Forty years ago, in the heart of Soviet Central Asia, the world made a groundbreaking commitment to health. The Alma Ata Declaration set the stage for global health as we know it today. It reaffirmed health as a state of being that means more than just not being sick. It identified socioeconomic inequities as a cause of poor health, gave states responsibility for the health of their citizens, re-committed to health as a right and, finally, committed to first-level, frontline health care as the key to achieving health for all.
We’re not there yet. Economic inequities have gotten worse, not better. Governments continue to abdicate their responsibility for the health of their citizens. Front-line, primary health care remains inaccessible to far too many people.
Forty years later, the Global Conference on Primary Health Care re-committed to health for all, once again in Central Asia. Led by the World Health organization (WHO), the Ministry of Health Care of Kazakhstan, and UNICEF, the conference renewed the global commitment to primary health care to achieve universal health coverage and the Sustainable Development Goals.
It started off with a powerful call for equity. “Today, instead of health for all, we have health for some,” said Dr. Tedros Adhanom Ghebreyesus, Director-General of the WHO, at the start of the conference.
This conference focused on primary health care as the approach to solve today’s health and healthcare challenges. Primary health care is front-line health care – the first health care worker seen by a patient. That may be a nurse, a community health worker, or a family physician. Strong primary health care systems ensure that people get the care they need before it worsens into an emergency. Chronic diseases, which make up the majority of the global burden of illness and death, are best addressed through regular, patient-centered health care. According to WHO, “At its heart, primary health care is about caring for people, rather than simply treating specific diseases or conditions. PHC is usually the first point of contact people have with the health care system. It provides comprehensive, accessible, community-based care that meets the health needs of individuals throughout their life.”
Finally, the Global Conference on Primary Health Care ended with a new declaration, the Declaration of Astana. The Alma Ata declaration shaped the entire discipline of global health and committed the world to health for all. The Declaration of Astana seeks to bring back that energy.
“We strongly affirm our commitment to the fundamental right of every human being to the enjoyment of the highest attainable standard of health without distinction of any kind. Convening on the fortieth anniversary of the Declaration of Alma-Ata, we reaffirm our commitment to all its values and principles, in particular to justice and solidarity, and we underline the importance of health for peace, security and socioeconomic development, and their interdependence.”
The declaration goes on to call for a focus on primary health care in order to achieve universal health coverage, address the need to address chronic and noncommunicable diseases, and mention the link between health care expenses and extreme poverty. The commitment section leads with a promise to make bold political choices for health across all sectors. There was no such explicit mention of domestic politics as factor in health. The declaration ends with this, “Together we can and will achieve health and well-being for all, leaving no one behind.”
That’s an ambitious goal, and it’s going to require serious top-level commitment to make it happen. There are a few signs that the commitment is there – the Astana declaration, unlike the Almaty declaration, explicitly calls for “bold political choices” in support of health for all. However, current global health funding levels simply aren’t high enough to bring this kind of change.
Global commitments on communicable diseases like TB and HIV consistently fall short of what is needed to stop their spread. In 2018, for TB alone, there was a funding gap of 3.5 billion dollars. In order to reach 2020 targets on HIV reduction, the world must increase the amount of resources available for the HIV response by 1.5 billion dollars each year between 2016 and 2020. As of 2018, the response was falling short. At present, most funding for chronic and noncommunicable disease care is paid out of pocket by patients. As referenced in the Astana declaration, this can drive families into extreme poverty, or keep them trapped there. Universal health coverage is the best way to address that trap. However, while UHC is good value for money, it is not cheap, and few governments in poor countries have shown a commitment to funding it.
We had forty years and we didn’t manage it. Will the next forty be the time we need?