The visions of Alma Ata revisited

Thirty years ago the slogan "health for all" resounded in the corridors of international and domestic health organizations. A year later the vision was left in favour of a more selective approach. Now with the increased focus of global health initiatives on health systems strengthening, the idea is examined with renewed enthusiasm.

Alma Ata was the site of a ground-breaking conference held in Kazakhstan in 1978. The International Conference on Primary Health Care brought together 134 nations and more public health ministers than had ever gathered together before. It became the birthplace of primary health care.

It was the first time that the health care problems of low and middle income countries had been put at the top of the agenda and the concept of "health for all" conceived as stated in the WHO-UNICEF Alma-Ata declaration. The conference highlighted the close ties between development and health needs and the importance of multi-sectorial approaches in achieving the highest level of health. Involving the social, educational and financial sectors was also deemed vital in order to achieve good health.

However, in spite of the energy, excitement and an action orientated declaration, a year later the "health for all" message was replaced by a new one: selective primary health care (PHC). This new strategy was based on the premise that comprehensive approaches to achieving better health were too costly. Selective PHC was considered to be an interim approach focusing on a limited number of diseases known to have cost-effective solutions. The age of so-called "vertical" programming was upon us.

Whilst the success of many vertical programmes in achieving important health outcomes is evident, there has been a renewed focus on integration of services, strengthening of health systems and community engagement. The spotlight is once again on equity and the importance of universal access to basic health care services - especially for vulnerable populations. The message of Alma Ata has renewed relevance for the twenty-first century and has many vigorous protagonists.

Symposium: Alma Ata - 30 years on

A symposium of such like-minded individuals took place in London in September of this year, at the School of Oriental and African Studies (SOAS). The meeting was supported by the London School of Hygiene and Tropical Medicine, The Lancet, DfiD (UK) and the Royal Society of Tropical Medicine. It was attended by researchers and policymakers from around the globe.

The aim of the meeting was to reflect on the success and failures of PHC during the last 30 years in order to apply the lessons learned to health systems strengthening in the future. Leading academics and policy makers were invited to present over two days and the quality of presentations was subsequently very high.

Lay health workers make a difference

The role of lay health workers and civil society in providing basic health care was a recurring theme over the two day conference. Presentations from India, Pakistan and Bangladesh, amongst others, all highlighted the substantial contribution that trained volunteers can make, particularly within the often neglected areas of maternal, newborn and child health.

Professor Zulfiqar Bhutta from Pakistan presented the findings of systematic review of the evidence looking at integrated primary health care strategies for maternal, newborn and child health. The review found that whilst there are gaps in the knowledge base for integrated programmes and on the effect they have on mothers and newborns, there were 27 effective primary health care interventions that could have an impact on the health of mothers and their children.

According to the findings of the review, if it is possible to scale up these interventions to a pragmatic level (meaning not necessarily 100 percent coverage), we could prevent over one in five maternal deaths, 20 percent of neonatal and 30-40 percent of post-neonatal deaths under 5 years . The study is published in the Lancet and was funded by Norad.

The poor affected by a double burden of disease

The burden of chronic diseases in low and middle income countries is becoming more and more significant, especially due to ageing populations and mental health issues. This was reiterated by the former Minister of Health for Mexico and incoming Dean at Harvard School of Public Health, Julio Frenk, who described the double burden of chronic and communicable diseases faced by today's poor.

The importance of creating and disseminating new knowledge was also a recurrent theme at the symposium. Health systems research is considered a vital means of improving dialogue with policymakers across other sectors relevant for the determinants of health. It is currently a neglected area which requires urgent funding and capacity building.

Relevant for the 21st century

There is little doubt that Alma Ata appears to have as much relevance for the 21st century as ever. Whilst there are considerable challenges and potential barriers to achieving "health for all", there is renewed enthusiasm within the global health community. This, together with the increased focus of large global health initiatives on health systems strengthening, mean that the world may be better placed to achieve universal access to basic health care than 30 years ago. This year's World Health Report launched by WHO and partners in Alma Ata earlier this week should hopefully spur further discussion and concrete action through the scaling up efforts for the MDGs.