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Alma Ata Revision

Alma Ata Revision

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Vol 372 September 13, 2008
Alma-Ata: Rebirth and Revision 1Alma-Ata 30 years on: revolutionary, relevant, and time torevitalise
 Joy E Lawn, Jon Rohde, Susan Rifin, Miriam Were, Vinod K Paul, Mickey Chopra
In this paper, we revisit the revolutionary principles—equity, social justice, and health for all; community participation;health promotion; appropriate use of resources; and intersectoral action—raised by the 1978 Alma-Ata Declaration, ahistoric event for health and primary health care. Old health challenges remain and new priorities have emerged (eg,HIV/AIDS, chronic diseases, and mental health), ensuring that the tenets of Alma-Ata remain relevant. We examine30 years of changes in global policy to identify the lessons learned that are of relevance today, particularly for acceleratedscale-up of primary health-care services necessary to achieve the Millennium Development Goals, the modern iterationof the “health for all” goals. Health has moved from under-investment, to single disease focus, and now to increasedfunding and multiple new initiatives. For primary health care, the debate of the past two decades focused on selective (or vertical) versus comprehensive (horizontal) delivery, but is now shifting towards combining the strengths of bothapproaches in health systems. Debates of community versus facility-based health care are starting to shift towardsbuilding integrated health systems. Achievement of high and equitable coverage of integrated primary health-careservices requires consistent political and financial commitment, incremental implementation based on local epidemiology,use of data to direct priorities and assess progress, especially at district level, and effective linkages with communities andnon-health sectors. Community participation and intersectoral engagement seem to be the weakest strands in primaryhealth care. Burgeoning task lists for primary health-care workers require long-term human resource planning andbetter training and supportive supervision. Essential drugs policies have made an important contribution to primaryhealth care, but other appropriate technology lags behind. Revitalisng Alma-Ata and learning from three decades of experience is crucial to reach the ambitious goal of health for all in all countries, both rich and poor.
Alma-Ata’s 30th anniversary
This special issue of 
The Lancet 
marks the 30th annivers-ary of the Alma-Ata Declaration (panel 1).
2008 haswitnessed a plethora of events to mark the occasion,ranging from conferences
to reports
to special issues of journals like this one. Is this a reflection of sentimentalnostalgia for a remarkable event, and equally remarkableleadership? Or is this a relevant inquiry at a critical timein the development of equitable and affordable healthsystems? What can we learn from what worked and whatdid not work, what has been sustained and what has not?Many of the health challenges we face today, both in richand poor countries, echo those that led to the meeting inAlma-Ata. Demographic and epidemiological transitionshave strained health systems as new diseases haveemerged, while the old remain. Concerns about theaffordability of health care, with an ever expanding menuof newer drugs and procedures, are near universal,whether driven by the demands of an ageing populationand increasing chronic diseases, by the persistence of infectious diseases and maternal, newborn, and childhealth conditions, or by challenges that have emergedsince 1978, such as HIV/AIDS. The current crisis inhealth, with increasing demand, rising costs, and a returntowards curative and hospital care, makes re-explorationof the Alma-Ata principles timely and relevant.The recent interest in reinvigorating comprehensiveprimary health care, renewed recognition of the im-portance of community ownership, including expandeduse of mid-level and community health workers,
and agrowing recognition of the social determinants to healthand the multisectoral response required, are indicative of the ongoing relevance of Alma-Ata.
Shifts in global healthin recent years are as revolutionary as those at the time of Alma-Ata. Today’s Millennium Development Goals(MDGs), with three explicit health-related goals—forchild survival (MDG 4), maternal health (MDG 5), andHIV, tuberculosis, and malaria (MDG 6)—are garneringa more cohesive commitment than their predecessorgoals: the less clearly defined Alma-Ata challenge of health for all by the year 2000, and the ambitious remit of the 26 goals of the 1990 World Summit for Children.Technical agreement has advanced around what to do toimprove survival in the poorest countries, catalysed inpart by a number of 
but how to achievethese improvements remains a challenge.Here, we review 30 years of policy shifts in primaryhealth care in the global context, with a particular focuson maternal, newborn, and child health. Today, there isgreater commitment and resources for global health.However, as evidenced over the past 30 years, globalcommitment does not necessarily translate intosustainable health improvements or to lives saved,especially among the poor. Were the comprehensiveaspirations of Alma-Ata unrealistic, and what can welearn for the scale-up of universal care now? Are therekey components of primary health care that were wrong,or did they fail from neglect? Do we have the evidence
2008; 372: 917–27
page 863
This is the first in a
o eight papers about Alma-Ata:rebirth and revision
Saving Newborn Lives/Save theChildren—US, Cape Town,South Africa
 (J E Lawn MRCP [Paeds])
; HealthSystems Research Unit, MedicalResearch Council South Africa,Cape Town, South Africa
(J E Lawn, M Chopra MSc)
;Institute of Child Health,London, UK
(J E Lawn)
;Management Sciences forHealth, Boston, MA, USA
 (J Rohde MD)
; James P GrantSchool of Public Health, BRACUniversity, Dhaka, Bangladesh
 (J Rohde)
; London School of Economics, London, UK
(S Rifin PhD)
; National AIDSControl Council, Nairobi, Kenya
(Pro M Were DrPH)
; AMREF,Nairobi, Kenya
(Pro M Were)
;and All India Institute of Medical Sciences, New Delhi,India
(Pro V K Paul MD)Correspondence to:Dr Joy Lawn, 11 South Way,Pinelands, Cape Town,South Arica
Vol 372 September 13, 2008
required to guide priorities, and to measure and sustainprogress to make a second primary health-care revolutionwork? A number of papers in this special issue tackledimensions of progress and change in more detail.Country progress is the real test—have deaths beenreduced? Has health been improved? How equitable areprimary health-care services?
