Alma Ata, Astana and beyond—patients and communities as the core of universal primary healthcare

Anya de Iongh, Sarah Markham, and Rakhal Gaitonde

As the 40 year anniversary of the Alma Ata Declaration on Primary Health Care arrives, it prompts a range of reflections, on primary healthcare and its position in the wider landscape of health, as well as the virtues and realities of bold global visionary documents.

The original declaration of Alma Ata in 1978 urged us away from the medical model with its acknowledgement of health as a human right, the social determinants of health, and centering the participation of people and their communities. While progress has been made, we are faced with widely varying gains and stubborn inequalities along various axes. There remains much for us to do in order to reach the aims that the declaration originally set out to achieve.

On the 25-26 October 2018, world leaders will meet in Astana, Kazakhstan, to renew a commitment to primary healthcare and to achieve universal health coverage and the Sustainable Development Goals (SDGs). The proposal for the Astana Declaration on Primary Health Care 2018 is clear on the role of primary healthcare as a “necessary foundation to achieve Universal Health Coverage.”

The dynamic relationship between primary healthcare and universal health coverage was critiqued by the People’s Health Movement, a global network of grassroot health activists and civil society organisations from over 70 countries. They commented that “Primary healthcare is broader and indeed subsumes universal health coverage, which is, in many countries, being implemented by private health insurance companies and aggravating health inequalities.”

In response to this, The People’s Health Movement have released an “Alternative Civil Society Astana Statement on Primary Health Care.

The 2018 Astana Declaration, proposed by the World Health Organisation, is structured to highlight our collective assets (political will, knowledge, technology, and people), before detailing the challenges and actions required. This reflects an asset-based approach, which is an important principle of partnership and development praxis.

“People” are rightly considered an “asset” in themselves, however it is important to highlight the integral role that people (patients and communities) play in strengthening other assets, and the health system as a whole. Political will has grown due to the emergence of new partners and stakeholders, with patient advocates, campaigners, and activists central to the process, as the patient movement expands.

Knowledge must be understood as inclusive of epistemic justice; regard for the knowledge of the individuals and communities, as both patient and participant. Having a collective appreciation of epistemic justice and governance is the foundation on which to build and critique our knowledge beyond formal academic and clinical research to inform primary healthcare development.  

Technology brings enormous positive potential, together with risks of further extending inequalities through the digital divide. Many of the best examples of accessible, practical, and impactful health technology have been developed by people as patients or carers, or via co-production.

As strong and increasingly agile as these assets are, the challenges are still considerable. There is no indication as to why these assets did not achieve WHO’s goal of “Health for All”, which formed the basis of WHO’s primary healthcare strategy. Open and transparent discussion and acknowledgment of these reasons is needed to transform good intentions into reality.

The actions put forward to address these challenges focus first and foremost on “empowering people to take ownership of their health and healthcare” which is to be welcomed.

We believe that empowered citizens with knowledge, motivation, confidence, and skills can have an enormous impact in terms of individual resilience-building, wellbeing, and health outcomes, and in developing and managing healthcare systems. However, they cannot be seen as a cover-up/sticking plaster negating the need to address the wider social and environmental determinants of health and inequalities that underpin so many health needs. One important example is the impact of climate change, which is havingand will increasingly havea significant impact on global health. PHM is suggesting that healthcare should be provided in a way that is aligned to the Earth Charter, and thereby recognises that healthcare is a major global industry that has a contributing role to play in supporting the health of our planet.

Exploration of these declarations and reflection in the context of their anniversaries raises another debate regarding their impact. In a world of evidence based medicine and “informed policy”, do we know how many of these ambitious global goals are achieved, and how the benefits are distributed among people more vulnerable and marginalised? Indeed, how much progress made towards them is attributable to the vision in the original declarations?

The bold declaration in the original 1978 declaration of “an acceptable level of health for all the people of the world by the year 2000…” has not been achieved. Has the progress that has been seen in the past forty years happened because of or despite global declarations?

The 1978 and the 2018 declarations are both short and succinct, which hopefully gives them more impact. But it leaves unanswered questions about how this will be funded, and the specific responsibility that still sits with individual governments and how corruption and industry influence will be monitored, regulated, and countered for the greater good.

The principle of universal primary healthcare for all is undisputed. We are one, but we are all uniquely different. It requires courage, honesty, and solidarity to translate these visions of universality and individuality into reality. Patients, carers, and communities at large continue to inspire and innovate towards thisare those with power ready to do what it takes as well?

#PrimaryHealthCare #HealthForAll #Astana2018

Anya de Iongh is patient editor for the BMJ and works nationally and locally around person-centred workforce development and self-management support services.

Competing interests: Full details here.

Sarah Markham is an academic mathematician and patient representative currently pursuing a second PhD in theoretical computer science. She is a member of the BMJ Patient Advisory Panel. Twitter: @DrSMarkham

Competing interests: None declared.

Rakhal Gaitonde is a community health researcher and activist. He is currently pursuing his PhD in Public Health from Umea University, Sweden and is on the BMJ Patient Advisory Panel.

Competing interests: Full details here.