ALMA-ATA at 40: A Milestone in the Evolution of the Right to Health and an Enduring Legacy for Human Rights in Global Health

Benjamin Mason Meier, Maximillian Seunik, Roopa Dhatt, and Lawrence O. Gostin

Forty years ago, the World Health Organization (WHO) and UNICEF convened the International Conference on Primary Health Care on September 6, 1978 in Alma-Ata, USSR (now Almaty, Kazakhstan). With representatives from 134 states, this conference adopted the Declaration on Primary Health Care (known as the Declaration of Alma-Ata), through which delegates memorialized their agreement that primary health care was indispensable to realizing human wellbeing through underlying determinants of health. Creating a framework to guide states in the multisectoral policies necessary to realize a wide range of health-related human rights, the resulting Declaration of Alma-Ata would take an encompassing view of health, embodying the idea that human rights and public health are deeply interconnected and mutually reinforcing.

Below: A poster for the 1978 International Conference on Primary Health Care and the resulting Declaration of Alma-Ata

The Declaration thus became crucial to reaffirming the right to health in the WHO Constitution, re-engaging human rights in global health governance, and redefining health-related human rights. This introductory post in the Alma-Ata blog series examines its historical importance, analyzing how this seminal public health declaration has structured the evolution of human rights in global health over the past 40 years. The Declaration holds modern lessons for the continuing advancement of the right to health through universal health coverage; this blog series will prove crucial to understanding that enduring legacy.

A Rights-Based Approach to Primary Health Care

Viewing health promotion to be a human rights challenge, WHO’s Health for All strategy in the 1970s would seek to realize a level of health that would allow all individuals to lead socially and economically productive lives.1 WHO considered this rights-based strategy to be integral to global efforts to realize a New International Economic Order (NIEO), seeking equity in development as a human rights imperative and a basis to assure public health.2

Under this socio-economic approach to public health, WHO would come to echo the basic needs approach of human rights advocates, emphasizing primary health care as a means to realize underlying determinants of health and achieve WHO’s goal of health for all—not only as a foundation for economic growth but also as a human right and end unto itself.

WHO leaders referred to this moment as “the onset of the health revolution,” with the Health for All strategy providing a rights-based mission for WHO that had been wanting since the right to health was first proclaimed in the 1946 WHO Constitution.3 Seeking a New International Health Order as a means to health equity through international development, WHO Director-General Halfdan Mahler concluded that “this movement toward justice in health will require concerted action by the international community through the adoption of a global strategy for primary health care.”4  

The Declaration of Alma Ata provided this global strategy for primary health care consistent with WHO’s vision of health and human rights. The 1978 International Conference on Primary Healthcare framed a rights-based approach for achieving WHO’s Health for All strategy—shifting the human right to health from vertical hospital-based technologies to horizontal public health systems and determinants of health outside the purview of health ministries.

Left: US representative Theodore Kennedy and WHO Director-General Halfdan Mahler at the 1978 International Conference on Primary Health Care

The Declaration outlined state obligations for primary health care, “essential health care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination.”5 In specifying that health is a fundamental human right, reaffirming the preambular language of the WHO Constitution, Article I of the Declaration of Alma-Ata proclaimed that:

health, which is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.6

This primary health care framework would seek to ensure multisectoral focus on underlying determinants of health, community participation in health planning and implementation, health equity within and between countries, and progressive realization of health-related human rights. By laying out criteria for national policy in developing primary health care—and declaring these criteria to be human rights that would have priority over other national goals—the Declaration presented a unifying framework for advancing public health under the right to health.

