This April, the Pan-American Health Organization (PAHO) released a report entitled “Universal Health in the 21st Century: 40 Years of Alma-Ata.” As the title implies, the report commemorates the 40th anniversary of the Alma Ata Declaration on Primary Health Care (PHC), arguably one of the most important documents in the history of global health. Last year, the global health community convened the Global Conference on Primary Health Care to celebrate this milestone, culminating in the crafting of the Astana Declaration which repositioned PHC in the era of Universal Health Coverage (UHC) and the Sustainable Development Goals (SDGs).
It should be noted that among the six regions of the World Health Organization (WHO), only PAHO created a high-level commission (led by former Chilean president and now UN Human Rights Commissioner Dr. Michelle Bachelet) to revisit Alma Ata’s relevance for the region today – although Europe (EURO), South East Asia (SEARO), and the Eastern Mediterranean region (EMRO) also published their own reports. One may argue that PAHO is perhaps the most forward-looking WHO region, having previously recommitted to PHC and established a Commission on Equity and Health Inequalities led by Sir Michael Marmot. After all, PAHO pre-dates WHO by 46 years.
But it seems that not only in terms of process PAHO is ahead of the game; the region really “gets” the message. The report’s title is already a deviation from current dominant global health discourse – rather than calling the health goal ‘universal health coverage,’ the region uses instead ‘universal health.’ To further illustrate this stark difference, PAHO’s theme for World Health Day last April 7 did not follow the global theme, using ‘universal health’ instead of UHC.
While the PAHO report did not define universal health explicitly, it certainly pointed to a much broader concept that goes beyond UHC, which is traditionally defined as “access to quality healthcare without facing the risk of financial hardship.” Like Alma Ata, the report referred to the human rights framework as universal health’s foundational basis, and emphasized PHC as still, first and foremost, a political strategy – not just a level or package of care – for health system transformation. It also reiterated that the state has the “ineluctable responsibility” to make the exercise of the right to health a reality.
Reflecting the long tradition of Latin American social medicine, the report also highlighted the importance of addressing the dynamic “social determination” – not the (more) static and decontextualized “social determinants” – of health, recognizing multiple layers of inequality and vulnerability that are driven by societal processes and power dynamics. The report admitted that the “Health for All” goal of Alma Ata remains unmet up to this day, and identified numerous reasons for this failure, including the neglect of social determination processes in health sector reform agendas over the past decades, which mostly focused on traditional healthcare.
Apart from the report’s philosophical basis and situational analysis, equally important are the content and structure of its recommendations. Several of the key recommendations hark back to Alma Ata’s principles such as developing community-centered PHC models and creating spaces for social participation. The report also called for greater investments in human resources, which it called “protagonists” in the construction and consolidation of PHC-based models of care.
Among the recommendations, three things are worth noting. First is the emphasis on the need to “regulate and oversee the private sector” to ensure that their operations “are consistent with the objective of ensuring the right to health.” This strong language on private sector engagement hugely veers away from the business-friendly approach currently undertaken by WHO headquarters (for instance as reflected in the recent inaugural WHO Partners Forum), other global health organizations, and even national governments. The second is the need for revitalizing public health functions (such as water and sanitation) which are entirely neglected in the UHC agenda with its narrow focus on medical care; admittedly, some may be assuming that these are taken care of in other SDG goals and targets. Finally, addressing the ‘building block’ of health financing is enumerated last among the 10 recommendations, which is a total flip of mainstream UHC discussions that tend to put financing matters first.
To be sure, similar to the Alma Ata story, the success of PAHO’s new vision of universal health will depend on its effective implementation, which is complicated by dominant market forces and ongoing political strife within the region. To ensure that this aspirational report turns into concrete results, shortly after its publication PAHO also launched a Regional Compact on Primary Health Care for Universal Health, which laid out a set of ‘PHC 30-30-30’ targets – that by 2030, at least 30% of the barriers that hinder access to health will be reduced and at least 30% of the entire public health budget will be allocated to the first level of care. These targets may appear narrow compared to the region’s broad universal health vision, but perhaps they serve as a good starting point for the way forward.
There is no doubt that UHC remains the main agenda in global health today, as cemented in the SDGs, articulated in various global health policies, and prioritized in WHO’s triple billion strategy and the Global Action Plan. But PAHO’s apparent “rebellion,” through the adoption of universal health, provides a (welcome) reminder that we need to avoid a myopic view of health if Alma Ata’s “Health for All” vision is to succeed this time around.