PHA-Exchange> 25 years anniversary Alma Ata

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Alma Ata

Political assumptions. Limits of the proposal.
Local contexts and application

1. A quarter of a century after the Declaration of Alma-Ata, we might
legitimately ask whether and to what extent its principles were correct, the
hopes on which it rested reasonable, and the ensuing programme realistic.
Personally I do not believe that "health for all" was or is a utopia. It
was - and remains - an obligation of humanity and an attainable goal. The
status review which I am proposing should be understood as a prospective
analysis, not a lamentation. In this brief exposition, in these few lines, I
will attempt a) first of all to summarise succinctly the international
context and the spirit of the original Declaration; b) to continue by
pointing out the major differences between the situation then and now, and
c) to finish with an outline of the future.

2. Unless I am mistaken, the Declaration of Alma-Ata was, like all
international agreements, the result of both a complex intersection of
interests among those actors with global decision-making power, and the
relative autonomy of the international organisations. The various models of
development in vogue at the time found a point of confluence in the Primary
Health Care strategy. In retrospect, it is striking how far the Declaration
succeeded in capturing with total clarity the tension between the two
parallel and dominant conflicts of the day: the East-West conflict, and the
North-South conflict. A striking result, above all, was the fact that the
World Health Organization, though susceptible to political
instrumentalisation, did wish to see itself as an appropriate authority for
articulating desires and possibilities. Obviously, WHO's problem then, which
is not that much different to its problem now, was its lack of power. Yet
despite this weakness, it did know how to raise the Declaration into a
legitimate platform for the claims of the least well protected, calling for
the principle of competition to be replaced by that of solidarity.

3. The Declaration of Alma-Ata was thus based on a normative postulate: the
need for a New International Economic Order. This was its fundamental
precondition: recognition of the compelling right to development as an
inalienable human right.

4. Nonetheless, the really innovative aspect of the Declaration of Alma-Ata
was the structural relationship established between economic growth and the
health of the population. The New International Economic Order was not just
a hypothesis, but was to be understood above all as an objective. The basic
concept, then, was health as an instrument of growth and development.

5. The Declaration of Alma-Ata thus marked a conceptual revolution in health
by introducing the notion that: the object of medical sciences is not the
body of the individual, but the spiritual and physical wellbeing of the
community. At the time, this shift in focus from the individual to the
social, from a purely physical to a holistic understanding of the human
being, was incorporated into the design of a new health methodology: Primary
Health Care.

6. The principles for this methodology proposed by the Declaration of
Alma-Ata were few, but sound:

? health sector coordination at the international level (resource transfer,
support, exchange)

? health sector coordination at the national, regional and local levels
(coherent resource management and joint planning of measures)

? community participation (active involvement of the population in the
planning, implementation and evaluation of health programmes)

? self-reliance (yes to cooperation, no to dependence)

? globality, continuity and integration of all health systems, at all
levels: promotive, preventive, curative and rehabilitative

? recovery of traditional medical knowledge (sound management of all
indigenous resources)

7. The wisdom of this vision, and the difficulties involved in implementing
it, are familiar to us. Yet they cannot be evaluated without taking into
account the enormous changes that came about in the two decades which
followed. It is indisputable that the two key conflicts - East/West,
North/South - which prefigured the Declaration subsequently became
dissipated in various ways: on the one hand through the collapse of the
Soviet Union and of authoritarian socialism in Central Europe, and on the
other through the structural changes in the global economy. Yet the new
international economic order envisaged did not materialise. What did emerge
was the controversial phenomenon of "globalisation". This frequently
discussed process has often been defined as a universalisation of the
marketplace, a relative collapse of the nation state, and a process of
cultural homogenisation. As we know, there is no shortage of either
apologists or critics of globalisation. For some, the opening-up of world
trade represents a unique opportunity for development by the poor countries,
whilst others produce figures demonstrating that the only result has been a
widening of the gap. It is striking that, whilst the term "globalisation"
does not appear in the Declaration - and therefore goes unacknowledged, the
call for a New International Economic Order did not imply leaving
development to the fate of the market, but implied placing it in the
responsible hands of the nation state. Yet this is not the only point where
contrasts become evident. The Declaration also devotes little attention to
environmental problems. It should not be forgotten that it predated
Chernobyl. This relative indifference to the ecological dimension of human
health is also reflected in the absence of the notion of "sustainability".
It did of course speak of self-reliance and self-determination, but this
emphasis on horizontal solidarity seemed to obscure the importance of the
social contract between the generations. Equally pallid was the image of
civil society which the Declaration put across. Though it called for
community participation, it insisted above all that governments were
responsible. Finally, whilst the Declaration did not discuss forms of
government, it goes without saying today that health work is inseparably
linked to democratic growth.

8. Other marked differences -like the incorporation of gender issues in
health - between the visions of the Declaration and our present-day world
could also be listed. I would like to conclude my thoughts by reflecting on
what I consider to be the future challenges. During these 25 years we
learned both how difficult it can be to effect positive changes, and how
rapidly negative changes can spread. I am thinking for instance of HIV/AIDS,
another phenomenon which came after the Declaration, impacting at both the
epidemiological and the public awareness levels. And we do not know what
awaits us (SARS). To sum up, I would speak of three axes along which we
should re-orient programmes.

9. The right to health. Also addressed in the Declaration, this remains a
basic instrument of health work to empower those most in need. The
Declaration contained an everlasting idea, that health is such an important
right as self-determination and respect for the human being. This right must
be articulated through the responsibility accountability and transparency of
the Governments together with civil society and community participation and
responsibility.

10. Sustainability. This is another word which we have incorporated, using
it to denote both the ecological challenge, and an integral aspect of
strategic planning for health. As a result, I would say - tautologically -
that health must not be produced at the expense of health.

11. Coordination. I believe this is a key word. It was included amongst the
Declaration's aims. Our globalised world has perfected technologies such
that we are now able to achieve significant synergistic effects using fewer
resources.

Dr. Nina Urwantzoff/10. April 2003
Misereor
Urwantz at misereor.de