An Evolving Rights-Based Agenda for Health Promotion 

However, the Declaration was conceived during a challenging period in global governance for health, with an ensuing counter-revolution blunting adoption of primary health care through:

  • Medical opposition: physicians inside and outside WHO resisted the rights-based agenda of Alma-Ata, perceiving the focus on socioeconomic equity as an attack on the medical establishment.
  • Cold War geopolitics: competition between superpowers would lead WHO to proclaim itself apolitical, creating uncertainty in political leadership to advance public health through human rights.
  • Neoliberal reforms: global economic governance shifted national budgets away from health spending, with these structural adjustments leaving nations without governmental systems to address underlying determinants of health.7

Because the Declaration was not advanced as a binding WHO treaty, it lacked an accountability framework to assure government efforts to implement human rights obligations for health equity through multisectoral primary health care systems.8

Recognizing WHO’s limitations in advancing a rights-based health promotion agenda, a new wave of public health activists in the 1980s sought to resurrect the spirit of Alma-Ata as a basis for health promotion. Motivated by emergent activist movements—calling for women’s rights, LGBT rights, and environmental rights—these efforts launched a decades-long journey to codify the Declaration’s vision of an expansive right to health.9

Left: Delegates at the 1986 Ottawa Conference on Health Promotion

In seeking to move toward ‘a new public health,’ the 1986 Ottawa Charter for Health Promotion reflected Alma-Ata’s positive and expansive definition of public health as a foundation of health policy.10  As this health promotion agenda advanced, WHO came to recognize an inextricable linkage between public health and human rights in the AIDS response.11 This linkage was formalized in the 1989 Convention on the Rights of the Child, affirming primary health care as necessary to realize the child’s right to the highest attainable standard of health.12

With the Cold War coming to an end, the 1993 Vienna Declaration and Programme of Action would unite the world in proclaiming that all human rights are universal, indivisible, interdependent, and interrelated.13 Drawing on this new understanding of human rights, health-related rights advanced through sexual and reproductive health, first in Cairo, where notions of primary care were extended in the 1994 Conference on Population and Development (ICPD), and the following year in Beijing, where the 1995 UN Conference on Women emphasized empowerment as a means to health. These advances marked a dramatic departure for public health—uniting disparate health issues under the banner of reproductive rights and situating these rights as social determinants of health.14

The 21st century would codify these human rights foundations of public health. In 2000, the UN Committee on Economic, Social and Cultural Rights (responsible for interpreting obligations of the right to health) adopted General Comment 14, which explicitly reaffirmed the Declaration of Alma-Ata’s approach to the human right to health, clarifying legal obligations to realize underlying determinants of health.15 Even as the 2000 Millennium Development Goals failed to reflect the centrality of human rights, momentum for human rights in public health would advance through the:

  • examination of determinants of health by the UN Special Rapporteur on the Right to Health
  • professionalization of human rights mainstreaming in the WHO Secretariat, and
  • accountability for health-related human rights through the UN Human Rights Council’s Universal Periodic Review.

Civil society sought to capitalize on these interconnected global health and human rights advancements, drawing on the obligations first put forward in Alma-Ata to shift global governance toward a rights-based health in all policies approach under the Sustainable Development Goals.16  

Re-engaging the Right to Health as a Framework for Universal Health Coverage

Bringing together WHO governance and civil society advocacy, the right to health now provides a moral foundation and political catalyst to advance global health policy for universal health coverage (UHC). As Dr. Mahler did in the leadup to Alma-Ata, WHO’s new Director-General, Dr. Tedros Adhanom Ghebreyesus, has provided vocal leadership in advancing human rights in global health, advocating that “universal health coverage is our best path to live up to WHO’s constitutional commitment to the right to health.”17

Below: WHO Director-General, Dr. Tedros Adhanom Ghebreyesus

WHO now invokes human rights as a foundation for its UHC initiative—ensuring that quality health services can be accessed equitably and without financial hardship. As WHO moves toward the finalization of its Astana Declaration on Primary Health Care, there is an opportunity to further the evolution of the right to health to encompass rights-based determinants of health, evoking human rights to empower people and their communities to be owners, advocates, and drivers of UHC.18

Signaling a determination to facilitate accountability for the progressive realization of the right to health through UHC, WHO has sought to expand collaborations with civil society and the Office of the High Commissioner for Human Rights (OHCHR).19 With these new partnerships examining human rights “to health and through health,” the right to health can provide a normative foundation for WHO’s ongoing campaign to frame UHC as the overarching focus of all WHO activities. This continues the legacy of Alma-Ata by re-engaging the human rights obligations necessary to realize the highest attainable standard of health.

