Freetown, Sierra Leone, January 2013: a meeting was taking place on the first floor of the Connaught Hospital, the country’s leading medical institution. The windows were open in the hope that the slight breeze would cool the visiting health ministry officials, suffering in the stifling heat. Suddenly the sound of a woman shouting and weeping came from the courtyard. A small boy of five stood next to her, looking straight ahead, showing no emotion. The mother had just learned that her child was blind and would stay that way for the rest of his life. The disease he was suffering from would have been easy to treat, even at a local health centre, but the family had waited too long and it was now too advanced for even the best doctor in the country to save his eyesight. The financial resources and manpower needed to treat the child were available, and so were the drugs. The tragedy lay in the failure of Sierra Leone’s public information policy and the health system’s inability to identify those at risk.
At the time of the Alma Ata Declaration 35 years ago, the World Health Organisation (WHO) decided to focus on primary healthcare. The idea was to bring the available services closer to the public, by creating a network of rural dispensaries. Geographical coverage improved, but a failure to adapt to local needs became apparent. For example, the pursuit of “vertical” programmes (targeting a single disease) has led to a situation where health services function in isolation, in an uncoordinated manner, and are unable to respond to people’s real health needs, which can be complex and require several different areas of medical expertise. Professor Peter Piot, director of the London School of Hygiene and Tropical Medicine, recognises that when “AIDS was spreading, it was vital to act quickly and on a large scale. Times have changed, and AIDS is now regarded as a chronic disease. It is increasingly important for health systems to be able to provide ongoing care. Creating parallel or vertical systems is no longer viable.”
Many eradication strategies have worked very well: the campaign to eradicate the Guinea worm has now virtually achieved its goal. But they have also shown their limitations, as inequalities between different population groups in the same country have grown (1). It has also become apparent that each health system is unique and needs to be approached as a whole (2). It seems inconceivable that a child should be vaccinated on a regular basis by health workers, and then die from diarrhoea after drinking water from a lake because the dispensary didn’t have the right drugs. Healthcare professionals may feel that not integrating the different programmes is technically easier, but it makes for inefficiency.
The epidemiological characteristics of developing countries have changed since Alma Ata. Globalisation has increased the risks of pandemics and the trafficking of counterfeit medicines. And the distinctions made are no longer between infectious and non-communicable diseases, but between chronic and acute pathologies. In the 1970s a disease was seen as a succession of episodes whose outcome would be either a cure or death; today patients learn to live with diseases such as asthma, diabetes, epilepsy, cardiac, renal or respiratory insufficiency, and even HIV.
Technological progress has also transformed health systems. Countries with a limited income can now buy diagnostic, prevention and treatment equipment they could never have afforded 30 years ago. The development of telecommunications (mobile phones, the Internet) makes it possible for patients to ask for a medical evacuation; telemedicine means that specialists can be trained remotely, even from the other side the world.
The financing of health systems is probably the area that has changed the most since Alma Ata. Today, the principles of the Bamako Initiative, which stipulate that patients must always pay for their treatment, are being questioned once more. Access to healthcare is still a major issue in societies where most of the population live below the poverty line. In Burkina Faso, 40,000 children a year die before their fifth birthday. The country has developed its health organisations and increased the number and the level of skill of its health professionals, but, as Dr Pierre Yameogo of the General Health Directorate explains, “For many families paying for treatment is nearly impossible. Households have little in the way of savings.” Burkina Faso is examining the possibility of providing free healthcare. “It’s a matter of ensuring that the patient is truly at the heart of our health system, and has full access to all the medical resources that the country has to offer. Then we will be able to save many children.”
The lack of adequate funding for health systems in the South has been compounded by a brain drain to the North. Observers estimate that 23,000 African health professionals emigrate to rich countries every year (3): there are more Beninese doctors in Paris than in Benin.
More coordination mechanisms have been set up to harmonise practices and avoid inefficiencies. Health 8 brings together seven international health-related organisations and the Bill & Melinda Gates Foundation, to coordinate their action, and the World Bank, GAVI Alliance (4) and the Global Fund to Fight AIDS, Tuberculosis and Malaria have agreed to work together to strengthen health systems. But maybe it is time for a Marshall Plan? The discussions under way between the Global Fund and the World Bank could create new opportunities to introduce innovative mechanisms better geared to the needs of the 21st century.