4.2.

1 What is the Alma‐Ata Declaration:

In September 1978, the International Conference on Primary Health Care was held in Alma‐Ata,
USSR (now Almaty, Kazakhstan). The Declaration of Alma‐Ata, co‐sponsored by the World Health
Organization (WHO), is a brief document that expresses "the need for urgent action by all governments,
all health and development workers, and the world community to protect and promote the health of all
the people of the world." It was the first international declaration stating the importance of primary
health care and outlining the world governments' role and responsibilities to the health of the world's
citizens.

The Declaration of Alma‐Ata begins by stating that health, "which is a state of complete physical, mental
and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right
and that the attainment of the highest possible level of health is a most important world‐wide social
goal . . . " It goes on to call for all governments, regardless of politics and conflicts, to work together
toward global health. These are still some of the fundamental tenets that guide the work of the WHO
today.

Those who ratified the Declaration of Alma‐Ata hoped that it would be the first step toward achieving
health for all by the year 2000. Although that goal was not achieved, the Declaration of Alma‐Ata still
stands as an outline for the future of international healthcare.

4.2.2 International conference on primary health care:

The Alma‐Ata Declaration of 1978 emerged as a major milestone of the twentieth century in the
field of public health, and it identified primary health care as the key to the attainment of the goal of
Health for All. The following are excerpts from the Declaration:

Declaration:

I
The Conference strongly reaffirms that health, which is a state of complete physical, mental and social
wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that
the attainment of the highest possible level of health is a most important world‐wide social goal
whose realization requires the action of many other social and economic sectors in addition to the
health sector.

II
The existing gross inequality in the health status of the people particularly between developed and
developing countries as well as within countries is politically, socially and economically unacceptable
and is, therefore, of common concern to all countries.

III
Economic and social development, based on a New International Economic Order, is of basic
importance to the fullest attainment of health for all and to the reduction of the gap between the
health status of the developing and developed countries. The promotion and protection of the health
of the people is essential to sustained economic and social development and contributes to a better
quality of life and to world peace. IV The people have the right and duty to participate individually
and collectively in the planning and implementation of their health care.

V
Governments have a responsibility for the health of their people which can be fulfilled only by the
provision of adequate health and social measures. A main social target of governments, international
organizations and the whole world community in the coming decades should be the attainment by all
peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and
economically productive life. Primary health care is the key to attaining this target as part of
development in the spirit of social justice.

VI
Primary health care is 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 selfreliance 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.

VII
Primary health care:

1. reflects and evolves from the economic conditions and sociocultural and political characteristics of
the country and its communities and is based on the application of the relevant results of social,
biomedical and health services research and public health experience;

2. addresses the main health problems in the community, providing promotive, preventive, curative
and rehabilitative services accordingly;

3. includes at least: education concerning prevailing health problems and the methods of preventing
and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe
water and basic sanitation; maternal and child health care, including family planning; immunization
against the major infectious diseases; prevention and control of locally endemic diseases; appropriate
treatment of common diseases and injuries; and provision of essential drugs;

4. involves, in addition to the health sector, all related sectors and aspects of national and community
development, in particular agriculture, animal husbandry, food, industry, education, housing, public
works, communications and other sectors; and demands the coordinated efforts of all those sectors;

5. requires and promotes maximum community and individual self‐reliance and participation in the
planning, organization, operation and control of primary health care, making fullest use of local,
national and other available resources; and to this end develops through appropriate education the
ability of communities to participate;
6. should be sustained by integrated, functional and mutually supportive referral systems, leading to
the progressive improvement of comprehensive health care for all, and giving priority to those most in
need;

7. relies, at local and referral levels, on health workers, including physicians, nurses, midwives,
auxiliaries and community workers as applicable, as well as traditional practitioners as needed,
suitably trained socially and technically to work as a health team and to respond to the expressed
health needs of the community.

VIII
All governments should formulate national policies, strategies and plans of action to launch and
sustain primary health care as part of a comprehensive national health system and in coordination
with other sectors. To this end, it will be necessary to exercise political will, to mobilize the country's
resources and to use available external resources rationally.

