Intended for healthcare professionals

Rapid response to:


Alma Ata and primary healthcare: back to the future

BMJ 2018; 363 doi: (Published 22 October 2018) Cite this as: BMJ 2018;363:k4433

Rapid Response:

Re: Alma Ata and primary healthcare: back to the future

The Institute of Health Promotion and Health Education fully agrees with Bhutta and colleagues that the principles set out in the Alma Ata Declaration are “ fresh and relevant today as they were 40 years ago.”(1) Crucially, Alma Ata declared that the existing gross inequality in the health status between advantaged and disadvantaged individuals was “politically, socially and economically” unacceptable.(2)

The original conference called for urgent national and international action to develop and implement primary health care throughout the world. It should be noted that here the World Health Organization was using the primary healthcare concept in its broadest form – far more than primary medical care. Importantly it included: education; the food industry, housing, communications and other sectors and community involvement. Today, this multi sectoral approach is still required if we want to tackle some of our pressing public health issues such as heart disease, mental health, obesity and accidents.(3-7)

Doctors and nurses in primary care have tremendous potential to be more involved in prevention and health promotion work both at an individual level and with more “upstream” structural approaches.(8-9) However, many face significant barriers including: capacity issues; high workload; lack of training; and balancing the needs of individuals with the needs of the population. (9-11,)

The health promoting general practice is essentially the gold standard for health promotion work in this setting, and is based on similar principles to those for health promoting schools and health promoting workplaces. A key element of health promoting settings is the empowerment of individuals and communities. To become recognised as a health-promoting general practice staff must commit to fulfil three conditions: create a healthy working environment; integrate health promotion into practice activities; and, establish community involvement.(9)

It is important to highlight that general practice is one, but only one, key setting for health promotion activities, and alliances with other settings and groups will be needed for the benefit of patients as well as staff.(9) Synergy can be created if we also have health promoting hospitals, schools and workplaces.

It is encouraging that the Secretary of State for Health and Social Care’s new vision 'Prevention is better than cure' states that investment in primary and community healthcare will be prioritised.(12) It is also positive that the document mentions the need to work across different settings such as schools and workplaces. Directors of Public Health and their multidisciplinary teams potentially will have crucial roles in coordinating, supporting and driving forward action in the different settings, but adequate resources will be needed.(13-15)

Although much has changed since the Alma Ata Declaration, the UK is still grappling with preventable illness, early deaths and substantial inequalities in health status. We believe that when the new Green Paper on Public Health is produced early next year the authors should take heed of the tenets of the Alma Ata Declaration and the updated Astana Declaration and be guided by the Ottawa Charter for Health Promotion.(2,16-18) If they do this then they will shift the emphasis from merely tackling illness to a more positive and powerful one of promoting health.

1) Bhutta Z, Atun R, Ladher N, Abbasi K. Alma Ata and primary healthcare: back to the future. BMJ 2018; 363 :k4433

2) World Health Organization. Declaration of Alma-Ata. International conference on primary health care. Kazakhstan, USSR. 1978.

3) Karwalajtys TKJ, Kaczorowski J. An integrated approach to preventing cardiovascular disease: community-based approaches, health system initiatives, and public health policy. Risk Manag Healthc Policy. 2010;3:39–48.

4) Cattan M, Tilford S. Mental health promotion a lifespan approach. Maidenhead: Open University Press, 2006

5) Watson MC, Theaker T. Re: Fight childhood obesity with multiple methods, not just more taxes, MPs hear. BMJ Rapid Response. 07 May 2018.

6) Watson M C and Errington G. Preventing unintentional injuries in children: successful approaches. Paediatrics and Child Health. 2016; 26(5), 194-199

7) RoSPA. Safe and active at all ages: a national strategy to prevent serious accidental injuries in England. Birmingham: RoSPA, 2018.

8) Tones K, Tilford S. Health promotion: effectiveness, efficiency and equity. Cheltenham: Nelson Thornes, 2001.

9) Watson, M. Going for gold: the health promoting general practice. Quality in Primary Care. 2008; 16:177-185.

10) Peckham S, Falconer J, Gillam S, Hann A, Kendall S, Nanchahal K, et al. The organisation and delivery of health improvement in general practice and primary care: a scoping study. Health Serv Deliv Res 2015;3(29)

11) Allen L, Barkley S, De Maeseneer J, van Weel C, Kluge H, de Wit N, Greenhalgh T. Unfulfilled potential of primary care in Europe. BMJ 2018; 363 :k4469

12) Department of Health and Social Care. “Prevention is better than cure.” London: DHSC, 2018.

13) Watson MC and Lloyd J. Re: BMJ briefing: meet the new masters of public health. British Medical Journal Rapid Response 8th July 2013

14) BMA. Funding for ill-health prevention and public health in the UK. London: BMA, 2017.

15) Watson M C and Thompson S, 2018. Government must get serious about prevention. BMJ 2018;360:k1279.

16) World Health Organization. Ottawa Charter for Health Promotion. Copenhagen: World Health Organization, 1986.

17) WHO, UNICEF. Declaration of Astana. Global Conference on Primary Health Care: from Alma-Ata towards universal health coverage and the Sustainable Development Goals. Astana, Kazakhstan, Oct 25–26, 2018. Geneva and New York: World Health Organisation and the United Nations Children's Fund, 2018.

18) Thompson S R, Watson M C, and Tilford S. The Ottawa Charter 30 years on: still an important standard for health promotion. International Journal of Health Promotion and Education. 2018,56(2), 73-84.

Competing interests: No competing interests

13 November 2018
Michael Craig Watson
Associate Professor of Public Health.
Professor Sylvia Tilford (Past-President, Institute of Health Promotion and Education,
University of Nottingham, Faculty of Medicine and Health Sciences, Queen's Medical Centre, Nottingham. NG7 2HA.