Аннотация
The Alma Ata declaration was a product of its time. It came about from a recognition that, in an increasingly prosperous world, many people were being left behind. In the world’s poorest countries, tens of thousands of people were dying every year from entirely avoidable conditions, lacking access to even the most basic health services. At the same time, those in the richest countries were benefiting from pharmaceutical and technological advances that would have been undreamed of even a decade earlier. Forty years on, much of what it said is now taken for granted, such as health being a human right, that inequality of health status between rich and poor countries is unacceptable, and that primary health care offers a means to ensure that at least basic care is provided to those in need. At Alma-Ata, primary health care was viewed as having seven main elements. These included addressing the main health problems of the community, including education, secure food supply, safe water and immunization, reaching beyond the health sector to embrace other areas of life, including agriculture, housing and industry, community engagement and the involvement of people from a wide range of disciplinary and professional groups. Yet, while all of these elements are now widely accepted, some, especially in the USA, regarded it as extremely controversial to suggest that governments should take on this role. Others argued that even its modest goals were unrealistic and idealistic. Their arguments prevailed and a much narrower definition of primary health care was adopted, based on a much more limited set of interventions, primarily focused on maternal and child health.1 This has now changed. The Sustainable Development Goals, which provide the basis for measuring progress by every country in the world between 2015 and 2030 include a much wider range of health measures.2 SDG 3 seeks to ensure health and well-being for all, at every stage of life. It includes a series of detailed targets, some of which address child and maternal health as before, but others go beyond this to include a target of reducing by one-third premature mortality from non-communicable diseases, another on preventing and treating substance abuse, and another on achieving universal health coverage, including financial risk protection. Beyond them, health features in many of the other SDGs, in areas such as environmental damage, safe water and violence. Taken together, these show a global commitment to a much broader concept of health, and one that demands radical new approaches. These approaches must tackle the new threats facing humanity, especially the growth of non-communicable diseases and the challenge of providing universal health care3 so that those unfortunate enough to fall ill can receive the necessary life-sustaining treatment without being impoverished. For this reason alone, the 2018 conference in Astana, which has replaced Alma-Ata as the capital of Kazakhstan, offers a time to take stock of what has been achieved since 1978, reflecting on what has worked and what has not, and what is now needed. This stock-taking can benefit from an explosion of new knowledge, unimaginable to those who met in Alma Ata in 1978. The Global Burden of Disease project has done much to end the scandal of ignorance, whereby millions of people worldwide were born, lived and died without anyone ever recording the fact. We now know much more about their health and the conditions that are damaging it. We also know much more about what works to improve their health. We have a vastly expanded range of medicines, capable of at least controlling, and in some cases curing, most common diseases. We also have a much greater understanding of how to organize health services in ways that ensure the greatest benefit for the entire population, and how to configure our health systems to protect our populations from catastrophic expenditure while delivering high quality care. And crucially, we know that all of this is possible. Some countries in the world have achieved good health at low cost,4 even while others, including some of the richest in the world, have failed to deliver even basic care to all their populations.5 Our challenge is that, despite all of this knowledge, we often fail to achieve what is technically possible in far too many parts of the world, including both rich and poor countries. By taking advantage of the 40th anniversary of the original Alma Ata declaration, the 2018 conference will convene the health policy community from across the world to join it and reflect on how the legacy of the original declaration can be sustained, while adapting it to the new challenges of the modern world, thereby providing a road map for the next 40 years of global health. We are grateful to Hans Kluge, Peter Allebeck, Serzhan Aidossov and Elzhan Birtanov for helpful comments on an earlier version. Conflicts of interest: None declared.