IX
All countries should cooperate in a spirit of partnership and service to ensure primary health care for
all people since the attainment of health by people in any one country directly concerns and benefits
every other country. In this context the joint WHO/UNICEF report on primary health care constitutes a
solid basis for the further development and operation of primary health care throughout the world.

X
An acceptable level of health for all the people of the world by the year 2000 can be attained through
a fuller and better use of the world's resources, a considerable part of which is now spent on
armaments and military conflicts. A genuine policy of independence, peace, détente and disarmament
could and should release additional resources that could well be devoted to peaceful aims and in
particular to the acceleration of social and economic development of which primary health care, as an
essential part, should be allotted its proper share. The International Conference on Primary Health
Care calls for urgent and effective national and international action to develop and implement
primary health care throughout the world and particularly in developing countries in a spirit of
technical cooperation and in keeping with a New International Economic Order. It urges governments,
WHO and UNICEF, and other international organizations, as well as multilateral and bilateral agencies,
nongovernmental organizations, funding agencies, all health workers and the whole world community
to support national and international commitment to primary health care and to channel increased
technical and financial support to it, particularly in developing countries. The Conference calls on all
the aforementioned to collaborate in introducing, developing and maintaining primary health care in
accordance with the spirit and content of this Declaration.

4.3 Introduction of “health for all”:

 By the mid‐1970s international health agencies and experts began to examine

alternative approaches to health improvement in developing countries.
 The impressive health gains in China as a result of its community‐based health programs
and similar approaches elsewhere stood in contrast to the poor results of disease‐
focused programs.

 Soon this bottom‐up approach that emphasized prevention and managed health
problems in their social contexts emerged as an attractive alternative to the top‐down,
high‐tech approach and raised optimism about the feasibility of tackling inequity to
improve global health.

 Thus, “health for all” was introduced to global health planners and practitioners by the
World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) at
the International Conference on Primary Health Care in Alma Ata, Kazakhstan, in 1978.

 The declaration was intended to revolutionize and reform previous health policies and
plans used in developing countries, and it reaffirmed WHO’s definition of health in 1946:
“a state of complete physical, mental, and social well being, and not merely the absence
of disease or infirmity.”

 The conference declared that health is a fundamental human right and that attainment
of the highest possible level of health was an important worldwide social goal.

 To achieve the goal of health for all, global health agencies pledged to work toward
meeting people’s basic health needs through a comprehensive approach called primary
health care.

 Primary health care as envisioned at Alma Ata had strong sociopolitical implications. It
explicitly outlined a strategy that would respond more equitably, appropriately, and
effectively to basic health needs and also address the underlying social, economic, and
political causes of poor health.

 It was to be underpinned by universal accessibility and coverage on the basis of need,

with emphasis on disease prevention and health promotion, community participation,
self‐reliance, and intersectoral collaboration.

 It acknowledged that poverty, social unrest and instability, the environment, and lack of
basic resources contribute to poor health status.
 It outlined eight elements that future interventions would use to fulfill the goal of
health improvement: education concerning prevailing health problems and methods of
preventing and controlling them; promotion of food supply and proper nutrition; an
adequate supply of safe water and basic sanitation; maternal and child health care,
 including family planning; immunization against major infectious diseases; prevention
and control of locally endemic diseases; appropriate treatment of common diseases
and injuries; and provision of essential drugs.

4.4 Relevance of Alma‐ Ata to the primary health care system:

WHO has highlighted the importance of primary health care in tackling health inequality in
every country but after years of relative neglect; the World Health Organization has recently given
strategic prominence to the development of primary health care. This year sees the 36th anniversary of
the declaration of Alma Ata. Convened by WHO and the United Nations Children’s Fund (Unicef), the
Alma Ata conference drew representatives from 134 countries, 67 international organisations, and many
non‐governmental organisations. (China was notably absent.) Primary health care “based on practical,
scientifically sound and socially acceptable methods and technology made universally accessible through
people’s full participation and at a cost that the community and country can afford” was to be the key to
delivering health for all by the year 2000.Primary health care in this context includes both primary
medical care and activities tackling determinants of ill health.

