International conference on Primary Health Care – CC by SA 3.0 via Wikimedia Commons
With little coverage in the mainstream media, many health care improvers may not have heard about the recently celebrated 40th anniversary of the Declaration of Alma-Ata. However, this groundbreaking pronouncement in support of comprehensive primary care is significant for all who care about advancing health and health care. Hema Magge, MD, IHI’s Country Director for Ethiopia, recently explained why.
What is the Alma-Ata declaration?
In 1978, in Alma-Ata (now Astana, Kazhakstan), leaders from 134 countries identified primary care as essential to achieving health for all. They issued a global declaration that described health as “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity” and asserted that health is “a fundamental human right.” It was the world’s first international declaration stating the importance of primary health care.
Why is it important to commemorate Alma-Ata?
I believe the Alma-Ata Declaration is the foundation of IHI’s mission to advance health and health care for all. The anniversary also provides the global community the opportunity to take stock of the advances we’ve made and deepen our commitment to achieving the social justice vision that remains out of reach for far too many of the world’s poor and marginalized groups. The role of quality care is gaining greater visibility on the world’s stage and provides an opportunity for IHI and others to reenergize our efforts, deepen our existing expertise into new areas, and continue to support countries and communities in these critical efforts.
Alma-Ata asserted in 1978 that health “requires the action of many other social and economic sectors in addition to the health sector.” Was the declaration ahead of its time?
It depends on who you ask. To the millions of people living in cycles of poverty and illness — poverty and illness that don’t happen by accident but are deeply intertwined with historical factors such as economic policies of structural adjustment imposed by the dominant political power structures — I would imagine it was about time.
Alma-Ata set the year 2000 as the goal for attaining health for all. How did actions following the declaration fall short?
Alma-Ata was a bold and ambitious human rights approach to the health of the world. There were many in public health at the time who deemed this unattainable, unmeasurable, idealistic, and unrealistic. As a result, “selective primary health care” was introduced. This approach focused on developing low-cost solutions to specific, measurable, disease-based targets as the full scope of primary care for low-income countries. As a result, GOBI — growth monitoring, oral rehydration treatment, breastfeeding, and immunization — became the guiding design for public health targets.
This was deeply counter to the rights-based approach outlined in Alma-Ata. It assumed that the resource supply for health for the world’s poor was fixed at the current state, rather than requiring a transformation to achieve the moral imperative of health for all. By focusing the world’s resources in this circumscribed agenda, the bar was set much lower than would be acceptable to us in our own communities or families.
When the HIV/AIDS epidemic plagued sub-Saharan Africa, many of these same powerful voices argued that treatment was not feasible for the millions of affected Africans. Thankfully, professional communities, health care providers, and activists joined together to fight for access to life-saving treatments and the right to health. I like to think this was one way of reviving the ideals of Alma-Ata.
What role can committed quality improvement professionals play to fulfill the promise of the Alma-Ata declaration?
Quality improvement professionals play a huge role in achieving health for all through providing not only access to care, but access to high-quality care. One caution is that in the pursuit of fast solutions, we do not simultaneously shy away from the larger, more audacious transformations that may be needed to treat every patient as you would treat your mother, sister, daughter, or son.
In Ethiopia, we are working in close partnership with public sector health care workers, managers, and leaders, to strengthen primary care delivery systems across rural and remote regions of the country to achieve this vision. We train health care workers in clinical skills and improvement methods, bring patients into the quality improvement process to ensure that care is designed to meet their needs, support equipment and infrastructure, establish hospital neonatal care services, and provide care for complications of labor and delivery to stop preventable deaths of mothers and newborns.
In many places, needs are urgent. But, as the spirit of the Declaration of Alma-Ata reminds us, care must always be high quality to save lives and achieve health.
Editor’s note: This interview has been edited for length and clarity.
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