Matthew Bramall recounts the radical goals of the Alma Ata declaration on global health – and how they were undermined by neoliberalism and structural adjustment policies.
2018 is an incredibly important year for health: the NHS turns 70 years old. This is both an opportunity to celebrate “the most civilised step any country had ever taken” and renew our attention on the overcoming the problems – underfunding, privatisation, PFI – that threaten its existence.
At the same time, but with less fanfare, the World Health Organisation is celebrating the 40th Anniversary of the Alma Ata declaration. Like the founding of the NHS, the Alma Ata declaration was a watershed moment in (global) health – and it continues to nourish and inspire social movements around the world due to its positive, holistic and radical approach to health.
The Alma Ata declaration came out of the first International Conference on Primary Health Care in 1978. It was a watershed moment that called for ‘Health for All by the year 2000’ – and it is worth revisiting for a whole variety of reasons. Firstly, it signalled a shift towards a social model of health. This meant promoting primary health care as the means for achieving ‘health for all’, for all countries. Primary health care sounds familiar, but it’s much more radical than the name suggests, putting community involvement at the heart of health services. This framework recognises the need for culturally and technologically appropriate health services, and focuses on the social and economic determinants of poor health – water, food, nutrition – and placing health central to social and economic development. It’s a far cry from top-down vertical, technological fixes that dominated the global health agenda in the 1950s and 60s, and which continue to dominate today. Quick, cost-effective, public health interventions because the norm as they are an easier sell than building health systems and empowering communities, and taking the necessary preventative measures to ensure health for all.
Secondly, Alma Ata called for a political response to ensure the goal of achieving health for all was realised. To achieve this the official declaration, signed off unanimously by all members of the WHO, it explicitly recommends a shift from militarisation to peace, and a redistribution of power from the global north to the global south, lending its support to, and drawing inspiration from, the calls for a New International Economic Order (NIEO). It’s a staggeringly utopian and powerful document, built on years of research that had demonstrated that primary health care approaches were the best way to improve health. And like the founding documents of the NHS, a reminder of how far we have been blown off course over the last 40 years.
But in the same way that the NHS vision of universal public healthcare has been progressively undermined, so has the inspiring vision of the Alma Ata declaration. Both have been progressively weakened by neoliberalism – backed into a more corporate and less ambitious model of healthcare. As we rightly renew our calls for the NHS to be restored, we must renew our commitment to the same lofty ambitions for global health too.
Almost immediately after it was signed off, the Alma Ata declaration and the commitment to primary health care were attacked. A year later, at a meeting of international donors and aid agencies, the concept of ‘selective’ primary health care appeared– reintroducing top-down, technologically driven health programmes and public health interventions. These could be measured, evaluated – and controlled – by donor governments and agencies much more easily than the more nebulous primary health care approach which insisted on community participation and intersectoral approaches. And whilst the rhetorical commitment to PHC was arguably never matched with funding commitments and reforms, it never really had the chance to get off the ground.
Not long after this, the idealism of the Alma Ata declaration was subsumed as rising inflation, debt crises and recessions across the global South resulted in the imposition of structural adjustment policies. This reduced health budgets and forced governments to adopt an approach to health care that was a far cry from the Alma Ata’s commitment to social justice. It’s a story familiar to most of us: the crisis of US hegemony was quickly averted and neoliberalism won out, to the detriment of the world’s poor and the prospects of genuine human development.
The triumph of neoliberalism in global health governance becomes clear when we compare the draft Alma Ata 40 declaration due to be presented later this year and the original declaration. Gone are the calls for a New International Economic Order and reducing gap between the ‘haves’ and the ‘have nots’, and gone are the calls for reduced spending on military. Whilst the draft Alma Ata 40 does reaffirm its commitment to primary health care, which is to be applauded, it does so in the context of achieving the Sustainable Development Goals (SDGs) and the Universal Health Coverage (UHC) 2030 agenda, which themselves have been subject to criticism for failing to take account of the very imbalances of power that are fundamental to the analysis underpinning the original Alma Ata declaration.
Whilst the draft Alma Ata 40 document commits to reversing the ‘unregulated expansion’ of the private sector and rising costs, it’s highly unlikely that this will translate into action when UHC2030 agenda is dominated by the likes of the World Bank who have promoted ‘health sector reform’ and the role of the private sector in health for decades. The parallels with the UK are obvious. Whilst politicians commit to maintaining the NHS, utilising its spirit for political gain, they often fail to challenge the fundamental ideologies that undermine it.
Fortunately, there are activists around the world keeping the spirit of Alma Ata alive. This year, the People’s Health Movement (PHM) with convene in Bangladesh, for the 4thPeople’s Health Assembly. There, activists will again reaffirm the words of Halfdan Mahler, the Director General of the World Health Organisation responsible for the radical Alma Ata declaration, who continued to insist “that unless we all become partisans in renewed local and global battles for social and economic equity in the spirit of distributive justice, we shall indeed betray the future of our children and grandchildren.”
So whilst the NHS celebrations get the headlines in the UK we should join the activists at the People’s Health Assembly and learn from them as they continue the struggle to achieve health for all, recognising that this is impossible without tackling the biggest obstacle to health justice – neoliberalism and unjust global power imbalances that create and recreate poverty and poor health.