The Politics of the World Health Organization

THE LONG AND DIFFICULT ROAD TO ALMA-ATA:

A PERSONAL REFLECTION

Socrates Litsios

This account of the events leading up to the Alma-Ata Conference in Sep-

tember 1978 (covering the years 1970 to 1978) is based on the author’s recol-
lections and his recent research of World Health Organization documents. The
author builds his story around four themes: why the Soviets, in particular,
wanted the conference; why the new WHO director-general did not; the time
and energy lost by holding the conference; and what might have happened if it
had not been held. The story involves not only people and their political and
health ideologies but also reflections on the continuing question of how best
to improve the health of communities. The account reveals how Alma-Ata
constrained attempts by the new leadership of WHO to transform the way in
which the organization fulfilled its international health responsibilities.

On December 19, 1976, I jotted down some questions in my “diary” (an average of
one entry per year at that time): “Will the Regional Directors present Regional
reports at Conference? Will NGOs show up? Why did the Russians want
Conference?” To the last question, I scribbled some possible answers: “Fear of
Chinese influence in WHO; to prepare for Olympics; Venediktov running for
DG [director general]; to gain influence in the third world (pay for tickets).”
On January 10, 1977, I wrote, “Now the word is that Conference will be voted
down! Venediktov staying away until decision taken. Tejada hoping (as he says
DG is) that this will happen.” (Venediktov was the Soviet delegate to the World
Health Organization charged with promoting a Soviet site for the International
Conference on Primary Health Care. Tejada was the responsible WHO assistant
director-general for the conference.)
Aside from a few more notes that I made during those years, this essay
reflects my current view of the past. However, I have not only relied on my

International Journal of Health Services, Volume 32, Number 4, Pages 709–732, 2002

ã 2002, Baywood Publishing Co., Inc.

709
710 / Litsios

memory; I have researched relevant documentation so as to provide the reader

with further sources to explore that rich and exciting period of WHO’s history.
The story of the Alma-Ata conference (held in Alma-Ata, Kazakstan, in 1978) is
not a simple one to tell. Not only does it involve people and their “ideologies,” in
both politics and health, but it touches on ever-present questions about how best
to improve the health of communities, especially those in greatest need. But, of
equal importance to our story, Alma-Ata generated constraints that significantly
interfered with the efforts of the new leadership of WHO to radically transform the
manner in which the organization fulfilled its international health responsibilities.
The story is further complicated by the many years it took to unfold. More than
four years would pass from the day a conference was proposed (in May 1974)
to the time it was held (in September 1978). The Alma-Ata story, however, goes
back even further, to the May 1970 World Health Assembly, when the Soviets
proposed and the assembly adopted resolution WHA23.61, “Basic Principles for
the Development of Health Services” (1).
Much of this essay turns on events that took place during an eight-year period,
1970 to 1978. Two WHO personalities were particularly important in what
might be called the management of these events: Dr. Halfdan T. Mahler, assistant
director-general from 1970 to 1973, when he was elected director-general; and
Dr. Kenneth N. Newell, director of Research in Epidemiology and Communi-
cations Science from 1967 to 1972, when Mahler appointed him director of the
new Division of Strengthening of Health Services. Both men were visionaries
who shared common values that included dedication to the pursuit of human
development and justice. Newell left WHO in early 1977, but subsequently
contributed to the preparation of early drafts of the background paper for
Alma-Ata.
Outside WHO, only one name will enter our history: Dr. D. D. Venediktov, of
the U.S.S.R. No other delegation pressured WHO in as consistent and aggressive
a manner as the Soviets. Venediktov was the chief Soviet delegate during this
period; his position in the Soviet Union was that of deputy minister of health.
It was Venediktov who, from as early as 1970, played a prominent part in pushing
for WHO to give high priority to health services and who adroitly maneuvered
to ensure that the International Conference on Primary Health Care would take
place in his country.
I relate the story of Alma-Ata in four parts, posing four questions: Why did
the Soviets want the conference? Why did Mahler not want the conference,
particularly one located in the Soviet Union? How much time and energy did
WHO lose by holding the conference? And what if no conference had been
held? Each part addresses the same eight-year period. The most critical events of
this period, summarized in Table 1, are described in more detail in the course of
the essay. I participated in some of these events in my capacity as chief of
operational research (1967–1972) in the Division of Research in Epidemiology
and Communications Sciences, co-chief of Functioning of Health Services
 The Road to Alma-Ata / 711

Table 1

Key events in the Alma-Ata story, 1970–1978

1970 Adoption of resolution WHA23.61: “Basic Principles for the Development

of Health Services.”

1971 Executive board chooses “Methods of Promoting the Development of Basic

Health Services” as the subject for its organizational study (1971–1973).

1972 UNICEF/WHO Joint Committee on Health Policy (JCHP) chooses to evalu-

ate existing basic health services; new Division of Strengthening of Health
Services (SHS) created, with Dr. Newell as director.

1973 Executive board completes its organizational study; Dr. Mahler takes over
as director-general of WHO.

1974 Soviets propose holding an international conference.

1975 “Alternative Approaches to Meeting Basic Health Needs in Developing

Countries” presented to WHO and UNICEF executive boards; international
conference agreed to; Newell’s Health by the People published.

1976 Executive board’s ad hoc group agrees to hold the International Conference
on Primary Health Care, in the Soviet Union.

1977 Adoption of resolution WHA30.43: “Health for All by the Year 2000” (HFA).

1978 International Conference on Primary Health Care held in Alma-Ata,

September 6–12.

(1972–1975), and co-chief of Primary Health Care and Rural Development

(1975–1980) in the division of Strengthening of Health Services.

WHY DID THE SOVIETS WANT THE CONFERENCE?

