After Alma Ata, after Astana: a new year of Global Health and UHC
David Bannister, January 2019
The world of 'Global Health' comprises various communities with their own concerns, cliques and calendars, varied ideologies and disparate social networks. As a group who are at once part of this global health ecosystem while also observing it for our research, our project started at quite a fortuitous moment last October. The start of the research coincided with one of the relatively rare events that brings together many - although far from all - of the groups interested in or responsible for those transnational policy shifts that filter through in unexpected ways to influence the arrangement of health services, in African states and elsewhere.
That was the Global Conference on Primary Health Care , an inter-ministerial and civil society event organised by the WHO and held in October 2018 in Astana, Kazakhstan's capital. This opening blog post for the project is a brief reflection on Astana and a few of its themes, as we head into another year of conferences and policy making - including the African Health Agenda International Conference in Rwanda this March, and the United Nations High Level Meetingon 'Universal Health Coverage: Moving Together to Build a Healthier World', scheduled for September 2019. As one aspect of this project we are interested in the linkages, diffusion and disjunctures - ideological and rhetorical, social, political and economic - between what is spoken about at these events and what happens among politicians, officials, health workers and communities in particular African states.
The date and location of last year’s Astana conference were intended to link the event to the 40-year anniversary of the Alma Ata International Conference on Primary Health care, held in 1978 in Kazakhstan’s largest city Alma Ata (now Almaty), under a very different geopolitical dispensation for both the host country and the world. In 1978 Kazakhstan was an important but outlying province of the Soviet Union – it is now an increasingly wealthy (and increasingly unequal) petro-state, with Astana developed as a post-Soviet capital of gleaming gold plate-glass and high technology.
In 1978, the Alma Ata conference took place in a late Cold War world still defined by the economic and political poles of the two major powers, with many non- or less-aligned states’ positions arrayed between them. The Cold War world is still often represented in Manichean terms, in both popular and academic literature. But looking back at 1978, it is by no means clear that a comparable range of alternative visions exists today – for the overall arrangement of economies, for the respective roles of the state or private sector, for the provision and financing of health services, and for what constitutes the public good. In terms of health, there has been some excellent historical scholarship on the social currents that shaped the Alma Ata Declaration that emerged from the 1978 Conference, which insisted on the duty of states to provide ‘Health for All’ through the expansion of primary health services. (The list at the end of this post gives a few examples of this kind of research)
This year, as members of the project carry out research in West, East and Southern Africa, we’ll be examining what last year’s equivalent declaration to Alma Ata – the inter-state Declaration of Astana 2018 – might mean for people living in particular African states. The declaration reaffirmed health as a human right, and identified the strengthening of primary health care as a ‘cornerstone’ of global health policy. But in the Astana declaration, the expansion of primary health care has arguably been subordinated to the achievement of Universal Health Coverage – with all of the possibilities and ambiguities covered by that term – as the central object of national and global health policy.
Universal Health Coverage is of course a central theme of our research project, both in its present meanings and longer history, so there will be more on this in future posts. But before ending here, some brief thoughts on the peculiarly elisive jargon of Global Health. This was very much in evidence over the days of the Astana conference and its side events, and is widespread in the printed materials and presentation slides that issue from almost any similar event. It’s clear that the language of international health policy has changed over the past 40 years, but it’s less clear what these changes mean. To what extent are these just trivial and incidental lexical innovations, or conversely to what extent do they reflect the ways in which international health policy is produced or constrained by broader economic and political ideologies? What do these new terms elucidate or obscure? These are some of the questions we hope to pursue (and others have already discussed this lexical shift – again, see the list at the end of this post)
In health, as with many other areas of human activity, ‘International’ has become ‘Global’. As with almost every similar conference of the early 21st century – but unlike at Alma Ata –Astana was an event intended to bring together the “stakeholders”. This is a term which was rarely encountered before the late 1980s, when its use exploded during that period of profound economic and political reconfigurations which are often grouped together under the conceptual umbrellas of neoliberalism, globalization and structural adjustment. Listening to some of the discussions in Astana, other terms of art often came up in regard to the role of state and its relationship with other funders or financiers of health coverage. “Catalytic capital”, “blended financing” and “multi-sectoral financing” were proposed as the necessary and inevitable counterweights to the shortfalls of developing countries’ “domestic resource” - the capacity of the state to finance and operate its own health services directly, using its own facilities and personnel, funded nationally from taxation or state insurance.
Among attendees at Astana the appropriate balance between “domestic resources” and “catalytic capital” was the subject of ongoing debate around UHC and ‘equity’ – another term which can obscure as much as it reveals. As this article began by saying, the global health community is no monolith. What counts as efficient, sufficient or fair Universal Health Coverage is a strongly contested area, as is the role of NGOs and the for-profit sector in African health. This year, as one part of our research, we’ll be thinking about the gaps between the optimistically elisive terms that were everywhere at Astana, their various meanings, and their eventual implications for people in Ghana, Kenya, Tanzania and Zambia.
List of some relevant articles:
Anne-Emanuelle Birn (2016). "Neoliberalism Redux: The Global Health Policy Agenda and the Politics of Cooptation in Latin America and Beyond." Development and Change 47 (4): 734-759.
Anne-Emanuelle Birn (2014). "Philanthrocapitalism, past and present: The Rockefeller Foundation, the Gates Foundation, and the setting (s) of the international / global health agenda". Hypothesis 2014, 12 (1)
Susan L. Erikson (2015). "Secrets from Whom? Following the Money in Global Health Finance ” Current Anthropology 2015 56: S12, S306-S316
Gorsky, M; Sirs, C (2018). “The Rise and Fall of 'Universal Health Coverage'; as a Goal of International Health Politics, 1925-1952 ”. American Journal of Public Health. e1-e9
Manton, J., & Gorsky, M. (2018). Health Planning in 1960s Africa: International Health Organisations and the Post-Colonial State. Medical History, 62(4), 425-448
James Pfeiffer and Rachel Chapman (2015). “An anthropology of aid in Africa”. The Lancet , Volume 385 , Issue 9983 , 2144 – 2145
Ruth Prince (2017). “Universal Health Coverage in the Global South: New models of healthcare and their implications for citizenship, solidarity, and the public good”. Michael 2017; 14: 153–72.
Storeng, KT and A. Mishra (2014). "Politics and practices of global health: Critical ethnographies of health systems." Global Public Health 9 (8): 858-864.
And see this Google Ngram for the historical frequency of the word 'stakeholder' in printed literature.