The Delhi Declaration 2018: “Healthcare for All Rural People” – Alma Ata Revisited

Abstract

In the 40^th anniversary year of Alma Ata: Health for All by 2000 conference, Academy of Family Physicians of India organized the 15^th WONCA World Rural Health conference in New Delhi from 26 to 29^th April 2018. More than a thousand delegates (1044) from 40 countries participated in this international conference. The conference attracted a multidisciplinary participation from various backgrounds with an interest in rural primary healthcare. Theme of this conference was “Healing the Heart of Healthcare-Leaving No one behind”. The conference aspired to bring rural healthcare on global agenda. This was the first ever World Rural Health Conference organized in South Asia, incidentally a quarter of human population lives in South Asia, majority of which is based in rural habitat. The conference culminated with the unanimous adoption of the Delhi Declaration; calling for people living in rural and isolated parts of the to be given special priority, if nations are to achieve universal health coverage. The declaration has been cited at the website of the World Health Organization and is available in six languages (Chinese, English, French, Japanese, Portuguese, and Spanish.

15^Th World Rural Health Conference

In the 40^th anniversary year of Alma Ata “Health for All by 2000” conference, Academy of Family Physicians of India organized the 15^th WONCA World Rural Health conference in New Delhi from 26 to 29^th April 2018. More than a thousand delegates (1044) from 40 countries participated in this international conference. The conference attracted a multidisciplinary participation from various backgrounds with an interest in rural primary healthcare. Theme of this conference was “Healing the Heart of Healthcare-Leaving No one behind”. The conference aspired to bring rural healthcare on global agenda. This was the first ever World Rural Health Conference organized in South Asia, incidentally a quarter of human population, majority of which is based in rural habitat, lives in South Asia. The conference culminated with the unanimous adoption of the Delhi Declaration; calling for people living in rural and isolated parts of the to be given special priority, if nations are to achieve universal health coverage. The declaration has been cited at the website of the World Health Organization (WHO) and is available in six languages.

The members of the United Nations have put “leaving no one behind” at the heart of the Sustainable Development Goals 2030 (SDG 2030) agenda. There is a special emphasis on those left furthest behind and the most excluded. Half the world's population currently lives in rural and remote areas. The rural-urban divide is a consistent feature across the world, existing in all regions and within all countries and poses a major challenge to the nationwide provision of health services. WRHC 2018 was organized in the background of aspiration for achieving SDGs by 2030. Health is centrally placed in the SDG 2030 agenda. The health goal (SDG3) is comprehensive: “to ensure healthy lives and promote well-being for all at all ages.” The implementation of SDGs needs every country to judiciously prioritize, and to adapt the goals in accordance with local challenges, capacities, and resources available. A country's approach must systematically and simultaneously address legal coverage and rights, health-worker shortages, extension of health-care protection, and quality of care. 15^th WONCA World Rural Health Conference brought together stakeholders from all over world; bringing together international best practices and brainstorming sessions addressing current and future challenges in rural health. Poor health constitutes suffering and deprivation of the most fundamental kind. Rural habitat poses a severe disadvantage to the rural population in terms of access to healthcare services. Only a comprehensive approach can address these inequities arising from poor healthcare systems.

The conference culminated with the unanimous adoption of the Delhi Declaration; calling for people living in rural and isolated parts of the to be given special priority, if nations are to achieve universal health coverage. Delhi declaration revisited the Alma Ata Declaration with the aim to achieve a highest possible level of health for the communities we serve, with the goal of “Health for All Rural People.” The Delhi Declaration identifies six areas as priorities in order to achieve “Health for All Rural People”

1. Equity

2. Access to care

3. Rural proofing of policy

4. Health system development

5. Developing and educating a workforce fit for the purpose

6. Realigning research to the people and communities.

The declaration will serve to influence policy on rural health practice all over the world particularly focusing on primary healthcare in rural areas with family physicians at the forefront in order to achieve Universal Healthcare.

The Delhi Declaration 2018: Alma Ata Revisited

(World Organization of Family Doctors – World Rural Health Conference, April 2018)

We, the delegates at the 15^th WONCA World Rural Health Conference, call on the international community to reaffirm the principles of the Declaration of Alma-Ata. We call on the United Nations, its specialized agencies, and national governments to continue to strive to achieve the goals set 40 years ago.

The Declaration of Alma-Ata defined health as “a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity.” As rural healthcare practitioners, we base our work on this understanding. We strive for the highest possible level of health for the communities we serve, with the goal of “Health For All Rural People.”

