The health vision, expressed by the Alma-Ata Declaration 30 years ago, to strengthen health systems from a bottom-up approach was challenged by those who argued that to achieve a measurable effect it was necessary to focus on a limited number of cost-effective interventions through selective primary health care.

The World Bank report (1993) marked the change to healthcare services in poor countries. It replaced Primary Health Care with "Health Sector Reform" and focused on user pays, cost recovery, private health insurance, and public-private partnerships. The "Health Sector Reform" parted from the spirit of the Alma Ata Declaration, introducing policies, which were not debated or agreed collegially as the Alma Ata was and which took health politics away from people.

The developments of the last 30 years have been shaped by this shift in international development strategies. The emphasis on delivering cost-effective interventions from international organisations in combination with a weak role for the state, and even in some cases attempts to circumvent state involvement, has resulted in a range of selective programmes operating at the same time in countries with limited capacity to deliver. These developments were compounded by pressure for privatisation and market praise, examples of which ironically grew in number in spite of clear evidence of the need to strengthen health systems. Moreover, the preference of the rich for private health care reduces their financial participation in public health care systems, thus increasing the fiscal burden of universal coverage and access for the poor. The poor and other vulnerable groups have been particularly affected as health care has been transformed into a commodity. This policy shift has increasingly blurred the value foundation of health as human right. Thus in the last three decades the world health policy has shifted from the previous vision of "health for all" to an MDG agenda, which even within its limited scope seems to be hardly achievable.