The Alma-Ata Decade : the crisis of development and international health

The paper analyzes formulations in the area of international health at the time of the International Conference on Primary Health Care, held in Alma Ata, Kazakhstan, in 1978. It is set within the context of the broader debate on development and international cooperation throughout the 1970s. Three sets of concepts and prescriptive formulations were examined namely: the New International Economic Order (NIEO), the Dag Hammarskjöld Report (DHR) and the Basic Human Needs Approach (BHN). They were compared with the proposals in documents from the World Health Organization and in the statements from Halfdan Mahler, its director. As a whole, this set of formulations and proposals share a broad spectrum of terms and notions, as well as much of the expectations for change and tensions that existed in the classic period of development during the later years of the post-war era.


Introduction
Concepts on the development of society and the ways in which development can be achieved define -obviously -the practices of cooperation for development.. Throughout time, changes referring to the ways in which cooperation in health was conducted was connected to changes in the historical trajectory of the concepts around development itself.
This paper examines, using an historical perspective, the values and prescriptions of development and cooperation in the vibrant years of the 1970s.It seeks to shed new light on the process that, in the ambit of international health, culminated in the officialization in 1978 in Alma-Ata, the then Soviet Union, Primary Health Care (PHC) as a strategy aimed at providing Health for All in the Year 2000 HFA2000 1 .The commencement of PHC and the Alma-Ata conference have been examined by participants in the events and by historians [2][3][4][5] .Our focus, however, is concentrated in a journey of the ideas around development, international cooperation and their relationship with the collection of PHC ideas.In the first section, we discuss the principal components, the expectations and the problems of the First Decade of the Development of the United Nations through the 1960s.In the second section, we sought to examine the content of three formulations on development and what they meant in practice -the New International Economic Order (NIEO), the Dag Hammarskjöld Report (DHR) and the Approach of the Basic Human Needs (BHN) -present in the debates in the 1970s.Finally, the ideas and constant prescriptions of these formulations were checked with statements in the official documents from the WHO and in discourses from its director general, Halden Mahler.As will be seen, the documents from the forums on development and those on international health share a great deal of terms and notions as well as the expectation of change.In addition, these forums made evident the tension in the last year of the classic period of development after the World War II.

The first decade: from optimism to frustration
In September 1961, John Kennedy persuaded the most affluent nations to use their power to change the decade which began as a period aimed at development.The XVI General Assembly of the UN welcomed the initiative which started the United Nations Decade for Development.Considering the diagnosis that the distance between the developed countries and those that were not growing since the end of the second world war, measures were proposed to, in theory: promote exportations of the less developed countries, ensure that these countries enjoy the benefits obtained through the use of their primary products and to stimulate the flow of public and private resources for their economies.International aid should have reached 1% of Gross Domestic Product for every developing country reaching betters indicators of development and it was thought that resources that were not spent in the arms race, could have converged towards development.Social policies were envisioned to "would accelerate the eradication of illiteracy, hunger and illnesses" and permit improvements in general education and technical training [6][7][8] .It should be noted that this resolution was preceded by the announcement and formalization in August 1961, of the Alliance for Progress 9,10 .Social policies were themes in the debate on development after the Second World War from the end of the 1950s 8,[11][12][13][14][15] .However, only one decade later, the concerns in relation to development once again arose.In the Pan-American arena, for example, it was clear with the signing of the Bogota Minutes in 1958, and with the Alliance for Progress and its Decade Plan for Public Health in 1961; which made the themes on health become more relevant in inter-American debates 9 .
The results of the first decade of development were frustrating.There was a general feeling of ineffectiveness opening the space for criticism of the model itself of development that was supposed to reduced backwardness.The Alliance for Progress which set as a very basic rhetorical goal the promotion and strengthening of democracy in Latin American countries was equally frustrated.This was evident in a number of reactionary conspiracies and direct intervention of the US military.In 1964, US marines disembarked in the Dominican Republic to overthrow a government that did not follow the policies of Washington in the first open intervention in the region in fifty years.In face of this discouraging image of traditional development schemes, alternative concepts on development began to obtain greater circulation amongst intellectuals and politicians 5,8,16 .
