From primary health care to universal coverage – the “affordable dream”

Three decades after the 1978 Health for All declaration, WHO called for a renewed focus on primary health care with the launch of the 2008 World Health Report. When countries sought guidance on financing health care, we commissioned a 2010 report on universal health coverage, a concept we then pioneered as central to the Sustainable Development Goals and the ambition to leave no one behind.

Primary health care

Doctor examining a patient
WHO/Yoshi Shimizu

The 1978 Declaration of Alma-Ata, which set out primary health care as the way to achieve health for all by the year 2000, launched a revolutionary movement that did great good but eventually faltered, partly because it was so profoundly misunderstood. It was a radical attack on the medical establishment. It was a standoff between proponents of basic versus specialized care. It was hopelessly utopian; a selective approach, based on just a few inexpensive interventions that brought rapid results, had a better chance of success.

With its reliance on community health workers, it looked cheap: third-rate care for the Third World. For some countries, a declaration associated with a Soviet city raised suspicions that the call was a veiled attempt to push governments towards socialized medicine.

By the mid-1990s, a WHO review of changes in the development landscape bleakly concluded that the goal of health for all by 2000 would not be met. The emergence of HIV/AIDS, the related 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.

"The 1978 Declaration of Alma-Ata set out primary health care as the way to achieve health for all by the year 2000."

Dr Chan, WHO Director-General

By the start of the 21st century, when the Millennium Development Goals were put forward as the overarching framework for development cooperation, the epidemics of AIDS, tuberculosis, and malaria were raging out of control. The yearly number of preventable maternal and childhood deaths had been stuck above 10 million for decades. Emergency action was needed.

The global health initiatives that were established to pursue the health-related goals eventually had a tremendous impact, readily measured in the number of interventions delivered, deaths averted, and lives prolonged. All of these initiatives depended on well-functioning health systems to deliver medical commodities, yet rarely made the strengthening of health systems an explicit or funded objective. In many cases, weak public health infrastructures were simply bypassed through the construction of parallel systems for the procurement and distribution of interventions, for laboratory services, and for budgeting, financing, and reporting.