The Astana Declaration (14) Alternative Civil Society Astana Declaration

2 November, 2018


As we discuss the Astana Declaration it might be useful for us to also share the ‘alternative’ Astana declaration issued by civil-society during the conference (see below).

When you consider that most of the world’s health ministers didn’t bother to attend the meeting in Astana, I’m not sure whether tinkering with the words of the official declaration is going to be hugely meaningful for those at the sharp-end of global inequity and inequality… though ironically maybe good in justification of a grant application for funding to the very agents who helped build the doomed PHC silos post Alma Ata! These failed for a variety of reasons, though my personal belief is that the prime failure was because PHC wasn't properly integrated into national health systems (and especially District level systems).

I was particularly pleased to see the ‘caution’ about UHC in the opening paragraphs of the alternative declaration. The latest issue of Africa Health [] (now published by Francis Omaswa’s ACHEST and readable here) includes an excellent thought piece by Dr David Okello on this.

And reading Bill Brieger’s Tropical Health Matters [ blog, he reports from Astana on the serious lack of discussion towards coherent implementation plans for PHC post Astana

In my view we have some dangerous distractions going on here if health ministers are allowed to turn the other way (to insurance co’s) for finance on UHC; and to communities for finance on PHC. In much of Africa PHC is still not integrated into district health systems which is why community health workers find themselves out on a limb… unpaid, unmotivated and unsupported. Government has to be at the core of policy and systems within the health pyramid. If not, then the mantra of ‘leaving no one behind’ is a monstrously undeliverable slogan.



HIFA profile: Bryan Pearson published Africa Health journal for 40 years before handing it over in August 2018 to the African Centre for Global Health and Social Transformation (ACHEST) in Kampala. He remains Consulting Editor on the title and occupies the rest of his time providing communications consultancy services on health and other development issues; as well as developing a mango and pineapple farm in Ghana’s Volta Region; and an eco tourism project at Watamu on Kenya’s magnificent coast.



We, members of public interest civil society organisations and social movements, some of whom are participants at the Global Conference on Primary Health Care, re-affirm our commitment to primary health care (PHC) in pursuit of health and well-being for all, aiming to achieve equity in health outcomes.

We envision:

- Societies and environments that prioritize, protect and promote people’s health;

- Health care that is accessible, affordable and acceptable for everyone, everywhere;

- Health care of good quality that treats people with respect and dignity;

- Health systems over which communities are able to exert control

Although these objectives are shared in the official Astana Declaration (version 16th August 2018) it is concerning that the latter frames PHC primarily as a foundation of UHC. PHC, is broader and indeed subsumes UHC, which is, in many countries, being implemented by private health insurance companies and aggravating health inequities. Additionally, the official declaration (version 16th August) is insufficiently clear that governments have primary responsibility for health service delivery and for ensuring that social determinants maximise health and equity. While the official declaration recognises "that people in all parts of the world have unaddressed health needs and inequities persist", it does not acknowledge that health gains in some places are being reversed. These issues and their fundamental economic and political causes which are responsible for widening inequalities worldwide need to be more explicitly stated. These are some of the reasons why People’s Health Movement and its constituency feel it necessary to elaborate an Alternative Declaration.

Attaining the highest possible standard of health is a fundamental right of every human being, as stated in the Constitution of the World Health Organization. Forty years ago, in 1978, world leaders made the historical commitment to achieve health for all through Primary Health Care in the Declaration of Alma-Ata. We, the undersigned, express the need for urgent action by all international agencies and governments, all health and development workers, and the world community to protect and promote the health of all the people of the world, hereby makes the following Declaration:

1. We the undersigned strongly reaffirm that health, which is a state of complete physical, mental, social, cultural, and ecological wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization is the responsibility of governments and requires the action of many other social and economic sectors in addition to the health sector. People’s health depends on working and living conditions that promote flourishing lives and a healthy and protected natural environment.

2. The existing extreme and growing inequality in the economic and health status of the people both across the world, as well as between and within countries is politically, socially, economically and ethically unacceptable and a source of conflict and environmental destruction and is, therefore, of common concern to all countries.

3. Equitable economic and social development, will require rejection of the currently dominant neo-liberal paradigm and establishment of a sustainable and equitable economic order globally and nationally. Amongst other interventions regulation of financial flows and of tax havens and evasion are urgently needed. These changes are of basic importance to the fullest attainment of health for all and to the reduction of the gap in the health status within and between countries. The promotion and protection of the health and wellbeing of all people will enable sustainable and equitable forms of social and economic development that will contribute to world peace and environmental protection.

4. The people should be afforded every opportunity to participate individually and collectively in the planning and implementation of their health care. This participation should respect age, gender, ethnicity and socio-economic status and use digital technologies where appropriate.

5. Governments have a responsibility to realise the right to health of their people along with other rights specified in the UN Declaration of Human Rights. A main social target of governments, international organizations and the whole world community in the coming decades should be the attainment by all peoples of the world of a level of health that will permit them to lead socially and economically flourishing lives. The United Nations SDGs could be important in reaching this target if they are underpinned by the establishment of a global and national equitable and sustainable economic order. Primary health care is the key to attaining Health for All as part of development in the spirit of social justice, and which is eminently possible given current knowledge, technology and resources.

