Primary health care: 36 years since Alma‐Ata:
The 1978 Declaration of
Alma‐Ata was groundbreaking because it linked the rights‐ based approach to health to a viable strategy for
attaining it. The outcome document of the International Conference on Primary
Health Care, the declaration identified primary health care as the key to
reducing health inequalities between and within countries and thereby to
achieving the ambitious but unrealized goal of “Health for All” by 2000.
Primary health care was
defined by the document as “essential health care” services, based on
scientifically proven interventions. These services were to be universally
accessible to individuals and families at a cost that communities and nations
as a whole could afford. At a minimum, primary health care comprised eight
elements: health education, adequate nutrition, maternal and child health care,
basic sanitation and safe water, control of major infectious diseases through
immunization, prevention and control of locally endemic diseases, treatment of
common diseases and injuries, and the provision of essential drugs.
The declaration urged
governments to formulate national policies to incorporate primary health care
into their national health systems. It argued that attention be given to the
importance of community‐based care that
reflects a country’s political and economic realities.
This model would bring
“health care as close as possible to where people live and work” by enabling
them to seek treatment, as appropriate, from trained community health workers,
nurses and doctors.
It would also foster a
spirit of self‐reliance among individuals within a community and
encourage their participation in the planning and execution of health‐care programmes. Referral systems would complete the
spectrum of care by providing more comprehensive services to those who needed
them most – the poorest and the most marginalized.
Alma‐Ata grew out of the same movement for social justice
that led to the 1974 Declaration on the Establishment of a New International
Economic Order. Both stressed the interdependence of the global economy and
encouraged transfers of aid and knowledge to reverse the widening economic and
technological divides between industrialized countries and developing
countries, whose growth had, in many cases, been stymied by colonization.
Examples of community‐based innovations in poorer countries after World
War II also provided inspiration. Nigeria’s under‐five
clinics, China's barefoot doctors and the Cuban and Vietnamese health systems
demonstrated that advances in health could occur without the infrastructure
available in industrialized countries.
The International
Conference on Primary Health Care was itself a milestone. At the time, it was
the largest conference ever held devoted to a single topic in international
health and development, with 134 countries and 67 non‐governmental organizations in attendance.
Yet
there were obstacles to fulfilling its promise. For one thing, the declaration
was non-binding.
Furthermore,
conceptual disagreements over how to define fundamental terms such as
‘universal access’, which persist today, were present from the beginning. In
the context of the cold war, these terms revealed the sharp ideological
differences between the capitalist and communist worlds, discord perhaps
heightened by the fact that the Alma-Ata conference took place in what was then
the Union of Soviet Socialist Republics.
As
the 1970s gave way to a new decade, a tumultuous economic environment
contributed to a diversion away from primary health care in favour of the more
affordable model of selective health care, which targeted specific diseases and
conditions.
Insufficient
progress towards the Millennium Development Goals, coupled with the threats
posed to global health and human security by climate change, pandemic influenza
and the global food crisis, have led to renewed interest in comprehensive
primary health care.
Yet
the many challenges that prevented Alma-Ata’s implementation have evolved and
must be confronted to achieve its goals now. Drawing on the growing body of
evidence about cost-effective initiatives that integrate household and
community care with outreach and facility-based services – such as those for
maternal and child health.
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