Primary health care: making Alma-Ata a reality

HandsGlobeThe 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 prioritization 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 revitalizing 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, inter-sectoral 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 prioritize research questions and suggest actions and measures for stakeholders both locally and globally, which are required to revitalize primary health care.


The 1978 Alma-Ata Declaration introduced revolutionary principles into health care—equity, social justice, and health for all; community participation; health promotion; appropriate use of resources; and inter-sectoral action— an historic event for health and primary health care.

Old health challenges remain and new priorities have emerged (eg, HIV/AIDS, chronic diseases, and mental health), ensuring that the tenets of Alma-Ata remain relevant.

We need to examine these past 30 years of changes in global policy to identify the lessons learned that are of relevance today, particularly for accelerated scale-up of primary health-care services necessary to achieve the Millennium Development Goals, the modern iteration of the “health for all” goals.

Health has moved from under-investment, to single disease focus, and now to increased funding and multiple new initiatives.

For primary health care, the debate of the past two decades focused on selective (or vertical) versus comprehensive (horizontal) delivery, but is now shifting towards combining the strengths of both approaches in health systems.

Debates of community versus facility-based health care are starting to shift towards building integrated health systems.

Achievement of high and equitable coverage of integrated primary health-care services requires consistent political and financial commitment, incremental implementation based on local epidemiology, use of data to direct priorities and assess progress, especially at district level, and effective linkages with communities and non-health sectors.

Community participation and inter-sectoral engagement seem to be the weakest strands in primary health care. Burgeoning task lists for primary health-care workers require long-term human resource planning and better training and supportive supervision.

Essential drugs policies have made an important contribution to primary health care, but other appropriate technology lags behind. Revitalizing Alma-Ata and learning from three decades of experience is crucial to reach the ambitious goal of health for all in all countries, both rich and poor.


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