Primary health care and England: the coming of age of Alma Ata?

The Alma Ata Declaration is now 28 years old. This article uses its framework to assess the changes that have occurred in recent years in the English health system. It summarises the health reform changes that have occurred internationally and those in the English health system in two eras, pre- and post-1997 - when the Labour Party came to power. It concludes that linked forces of managerialism and consumerism have had an impact on the health system which has undergone a number of structural changes in recent years. It suggests that the original Alma Ata focus on equity is being modified by the concept of choice. The tensions between central priorities, often reflected in targets, and local accountability and needs are explored. There appears to be a greater interest in seeking genuine health (rather than solely health care) change, with attendant public health and partnership policies, however the gap between policy and practice still needs to be bridged, and questions as to the appropriate locus and leadership for health promotion activities addressed. However there have been numerous institutional changes which carry the danger of distracting from the purpose of achieving health change, and which continue to raise questions as to the appropriateness of a market model for health. Finally the paper argues that the PHC framework of Alma Ata remains a useful framework for assessing health systems, but needs to be tailored to, and prioritised within, a political dynamic.