During the 1950s and the 1960s, the first priority of WHO was the eradication
of malaria and control of certain other diseases. WHO’s commitment to the
malaria-eradication campaign was largely promoted by the U.S. government and
began in the middle of the 1950s, at a time when the Soviets were not participating
in the work of WHO, having withdrawn in 1949, only to return in 1957 (2).
Criticism of the eradication campaign began in the early 1960s, much of it coming
from those, including the Soviets, who thought the development of health services
712 / Litsios

was not receiving adequate attention due to the attention being given to malaria.
As it became more evident that eradication was impossible, the Soviets took the
lead in calling for a review of the campaign. That review took place in 1969 and
essentially led to the abandonment of the eradication goal.
The failure of the malaria-eradication campaign left the door open for the
Soviets to take a leading position in the development of health services. Having
fought the battle against WHO’s vertical campaigns of the 1960s, the Soviets
sought to gain as much political advantage as possible from what they had
accomplished in this field. Their first step was to introduce a draft resolution to the
1970 World Health Assembly on the subject. I first learned about this resolution
during a visit to the Soviet Union in 1971, when I came upon a pamphlet that
described the Soviet’s contribution to the United Nations system. Concerning the
work of WHO, it stated that the foremost accomplishment to date had been the
adoption of resolution WHA23.61, “Basic Principles for the Development of
Health Services”! This achievement was of such importance (to the Soviets) that
no resolution on health services could ever hope to get passed without some
obligatory reference to it. Even then, it was a rare event when the Soviet delegate
did not ask for greater attention to “their” resolution.
It was Venediktov who alerted the twenty-third World Health Assembly, in
1970, that the Soviet delegation wished to propose a resolution “on the scientific
or rational principles upon which the development of a national public health
system should be based” (3). From the discussion, it seems clear that the other
delegations were not well prepared to discuss the resolution’s contents adequately.
Nevertheless, before WHA23.61 was adopted, some changes were introduced
and passed.
Two issues dominated the brief but intense discussion on the final wording
of this resolution. One concerned the role of the state, the other whether or
not services should be free. The Soviet delegation proposed that the state be
fully responsible for the provision of health services; others, particularly the
U.S. delegation, thought this responsibility should be shared by other elements
in society. Thus, whereas the Soviets envisaged health protection being
accomplished through the “establishment of a system of national health services
based on a single national Plan,” the final version read “through the establishment
of a nation-wide system of health services based on a general health plan and
local planning.” However, the U.S. delegation was unsuccessful in its attempt
to replace all other references to “national” by “nation-wide.” The Soviets
also proposed the “participation of wide sections of the public and the whole
population in the carrying-out of all public-health programmes” as an expression
of the “responsibility of society for protecting the health of its members.” The
latter was reworded in the final resolution to read “personal and collective respon-
sibility of all members of society for protecting human health.” The provision
of the “highest possible level of skilled, universally available medical care, free
of charge” was replaced by the provision of the “highest possible level of skilled,
 The Road to Alma-Ata / 713

universally available preventive and curative medical care, without financial or

other impediments” (3).
Venediktov was given a golden opportunity when the executive board, in
January 1971, had to select a subject for its Future Organizational Study (4). Three
topics were proposed by the secretariat: (a) the use of computer services in WHO
programs, (b) the scope of information systems in WHO, and (c) the role of the
new managerial sciences in public health administration. The delegates were
divided in their opinion until the U.K. delegate—for reasons he did not elaborate
on, other than indicating that most previous studies “had been relatively sophis-
ticated and perhaps were of interest only to the more developed countries,”—
suggested “a study on methods of promotion of basic health services.” Venediktov
jumped on the suggestion, indicating that it “was the most interesting and the
most challenging.” Others followed, and the executive board found itself involved
in a topic radically different from any of those the secretariat had proposed.
Newell, when he was appointed director of the Division of Strengthing
of Health Services (SHS) in 1972, inherited the responsibility of serving the
executive board group formed to conduct this study. The group submitted its
report to the board in January 1973 (5). Its key conclusion was that the basic
health services approach, one that had been developed and promoted by WHO
from the early 1950s, had failed and that a “major crisis” was “on the point of
development,” which must be faced at once. The crisis was reflected in the
“widespread dissatisfaction of populations” for reasons that included “a feeling
of helplessness on the part of the consumer, who feels (rightly or wrongly) that
the health services and the personnel within them are progressing along an
uncontrolled path of their own which may be satisfying to the health professional
but which is not what is wanted by the consumer.”
Venediktov, after noting that “the Group might have drawn more fully on
resolution WHA23.61,” identified three shortcomings in the report (6). First, it
ignored the socialist countries, where such problems “had been successfully
tackled.” Second, it lacked a definition of “public health.” And third, it indicated
that “no list of minimal requirements for health services actions . . . existed, or
should exist,” whereas Venediktov thought “it was possible to draw up a model
of a health service system that all countries would find useful.”
The board passed on the study results to the World Health Assembly, which in
turn, addressed the subject. Two points deserve mention. First, Venediktov chose
this assembly to propose “a substantial strengthening of the role of the Executive
Board and the Assembly in systematically reappraising our programmes and in
improving the structure of our Secretariat’s activities”; and second, the resolution
adopted requested the director-general to report to the board “on a compre-
hensive long-term research programme with systems of health care organization
on local and country-wide levels . . . as well as on the steps to be taken for the
implementation of the conclusions and recommendations of the study and their
impact on future programmes of the Organization” (7). Not included in this
714 / Litsios

resolution was the Polish delegate’s proposal that the board take on the respon-
sibility of reviewing the work of WHO in this field.
Newell was responsible for preparing the director-general’s next report to the
executive board on this subject. It was presented to the board in January 1975 (8).
Entitled “The Promotion of National Health Services,” it proclaimed that the
development of “primary health care services at the community level is seen as the
only way in which the health services can develop rapidly and effectively.”
This development was to be guided by seven principles, which stressed the
need (a) for shaping primary health care (PHC) “around the life patterns of the
population”; (b) for involvement of the local population; (c) for “maximum
reliance on available community resources” while remaining within cost limita-
tions; (d) for an “integrated approach of preventive, curative and promotive
services for both the community and the individual”; (e) for all interventions to be
undertaken “at the most peripheral practicable level of the health services by the
worker most simply trained for this activity”; (f) for the design of other echelons of
services in support of the needs of the peripheral level; and (g) for PHC services to
be “fully integrated with the services of the other sectors involved in community
development.” The report described various activities on the part of WHO. It
largely side-stepped the issue of “research,” which had been given prominence in
the resolution calling for the report, merely indicating that the WHO activities
supporting the development of PHC included “studies that could be regarded as
research . . . [but] that this research is not independent of the activity with which it
is associated.” The “objectives of each country’s programme should be the prime
determinant of the research.” WHO was expected to “contribute to evaluative
efforts where the resources required are beyond national capacities.”
A parallel history, of perhaps even greater importance to the refinement of
the PHC concept, was a study commissioned, in February 1972, by the
UNICEF/WHO Joint Committee on Health Policy (JCHP) to evaluate existing
basic health services (9). This study was crucial, as it allowed SHS staff to gather
information from a wide range of sources from which a selection of “promising
programs” was made. Some of these programs were visited and a draft report was
prepared for a consultation, which took place in mid-1974. The final report,
Alternative Approaches to Meeting Basic Health Needs in Developing Countries,
was presented to the twentieth session of the JCHP in February 1975 for approval,
then to the UNICEF executive board in May 1975 for endorsement (10).
The important publication Health by the People, edited by Newell (11),
appeared shortly after publication of the JCHP report. It built on most of the JCHP
projects while adding several new ones. Several of the alternatives included in
the JCHP study and in Health by the People were brought to the attention of
WHO by staff members of the Christian Medical Commission. Mahler invited
the commission to introduce PHC to the WHO directors in 1974 (12). Nita Barrow,
then deputy director of the Christian Medical Commission, tells how she
responded: “But this is like David and Goliath.” “Yes,” Mahler replied, “but I am
 The Road to Alma-Ata / 715

