In the summer of 1978, as the Cold War was waning, representatives from 134 countries and 67 health organizations traveled to the city of Alma-Ata, in the Soviet Republic of Kazakhstan, for the International Conference on Primary Health Care. In a culminating moment, the 3,000 people in attendance listened as Dr. Marcella Davis, a representative from the ministry of health in Sierra Leone, read aloud the Alma-Ata Declaration:
“The Conference strongly reaffirms that health, which is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector...”
“It was aspirational,” says Dana Hovig, director of Integrated Delivery at the Bill & Melinda Gates Foundation. “It put a stake in the ground that health is a human right. Until that moment, there wasn’t global agreement about that.”
Initially, enthusiasm was high for the Declaration and its central goal: “Health for all by the year 2000.” But 40 years later, given the state of primary health care in many low- and middle-income nations, achieving that goal is still a long way off.
So, what went wrong?
In part, health crises like malaria, the HIV/AIDS epidemic, and the rise of drug-resistant tuberculosis have demanded targeted action, diverting attention from efforts to develop primary health care systems. The Declaration also gave rise to conflicting philosophies in how best to build such systems.
“There were competing ideologies about how to implement Alma-Ata,” Hovig says. “Do you start by trying to do a few things well, or redesign systems to deliver all essential health services? Do you start by delivering to the well-off population and hope that it trickles down, or do you start with the poorest and most vulnerable? People struggled over these ideologies for years, until many health organizations sort of retreated from primary health care, focusing on a few high-impact efforts whose progress was quantifiable. The plan to invest in primary health care systems and ‘health for all’ was lost along the way.”
This week, Hovig will be among the thousands of leaders and global health experts gathering in Kazakhstan to reaffirm their commitment to the Alma-Ata Declaration. The conference will be a chance to celebrate the global health successes of the past 40 years–progress in vaccines, family planning, malaria, HIV treatment, and more–while also exploring what next steps are needed to finally achieve “health for all.”
At the Gates Foundation, the anniversary is an opportunity to reflect on how the organization’s role in strengthening primary health care systems has evolved in recent years.
“Through the foundation’s journey in primary health care, we’ve learned the value of systems-based approaches that support a person’s whole health, not just taking care of illness,” Hovig says. “That means helping put health workers into communities who can deliver targeted solutions for things like malaria, HIV, and family planning services, plus listen to people and help manage their whole health.”
To continue doing that better, Hovig says, the foundation looks for answers in countries with well-performing primary health care systems. “How can we help other countries adapt and replicate that success?”
A Soviet propaganda film from 1978 about the Alma-Ata Declaration might hold some clues (along with some great fashion, music, and documentary footage from the time period). In an interview with Dr. R. Soebekti, Indonesia’s then-director general of community health services, he described how Alma-Ata could lead to on-the-ground improvements in primary health care, under the right circumstances.
“This conference...will further strengthen the backing that we need,” Soebekti said. “The political will of the governments will be there for us, the professionals, and it will be much easier to implement the primary health care concept.”
In another interview from the 1978 film, Dr. Davis shared a vision of what Alma-Ata could achieve in the region of West Africa.
“We hope that from this conference will emerge the strategy for world action to bring relief to the masses of people in the developing countries who do not have access to any sort of health care,” Davis said. “...we hope that through development in the health sector we’ll be able to bring up the standard of living of our people.”
Soebekti and Davis' comments identified three issues that have played key roles in whether nations have developed effective primary health care systems: political will, financial backing, and world action. Indonesia was one of many primary health care success stories, thanks in large part to the efforts of Dr. Soebekti who implemented “bottom-up” reforms in community health. Meanwhile, Sierra Leone is one of several West African nations who aren’t much better off today than they were in 1978.
The problem for low- and middle-income countries is their annual budgets are stretched thin between the competing demands of infrastructure, military, education, health, and more. Line items like health and nutrition services for women, children, and adolescents get shortchanged.
“When governments do spend money on health, too often it’s for secondary and tertiary care,” Hovig says. “Most health systems and national health insurance agencies are set up to react to illnesses and emergencies rather than preventative care and promoting wellness. And even those services rarely reach the poorest and most vulnerable populations. If a country spends a sufficient amount on primary health care programs, including for the poor, they can meet 80 to 90 percent of people’s health needs throughout their life. It’s not an either/or situation – we need both.”
If poor health conditions are the same today in parts of the world as in 1978, why expect reaffirming the Alma-Ata Declaration to have a different result? The best reason for optimism is because developing nations have access to new tools. And there are success stories to point to, like Rwanda, a low-income nation that has built a robust primary health care system. Their example is inspiring the leaders of other countries to take more seriously the task of strengthening their own primary health care.
Burkina Faso belongs to a new wave of countries whose decision to prioritize primary health care bodes well for the future of the Declaration. The small West African nation has been accepted into the Global Financing Facility, an innovative funding institution that works with the World Bank, and is poised to receive a multi-million dollar package of loans and grants over the next five years. The funds are earmarked entirely for strengthening Burkina Faso’s health system (especially underfunded programs like health and nutrition services for women, children, and adolescents). Their project is emblematic of what the GFF aims to achieve. Burkina Faso is taking a leadership role, agreeing to co-host (along with the Government of Norway, the World Bank Group, and the Gates Foundation) the GFF Replenishment Event on November 6 in Oslo, Norway.
“Burkina Faso is known as a ‘locomotive’ of the Ouagadougou Partnership in Francophone West Africa,” says Shelby Wilson, a senior program officer at the Gates Foundation. “They’ve increased voluntary access to contraception by 25 percent in just three years. Not only that, Burkina Faso was one of the first countries in the Sahel to join the Scaling Up Nutrition Movement in 2011.”
Wilson adds: “The term ‘country-led’ is a buzzword in global health, but it’s true in the case of Burkina Faso. The Minister of Health, Nicolas Meda, has a strong vision for a national health system that values prevention and puts the community and primary health care at the center toward achieving universal health coverage. We see our role at the foundation as supporting this vision because any positive impact in Burkina Faso can inspire the rest of the region.”
In other words, Burkina Faso has the three pillars Soebetki and Davis mentioned in 1978: political will, financial backing, and world action. If that is the recipe that can make the Alma-Ata Declaration work, then there is reason to believe it won’t take another 40 years to achieve “health for all.”
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