Abstract
The recent global meeting in Astana, Kazakhstan, of health ministers, chief medical officers, senior members of public health and non-governmental organisations and civic activists, some 3000 people in all, was convened to take stock of the impact of the Alma Ata Declaration and recommit to the attainment of Universal Health Care Coverage, grounded in public health and prevention. That original meeting in 1978, in the former Kazakhstan capital of Alma Ata (now renamed Almaty), came about because of increasing international concern that the post World War II domination of medical care systems by hospitals was squeezing out both public health and the first points of contact between communities and reliable clinical advice. Unlike many such declarations by international bureaucracies, Alma Ata turned out to be truly a landmark intervention in the sense that it has shaped health policy discussions ever since and has proved influential in changing the face of healthcare in numerous countries, not least in South America and Scandinavia. It paved the way for the World Health Organization (WHO) Strategy of Health for All by the Year 2000, with its emphasis on public engagement, partnership working and strengthened Primary and Community Care grounded in Public Health, and gave birth to its golden child, the Healthy Cities Movement. Over 30 years later, ‘Healthy Cities’ can boast of extensive networks of collaborating cities around the world with over 1400 WHO cities in the European Network alone.
However, despite many achievements over the past four decades with reduced infant and maternal mortality rates and increasing life expectancy in many places, the widespread adoption of family planning, with its beneficial impact on the position of women and their families, and the tide turning on the HIV epidemic, there is much still to be done. Both the existing challenges, together with new ones in an increasingly fragile world, with a rapidly ageing population, the emergence of non-communicable disease and mental health as top priorities, the threats to public health from political instability, violence and mass migration, have been exacerbated by 10 years of austerity. Many countries have struggled to refocus resources away from the voracious financial appetites of hospitals even when it means thousands of avoidable hospital admissions and ‘blocked’ hospital beds through neglect of public health and appropriate housing stock, prevention and strong primary and community care. In the case of England, significant additional monies provided as a result of the Wanless review almost 15 years ago, which was intended to create a ‘fully engaged scenario’ of upstream action and prevention, disappeared into wasteful Private Finance Initiatives to build new hospitals and significant pay rises for clinical staff with no commensurate changes in the balance of investment towards prevention.
In galvanising health leaders’ attention for a few days in October, the WHO sought to re-energise the Alma Ata Declaration for a new generation of millennials, much as the original had for the baby boomers in 1978. The agenda is potentially intimidating. Around the world, hundreds of millions of children, adolescents and adults lack access to quality, affordable health services, major inequalities in health are putting the wellbeing and prosperity of individuals, communities and societies at risk and over six million children die each year from preventable conditions. Other complex challenges including conflict, disease outbreaks, natural disasters and climate change are highlighting the urgent need for robust health systems and healthcare systems that can respond in this challenging environment. The new Declaration, agreed in Astana, links the movement for 21st Century Primary Health Care both to the recent United Nations Sustainable Development Goals for 2030 and to the healthy cities work now led by elected city mayors and politicians around the globe. There were calls in Astana to invest in people, places and partnerships to protect health and wellbeing and produce prosperity, peace and to safeguard the planet for future generations. It was argued that health and social care must be coordinated across the lifecycle and it was time for health to be seen as a human right.