www.jogh.org Gijs Walraven Aga KhanDevelopmentNetwork,Geneva,Switzerland useful? Healthon , is it The 2018 Declaration Astana JoGH ©2019EUGHS © 2019TheAuthor(s) inequalities atlowercost. outcomesandreduced evidence ofbetterpopulation spired byAlma-Atawith strong with primary in of theworld,therearecountries all” remains unfulfilled in much Although the goal of “health for • doi: 10.7189/jogh.09.010313 40 human spirit and made space for solutions created, owned and sustained by communities. Primary health human spirit andmade spaceforsolutions created, health owned andsustained bycommunities. Primary With healthcare anemphasisonlocalownership,primary honoured theresilience andingenuityofthe THE LEGACYOFALMA-ATA [ overall the of centre the at care health primary put truly to taken are actions specific unless persist will inequalities health and deficient be also will Alma-Ata to successor a as Declaration Astana 2018 the of grettably in many countries commitments have gone unfulfilled. This viewpoint argues that the outcomes unacceptable: economically, socially, andpolitically[ tion, andappropriate useofresources, aswellbystatingthatinadequateandunequalhealthcare was the core principles of universal access to care, equity, community participation, intersectoral collabora and emerged” [ was “oneoftherare occasionswhere asublimeconsensusbetweenthehavesandhave-notsinlocal Halfdan Mahler, theinspirationaldirector-general oftheWorld HealthOrganization atthetime,AlmaAta to According objective. measurable than rather aspirational highly a – infirmity” or disease of absence merely not an well-being, spiritual and mental physical, of state “a wheredefinition, is health stitutional year 2000” [ Alma-Ata Declarationwasapproved, withtheambitiousgoalofachieving“healthforallby healthcare. primary On12September1978the maty toattendaconference oninternational years ago,healthexpertsandpolicymakersfrom 134countries convenedinwhatisnowAl 1 ]. ‘Alma-Ata’s’ target of“healthfor all” wasbasedonthe World HealthOrganization’s con 4

]. - 2 justified by epidemiological importance and technical affordability. technical and This importance epidemiological by justified thatweredown courseofactionandfocussing onfewerinterventions most of theDeclaration,asimpler approach wasproposed involvingamore top poor people,asecondratesolution forpoorcountries.Andwithinayear was careregarded it for poor some care. cheap: For health as first-level on on themedicalestablishment, anditwasconfusedwithanexclusivefocus almost immediatelymisunderstood;itwasregarded bysomeasanattack Unfortunately, thecomprehensive approach proposed underAlma-Atawas sources investedrationallyinthedifferent levelsofcare. households tohospitals,withprevention asimportantcure, andwithre care alsooffered awaytoorganize thefullspectrumofhealthcare, from ]. Its Declaration revolutionized the world’s interpretation of health with 1

3 ]. Theseprinciplesremain relevant today, butre June 2019 •Vol. 9No. 1•010313 - - - - -

VIEWPOINTS VIEWPOINTS June 2019 •Vol. 9No. 1•010313 ‘Astana’ commits itself to prioritizing disease prevention and and aims to meet all peo ities inhealthoutcomespersist”. many people,particularlythepoor, andstates thatitis“unacceptableinequityinhealthanddispar ma-Ata core principles[ Al the to commitment reaffirms the and kind”, any of distinction without health of standard attainable affirms the “commitment to the fundamental right of every human being to the enjoyment of the highest healthcarehensive primary forallwiththeAstanadeclaration.Thenewdeclaration In October2018,2000delegatesfrom more than120countriesrenewed thecommitmenttocompre THE ASTANADECLARATION inequalities atlowercost.ExamplesincludeChili,Cuba,Ethiopia,Nepal,RwandaandSriLanka[ health care inspired by Alma-Atawithstrong evidence of better population health outcomes and reduced primary with countries are there world, the of much in unfulfilled remains all” for “health of goal the toattainanacceptablelevelofhealth,equitablydistributedthroughouton trying theworld”[ knew thatwouldhavebeenimpossible.Ourgoalwastofocusworldattentiononhealthinequalitiesand for all”goal,HalfdanMahlersaid“thegoalwasnottoeradicatealldiseasesandillnessesby2000;we The goalof“healthforall”bytheyear2000wasnotmet.Whenaskedaboutmeaning oped inlinewiththisselectiveapproach. priorities. Onecanargue thatthehealth-related MillenniumDevelopmentGoalsorMDGswere devel took thedecisionsoutofhandscommunities,butrapidlyreached highcoveragefortheselected immunization, familyplanningandmicro-nutrients were delivered through “vertical” programmes, which andchild health, intheareasly empoweringcommunitiestomakechoices.Interventions ofmaternal more selectiveapproach wasconsidered tobemore feasible,measurable,rapid,andlessriskythanreal because thefacilities are available. simply condition, common a of diagnosis the confirm to used be to arelikely tests diagnostic expensive more , care referral level next a to admitted is hospital district or community referral level first and equipmentbeingusedonly onpatientswhoneedit.Ifapatientshouldhave beentreated ata in reasonable travel distance. This system is also economical because it should lead to expensive skills vantageous forthepatientand relatives, healthcare asprimary facilitiescanbesmallandtherefore with delivery,they gotoanextlevelofhealthservice andthesameappliesfor furtherlevels.Thesystemisad healthcare centre.a primary Onlyifthatcliniclackstheskillsand equipmenttotreat thepatientwill to instance first the in go will patient a promotionand level, community the preventionat and activities vision areality are asabsenttheywere in 1978.Inawell-functioninghealthsystemthere are health shrined in the Alma-Ata Declaration and the desire to achieve it, the specific actions needed to make this Although the Astana Declaration reconfirms the solidarity of commitment to the right of en LACK OFSPECIFICS cluding SDG1–‘endpoverty’[ orient theirhealthsystemstowards care primary are betterplacedtoachievealmostalloftheSDGs,in pation’ (SDG 6) and ‘intersectoral collaboration’ (SDG17), while evidence shows that countries that re the AlmaAtaandAstanaprinciplesthrough otherSDGssuchas‘equity’(SDG10),‘communitypartici able DevelopmentGoal(SDG)3[ Further, Astana incorporates ‘universal health coverage’ that is at the centre of the health related Sustain change. climate of impacts health the and injuries issues, health mental including diseases municable andpalliativecare.itative services ThenewDeclarationrecognizes theincreasing importanceofnon-com ple’s healthneedsacross thelifecoursethrough comprehensive preventive, promotive, curative,rehabil Astana tosucceedarelow. health careattheexpenseofpopulationhealth.Ifthisisnotaddressedodds Unfortunately, since1978,inmanycountriesthebalancehastiltedtowardspersonal

