ALMA-ATA at 40: Its Values are Relevant to the Data Economy
Carmel Williams
In 1978 when the Alma-Ata Declaration called on urgent action by all governments to protect and promote the health of all, primary health care was described as ‘essential health care, based on practical, scientifically sound and socially acceptable methods and technology made universally accessible … and at a cost that the community and country can afford to maintain…’. It was also, in the first paragraph, acknowledged as a fundamental human right.
Forty years ago, achievement of primary health care for all was seen to be dependent upon a “New International Economic Order”. The Declaration twice referenced the UN declaration adopted in 1974 that aimed to rebalance power (and trade) by restructuring some fundamentals in the world economy, and providing greater benefits and participation to poorer countries. In comparison, the Astana Declaration on primary health care, due to be released in October 2018, shies away from such bold comments and instead states its commitment to ‘enabling people and communities to pursue the knowledge, skills and resources needed to take care of their own health, including the use of digital technologies.’
Predating neo-liberalism, Alma-Ata made no mention of the private sector, or partnerships with business. Rather, it proclaimed that ‘Governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures.’ In contrast, the 2015 founding document of the Sustainable Development Goals (SDGs), identifies universal health coverage (not care) as an SDG, and stresses the importance of the private sector in the achievement of it, and in all other goals. “We recognize that we will not be able to achieve our ambitious Goals and targets without a revitalized and enhanced Global Partnership…bringing together Governments, civil society, the private sector…”. Similarly, the Astana Declaration states, ‘We have more partners and more stakeholders, both public and private, working toward common goals …’ downplaying the essential role of government in achieving primary health care for all, and not acknowledging human rights obligations of states.
While the private sector has always played a part in delivering healthcare goods and services, and medicines and devices, there has been a diversity of providers, especially across the different segments of health care. For example, the providers of diagnostic services and tools have been different from providers of pharmaceuticals, and from health care services, and information management systems. Despite controversy and abuses, the intellectual property regime puts a limit on the length of time products can remain under the production of their inventors exclusively, thereby promoting competition and price control within health systems. But the diversity of competitors is being reduced, and the ownership of the core currency of a new economy—data—is falling into fewer hands. In our emerging data-driven economy, the previous components of health systems are no longer discrete. Data is the basis of patient information, management and financing systems, as well as being key to new diagnostic and treatment services. The owners of big data, and the very few companies with the capacity to manipulate and analyse big data, and to use it to drive artificial intelligence (AI) health services, are starting to own the building blocks of healthcare.
It is estimated that the financial value of the AI health market will be $6.6 billion by 2021—and it is currently expanding each year by 40%. One company deeply involved in the development of data-driven health care is Google. Its analytic tools and resources and access to vast data sources place it in an extremely powerful position, partnering in many of the large scale developments of data-based diagnostic apps and AI devices. Examples so far include predicting multiple medical events in patients on admission to hospital; developing an alogrithm for eye scans to detect diabetic retinopathy; detecting cancer metastises on pathology slides; developing an app to detect acute kidney failure (controversial for many reasons, including its use of non-anonymised UK NHS patient records); and making AI surgical robots.
The imminent Astana Declaration enthuses about technology, stating “More effective, more affordable medicines, diagnostics, and other technologies are broadening the range of available and affordable health services, which should be included in primary care. Innovations in technology can improve access to health care, especially for vulnerable and marginalized people. Digital technologies in particular can be harnessed to improve health literacy, enabling people and communities to take control of their own health.”
But there is little evidence to support these claims that technology drives more affordable medicines and health services. In 2016, US health care costs were US $3.3 trillion, 17.9% of GDP, compared to $27.2 billion in 1960, or 5% of GDP. In the UK, estimated NHS spending on medicines had an average growth of around 5 per cent a year between 2010/11 and 2016/17. Access to new digital technologies for people in countries with the worst health indicators, such as very high maternal and infant mortality ratios, is extremely limited, largely because internet penetration is critically low. Of the 24 countries where less than 10% of the population has online access, the maternal mortality ratios range from 115 to 1374 (average 532) per 100,000 live births, compared with the average of 14 across OECD countries. Therefore, it would appear that data-based technologies are not successful in lowering health care costs in high-income countries and are not available in low-income countries.
Governments, which have right to health legal obligations to provide healthcare equitably, and primary health care to all, will be left vulnerable to the price demands of the monopolistic multinational corporations that are becoming so influential in health. The big data that is the basis of digital technology, including AI for health, has been gathered from multiple sources—often ‘donated’ by individuals and governments generally without any true understanding as to the value of their data nor as to how it will be used. Commenting on one partnership in the UK, Dickens and McGoey wrote, “Partnerships like DeepMind-NHS threaten advancement of the right to health by implementing a business model that could exacerbate existing inequalities in the NHS system and prioritise corporate profits at the expense of public interest.”
Protection is needed. Whether this protection takes the form of states insisting on ownership of products developed from state owned or funded data, or people understanding the true value of what they are presently giving away, it is imperative that states act now to protect people’s rights and secure an equitable future. It is naïve to develop partnerships with the private sector, through which they receive medical and other data at no cost, and expect their intention is to simply improve health without reaping significant returns. The lack of protection arises from our collectively poor understanding of the new economy. As Taplin wrote in the New York Times, “The rise of artificial intelligence combined with Google’s omnipresence in our lives is an issue that is not well understood by politicians or regulators. America is slowly waking up both culturally and politically to the takeover of our economy by a few tech monopolies.”
In 1978, it was agreed that governments had responsibility for the provision of health care, including ‘essential health care…and technology’. But in 2015 the UN declared, “We recognize that we will not be able to achieve our ambitious Goals and targets without a revitalized and enhanced Global Partnership…bringing together Governments, civil society, the private sector…”. Private sector survival is dependent on profit. For the private sector that owns big data and AI, the SDGs present the opportunity to turn a profit while ostensibly addressing poverty and poor health. We are ignoring the lessons of the past. The 2008 World Health Report on primary health care noted that health systems were not gravitating towards equity and social justice, nor achieving the Alma-Ata’s aspirations. One of three trends the 2008 report found particularly worrisome was the flourishing of “unregulated commercialization of health”.
Regulation is therefore a part of the protection that states must put in place urgently. Without regulation and other protections, the tech giants that own our data could price the end products of the data so they are only accessible by the wealthy. This will lead to greater inequity, with the global wealthy living longer and healthier lives. Those already suffering from living in poverty become at risk of further neglect, a direct contradiction of the SDG aspiration to ‘leave no one behind’.
In the past 40 years technology has evolved in ways unimaginable to those who drafted and agreed the Alma-Ata Declaration. But human rights and everyone’s entitlement to the right to health remain unchanged. It is incumbent upon states to respect, protect and fulfill these rights, and in order to do so, they must act quickly to keep control of health systems.
Carmel Williams is the executive editor of Health and Human Rights Journal, and a senior research officer in the Human Rights, Big Data and Technology research project at the Human Rights Centre, Law School, University of Essex, UK.