The emergence of Primary Health Care

Hello. It’s great to talk to you again. This session is about the story of health systems and global health. I came into this story as an active participant in the mid 1980s. So to some extent, it’s the story of my life preoccupation since then. And it’s something quite close to my heart. I’m going to start the story with the primary health care movement, which can be traced back to two main strands of thinking in the 20th century. The first is pre-communist and early communist China. Everyone has heard of the barefoot doctors. But few know that their origins predate the Chinese revolution of 1948.

After 1948, the commune, or co-operative system of organisation, facilitated a contributory system to support basic health care. Together with a very basic set of capacities that barefoot doctors could use to respond to health problems at the co-operative level, the early communist period also emphasised health campaigns like those against the four pests– mosquitoes, rats, flies, and sparrows. The ecological imbalances caused by the extermination of sparrows were catastrophic. And that part abandoned after a short period. The second root of the primary health care movement can be found in the African socialism of Julius Nyerere. This also emphasised self-reliance and basic responses to health problems at community level. The practical implementation of the ideas proved less successful than in China.

And neither economy nor health system thrived under this philosophy. But Nyerere’s premise in the quote about hospitals versus basic medical services remains a guiding principle for much health systems’ thinking. In 1978, primary health care became the consensus approach to building health systems in the quite newly independent states of Africa and the more established ones of Asia and Latin America. The International Conference on Primary Health Care in September 1978 in Alma Ata, now Almaty in Kazakhstan, remains a major reference point in the story of global health and was revisited by the World Health Report in 2008. And the Lancet special issue in the same year, 30 years later, focused on the continuing relevance to health systems development.

There have been major global changes since 1978. The majority of countries that were low income then are now middle income. The HIV/AIDS epidemic shifted thinking considerably. And epidemiological and demographic transitions have shifted attention from infectious diseases in childhood and women of reproductive age. But the consensus in 2008 was that the primary health care model still provided the appropriate framework for the development of health systems. The seven elements, or slightly differing versions over time, were once the mantra of every international public health chorus, including the one I participated in in 1984. Beyond these elements, though, primary health care was a philosophy or ideology with political resonance.

For many, it was about redistribution of authority over health issues from central to local levels and to community and individual empowerment for people to own and manage their own health. And for many, primary health care still means a more politicised and community-based movement, while primary care is the appropriate term for the set of services that are made available at the base level of the health system. However, no sooner was the ink dry on the consensus statement than significant dissent between the contrasting versions of selective and comprehensive PHC broke out.

Walsh and Warren’s paper, published less than a year after the conference proposed a limited list of cost-effective interventions that they considered a kind of operationalisation of the ideas of Alma Ata. The broader political agenda was effectively sidelined by this approach. And a considerable push-back on the selective primary health care idea was voiced in response. Hence, the consensus descended into dissensus or even ideological warfare. Other debates about primary health care, like how to finance it and who should provide it, broke out later.

As I mentioned earlier, from a contemporary perspective, we might query the appropriateness of either comprehensive or selective vision to conditions that were not envisaged in 1978– ageing populations and the rising importance of non-communicable diseases in low, middle, and high income countries alike. These developments imply a need for the primary health concept to evolve to embrace approaches to managing multiple chronic conditions individually and in combination.

And while basic packages of services are still proposed to incorporate chronic conditions– for example, WHO has proposed the package of essential non-communicable disease interventions, known as PEN– these ideas continue to contrast with ideas of individual and community empowerment to manage health conditions and the politics of regulating the activities of corporations such as those selling cigarettes and soft drinks and their implications for NCDs.