Primary Health Care and England: The coming of age of Alma Ata?

Abstract

The Alma Ata Declaration is now 28 years old. This article uses its framework to assess the changes that have occurred in recent years in the English health system. It summarises the health reform changes that have occurred internationally and those in the English health system in two eras, pre- and post-1997 – when the Labour Party came to power. It concludes that linked forces of managerialism and consumerism have had an impact on the health system which has undergone a number of structural changes in recent years. It suggests that the original Alma Ata focus on equity is being modified by the concept of choice. The tensions between central priorities, often reflected in targets, and local accountability and needs are explored. There appears to be a greater interest in seeking genuine health (rather than solely health care) change, with attendant public health and partnership policies, however the gap between policy and practice still needs to be bridged, and questions as to the appropriate locus and leadership for health promotion activities addressed. However there have been numerous institutional changes which carry the danger of distracting from the purpose of achieving health change, and which continue to raise questions as to the appropriateness of a market model for health. Finally the paper argues that the PHC framework of Alma Ata remains a useful framework for assessing health systems, but needs to be tailored to, and prioritised within, a political dynamic.

Introduction

Two years ago, the 25th anniversary of the Alma Ata Declaration passed quietly. Yet for many health systems, especially in low-income countries, Alma Ata with its Primary Health Care (PHC) strategy was influential in setting the health policy agenda during the 1980s. In contrast, in high-income health systems, such as the UK, the Primary Health Care strategy was ignored as irrelevant on the presumption that primary level services were already well-developed. Although referred to as “the cornerstone of health services system in the United Kingdom as well as in many countries” [1] the interpretation of PHC as a focus on services, ignored, as we shall argue, the wider universal principles underpinning Alma Ata [2]

However by the 1990s the Alma Ata polices were overshadowed by policy fascination with health sector structures and reforms. Indeed in some parts of WHO, its original sponsor, it was even regarded as an historic process with little current relevance. Yet the agenda set by Alma Ata is re-emerging albeit hesitantly in key international policy organisations including WHO [3], [4], [5], [6].

This article assesses the current health policies and system in England [7] against the PHC approach. It starts by summarising the key elements of Alma Ata, and analyses the historical shifts that have occurred since then. It then assesses the current health system in England using the PHC principles and concludes by identifying future challenges.