4.4.1 Characteristics of primary health care from Alma Ata declaration:

 Evolves from the economic conditions and socio‐cultural and political characteristics of a
country and its communities
 Is based on the application of social, biomedical, and health services research and public health
experience
 Tackles the main health problems in the community—providing promotion, preventive, curative,
and rehabilitative services as appropriate
 Includes education on prevailing health problems; promotion of food supply and proper
nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care,
including family planning; immunisation against the main infectious diseases; prevention and
control of locally endemic diseases; appropriate treatment of common diseases and injuries;
and provision of essential drugs
 Involves all related sectors and aspects of national and community development, in particular
agriculture, animal husbandry, food, and industry
 Requires maximum community and individual self‐reliance and participation in the planning,
organisation, operation, and control of services
 Develops the ability of communities to participate through education
 Should be sustained by integrated, functional, and mutually supportive referral systems, leading
to better comprehensive health care for all, giving priority to those most in need
 Relies on health workers, including physicians, nurses, midwives, auxiliaries, and community
workers as well as traditional practitioners, trained to work as a team and respond to
community’s expressed health needs.

4.4.2 Essential components of effective primary health care:

 Well trained, multidisciplinary workforce

 Properly equipped and maintained premises
 Appropriate technology, including essential drugs
  Capacity to offer comprehensive preventive and curative services at community level
 Institutionalised systems of quality assurance
 Sound management and governance systems
 Sustainable funding streams aiming at universal coverage
 Functional information management and technology
 Community participation in the planning and evaluation of services provided
 Collaboration across different sectors—for example, education, agriculture
 Continuity of care
 Equitable distribution of resources

4.4.3 Progress and context

In 2008, the 30th Anniversary of Alma‐Ata, primary health care (PHC) was reaffirmed as the key
global strategy for attaining optimal health. Celebratory meetings were held under the auspices of the
World Health Organization (WHO) in all its regions. The WHO World Health Report 2008 (WHR08) was
devoted to PHC (WHO 2008). In 2008 The Lancet produced a themed issue on PHC. Notwithstanding
these activities and publications there remains confusion, disagreement, and controversy around PHC in
terms of its content, emphasis and application.

In the thirty years since the Alma‐Ata Declaration there has been significant progress in global
health with an overall increase in life expectancy. However, rapidly widening inequalities in health
experience between and within countries – and even reversals in Africa and the former Soviet bloc
countries – have led to a re‐examination of the current context and content of health policies and why
the Alma‐Ata Declaration failed to lead to health for all (Commission on Social Determinants of Health
2008). The key question is whether PHC, as originally elaborated at Alma‐Ata, remains a feasible option.
This re‐examination shows that a series of reform projects, with some key common features, driven by
vested interests and short‐sightedness, have perpetuated or aggravated the conditions that underpin ill‐
health and undermined the ability of health systems to function appropriately. Key among these are
selective PHC, health sector reform, and the global health partnerships. These have depoliticized health
and undermined the spirit of PHC.