Alma-Ata: revisiting the vision of health for all
The context of the Alma-Ata Declaration was remarkable,pulling together high level leaders of east, west, north,and south, and of UN agencies which traditionallyworked inadequately together. The meeting of healthministers and their advisers took place in a city in what isnow Kazakhstan and necessitated the building of a new
Panel 1:
Declaration of Alma-Ata International Conference on Primary Health Care, Alma-Ata, USSR, September, 1978
I The conference strongly reaffi rms that health is a fundamental human right and that the attainment of the highest possiblelevel of health requires the action of many other social and economic sectors in addition to the health sector.II The existing gross inequality in the health status of the people is politically, socially, and economically unacceptable.III Economic and social development is of basic importance to the fullest attainment of health and the health of the people isessential to sustained economic and social development and contributes to a better quality of life and to world peace.IV The people have the right and duty to participate individually and collectively in the planning and implementation of theirhealth care.V Governments have a responsibility for the health of their people. Primary health care is the key to attaining this target as part of development in the spirit of social justice.VI Primary health care is essential health care based on practical, scientifically sound, and socially acceptable methods andtechnology made universally accessible to individuals and families in the community through their full participation and at acost that the community and country can afford to maintain at every stage of their development in the spirit of self-relianceand self-determination. It forms an integral part both of the country’s health system, of which it is the central function andmain focus, and of the overall social and economic development of the community. It is the first level of contact of individuals,the family, and community with the national health system, bringing health care as close as possible to where people live andwork, and constitutes the first element of a continuing health-care process.VII Primary health care: (1) reflects and evolves from the economic conditions and sociocultural and political characteristics of thecountry and its communities and is based on the application of the relevant results of social, biomedical, and health servicesresearch and public health experience; (2) addresses the main health problems in the community, providing promotive,preventive, curative, and rehabilitative services accordingly; (3) includes at least: education concerning prevailing healthproblems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequatesupply of safe water and basic sanitation; maternal and child health care, including family planning; immunisation against themajor infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases andinjuries; and provision of essential drugs; (4) involves, in addition to the health sector, all related sectors and aspects of nationaland community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works,communications, and other sectors; and demands the coordinated efforts of all those sectors; (5) requires and promotesmaximum community and individual self-reliance and participation in the planning, organisation, operation, and control of primary health care, making fullest use of local, national, and other available resources; and to this end develops throughappropriate education the ability of communities to participate; (6) should be sustained by integrated, functional, andmutually supportive referral systems, leading to the progressive improvement of comprehensive health care for all, and givingpriority to those most in need; (7) 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 andtechnically to work as a health team and to respond to the expressed health needs of the community.VIII All governments should launch and sustain primary health care as part of a comprehensive national health system incoordination with other sectors.IX All countries should cooperate in a spirit of partnership and service to ensure primary health care for all people since theattainment of health by people in any one country directly concerns and benefits every other country.X An acceptable level of health for all the people of the world by the year 2000 can be attained through a fuller and better use of the world’s resources, a considerable part of which is now spent on armaments and military conflicts. A genuine policy of independence, peace, détente, and disarmament could and should release additional resources that could well be devoted topeaceful aims and in particular to the acceleration of social and economic development of which primary health care, as anessential part, should be allotted its proper share.
Abridged from reference 1.
Vol 372 September 13, 2008
hotel to house delegates and the chartering of planes tofly in most participants. But even more remarkable thanthe context was the content of the Declaration. Althoughbilled as a primary health-care revolution, the contentwas much wider—a comprehensive philosophy fordevelopment (panel 1). It presented a shift in thinkingthat saw health not merely as a result of biomedicalinterventions but also an outcome of social determinants.Motivated by the call for social justice, Alma-Ata identifiedthe key principles of equity and community participa tionsupported by health promotion, intersectoral collabora-tion, and appropriate use of resources. According toHalfdan Mahler, WHO’s Director at the time, Alma-Atawas “one of the rare occasions where a sublime consensusbetween the haves and the have-nots in local and globalhealth emerged”.
Alma-Ata’s definition of health was based on WHO’sconstitutional definition, where health is “a state of physical, mental and spiritual well-being, not merely anabsence of disease or infirmity”
—a highly aspirationalrather than measurable objective. Primary health carewas defined as “the first level contact of individuals, thefamily, and community with the national health systembringing health care as close as possible to where peoplelive and work, and constitutes the first element of acontinuing health care process”.
