The International Conference on Primary Health Care was convened in Alma-Ata, Kazakhstan, in 1978, and was attended by virtually all the member nations of the World Health Organization (WHO) and UNICEF. The Alma-Ata Declaration of 1978 emerged as a major milestone of the twentieth century in the field of public health, and it identified primary health care (PHC) as the key to the attainment of the goal of Health for All (HFA). Following are excerpts from the declaration:
- The Conference strongly reaffirms that health, which is a state of complete physical, mental, and social well-being, 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.
- The existing gross inequality in the health status of the people, particularly between developed and developing countries as well as within countries, is politically, socially, and economically unacceptable and is, therefore, of common concern to all countries.
- The people have a right and duty to participate individually and collectively in the planning and implementation of their health care.
- Primary health care is essential health care based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family, and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first elements of a continuing health care process.
- An acceptable level of health for all the people of the world by the year 2000 can be attained through a fuller and better use of the world's resources, a considerable part of which is now spent on armaments and military conflicts. A genuine policy of independence, peace, détente, and disarmament could and should release additional resources that could well be devoted to peaceful aims and in particular to the acceleration of social and economic development of which primary health care, as an essential part, should be allotted its proper share.
TWENTIETH-ANNIVERSARY MEETING IN ALMATY
In the ensuing years, several United Nations agencies and conferences have formulated strategies for human development stressing equity, the wellbeing of populations, and the alleviation of suffering and ill health.
In 1998, an International Meeting on Primary Health Care, held in Almaty, Kazakhstan (same city, changed name) recognized the historical significance of the 1978 conference and the Declaration of Alma-Ata. It is useful to quote some of the reflections of leaders in the health sector with respect to the twentieth-anniversary meeting in Almaty on their reflections on Alma-Ata.
- Dr. Gro Harlem Brundtland, Director General of WHO: "Health for All is a message to all stakeholders. Considering the forces shaping the world, with both progress in health and growing inequalities, there is a place for 'a new universalism' in health: with universal access to quality care as the bedrock principle. Commitment to primary health care, still a crucial part of the health sector twenty years after Alma-Ata. Reduce disparity between the outcomes of poor and those better off, anchored in equity and solidarity."
- Dr. Halfdan Mahler, Director General Emeritus of WHO: "Health is not a commodity that is given. It must be generated from within. Health action should not be imposed from the outside, foreign to the people; it must be a response of the communities to problems they perceive, supported by an adequate infrastructure. This is the essence of the filtering inwards process of primary health care."
- Dr. Jo E. Asvall, Regional Director Emeritus, European Office of WHO: "The European Health for All Policy—Health 21—takes the PHC issue more seriously than ever before. Health 21 goes deeper into discussions of how PHC in our pluralistic societies at the end of the twenty-first century needs to be designed to embrace all the major components of lifestyles, environment, and health care issues."
- Dr. Carl Taylor, Professor Emeritus, Johns Hopkins University: "New understanding of growing social pressures and rapidly growing impatience of deprived millions around the world make this a critical time to promote community-based primary health care and social mobilization—goals which have recently been given special priority by UNICEF."
At the twentieth-anniversary meeting in Almaty, those present recognized that the principles and actions that characterize PHC at a global level include the strengthening of equity, health gain, quality of care, gender sensitivity, acceptability, participation, cost-effectiveness, and other HFA values.
PRIMARY HEALTH CARE IN RURAL HAITI
Given the global importance of primary health care on the one hand, and the need to adapt it to the specific concerns of local populations on the other, it is instructive to look at a case study that illustrates some of its essential dimensions.
The Hospital Albert Schweitzer (HAS) in the Artibonite Valley of rural Haiti was founded in 1952 as a private, not-for-profit organization. The HAS programs evolved from being mainly hospital based—serving those who could reach the institution—to recognizing the importance of primary health care that can reach every person in the population. This is accomplished through programs organized around three levels of health care: (1) home visiting by local health workers trained in fundamental disease-prevention and health-promotion programs; (2) health centers within reach of every community, where local health workers can provide curative and preventive care; and (3) hospital care, which serves as a back-up for all peripheral services and can provide advanced curative care as needed.
While there are modest financial charges for care, no one is denied care because of cost. The programs are built on extensive discussions and interactions with community people as well as with the government of Haiti. A health information system provides data that directs care toward all in the population, with particular concern for those who may be in special need, such as people who live in remote mountain areas. Responding to differential needs is an example of the pursuit of equity. Continuous interactions with government are oriented toward sharing knowledge and methods so as to benefit the larger population of Haiti.
The Declaration of Alma-Ata was a foundational event in the modern history of public health. While not all of its goals have been achieved, and the changing international health and development sector have called for adaptations of the PHC concept, there is no doubting the importance of Alma-Ata and its contributions through the concepts of Health for All and primary health care.
JOHN H. BRYANT
World Health Organization (1975). Declaration of Alma-Ata. Available at http://www.who.int/hpr/docs/almaata.htm/.
—— (2000). Primary Health Care 21, Everybody's Business—An International Meeting to Celebrate 20 Years after Alma-Ata, Almaty, Kazakhstan, 27–28 November 1998. Geneva: Author.
World Health Organization and UNICEF (1978). Primary Health Care: Report of the International Conference on Primary Health Care. Alma-Ata USSR. 6–12 September, 1978. Geneva: WHO.