Benjamin Mason Meier is an Associate Professor of Global Health Policy at the University of North Carolina at Chapel Hill, USA.

Maximillian Seunik is a Program Coordinator with Grand Challenges Canada.

Dr. Roopa Dhatt, is Executive Director & Co-Founder of Women in Global Health, Primary Care Physician in Washington, DC, USA.

Lawrence Gostin is O’Neill Chair in Global Health Law and Director, WHO Collaborating Center on National and Global Health Law, Georgetown University, Washington DC, USA.

References

  1. World Health Assembly, Resolution 30.43. Technical Cooperation. 1977.
  2. O. C. Eze, “Right to health as a human right in Africa,” in The Right to Health as a Human Right. (The Netherlands: Sijthoff & Noordohoff 1979), pp. 76-93.
  3. T. A. Lambo, “Towards justice in health,” World Health July 2-5, (1979) p. 4.
  4. C. O. Pannenborg, A New International Health Order: An Inquiry into the International Relations of World Health and Medical Care. (Brill 1979); H. Mahler, “Justice in health,” WHO Magazine (May 1978) p. 3.
  5. Declaration of Alma-Ata, International Conference on Primary Health Care (1978). Available at: http://www.who.int/publications/almaata_declaration_en.pdf.
  6. Ibid.
  7. B. M. Meier, “Global health governance and the contention politics of human rights: Mainstreaming the right to health for public health advancement.” Stanford Journal of International Law 46. (2010), pp. 1-50.
  8. World Health Organization. “From Alma Ata to the year 2000: Reflections at the midpoint.” (1988).
  9. M. Hills and D. McQueen, “The Ottawa Charter for Health Promotion: a critical reflection,” Promotion & Education, Supplement2 (2007), p. 9.
  10. The Ottawa Charter for Health Promotion, First International Conference on Health Promotion (1987). Available at: http://www.euro.who.int/__data/assets/pdf_file/0004/129532/Ottawa_Charter.pdf?ua=1.
  11. S. Gruskin, J. Mann, and D. Tarantola, “Past, Present, and Future: AIDS and Human Rights.” Health and Human Rights (1998), pp. 1-3.
  12. Convention on the Rights of the Child (CRC), G.A. Res. 44/25, Art. 24 (1989). Available at http://www2.ohchr.org/english/law/crc.htm.
  13. United Nations, World Conference on Human Rights: Vienna Declaration and Programme of Action, Vienna, June 14–25, 1993, UN Doc. No. A/CONF.157/24 (Part I) (1993).
  14. A. E. Yamin and A. Constantin. “The Evolution of Applying Human Rights Framework to Health,” in Human Rights in Global Health: Rights-Based Governance for a Globalizing World. (New York: Oxford University Press 2018), pp. 43-62.
  15. Committee on Economic, Social and Cultural Rights, General Comment 14, The Right to the Highest Attainable Standard of Health, UN Doc. E/C.12/2000/4 (2000).
  16. G. Ooms et al., “Is Universal Health Coverage the Practical Expression of the Right to Health Care?” BMC International Health and Human Rights. 14:3 (2014).
  17. B. M. Meier, “Human Rights in the World Health Organization: Views of the Director-General Candidates.” Health and Human Rights Journal. 19(1). (2017), pp. 293-298.
  18. WHO, Astana Declaration on Primary Health Care: From Alma-Ata towards Universal Health Coverage and the Sustainable Development Goals. 28 June 2018. Available at http://www.who.int/primary-health/conference-phc/DRAFT_Declaration_on_Primary_Health_Care_28_June_2018.pdf.
  19. F. Bustreo et al. “The Future of Human Rights in WHO,” in Human Rights in Global Health: Rights-Based Governance for a Globalizing World. (New York: Oxford University Press 2018), pp. 155-177.