Editor's note: This is the third in a series reviewing the 1978 Alma-Ata Declaration as we approach its 40th anniversary on September 12, 2018. In this article David Bishai, Professor at the Bloomberg School of Public Health at Johns Hopkins University, examines 40 years of fluctuations in public health approaches to delivering health for all, and recommends vital strategies to consider during coming months.
Political scientist Gill Walt articulated a fundamental tendency of health systems: They serve power, not need. Health systems often default to a “top-down” mode of governance, whereby a strong, resource-rich entity provides products and services for the sick that are based on finances that flow from nation to county to village to person. Another model is known as “bottom-up,” where community coalitions marshal their resources and generate local political will to alter the social, physical, and behavioral environment that is causing ill health.
In 1978, health leaders from around the world forged an international consensus on "Primary Health Care" (PHC) that would subsume both top-down and bottom-up strategies and ensure that both approaches penetrated broadly and involved all elements of society. Signed in the city of Alma-Ata (now Almaty, Kazakhstan), it is now known as the Alma-Ata Declaration.
In the coming months, this historic debate on how best to achieve health for all will be elevated once again during events recognizing the 40th anniversary of the Alma-Ata Declaration.
Glimpse Backward to Understand Health-For-All Approaches of today
Picture this scene from 1969: The World Health Organization (WHO) released a harsh internal review report on its malaria eradication program in Mozambique. Unable to overcome biological, institutional, and political challenges, the review documented not only failure to control malaria, but failure to extend basic health rights to the poor. During the 1950s and ‘60s, the U.S. government was a prominent supporter of the WHO’s campaign to eradicate malaria through large-scale, top down campaigns in mosquito control where the resources of many nations were deployed to find and kill anopheles mosquitoes and the malaria parasites they carried. A consortium of U.S. federal and local health officials had eradicated indigenous malaria from the continental U.S. in 1951, and felt confident their approach could do the same for the rest of the planet. They underestimated the vast differences between killing mosquitoes in Mississippi and Mozambique. The WHO was losing credibility due to a losing top-down battle against this one disease. Change had to come.
In 1973, the WHO elected Halfdan Mahler as director general. Mahler understood that the failure of the malaria program implied the need to change strategy. Mahler set the WHO on a course to augment its top-down efforts by studying and promoting bottom-up community efforts that would lay the groundwork for community-based PHC. Mahler found an ally in Dr. D.D. Venediktov, the USSR’s delegate to the WHO, who proposed to Mahler an idea for a global conference on “Primary Health Care.”
In the lead up to the Primary Health Care conference, the WHO searched for examples of success in public health and primary health care that could be studied and replicated. In 1975 the Christian Medical Association collected a set of case studies of primary health care approaches used in India, China, Cuba, Iran, Tanzania, and others. These best practices in primary health care integrated the provision of basic curative services (such as antibiotics); preventative services (such as vaccines); and nutrition - along with evidence-based decision making at the community level to identify and address social and environmental threats to public health. These included water, sanitation, mosquito and vermin control, and hygiene.
At the Alma-Ata Conference of 1978, these case studies were on everyone’s mind as 134 ministers of health voted to endorse a declaration that emphasized the critical requirement for all governments to ensure they had health systems that provided access to effective, quality, basic health services and public health. The declaration drew attention to health determinants like income distribution, education, employment, social supports, housing, nutrition, water, and agriculture. It was a shining moment for PHC and bottom-up governance. However, not everyone agreed.
In 1979, a follow-up conference was held by the Rockefeller Foundation and UNICEF in Bellagio, Italy. The attendants at the Bellagio conference favored top-down governance models, and they coined a new term, “selective” primary health care, organized around illness-specific grants that emphasized the delivery of health commodities like vaccines, contraceptives and oral rehydration salts to individuals, instead over changing how communities undertook prevention. The switch back to top-down strategies represented a reassertion of the power and role of global agencies. By focusing on products that had high impact this model was able to achieve and document sizable gains in health and wellbeing. Additionally, many countries found that with external funding, these selective interventions could be delivered, the deliveries could be tracked, and millions of lives could be saved with a direct attribution to the funding agency. Simultaneously, a few other countries outside the orbit of Western dominated foreign-aid agencies continued to pursue the original Alma-Ata Declaration’s comprehensive, community-focused strategies and were able to sustain health improvements as well. The bottom-up approaches worked well in Vietnam, Cuba, Sri Lanka, and Nepal but went unheralded in the West.
The Status Quo - where are we at today?
Fast forward 40 years to another global realization of stalled progress: The United Nations Millennium Development Goals set targets for progress in maternal and child health that were largely not met by the 2015 milestone. Fewer than 30% of countries met the goal for under 5 mortality reduction by 2015 and fewer than 10% met the goal for maternal mortality reduction. The pace of life expectancy gains is slowing at all levels of wealth and all levels of health. Once again a new director of the WHO has recognized a need for course correction, and another global conference is to be held.
Road Ahead - Chances for Big Change?
In homage to the past, the WHO is hosting the 2018 global congress on Primary Health Care in Astana, the modern capital of Kazakhstan. Early indicators suggest that the Astana conference will emerge with a new Astana Declaration that again resolves the debate between top-down strategies and bottom-up strategies by saying “both matter.” History tells us that the big money in global health will eventually want to go back to top-down distribution of commodities to satisfy Western donors’ desire to track and seek attribution for saving the lives of the disadvantaged. The perennial debate between top down and bottom up will end with the same consensus as 40 years ago: We need both top-down and bottom-up approaches to health governance.
What comes next? Will Gill Walt’s prophecy that health systems serve power prove true again? The answer falls to us as researchers, practitioners, and policymakers. It depends on our passion to advance health for all and by all. Wherever each of us is located, let’s use what we know about public health to convene our communities and address the problems shared collectively by our families and neighbors, locally and globally. Bottom-up strategies are never meant to replace top down. They are meant to amplify and enhance top-down approaches, but they can easily be extinguished and trampled. All it will take for a new era to dawn is for the protagonists of top-down interventions to recognize the unique value of including and giving control to those affected by and knowledgeable about health problems in the context only they know best.
The threats to health in the 21st century will not, and cannot, be addressed solely with pills, vaccines, and other magic bullets, though these approaches are indispensable. The road from Alma-Ata to Astana and into the future requires each of us to turn our minds and hands to the work of community-based public health practice.
Alma-Ata Declaration - http://www1.paho.org/English/DD/PIN/alma-ata_declaration.htm
Alma-Ata 40th Anniversary Celebration at Johns Hopkins on 12th September, 2018 - Bloomberg School of Public Health will host an educational event to mark the 40th anniversary. Registration and information here.
Global Conference on Primary Health Care in Astana, Kazakhstan on 25-26 October 2018 draws health advocates, practitioners, researchers, and policymakers together to renew a commitment to primary health care to achieve universal health coverage and the Sustainable Development Goals. Registration and information here.
Dr. David Bishai is a Professor at the Bloomberg School of Public Health at Johns Hopkins University and President of the International Health Economics Association