a parson’s son and I know what David did to Goliath” (13). Newell was the only
WHO director to respond enthusiastically; he quickly involved SHS in joint
activities with the Christian Medical Commission.
Returning to the January 1975 executive board, Venediktov noted that the
subject “was too large to be considered at a single session of the Board or even of
the Health Assembly,” and went on to propose a “conference on the same scale
of the World Population Conference” (14). The Soviet delegation had earlier
made a similar proposal, during the 1974 assembly, when it requested that an
international conference be organized under WHO auspices “for the exchange of
experiences as regards the development of national health services” (15). The
proposal was rejected in 1974; nor did the board accept Venediktov’s proposal in
January 1975. But at the 1975 assembly he was able to push the adoption of
resolution WHA28.88, which considered an international meeting or conference
“desirable” (16).
When Newell introduced the PHC report to the 1976 executive board, he
indicated that the director-general “was not convinced that the time was opportune
[for an international conference] . . . he felt that action should be directed to the
regional, sub-regional and national levels and pursued with clear knowledge
and awareness of the problems and present solutions of individual countries.”
He noted that “a formal offer to host the conference had been received from the
Minister of Health of Egypt” (17).
Venediktov responded immediately and sharply. “He failed to understand
how the desirability of holding the conference could now be questioned.”
He indicated that Newell had omitted mentioning that the U.S.S.R. had also
proposed holding a conference in 1977 in any of the republics of the Soviet
Union. Furthermore, his government was willing to make “substantial finan-
cial resources available . . . in particular to cover the costs of participants
from developing countries.” Mahler apologized to Venediktov, explaining
that the resolution had referred to the “desirability” of holding the conference;
now it was up to the board to “consider the most appropriate time for such a
conference.”
After a very long discussion, the board voted in favor of a conference to be held
in 1978. It established an ad hoc committee to decide on the “detailed objectives,
the agenda, the place, the date, the participants and the nature of the preparatory
steps necessary to fulfil the objectives of an international conference on primary
health care.” This committee met at the end of March 1976.
Between January and March, the Soviets were able to place sufficient diplo-
matic pressure on Egypt to cause that government to withdraw its offer. The
WHO secretariat approached other countries. Costa Rica, with U.S. support,
came forward, but could not guarantee, by the time the ad hoc group met, that the
necessary hotel and conference facilities would be available, nor was it in a
position to offer significant financial support to host the conference. Although the
possibility of holding the conference in Geneva was debated, the board’s ad hoc
716 / Litsios

group had no choice but to accept the only viable proposal—that of the Soviet
Union. To seek another location, one more acceptable to those who opposed
holding the conference in the Soviet Union, would only cause further delays and
risk provoking a further escalation of tensions with the Soviets.
For more than six years the Soviets had struggled to find a way to use the subject
of health services development to promote their accomplishments in this field.
It was a natural forum, in which they might demonstrate to the underdeveloped
world what their form of socialism could accomplish that other political systems
could not. They were successful in getting WHA23.61 adopted. They were
unsuccessful in strengthening the executive board and assembly where they
could hope to gain greater control over the work of WHO. They were again
successful in getting an agreement not only that a conference was desirable but
that it should take place on their soil.

WHY DID MAHLER NOT WANT THE CONFERENCE,

PARTICULARLY ONE LOCATED IN THE SOVIET UNION?

That Mahler did not want the conference seems clear from the steps taken to block
the idea from the first moment it was put forward. When the Soviets proposed it
during the 1974 World Health Assembly, the idea was eliminated in a working
group chaired by Professor Sulianti Saroso, a close friend of Newell. When it was
proposed during the January 1975 session of the executive board, the working
group that dealt with the subject was chaired by the U.K. representative, John
Reid, who was close to Mahler. The 1975 assembly working group, however, was
chaired by Professor Orha of Romania. Symbolically, he waived his prerogative
as chairman to allow Venediktov to introduce the revised draft resolution, which
was passed with virtually no discussion.
To answer the question why Mahler objected to the conference, we first need to
look carefully at his agenda for WHO, an agenda that was taking shape precisely
during the time that PHC was emerging as the new, post-malaria-eradication,
priority for the organization. And to do so, we need to consider where Mahler
had come from and what new ideas he was bringing to WHO.
Before Mahler was appointed assistant director-general in 1970, he was director
of Project Systems Analysis, a position to which Dr. Marcolino Candau, director-
general, had appointed him in 1969, with, as legend has it, the intention of
eventually designating Mahler as his successor. There were other candidates,
but with the support of Candau, Mahler was elected director-general and took
office in 1973. Before leading Project Systems Analysis, Mahler had been
chief of the Tuberculosis Unit at WHO headquarters (1962–1969). Earlier he
had spent ten years in India, as senior WHO officer attached to the National
Tuberculosis Programme.
Much of Mahler’s thinking on WHO’s role can be traced back to his experiences
in India. This is not the place to try to justify that assessment, but I will relate
 The Road to Alma-Ata / 717