At the end of the 1960s, criticism of the practices on international cooperation culminated in the definition of the terms of an 'International Strategy for the Second Decade of Development from the UN', that revised various themes on traditional economics and also tried to respond to concerns on the accelerated population growth and a need for greater equity in the redistribution of the benefits of development.The social themes agenda were the following: improvements in general well-being, a more equitable distribution of income, a rise in the level of employment, improvements in education, health, nutrition and protecting the environment 17 .
The means of implementing these goals were to be the object of wide debate throughout the 1970s.For the effect of contextualization of the international health agenda, it is appropriate to examine in greater detail, three sets of formulations that intertwine with each other exposing concerns, frustrations and criticisms.These interactions had repercussions in the institutional arena for development throughout the decade.

The debates on a new order
The first process was the formulation by the United Nations in 1974 of the guidelines of a New International Economic Order (NIEO).Its origins can be traced back to the Movement of Non-Allied Countries organization which became formalized in 1961 and the formation of the group of 77 in the scope of the United Nations Conference on Trade and Development (UNCTAD) in 1964 18 .Between 1962 and 1971, the UN was directed, for the first time, by a non-European, the Burmese U Thant, who promoted the admission of new states in the agency; usually Asian and African countries that had recently gained their independence.The admission of new UN members changed, in a sensitive way, the balance of power in the General Assembly.In terms of the immediate context, NIEO was connected to the decline of the US economy in the international economic scenario.This was a consequence of the internationalization of the crisis in the financial transactions that occurred in the United States and led to the collapse of the Bretton Woods agreement in 1971.These events were accompanied by the defeat of the Americans in Vietnam and the critical situation generated the first petroleum crisis;.Both of these events started in 1973 and were considered part of a process of decline of the United States hegemony 19 .In this crisis environment, nations known as third world countries led by the President of Algeria, Houari Boumedine, advocated for the carrying out of a special session of the United Nations General Assembly to debate the question of raw materials and the relationship between industrialized and developing countries.In 1974, the VI Special Session of the United Nations General Assembly approved a Declaration and an Action Program that called for the establishment of a New International Economic Order 8,20,21 .
Once again, it was recognized that the benefits of any economic advances and technological progress was inequal in the majority of countries.It was understood that this inequality no longer corresponded to the political position that third world countries had attained and that the traditional international political order established by the end of the Second World War was obsolete.In a growing scenario of interdependence, measures were proposed for the establishment of a new international regime concerning economic exchanges 8 .It was hoped that this regime would have a positive impact in the political and social arenas and foster economic development in socalled peripheral world based on the principles of: equality between countries, equality with sovereignty, interdependence, common interests and cooperation.The association of developing countries was considered legitimate for the negotiation of volume and the prices of raw materials.The decision supported the recent and coordinated elevations in the price of petrol.With a discordant vote by the US, the Charter of Economic Rights and Duties of States affirmed the full sovereignty of each state in relationship to the existing resources in their territory as well as their right to regulate the activities of foreign companies 8,20,22 .
NIEO focused on economic themes such as the relative prices of primary goods and industrialization.The last element became a central strategy for the leaders of developing countries especially for those with the biggest potential in expanding their domestic market and their competitiveness in foreign markets 23,24 .Another of the strategies advocated in the NIEO framework, was Technical Cooperation among Developing Countries (TCDC), with the intention of taking advantage of accumulated experiences in countries and encouraging their integration and "self-sufficiency in economic, scientific and technological material."In addition, it was sought the endogenous development of technologies adapted to the local context 25 .
In spite of their third-world roots, it would be a mistake to consider that the design of a New International Economic Order was monopolized by leaders of developing countries.The term, and its variations, took on a multiplicity of definitions and its strategic and practical meaning was the object of considerable disputes 26 .In 1975, when a new special session of the General Assembly of the United Nations took place, considerable international and public opinion was in favor of a New Order and of the need for a common political force going in the same direction.Even with conservative North American diplomacy of Nixon and Kissinger, the main reaction of US diplomacy was to accept the term and negotiate.However, in spite of this imagined and celebrated consensus, the practical meaning of the NIEO remained open.In this way, NIEO was mainly an arena for disputes 27 .
