The Alma Ata Conference on Primary Health Care, held on 12 September 1978 in Kazakhstan, completely changed the vision, role and work a health care system should undertake to improve the health of its population.
In the subsequent Declaration, agreed upon by all participants, it was accepted that health is a fundamental right that does not depend exclusively on the health care system, and that health inequalities between countries and people is a problem that affects the whole planet. There was also verification that economic and social development based on a so-called New International Economic Order were key aspects if the best health possible was to be reached.
Another pivotal aspect that appeared in the Declaration was the leading role attributed to people in decisions made about their own health, since it involved the population’s participation in planning and applying their health care, both collectively and individually. There were also demands made on governments to promote health and social policies to allow people access to an adequate level of health care. Primary Health Care (PHC) was key to this level of health care being reached and was demanded for all populations as part of development in alignment with the spirit of social justice.
This PHC was defined as:
“Essential health care based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination”.
Its aim was: health for all by the year 2000, an objective that was clearly not reached.
The Alma-Ata Declaration was based on four aspects that revolutionised the way to approach health care:
Nevertheless, the way it subsequently developed saw different readings of what PHC meant. Ranging from a restrictive view (the most widespread today), in its exclusive understanding as an initial entry point to health care services for the population, via a philosophy or way of working that must affect the whole health care system, to an integral strategy that must influence a country’s policies in their entirety, including international policies.
In the strictest sense, there are virtually no cases of countries that have taken on this Declaration in its entirety. Although there has been huge progress in the field of world health since 1978, the main objective of “health for all by the year 2000”, and advances in the fight against health inequality, have been notably unequal.
Forty years on from Alma Ata, a new conference in Astana has been scheduled for the end of 2018 with the aim of redefining PHC and setting it up for new challenges. Now is the time to decisively face the challenges that get in the way of health being an effective right for all. Without universal health there can be no well-being, no individual or collective prosperity, and the SGDs’ commitment to “leave no one behind” will not be met.
We have to admit that a few days before this conference is held our impressions do not breed great optimism. The reactions of civil society and prominent political figures demonstrate that the intentions are to sign a gentler and less committed declaration that the Alma-Ata Declaration.
The conference should give rise to states prioritising and protecting everyone’s health, to providing affordable and accessible health care for everyone, everywhere, care that should be high quality and treat people with respect and dignity. Finally, this vision assumes that the population must be committed to their own health.
The new context of the SDGs and Universal Health Coverage (UHC) is present in the drafts of the Declaration. It confirms that PHC is the most efficient, effective and equal approach to ensuring health, and one of the cornerstones to attain UHC.
To achieve the current challenges for people’s health and development, the draft of the conference proposes PHC that:
The success of achieving PHC is based on: political commitment, knowledge, technology and people’s participation. And the challenges are:
Although there are many positive aspects in this Declaration, there are voices that denounce major shortfalls. Michelle Bachelet, president of the High-Level Commission convened by the Pan American Health Organisation (PAHO) to put forward solutions to increase access and health coverage in the Americas region for 2030, leaving no one behind, sent a letter to the WHO chairman asserting that certain key messages from Alma Ata had lost clarity. She believes that there must be recognition of the difficulties for PHC to develop in recent years, including the commercialisation of health, and the need to analyse factors making the full implementation of PHC difficult. This Declaration must also include definitions that avoid reductionist views of PHC.
Develop strategies to eliminate access barriers (due to migration, ethnicity, gender or social determinants) and facilitate the population’s genuine participation. These are aspects that could improve the Declaration.