one story he told, in perhaps 1975 (notes undated), that captures the essence of
what he had learned there. His work in India had demonstrated that TB could be
treated on an ambulatory basis. With this information in hand, he recounts,
“[we went] with tears in our eyes, to the Minister and we said ‘Madame Minister,
now that we have shown this you will have to close down all your tuberculosis
hospitals because we need the money in order to do ambulatory kind of treatment’
and she looked at me and said ‘you must be a crazy man, even an elephant would
cry over your naivete. How do you think I as a politician can close down the
hospitals, you must be mad’.”
The paradox of Mahler is that this experience did not stop him, while director-
general elect, from advising a “very powerful president of a developing country,”
who had asked Mahler what he could do to develop a health care system (which
Mahler told him he did not have) as follows: “I think the first step is to close the
medical schools for two years. Then we can discuss what the medical schools were
supposed to do, because they really constitute the main focus of resistance to
change” (18). On another occasion, Mahler related the example of a developing
country in which health was declared as “a universal human right” but in which
one found, in one province, “80 per cent of the health budget being used to support
one teaching hospital, whereas in outlying parts complete coverage is supposed
to be achieved by one general purpose dispensary for half a million people” (19).
Such statements, similar to many others I could quote here, came to be used by
many observers to characterize Mahler’s radical, anti-medical position. Lost
somewhat in this popular image was his deep allegiance to rational methods of
decision making, methods that characterize the “systems approach.”
Being an advocate of rationality did not interfere with Mahler’s somewhat
colorful impromptu speaking abilities. For example, in one meeting I recorded
him saying, “no longer is the third world happy ‘licking technical assistance
lollipops.’ They taste good but ruin your teeth and you need teeth [self-reliance]
for development.” On this same occasion, Mahler addressed the question of the
systems approach: “it should never be considered as narrow technology—then it
would oppress—it should free and enable us to see and face reality . . . and free the
revolutionaries to engage the problem of change. . . . Medical people are not good
systems people . . . systems thinking should get us out of our cocoons.”
The image of change that Mahler repeatedly evoked was change led by
enlightened leaders who would be sensitive to the revolutionary possibilities for
change emerging from within the system, preferably at the periphery, where those
in greatest need reside. He believed this model applied as much to national health
systems as to WHO. If WHO was to reform its approach as a partner to countries,
the new relationships between nations and the organization would emerge from
the experiences of a few countries, not from an overhaul of headquarters first.
WHO headquarters was an obstacle, as was the heavy machinery of the executive
board and assembly. More reliance on WHO at the country and regional levels was
required. Indicative of Mahler’s thinking is his observation, during an interview
718 / Litsios

with a Danish newspaper in early 1994, that “at times I imagine that I will get the
task of reconstructing WHO from the ground. The Organization should do the
same, but for a tenth of the funds. That would not be impossible” (emphasis
added). Only in this way could WHO-assisted country programs move from
a “patchwork of activities, lacking general purpose and balance and bearing
insufficient relationship to national development” toward “a single programme
approach within which projects should be identified as specific sets of activities
to be implemented in a given period but in relation to overall objectives”—a
conclusion reached in the organizational study “Interrelationships between the
Central Technical Services of WHO and Programmes of Direct Assistance to
Member States” (20).
This brief description of Mahler’s philosophy is probably enough to
indicate why he was in such disagreement with PHC being kidnapped by the
Soviets. As the battle lines surrounding WHA23.61 already had revealed, Mahler
found the Soviet model totally inappropriate. Not only was it highly centralized,
leaving little chance for change from “below,” but it was also over-medicalized.
There was little to be learned from the Soviet system that could be used by the
developing world.
The need to build from the ground is reflected in Mahler’s first annual report
for WHO, prepared in early 1974 (21). In this report he noted that “a turning-
point in the life of the Organization” may have been reached, which stemmed
from the “unequivocal admission” that “the most signal failure of WHO as
well as of Member States has undoubtedly been their inability to promote
the development of basic health services and to improve their coverage and
utilization.” As there were few models to “demonstrate that primary health
care can come out of the villages at a reasonable cost and in a manner that
is technically and socially acceptable,” Mahler said, it is “an urgent task for
WHO to seek a number of innovator countries that will be willing and able to set
up such systems of primary health care and demonstrate their effectiveness”
(emphasis added).
With the passing of each year, Mahler clarified his vision of a WHO that was
fully relevant to the needs of its member states. While doing so, he became a strong
critic of prevailing practices, especially those of headquarters staff, that were
not in line with this vision. When presenting to the staff, on June 8, 1976, the
implications of recent program budget proposals that would require “operational
economies in the Headquarters component of the budget,” he identified a
number of such practices (22). There is no room, he said, for what he would call
“secretariat projects” that are “so often self-glorifying and self-perpetuating.”
Nor is there room “for the writing of those documents, guides and manuals that
occupy staff excessively yet serve little practical purpose.” Only by becoming
“their pupil” could one hope to serve the regions and individual member states.
Mahler divided headquarters functions into two broad categories: information
transfer and technical cooperation. He contrasted the “collection and publishing
 The Road to Alma-Ata / 719

of nondescript information” with “genuine information transfer, using WHO

as a neutral ground for absorbing, distilling, synthesizing and disseminating
information that has practical value for countries in solving their health prob-
lems.” Concerning technical cooperation, he cited as “outstanding examples
of cooperation with the regions in meeting countries’ needs” the smallpox-
eradication program and the new program of research on tropical diseases.
Later in this essay I give further attention to Mahler’s vision for WHO. It
suffices at this point to state the obvious: no international conference could
possibly serve as a vehicle for either “genuine information transfer” or technical
cooperation, which consists of activities that “will contribute directly and
significantly to the improvement of health status.” The Soviets, of course, used
the occasion to arrange visits to show off their health services to all delegates.
WHO did what it could to make it clear that the official agenda of the conference
did not include those visits.

HOW MUCH TIME AND ENERGY DID WHO LOSE

BY HOLDING THE CONFERENCE?

To begin with, much time and effort was spent on deciding what words to
use in writing position papers. Much disagreement emerged, some of which is
described below. Such disagreement could be taken as an indication that WHO
did not know what it was writing about. Following Mahler’s line of thinking, I
would prefer to see this as an example of an inappropriate use of headquarters
time and energy. Whether or not the staff could agree on what to present to an
international conference had nothing to do with whether national governments
could or would agree to do something about their health services along the lines
discussed and agreed upon earlier.
Needless to say, considerable staff resources were used to develop the agenda
for the conference and to prepare and manage a pre-conference program. The
overall responsibility for the conference fell up the steering committee on Primary
Health Care, which consisted of two assistant director-generals, with Newell
acting as secretary. Dr. David Tejada, who joined WHO headquarters in 1974,
was the technical assistant director-general. He had previously been responsible,
in the Pan-American Health Organization, for a Latin-American planning
approach that was quite rigid and very “top heavy,” so there was reason for
concern about his being given this responsibility. Nevertheless, he brought with
him some managerial approaches that were quite stimulating, though may not
have been what the Mahlerian revolution called for.
Tejada believed that to succeed in changing WHO’s role, the staff should be
fully involved in that change. Following the much touted Japanese managerial
approach, which sought full staff consensus before implementing any new
strategy, Tejada pushed for wide-scale staff participation in all aspects of the PHC
philosophy. Five working groups were established, open to all staff interested in
720 / Litsios

