Return to Alma-Ata
Dr Margaret Chan
Director-General of the World Health Organization
30 years ago, the Declaration of Alma-Ata articulated primary health care as a set of guiding values for health development, a set of principles for the organization of health services, and a range of approaches for addressing priority health needs and the fundamental determinants of health.
The ambition, which launched the health for all movement, was bold. It assumed that enlightened policy could raise the level of health in deprived populations and thus drive overall development. The declaration broadened the medical model to include social and economic factors, and acknowledged that activities in many sectors, including civil society organizations, shaped the prospects for improved health. Fairness in access to care and efficiency in service delivery were overarching goals.
With an emphasis on local ownership, primary health care honoured the resilience and ingenuity of the human spirit and made space for solutions created by communities, owned by them, and sustained by them. Above all, primary health care offered a way to organize the full range of health care, from households to hospitals, with prevention equally important as cure, and with resources invested rationally in the different levels of care.
The approach was almost immediately misunderstood. It was a radical attack on the medical establishment. It was utopian. It was confused with an exclusive focus on first-level care. For some proponents of development, it appeared cheap: poor care for poor people, a second-rate solution for developing countries.
Nor could the visionary thinkers in 1978 have foreseen world events: an oil crisis, a global recession, and the introduction, by development banks, of structural adjustment programmes that shifted national budgets away from the social services, including health. As resources for health diminished, selective approaches using packages of interventions gained favour over the intended aim of fundamentally reshaping health care. The emergence of HIV/AIDS, the associated resurgence of tuberculosis, and an increase in malaria cases moved the focus of international public health away from broad-based programmes and towards the urgent management of high-mortality emergencies.
In 1994, a WHO review of world changes in health development since Alma-Ata bleakly concluded that the goal of health for all by 2000 would not be met.
What can be gleaned from the experiences of a movement that failed to reach its goal? Apparently, quite a lot. Today, primary health care is no longer so deeply misunderstood. In fact, several trends and events have clarified its relevance in ways that could not have been imagined 30 years ago. Primary health care increasingly looks like a smart way to get health development back on track.
The Millennium Declaration and its Goals breathed new life into the values of equity and social justice, this time with a view towards ensuring that the benefits of globalization are more evenly distributed between countries. The AIDS epidemic showed the relevance of equity and universal access in a substantial way. With the advent of antiretroviral therapy, an ability to access medicines and services became equivalent to an ability to survive for many millions of people.
Stalled progress towards the health-related Millennium Development Goals forced a hard look at the results of decades of failure to invest in fundamental health infrastructures, services, and staff. As we have seen, powerful interventions and the money to purchase them will not buy better health outcomes in the absence of efficient systems for delivery.
The rise of chronic diseases has uncovered further problems: the burden of long-term care on health systems and budgets, the costs that drive households below the poverty line, and the need for prevention in a situation in which most risk factors lie outside the direct control of the health sector. In other words: fairness, efficiency, and multisectoral action.
In August 2008, the Commission on Social Determinants of Health issued its final report. Its arguments make a compelling call for close attention to health in all government policies, in all sectors. Gaps in health outcomes are not a matter of fate—they are indicators of policy failure. Not surprisingly, the report champions primary health care as a model for a health system that acts on the underlying social, economic, and political causes of ill health.
In October 2008, WHO will issue its World Health Report on primary health care. Timed to commemorate the Alma-Ata anniversary, the report offers practical and technical guidance for reforms that can equip health systems to respond to health challenges of unprecedented complexity. Although the report does not aim to launch another social movement, it does ask political leaders to pay close attention to rising social expectations for health care—care that is fair as well as efficient, and incorporates many of the values so brilliantly articulated 30 years ago.
(Reproduced with permission from The Lancet.)