This month marks the 40th anniversary of the International Conference on Primary Health Care (PHC), cosponsored by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF), and held in Alma-Ata, Kazakhstan, USSR.
As widely chronicled, this unprecedented gathering of 3000 delegates from 134 countries and 67 nongovernmental organizations portended a break with international health’s prevailing top-down and narrowly technical disease-eradication approach.1 Attendees exchanged national experiences of PHC, defined as “essential health care based on practical, scientifically sound and socially acceptable methods and technology”2(p1) as part of “comprehensive national health system[s].”2(p3) The delegates affirmed, by acclamation, the Alma-Ata Declaration—calling for “urgent and effective national and international action to develop and implement [PHC] throughout the world . . . in a spirit of technical cooperation and in keeping with a New International Economic Order”2(p3) (on the basis of economic sovereignty and an equitable system of trade). Reflecting the ascendance of the UN’s Group of 77 countries (nonaligned with either the US or Soviet blocs), the declaration underscored principles of universal accessibility, community participation, intersectoralism, and self-determination, and decried the “gross inequality” in health status across and within countries as “politically, socially, and economically unacceptable.”2(p1)
Despite UN backing, aspirations to attain “health for all by the year 2000” were soon dashed by geopolitical exigencies, including a (largely orchestrated) Third World debt crisis, a conservative ideological turn with Margaret Thatcher’s 1979 election in the United Kingdom—and then Ronald Reagan’s in the United States—that heralded the rise of neoliberal policies, and the Soviet invasion of Afghanistan. Among other effects, domestic public spending on social welfare shrank worldwide and most states slashed commitments to multilateral agencies, not only debilitating WHO’s ability to implement PHC but challenging its position as the world’s preeminent health authority. Meanwhile, the Rockefeller Foundation proposed, and UNICEF soon spearheaded, a “selective” variant of PHC, transforming Alma-Ata’s idealistic vision into a narrow and depoliticized package of “child survival” interventions.
Although valid, this familiar account also overlooks the role of various key players and events that help to explain how, why, and by whom Alma-Ata is remembered.
For example, standard narratives misread the role of both the Cold War and the USSR in the making of Alma-Ata, forgetting that the conference took place during a period of détente in US–Soviet relations. Despite the Soviets’ active participation in WHO’s disease campaigns (especially against smallpox), they consistently critiqued WHO’s reductionist approach to health improvement on a global scale. Instead they advocated a comprehensive PHC approach—a cornerstone of the Soviet health care system since the 1917 Russian Revolution. Prevailing caricatures of the Soviets as insistently pushing to host the conference1,3 belie the reality that they were all but forced into hosting it. Although WHO’s director-general Halfdan Mahler concurred with the Soviet critique of vertical disease campaigns, his PHC deputy Kenneth Newell maneuvered to control the conference, concerned it would promote socialist medicine. Perhaps fearing US repercussions, Newell kept tight reins over preparations, excluding Soviet WHO representative Dmitry Venediktov from the organizing committee other than for logistical matters and keeping most conference documents (including the proposed declaration) under wraps until the last minute.
For their part, the Soviets underestimated the opportunity presented by the conference, effectively displaying the Soviet model and its technological progress, but not anticipating its international resonance or domestic utility. Although the conference was formally approved by the Communist Party secretariat, Soviet leader Leonid Brezhnev did not attend, and there was no coverage by Izvestiya and Pravda, the country’s leading mouthpieces. Instead, responsibility was relegated to Kazakhstan, where the conference was championed by the republic’s ambitious health minister Turgel’dy Sharmanov.4 Still, the showcasing of regional health development through delegate site visits (Figure 1) across Central Asia allowed visitors, as the Soviet health minister stated, to see for themselves:
FIGURE 1— A Helicopter Sits in the Background as 2 Medical Nurses Treat a Patient Outside the Entrance to the Tent of a Nomadic Family, Kazakhstan, USSR, 1978
Source. World Health Organization, 1978, printed with permission.
what great achievements the peoples of former underdeveloped backwaters of Tsarist Russia have achieved in the field of peaceful industrial construction, in science and technology, in culture and arts, in the protection of public health.5(p3)
Many PHC advocates considered the Soviet health system too medicalized and dependent on trained health care professionals to serve as a model for developing countries. They saw it as lacking a community participation component, displaced by the unified state-level system of integrated preventive and curative medical services, biomedical research, health education, and public health activities. Yet it remained attractive to others.
