From Alma-Ata to Astana

In 1978, in Alma-Ata (now Almaty) in the Soviet Union, a conference on primary health care is still legendary for defining the most ambitious and progressive vision for global health we have ever seen. Despite the Cold War differences, countries jointly produced a Declaration which remains a touchstone for all those who believe in a fairer world with inequalities in health and well-being reduced and people empowered with more control over their lives.

Alma-Ata promised to achieve “Health for All by the Year 2000” and the reasons why this did not happen have been much analysed. Economic structural adjustment policies encouraged countries to cut public spending, and those who were dependent on the IMF and the World Bank were powerless to argue. UNICEF and the World Bank encouraged governments to charge people fees for using primary health care, long after there was evidence that this makes the poor stay away. And, perhaps, most lastingly, the global health world found it easiest to talk about a few specific services than the whole comprehensive health needs of a population.

Now, in 2018, the capital of independent Kazakhstan is Astana, a gleaming modern city, and it is here that the 40th Anniversary conference on primary health care is being held. It is 1,300 kilometres, 40 years and a very different world apart.

In many ways, the comprehensive approach to health is back in fashion, with the commitment to Universal Health Coverage (UHC). It is clear that donors’ approach, focussing on specific disease or service initiatives, is running out of steam. Without strong health systems and sufficient financing in countries, these improvements are unlikely to be maintained when donor money moves away. So it is a very welcome corrective to be talking about UHC and the decisions that governments of low- and middle-income countries make for themselves.

Despite this renewed interest in health systems, UHC and primary health care, the world we are now living in does not seem to have the ideological equipment to achieve the changes that everyone says they want to see. Health is political but this is health without politics. If we want universal primary health care, we must talk about governments’ duties towards their citizens and how health promises affect elections. If we want primary health care funded, we must talk about why governments allow the wealthy to escape fair taxation and spend so much less than the recommended 5% of GDP on health. If we want health to be a right not a commodity, we must talk about the human rights legal commitments and the role of courts in enforcing them. If we want people to participate in their own health, we should be talking about the repression of free speech in many countries and the disempowerment of civil society.

Instead, in this glitzy event, ministers give speeches saying how well they are doing and there is no debate to challenge them. There is recognition that inequalities are growing but not the political drivers of this. The private sector and technological solutions are celebrated as the future, without looking at why these are never available equally to all people.

The death of politics in global health means no discussion here in Astana about the role of nation states. The desire to pretend there is consensus between such different governments means a polite avoidance of differences of opinion. This is not how change happens. We need to put the politics back into global health to achieve everyone’s right to primary health care.

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