ALMA-ATA at 40: Time for a Critical Health Economics

Sara L.M. Davis

When the Alma-Ata declaration was launched in 1978, it called for “urgent action” by states and others to ensure a “level of health that will permit [people] to lead a socially and economically productive life.”[1] A product of its time, the declaration emphasized that economic development was an unqualified social good; the world did not know as much in 1978 about the problems that unrestrained economic development brings, such as climate change and widening inequality. But how should countries allocate resources in order to deliver on this health commitment? Today, many health planners rely on health economics approaches, such as cost-effectiveness analysis, to make these difficult choices. However, while cost-effectiveness offers the potential of improving equity, it also brings the risk of reinforcing discrimination against hidden and marginalized groups.

The declaration identified primary health care as key to attaining health equity for all. However, early critics of Alma-Ata described this as overly ambitious.[2] A subsequent meeting organized by the Rockefeller Foundation developed an interim strategy, with four targets seen as more attainable: growth monitoring, oral rehydration techniques, breast-feeding, and immunization, or “GOBI”.[3] Twenty-two years later, the most authoritative interpretation of the right to highest attainable standard of health, General Comment 14, again ducked the thorny question of prioritization.

While recognizing that states have limited resources and that they should progressively realize the right to health, General Comment 14 still lays out a long list of minimum obligations to ensure health access for all. These include non-discrimination in access to health services (something that the People Living with Stigma Index finds is widespread for people living with HIV) and an expansive list of minimum core services:

  • essential primary health care
  • non-discriminatory access to health facilities, goods and services
  • access to minimum essential food
  • access to basic shelter, housing, sanitation, and an adequate supply of safe and potable water
  • essential drugs as defined by WHO
  • equitable distribution of all health facilities, goods and services
  • a national public health strategy and plan of action by which progress can be closely monitored that also pays particular attention to all vulnerable or marginalized groups.[4]

In addition, obligations of “comparable parity” include:

  • reproductive, maternal and child health care
  • immunization against the major infectious diseases
  • measures to prevent, treat and control epidemic and endemic diseases
  • access to information about main health problems in the community
  • training for all health personnel, including on health and human rights.[5]

The scope of these minimum obligations is breathtakingly beyond the reach of most developing countries: control of epidemics, for example, has so far proven elusive.[6] In fact, many high-income countries probably fall short of this standard.

In response, cost-effectiveness has emerged as a dominant paradigm in global health financing. Today, countries increasingly submit investment cases—analyses of the optimal allocation of resources based on epidemiological and cost analyses—as part of their funding requests for health aid.[7] Even WHO is now preparing an investment case for its Global Program of Work to persuade its donors to continue their support.

Health economics first emerged in the mid-20th century as a way to reframe expenditure in health as an investment that improves economic productivity—note again the references in Alma-Ata to economic development as a universal goal.[8] While human rights advocates argue that sufficient resources exist for health, the premise of health economics is that resources are limited; because the underlying premise is that “the individual will always try to maximize her own gain for the least possible investment”, health officials must make the difficult choices. As a World Bank health economist put it, “Not only will insured individuals generally purchase too much health care when it is subsidized, but they may also purchase the wrong kind of care, by going to an expensive hospital when a visit to a clinic might have been adequate.”[9]

The task facing the health official is to choose “winners and losers”: to optimize collective resources in order to ensure the greatest benefit to the collective population.[10] Cost-effectiveness analysis uses data about the costs of different services, and data on the health outcomes of each service, to generate and compare future scenarios that combine services in different ways. This enables health planners to choose how best to deliver maximum health impacts within a fixed budget.[11]

For its champions, cost-effectiveness analysis is a tool to promote equity:

Indeed it might be argued that failure to use economic evaluation in the decision-making process can itself be unethical, as it may mean that resources are consumed in ways that are ineffective, thus denying others the opportunity to benefit from help and support.[12]

In most cases, with a limited bucket of funding, it is expected that tough choices need to be made. There will be “some form of rationing”, as Yazbeck’s “Idiot’s Guide to Prioritization in the Health Sector” puts it:

Any way you cut it, a prioritization exercise such as developing a benefits package will produce winners and losers, especially in poor countries with large populations and small budgets for health. Losers in this context are the group of people that inevitably will get less, in terms of benefits or services, than others.[13]

But isn’t being a loser, in the context of access to state services, just another word for indirect discrimination?

