Most anti-colonial movements in the second half of the 20th Century promised to provide universal access to health services. The Alma Ata Declaration of 1978 presented a consensus view of how governments could deliver on this promise. During the next thirty years, people experienced dramatic health improvements in some countries or districts, but they continued to suffer high levels of avoidable disease and early death in many others. The existence of effective health care technologies combined with the reality that hundreds of millions of people still do not have access to effective health services has led in recent years to national and international political pressure for action and significant funding to address this reality.

This paper argues that effective strategies for increasing access to the benefits of health-related science and technology cannot just be viewed as technical challenges but must be grounded in the profound changes in political economy of the last thirty years. These include demographic shifts and changes to national and global economic arrangements, channels of knowledge flow, the organisation of politics and governance and the understanding of how innovations arise and are spread. Failure to take this into account could reduce the impact of these investments or even lead to unintended adverse consequences.