The Alma Ata Declaration Still Relevant

The Alma Ata Declaration was formally adopted at the International Conference on Primary Health Care in Alma Ata (in present Kazakhstan) in September 1978 (WHO, 1978). It identifies and stresses the need for an immediate action by all governments, all health and development workers and the world community to promote and protect world health through Primary Health Care (PHC) (ibid). This has been identified by the Declaration as the key towards achieving a level of health that will allow for a socially and productive life by the year 2000.

The principles of this declaration have been built on three (3) key aspects which include:

Equity – It acknowledges the fact that every individual has the right to health and the realisation of this requires action across the health sector as well as other social and economic sectors.

Participation – It also identifies and recognises the need for full participation of communities in the planning, organisation, implementation, operation and control of primary health care with the use of local or national available resource.

Partnership – It strongly supports the idea of Partnership and collaboration between government, World Health Organisation (WHO) and UNICEF, other international organisations, multilateral and bilateral agencies, non-governmental organisations, funding agencies, all health workers and the world community towards supporting the commitment to primary health care as well as increasing financial and technical support especially in developing countries.

Other important principles identified by the Declaration include: health promotion and the appropriate use of resources.

The declaration calls on all governments to formulate strategies, policies and actions to launch and sustain primary health care and incorporate it into the national health system. It was endorsed by the World Health Assembly in 1978 hence enshrining it into the policy of the WHO (Horder, 1983).

Background

Back in the 1960s and 1970s, many developing countries of the world gained independence from their colonial leaders. In efforts to provide good quality healthcare service for the population, these new governments established teaching hospitals, medical and nursing schools most of which were located in urban areas (Hall & Taylor, 2003) thus creating a problem of access to ‘good quality’ health service especially for people that reside in rural communities.

Successful programmes were initiated by Tanzania, Sudan, Venezuela and China in the 1960s and 1970s to provide primary care health services that was basic as well as comprehensive (Benyoussef & Christian, 1977; Bennett, 1979). It is on the basis of these programmes that the term ‘Primary Health Care’ was derived (Hall & Taylor, 2003). In low income countries, the primary health care strategy as described by the Alma Ata was very influential in setting health policy during the 1980s however in high income countries such as the United Kingdom, it was considered irrelevant on the presumption that the level of primary care service was already well developed (Green et al., 2007).

Primary health care has been defined in the Declaration of Alma Ata as;

“essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self reliance and self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main 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 and work, and constitutes the first element of a continuing health care process.” (WHO, 1978)

The Alma Ata Declaration brought about a shift on emphasis towards preventive health, training of multipurpose paramedical workers and community based workers (Muldoon et al., 2006).

In order to achieve the global target of health for all by the year 2000, goals were being set by the WHO (WHO, 1981) some of which include:

At least 5% of gross national product is spent on health.

A reasonable percentage of the national health expenditure is devoted to local health care.

Equitably distribution of resources

At least 90% of new-borne infants have a birth weight of at least 2500g.

The infant mortality rate for all identifiable subgroups is below 50 per 1000 live-births.

Life expectancy at birth is over 60 years.

Adult literacy rate for both men and women exceeds 70%.

Trained personnel for attending pregnancy and child birth and caring for children for at least 1 year of age.

It has been over 30 years now that the Declaration of Alma Ata was adopted by the WHO. A look at the current health trend around the world especially in developing countries such Nigeria, Ghana, Niger, Zimbabwe and so many others will reveal that the goal of achieving health for all by the year 2000 through primary health care has not been a reality. Although there have been reasonable improvement in immunisation, sanitation and access to safe water, there is still impediments in providing equitable access to essential care worldwide (WHO, 2010)

What went wrong?

Lawn et al. (2008) explain that the Cold War significantly impeded the desired impact expectation of the Alma Ata Declaration in the sense that global developmental policy at that time was dominated by neo-liberal macro economical and social policies. The effect of this on poorer countries of the world particularly in Africa was implementation of structural adjustment programmes in effort to reduce budget deficit through devaluations in local currency and cuts in public spending. This resulted in the removal of subsidies, cost recovery in the health sector and cut backs in the number of medical health practitioners that could be hired. The introduction of user charges and encouragement of privatisation of services during this period had an untoward effect on poor people who could not afford to pay for such services. The combination of these factors hence resulted in part to the crippling of the quality of service that can be provided at the primary care level. People who could afford such service resorted to health service offered at secondary or tertiary care which in most cases is difficult to access.

The introduction of a new concept of ‘Selective’ Primary Health Care as proposed within a year of the adoption of the Alma Ata Declaration by Walsh & Warren (1979) changed the dimension of primary health care. This ‘interim’ approach was proposed due to the difficulty experienced in initiating comprehensive primary health care services in countries with authoritarian leadership (Waterston, 2008). Walsh & Warren (1979) argued that until comprehensive primary health care can be made available to all, services that are targeted to the most important diseases may be the most effective intervention for improving health of a population. The measures suggested include; immunisation, oral rehydration, breast feeding and the use of anti malarias. This selective approach was considered as being more feasible, measurable, rapid and less risky, taking away decision making and control away from the community and placing it upon consultants with technical expertise hence making it more attractive particularly to funding agencies (Lawn et al., 2008). An example of a selective primary care approach is the Expanded Programme on Immunisation (EPI). Selective primary health care is concerned with providing solutions to particular diseases such as HIV/AIDS and tuberculosis while comprehensive primary care as proposed the Alma Ata begins with providing a strong community infrastructure and involvement towards tackling health issues (Baum, 2007).

