BMJ  2007;335 (15 September), doi:10.1136/bmj.39336.570116.47

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The fight for primary care

Thirty years ago next year, the Alma Ata Declaration set a new framework for international health. At a meeting convened by WHO in the capital of what is now Kazakhstan, the world's nations agreed that health was far more than the absence of disease, that it was an inalienable right, that urgent action was needed to tackle health inequities between and within countries, and that primary care was the key to achieving health for all. The year 2000 came and went with fireworks but with health still in the hands of the world's wealthy few. As the new deadline of 2015 nears, we should examine how far we are from Alma Ata's vision.

Few can doubt the vision itself, but in most parts of the world the reality lags far behind. Many countries lack basic healthcare infrastructure. Shiny, high tech hospitals symbolise progress and prestige far more powerfully than basic primary care. International aid is still in thrall to disease-specific programmes, with their allure of quick results, recipient accountability, and donor control. But as highlighted in the BMJ over 10 years ago (BMJ 1995;310:178-82) and again by Roger England this week (doi: 10.1136/bmj.39335.520463.94), these programmes distort countries' efforts to deal with their problems. The real answers to improving health lie in the longer term, less glamorous, and far messier approach of building capacity on the ground.

So we should welcome news this week from two initiatives: an interim report from the Commission on Social Determinants of Health (doi: 10.1136/bmj.39328.478044.80, doi: 10.1136/bmj.39282.431100.AD) and the announcement of a new international health partnership to build health infrastructure in the world's poorest countries. This scheme acknowledges that too much has been spent on disease-specific programmes. It will focus instead on raising health budgets, training healthcare workers, and improving access to basic services. But even with such clear aims, disease-specific rhetoric can be hard to resist. In announcing the new partnership Gordon Brown talked of "triumphing over ancient scourges" rather than building accessible primary health care (doi: 10.1136/bmj.39335.610394.DB).

Developed countries are not immune from this tertiary, disease based thinking. From the UK, Nick Timmins reports that closing hospitals always generates a public outcry, even if there's evidence that it will improve services (doi: 10.1136/bmj.39335.652488.DB). And Iona Heath turns a critical eye on Ara Darzi's vision for transforming health care in London (doi: 10.1136/bmj.39331.651250.59), arguing that the need to tackle health inequalities is being used to justify further fragmenting of general practice. "Who thought it could possibly be a good idea to ask a tertiary care specialist to redesign the provision of primary care," she asks.

Lord Darzi has now been joined at the department of health by another specialist surgeon, Bruce Keogh, so it may be worth keeping in mind the old adage: all surgeons know how to operate, a good surgeon knows when to operate, but a great surgeon knows when not to operate. As Alan Maryon-Davies says (doi: 10.1136/bmj.39328.478044.80), Alma Ata was a seminal moment in the history of global public health. It also has important messages closer to home.

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