4 ]. TheAstanaDeclarationrecognizes thatremaining healthyischallengingfor 8 , 9 7 ]. ]. The2015SDGsthatsucceededtheMDGscanprovide impetusto 2 www.jogh.org • doi: 10.7189/jogh.09.010313 2 ]. Although ]. Although 3 , 5 , 6 ]. ------www.jogh.org ment Network/Sandra Calligaro). Photo: Communitymidwiferyschool in Badakhshanprovince, Afghanistan(AgaKhanDevelop • doi: 10.7189/jogh.09.010313 ease or thepromotion of health. Worrisome trends include health systemsthatfocusdisproportionally dis of prevention than rather cure, of benefits the of overestimation an and technology medical vanced ad on overreliance an reflect systems care health of ills the of Many consultations. routine or services isresultingcomplexcarehospital-based specializedservices inunnecessary preference topreventive seeking to constraints financial of patients free that policies financing health and technologies, medical The availability of greatly expanded specialist diagnostic and therapeutic options due to the growth of tions arehealthcare muchhigheratthehospitalthantheywouldhavebeenaprimary . often more affluent urban patients with common conditions. The costs of treating these common condi this istoooftenthecaseatlowerlevelsofhealthcare system.Thushospitalsbecomeusedbylocal, happen becauseitisknownthatthehospitalhardly everrunsoutofsupplies,particularlydrugs,while direct toitsoutpatientdepartmentinthehopeof‘best’treatment,care. bypassingprimary Itmayalso knows thatthehospitalhasbetterfacilitiesanddoctorswithspecializedskills.Thepatientthusgoes ed inahospitalcouldhavebeentreatedhealthcare inaprimary centre. Thisispartlybecausethepatient In practice, in many countries this system does not work as intended. A high proportion of patients treat health staff [ play avitalrole healthcare insuchaprimary system,especiallyiftheyworktandemwithfacility-based ‘quality oflife’,whilestillproviding individualhealthcare [ forthecommunitythroughinterventions co-creation, andadvocateforimproved livingconditionsand cal healthproblems andtheirsocialdeterminants,planthemosteffective preventative andtherapeutic orientation tothepopulationrequires healthcare thefacilitybasedprimary workertounderstandthelo Health care of the person should take into account the influences and context of the community [ is notaddressed theoddsofAstanatosucceedare low. countries thebalancehastiltedtowards personalhealthcare attheexpenseofpopulationhealth.Ifthis andthebroaderhealth services healthcare. perspectiveofprimary Unfortunately, since1978,inmany ‘contact’ first-level of view narrow a differencebetween major a is This populations. and providerscare Specific actions to make Astana successful should promote major shifts in the relationship between health approach beyondMinistriesofHealth[ ers peopleandcommunitiestoplayanactiverole inshapingthepoliciesandawhole-of-government health care.icy frameworks in support of primary It also requires approach a participatory that empow health care atthecentre ofefforts structures andpol toattainuniversalhealthcoverageandgovernance ant [ and ensure afunctionalreferral andotherlevelsofcare” systembetweenprimary isinthisregard import many high-income countries. The statement in the Astana Declaration to “strive to avoid fragmentation If Astanaistoberealised, lower-income countriesshouldnotmakethesamemistakeasonemadeby unregulated commercialization ofhealthcare toflourish. on anarrow bandofspecializedcurativecare, andwhere ahands-off approach hasallowed togovernance 6 ]. To movethisforward requires strong politicalcommitmentandleadershipthatplacesprimary 13 ].

10 ]. 3

- all”, including, andespecially,poor. the full potentialofAlma-Ata,and reach “healthfor the unlocking finally to key the lie may tiatives portant role inthis[ Performance Initiative(PHCPI) canplayanim and effectiveness, Health Care and the Primary improvements health care quality inprimary and practiceshasgoodpotentialtoaccelerate measurement andsharingofeffective models vision intoapracticalsetofactions[ istan isarecent exampleoftranslatingsucha inAfghan of aBasicPackageHealthServices dence-based entitlements[ teeing anexplicitandaffordable setofevi ease prevention andhealthpromotion, guaran continuity ofcare andfocusedattentionfordis tion, through proactive strategies, favouring popula defined a of basis the on provided are The visionistoassure thathigh-qualityservices 12 ]. workers can help, and ]. Communityhealthworkerscanhelp,and June 2019 •Vol. 9No. 1•010313 16 ]. Insuchactionableini 14 ]. The introduction ]. Theintroduction 15 ]. Better ]. Better 11 ]. An ]. An ------

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