Elsevier

The Lancet

Volume 372, Issue 9642, 13–19 September 2008, Pages 1001-1007
The Lancet

Series
Primary health care: making Alma-Ata a reality

https://doi.org/10.1016/S0140-6736(08)61409-9Get rights and content

Summary

The principles agreed at Alma-Ata 30 years ago apply just as much now as they did then. “Health for all” by the year 2000 was not achieved, and the Millennium Development Goals (MDGs) for 2015 will not be met in most low-income countries without substantial acceleration of primary health care. Factors have included insufficient political prioritisation of health, structural adjustment policies, poor governance, population growth, inadequate health systems, and scarce research and assessment on primary health care. We propose the following priorities for revitalising primary health care. Health-service infrastructure, including human resources and essential drugs, needs strengthening, and user fees should be removed for primary health-care services to improve use. A continuum of care for maternal, newborn, and child health services, including family planning, is needed. Evidence-based, integrated packages of community and primary curative and preventive care should be adapted to country contexts, assessed, and scaled up. Community participation and community health workers linked to strengthened primary-care facilities and first-referral services are needed. Furthermore, intersectoral action linking health and development is necessary, including that for better water, sanitation, nutrition, food security, and HIV control. Chronic diseases, mental health, and child development should be addressed. Progress should be measured and accountability assured. We prioritise research questions and suggest actions and measures for stakeholders both locally and globally, which are required to revitalise primary health care.

Section snippets

Revisiting Alma-Ata

30 years after the Alma-Ata Declaration for primary health care, “health for all”1 remains a long way off for many countries, even those that are on track for mortality reduction goals, yet it remains the ultimate vision. The Millennium Development Goals (MDGs), which were adopted in 2000 as the next generation of the “health for all goals”, specify eight aims and measurable targets, including reduction in maternal and child mortality and in the burden of HIV, malaria, and tuberculosis, and

Where are we now, and what are the gaps?

Despite the ideals and enthusiasm after Alma-Ata, primary health care continues to be inadequately supported and resourced.12 The coverage and quality of services in some countries has deteriorated because of conflict, poor governance, structural adjustment, population growth, and disinvestment in health.13, 14

There are notable exceptions, as shown by the 30 low-income countries that have made steady progress to reduce deaths in children younger than 5 years and, in some cases, also newborn and

Revitalisation of primary health care at scale

All levels—individual, family, community, facility, district, provincial, national, and global—have a role and responsibility if health for all is to be achieved. To deliver results with a primary health-care approach will need partnerships, links, and an enabling environment including bottom-up support from empowered communities, top-down support from responsible governments and across municipal and state levels, and external support with technical and financial resources, when needed and

Research priorities for primary health care

The so-called 10/90 gap indicates the imbalance of having a small proportion (10%) of research funding addressing the health needs of most of the population (90%) worldwide.38 Identification of research priorities for primary health care is important for optimising the effective use of scarce resources. Reviews have established the scarcity of rigorous evidence for implementation and delivery of services generally and for human resources particularly, especially in low-income and middle-income

Renewing commitment and investment in primary health care

We call for the global health community, governments, national authorities, international agencies, and civil society to revitalise primary health care according to the original tenets of Alma-Ata and to monitor progress. We propose the establishment of a process to set new measurable targets that build on, yet go beyond, the MDGs to reflect the broader primary health-care agenda and to ensure continued momentum towards health for all after 2015. A possibility for one such goal could be a

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