4.4.4 Four Assaults on Primary Health Care:

1. Selective Primary Health Care – introduced in the late 70’s. The comprehensive approach to PHC
with its emphasis on equity and its call for a model of socioeconomic development conducive to Health
for All, was quickly undermined by experts at John Hopkins School of Public Health, who claimed it was
too complex and too costly. Instead, they advocated Selective Primary Health Care, focusing on a few
“cost effective”, top‐down technological fixes “targeting” high risk groups. UNICEF quickly adopted this
selective approach, which in practice focused mainly on oral rehydration therapy and immunization.
While these so‐called “twin engines” of the Child Survival Revolution did succeed in somewhat reducing
child mortality, they did discouragingly little to reduce poverty, hunger, or children’s quality of life. For
this, a comprehensive approach is needed that confronts the root causes. While progress in
implementing the PHC strategy in most low and middle income countries (LMICs) has been greatest in
respect of certain of its more medically‐related elements, the narrow and technicist focus characterizing
what has been termed the ‘selective PHC’ approach (Walsh and Warren 1979) has at best delayed, and
at worst undermined, the implementation of the comprehensive strategy codified at Alma‐Ata. The
latter insisted on the integration of rehabilitative, therapeutic, preventive and promotive interventions
with an emphasis on the latter two components. Selective PHC (SPHC) took the form in many LMICs of
certain selected medical – mostly therapeutic and personal preventive – interventions, such as growth
monitoring, oral rehydration therapy (ORT), breastfeeding and immunisation (GOBI). These constituted
the centrepiece of UNICEF’s 1980s Child Survival Revolution, which, it was argued, would be the ‘leading
edge’ of PHC, ushering in a more comprehensive approach at a later stage (Werner and Sanders 1997).
The relative neglect of the other PHC programme elements and the shift of emphasis away from
equitable social and economic development, inter‐sectoral collaboration, community participation and
the need to set up sustainable district level structures suited the prevailing conservative winds of the
1980s (Rifkin and Walt 1986). It gave donors and governments a way of avoiding the fuzzier and more
radical challenges of tackling inequalities and the underlying causes of ill‐health. Some components of
comprehensive PHC, especially the promotive interventions, have remained marginalised ever since
Alma‐Ata. These require for their operationalisation the implementation of such core principles of PHC
as ‘intersectoral action’ and ‘community involvement’, and, increasingly with economic globalisation,
intersectoral policies to address the social determinants of health (SDH) (Sanders et al. 2009). PHC has
been defined (even in the Alma‐Ata Declaration) as both a ‘level of care’ and an ‘approach’. These two
different meanings have persisted and perpetuated divergent perceptions and approaches. Thus, in
some rich countries and sectors, PHC became synonymous with first line or primary medical care
provided by general doctors, and simultaneously PHC has been viewed by many as a cheap, low
technology option for poor people in LMICs. The Alma‐Ata Declaration was one of the last expressions of
the development thinking of the 1970s where the non‐aligned movement declared its commitment to a
‘New International Economic Order’ (Cox 1997) and a ‘Basic Needs Approach’ to development. These
visionary policies were buried in the 1970s debt crisis, stagflation, and the dominance of global
economic policy by neoliberal thinking. This, together with rising unemployment and changes in the
labour market, changes in demographic and social trends, and rapid technological advances with major
cost implications for health services, has, over the past two decades, driven a process of ‘health sector
reform’ in industrialized countries and LMICs.

2. Structural Adjustment Programs – introduces in the early 1980s. In the 1960s and 70s the
governments and banks of the North loaned a vast amount of money to poor countries in the South to
promote a model of development that replaced rural peasants and urban workers with fossil fuel
consuming machines. This brought large profits for foreign investors and massive joblessness and
increased poverty for the many. When poor countries began to default on their loans, the World Bank
and IMF stepped in with bailout loans. There were tied to structural adjustment programs (SAPs). These
required debt‐burdened countries to reduce public spending, including that for health and education, to
free up money to keep servicing their debts to the Northern Banks. Whereas the Alma Ata Declaration
has called for increased government spending on health, SAP’s pressured the poor countries to reduce
and privatize public services. “Cost recovery” schemes (with introduction of “user fees”) placed health
services out of reach for many poor families. As a result in some countries child mortality, sexually
transmitted diseases and rates of tuberculosis drastically increased. In terms of the pursuit of Health for
All, this was a giant step backwards.

