ALMA-ATA at 40: Reviving an Old Script to Strengthen Health Governance

Allan Maleche and Nerima Were

The Alma-Ata Declaration had the wisdom 40 years ago to state:

All governments should formulate national policies, strategies and plans of action to launch 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.

The declaration predated today’s understanding of accountability and human rights obligations pertaining to health, but it drew the world’s attention to the critical role that politics and resourcing plays in sustaining primary health care.

Kenya was one of the 134 WHO member states that adopted the declaration in September 1978. Furthermore, the right to the highest attainable standard of health is guaranteed in the Constitution of Kenya, 2010. Article 53 (1,c) guarantees children’s immediate right to health. The importance of health, and the duties of the Kenyan state to respect, protect and fulfill health rights, is therefore well documented, and of great concern to people in Kenya. In keeping with the declaration, Kenya has indeed put policies and strategies in place to provide primary health care, particularly vaccination and immunization. The challenge remains full implementation and sustainability of interventions that are heavily donor driven.

So it is no surprise that recent scandals about misappropriation of donor funding for health has left Kenyans disillusioned with its health governance. Chief among the scandals is the embezzlement of funds earmarked for child immunization—one of the key features of primary health care, referred to in both the Alma-Ata and as a core obligation in the right to health. In May 2016, the Global Alliance for Vaccines and Immunization (GAVI) released an audit of the Kenyan Expanded Programme of Immunisation. The audit uncovered questionable expenditure of US$1.6 million, relating to money paid directly to the Ministry of Health, which has been embezzled, misappropriated, mismanaged, lost and/or stolen. Other scandals have been exposed by the media, and also by the Office of the Inspector General of the Global Fund to Fight AIDS Tuberculosis and Malaria. The lack of accountability and transparency in the Ministry of Health in Kenya (and elsewhere) has led to the United States Agency for International Development (USAID) suspending direct assistance to the ministry.

Although Kenya repaid the misappropriated funds to GAVI in one single installment, at more than two years after the report it has still failed to address these accusations and prosecute the individuals implicated in the irregularities. It has also failed to open the books to show from which organ’s budget the repayment was made and has not responded to requests from civil society to explain the processes. The consequences of these actions are having a direct impact on the sustainability of the country’s health system, and on primary health care.

There have been frequent strikes by health care workers, drug stock outages, essential equipment failures, and related challenges across all components of the sector. The scandals are threatening to unravel health gains made by including the right to health in the Constitution.

Alma-Ata first stressed the importance of national plans developed inclusively, which then led to more specific accountability processes within the UN Human Rights mechanisms. The state as duty bearer is responsible for the realization of health rights, and it must be held to account for these duties—accountable to its citizens and residents as well as the international community. This also requires transparency about the scandals and the impact they have had on its right to health obligations. Accountability demands an openness, which in this case would apply to the actions surrounding the repayment of the embezzled funds.

Kenya’s loss of funding from international donors is having a direct impact on primary health care, and on its ability to continue to attract funds. Alma-Ata aspired to achieve “Health for All” by 2000. Now, 18 years beyond the goal, Kenya remains dependent on development partners for primary health care. Children’s right to health cannot be fulfilled without donor support, especially for vaccinations, and nor can Health for All hope to be attained.

States and external partners are both accountable for the way resources are spent, and for demonstrating transparency about funding. In addition to claiming back misused money, external partners can build relationships with prosecution agencies; require regular updates on remedial actions being taken; and engage with communities to create a sustainable watchdog mechanism. Critically, states and external partners should accept that accountability cannot be achieved without the creation of institutions that foster transparency. Such steps, taken with the support of the donors, would take us closer to reducing, in the words of the Alma-Ata,

…gross inequality in the health status of the people particularly between developed and developing countries as well as within countries [which] is politically, socially and economically unacceptable and is, therefore, of common concern to all countries.

Allan Maleche is a human rights lawyer, advocate of the High Court of Kenya, the Executive Director for the Kenya Legal and Ethical Issues Network on HIV and AIDS (KELIN), Board Member Developing Country NGO Constituency of the Global Fund, Board Member of the Audit and Finance Committee, Former Chair Implementer Group of the Global Fund and Elizabeth Taylor Human Rights Awardee

Nerima Were is a human rights lawyer, advocate of the High Court of Kenya, Programme Manager at KELIN, Tutorial Fellow at the University of Nairobi, Legal Scholar and a 2018 Mandela Washington Fellow (Young African Leaders’ Initiative).