The 30th Anniversary of the Alma-Ata Declaration
The Lancet Special Series
Alma-Ata: A Revolution for Primary Health Care
Over 30 years ago, the founding chair of the Department of International Health, Professor Carl Taylor, signed his name to an historic document in global health: The Declaration of Alma-Ata International Conference in Primary Health Care. He and the other signatories from 134 countries were ambitious. Their goal was “Health for all by 2000.” Although that goal was not reached, the Declaration has been a revolutionary force in public health. And while new challenges have emerged since its signing, Alma-Ata’s legacy can be felt in myriad areas of global health, from the Millennium Development Goals to the many projects implemented by our own Department that utilize community strengths in primary health care programming.
For the Declaration’s 30th anniversary, The Lancet published a special Alma-Ata Series, with funding from the Norwegian Agency for Development Cooperation and Aga Khan University. The Series sets out not only to commemorate the signing, but also to revisit the Declaration’s core principles, assess its legacy, and reflect on the lessons learned from 30 years of work it has influenced. The Department of International Health has been at the forefront of the struggle to attain “health for all” since its inception. In this seminal Lancet publication, current Chair Dr. Robert Black helps to define the present situation and articulate the challenges for the future.
The Success of Primary Health Care
The Alma-Ata Series recognizes the renewed and reinvigorated interest in comprehensive primary health care and acknowledges the importance of the Declaration’s core principles, which include equity, social justice, community participation, and health for all. Yet, health outcomes are often difficult to attribute directly to improvements in primary health care.
To better understand the overarching patterns and lessons from the past 30 years, the fourth paper of the Series charts the progress in primary health care in 30 low- and middle-income countries with the greatest yearly reduction in mortality of children under 5. By analyzing the progress made in these 30 countries, the paper seeks to identify pathways for building comprehensive and equitable primary health-care systems associated with declines in mortality.
At least half of the best performing countries faced major impediments, such as extreme poverty, civil unrest and high HIV/AIDS burdens. Despite these obstacles, they were able to reduce mortality rates through high coverage of selective services. The analysis shows, however, that to attain further significant reductions, countries will need to develop comprehensive primary health care with a reliable referral system.
Overall Lessons Learned from Countries Making Progress
- Accountable Leadership, consistent national policy progress with time
- Building coverage of care and comprehensive health systems with time
- Community and family empowerment, involving the community both in health promotion and demand for care
- District-level focus, with data to set priorities for funding
- Equity priority, removing financial barriers for the poorest families
New Initiatives to Improve Maternal, Newborn and Child Health (MNCH)
The Department has also been a leader in developing methods to measure the burden of maternal, neonatal and child mortality. In 2005, for example, Department faculty led the Lancet Neonatal Series that looked at both the burden of disease and the impact of various interventions. And last year, the Countdown to 2015 Working Group on Coverage, led by Dr. Jennifer Bryce, found that the implementation, uptake and equity of MNCH interventions vary greatly in the most at-risk countries.
The Alma-Ata Series builds on the work from these studies and others by systematically reviewing the effectiveness of MNCH interventions. The analysis identified 37 key promotional, preventive and treatment interventions and strategies for delivery of primary health care. Examples of these evidence- and community-based MNCH interventions and delivery strategies include the following:
- Promotion of skilled care for childbirth
- Vitamin A supplementation
- Preventive zinc supplementation
- Community detection and management of pneumonia with short course amoxicillin
In addition, the authors performed two case studies on how a set of interventions could best be delivered within existing health systems. Models were developed to predict the potential effect of integrating key interventions into the primary health care systems in Pakistan and Uganda. The model was based on the capacities of existing systems and care providers. Using only the primary health care system, and increasing coverage to feasible levels in the short term, the model predicted the following reductions in mortality:
- maternal deaths: 20-30%,
- newborn deaths: 20%
- deaths of children under 5 years: 29-40%
A Moral Imperative
With the legacy of Alma-Ata in mind, the authors call the scaling up of community-based primary care a “moral imperative.” Seventy-five percent of the countries with the highest burden of maternal, newborn and child deaths are off their MDG 4 and 5 targets. This review provides further confirmation that evidence-based interventions exist and can be implemented feasibly.
Achieving Health for All
The final paper of the Lancet Alma-Ata Series charts the course for realizing the Declaration’s ultimate goal of health for all. Despite incomplete success, the paper reasserts the critically essential role of primary health care. Moreover, with growing demands placed on already strained health systems, Alma-Ata’s principles of community participation and intersectoral collaboration are proving more relevant than ever.
MDGs and scaling up
The Millennium Development Goals (MDGs) for 2015, which are descendants of Alma-Ata, will most likely not be met without a reinvestment in primary health care. To successfully strengthen primary health care, approaches must be feasible and based on solid evidence. As a guide for future endeavors, the paper offers seven priorities:
- Making and keeping health and health equity a priority
- Implementation of integrated primary health care at scale
- Ensuring equity and sex equality
- Facilitating community participation and empowerment
- Linking health and development
- Measuring change and ensuring accountability
- Investing in innovation for drugs and technologies, and in implementation research
Research Priorities and the 10/90 Gap
Thirty years ago, evidence on cost-effective interventions was scarcer, and there were no specific health targets such as the MDGs. Research and innovation are still needed to scale up and improve health outcomes. And, as research and analysis become more widely available and complex, effective communication between policymakers, researchers and stakeholders becomes correspondingly more essential.
Despite increased investment, only 10 percent of research funding is allotted to address 90 percent of the world’s population. To focus these limited resources, the authors developed research priorities for PHC in general, as well as several specific to maternal, newborn, and child health:
- Cost-effectiveness of approaches to providing postnatal and newborn care
- Cost-effectiveness of service delivery models for integrated MNCH services
- Cost-effectiveness of supportive supervision initiatives to improve the interaction between health centers and referral units
- Comparison of models of scaled-up community IMCI
- Assessment of methods to monitor child and maternal mortality on a yearly basis
The Alma-Ata Series is more than just commemorative. It is a call to recommit to the Declaration’s principles—equity, social justice, community participation, and health for all. Furthermore, the articles offer new evidence for the importance and effectiveness of primary health care, and they set new priorities and guidelines for achieving the ultimate goal of health for all. Finally, the Series itself is a testament to the Department’s ongoing commitment to primary health care and improving global health. The founding Department Chair signed the Declaration; our current Chair authored several of the influential articles in the Series; and most telling of all, the work of faculty are cited heavily throughout this special series that launches the next 30 years in global primary health care.