Health Policy and Development Department of Health Sciences of Uganda Martyrs University ISSN: 1728-6107 EISSN: 2073-0683 Vol. 2, Num. 1, 2004, pp. i-ii

Health Policy and Development Journal, Vol. 2, No. 1, April, 2004, pp. i-ii

Editorial

FROM ALMA ATA TO MILLENNIUM DEVELOPMENT GOALS: 25 YEARS OF BROKEN PROMISES?

Code Number: hp04001

Between September 6 and 12, 1978, UNICEF and World Health Organization (WHO) convened an international conference on Primary Health Care (PHC) in Alma Ata, a small city in the former Union of the Soviet Socialist Republics (USSR). The conference was concerned with basically three key issues: one, the widening gap in health between developed and developing countries; two, medicalization of health without addressing the wider causes of poor health; and three, health care systems were becoming complex and socially irrelevant, as they were being distorted by technology and trade.

At the end of the historical and emotional conference, UNICEF and WHO published a joint report (WHO, 1997). The meeting agreed that a PHC strategy was to be adopted to solve the global problems of health. PHC was defined as essential care that is accessible, affordable and acceptable to all, and implemented with everybody’s participation. It was to be part of the overall development of a nation. It was valid for all nations, whether developed or under-developed. Its form would vary with political, economic, social and cultural contexts. However, it would be shaped by the social goals of equity and maximization of the quality of life for the greatest possible number of people in a country. It would require appropriate technology, community health workers and traditional birth attendants at community levels of care; health system reorganization; inter-sectoral collaboration; learning through experience; and operational research.

Resistance was expected, as PHC would bring about far reaching changes and consequences. But with political will and community involvement, it was hoped that PHC could be implemented. Medical industry was encouraged to get involved in producing low cost technology. Particular note of resistance to PHC was noted from economists who did not regard PHC as a serious strategy. They argued that what a country needed was economic growth, which would bring about in its wake the solutions to all health problems. Note was also made of the misguided support for PHC because it was thought to be a cheap form of health care system.

It was agreed that political commitment would only be demonstrated by the level of resources committed to PHC, and in particular the proportion of the national budget that would enable whole populations to have access to basic health care. It was resolved that there was need for an international mechanism to achieve a fair health distribution based on an explicit global health policy. There was therefore need for a global governance for PHC, where non-Governmental Organizations (NGOs) were urged to participate. Countries were urged to put PHC high on the policy agenda.

Targets for health for all (HFA) had been set in the World Health Assembly (Resolution WHA 30.43 of 1977). The resolution defined HFA as the "attainment by all citizens of the world by the year 2000 a level of health that will permit them lead a socially and economically productive life". The targets were later set as follows; that, by the year 2000: 1) the minimum life expectancy anywhere in the world would be 60 years; 2) infant mortality rate would be 50/1000 at most anywhere in the world; 3) 90% of infants in any country would conform to the national nutritional reference (i.e. at least 90% of children would be well-nourished in any country); 4) under-five child mortality rate would not be more than 70/1000 in any country; and 5) maternal mortality ratio in any country would be reduced by half from its baseline value in 1978 of each country (WHO 1997).

On the eve of the magical year 2000, when these health targets should have been attained, it became clear that none of the targets could be met. In fact, a considerable amount of social welfare and health gains made in 1960s and 1970s were found to have been eroded by the year 2000 (WHO, 2003). Therefore, a new strategy had to be adopted to push the health and social welfare agenda forward. The strategy was the Millennium Development Goals (MDGs), which set new social welfare targets for the year 2015, with the global partnership as the envisaged mechanism for attaining the targets.

To reflect on these historical health sector events spanning 25 years, the Department of Health Sciences of Uganda Martyrs University (UMU) organised a conference from December 8^th to 9^th 2003 on the theme "From Alma Ata to the Millennium Development Goals: 25 years of broken promises". Every year the department organises a conference on an important health related issue. The year’s event was particularly important as it fell on the 10^th anniversary of Uganda Martyrs University and on the 25^th anniversary of the Declaration of Alma Ata.

Fourteen speakers from the Uganda Ministries of Health and Finance, Makerere University, National Council for Children, UNICEF Uganda, UNICEF headquarters in New York, WHO headquarters in Geneva, the Department of Health Sciences itself, presented and discussed a wide range of topics. Among the participants were Members of Parliament, representatives of various Non-Governmental Organizations active mainly in the health sector, the UCMB (Uganda Catholic Medical Bureau); the UPMB (Uganda Protestant Medical Bureau); International Aid Agencies such as DANIDA and Irish Aid, District Health Offices, and Diocesan Health Offices. Many representatives from national and international organizations had been invited.

Important issues were discussed, ranging from the historical events and movements of ideas that led to the formulation of the principles of PHC described in the Declaration of Alma Ata in 1978, to the ways in which this had been attempted, betrayed, and made to fail. There was a near unanimous agreement on the fact that countries did not keep PHC promises. Neither did any of the other alternative strategies put in place, from the Selective Primary Health Care to the Bamako Initiative, to Health Sector Reforms, deliver the goals agreed in PHC.

On Bamako Initiative (BI), Dr Paganini, the former head of the Bamako Initiative Management Unit in New York, observed that its main objective and its very spirit were often misunderstood and betrayed. He argued that the BI was not so much about money and revolving funds to buy drugs. It was mainly about communities controlling resources and making decisions. It was about "empowering" poor communities, an often-abused concept that even in the case of BI was obscured, often intentionally, because of its obvious political overtones. Politics has been recognised as the hub for health policy-making and, even more important, of health policy implementation. Politics deals also with how resources are used and distributed. However, words and action, real commitment to poverty eradication and lip service never converged.

MDGs were discussed in the UMU conference. To those who see them as the "latest lullaby to keep poor nations sleeping while rich nations keep robbing them", this dangerous possibility is ominously there. It is looming. But the fact that about 140 Heads of State and Government from as many countries put their signature on the goals cannot be ignored. They solemnly took the commitment to:

1. Eradicate extreme poverty and hunger
2. Achieve universal primary education
3. Promote gender equality and empower women
4. Reduce child mortality
5. Improve maternal health
6. Combat HIV/AIDS, malaria, and other diseases
7. Ensure environmental sustainability
8. Develop a global partnership for development (UNICEF 2002)

Will the MDGs be achieved? Doubts have already been expressed and they seem more than justified. Achieving them is possible. The resources are available. It is their use that must be decided upon. The MDGs are, and must be seen, as a real test of relevance for the "powerful of the world". The politicians, the rulers and those who decide on how resources are shared and if they must be used to promote better living conditions for all, have a case in their hands.

When HFA was adopted as an imperative social goal for the world community, the year 2000 seemed very far. The same could be said for the goals set in September 1990 in the World Summit for Children (UNICEF 2002). Now ambitious but imperative Millennium Development Goals have been set to be achieved by the year 2015. How likely is it that by the year 2015 the promises will be kept? The "world community" can and should do better. We all can do better. A better legacy can and should be left to the future generations.

• UNICEF 2002 A World Fit For Children: Millennium Development Goals, Special Session on Children. Documents, and The Convention on the Rights of the Child. UNICEF, New York.
• WHO 1997 Health for All: Reflections at Midterm WHO, Geneva.
• WHO 2003. The World Health Report 2003: Shaping the future. WHO, Geneva.

Copyright 2005 - Department of Health Sciences of Uganda Martyrs University