On the 25th and 26th of October, a critical mass of high level policy makers, experts and health workers met in Kazakhstan under the leadership of the WHO, and signed what is being called the Astana declaration. The declaration builds on and reaffirms the more famous Alma-Ata declaration from 40 years ago, and aims to transform the way health systems function worldwide. For such an important event, it’s received very little attention in the popular media.
So what is it all about, and why should we care?
The Alma-Ata declaration, signed by 100 countries back in 1978, marked a transformative shift in how the world thought about health and healthcare. After an attempt at targeted disease elimination in Mozambique went tragically wrong, costing thousands of lives, a number of countries got together and decided it was time for a change. They decided that the way to save lives was by looking at three things differently: first, that good health was a right of every person, and so the state should consider it a responsibility to ensure access to it. Second, that health is the result of not just the availability of treatment, but the social and economic factors that make people vulnerable to illness, and these need to be addressed to prevent illness from occurring. And finally, that since most countries with the lowest levels of health were poor, and primary health services are the most cost-effective way to improve, these services would be the priority focus of the health system.
In the years since Alma-Ata very few countries have actually implemented this approach, but those who have, like Vietnam, Thailand, United Kingdom, Canada and Nicaragua, have reaped the benefits. These countries are able to boast much better health outcomes—comparable to high income countries—at much lower levels of health spending. So why did everyone else fall behind? Alma-Ata wasn’t binding on signatory countries, and had many opponents: principally those who either felt it was too idealistic, or those who felt it wasn’t the right way of doing things. The realists believed that investing in health systems without specific, narrow targets would be an inefficient use of resources: they developed a targeted approach to primary healthcare instead, which focused on achievable, measurable goals like increasing breastfeeding, use of family planning, and vaccinations. The naysayers simply felt that primary healthcare wouldn’t solve the big diseases which were the real problem—and that increasing investment in research and development of treatments for those were a greater priority. These groups actually defined the direction taken after Alma-Ata by many health systems around the world.
Wise words at Astana
Primary healthcare doesn’t just address illness before it goes critical, it also improves people’s quality of life by preventing diseases from happening in the first place. For instance, anaemia and malnutrition weaken people’s immunity, so they become more susceptible to every other kind of disease. Despite this being well-established, around half of Indian women are still anaemic today, causing grave risks to their everyday health, to the outcomes of their pregnancies, and the health of their unborn children. Nutrition counselling and food supplementation could so easily change all that.
Recognising this, the community that met in Astana resolved to return to the basics of what we know. They signed an agreement that the health systems of the future would provide high-quality, affordable and accessible healthcare to all; that not just health workers but entire societies and environments would consider the health of their residents a priority; and that communities would themselves lead this effort, through health systems that are accountable to their users.
What did the Astana Declaration add to the already widely endorsed Alma Ata Declaration? It emphasizes people as ‘owners’, ‘advocates’ and ‘architects’ of their own health and the healthcare they need, it envisions societies, environments and systems that treat those needs with quality and dignity, and it enjoins systems to focus on the most excluded through better financing, regulation and accessibility through technology.
However, as with Alma-Ata, there are plenty of criticisms of the Astana declaration: that it doesn’t set out measurable commitments; that it doesn’t do enough to address the effects of economic inequality, climate change and poor governance on health; and that it still isn’t binding in any way.
So what does Astana mean for India’s health sector?
More attention to health workers, innovative technologies and integration of service delivery systems creates new areas for investment and synergy for private players. At the conference India’s Health Minister, J P Nadda, announced that India’s new Ayushman Bharat Health and Wellness Centers were an attempt to move towards exactly this kind of comprehensive primary health care. Multi-sectoral collaboration, as Mr Nadda pointed out, will be required, bringing insights and leveraging resources from different sectors to strengthen health outcomes.
Models from smaller, civil society actors can show the way: The Invest4Wellness program, a primary care model that integrates health and wealth interventions as well as a strong outreach component for engaging communities in their own healthcare, is one such system innovation.
Healthcare, as Alma-Ata first pointed out, has a two-way relationship with society and the economy: good health is key to building resilient economies and cohesive societies, and social and economic factors are in turn key determinants of a population’s health status. So if you do not care about primary health care for the country who else will? The Astana 2018 Declaration puts communities at the heart of it all, fuelled by good systems, structures, resources, technology and policies….the one strong step towards achieving Health For All.
Dr Angela Chaudhuri is an international public health expert and a freelance journalist. She is a Director, Swasti Health Catalyst and serves on the board for The Partnership of Maternal Newborn and Child Health. She leads Learning4impact knowledge collaborative supported by USAID India Health Office.
Rhea John works on research communications, social policy and inclusion as Knowledge Distiller at Learning4impact.