participating in the development and implementation of this new approach to

health systems development. Unfortunately, this open and participatory approach
contributed to a weakening of Tejada’s authority. The backlash from the regions
was intense and understandable. Very simply put, they raised the question, how
could headquarters staff have so much free time on their hands to spend discussing
PHC at a time when the regional offices were short-handed and countries were
in need of extra hands to help implement PHC?
And discuss and write we did. For many it seemed that almost by a sleight
of hand the basic health services (BHS) had given way to primary health care.
Did this really represent a radical departure with the past? Those of us involved
in the task of formulating principles thought so at the time. But it was hard
to put one’s finger on how PHC differed from BHS. One attempt was that
PHC = BHS + community participation + intersectoral action. But then it was
noted that the original 1952 description of BHS incorporated both community
participation and intersectoral action (23). Sometime in 1976, I “discovered” the
report of the 1937 Intergovernmental Conference of Far-Eastern Countries on
Rural Hygiene, held in Bandoeng, Java, in which I found principles in total
agreement with those of PHC (24). I even managed to prepare a paper for Mahler’s
signature that speculated on why Bandoeng had not led to the changes that were
now, again, being called for (25).
A director-general’s conference was held in 1976 for all staff in Geneva to
discuss PHC. At this occasion, we saw films of different BHS projects, made in the
1950s. They were beautifully photographed. In one, the local sanitary aide leaped
on his horse and rode fast to the nearest health center to announce a plague
outbreak. In another, nurse assistants (fully dressed in uniforms) addressed a
crowd on nutritional values of foods—most of which could only be found in
developed countries. Even so, many in the audience, including a few in the
PHC organizing committee, took these examples of BHS projects as illustrating
PHC in action!
As it became clearer that an international conference could not be avoided,
pressure mounted to “define” PHC. The principles enunciated in 1975 did not
seem to be good enough. What was needed was a definition in addition to a
descriptive text that could take the form of principles if need be. Much of the latter
part of 1977 was spent on drafting definitions and descriptions of PHC. Many staff
members participated in this effort. The following is a sampling of suggestions
gathered from senior staff:

PHC is a development in health care systems that is equitable, holistic,

endogenous, need-oriented, community controlled and established on a trans-
formed and other related social infrastructures.

PHC is an approach that integrates all health activities that are carried out at
the interface between health services and the communities served.
 The Road to Alma-Ata / 721

PHC is a means of improving and safeguarding the health of communities

using, so far as is possible, community participation and resources and
complementing these, to the extent necessary, by government services.

PHC is an integrated complex of preventive, promotive, curative and rehabili-

tative services for the individual, the family and the community aiming at
making health care accessible to all people as and when required.

PHC includes those health measures and activities that are undertaken at
the first level at which the national health care system is in contact with
individuals and with the community.

One key point of contention was whether PHC activities were primarily
limited to what could be provided by government services or whether they
could also include services independent of the government and organized
“by the people.” Mahler thought the latter a real possibility, as reflected
in his statement to a meeting with UNICEF in early 1977 (I paraphrase
from memory) that he could easily imagine PHC best thriving where there
were no organized health services! The tension between advocates of a
community-centered and a health-services-centered vision of PHC continued to
and beyond Alma-Ata.
Not all staff wished to serve the needs of the conference. One of the more
dramatic bureaucratic moments I witnessed was at a meeting of the PHC steering
committee on November 26, 1976. Newell, as secretary to the steering com-
mittee for the conference, after having prepared an elaborate working paper
on preparatory steps leading to the conference, announced that “while playing
an important part in the wider WHO programme on primary health care, [the
conference] could not be thought of as the main thrust of such a programme.”
He agreed that a full-time secretariat was needed, but it should not include any
current members of the primary health care group of SHS!
Newell left WHO in January 1977. The preparatory work continued. Most
important was the drafting of the background paper for Alma-Ata. Mahler asked
Newell, who was now in New Zealand, to prepare a first draft. There is no
doubt, given the personal and professional changes in his life at that time, that
Newell experienced great difficulties in giving adequate attention to this paper.
Nevertheless, he completed the first draft by June 1977 and the second by October.
Both drafts were widely circulated within WHO and UNICEF. Everyone found
“excellent material” in these drafts, but Newell’s line of presentation proved
too complex for most and too “academic” for many to follow. Both drafts were
found to be too long and too argumentative, highlighting constraints and problems
to the detriment of solutions. My own detailed comments at the time were replete
with questions and disagreements. However, there was much to be admired in
his text, as discussed below.
722 / Litsios

Eventually, Newell’s drafts were put aside and other participants were invited
to contribute further to the elaboration of various themes and issues that had
been identified for inclusion in the position paper to be presented to Alma-Ata.
A drafting committee was established under the chairmanship of Tejeda. The
key writer of the final version was Dr. J. I. Cohen, director of Programme
Promotion. As Mahler’s éminence grise, he was in the ideal position to write
and speak on Mahler’s behalf. The text presented to Alma-Ata was simple and
brief. At the time, I was extremely disillusioned with Cohen’s product, although I
recognized that its simplicity greatly facilitated the consensus-gaining process.
Before looking more closely at what Newell had proposed that did not get
into the Alma-Ata background paper, we should briefly look at how Mahler
was portraying PHC in his “Blueprint for Health for All” (HFA) (26). Newell
was drafting his texts just at the time that Mahler was elaborating on how HFA
needed to be approached.
Mahler outlined his HFA “blueprint” in his presentation to the regional
committees. Some of its essential elements included: “adequate food and housing,
with protection of houses against insects and rodents; water adequate to permit
cleanliness and safe drinking; suitable waste disposal; immunization against
the major infectious diseases of childhood; and the prevention and control of
locally endemic disease.” The blueprint identified certain priority programs.
These included PHC—“a front-line activity that is the cornerstone to ensure
essential health for all in any society”—and the control of communicable and other
locally important diseases, appropriate health technology, drugs, basic sanitary
measures, and the people to conceive and deliver these programs and manage the
systems. PHC could not be effective alone; “it had to form part of a broader health
system, and the components of that system must be organized in such a way as to
support its needs.”
Health systems research was specifically earmarked for strengthening the
prevention and control of communicable diseases Such research was “badly
needed” and “sorely neglected.” Mahler’s frustrations with the work of the
Division of Research in Epidemiology and Communications Science in this field
no doubt led him to add the qualifying phrases: “Let theoreticians work together
with you if you need their support, but do not let them dictate sophisticated
methodologies that have not been rigorously tested. Osmotic forces will provide
them with the practical experience they need and you with any theoretical basis
that you might lack. The indispensable ingredient for successful health systems
research is tough operational discipline combined with the political guts to use
the information generated by the research.”
Mahler went on to identify some “mechanisms for health development.” Here
he included, at the national level, country health programming and national health
advisory councils and, at the regional level, regional panels of experts, a center or a
network of centers to serve the region for operational research, development, and
training in specific program areas, and technical cooperation among developing
 The Road to Alma-Ata / 723