3. World Bank’s takeover of Third World Health Policy – in the 1990s. Prior to the 1990s the World
Bank invested almost nothing in health. But in the 1990s the Bank discovered that poor health reduces
worker productivity, thus impeding economic growth (of big industry). So over a few years the Bank
increased its investment in health to where, by the late 1990s, it was spending on the health sector
three times as much as the entire WHO Budget. In terms of guiding Third World health policy, this has
relegated WHO to second place, not only because of the Bank’s greater spending, but because it can tie
its health reform “recommendations” to urgently needed (or strongly desired) loans. In its 1993 World
Development Report, titled Investing in Health, the Bank spells out its health policy recommendations.
These are essentially a free market version of selective health care. Governments should determine
which health interventions to support according to their cost effectiveness in terms of keeping workers
on the ob. Persons who cannot contribute to the economy – such as elderly and severely disabled
persons – are ranked as of lower “value” and therefore merit little or no public assistance. Another
dehumanizing step backwards in terms of Health for All!

4. The Mcdonaldization of WHO and UNICEF – in the 2000’s. Partly because of shortage of funds,
and partly because of influence of corporate gifts, in the last few years both WHO and UNICEF have
entered into an increasing number of “partnerships” with transnational corporations, including drug and
junk food companies. An example is UNICEF’s recent plan with fast – food giant, Mcdonalds. On its
promotion McDonalds will include UNICEF public helth messages and boost sales of Big Macs by
announcing that part of the purchase price goes to UNICEF. In Nigeria UNICEF has made a similar
agreement with Coca Cola. Such compromises with industries that promote conducive to obesity, heart
disesases, stroke and diabetes are not conducive for Health for ALL. Partnerships with other pre‐
packaged mass‐produced food with endorsement by WHO or UNICEF. Even if these costly foods have
improved nutritional content, they are still a threat to health. If poor families spend their limited money
to buy them rather than cheaper staple foods (like Maize and beans), the end result is more
undernourished children. The Alma Ata declaration called for combating the underlying social and
structural causes of poor health. To the contrary, these new partnerships by UNICEF and WHO with
transnational corporations further entrenches and legitimizes the forces that put healthy profits before
people.

4.4.5 Corporate rule as a threat to world health.

All of these four “assaults” on Primary Health Care as conceived in Alma Ata are manifestations of the
dominant “free market” paradigm of development. As undemocratic as it is unsustainable, it promotes
economic growth of the rich regardless of the human and environmental cost. That the current model of
economic development driven by a deregulated market system is dangerous to health is evident when
we consider the impact of its biggest industries. In economic terms, the world’s three biggest industries
are:

1) Military/arms.

2) Illicit drugs, and

3) Oil.

All three of these colossal industries poses far‐reaching dangers to the sustainable well being of
humanity and the planet. Yet because the money proffered by these industries strongly influences who
gets elected to public office, it undermines democratic process. It impedes humanity from taking
decisive steps to rein in the biggest emerging global threats to human health such as global warming,
the pending Third World War, the deepening poverty of one third of humanity, the global pandemic of
crime and violence and the disempowerment that leads to terrorism. Rather than confront the
underlying causes of these globalized threats to health, the world’s chieftains – with their ties to the
arms, drugs and the oil industries – use the current crises as a pretext to systematic role‐back of civil
rights, public services and rein in on corporate greed. In sum, far from progressing toward Health for All,
humanity may currently be on a collision course toward Health for no one. It is time to collectively wake
up and change course.

4.4.6 Primary health care: 36 years since Alma‐Ata:

 The 1978 Declaration of Alma‐Ata was groundbreaking because it linked the rights‐
based approach to health to a viable strategy for attaining it. The outcome document of
the International Conference on Primary Health Care, the declaration identified primary
health care as the key to reducing health inequalities between and within countries and
thereby to achieving the ambitious but unrealized goal of “Health for All” by 2000.

 Primary health care was defined by the document as “essential health care” services,
based on scientifically proven interventions. These services were to be universally
accessible to individuals and families at a cost that communities and nations as a whole
could afford. At a minimum, primary health care comprised eight elements: health
education, adequate nutrition, maternal and child health care, basic sanitation and safe
water, control of major infectious diseases through immunization, prevention and
control of locally endemic diseases, treatment of common diseases and injuries, and the
provision of essential drugs.

 The declaration urged governments to formulate national policies to incorporate

primary health care into their national health systems. It argued that attention be given
to the importance of community‐based care that reflects a country’s political and
economic realities.

