From Alma Ata to UHC: even more than before, accountability will be key

By on May 25, 2018

DGD funded student/ researcher

Almost right after the Alma Ata declaration forty years ago, health started being treated (again) as a problem in search of technical solutions: good policies, drugs, reformed financial markets, …. When correctly mixed as prescribed, results are down mostly to implementation, was the predominant message, in spite of the (just agreed upon) Alma Ata declaration. Since then, the world has certainly seen an abundance of these ingredients without the expected end result, though – health. There is progress on some health indicators, certainly, but by and large, ‘Health for All’ has not been realized, and that’s putting it mildly. Increasingly, the world seems to be heading for a perfect storm.  Alma Ata 2.0 will have its work cut out.

In this period of renewed global commitment to achieve Universal Health Coverage (UHC) by 2030, should we simply recycle these ingredients or come up with new ones? What could we do differently? These were the thoughts on my mind as I received an invitation to speak at an annual high-level global health pre-World Health Assembly workshop in Geneva. Organized by the International Federation of Medical Students Association (IFMSA) as part of activities leading to the 71st World Health Assembly, the panel discussion focused on challenges on the road to UHC, with the aim of generating discussion around the wide range of circumstances that exist across the world and at different levels regarding the realization of health for all.

Among others, I heard about challenges impeding access to drugs and vaccines. For example, issues around transparency between pharmaceuticals and countries with respect to drug and vaccine pricing featured prominently at the workshop. How do we align the commercial interests of drugs producers with the social goals of universal access to drugs, particularly among populations that do not constitute an effective market? In the increasingly large and complex network of actors, how do we pin down “who” is accountable, to “whom” and for “what” in terms of drugs and vaccines access? Progress is being made though, with Brazil’s recent example of being able to negotiate a huge price reduction for Hepatitis C treatment, while rejecting unfair patents for hepatitis C and HIV treatment.

The discussions also touched on existing challenges with social and financial protection for health. Panelists made clear that healthcare is not a luxury and that universal healthcare is achievable for all countries and at every income level. A core question arising then was: what is the best financial arrangement to achieve UHC? To answer this, the panel acknowledged that every country’s journey to UHC is unique, and that it is unproductive to speculate on a “universal” financial pathway or framework towards UHC, although many proven financial arrangements exist. What is clear, however, is that UHC is impossible without full involvement and commitment of the government. Whether UHC is achieved, eventually, is inextricably linked to broader equity efforts of redistributing power, and resources. ( In this short editorial, we make abstraction of Richard Horton’s very valid point that UHC is never fully guaranteed and is thus a permanent political struggle rather than a destination. )

While it is impossible to have a universal framework for UHC’s realization, the plurality of pathways to UHC also throws up a bigger challenge. How do we make sure that actions are consistent with the goals of UHC? The renewed push for ‘health for all’, in the current framing of UHC, on the eve of celebrating 40 years since Alma-Ata (which includes a renewed focus on primary health care), is perhaps an important occasion to reflect on the changing dynamic of global health landscape. Many of the barriers to achieving health for all since Alma Ata remain firmly in place, but significant changes along power structures, new technological trends and social upheaval at national and global levels have also occurred over the past decades. Some of these changes come with innovative opportunities that make UHC (more) possible (for example innovation from better technologies), but it’s obvious that many of these changes have also brought about new challenges and even threats (for example, increased actor diversity in the global health landscape) that may constrain UHC. All this calls for better political- rather than technical – strategies that can leverage the changed power relationships while taking advantage of the new opportunities.

Even more important, however, is how to tackle the question of accountability in the Alma Ata 2.0 era. This goes back to the question of “who” is accountable to “whom” and for “what”? While we can agree that the answers to these questions are context dependent, it should be borne in mind that failures at global levels often have destructive effects reverberating through health systems at all levels.

Recently, I came across the following quote by H.L Menken: ‘For every complex problem there is a solution that is simple, direct, understandable and wrong!’  A very apt quote in the era of wicked problems, also in the area of health.  Having said that, I would still argue that one issue is key on the road to UHC: accountability at all levels. Accountability is often lacking, unfortunately.  This is not to suggest that other challenges are less important or haven’t evolved over time but rather that accountability is the one cord that binds almost all other (UHC related) challenges together. In light of increased complexity and actors, accountability seems even more important than before.

Accountability- It may be simple, direct and understandable but this time it is almost certainly right. UHC needs more of it; Alma Ata 2.0 also.

So we better get it right this time.


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