6. Effective and accountable global governance for health is required to realise PHC. This should include means of effective taxation to ensure that all individuals and corporations pay their fair share of taxes to enable the funding of health and other services beneficial to health;

7. By 2018 the survival of life on earth is threatened by accelerating climate change. Thus part of the PHC approach should be to endorse the Earth Charter (2000) which proposed we are all citizens of our planet as well as our nation states. It recognised the interconnections between living in harmony with and protecting the natural environment and other species, and living in peace, with equity and social justice within human societies; all core parallel principles shared with the Primary Health Care movement.

8. Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation in the spirit of self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It gives particular emphasis to the household and community levels and the first level of care bringing comprehensive health care as close as possible to where people live and work, and is fully integrated with other levels of care.

9. Primary health care:

I. reflects and evolves from the economic conditions and sociocultural and political characteristics of a country and its communities and is based on the application of relevant social, biomedical and health systems research and public health experience;

II. addresses the main health problems in the community, providing promotive, preventive, curative, rehabilitative and palliative services accordingly;

III. includes at least: literacy concerning prevailing health problems and the methods of preventing and controlling them; promotion of a healthy food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases and non-communicable disease including mental illness; appropriate treatment of common diseases and injuries; and provision of essential drugs;

IV. involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, trade, food, industry, education, housing public infrastructure, communications and information technology and other sectors; and demands the coordinated efforts of all those sectors;

V. requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources; and to this end develops through appropriate training the ability of communities to participate;

VI. should be sustained by integrated, functional and mutually supportive referral systems, leading to the progressive improvement of comprehensive health care for all, and giving priority to those most in need;

VII. relies, at local and referral levels, on health workers, including physicians, nurses, midwives, mid-level workers and community health workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community. All governments should formulate national policies, strategies and plans of action to strengthen and sustain primary health care as part of a comprehensive national health system and in coordination with other sectors. To this end, it will be necessary to exercise political will, to mobilize the country’s resources and to use available external resources rationally.

10. While technology has brought health benefits, care must be taken to ensure that technology is used with intelligence so that:

I. New bio-technology and artificial intelligence should be assessed in terms of its potential to do harm as well as good and in terms of its contribution to overall population health and equity and be regulated as necessary

II. Over-servicing, especially in the private sector, requires regulation. One aspect of this which is contributing to the crisis of anti-microbial resistance is irrational and overuse of antibiotics in both the health and industrial farming sectors

III. The use of digital technologies has the potential to increase access and quality of care but strategies must be informed by an awareness of the digital gradient, which mirrors socio-economic inequities. Special measures need to be taken to flatten this gradient.

11. An essential component of primary health care is universal health coverage which should be universalist, based on social solidarity and built on a unified public funded system, with most service provision through public institutions.

12. Since the protection and attainment of health by people in any one country directly concerns and benefits every other country development assistance, including donor programs must be accountable to and strengthen national public health systems and address the social, environmental and ecological determinants of health.

13. The training of health personnel requires to be more strongly oriented to primary health care and employment conditions need to ensure fair and safe working situations. Distribution of health personnel is grossly inequitable and reflects the inverse care law. Global and national policies should institute policies to mitigate the brain drain from low and middle income countries to high income countries by inter alia increasing production of their own health workers and compensating sending countries for their losses in training costs.

14. Health gains from the implementation of an effective primary health care system can be easily undermined by the commercial determinants of health including promotion and trade of health harming commodities (e.g. food, alcohol, tobacco) and environmentally damaging extractive industries. Global and national policies, including effective regulation, are needed to prevent their adverse impacts.

15. An acceptable level of health for all the people of the world can be attained through a fuller and better use of the world’s resources, a considerable part of which is now spent on armaments and military conflicts. A genuine policy of independence, peace, and disarmament could and should release additional resources that could well be devoted to peaceful aims and in particular to the acceleration of social and economic development of which primary health care, as an essential part, should be allotted its proper share.

We the undersigned representing a wide range of public civil society organisations and social movement call on the Global Conference on Primary Health Care to undertake urgent and effective national and global action to develop and implement primary health care throughout the world and particularly in low and middle income countries in a spirit of technical cooperation and in keeping with a sustainable and equitable economic order.

It urges governments, WHO, and other international organizations, as well as multilateral and bilateral agencies, nongovernmental organizations, funding agencies, all health workers and the whole world community to support national and international commitment to primary health care and to channel increased technical and financial support to it, particularly in low and middle income countries.

We call on all the aforementioned to collaborate in strengthening, developing, funding and maintaining public health systems based on primary health care in accordance with the spirit and content of this Declaration.


Bryan Pearson

Managing Director

FSG Africa Ltd

Vine House, Fair Green, Reach, Cambridge CB25 0JD, UK

Tel: +44 1638 743633.

Fax: +44 1638 743998.

Mobile: +44 790 999 7256

HIFA profile: Bryan Pearson published Africa Health journal for 40 years before handing it over in August 2018 to the African Centre for Global Health and Social Transformation (ACHEST) in Kampala. He remains Consulting Editor on the title and occupies the rest of his time providing communications consultancy services on health and other development issues; as well as developing a mango and pineapple farm in Ghana’s Volta Region; and an eco tourism project at Watamu on Kenya’s magnificent coast. bryan AT