The shift in maternal, new-borne and child health as a result of programmes that removes control from the community hinders the actualisation of the goals of primary health care as emphasized by the Alma Ata Declaration. The reversal of policy in the 1990s by the WHO and other UN agencies to discourage traditional birth attendants and promoting facility based birth with skilled personnel (Koblinsky et al., 2006) is an example of such.

The World Bank’s report ‘Investing in Health’ which was published in 1993 saw the World Bank become a great influence and major key player in international public health as such robbing the WHO of the prestigious position (Baum, 2007). It considers investments for interventions that only have the best impact on population health as such removing local control and advocating a ‘vertical’ approach to health. This move counteracts the process of the social change described by the Alma Ata Declaration which is necessary for realisation of its goals.

These go to show that consistency both in leadership (locally and globally), policy as well as good evidence (to drive policy making and actions), are important ingredients for global initiatives to succeed.

What went right?

Even with the several elements that prevailed against the achievement of the collective goals of the Alma Ata Declaration, several case studies show that when provided with a favourable environment, primary health care as prescribed by the Alma Ata is sufficient to bring about a significant improvement in the health status of any population or country.

Case study 1: Primary Health Care in Gambia

Using data obtained from a longitudinal study conducted by the United Kingdom Medical Research Council over a 15 year period for a population of about 17,000 people in 40 villages in Gambia, Hill et al. (2000) compared infant and child mortality between village with and without primary health care. The extra services that were provided in the villages with primary health care include: a village health worker, a paid community nurse for every 5 villages and a trained traditional birth attendant. Maternal and child health services with vaccination programme were accessible to residents of both primary health care and non primary health care villages. There was marked improvement in infant and under 5 mortality in both sets of villages.

After primary health care system was established in 1983, infant mortality dropped from 134/1000 in 1982 – 83 to 69/1000 in 1992 – 94 in the primary health care villages and from 155/1000 to 91/1000 in non primary health care villages over the same period of time. Between 1982 and 83 and 1992-94, the death rates for children aged 1-4 fell from 42/1000 to 28/1000 in the primary health care villages and from 45/1000 to 38/1000 in the non primary health care villages. However, in 1994 when supervision of primary health care was weakened, infant mortality rate in primary health care villages rose to 89/1000 for primary health care village in 1994 – 96. The rate in non primary health care village fell to 78/1000 for this period.

The implementation and supervision of primary health care is associated with a significant effect on infant mortality rates for these groups of villages that benefitted from the programme.

Case study 2: Under 5 mortality and income of 30 countries

To assess the progress for primary health care in countries since Alma Ata, Rohde et al. (2008) analysed life expectancy relative to national income and HIV prevalence in order to identify over achieving or under achieving countries. The study focused on 30 low income and middle income countries with the highest year reduction of mortality among children less than 5 years of age and it described coverage and equity of primary health care as well as other non health sector actions. The 30 countries in question have scaled up selective primary care (immunisation, family planning) and 14 of these countries have progressed to comprehensive primary care which has been marked with high coverage of skilled birth attendants. Equity with skilled birth attendance coverage across income groups was accessed as well as access to clean water and gender inequality in literacy.

These 30 countries were grouped into countries with selective primary care; mixture of selective and comprehensive primary health care; and comprehensive primary health care alone. The major players among countries with comprehensive primary health care are Thailand, Brazil, Cuba, China and Vietnam. Overall, Thailand tops the list and it has comprehensive primary health care. Maternal, new-borne and child health in Thailand were prioritised even before Alma Ata and has been able to increase coverage for immunisation and family planning interventions. The Government investment in district health systems provided a foundation for comprehensive primary health care in maternal, new-borne and child health as well as other essential services. Community health volunteers also played a significant role towards Thailand’s medical advancement. They promoted the use of water sealed latrines to improve sanitation and were very instrumental towards the decline of protein calorie malnutrition in pre-school children in the past 20 years (WHO, 2010). Participation of the community health volunteers is a major source of community involvement into health care of Thailand (ibid).

The following factors were identified as important lessons from high achieving countries: accountable leadership and consistent national policy progress with time; building coverage of care and comprehensive health systems with time; community and family empowerment; district level focus which is supported by data to set priorities for funding, track results as well as identify and redress disparities; and prioritising equity, removing financial barriers for poorest families and protection against unavoidable health cost.