The second set for the criticism of the formulations in relation to the development model, is the fruit of an initiative of the Hammarskjöld Foundation with headquarters in Stockholm, Sweden and of the United Nations Development Programme (UNDP).A large group of intellectuals from around the world were mobilized to proposed a new set of concepts and a new agenda that should be presented to the United Nations General Assembly in September 1975.The final report of the initiative explained that its preparations had occurred due to "a deep crisis in development" recognizing the importance of the Strategy for Development and the first documents from NIEO, thus having a critical position 28 .
The document also supported the results with a set of thematic international conferences.The themes of these conferences included: the Environment (Stockholm 1972), Raw Materials and Development (New York 1974), Population (Bucharest 1974), Food (Rome 1974), Rights on the Seas (Caracas, 1974 and Geneva 1975), Industry (Lima 1975) and a call for a World Conference on Employment that was being prepared.These international meetings, and others that have not been listed, can be considered as conforming to a conference cycle that extended until the latter part of the 1970s.Some authors 8,29 referred to these events as being instrumental in enlarging the NIEO agenda that became broader.Without commitment to these classifications, this paper sought to observe the International Conference on Primary Health Care in Alma-Ata 1978 as one of the latest conferences in the cycle.
In the debates, the Dag Hammarskjöld Report defined development as a very complex process that should be deeply and firmly anchored on the structure of social formations.In addition, there was no single formula for promoting and achieving development even though a special emphasis towards the poorest part of the pop-ulation was recommended.The initiatives to be implemented with these groups should have sustained and sufficient resources 8 .Bolstered by the dependency theories, the report diagnosed that the present problems were rooted in the northsouth exploitation structures and in the complicity of local elites in the third world.Acording to the report the problematic situation was sustained by policies in the industrialized countries as well.In terms of similarities of the report with that of the NIEO, the strengthening of collective self-sufficiency of the third world countries was proposed as well as their selective participation in the international circuits of trade and finance in accordance with the interest of each nation 8,28 .
The report also registered ecological concerns as a limitation to be imposed on development.In this way, changes in lives styles in developed countries were recommended as well as the adoption of an international, economic and social regime ecologically more just.Amongst the initiatives advocated was, for example, a greater parsimony in the consumption of food and energy based on petrol and longer lives for durable goods.Thus, the problem of development stopped being a question exclusively of the third world.It started to include models related to central countries and their non-critical diffusion in the world as a whole.It started to include models related to central countries and their non-critical diffusion in the world as a whole 8,28 .
In a chapter that seeks to define a conceptual model for an alternative development model, areas such as food, habitation, health and education will be briefly discussed.With reference to health, we noted a general agreement that health conditions depend on the food, housing and preventive measures without however, "the practical implications of this assertion which has still not been established" 28 .The satisfying of the basic health needs would mean measures such as: the reallocation of resources that advocate preventive actions, the integration of health services into "the services for development as a whole" 28 and the adaption of health actions to specific circumstances with reoccurrence in the use of locally available resources.A public service geared towards meeting basic needs, would be supported through radical decentralization that would favor the participation of the communities and that should be supported in "a health care workers network" and in local units responsible for the majority of care given.The scientific research in health should have as the object of the problems at all levels, according to the spe-cifics of each society, "the local health centers to the university hospitals".Notions that were very similar with reference to relations between health and basic needs were also defined not just by the WHO but also in forums and agencies such as UNICEF particularly when it was directed by the American diplomat Henry Labouisse who was Executive Director during the period 1965 to 1979 28 .
The emergence of the concept of Basic Human Needs (BHN) can be traced to a discourse of Robert McNamara in 1972 as the President of the World Bank.On that occasion, the Mc-Namara´s rhetoric vehemently denounced the precarious living conditions of poor populations and his intention to conciliate economic growth with social justice.The challenge consisted of, in the opinion of the Bank´s director, an increase in international aid guaranteeing that the resources would get to those most in need.As a pre-condition, the governments of the countries that would receive resources ought to establish precise goals to improve nutrition, living and health conditions as well as literacy and employment levels.The proposal was a call for change in order to conserve and for obtaining some minimum living conditions for individuals and families entering the world of production and economic consumption.Based on this approach, the World Bank became to some degree interested in promoting changes in basic living conditions even though it had a portfolio that to a greater extent, was guided by major financial infrastructure projects 8,16 .These concepts were the basis of the Banks´s agenda development strategy aimed at those in "extreme poverty" and "target groups" and to foster "integrated rural development" throughout the 1970s 16 .