This question appears especially sharply in the context of HIV financing. As global funding for HIV shrinks, countries are asked by donors to target interventions aimed at key populations—such as men who have sex with men, people who inject drugs, sex workers, and transgender people. However, many countries lack data on key populations, who may be hidden due to criminalization, stigma or marginalization.

The problem becomes even more dire for populations not defined by UNAIDS as “key”, those for whom even less HIV research has been done: indigenous peoples, racial or ethnic minorities, persons with disabilities, to name a few. Where governments deny the populations even exist—Nepalese minorities in Bhutan, for example, or transgender men in Uganda—there is little data on their HIV resource needs. The existence of data would assert the reality of bodies that the state cannot, for one reason or another, politically afford to recognize.

Lack of data for disfavored populations means lack of a basis on which to evaluate the cost-effectiveness of HIV interventions targeted to them. In some cases, health officials and advocates decide to direct funding to specific key populations despite the lack of data. However, because it classifies interventions targeted at key populations, HIV cost effectiveness analysis can also pit populations against one another, and against a much larger, unmarked “general population”, in a race for funding and programming that smaller groups who lack data are set up to lose.

Human rights and health economics could be complementary. Global rights standards, including Alma-Ata, recognize inequality, discrimination, and other barriers to accessing health services, but are frankly unrealistic about budgetary constraints and data gaps. Health economics tools may be realistic about resource constraints, without addressing the complex barriers discrimination and inequality create to accessing health for those most often left behind. To move beyond this impasse, human rights scholars and health economists should come together to forge a critical health economics that recognizes that health is the product of a political context, one that shapes data and even research agendas.

More broadly, we also need to work together to challenge the concept of the limited bucket of funds—the paradigm of scarcity that is becoming increasingly normalized, at a moment of starkly growing global inequality. Economic development, as promoted by the Alma-Ata Declaration, is only a social good if it truly benefits all.

Sara L.M. Davis, Ph.D. (aka Meg) is an anthropologist and writer. Her forthcoming book is The Uncounted: Politics of Data in Global Health

References

[1] Alma Ata Declaration, paragraphs II and V.

[2] Cueto, Marcos. “The origins of Primary Health Care and selective Primary Health Care.” American Journal of Public Health 94, no. 11 (November 2004): 1864–74. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448553/ (Accessed 31 July 2018).

[3] Cueto, “The origins of Primary Health Care.” Walsh, Julia. “Selective primary health care: An interim strategy of disease control in developing countries.” Social Science and Medicine, Part C: Medical Economics. 14, no. 2 (July 1980): 145-63.

[4] Declaration of Alma Ata. International Conference on Primary Health Care. Alma Ata, USSR (6-12 September 1978); paragraph 43.

[5] Declaration of Alma Ata, paragraph 44.

[6] Tobin, John. The Right to Health in International Law. Oxford, England: Oxford University Press, 2012; p.244.

[7] The Global Fund to Fight AIDS, TB and Malaria. The Applicant Handbook: A practical guide to preparing a funding request following receipt of an allocation letter. November 2017, p. 3.

[8] Jakovljevic, Mihajlo (Michael), and Seiritsu Ogura. “Health Economics at the Crossroads of Centuries – From the Past to the Future.” Frontiers in Public Health 4 (June 9, 2016). https://doi.org/10.3389/fpubh.2016.00115; Mushkin, Selma J. “Toward a Definition of Health Economics.” Public Health Reports 73, no. 9 (September 1958): 785–94; Alma Ata Declaration, paragraph III.

[9] Jack, William. Principles of Health Economics in Developing Countries. DC: World Bank Institute, 1999; p.106.

[10] Carrin, Guy, ed. Health Financing in the Developing World: Supporting countries’ search for viable systems. Brussels: University Press Antwerp, 2011; p. 409.

[11] Carrin, Guy, ed. Health Financing in the Developing World; p. 410-11.

[12] Dudley, Michael, Derrick Silove, and Fran Gale. “Introduction: Overarching Conceptual Issues.” Mental Health and Human Rights: Vision, praxis and courage. Oxford: Oxford University Press, 2012; p. 53.

[13] Yazbeck, Abdo S. An Idiot’s Guide to Prioritization in the Health Sector. Washington, DC: The World Bank, 2002; p. 7-8.