countries. A new type of ministry of health was envisaged, ministries that

“must gear themselves in all their departments to the new role of health policy
formulation directed towards social goals, health programme formulation to give
effect to these policies, and health systems development to implement these
programmes.” The advisory council, on which the community and sectors other
than health would be represented, was one in which “health development in all its
intersectoral ramifications can be thrashed out and health economics and health
ethics can be brought together.”
Let us return now to Newell’s draft, which not only is of historical interest but,
more important for our story, allows us to better understand the difficulties WHO
was having in positioning PHC within the wider domain of social and economic
development. I review here two aspects of his material, those portions that
addressed poverty and those on appropriate technology. Newell drew heavily
on Mahler’s notion of “social poverty”: unemployment and underemployment,
economic poverty, a scarcity of worldly goods, a low level of education, poor
housing, poor sanitation, malnutrition, social apathy, and a lack of will and
initiative to make changes for the better (27). These points can be seen in the
following selections from Newell’s draft (28):

Social equity in health cannot mean that all people should receive an equal
health expenditure because their needs vary grossly and the whole idea of a
national service (whatever alternative form) is a pooling of resources for the
good of all. At the other extreme it cannot mean that every person in need
should be able to receive automatically the ultimate extreme expression of
technological sophistication because we are aware that this is an open ended
possibility to which not even the richest country can hope to aim, and which
may not even be useful.
If neither of the decision extremes is acceptable there needs to be some
criteria developed to decide where in each sub-problem the resource allo-
cation point in the spectrum should be. At present the unstated criteria is often
technological efficiency, cost, and the ease of application and administration.
It has proved easier to decide upon building a hospital than a health centre; to
agree upon a health service in the big cities where there are doctors than in a
rural area where they are few and far between; to invest in an intensive care
unit rather than in a bicycle for a nurse. The Primary Health Care criteria in
this dilemma are:
—the use of “appropriate” technology;
—concentrate upon the simple things first;
—start from the periphery of the pyramid;
—overcome selection of those in need on the basis of poverty or geography;
—make debate upon the implications of such decisions public and not
restricted to the technocrats.
Curative medicine is largely ineffective in decreasing the ill effects of
poverty related ill health. Immunisation against measles for those children at
risk decreases measles, but the same or similar children can then die from
724 / Litsios

dehydration following diarrhoeal diseases or pneumonia. Those suffering

from protein or caloric malnutrition and who are “treated” appear to return
frequently or be repeaters. The expressions of a poverty syndrome may be
highly specific such as xerophthalmia, but frequently there is a wide range of
possible expressions resulting from similar causes. It is like a leaky bucket
which does not hold water even if you plug one of the holes.
It has been said that, by definition, a person or family in poverty cannot be
healthy whatever other measures a health service can take. The reverse may
not be true and a non poverty family while being assisted by a health service
can be healthy without it. Does the health sector feel strongly enough about
this to suggest that it could be justified on health grounds to use health
resources for measures to decrease poverty or even to transfer health resources
to other sectors which may be able to do this more efficiently than they?
A further level of action could be a more restricted but specific one of
concentrating upon those fragments of the poverty groups whose poverty
is partly related or dominated by health hazards, and trying to decrease
their risks.

In the final version that went to Alma-Ata (29), references to poverty were
reduced to two points:

In developing countries in particular, economic development, anti-poverty

measures, food production, water, sanitation, housing, environmental pro-
tection and education all contribute to health and have the same goal of
human development.
The other levels of the country’s health system can also assist development
on condition that they are attuned to providing support to the full range of
primary health care activities. For example, they can concentrate selectively
on combating health risks which directly or indirectly influence poverty.

The Declaration of Alma-Ata makes no reference to poverty.

This lack of any reference to poverty can be explained by the manner in which
the Alma-Ata document approached the relationship between PHC and health
development. Whether Mahler had changed his ideas on this relationship between
the time he introduced his notion of “social poverty” in 1975 and the time of
Alma-Ata is not clear to me. However, certain developments suggest that he
had done so.
In 1976, the U.N. system launched one of its periodic battles against poverty,
this one in the context of rural development. Only after Alma-Ata did I find a file
that contained minutes of various internal meetings on this subject. These minutes
and related notes portray Newell strongly promoting the idea that WHO should
take a firm position on poverty, and Mahler replying that he was not prepared to do
so until it was clearer just what role Newell had in mind for the organization.
A revealing statement, which by chance I overheard, was Mahler saying to
Newell “thanks for nothing” at the end of the World Health Assembly debate in
 The Road to Alma-Ata / 725

May 1976 that had led to the adoption of resolution WHA29.74—which, by the
way, requested the director-general “to take appropriate steps to ensure that WHO
takes an active part, jointly with other international agencies, in supporting
national planning of rural development aimed at the relief of poverty and the
improvement of the quality of life” (16). My interpretation of Mahler’s “thanks
for nothing” is that the issue had not been aired properly. No discussion had
taken place during the 1976 assembly on the role for WHO. The issue had found
its place in the resolution only because it was in the secretariat’s background
paper and no one had objected to its inclusion. This was a far cry from the ideal
situation, in which the governing bodies would have given their total and con-
sidered consent to WHO taking “an active part” in anti-poverty planning efforts.
Resolution WHA29.74 referred to “the relief of poverty and the improvement of
the quality of life,” whereas the Alma-Ata document confined itself to indicating
that the shape of PHC “is determined by social goals, such as the improvement
of the quality of life and maximum health benefits to the greatest number.”
PHC could not be expected to relieve poverty on its own. Instead, it could
contribute to making people healthier; as a result, they are “more likely . . . to be
able to contribute to social and economic development, and such development
in turn provides the additional resources and social energy that can facilitate
health development.” Presumably, the health sector would have a greater impact
on poverty alleviation through actions at the central level, such as strong policy
positions developed by the national advisory health council.
Such a role for the health sector, while less than what Newell and those of
us involved in the interagency rural development exercise had in mind, is not
unreasonable and may in fact have been a more realistic role for WHO at the time.
But this role should have emerged from a deeper consideration of what HFA
was all about. No serious discussion of HFA took place. It was even mocked
by high-level staff, who counted the number of days remaining until the end of
the century. But after four years of debating what PHC was or was not, Mahler
probably concluded that rather than continuing further debate on the subject of
HFA, it was time to move on to action. The only real hope was to find a sufficient
number of countries ready to demonstrate that the health sector could be deeply
and productively involved in achieving truly social goals. Once that happened,
WHO would align its strategies and programs accordingly.
Concerning appropriate technology, Newell had this to say in his draft for
Alma-Ata (28):