In another institutional context , the idea of emphasis on the poorest was present in the international debates on employment and income policies from about the end of the 1960s 16 .In the middle of the 1970s, more precisely in 1976, the International Labor Organization (ILO) during the World Conference on Employment, adopted the BHN as an organizing concept aimed at providing alternatives to development based on the intensive use of labor.What was recognized, as noted by Pereira 16 and indicated in the registers at the time 30 , were the alternatives based on intensive work and they were aimed at meeting basic needs which was in symphony with the recent legislation in the United States on the policy of bilateral cooperation with the World Bank guidelines and with the position of the European do-nors, even though the delegation from the United States stayed reticent during the conference 16 .
The approach of the BHN, according to the OIT, took into account two dimensions.It included a minimum requirement for families in relation to food, clothing, shelter and housing.It also covered essential services such as the quality of water and sewage sanitation, public transport, health, education and cultural installations 30 .A proposal such as this was well received by a wide-reaching audience owing to concern for the poorest.However, the greater part of the attention for those in power in the third world was concentrated in proposals where the idea of the modification of exchange relations and the division of labor between the North and the South remained and there was a clear preservation in the absolute sovereignty of the countries for their internal issues.However, the BHN received considerable international attention on development even with different metrics.Criticism directed towards the distribution of resources towards the outskirts of the countries, put on the agenda the domestic policies.The leaders of the countries in development feared that due to unequal negotiations, financial aid officers could interfere in national themes.They also feared that the emphasis of the poorest would end up in the restricting of the flow of investments for countries with average GDPs reducing the support for industrialization and restricting the transference of more sophisticated technologies 23 .This tension came out in the conference debates and exceptions were included in the final document aimed at the preservation of the sovereignty of the countries 31 .
However, the emphasis on absolute poverty present in the OIT document and in the World Bank proposals saw, as noted by Pereira 16 , a moving of the theme of equity in the critical rhetoric of development.In this way, the inequality in the distribution of wealth in relation to the social classes, became less audible and limited to social changes that could be substituted by the idea of humanitarian aid to the less fortunate.The idea of an "adjustment of the human face" would just be an element of hope for some of the progressive people who put in the possibility of development with social justice and a new international order through the 1970s when the following occurred: the momentary changes in the debt crisis for third world countries in the beginning of the 1980s, the "international order of sovereignty" being replaced by the "liberal international order" 7 , when macro-economic adjustments moved to being imposed as a precondition for obtaining international financial aid and when there is a deepening of the idea and desperation of the poorest.

Health, Primary Health Care and the debate on development
The essential components of the PHC, such as that which is established by the Alma-Ata conference, are well known by the readers.They can be easily recalled 32 and they do not need to be mentioned again here.What is more important in our study is to examine the connection between the values and principles that exist and the debates concerning development.
The WHO under the leadership of Mahler, expressed early its opinion on development by making critical formulations of this concept.These formulations found in UNICEF directed by Labouisse a partner in the promotion of this concept.In 1973, the Executive Committee of the WHO, understood that international health was on the verge of a "serious crisis" that threatened the social stability of countries 33 .One of its causes would be the "incapacity of the services in eliminating the important existing differences with reference to the health situation between the difference countries in the outskirts of the same country" 33 .For Mahler it was not sufficient to show his strong commitment to change in what was considered radical in his agency and in traditional health practice.Thus, in his known formulation: "many social transformations and revolutions occur because the social structures are falling apart.There are signs that the scientific and technical structures in public health are also falling apart" 5 .
