Perspective

From Alma-Ata to Rio: health for all to all for equity

Ravi Narayana & Thelma Narayana

The WHO South-East Asia Region was one of

the crucibles for development of the primary
health care (PHC) concept. The Bandung
Conference on Rural Hygiene held in 1937 drew
global attention, through the League of Nations
Health Organization, to the health needs of
the poor rural populations.1 The first primary
health units were started in Ceylon (now
SriLanka) and Mysore state of Southern India
in 1929. The Government of India established
Health Survey and Development Committee
(Bhore Committee) in 1946, identified
access to safe water, sanitation, housing and
adequate nutrition as essential conditions
for healthy living with a curative-preventive
mix of services available irrespective of the
ability to pay, and emphasized intersectoral
actions.2 Subsequently, primary health centres
developed in several countries to reach
the rural and marginalized populations. In
Bangladesh, India, Indonesia, Nepal, Pakistan,
Sri Lanka and Thailand several communitybased primary health care experiments by
civil society organizations complemented the
primary health care system development by
the State. These advances made significant
contribution to the development of primary
health care (PHC) as an approach to health
system strengthening.3
In 1976, a symposium organized by the
Indian Council of Medical Research, New Delhi
concluded that primary health centres should

include primary medical care, an efficient

referral system, maternal and child health
(MCH) services, environmental sanitation,
safe water supply, health intelligence, control
of communicable diseases, school health,
family planning, health education, recording
of births and deaths, and family folders.4
A symposium held in 1980 focused on
the evaluation of alternative health-care
experiments. It endorsed the development of
a network of frontline health workers to link
communities with PHC teams and highlighted
innovations like health cooperatives, nutritionlinked programmes and the use of local
and traditional health resources and human
power.5
The 1978 Alma-Ata declaration ushered
in a new paradigm of health focused on
PHC and health for all. 6 It emphasized
equity, appropriate technology, inter-sectoral
development and community participation,
and health as a right. However, the significance
of these radical concepts was soon lost, as
focus continued on communicable diseases
and MCH problems, with a more orthodox
approach of tracking mortality and morbidity
trends resulting in single disease-oriented
approaches. Subsequently noncommunicable
diseases and occupational/environmental
health problems emerged as new priorities.
Broader determinants like lifestyle behaviours,
individual and collective risks and other

Society for Community Health Awareness, Research and Action (SOCHARA), Bangalore, Karnataka, India.
Correspondence to Ravi Narayan (email: ravi@sochara.org)

WHO South-East Asia Journal of Public Health 2012;1(1):4-7

Ravi Narayan et al.

upstream factors were identified, leading to

broadbased health promotion strategies in
many regions including Asia.
Synergy as well as dissonance developed
between the PHC-oriented policies and
national disease control programmes in the
1980s. Some deviations also took place in the
1990s. Globally, the new economic policies led
to declining health and social sector budgets,
which affected the development of the PHC
infrastructure. Increasing numbers of global
public-private partnerships, with a selective
biomedical disease control focus, contributed
to the shift from comprehensive PHC to topdown techno-managerial approaches. Social
justice and equity, links between health and
development, intersectoral coordination,
community participation in health decisionmaking and health as a universal human
right, which were at the core of the Alma-Ata
declaration, received less attention. Market
approaches to health care prevailed with
growing privatization and commercialization.
At the same time, a broader social analysis
of the health situation and health system also
evolved. The earliest descriptions came from
India in the 1980s7 and from London, United
Kingdom, in the early 1990s.8 The former
reiterated that health service development
is a socio-cultural process, a political process,
a technology and managerial process with an
epidemiological and sociological perspective.
The latter emphasized that the primary
determinants of disease are mainly economic
and social and medicine and politics cannot
and should not be kept apart.
From the late 1990s, as health disparities
widened, an increasing convergence
between socio-epidemiologists, public health
practitioners, and social activists took place
with a strong community voice. They were
alarmed at the increasing inequity between
and within countries. Innovative projects to

