What is different now ?

1. What is different now? A Christian Medical Commission’s Role in Health Planning International Review of Mission Vol. 58(230) April 1969 Carl E Taylor MD DrPH Professor Emeritus of International Health Johns Hopkins Bloomberg School of Public Health

2. Problem Areas Requiring a New Orientation in Medical Missions • Reappraisal of the Justification for Christian Medical Work • Evangelism vs. Socially Oriented Mission • Rapid Growth of National Health Services • Nationalism and Health as a Public Right • Rising Costs of Medical Work • The Dilemma of Self-Support • Serve the Wealthy vs. “Robin Hood” approach

3. Problem Areas Requiring a New Orientation Mission (continued) • Obsolescence of Facilities • Manpower Problems and Training Levels • Quantitative/Qualitative Dilemma • Community Involvement

4. Health Planning as a New Discipline • Historical Patterns of Health Planning • Natural History of Health Services Development • Traditional Systems of Care • Elite Medical Care • Mass Development of Curative Services • Mass Preventive Services • Comprehensive Care

5. 3. Steps of the Planning Process • Statement of Broad Objectives & Policies • Data Gathering • Statement of Priorities • Outline of Alternative Program Possibilities to Meet Priority Problems • Detailed Statement of Plan • Implementation • Evaluation

6. Administrative Framework for Planning • Balance of Centralization and Decentralization of Particular Functions • Local Participation in Priority Setting • Flexibility in Implementation for Innovation • Balance of Power • Committees or Panels • Technical Planning Staff

7. September 1968 CMC Statement “…representing the world-wide Christian ministry of healing” “…certain insights…” • The Christian Calling • Need for Change • New Directions • 9 Specific Objectives

8. September 1968 CMC Statement (cont.) • Comprehensive Health Care • Community Orientation • Co-operation with Government & Other Agencies • Inter-church Co-ordination and Co-operation • Dynamic Planning Process with locally determined priorities set within guidelines and norms established by donors • Reorientation of Personnel • Administrative re-organization for planning and evaluation • Data gathering systems focused on only essential information • Facing the Problem of Population Dynamics

9. 35 YEARS LEARNING THE LESSONS OF ALMA ATA Carl E. Taylor MD DrPH Professor Emeritus of International Health

10. ALMA ATA Building up to 1978 • Great to be with Jack Bryant chair of CMC. • Julie Richmond and Jack Bryant • Heads of US delegation • US role essential for unanimous vote • “Had to try for unanimous vote of approval of Report by Acclamation” (Mahler’s goal) • To prevent what “happened at Women’s Conference at Mexico.”

11. Halfdan Mahler as Director General • Appointed in 1972 as DG of WHO • Unique ability to Communicate Inspiration and Vision • Great admiration for him since1960s in India and TB • Many years exploring Primary Health Care potential • Led 1974 vote by WHA for Primary Health Care focus • (Litsios) article AJPH onMid 1960s role ofChristian Medical Commission (CMC) • Pioneered demonstrations of impact rural projects such as Jamkhed in India,Guatemala and Indonesia Halfdan Mahler at Buenos Aires Conference 2007

12. Personal Memories Revived • National Library of Medicine prepared exhibit on Global Health starting in 2006 • Opened April 17th and will continue for 2 years • Focus on Primary Health Care & Equity • Long untouched trove Precious Old Books • Found Original Alma Ata documents, • First edition of Full Conference Report and Original Declaration • Currently with Elizabeth Fee for book on history of WHO • Tucked into back cover was a folded old yellow notebook page with notes probably written on plane going home from Alma Ata

13. Assignments of Drafting Committee Josh Cohen, Deputy to Halfdan, would himself edit the final draft • Including the Declaration I was assigned Sections 2 and 3 • Bring together 2 years of intensive work • Operational Aspects for doing PHC

14. Health For All by the Year 2000 Over 100 ten minute speeches by Ministers of Health Developed Countries said Health for All by the year 2000 Developing Country Ministers said HealthFor All Equity was Halfdan’s Goal

15. “Great Arguments on paras 40 to 48” 40 to 48 were carefully crafted sections describing all aspects of Community Role and Community Capacity Considered extreme by “Top Downers”

16. Tough Negotiations Drafting Committee was called in to negotiate when any group mobilized and tried to change wording Resulted in really tough negotiations on: 1. Major crisis “big push by Pharmaceuticals for special place” “starting a change wave” 2. “National Associations of Doctors” wanted to emphasize the importance of doctors

17. Post Conference • Five years promised great funding building health center infrastructure, PHC training • Selective PHC took over with dramatic Top Down shift to Vertical funds • At the time Evaluations showed no improvement in Health Indicators … yet …

18. Straw man Fallacy Greek Allegory of beating on straw men created by ourselves, rather than real antagonists Straw Men of Primary Health Care Article (1988 Soc Sci Med) With Richard Jolly, Jim Grant’s Deputy at UNICEF

19. Straw Men of Primary Health Care Battle between SPHC & CPHC … • Has been a fake but self-satisfying war • Both sides recite slogans and wave banners • Repeat arguments without understanding • Straw man distortions of opponents’ positions First strawman: ridiculed 8 components of Alma Ata as impossible and inefficient SPHC publications ignored the Basic Alma Ata documents Other side repeated same arguments in depth

20. What Would JIM GRANT Say Now? I was working for Jim for UNICEF China-Rep 1994 Jim Grant UNICEF GOBI—FFF • Experts took over meeting on the Child Survival Revolution Long arguments quoting Jim’s dad John B “Let’s Pick the Low Hanging Fruit, then..” When outside funding stops “What is sustainable?” I think Jim would have had the courage to change priorities now

21. Go beyond Randomized Controlled Trials • Good thinking in Cesar Victora’s questions about Evidence: Plausability, and Adequacy • RCTs and Efficacy/Effectiveness debate • UNICEF meeting to Review Evidence for Community Based PHC (CBPHC) (Henry Perry, Bob Black) • Conceptual Framework balances Health Systems with Community Empowerment