It is not enough that the State or private providers put at our disposal facilities and services that sustain universal health coverage, our health is primarily our – the individual’s – responsibility
By Dr R Neerunjun Gopee
World Health Day is observed on April 7 every year since 1950, and is marked by activities, among others public awareness campaigns, which extend beyond the day itself. It serves as an opportunity to focus worldwide attention on important aspects of global health (e.g. maternal and child care, mental health, climate change), and each year a specific health theme is chosen to highlight a priority area of concern for the World Health Organization. This year the theme is: Universal health coverage: everyone, everywhere, and the slogan is ‘Health for All’ – by 2030.
By Universal Health Coverage is meant ‘ensuring that all people and communities have access to quality health services where and when they need them, without suffering financial hardship. It includes the full spectrum of services needed throughout life – from health promotion to prevention, treatment, rehabilitation, and palliative care – and is best based on a strong primary health care system’.
In 1979, the 32nd World Health Assembly launched the Global Strategy for health for all by the year 2000 by adopting resolution WHA32.30. That was in the wake of the Alma Ata Conference (USSR) in 1978, when the Declaration of Alma-Ata was adopted at the International Conference on Primary Health Care (PHC). It was the first international declaration underlining the importance of PHC. This was reaffirmed at the Global Conference on Primary Health Care held in October 2018 in Astana, Kazakhstan, which marked the 40th anniversary of the Alma-Ata Declaration, and united world leaders to affirm that strong primary health care is essential to achieve universal health coverage.
By ‘health for all by the year 2000’ was meant ‘the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life’, calling on governments, international organizations and the whole world community to take this up as a main social target in the spirit of social justice.
The fact that 40 years later WHO has felt the need to re-launch the slogan ‘Health for All’, this time ‘by 2030’ means that the goal of 1979 of ‘Health for All’ by 2000 has not been achieved. The reason for this is contained within the very definition of health by WHO itself, namely that health is ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’, which thus seeks to include social and economic sectors within the scope of attaining health which the Alma Ata Declaration affirmed as a human right.
The impact of these sectors on the health of peoples has been captured in the term ‘social determinants of health’, recognized by WHO as ‘the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels’. Given these factors – money, power and resources -, it is inevitable that ‘the social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries’. In particular the inequality of health status between the developed and the developing countries is deemed to be politically, socially and economically unacceptable. The implication is that equitable economic and social development is a pre-requisite to the attainment of health for all.
It is of interest that, according to an Indian online site ‘Docplexus’, ‘even in a most advanced country like the US, three in ten people do not have access to health care for financial reasons, and two out of ten do not seek medical attention due to geographical barriers they face’.
We do not realise how fortunate we are in Mauritius that from the beginning we have adopted the welfare state model of health care, based on the UK one, of providing health care to all free of cost at the point of service, something we are still able to do with a total health expenditure less than 6% of GDP (2016) – compare this with nearly 18% for USA (2017) which is the highest in the world, and rising.
Following the Alma Ata Declaration of 1979, our PHC was revamped so as to further strengthen the integration of services at the primary care level, building on the trend set when the SSRN Hospital came into being. This became even more necessary and important with the rise of the Non-Communicable Diseases which was revealed by the first non-communicable disease (NCD) survey commissioned by WHO and carried out in 1987, and all subsequent surveys since, 5-yearly, have but confirmed this worrying trend.
According to our National Health Accounts Report (2017) the country spent an estimated amount of Rs 16.5 billion on non-communicable diseases, out of which, spending on cardiovascular diseases and diabetes were Rs 3.57 billion and Rs 1.2 billion respectively. While Government remains committed to sustaining free universal coverage of quality healthcare services, provided on the basis of need, to the population, it is a matter of concern that the largest share of total spending, in the public and private sectors, is accounted for by hospital inpatient services.
In other words, despite the fact that we have a very strong PHC, the curative services predominate over the promotive and preventive services in terms of claiming our financial and other resources, whereas the reverse ought to be the case. To a large extent, as the National Health Accounts Report shows, this is because of the NCDs – and the NCDs are directly the consequence of the lifestyle of the people, that is, how they live: from the health point of view, essentially it is what and how much they eat and drink, and whether they do enough of physical activity, or ‘diet and exercise’. As such lifestyle is a ‘composite of motivations, needs and wants, and is influenced by culture, family, reference groups and social class’.
Transcending all these variables, the health information conveyed to the population by the Ministry of Health and Quality of Life post the 1987 NCD survey using all forms of communication, and the structures put up to deal with the NCDs have continually been updated and upgraded to face the challenge. The missing element, unfortunately, is the poor level of response of the people in looking after their own health, a fundamental principle of PHC which emphasises the participation of people as a group or individually in planning and implementing their health care as a human right and duty.
People forget the duty part and focus on the right aspect. They therefore prefer to indulge in wrong lifestyles – fast food, risky behaviours like substance abuse, lack of adequate physical activity among others – and then expect health professionals to perform miracles of cure when they fall prey to disease much of which is their own making.
Paradoxically, despite that, we have made remarkable health gains, as our health indicators (the NHA Report referenced) show, with Life Expectancy at birth of 74.7 years, Infant Mortality Rate per 1000 live births of 12.2 and Maternal Mortality Rate of 0.74 per 1000 live births – the best in Sub-Saharan Africa, as we tend to boast.
That may well be so, but we can still do better if we exercise greater individual responsibility for our health. It is not enough that the State or private providers put at our disposal facilities and services that sustain Universal Health Coverage. In our current stage of epidemiological transition (from infectious or communicable diseases to NCDs), our health is primarily our – the individual’s – responsibility.
That must be for all of us the carry home lesson on the occasion of World Health Day.
* Published in print edition on 12 April 2019