Series30 years after Alma-Ata: has primary health care worked in countries?
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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
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