In the autumn of 1978, the world was smack bang in the middle of a cold war that was (again) deteriorating rapidly, yet within the global health community, a different kind of war was being waged. In the battle against ill-health, the rallying cry was “Health for all by the year 2000”, Primary Health Care (PHC) was seen as crucial to achieving that goal, and “Alma Ata” was born.

In the period immediately after the declaration, there was a wave of optimism around this new idea which promised to revolutionise healthcare, unfortunately, it was quickly replaced by a more “pragmatic” view of the concept,  due to a number of reasons. Sounds a bit like the average marriage, doesn’t it? These days, it even seems that the global health community has moved on, as talk has turned to Universal Health Coverage (UHC). The new Alma Ata 2.0 declaration positions PHC very much as a “means towards achieving UHC”, for example.

So 40 years on, and the equivalent of a middle aged human, what can be done to keep the Alma Ata vision relevant?

We have borrowed from the advice given to people who are experiencing a midlife crisis, and tried to adapt it to fit this context.

1. Appreciate the life you have. A lot has been achieved since the conference in Kazakhstan, and while the goal of health for all is far from being achieved, it is important that we celebrate the progress that has been made all over the world, so far.
2. Move forward, not backwards. While it is tempting to look backwards and think of what could have been, especially in this anniversary year with all its associated poignancy, it is more important to continue to push forward. Even when there are new concepts like UHC, we must remain cognizant of the fact that primary health care will be central to the achievement of such ideas.
3. Nurture your friendships. Good networks are important when one needs to push forward a new idea, or breathe new life into a tired one. With all the progress in pursuing PHC, it is easy to forget that people are at the heart of the policy. We must take stock of PHC stakeholders, and strengthen partnerships to continue the Alma Ata momentum. Global actors must be willing to work with more local actors, governments with civil society, and every stakeholder should be given the opportunity to contribute whatever they can to achieving the goal. This must however be done with caution, because while exploring new collaborations with different stakeholders will provide fresh perspective for this four decade policy, one must remember that some “friends” are more trustworthy than others.
4. Avoid turning to alcohol and drugs. In a world where NCDs have become the major cause of death, it is important that we watch out for them, if we are to achieve the goal of health for all. Primary health care should continue to be the focal point for caring for people suffering from such conditions, however, it should also become more occupied with preventative and health promotion measures.
5. Journal your experiences. Documenting both successes and failures is crucial. Although no two contexts are exactly alike, sharing experiences and stories from the field could inspire others, and give them ideas about how to improve primary health care in their own particular settings.
6. Last but not least, stay away from buying that fancy sports car/Harley Davidson and do not succumb to a new crush: in spite of all the talk in global health of the need for ‘innovation’, the old spirit, vision and values of Alma Ata remain very relevant and needed. Unlike for your iPhone and other capitalist toys, when Alma Ata needs an update, you don’t actually have to renew the whole thing.

This piece was written tongue in cheek, but for people like us who were too young to remember, or were born post-1978 and are not personally affected by the loss of the Alma Ata dream, the most obvious thing to do is to focus on the future rather than the past. The truth is giving up is impossible, because after all we still want health for all, even we have had to move the benchmark!

PS: Perhaps ten years from now, when we go through our own midlife crisis, we might think differently : )

In the past half-decade, there has been a lot of progress in terms of “leaving no one behind” on the road to UHC, although much remains to be done. Still, frameworks such as the Sustainable Development Goals (SDGs), the UHC cube, and the six building blocks of the health system have allowed the health community to adopt a more organised and strategic approach towards the achievement of this global aspiration, not to mention the more systems & complexity-oriented approaches and frameworks. For sure, no framework has been left behind on the UHC journey. However, we know that applying such frameworks and approaches in fragile contexts, such as countries under conflict, is a very challenging endeavour indeed. Different strategies must be adopted to address gaps in these fragile settings.

In line with this, and to commemorate UHC Day, the Belgian Development Cooperation (through the Be-cause health platform) organised a round-table discussion on “Universal Health Care in Fragile Contexts” in Brussels  – also a ‘fragile setting’ of sorts, some would argue. For the first presentation, my colleagues Sara Van Belle & Willem van de Put from ITM shared findings from a recent research project on “Multi-Disciplinary Evidence on Coordination and Health Systems Strengthening (HSS) in Countries Under Stress” commissioned by the International Health Partnership for UHC 2030 (UHC2030). The second presentation came from Jessica Martini, on behalf of ACROPOLIS (ACademic Research Organisation for POLicy Support), a Belgian network focusing on governance for development, amongst others. She introduced practical guidance on how to work in fragile environments.

Typically, when UHC is discussed at events like this, I have noticed that of the building blocks, health financing or human resources are usually the stars of the show. Increasingly, governance is also being highlighted, as was the case here (and in Tokyo, I hear). In the Brussels meeting, however,  my interest was drawn more to the importance of health information systems. I was reminded of some articles I’ve read about countries with unstable financial systems, which opt increasingly for Bitcoin as a more secure and reliable alternate to their failing currencies. In these volatile situations, technology (like blockchain) allows for transparent checks and balances during transactions without the need for too much red tape. Applying this technology to fragile health systems (where there is, almost by definition, “instability” in governance, health service delivery, etc.), should help to reinforce the health information system, and provide different stakeholders with the data that is essential to the design of effective health system strengthening initiatives.

Both presentations emphasised the value of local perspectives and context when dealing with fragile settings, yet we know that there are still large disparities between the evidence being used (and generated) by external actors and reality on the ground. Big data, action research, and data management strategies may be the shots in the arm needed to change the game in countries under stress. In the same way that global UHC efforts have been designed to address the various health inequities, focusing on initiatives to improve health information systems will help reduce information asymmetry and strengthen the relationships between the different stakeholders.  With UHC Day in its 5^th year, now would be the perfect time to adopt new interventions on this – still somewhat ‘left behind’ – building block.