Case study 3: Integration of cognitive behaviour based therapy into routine primary health care work in rural Pakistan

Rahman et al. (2008) in a cluster-randomised control study in Pakistan shows the benefits derived when cognitive behaviour therapy in postnatal depression is integrated with community based primary health care. Training was provided to the primary health care workers in the intervention group to deliver psychological intervention. The health care workers also receive monthly supervision and monitoring. Significant benefit (lower depression and disability scores, overall functioning and perception of social support) was reported in the intervention group to suggest that this kind of measures as supported by the Alma Ata can drive the initiative towards ‘Health for all’.

It is evident and clear that countries that practiced comprehensive primary health care as enshrined by the Alma Ata reaped great benefits in terms of population health improvement. Although it has been argued that comprehensive primary health care is too idealistic, expensive and unattainable (Hall & Taylor, 2003), evidence suggest that it is more likely to deliver better health outcomes with greater public satisfaction (Macinko et al., 2003). This kind of care can deal with up to 90% of health demands in low income countries (World Bank, 1994).

Relevance of Alma Ata in this present time

Our present world that has been characterised by marked epidemiological transition in health. Low income countries as well as high income ones are faced with increasing prevalence of non communicable as well as chronic disabling disease (Gillam, 2008) hence, the existence of infectious diseases (malaria, HIV/AIDS, Tuberculosis etc), and diseases like cardiovascular disease and diabetes. For low income countries such as sub-Sahara African Countries, this constitutes a major health problem because their health systems are mainly oriented towards providing services inclined with maternal and child health, acute or episodic illnesses. As such current health systems need to have the capacity to provide effective management for the current disease trend. The Alma Ata provides a foundation for how such effective health service can be provided. Because, primary health care is the first line of contact an individual has to health care, it is thus very influential in determining community health especially when the community is fully empowered to participate. As societies modernise, as it is the case in our current world, the level of participation increases and people want to have a say in what affects their lives (Garland & Oliver, 2004). Thus, the level participation in health care is better off and more powerful in this present time than it was when it was the Alma Ata was adopted. Evidence suggest that the values as enshrined by the Alma Ata are becoming the mainstream of modernising societies and it is a reflection of the way people look at health and what they expect from their health care system (WHO, 2008).

Alma Ata failed in some countries because the Government of such countries refused to put strategies towards sustaining a strong and vibrant primary health care system that is appropriate to the health needs of the community such that access is improved, participation and partnership is encouraged and health is improved in general. There is no goal standard guideline or manual on Alma Ata but individual governments have to develop their own strategies which should be well suited towards meeting their own needs. The Alma Ata founding principles is still relevant towards achieving these goals especially as it brings health care to peoples door step as it encourages training of people to efficiently and effectively deliver health services. Evidence has shown that there is a greater range of cost effective interventions than was available 30 years ago (Jamison et al., 2006). It is for these reasons that primary health care is essential towards achieving the millennium development goals especially as it concerns child survival, maternal health, and HIV/AIDS, malaria, tuberculosis and other diseases.

The Alma Ata emphasises the importance of collaboration as an important tool towards introducing, developing and maintaining primary health care. This partnership as supported by the Alma Ata is essential to increase technical and financial support to primary health care especially in low income countries. It is a current trend to find an increasing mixture of private and public health systems as well as increasing private-public partnerships. Governments, donor and private organisations are now working together to promote and protect health unlike after Alma Ata (OECD, 2005). There is also increased funding and this is shifting from selective global funds to strengthening health systems through sector wide approaches (Salama et al., 2008). This kind of collaborations is a step in the right direction and when it is strengthened according to the principles of the Alma Ata, it will not only improve the buoyancy of the health care system but also improve participation and equity in the sense that health care is more qualitative and accessible to the people.

The years that followed after adoption of the Alma Ata by WHO member states was characterised by unstable political leadership and military dictatorship especially among low income countries which lead to neglect of the health sector. This created unfriendly environments for the development and maintenance of stable primary health care systems. In this current times however, most countries have embraced the democratic system of leadership that promotes equity, participation and partnership. Health equity is continually enjoying prominence in the dialogue of political leaders and ministries of health (Dahlgren & Whitehead, 2006). Thus, the environment being created is friendlier to the Alma Ata hence making it more relevant in this time. Thirty years ago, the values of equity, people centeredness, community participation and self determination embraced by the Alma Ata was considered as being radical but today these values have become widely share expectations for health (WHO, 2008).

Our current time has been marked by gross technological advancement which was not available in the 1970s. There is also an increased wealth of knowledge and literature on health and on the growing health inequalities between and within countries all of which was not available 30 years ago. All these put together provides a relevant foundation to support the Alma Ata in the present time making it more relevant in delivering effective health care service.

Conclusion

The prevailing political and economic situation around the world make the Alma Ata more relevant than it was in 1978. However, there is still need for more to be done. There is need for the revitalisation of primary health care according to the tenets of the Alma Ata and progress made should be consistently monitored. There is also the need for an increased commitment to the virtues of ‘health for all’ as well as increased commitment of resources towards primary health care which should be driven by good evidence base. It is important that emphasis be changed from single interventions that produce short term or immediate results to interventions that will create an integrated, long term and a sustainable health care system. Even with the challenges being faced so far with full implementation of the Alma Ata, the ideals are relevant still relevant now more than ever.