Primary Health Care
    25 Years of the Alma-Ata Declaration

Questions and Answers

What was the significance of the Alma-Ata conference? What is primary health care? How did Primary Health Care impact the health of the Americas? These and other questions about the International Conference on Primary Health Care of 1978 are answered here.

What was the significance of the Alma-Ata conference?
The International Conference on Primary Health Care (PHC) in Alma-Ata, Kazakhstan, in 1978, brought together 134 countries and 67 international organizations (China was notably absent). The conference defined and granted international recognition to the concept of primary health care (PHC) as a strategy to reach the goal of Health for All in 2000, as indicated in the Declaration released at the conclusion of the conference.

What is primary health care?
According to the Declaration of Alma Ata, primary health care, is "essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination."

What was the social framework of the Declaration of Alma Ata?
In terms of health, the 1970s were characterized by national efforts to expand access to health services. The advent of PHC and the commitment of Health for All by 2000 for the region of the Americas resulted in a reinforcement of the policies and strategies for the expansion of coverage throughout the region. The most recent antecedent was the III Special Meeting of Ministers of Health held in 1972 in Santiago, Chile, which concluded that health services did not manage to deliver benefits to the entire population. Thus PHC was born, as a policy of expanding coverage in order to resolve what at the time was called the crisis of access, the main indication of a major crisis, that of the health systems.

What was the political and demographic context in which PHC was implemented?
The economic context was critical. In a complete demographic transition, the population was becoming predominately urban. The political panorama was characterized by military dictatorships in many countries and unstable democracies in others - with some exceptions. In that scenario, the health services were organized with a centralized approach. Primary health care promoted the progressive strengthening of units of services and of local capacities (which in many countries would be called the primary care level) and that subsequently would serve as a basis for new approaches to social policies.

How was the application of the PHC implemented in the countries of the Americas?
The original definition of PHC proposed that it work implicitly as a strategy for health development as well as a level of care for health services. In the Americas, each country adopted and adapted primary health care in accordance with its own realities and sanitary and socioeconomic conditions. Under this perspective, numerous countries have conceived PHC as a primary care level which acts as a liaison to the community and introduces the population to the health system. Others interpreted it exclusively as a tool for social justice: the possibility of giving health care to the poor and marginalized populations without access to services, a process that was called "selective PHC." But the vision prevalent in the region is clear and categorical: PHC is not a package of "intervention limited to poor people," but a basic strategy for the achievement of greater coverage and equity.

How did PHC impact the health of the Americas?
From a historical perspective, PHC became a central element of national health policies and of regional responses to health problems in the countries of the Americas in the 25 years since Alma-Ata. The net gain in life expectancy obtained in the region in this period may be considered an indirect indicator of the positive influence the strategy of PHC has had on the population's health. In those 25 years, there has been a reduction in the risk of death (from 9 to 7 per 1,000 people) and life expectancy at birth in both sexes increased, on an average of 6 years: from 66 to 72.

In what countries was the impact of PHC greater?
The impact of the application of this strategy has been greater in those countries with small inequality in income distribution, regardless of absolute income levels. On the contrary, the impact of PHC has been much smaller in poor countries with high inequality in the distribution of income.

What were the major lessons of the application of PHC?
In the Americas, PHC became a pioneering experience for the development of health policies and marked the beginning of a paradigm of change in the practice of public health. Primary health care, by proposing a change in the model of service delivery, anticipated the processes of sectoral reform undertaken in the 1990s. Countries also used the strategy as a framework for human resource development in health. Furthermore, PHC gave priority to health promotion, emphasizing the anticipatory and preventive character of health action and the de-medicalization of public health.

Why do people believe the goal of Health for All was not reached?
Although the review and evaluation of the goal of Health for All by 2000 found significant advances in the health of the people of the Americas, hindrances remain which prevent full achievement of the goal. It is necessary to renew the ideals of the slogan Health for All, as a powerful vision of health needed to adjust health policies and achieve levels of health that make it possible to achieve a social and economically productive life for the people of the Americas. The renewal of this slogan requires a review of the principles of PHC and a reaffirmation of its adoption as a fundamental strategy for the health development.

What are possible steps for the future?
In the context of the changes which occurred in the Americas and the renewed perspective of Health for All, PHC has great potential as a vehicle to achieve five challenges for the future of health in the region: to guarantee the citizenship statute in health and the universality of access, while at the same time to prioritize the health of the least privileged groups and the reduction of inequalities in health; to improve the health of the population with reduction in infant and maternal mortality, increasing life expectancy and improving the quality of life; to develop effective health care that satisfies individuals, families and communities, and in which all of these participate; to coordinate the development of different health providers; and to strengthen the infrastructure and the institutional capabilities to ensure the adequate performance of essential public health systems.

In what social and sanitary context will PHC of the 21st century be developed?
There are particularly relevant elements which are important for the renewal of PHC in the Americas such as the changes in demographic and epidemiological profiles of the region. In particular, urbanization and demographic aging; chronic diseases, violence and disabilities; AIDS and other emerging diseases; vulnerability to disasters and to other circumstances with environmental impact; cultural, ethnic, gender, and lifestyle diversity and the impact of other major health determinants: the decentralization of political administration, the changes in care models and of health service management and the diversification of the traditional sanitary responses.

What is it the relationship between PHC and the Millennium Development Goals?
The Millennium Development Goals are a commitment made by the world's nations to improve the health and well-being of people throughout the world, including reducing poverty, infant and maternal mortality and the spread of HIV by 2015. Within the framework of PHC as a strategy aimed at improving the living conditions of communities, reducing the burden of disease, and favoring equity in health, the principles the PHC need to be aligned, harmonized, and adjusted along these goals. Due to its capacity for strengthening health services, PHC can become a basic strategy for the achievement of these internationally agreed-upon objectives.

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