melinda Gates Foundation. In a bid to speed up the malaria eradication process, Global Health Group Malaria Elimination Initiative was created with a major focus on collaborating with developing countries and regions towards finding a solution (Global Health Group, 2016). Based on past history, eradication of malaria is a viable option as most countries in Europe were able to entirely control the disease in the 1930s with the United States succeeding in the elimination process in 1951 (Bills and Melinda Gates Foundation, 2016). The research and investment in funding have started bearing fruit as the number of new malaria cases continue to drop globally with death reported decreasing by 60% between 2000 and 2015 (Global Health Observatory (GHO) Data, 2015). This success is attributable to several interventions effectively combined such as timely diagnosis, indoor spraying with insecticides, proper diagnosis-based treatment, and the use of bed nets sprayed with long-lasting insecticides that eliminate chances of mosquito bites while sleeping (Bill and Melinda Gate Foundation, 2016).

Countries in the world have formed numerous alliances and partnerships in the war against health concerns. In the 1990s and 2000s, organizations such as Global Health Partnerships and Global Health Initiatives (GHIs) were constituted with a membership of over 100 nations that aimed at responding to health crises in Sub-Saharan Africa (Global Health Care Watch 3, 2011). GHIs is an amalgamation of many bodies such as the Global alliance on the vaccine (GAVI) whose mandate includes the provision of vaccines and immunization programs, the Global Funds For AIDS, malaria, and TB, The World Bank Multi-country AIDS Programme (MAP), and the US President’s Emergency Plan for AIDS Relief (PEPFAR). GHIs have been instrumental in mobilizing funds for targeted diseases amidst criticism that they are more focussed on providing therapeutic measures to diseases such as antiretroviral for HIV/AIDS rather than emphasizing real causes and personal preventive measures such as mother to child transmission (p.16). Broader consequences, for instance, the gender-based violence and oppression that are dominant reinforcing factors and the plight of AIDS orphans were not put into perspective by the GHIs. Efforts to implement essential PHC services require a global community willing to support all member countries (Global Heath Care Watch, 3, 2011).

Despite all the challenges and the long journey ahead that the developing countries have to trek in implementing comprehensive PHC programs, it is fair to state that so far, PHC services have been equitable since their main users are children, women, and less privileged members of the society mainly in the rural setting, who are able to access services considered essential for primary health care (Vlassoff et al., 2010). Services that are available almost universally include emergency services, family planning, immunization, maternal and child healthcare, detection of infectious diseases, and school check-ups. Since health is a combination of the mental, social and physical wellbeing of a person as opposed to the narrow perception idealized by many as simply the absence of diseases in one’s system (Declaration of Alma-Ata, 1978), organizations committed to the eradication of certain diseases must entrust themselves to broadening their scope by including other essential services such as education and economic development programs.