We recognize that:

• The realization of this goal requires the action of other social and economic sectors in addition to the health sector: Health and well-being is driven as much by socioeconomic development as by healthcare

• Primary healthcare in rural and other areas must be delivered by teams of health workers with a broad range of skills and levels working together in partnership with communities

• Teams of health workers must focus on delivering comprehensive care that responds to the needs of individuals, families and communities, moving away from a narrow medical model, and siloed thinking

• Family doctors, working to their maximum scope, have an important role in delivering patient and community-centered care in rural areas

• Rural populations are becoming older, poorer, and more vulnerable – in the era of the SDGs we must promote equitable access to health and ensure no-one is left behind.

WHO's Global strategy on human resources for health: Workforce 2030 and the High-Level Commission on Health Employment and Economic Growth reinforce the need for an expanded and more socially accountable health workforce. Further, the Dublin Declaration on Human Resources for Health: Building the Health Workforce of the Future, emphasizes:

“The fundamental importance of a competent, enabled and optimally organized and distributed health and social workforce, especially in rural and under-served areas, for the strengthening of health system performance and resilience”

In this context, we believe that the needs of people living in rural and isolated parts of the world must be given special priority if nations are to achieve universal health coverage.

In the spirit of Alma Ata, the conference is committed to working with the international community and identifies the following six areas as priorities to achieve “Health for All Rural People.”

Equity and access to care

True universal health coverage will be achieved only when people in the rural areas of the world have equitable access to healthcare which overcomes the current geographic, social, economic, political, ethnic, and cultural barriers. Despite the fact that nearly 50% of the world's population live in rural areas, only 38% of the world's nurses and 24% of the world's doctors provide care for them. This inequity must disappear. Rural people deserve the same quality of care that their urban counterparts receive-accessible, affordable, and effective care that meets the population's health needs. According to the International Labour Organization, the rural-urban divide is omnipresent from the richest countries down to the poorest countries. Worldwide (174 countries), 56% of those living in rural areas are not covered by basic healthcare against 22% in cities and towns. Gender, cultural, age, and geographical issues are paramount in achieving equity for rural people.

Rural proofing of policy

Policies that affect the health of and determine the healthcare provided to rural people are often developed in urban centers of power. These often do not take the needs of rural people or the implications of policies for these people into account. Comprehensive research data need to be gathered and the voices of rural people need to be heard in developing policies that affect them. A process of rural health impact assessment or “Rural Proofing for Health” mitigates against the possible negative health effects of fragmented policy development.

Health system development

A health system, which features comprehensive primary healthcare, is the most effective and efficient in terms of cost and health outcomes. In this context, governments must invest in expanding their health systems with the development of multidisciplinary teams of health workers that have the skills to address the specific needs of rural and isolated communities. New and emerging technologies will play an increasingly important role in sustaining the health workforce and the health of rural and isolated communities. We call on the international community to invest in digital health and digital health education technologies in support of an appropriately trained rural health workforce.

Developing and educating a workforce fit for purpose

Evidence is clear that recruiting students from rural backgrounds, giving students substantial rural experience during training, and implementing specific rural training programs after qualification are the most effective interventions in achieving rural recruitment and retention. Rural health training schools must develop socially accountable curricula with a commitment to community engagement throughout. Isolation and rurality impose additional challenges for rural healthcare professionals to provide the services that are needed in rural areas. Rural healthcare thus needs generalist health practitioners and family doctors who are appropriately trained to have an extensive and comprehensive range of certified skills to meet the specific challenges that they will face in their everyday work. Conversely, sending newly trained healthcare workers without appropriate skills to work in unsupported rural environments puts patients at risk and dissuades young professionals from choosing a rural health career. Those health professionals working in rural communities must have a safe, fair working, and living environment.

Realigning the research

Urgent action is required to reverse the 90/10 research gap: Where <10% of worldwide resources for health research are dedicated to addressing the 90% of all preventable deaths in low-and middle-income countries. This inequity is even greater in rural areas. Rural data and rural research must be expanded to inform government decision-making on rural health services.

People and communities

Rural people deserve health systems that are sensitive to their cultures, languages, and traditions. Rural populations are aging more than in urban areas and as a result have a large number of vulnerable individuals. The burden of disease, especially as a result of noncommunicable conditions, is imposing increasing pressure on fragile rural health systems. The original Alma Ata declaration emphasizes that health and well-being are not just about health services but are also dependent on economic and social factors. We call on governments and policymakers to invest in the infrastructure, services, and the economies of rural areas. These together will have a lasting impact on the well-being of their rural populations.

Health for All Rural People is synonymous with the aspirations of Alma Ata and Universal Health Coverage. We call upon the United Nations, its specialized agencies and national governments to prioritize rural health, health workers, and the enabling infrastructure to eliminate the inequity that exists and to leave no-one behind.

-15^th WONCA World Rural Health Conference New Delhi, India, April 2018