 There was a shift in attitude from a focus on ill healthand hospitals, to a focus on communities and familiescontrolling their own health, putting the “public” intopublic health. The very idea of health for all energisedworkers and fuelled new efforts in many countries toimprove service coverage, especially for previouslyunderserved communities. The inherent focus on equity,the necessity of reaching the unreached and involvingthem not only in the benefits of health care, but moreimportantly, in the decisions and actions that collectivelymake health, was at once novel and revolutionary. Thus,the precepts of social justice became an integral part of health planning.The creation and acceptance of the Alma-AtaDeclaration was influenced by a range of successfulhealth projects run by non-governmental organisations,embedded in the community and responding to expressedand objective health needs and overall development,
Oral rehydration isinventedFamily planning is mainfocus of maternal andchild health programmesNational innovationssuch as China’s barefootdoctors inspire interestNon-governmentalorganisation innovationsin community activitiesHeavily indebted poor country initiativeUnited Nations reformRise of major new philanthropic foundationsStructural readjustmentAfrica hit by debt and HIV/AIDSGlobalisationAfrican and Asiancountries gainIndependenceCold War with influence of superpowers in some nationsEnd of Cold WarExpanded programme onimmunisation modelled onsmallpox campaignsChild survival revolution(1982) with leadership from Jim Grant of UNICEF andfocus on selectedinterventions (GOBI)Safe motherhood launched(1988) to address 500
000maternal deaths, initiallycalling for a comprehensiveapproach with empowermentas well as health careWorld Summit forChildren (1990) with 26goals focusing onselective and measurableinterventionsLimited funding andinterest in maternal andchild health—evenimmunisation fundingreduced markedlySafe motherhoodInitiative and WHO focuson skilled attendance, andreject training of traditional birthattendants
Child SurvivalSeries (2003) calls forsecond child survivalrevolution, refocusing onselective interventionsand reaching all childrenFirst Countdown to 2015focused on child survival(2005)
Neonatal SurvivalSeries (2005), shift of maternal and child health tomaternal, newborn, andchild health to save4 million neonatal deathsand calling for communityand facility interventions ina continuum of care
Maternal SurvivalSeries (2006) calls forfacility birth strategySecond Countdown to2015, with wider focus onmaternal, newborn, andchild health andreproductive health andcontinuum of care withcommunity and facility careSome countries initiate major change to primary healthcareTraining of traditional birth attendants and communityhealth workers is promoted as major strategy, often usingvolunteersWHO produces district health management toolsLimited global focus on primary health care andcommunity mobilisation or community based careSome countries persist especially in Latin America and theCaribbean and southeast Asia, or with socialistgovernmentsSome organisations persist especially NGOs either nationalsuch as BRAC or international such as Save and CARE, butmainly smaller scale implementationStatement regardingskilled attendance fordelivery and discouragingtraining of traditional birthattendants“Human resourcecrisis”(WHR 2006), plusmore evidence of effectbrings attention back tocommunity health workers
Mexico Seriesproposes the“diagonal”approach—acompromise betweenvertical and horizontalapproachesAlma-Ata 30 year celebration,reinvigorated interest inprimary health careMore focus on healthsystems strengtheningespecially for maternalhealth care and care of childhood illness
    G    l   o    b   a    l    h   e   a    l    t    h    P    H    C    W   o   r    l    d    M    N    C    H
HIV/AIDS emergesSmallpox eradicationHealth for all goals setWorld Bank report onhealth implementation of user fees particularly inmany African countriesHIV/AIDS becomes majorissue especially in someAfrican countriesLeadership vacuum forglobal health, particularlyin the UN systemNew funding for HIV,tuberculosis, malaria, andimmunisation (GAVI,Global Fund, President’s,Emergency Plan for AIDS)President’s Malaria InitiativePartnership for Maternal,Newborn and Child HealthformedBird flu investmentsIncreasing rhetoric regardinghealth systems buildingHealth 8 formed with moreunited UN leadership forglobal healthMore global leaders andpersonalities givingattention and funds forglobal health
From limited global health focus, to increasing fundingfor special issues, to multiple maternal, newborn, and child health initiatives and more attention to the link of health with developmentFrom comprehensive
selective, community
facility towards integrated delivery in the continuum of care, health system building, and human resource investmentFrom child only, to mother
child programmes towards mothers, newborn, and children integration
Alma-Ata declarationWorld Summit forChildren goals setCairo reproductivehealthMillennium DevelopmentGoals set
    2    0    1    5   :    M    i    l    l   e   n   n    i   u   m     D   e   v   e    l   o   p   m   e   n    t    G   o   a    l   s    t   a   r   g   e    t
    M   a    t   e   r   n   a    l ,   n   e   w    b   o   r   n   a   n    d   c    h    i    l    d    h   e   a    l    t    h    P   r    i   m   a   r   y    h   e   a    l    t    h   c   a   r   e    G    l   o    b   a    l    h   e   a    l    t    h
“Make every mother andchild count”, World HealthReport 2005; emphasis oncontinuum of care
Figure 1:
30 years since Alma-Ata—the shifts towards integration for global health, primary health care, and maternal, newborn, and child health

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