Introduction

The World Health Organization's (WHO’s) constitution defines health as ‘a state of complete physical, mental and social well being and not merely the absence of disease or infirmity’ (WHO, 1948, p 1). This may be widely accepted as an ideal, but in practice health continues to be perceived differentially by policy makers, health care providers, civil society groups and the general populace. One thing is certain: the evidence that health cannot be achieved through only biological and technological interventions is overwhelming.

Thirty years ago, there was a ‘revolution in thinking’ about health and health care at the International Conference on Primary Health Care at Alma Ata (WHO, 2008, p 747). The conference asserted that primary health care was the preferred strategy for global health policy, underpinned by core values. The Alma Ata Declaration (WHO, 1978) reaffirmed that health is a fundamental human right and proclaimed that the gross inequalities in health status between and within developed and developing countries were politically, socially and economically unacceptable. Governments who signed the Declaration committed themselves to making appropriate investments in economic and social development, and in health systems, to ensure ‘Health for All’ their citizens, including the poor; to provide access to affordable health care; and to community ownership of the organisation of health services. The resultant ‘Global Strategy of Health for All by the Year 2000’ determined that ‘all people in all countries should have at least such a level of health that they are capable of working productively and of participating actively in the social life of the community in which they live’ (WHO, 1981, p 15).

However, this vision was rapidly undermined by the International Monetary Fund's promotion of its ‘structural adjustment’ approach to economic development, supported by the World Bank, and was replaced with a ‘selective primary health care’ approach (Walsh and Warren, 1979) which focused on vertical single issue interventions (WHO, 2008). It has been argued that ‘Health for All’, based in primary health care, was not really given a chance, although countries like Mozambique, Cuba and Nicaragua demonstrated that the principles of equity and justice on which ‘Health for All’ was based could work (Magnussen et al, 2004).