Primary Health Care

Origins of PHC
Primary health care (PHC) can be traced to 19th century pathologist Rudolf Virchow, who believed that adequately addressing major diseases had to involve not only biomedicine, but also political commitment to social justice and improving the lives of the poor. Thus, “health is not only a by-product of social changes but an instrument to promote such changes” (source).

Most histories of primary health care begin at the 1978 International Conference on Primary Health Care, held at Alma-Ata in the USSR (now Almaty, Kazakhstan). While the Declaration of Alma-Ata unanimously agreed to at that conference was the first time PHC was formally defined, there were a number previous conferences on the topic, as well as several projects that had pioneered the approach in different ways and to varying extents. In particular, the World Health Organization (WHO) under the leadership of Halfdan Mahler had already begun a shift away from their large vertical, top-down strategies, especially in light of the failure of their malaria eradication efforts. Mahler proposed the goal of “health for all by 2000” at the 1976 World Health Assembly (cited here), and the Health for All slogan remains at the core the PHC movement to this day.

Alma-Ata
The weeklong International Conference on Primary Health Care culminated in the Declaration of Alma-Ata, which was unanimously accepted by the 134 member states and 67 organizations present. The Declaration called on all governments, NGOs and the “whole world community” to strive toward “a level of health that will permit them to lead a socially and economically productive life” by 2000 (Article V), and presented primary health care—as part of social justice-driven development—as key to achieving that goal. As defined in the Declaration, “primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination” (Article VI). Article VII describes the scope of PHC, noting that the areas mentioned represent the minimum of what PHC covers. Among these components, alongside biomedical standards like immunization, disease control and appropriate treatment, are “promotion of food supply and proper nutrition” and “an adequate supply of safe water and basic sanitation,” neither of which is traditionally considered part of health care based on the biomedical model, but clearly have direct and powerful effects on health. Additionally, the Declaration states that PHC “involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sectors; and demands the coordinated efforts of all those sectors” (Article VII)

Selective Primary Health Care
PHC was judged too large, costly and unwieldy to implement immediately, leading to the introduction of “selective primary health care.” Walsh and Warren proposed this in 1979 as an “interim strategy for disease control” in low-income countries (read it here). As a result of this new iteration of PHC, the broad approach envisioned through most of the 1970s became known as “comprehensive primary heath care.” Selective PHC eliminates the broad range of reforms needed to achieve Health for All, and instead focuses on highly-targeted goals like increased immunization and breastfeeding rates and available of oral rehydration therapy. These strategies were direct solutions to some of the most pressing illnesses–namely diarrheal diseases, measles, malaria and respiratory infections–but do not tackle larger, structural factors like food security, social equity, and water quality and access, which are once again relegated to the domain of development work rather than health. Many selective primary health care programs prevent deaths through treatment or direct prevention (immunization, food supplementation), doing little to address the social and environmental causes of the diseases. For example, instead of investing money in clean water, a selective PHC program will ensure adequate supply and access to oral rehydration salts. As a result of this limited “interim” strategy, the term “primary health care” is used to describe both a comprehensive system like that detailed in the Declaration of Alma-Ata and modeled by the CRHP, and to selective primary health care.

Renewed focus on comprehensive PHC
WHO’s 2008 World Health Report is dedicated entirely to review and discussion of Alma-Ata and PHC, in recognition of the 30th anniversary of the conference. It calls for a renewal of PHC, using the tagline “Now, More than Ever.” Why? “Globalization is putting the social cohesion of many countries under stress. […] Few would disagree that health systems need to respond better – and faster – to the challenges of a changing world. PHC can do that.” Read more here.

WHO also focused the 2008 Bulletin feautures on PHC, presenting a monthly series of PHC implementation (at the national level) from around the world. Read more here.
On the heels of WHO, The Lancet published a series of papers in September 2008 entitled “Alma-Ata: Rebirth and Revision.” PHC is described as worth returning to because it “is offering global health a lifeline,” which is especially important in light of “stalled” progress toward the Millennium Development Goals. (Source/more info here.)

Community Health Workers
The implementation of primary health care has been plagued by limited funding and political will, as well as a lack of a clear and widely-accepted understanding of what PHC entails. One key component of PHC that has been widely discussed, implemented and studied, however, is the community health worker model. Community health worker systems function in the PHC framework as a means of achieving community participation in health care, as well as serving as a low-cost means of health promotion and disease prevention. The projects that motivated the 1978 PHC conference at Alma-Ata differed in their approaches to PHC, but many included some kind of community health worker network—from China’s “barefoot doctors” to the Jamkhed’s Village Health Workers. Similarly, though it was just one part of the PHC framework envisioned in the Declaration of Alma-Ata, community health worker systems were widely and rapidly adopted in the subsequent years, often on a national scale. Most of these programs, however, lack the rest of the PHC “package”; regardless of how comprehensive it is, PHC is necessarily more than just community participation and access to preventive care/health promotion.

Further reading:
Bryant, JH and JB Richmond. “Alma-Ata and primary health care: an evolving story.” 2008.
(PDF here)

Cueto, Marcos. “The ORIGINS of Primary Health Care and SELECTIVE Primary Health Care.” 2004. (full text on PubMed)

Wollumbin, Jimi. “Holistic primary health care–origins and history.” 2012. (full text on web page)

The Global Health Education Consortium’s “Primary Health Care: Past, Present and Future” slides (from a 2009 presentation) are also an excellent overview of comprehensive PHC. See them here.