There is already a large body of opinion that considers that the precursors of
health and ill health start with factors abutting directly upon the individual and
the family, and that the life styles of communities matter (on health grounds).
If by knowledge, encouragement, agreement and understanding these factors
were known and accepted, then it might also be agreed that individual and
community funds could be used to further actions which would alter them.
726 / Litsios

If certain sanitary and environmental hazards exist in relation to water,

refuse disposal, housing, or living practices, it would appear more rational to
encourage villagers to study and solve such things for themselves rather than
to buy solutions for them.
Appropriate Health Technology starts with a health problem, but one within
its human and social context. The question is not just how to decrease the
incidence or prevalence of malaria (for example), but how this can best be
done in this or that country or in this or that group of very similar countries. It
takes not only the varied determinants of disease and the present drugs or
methods as its initial base of knowledge, but also the way in which people live,
what resources are available, the structure of the health delivery mechanisms,
and what people think is important. Consideration of such complexes
expressed as the implications of strategies and tactics requires more than
technological or bureaucratic debate. Most of the issues, that influence which
choice is to be made, can be properly discussed by all people even down to
the village level. It may be that such a review results in the conclusion that
nothing is useful and can be used to identify new areas of research. However,
frequently it shows positively that there is an acceptable strategy if some of
the essential pieces are developed further.
Much of the world is locked into a position where one starts with certain
classes of health workers (doctors, nurses, pharmacists, etc.) and then asks
[how] they can best be used or distributed. This seems to be a strange and
upside down way of asking what needs to be done and then passing on to who
should do it and in what way.
If one of the directions of PHC is to try to move towards the periphery
and to encourage actions as near to the people as possible, we can either say
that every family or community should have a nurse or a doctor or other
similar professional, or we can say that one list of actions can be done by a
person himself, or his family, another by this person of such a skill and role,
and so on up the training ladder.
Many immunisations are given by injection and there may be diffi-
culties, dangers, or major costs in arranging for injections to be given by
a health aid in a community. Therefore arguments are put forward that
the health aid should be better trained and equipped or that a different
level health worker should visit communities and give immunisations.
But these arguments may not be valid if the manpower difficulty were
widely known and linked with appropriate health technology and work
was started to develop oral vaccines, or ones that would pass through the
skin by means of impregnated sticking plaster or some such means. If this
need could be met then what health workers should do could be changed
and some actions could be transferred to the village aid, the school teacher,
or the mother.

The text that went to Alma-Ata certainly highlighted the importance of this
issue, but it lacked the vivid images that emerge from Newell’s draft. Also lacking
were the technical implications of how such knowledge of technology could be
obtained and used at the periphery by PHC workers. Here, the text should have
 The Road to Alma-Ata / 727

made reference to health systems research and even the contributions of regional
expert panels and collaborating centers.
Cohen’s paper to Alma-Ata, while touching on all aspects of HFA, as Mahler
had outlined earlier, concentrated on PHC. It was weak when discussing the
needed reforms at levels beyond the “front line” where PHC was to dominate. Its
simplicity belies the political challenge needed to bring about the changes it called
for. One example of this is the brief discussion under the heading “Logistics
of Supply.” Here, the text indicated that “once the decision has been taken to
adopt primary health care, it is necessary to make supplies available to the
community on a priority basis.” Not only was PHC reduced to a “decision,” but the
whole system of supplying the front lines with priority supplies was simply
expected to follow. Adding to the confusion of what PHC is and is not, it now
included all the essential elements for HFA that Mahler had identified, and it
had become the location where all “related sectors and aspects of national and
community development” were to be involved, as called for by the Declaration of
Alma-Ata. Alma-Ata had no choice but to make PHC the “key” to HFA.
More importantly, the Alma-Ata paper clearly was saying that enough was
known to implement PHC. This was a radical shift from the executive board’s
position paper in 1972, which called for the “utilization of trial areas” to test
methods and means “to make sure that they are suited to local conditions and
will enable the objectives to be attained with the resources available” (30). As
subsequent events would demonstrate, the Alma-Ata statement proved grossly
overoptimistic.

WHAT IF NO CONFERENCE HAD BEEN HELD?

In 1973, the World Health Assembly, in resolution WHA 26.35 (16), called upon
WHO to
concentrate upon specific programmes that will assist countries in developing
their health care systems for their entire populations, special emphasis being
placed on meeting the needs of those populations which have clearly insuffi-
cient health services;
improve its capability for assisting national administrations to analyse their
health delivery systems through organized research projects with the goal of
increasing efficiency and effectiveness;
so design its programmes as to encourage Member States to develop a strong
national will to undertake intensive action to deal with their long-term health
care problems as well as their immediate requirements in a form designed for
orderly development of health services, WHO resources being made available
to, and concentrated on, such Member States as have this will and request
assistance;
further develop management methods suited to health service needs and assist
countries in developing a national capability of applying these methods;
encourage and participate in gathering and coordinating local, national, interna-
tional and bilateral resources for the furthering of national health service goals.
728 / Litsios

And in 1975, the JCHP (31) called upon WHO to

study in detail not only the innovations described in this study but also those
that are occurring continuously in different parts of the world under different
sponsorships; record and monitor them; learn from them; evaluate them; make
their results widely available . . .;
pursue research on the effects of rural and community development on the
health of people and on the role that other sectors can play in the delivery
of primary health care, develop methodology for application of the findings,
and assist in its implementations;
seek the definition and adaptation of medical and health technology so that
primary health care workers can use as much of it as possible.