 This model would bring “health care as close as possible to where people live and work”
by enabling them to seek treatment, as appropriate, from trained community health
workers, nurses and doctors.

 It would also foster a spirit of self‐reliance among individuals within a community and
encourage their participation in the planning and execution of health‐care programmes.
Referral systems would complete the spectrum of care by providing more
comprehensive services to those who needed them most – the poorest and the most
marginalized.
 Alma‐Ata grew out of the same movement for social justice that led to the 1974
Declaration on the Establishment of a New International Economic Order. Both stressed
the interdependence of the global economy and encouraged transfers of aid and
knowledge to reverse the widening economic and technological divides between
industrialized countries and developing countries, whose growth had, in many cases,
been stymied by colonization.
  Examples of community‐based innovations in poorer countries after World War II also
provided inspiration. Nigeria’s under‐five clinics, China's barefoot doctors and the Cuban
and Vietnamese health systems demonstrated that advances in health could occur
without the infrastructure available in industrialized countries.

 The International Conference on Primary Health Care was itself a milestone. At the time,
it was the largest conference ever held devoted to a single topic in international health
and development, with 134 countries and 67 non‐governmental organizations in
attendance.

 Yet there were obstacles to fulfilling its promise. For one thing, the declaration was
non-binding.

 Furthermore, conceptual disagreements over how to define fundamental terms such

as ‘universal access’, which persist today, were present from the beginning. In the
context of the cold war, these terms revealed the sharp ideological differences
between the capitalist and communist worlds, discord perhaps heightened by the fact
that the Alma-Ata conference took place in what was then the Union of Soviet
Socialist Republics.

 As the 1970s gave way to a new decade, a tumultuous economic environment

contributed to a diversion away from primary health care in favour of the more
affordable model of selective health care, which targeted specific diseases and
conditions.

 Insufficient progress towards the Millennium Development Goals, coupled with the
threats posed to global health and human security by climate change, pandemic
influenza and the global food crisis, have led to renewed interest in comprehensive
primary health care.

 Yet the many challenges that prevented Alma-Ata’s implementation have evolved and
must be confronted to achieve its goals now. Drawing on the growing body of
evidence about cost-effective initiatives that integrate household and community care
with outreach and facility-based services – such as those for maternal and child health.

4.5 Alma Ata and the primary health care in India:

 The primary healthcare approach was described as "essential 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 the country can afford to maintain at every stage
of their development in the spirit of self‐reliance and self‐determination".

 The Alma‐Ata Declaration also emphasizes that everyone should have access to primary
healthcare, and everyone should be involved in it. The primary healthcare approach
encompasses the following key components: Equity, community
involvement/participation, intersectorality, appropriateness of technology and
affordable costs.

 Primary healthcare is a vital strategy that remains the backbone of health service
delivery.

 India was one of the first countries to recognize the merits of primary healthcare
approach. Long before the Declaration of Alma‐Ata, India adopted a primary healthcare
model based on the principle that inability to pay should not prevent people from
accessing health services.

 Derived from the recommendations of the Health Survey and Development Committee
Report 1946, under the chairmanship of Sir Joseph Bhore, the Indian Government
resolved to concentrate services on rural people. This committee report laid emphasis
on social orientation of medical practice and high level of public participation.

 With beginning of health planning in India and first five year plan formulation (1951‐
1955) Community Development Programme was launched in 1952.

 It was envisaged as a multipurpose program covering health and sanitation through

establishment of primary health centers (PHCs) and subcenters.

 By the close of second five year plan (1956‐1961) Health Survey and Planning
Committee (Mudaliar Committee) was appointed by Government of India to review the
progress made in health sector after submission of Bhore Committee report. The major
recommendations of this committee report was to limit the population served by the
PHCs with the improvement in the quality of the services provided and provision of one
basic health worker per 10,000 population.

 The Jungalwalla Committee in 1967 gave importance to integration of health services.

The committee recommended the integration from the highest to lowest level in
services, organization, and personnel.