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International Health

Globe Spring 2009
From the Chair

The year just finished commemorated the Declaration of Alma-Ata issued at an International Conference on Primary Health Care (PHC) in Alma-Ata, USSR, in September 1978.  A series in The Lancet, the WHO World Health Report, conferences, and other events looked back at what had been achieved in the last 30 years and importantly what more needs to be done to achieve the Declaration’s ambitious goals. The first two points of the Declaration, and probably the most important, affirm that health is a fundamental human right and that inequalities in health status around the world are unacceptable. However, it is perhaps the last of the ten points that had the most recognition through the slogan “Health for all by the year 2000.” As Carl Taylor and others who crafted this declaration and the global consensus behind it will attest, it is the “health for all” that was and should remain the focus.

There have been many improvements in health in the last 30 years, including remarkable declines in child mortality in many countries in the Americas, Asia and North Africa. Unfortunately in this metric and many others, sub-Saharan Africa and some South Asian countries have fallen short. In countries that have achieved gains against the traditional problems of populations suffering from poverty, high rates of infectious diseases and prevalent nutritional deficiencies, new challenges have emerged, including the rise in importance of non-communicable diseases. Interventions, especially for prevention of these conditions and management of chronic diseases, must now be incorporated into PHC.

The Declaration’s call for PHC to be essential health care made available in an integrated manner and with community participation has been violated more than honored in recent decades. An objective observer would have to say that the current state of health care in low-income countries is characterized by large and often increasing inequities, fragmented services driven by donor money and programs directed more by outside influences than national priorities and community needs.

An important publication in 2008, the Final Report of the WHO Commission on Social Determinants of Health,1 called for a new commitment to recognize and address the underlying determinants of poor health, i.e. the unequal distribution of power, income, goods and services. The Lancet theme issue on primary health care called for building integrated health systems and achievement of high and equitable coverage of essential services that address the most important health problems in these populations. Included analyses in these papers demonstrate that sustained and prioritized PHC has been associated with substantial gains in life expectancy and health equity, and that this has been possible even in countries with low incomes and political instability. Case studies of Pakistan and Uganda illustrate that inclusion of evidence-based interventions in maternal, newborn and child health programs could prevent 20-30% of maternal deaths, about 20% of newborn deaths and up to 40% of post-neonatal deaths in children up to 5 years old with only modest increases in program coverage that would be feasible in only a few years.

That the world did not achieve health for all by the year 2000 should not be regarded as a failure, but rather as a challenge to meet the latest global commitments, i.e. the Millennium Development Goals by 2015. The Alma-Ata Declaration provides important values and principles for action that along with a renewed commitment to social justice and integrated and prioritized health services will help countries achieve these goals.

1 Closing the gap in a generation: Health equity through action on the social determinants of health