Mahler and the WHO were equally clear in connecting HFA 2000 and Alma-Ata to reformist initiatives of great relevance to the development and practices of cooperation.At various opportunities and including the Alma-Ata Declaration, there were signs of its belonging in relation to the guidance towards NIEO 32 .This specific adhesion, however, would not occur without some difficulty.The NIEO documents were concentrated, as we indicated, almost exclusively on the economic aspects of the relations between the national states.They granted very little attention to social themes and health.On obtaining explanations concerning the initiatives towards a new order, the WHO principally mobilized the International Strategy for the Second Decade of Development 34 .In a general way, the Strategy was approved in October 1970 and it came be-fore the NIEO formulations.It attributed weight to: the social dimensions of development, "all the spheres in social life" including with reference to employment, education, health, housing, science and technology 17 .In this way, such as in other instances that have been mentioned here, the WHO adheres to the NIEO formulations seeking out what would be a forgotten social dimension.In a discourse, Mahler noted its obligation to emphasize how health could "relate productively to a new economic order or how I prefer to say a new development order in this socially irrational world" 35 .And going back to the statement with regard to health-development relations, he affirmed that no important distinctions should be made between the economy and social aspects since "...the means to obtain double development are intimately related" 32 .
Other points from HFA2000 and the PHC have connections with the original precepts of NIEO.We can mention here the intertwined ideas of collective self-sufficiency, technical cooperation between countries in development and appropriate technology.It is this last idea, for example, that permits the recommendation of the adoption of scientifically based solutions adapted to the needs and preferentially sustained by resources and locally available means.Experiences of these types would be especially recommended for the international exchange in the framework for technical cooperation between countries in development and for promoting greater collective autonomy 32 .It was registered by the Dag Hammarskjöld Report in 1975, as we saw, which is also clear in recommending initiatives with groups that are extremely fragile being supported by resources and means being effectively available in a sustained way which was argued at Alma-Ata.
Another aspect, however, which is relevant to understand the proposals of the WHO, has a tendency to move away from the ideas that were firstly presented in the NIEO documents.This is the case for the last one was in relation to countries or between blocks of countries.The problem in the absence of equity in the interactions is concentrated in the relations between those entities.At HFA2000 and principally at Alma-Ata, however, the central questions were put to the national organization for health systems.The principal guidelines and recommendations from Alma-Ata related to: the domestic policies of the national states, its internal organization and the equitable distribution of resources and means in its national spaces amongst its social classes and population groups.This essentially national guidelines and recommendations for the PHC and the problem of equity, made Alma-Ata become closer to the formulations both for the Dag Hammarskjöld Report as well as the Basic Human Needs.In these formulations, as we examined, NIEO is criticized for minimizing the problem of domestic maldistribution of income and resources.And, more than this, they attacked the national elites in their social formulations especially marked by inequality painted as accomplices and beneficiaries in the processes of exploitation.Not on few occasions has Mahler, in his statements in defending PHC, put the political and medical elites under similar focus.He reiterated the assuming of priorities for primary health care to the populations being socially and economically marginalized in the middle of rural and outer urban regions in the third world without however restricting the problem of countries in development or the most vulnerable social groups.Without also taking the emphasis on the importance derived from the national states as promoting agents for change 36 .
Thus, in its arguments on the affirmation of the pertinence of health themes as part of the agenda on the "new order", Mahler and the WHO followed the general tendency in the international debate towards a type of social emergency and making international health a tool for the promotion of social changes.It is important to highlight that this premise of the social condition would assume different intensities, matrixes and blends for international health according to the interests and political-ideological positions of the agents: from the social transformation to pragmatic guidance of the conservatives´ bias.Mahler and the WHO accompanied this tendency without escaping the tensions as informed by the content of these debates.In relation to this, it is worth noting that the Dag Hammarskjöld Report, as we saw and concerning its comments on health, bears similarities with the themes and guidance that became more present in the debates of international health.