WHO South-East Asia Journal of Public Health 2012;1(1):4-7

From Alma-Ata to Rio

monitor global and regional inequities evolved

such as the Global Equity Gauge Alliance. A
growing global campaign for health for all
as a fundamental human right also began to
emerge. In 2000, the first Peoples Health
Assembly in Savar, Bangladesh explored why
the Health for All goal had not been reached.
A Peoples Charter for Health adopted in the
Assembly stressed the principles of universal
comprehensive PHC envisioned in the 1978
Alma-Ata declaration.9 It stressed that now
more than ever an equitable, participatory
and intersectoral approach to health and
health care was needed. The Global Forum for
Health Research in Geneva, Switzerland took
this charter seriously and interacted closely
with civil society researchers at its annual
forum to discuss the issues of poverty and
health and the emerging concept of social
vaccines.10 Between 2002 and 2004 peoples
movements around this charter actively
advocated for putting social determinants
of health on the global agenda.11 This led to
significant initiatives that are now changing
the paradigm of health policy and action.
The World Health Report (2008) endorsed
equity, solidarity and social justice to drive
the PHC movement. It made evidence-based
arguments for PHC reforms to improve health
equity, to make health systems more people
centred, health authorities more reliable,
and to promote and protect the health of
communities. As part of the the way forward
it emphasized the need for mobilizing the
production of knowledge, commitment of the
workforce, and participation of the people.12
The WHO Commission on Social Determinants
of Health (2008) urged governments, policymakers and health activists to participate
actively in the global effort to redress
inequities in health between and within
countries as an issue of social justice. It
explored the deeper social determinants of
health equity, gender, political empowerment,

From Alma-Ata to Rio

social protection, healthy environment and

employment, etc.13 The Second Global Health
Watch Report offered an alternative analysis
arguing for policy changes, more research,
social accountability, market regulation and
appropriate interventions to support PHC with
an equity focus when markets fail.14
Recently in October 2011, government
representatives, supported by the largest-ever
presence of global civil society, expressed their
determination to achieve social and health
equity through action on social determinants of
health and well-being within a comprehensive
intersectoral approach.15 The most significant
part of the Rio Declaration was the reiteration
that health equity is a shared responsibility
and requires the engagement of all sectors of
government, of all segments of society, and of
all members of the international community,
in an all for equity and health of all global
action. While this may sound rhetorical, there
were new elements of realism in the declaration
including the commitment to empowering the
role of communities and strengthening civil
society contribution to policy-making and to
take action in advocacy, social mobilization
and implementation on social determinants of
health. The Third Global Health Watch Report
released at the Rio conference complemented
this global realism by highlighting a set of
achievable goals through a global Right
to Health movement that would foster
recognition of the right to health and health
care at country level, formation of health
rights monitoring bodies and accountability
agents, and regional and global solidarity on
health rights campaigns.16
Today, the PHC challenges at community
level in countries of the Region include agrarian
distress like farmers suicides, childhood
malnutrition, economic downturns affecting
PHC systems, climate change, social conflicts
and disasters affecting the broader context in

Ravi Narayan et al.

which health systems have to be developed and

sustained. These require study of factors such
as poverty, inequity, exploitation, violence and
marginalization. Recently this understanding
was put into action to strengthen public health
and epidemiology.17
To conclude, the WHO South-East Asia
Region has seen an emerging responsiveness,
b y g ove r n m e n t s a n d p e o p l e s h e a l t h
movements, for public policies that have
begun to influence the public health systems
in the Region. The Thai National Health Act
and the Indian National Rural Health Mission
are significant examples of civil society
engagement and responsive government
policies and partnerships. These exemplify
new developments that are equity-oriented
and social determinants-focused. What is now
needed is a continued evolution of this new
paradigm. Research on public health policy,
health systems strengthening, and community
action for health equity are required in the
Region. A new socio-epidemiology paradigm
must begin to reinvestigate health challenges
in the Region, building on the emerging
convergence between civil society advocacy,
academic analysis and responsive public
policy. The systems for health training,
research and policy formulation should be
geared up to meet the Health for All and All
for Equity Challenge.

References
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From Alma-Ata to Rio

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