It is thirty years since the Alma Ata Declaration outlined an international consensus on the need to provide universal access to primary health care (PHC). During the ensuing years some countries established well-organised government health services in which PHC played an important role. Many others were less successful. The lead up to our session at the Geneva Health Forum on future health systems provides a moment to reflect on some of the new challenges for PHC.

National governments and the international community are renewing their efforts to expand access to PHC and they have committed a lot of money for this purpose. But there have been many major changes in these last three decades that pose big challenges for the future of PHC. The drafters of the Alma Ata Declaration drew largely on the experiences of those post-revolutionary and post-colonial regimes, which were rapidly overcoming a lack of health facilities, health workers and drugs.

Whilst some remote areas still lack health services many settings have both trained and untrained people, providing health care and selling drugs. The boundary between public and private sectors is blurred and government health workers frequently ask for informal payments or see patients privately. Many of these activities occur outside an organised, regulated framework of health care provision. Potential users are much more likely to live near a health facility or some kind of provider than 30 years ago, but now they face major challenges in paying for care and finding competent providers and effective and appropriate drugs.

PHC was designed to deal with prevention/health promotion and with infectious diseases associated with poverty, poor sanitation and certain insect vectors. Although these illnesses persist, there is growing pressure on health systems to address other problems. One dramatic change has been the transformation of HIV infection into a chronic and progressive disease for which people can claim entitlement to treatment. People are also affected by other chronic conditions, associated with ageing and “lifestyle” changes. This raises difficult questions about which treatments are appropriate, who should pay for them and how health systems should be organised to help people manage long-term conditions.

Concern is growing about the potential threat of epidemics of new diseases or organisms resistant to the available drugs. Recent examples are SARS, multi-drug resistant tuberculosis and a possible influenza pandemic. Government responses rely heavily on convincing people to report suspicious outbreaks and cooperate with public health measures they may perceive to be against their short-term interest. This requires high levels of trust between the population and their health system.

More actors are involved in health systems than thirty years ago, including a variety of private providers of health-related goods and services, national and international NGOs, citizen advocacy groups and political parties (where competitive electoral politics have been introduced). Governments are seeking new ways to influence health systems with their powers to allocate money, enact and enforce laws and publish information. This sometimes involves new types of partnership for service delivery and regulation.

Finally, there have been dramatic developments of new technologies for diagnosis and treatment of disease, which influence the design of health systems. In addition, the rapid changes in information and communication technologies are having a big impact. Providers and users of health services increasingly have access to the mass media, mobile telephones and the internet. They carry health information produced by governments, professions, citizen advocacy groups and private companies. In contrast to 30 years ago, when health professionals were the major source of expert knowledge, people have a variety of sources from which to find information.

The anniversary of the Alma Ata Declaration provides a good opportunity to reaffirm national and international commitments to expand access to PHC. But, it is important to understand the changed context when formulating strategies for achieving this. Many innovations have emerged that involve quite different roles for governments, markets, civil society and individuals than the drafters of the Alma Ata Declaration envisaged. We need to find ways to involve all actors in an intensive process of innovation and learning if the latest statements of good intentions are to be translated into major improvements for poor people.