Elsevier

The Lancet

Volume 372, Issue 9642, 13–19 September 2008, Pages 950-961
The Lancet

Series
30 years after Alma-Ata: has primary health care worked in countries?

https://doi.org/10.1016/S0140-6736(08)61405-1Get rights and content

Summary

We assessed progress for primary health care in countries since Alma-Ata. First we analysed life expectancy relative to national income and HIV prevalence to identify overachieving and underachieving countries. Then we focused on the 30 low-income and middle-income countries with the highest average yearly reduction of mortality among children less than 5 years of age, describing coverage and equity of primary health care as well as non-health sector actions. These 30 countries have scaled up selective primary health care (eg, immunisation, family planning), and 14 have progressed to comprehensive primary health care, marked by high coverage of skilled attendance at birth. Good governance and progress in non-health sectors are seen in almost all of the 14 countries identified with a comprehensive primary health care system. However, these 30 countries include those that are making progress despite very low income per person, political instability, and high HIV/AIDS prevalence. Thailand has the highest average yearly reduction in mortality among children less than 5 years of age (8·5%) and has achieved universal coverage of immunisation and skilled birth attendance, with low inequity. Lessons learned from all these countries include the need for a nationally agreed package of prioritised and phased primary health care that all stakeholders are committed to implementing, attention to district management systems, and consistent investment in primary health-care extension workers linked to the health system. More detailed analysis and evaluation within and across countries would be invaluable in guiding investments for primary health care, and expediting progress towards the Millennium Development Goals and “health for all”.

Section snippets

Alma-Ata—worldwide rhetoric and country reality

Although an understanding of worldwide trends and policy shifts is important, improvements in health depend on what happens at national, subnational, and district levels and, ultimately, in the communities in which families live and die. In the past three decades, great progress has been made.1 For a girl born in Alma-Ata in 1978, the risk of dying before her fifth birthday was 7·3%. This risk for a baby born in 2008 in what is now Almaty, Kazakhstan is less than half at 2·9%. This reduction is

Data inputs and methods

We used data from Countdown to 2015,3 UN databases, mainly UNICEF,5 and other sources for this analysis (webtable 1). We analysed data from 90 countries with a Gross National Income (GNI) per person of less than US$10 000 and at least 100 000 births per year, to focus on what works at scale in low-income and middle-income countries (figure 1). We assessed present life expectancy in relation to GNI per person and HIV/AIDS prevalence to identify overachievers and underachievers.

To assess changes

Overachieving and underachieving countries for life expectancy relative to national income

Figure 2 shows a strong association between life expectancy and GNI per person. Among the 90 low-income and middle-income countries, the highest life expectancy is 78 years in Cuba and the lowest is 41 years in Zambia, closely followed by 42 years in Zimbabwe, where life expectancy continues to decrease precipitously. Many countries with a life expectancy greater than that expected for GNI per person have had the most rapid reductions in mortality rates for children less than 5 years of age,

Lessons learned from underachieving countries and those in which primary health care has not been sustained

Although reviews of country success stories are more likely to be publicised, we can still learn from countries where life expectancy is less than that expected on the basis of the GNI. Four distinct categories can be identified among these underachievers.

The first group of countries—eg, Angola, Iraq, and Chad—are examples of countries affected by conflict, where the infrastructure has been damaged or destroyed and the conflict has had a direct effect on life expectancy. Modern warfare

30 low-income countries with the most progress

We selected the top 30 low-income countries with the greatest average yearly reduction in mortality among children under the age of 5 years (1990–2006) as a marker of progress for primary health care (table 1). Together these 30 countries account for 2·6 billion people, more than 40% of the world's population but only 1·43 million deaths of children less than 5 years of age, about 15% of the worldwide total (table 1). The first 15 countries in the list are predominantly in southeast Asia, north

Pathways to progress for primary health care

Our analysis of 30 countries, selected on the basis of child mortality reduction, offers many lessons for the pathways to scale for maternal, newborn, and child health, and for primary health care generally. Many of the same principles apply to the care of chronic disease, HIV/AIDS, and tuberculosis, particularly with a selective start to build and then extend the system. Even for countries with very low income and a quarter of population living on less than $1 a day, reduction of mortality is

Further assessment and analysis

We believe our analysis of overachieving and underachieving countries has drawn attention to factors that help or hinder national progress for primary health care and indeed for health outcomes. However, many questions remain unanswered. Perhaps some of these questions cannot be addressed successfully through quantitative, multicountry statistical analyses of progress with time. Such analyses are associated with several difficulties, including measurement error (or important factors not

Health for all in every country—where will we be in 10 years?

30 years after Alma-Ata, many countries still have a high burden of disease with infections, such as high infection, malnutrition, and maternal and child health challenges, but also emerging chronic diseases, and high injury rates. Primary health care offers solutions and approaches to address these burdens but the increasing complexity threatens to overburden the health system. Our analyses indicate that most countries have made progress in increasing life expectancy; countries making most

References (42)

  • A Shankar et al.

    The village-based midwife programme in Indonesia

    Lancet

    (2008)
  • van Doorslaer et al.

    Effect of payments for health care on poverty estimates in 11 countries in Asia: an analysis of household survey data

    Lancet

    (2006)
  • E Gakidou et al.

    Assessing the effect of the 2001–06 Mexican health reform: an interim report card

    Lancet

    (2006)
  • A Haines et al.

    Achieving child survival goals: potential contribution of community health workers

    Lancet

    (2007)
  • B Ekman et al.

    Integrating health interventions for women, newborn babies, and children: a framework for action

    Lancet

    (2008)
  • M Marmot

    Achieving health equity: from root causes to fair outcomes

    Lancet

    (2007)
  • G Greco et al.

    Countdown to 2015: assessment of donor assistance to maternal, newborn, and child health between 2003 and 2006

    Lancet

    (2008)
  • CG Victora et al.

    Learning from new initiatives in maternal and child health

    Lancet

    (2007)
  • J Bryce et al.

    Countdown to 2015 for maternal, newborn, and child survival: the 2008 report on tracking coverage of interventions

    Lancet

    (2008)
  • Z Bhutta et al.

    Is there hope for South Asia?

    BMJ

    (2004)
  • State of the world's children 2008

    (2008)
  • Cited by (204)

    View all citing articles on Scopus
    View full text