Unexpectedly for WHO, progressive voices, notably from Latin America, decried PHC as being “primitive” health care (health care for the poor)6 that demanded unpaid community labor. These sentiments were also connected to the geopolitical context of PHC implementation; paradoxically, the détente that enabled Soviet, WHO, and Western parties to pursue their respective, if contrasting, PHC agendas was at the expense of a proxy Cold War in the Third World that generated brutal dictatorships in Latin America, Africa, and Asia.
Perhaps the biggest misjudgment on the part of the Soviets—and of WHO—was the failure to highlight the role of other sectors in achieving health improvements in the USSR, even though intersectoral principles were infused throughout the Alma-Ata Declaration (see the box on the next page). However, the Soviets were far more concerned with technological advancement: showing that their prowess was on par with Western technological progress was a top priority and considered much more important than demonstrating achievements in other aspects of social well-being (such as pensions, housing, sanitation, schools, maternal and child health protection), which the Soviets took for granted. But the timing was not propitious for intersectoralism or for PHC writ large; instead cost-effectiveness and financialization of the health sector took hold.
| I [as statement of goal]a 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. |
| VII [as a key normative dimension of primary health care] |
| Primary health care: 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. |
| VIII [as exhortation] |
| 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. |
a Bracketed phrases in italics and underlining inserted by the author.
Much has changed in international (and global) health in 40 years, yet the Alma-Ata Declaration remains the major international referent for those struggling worldwide for the people’s right to health.
The term PHC, if not its Alma-Ata spirit, has been widely adopted. Europe has paid closest heed, with the United States diluting PHC to “coordinated” medical care, certainly important, but hardly the political call for action invoked in the Alma-Ata Declaration. Understandably, Sharmanov and the Kazakhstan government have promoted the conference as a way of placing the republic on the global health map, celebrating every possible anniversary since 1978.4
Considering the neoliberal capitalist capture of health, WHO, and life itself—resulting in large-scale public downsizing and privatization of health and social services across wide swathes of the world, along with a reorientation of the state favoring financial interests and transnational corporations—it is not surprising that social justice–minded public health advocates, activists, and academics have repeatedly called for Alma-Ata’s renewal, most visibly expressed in the charter of the People’s Health Movement (est. 2000). WHO’s Americas office, bolstered by a “pink tide” of progressive governments across Latin America, deepened its PHC strategy with the 2005 Declaration of Montevideo emphasizing social inclusion, equity, social solidarity, accountability, and comprehensive care. As well, intersectoral efforts were reborn in the wake of the 2008 issuance of WHO’s Commission on Social Determinants of Health report via “whole-of-government” approaches and “health in all policies.”
But with WHO no longer at the fulcrum of global health, the possibilities are limited.7 The current push for “universal health coverage,” which calls for everyone to have health coverage regardless of whether it is equitable or funded and delivered publicly or privately, makes many yearn for Alma-Ata.
It is important to recall that Alma-Ata advocated state involvement in PHC without explicitly articulating support for publicly funded and publicly delivered care, arguably enabling its subsequent cooptation. Nonetheless, and crucially, the Alma-Ata Declaration called for a fundamental progressive transformation of power structures and political processes. In the end, the revitalization of a truly socially just version of people’s (primary) health care requires reinvigorated social justice–based political and social movements—an uphill struggle, to be sure, but a healthy one indeed.
ACKNOWLEDGMENTS
Many thanks to my comrades Laura Nervi, PhD, MPH, Mariajosé Aguilera, MPH, Nikolai Krementsov, PhD, MSc, Ramya Kumar, PhD, SM, MBBS, and Ted Brown, PhD, for their insightful suggestions.
