On the eve of Astana, Alma-Ata continues to provide guiding principles

I had just finished medical school in Spain in 1978 when representatives from 134 countries, 67 international organizations, and many nongovernmental organizations met in Alma-Ata, Kazakhstan, to write a declaration that transformed how we think about health. At that time, health services were merely curative and family medicine in its infancy. Family planning and mental health were not a part of basic services. In the 40 years since the declaration, much has changed. An essential package of services is the norm in many countries, and health education for prevention is a critical component of primary health care.

Alma-Ata was groundbreaking. The guiding principles and strategies stated at its declaration mark a before and after in global public health. However, its emphasis on primary health care and the provision of a comprehensive package of health services for all citizens have not always been the central objective of global policies for development in low- and middle-income countries.

Various factors moved the focus from the long-term goal that requires building stronger health systems to more immediate needs including interventions to control severe public health emergencies. The most relevant of these emergencies was the HIV epidemic in the 80s. Treatments that reduce its prevalence, morbidity, and mortality have made HIV control real, but it’s still a work in progress. We must continue with high-impact strategies to achieve an AIDS-free generation while strengthening countries’ health systems and including HIV care—already seen as a chronic disease—in the essential package of primary health care services.

It’s been interesting to observe the changes in public health systems over the past four decades. For me, three things gained relevance that Alma-Ata could not predict.

1. The original declaration could not have anticipated the huge funding gap for primary health care. Its statement that “Governments have a responsibility for the health of their people, which can be fulfilled only by the provision of adequate health and social measures” does not give details about how to finance primary health care services for all. Today, after the global financial crisis and the impoverishment of many countries related to high fertility, war, natural disasters, epidemics, and the high cost of medicines, financing health services is one of the global community’s main challenges.

Countries need to mobilize their own resources, consolidate public-private services’ mix, and increase funding for health. The international development community needs to align its interventions and invest more strategically.

2. While the Alma-Ata Declaration mapped many details related to primary care, in the ensuing 40 years, community health workers have become a critical component of many countries’ health systems. The declaration says that “Primary health care relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community.

Today, community health workers have been a significant addition to the formal health system but we need to increase efforts to consolidate their formal relation to the systems they serve.

3. Finally, even though the declaration recognized the existence of inequities in health status between “developed and developing countries,” today, given many factors, including global migration and displacement and growing pockets of poverty, health inequity is a major public health problem around the world, including throughout Europe, U.S., and Canada, not just in middle- and low-income countries. As a result of the growing recognition of this problem, many countries are developing policies that address social determinants of health in a wide variety of ways. Civil society’s responsibility for advocating and maintaining pressure on governments to formulate these policies and close the gaps should be promoted and enhanced.

Some people may think that the right to primary health care for all citizens is a simplistic strategy for poor countries. But nothing is further from reality. Countries with lower rates of morbidity and mortality, longer life expectancy, and a better quality of life offer quality primary care services for all.

Furthermore, JSI, as an organization that works in the United States and in many developing countries, knows that primary health care is not just for developing countries. It is part of how every system should approach the health of populations, from the most- to the least-developed.

It’s been 40 years since Alma-Ata declaration was issued and since then, we have seen more governments embracing health as a human right; we’ve seen maternal and child mortality decrease; we’ve seen more people with access to affordable health services; and more women and families with access to methods to decide the number of children to have.

Today, the Strategic Development Goals provide a strategic framework to reposition universal coverage of primary care services as the target of our interventions, and the Alma- Ata statement continues to provide us with the guiding principles to achieve them. But as the world has moved on, new considerations and approaches have also come to the fore. These are a few that jump to my mind as I reread the declaration 40 years later. I know there are others and I look forward to hearing colleagues’ thoughts on where we are today.

 

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