These resolutions were fully in keeping with Mahler’s vision for WHO. Most
importantly, WHO had in UNICEF a fully engaged partner; for the first time,
UNICEF and WHO were working together. Previously, the term “joint” had
simply applied to meetings between the executive boards of the two organiza-
tions. Following the 1972 joint organizational study on “alternative approaches,”
UNICEF staff actively participated with WHO staff to promote PHC and related
ideas. For example, following the 1972 JCHP study, all UNICEF field staff were
instructed to explore the possibility of initiating PHC-related efforts (32).
Had no conference taken place, there is little doubt that these joint efforts would
have intensified, especially in support of those countries that were willing to move
in the PHC direction. While we cannot say today whether such efforts would have
paved the way for a truly successful “revolution in health,” the chances for PHC to
take root would certainly have increased and the subsequent expansion of goals in
keeping with the broader mandate of HFA would have been greatly facilitated.
Had WHO, jointly with UNICEF, been able to “record and monitor [innova-
tions]; learn from them; evaluate them; and make their results widely available,”
an earlier and more impressive start would have been made. This would have
led to something more substantial to build on and more convincing to donor
agencies that preferred to “wait and see” before supporting approaches to
“meeting basic health needs in developing countries.” Also, WHO might have
been able to explore UNICEF’s recommendation that a “country’s primary health
care organization would be most effectively attached to the Prime Minister’s
office or another organ with intersectoral responsibility,” a recommendation
that WHO did not allow to appear in the joint paper that went to Alma-Ata (32).
As it was, UNICEF’s active involvement in and commitment to PHC and HFA
did not survive change in its leadership. When James Grant took over as executive
director in 1980, UNICEF moved in the direction of “selective PHC,” a direction
that Newell later described as a “counter-revolution”—a revolution that had
already started at Alma-Ata, where PHC was identified with a “list” of health
problems that needed to be addressed (33).
 The Road to Alma-Ata / 729

While Newell had demonstrated some ability to involve WHO headquarters

staff in promoting PHC in several countries, the results were far from dramatic
when looked at from a global perspective, although some very important develop-
ments did occur. One experience, included in Newell’s book, was a health services
development project in Iran (11). I mention this not only because it was the
only one in which I had some, albeit minor, involvement, but because Iran’s
experience deserves wider recognition (35). It was one of the few health services
development projects in which WHO was deeply involved from the earliest stages.
It survived the fall of the shah, and it seems to have formed the basis for the
subsequent evolution of the Iranian health system.
Iran was the first country in which a health services development institute was
created with the involvement of WHO. The essential idea of health services
development institutes was to facilitate the conduct of studies aimed at develop-
ing “a national capability of applying” methods and the results obtained. The
methodology of country health programming, developed earlier by a Project
Systems Analysis team under Mahler’s leadership, was being progressively intro-
duced in a number of countries at that time. It was WHO’s strategic wedge for
introducing change in national health systems. But country health programming
was a national responsibility, with WHO assisting upon request.
Mahler’s vision for WHO’s deeper involvement in socially relevant technical
cooperation included a heavy investment in building up WHO at the country and
regional levels. In 1974 he was already advocating for a strengthened role for
the regional committees and regional offices, in order to “develop an increased
capacity for political persuasiveness” on the part of WHO (36). Also, Mahler
envisaged that the WHO representatives would be stimulated and guided in this
regard, since it is on the representatives that “this new WHO statesmanship would
undoubtedly devolve, as well as heavier technical functions.” This would require
“a new type of WHO staff member,” one “thoroughly reoriented in modern
health management.”
If the collapse of the malaria-eradication campaign was the single event that
revived interest in basic health services, then logic suggests that PHC and HFA
should have addressed the problem of malaria as a first priority. I have no
knowledge of whether serious consideration was given to this direction of effort,
but at this point, thirty years after the collapse of that campaign, when malaria is
still a major killer and getting worse, the suggestion cannot be avoided (37).
Africa was then, as it is today, the region where malaria is most prevalent: more
than 85 percent of the world’s malaria cases and deaths occur on that continent.
However, Africa was largely neglected in the course of the global eradication
campaign (38). Although most observers understood the 1969 decision as marking
the end of that campaign, important vestiges from that period still dominated the
minds of most WHO malariologists (39). A major interregional conference was
organized in Brazzaville, Republic of Congo, in late 1972, entitled “Malaria
Control in Countries Where Time-Limited Eradication Is Impracticable at
730 / Litsios

Present” (40). The results of this conference could have been used later to justify
the creation of a regional panel of experts for Africa, whose mandate would have
been to provide the needed technical advice to governments engaged in controlling
malaria as best as they could with the resources available. What would have
emerged from such an investment of WHO’s resources is anyone’s guess. As it
was, the issue of malaria control and PHC did not become a major subject for
discussion at the global level until the 1980s.
Malaria control would also have provided an excellent example of what
was meant by achieving a “level of health that will permit [all citizens] to lead
socially and economically productive lives,” as called for by HFA. As Norman
Howard-Jones, a WHO staff member from 1948 to 1970, has pointed out, “this is
a far cry from the definition of the WHO constitution, but at least it is nearer
to reality” (41). Given the current deteriorating situation of malaria control, it
is perhaps not unreasonable to suggest that had the issue been addressed by
mechanisms promoted by Mahler under the banner of HFA, malaria would not
be the problem it is today.
I have chosen to use malaria to illustrate “what might have been” because this
is the area about which I am most knowledgeable. Other possible lines of action
that might have been followed include exploring more deeply, in countries, the
serious questions raised early on about the political feasibility of PHC. For
example, Charles Elliot (42) suggested that PHC might become no more than
a new form of “professional domination,” as suggested by:
—local communities tending to give health care a low priority,
—local communities making the “wrong” choices,
—the rapid professionalisation of frontline workers,
—the overstating of disease effects on a community.

No doubt I could give other examples to make the same point, namely that the
period 1972–1978 could have given rise to real progress in the field, from which
the right words might have followed to stimulate others to follow suit. But more
important than the “right words” is that real progress in enough countries might
have allowed Mahler to redesign WHO “from below.” Instead, this period saw
headquarters playing the dominant role in defining health policies for member
states, with the expectation that regional offices would line up in support of the
same policies. The regional offices I visited at the time resented this imposition,
but this did not prevent them from participating fully in the preparatory work
for the conference to ensure its success.
Ironically, while Alma-Ata and HFA helped establish a policy-making frame-
work that encouraged the decentralization of WHO, many new, donor-driven,
Geneva-based initiatives were established during Mahler’s period in office. Donor
agencies were not ready to follow suit—that is, to work together in individual
countries, fully committed to the goals of HFA/PHC, rather than develop indepen-
dent programs managed from Geneva. Thus, instead of this period building a new
 The Road to Alma-Ata / 731

relationship between WHO headquarters and the regional offices centered on the
successful work of innovator countries, the antagonism that had existed between
the two levels since the organization was founded only became more pronounced.
All this cannot rightly be blamed on Alma-Ata, but it cannot be denied that Mahler
was sidetracked and lost so much time and energy that he lost the impetus he had
had when he took over WHO in 1973. But all this is personal speculation; others,
no doubt, would reflect differently on “what might have been.”

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