The preparation of the conference and the reception of the Alma-Ata Declaration was far from being harmonious 2,3,5 .In a few years, for example, criticism would take UNICEF to take on the proposal of Selective Primary Care after the appointment of James P. Grant as the founding Executive Director in 1980 3 .Selective Primary Health Care, as one knows, was introduced into the debate by the Rockefeller Foundation initiative as a competition with other international agencies.It was an alternative having a preliminary character based on a cost/effectiveness character guided by specific indicators and few selected controls 5 .In relation to this, it is important to note that in 1978, a few days after the conference, Davidson Gwatkin became coordinator of the International Health Policy Program in the 1990s passing through UNICEF and the World Bank.He was a skeptic in relation to the final Alma-Ata results.In correspondence with the management at the Ford Foundation, Gwatkin -at that time working at the Oversea Development Council -being an influential think tank in Washington DC, financed by the Rockefeller and Ford foundations and directed by James Grant during the 1970s -expressed concerns with the idealized optimism of some members of the American delegation and the enthusiastic reception of the conference in some in the countries.Also, concern was expressed of the need for the establishment of a more robust process for monitoring and conducting evaluations of initiatives in the validations of strategies and procedures on the definition of a group of measures with quantifiable results being subjected to permanent accompaniment 37 .
To a large extent, the ways in which in the ambit of health there are expressions of positions that are equally present in debates on the developments in the 1970, it has been made more visible due to these criticisms.This was in relation to the content of an intended New Order and in a place that provided primary care for basic needs guided by poverty and the tension between reformists who were more or less radical and those that took a more pragmatic approach.NIEO and the PHC were also arenas for this.Mahler, for example, would have, according to Socrates Litsios, remained reticent in relation to possible adhesion to the basic-needs approach.In doing this, Mahler could deal with two issues.The first is the resistance of the representatives of third world countries in relation to possible interferences into their internal affairs.In second place, the approaches based on basic needs and absolute poverty.had implications on reaching the intended transformations by the movement he led.Through non-linear routes and in a way that was not predicted at that time ---and at the time of a major economic recession--, the conservative governments in the main industrialized countries and in many developing countries were pressured to make cuts in social programs.A new liberal order was effectively installed from 1980 which gave a reason for a large part of these fears.

Final Comments
The Alma-Ata Conference is often portrayed as a sort of founding event in the development of public health in Brazil.According to this view, the conference would have been the guideline to a series of initiatives that sought new and innovative ways to organize services and to deal with health care.In this paper, on the contrary, Alma-Ata is observed as an event that ended a phase of development thinking that can be traced to the Second World War.This was a classic period of development conceived and practiced according to the "international order of sovereignty" that would be replaced by a new "liberal order" or neo-liberalism 7 .We sought to apply and relate the concepts of international health of the end of the 1970s with the debates on development and international cooperation prevalent during the decade.In relation to the last part, we analyzed the results from the First Decade of Development and the crisis of the international order that existed.These resulted in the proposition for a review in the economic terms between rich and poor nations and almost immediately included a worry concerns: environmental issues, the distribution of wealth in social formations for employment and the inclusion of less well-off population groups.The depth and focus of the proposals varied.The common ingredients that made them relevant to sovereignty were: a general urgency for reform the economic and political order in existence, the role of the National States as essential bodies moving towards the process of change, the integrated planning of economic and social development activities, the belief in civil rationality and the belief in the possibility of a situation of solidarity between states and between the social classes.
International health documents and statements by Mahler, reveal the search for harmonization and inclusion of the health sector agenda in the wider more general debate on society.Some of the aforementioned components were present, specifically in the health announcements.Other common themes were: technology transference and the adequateness of particular situations, self-sufficiency, the mobilization of national populations and communities, the place of traditional knowledge and the formation of professionals who are able to plan, structure, manage and offer new ways of providing care.
The two spheres being development and health; together constitute conflicting arenas even with the possible consensus that exists at the end of each event or process for formulations which could suggest harmony and common thinking.
At the end of the 1970s and throughout the 80s, with the general crisis in capitalism, announced to the public opinion as fiscal crisis of the national states, the possibility of a rational solidarity between the states and among classes was radically replaced by the logic of the market.Movements around the First International Conference on the Promotion of Health culminated in the signing of the Ottawa Letter in 1984 and called for the holistic ideas from Alma Ata.However, the reformists´ impetuous characteristics of the international debates in the 1970s was a thing of the past and the movement for change had been inverted.In this environment, Primary Health Care as originally conceived in a generous and radical way, became a flag for resistance.