Revisiting Primary Health Care, 40 Years After the Alma-Ata Declaration

Last week, when I went to my office I had a pleasant surprise. An original 1978 copy of the Alma Ata declaration on primary health care (PHC) was on my desk, left by my JSI mentor Robert Steinglass. I picked it up, thumbed the pages, and inhaled the history. It reminded me that PHC is part of my DNA.

I grew up on the west coast of Scotland and benefited from the UK’s National Health Service (NHS). The NHS provides primary, secondary, and tertiary health care and preventive services free of charge. If a person is too ill to go out, s/he can request a free house call. All this is paid for by taxes, which amount to 8 percent of the UK’s gross domestic product. My family got care at the local PHC center, which provided integrated screening, preventive, and curative services, as well as nursing and social care, physiotherapy, and occupational therapy. My mum could get contraceptives, my sister’s vaccines, and my brother’s asthma treatment at the same place.

The Alma Ata declaration came at a time when countries were looking for alternatives to centralize health care structures. The 40-year-old declaration, with its ‘health for all’ goal, includes five underlying principles[1] of PHC:

1. Reducing exclusion and social disparities in health (universal coverage reforms).
2. Organizing health services around people’s needs and expectations (service delivery reforms).
3. Integrating health into all sectors (public policy reforms).
4. Pursuing collaborative models of policy dialogue (leadership reforms).
5. Increasing stakeholder participation.

These principles are more relevant now than ever before, especially with increasing isolationism and inequities, fear of integration, and top-down disease control, even in so-called ‘developing countries.’

Primary health care responds to people’s needs through bottom-up approaches that are accountable to citizens and communities; and human-centered design to support more appropriate, acceptable, and sustainable services. PHC philosophy also tries to address the socio-economic aspects of health through approaches that include education, nutrition, and water, sanitation, and hygiene. Today, PHC is a core of social welfare in Southern Indian states, Cuba, Sweden, Norway, Denmark, UK, France, Hong Kong, and Vietnam.

Why then, you might wonder, has this seemingly beneficial elixir for improving health not been adopted more widely? The answer requires an understanding of history, politics, and culture:

• PHC approaches were criticized as utopian. Selective primary health care, which recognized the need to be more targeted and ration services in low-resource settings with weak health systems, was developed as a compromise. Priority was given to services that were preventive and cost-effective, such as growth monitoring, oral rehydration, breastfeeding, and immunization.
• Some countries felt (and still feel) that PHC is ‘socialist’ and/or gives too much power to communities, which could threaten power structures from the medical establishment to governments to corporations.
• The PHC principles threatened the power base of doctors, the traditional rulers of health who thrive in vertical medicalized models of treatment-focused specialties rather than prevention, and illness rather than health.
• Funders (including ministries of finance, bilateral donors, and philanthropists) often want quick results that fit neatly within a political term, are attributable to their specific investments, and easily reported to taxpayers (voters). Such programs are often implemented in donor-convenient or disease-specific silo projects that do not favor holistic PHC approaches. Unfortunately, strengthening health systems and PHC is not a quick fix—it takes time to develop and show results and resource-poor countries have increased their dependence on richer countries different, often political agendas.
• Measuring PHC indicators and attributing the results of PHC investments is hard for donors, although doing so has become easier through the recent Primary Healthcare Performance Initiative.

While these practical issues were being debated in the 1980s, the pendulum swung back in favor of the vertically implemented programs such as smallpox and the global polio eradication goal (declared in 1988). The success of these programs drew attention from more horizontal ways of providing health and polarized the debate on how best to provide health care and control disease. Other vertical disease control programs, such as the measles-rubella initiative, promote campaign-style approaches to eliminate disease, which include plenty of rhetoric for strengthening systems but little in the way of budget commitments.

Gavi, the Vaccine Alliance, and the Global Fund for AIDS, TB and Malaria each allocate resources to strengthen health systems for countries to achieve disease-specific results, sometimes through PHC approaches. Each disease or program-specific initiative struggles with the challenge of how to strengthen health systems and contribute to underlying PHC services. Some argue, however, that this dilutes the focus from the specific disease or program.[2]

The political pendulum seems to be swinging more in favor of horizontal approaches again, with the Sustainable Development Goals (SDGs), which emphasize integrated approaches to achieving universal health coverage (UHC). Equity and community-based approaches are at the core of both and PHC are considered a cost-effective way to achieve these health outcomes. As evidenced by the April 28, 2018 article in the Economist, UHC is enjoying high visibility.

This gives me hope for the future of equitable health, as PHC and UHC attempt to meet the needs of communities that have the greatest disease burden and to minimize catastrophic health expenditures by those who can least afford them. There is plenty of evidence that UHC and PHC are achievable and can be the foundation for detecting and responding to infectious disease threats, as part of longer-term approaches to address the emerging Global Health Security agenda.

History may be made in October 2018, when global health and country leaders meet in Alma Ata again. I am optimistic about this recommitment to PHC principles as part of the SDGs and UHC, but see the following three conditions as imperative for the re-declaration to succeed:

1. Financial commitments to PHC must match the current rhetoric of political commitment to UHC.
2. More targeted efforts needed to prevent and treat noncommunicable disease, which, along with aging populations, comprise the greatest disease burdens.
3. Preventive, curative, and palliative health services must be provided by staff who are recruited and trained to deliver high-quality basic services to their own communities.

[1] http://www.who.int/whr/2008/whr08_en.pdf.

[2] Lancet Positive Synergies series, 2009.