Astana Rekindles Disputes about the Meaning of Primary Health Care

Two terms are often associated with the most immediate effects of the Alma-Ata Conference: inspiration and guidance. Based on this perspective, we ask: what inspires the Global Conference on Primary Health Care (PHC), which was held in October 2018 in Astana, Kazakhstan? What guides it, which meaning does it intend to apply to the health systems based on the reviews on PHC?

These are questions that follow the principle that the broader historical processes, as well as those that are specific to the field of health, will effectively result in changes in the health systems. The Astana Conference must be considered a political event that brings back to the spotlight disputes over the meaning of PHC, which is recognized as a fundamental, effective and efficacious strategy to reach better levels of health. It may be said that the recognition of the actual progress made by the countries and of the distance between what is potential and what was actually done were the bases to restore the commitment regarding PHC. This is a clear inspiration.

However, it is in the dispute over meanings (Cueto, 2018) that one may discern the configuration of different types of guidance for the planning of health policies, which is the territory for the consolidation of the inspirations and aspirations. In order for us to get close to this scenario, it is possible to consider not only the Declaration of Astana, but also the many materials – videos with interviews, panel presentations, speeches that stood out more, and the opinions expressed in documents that were simultaneously divulged – that made up the discussion in the conference (WHO/UNICEF, 2018; PHM, 2018), and that will keep feeding the debate whose developments include, for example, the way in which the PHC will be valued, and its link with the Sustainable Development Goals (SDGs) and the 2030Agenda, as well as the events with a political and technical nature, such as the United Nations General Assembly, in which PHC will be the main object.

Ever since the conference summons, it is possible to distinguish the combination of topics that concentrate the deepest divergences regarding the idea of Universal Health Coverage (UHC). Thought from a perspective that is in line with neoliberal normativity, UHC establishes itself as a guidance that is directly in conflict with the idea of social determinants of health. Thus, it guides towards a PHC that deviates from the expanded concept of health, basing itself in the classic and never fully overcome understanding of health as the lack of illness. In this case, ‘access’ is restricted to the health services and actions, and not to the highest levels of quality of life. In a context in which economistic reasoning prevails, UHC is easily converted into a renewal of the logic of selective PHC.

The emphasis and frequency with which some ideas are presented equally reveal what is behind this tension among meanings. Within the principles of the comprehensive PHC, intersectoriality and multisectoriality guide us towards political actions that confirm the complexity of the health-illness process due to which it is necessary to intervene in other levels of social life, in which the health determinants are located. In Astana, not necessarily confronting this idea, multisectoriality was often employed to refer to the importance of the private sector. Following this point of view, we can infer as a pressing guidance the incorporation of the private sector in PHC. The responsibility of the State regarding health as a human right becomes blurred, and the idea of ‘government choices’ gains focus.

Integrated to this debate, the ideas of authorship and responsibilization are worthy of reflection. Even though an interpretation that is more favorable and closest to the conception of social participation is possible, in the Declaration of Astana, in the topic ‘Empower individuals and communities’, the vision of production of health expressed in the texts takes on individualizing traits. Instead of aggregating the ability of the people to understand their health needs and to plan out the developments, the text may be read as a type of guidance towards the transfer of responsibility. More often than not, this idea is associated with blaming people for the precariousness of their life and health conditions, which historically occurs through the denial of the social inequities and of the political commitment to overcome them.

A perspective that is critical and, to a certain extent, worrying about the Astana Conference does not lead us to disregard it as a landmark in the process of fighting for meanings that strengthen the public and universal nature of health. By incorporating stances with conflicting meanings and interests that are probably irreconcilable, the Declaration of Astana elucidates what does not have a definition and, therefore, shows us the persistence of these spaces of dispute.

It is essential to champion a change in the awareness of people about the importance of collectively defending and demanding health as a right. This movement includes the health workers, who, over the course of the four decades since Alma-Ata, were trained and experienced their professional performance in a direct and everyday relationship with the people in the territories, consolidating an understanding of the value of PHC in the development of ways of meeting the health needs and providing care that is compatible with human dignity.

Referências

• CUETO, Marcos. O legado de Alma-Ata, 40 anos depois (Editorial). Trabalho, Educação e Saúde, Rio de Janeiro, v. 16, n. 3, p. 845-848, set.-dez. 2018 . Disponível em: <http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1981-77462018000300845&lng=pt&nrm=iso Acesso em: 2 jan. 2019
  » http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1981-77462018000300845&lng=pt&nrm=iso
• People’s Health Movement (PHM). Alternative Civil Society Astana Statement on Primary Health Care. Astana, 2018. Disponível em: <http://phmovement.org/alternative-civil-society-astana-declaration-on-primary-health-care/> Acesso em: 2 jan. 2019.
  » http://phmovement.org/alternative-civil-society-astana-declaration-on-primary-health-care/>
• World Health Organization (WHO); United Nations Children’s Fund (UNICEF). Global Conference on primary health care. Astana, 2018. Disponível em: <https://www.who.int/primary-health/conference-phc> Acesso em: 9 jan. 2018.
  » https://www.who.int/primary-health/conference-phc>

Publication Dates

• Publication in this collection
  24 Jan 2019
• Date of issue
  2019