Primary Care Research and Development 2004; 5: 284–288

Primary health care: a global overview

John Macdonald Men’s Health Information and Resource Centre, University of Western Sydney, Australia

Central to the original Alma Ata declaration was the notion of a system, which included the fostering of health through multisectoral collaboration. This aspect often gets referred to as comprehensive health care, in counter distinction to a selec- tive model, which emerged immediately following the confer- ence, as the former, though laudable in intent, was argued to be unworkable. Indeed from a global perspective, comprehensive primary health care, if noticed at all in the culture of western medicine, was relegated to being of relevance in ‘other’ places: so-called developing countries. Nevertheless, at the beginning of a new century, in a vastly different world to that of the 1970s, it is the central contention of this paper that it is still possible to assert that the primary health care model is still relevant À in all countries of the world. The work on the ‘social determinants of health’ increas- ingly adds weight to the arguments against the irrationality of an overemphasis on medical technical interventions to the neglect of the health-enhancing or health- threatening contexts in which people live out their lives. Consequently it is now becoming possible to think and plan the management of health, not just the management of disease.

Keywords: Alma Ata; primary health care; social determinants of health

Essential to the primary health care approach other conference, on health promotion, for the launched at the Alma Ata conference was the ‘reorientation’ of health services towards a more denunciation of the ‘gross inequality in the health health and less disease focus (WHO, 1986). One status of the people’ both between and within can conclude, in that sense, that the call for countries, described in the declaration of the con- primary health care has ‘failed’, ‘not worked’ or ference as being ‘politically, socially and economi- simply been ignored. We know that the influences cally unacceptable’ (WHO=UNICEF, 1978). A working against such radical changes as would be major part of the strategy proposed to remedy necessary carry great weight. Nevertheless, there this situation was to rely less on medicine and can be little dispute that the call for change more on a more social development approach to embedded in the primary health care movement is improving health in which health services part- as real today as it was three decades ago. nered other significant players, or ‘sectors’ such No one should suggest that PHC (or any other as education, agriculture, etc. (Macdonald, 1994). system or approach for that matter) has a for- A quarter of a century later, there is consider- mula to right these wrongs, but the logic behind able evidence that socio-economic inequalities, the PHC approach is increasingly being validated. again between and within countries, are on the For example, one of the key elements of the pri- increase and that health inequalities follow suit mary health care approach is a community-based (UNDP, 1997; Marmot and Wilkinson, 1999; focus and community-based mechanisms which Kawachi, 2000). There is not massive evidence of deal with local issues and link with systems health services following the exhortation of the ‘higher up’ (Zajac, 2003). The need for such mechanisms and such an approach is increasingly being felt in both ‘developing’ and ‘developed’ Address for correspondence: Professor John Macdonald, countries: foundation chair in Primary Health Care, Director, Men’s Health Information and Resource Centre, University of West- ern Sydney, Hawkesbury Campus Building P11, Locked Bag . Across a whole continent À Africa À our age 1797, Penrith South DC, NSW 1797, Australia. is witness to the tragedy of an epidemic of Downloaded from https://www.cambridge.org/core. IP address: 170.106.33.22, on 28 Sep 2021 at 17:53:19, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms#Arnold 2004 . https://doi.org/10.1191/1463423604pc218oa 10.1191/1463423604pc218oa Primary health care: a global overview 285

unimaginable proportions. At the end of 2002 addressed at the local level where possible, and there were 42 million people living with secondary and tertiary care would inform and HIV=AIDS, 29.4 million in sub-Saharan Africa back up this front-line service. In addition, great (UNAIDS, 2002). The disappearance of a emphasis would be placed on prevention of illness whole generation, those we can describe in and the maintenance of health. This orientation economic terms as ‘productive’: men and remains an enormous challenge, as it was in 1978. women from 18À45 has meant that top-down One of the contextual factors which helps health services, often hospital-based, even with explain the emergence of primary health care was the best will in the world, are left standing the critique of that time (1960sÀ1970s) of the impotent in the face of the health needs not model of development being promoted through- only of patients but, just as tragically, their out the world. The idea that modernization was children and the older generation left to care the way to go, along western lines, was behind for them. Similar tragic scenarios are emerging much of the interaction between developing coun- in other continents. tries and developed countries and the institutions . In so-called ‘developed’ countries, we have the dominated by these. The problem was that slavish phenomenon of an ageing population and a copying of western models, be it in education or often geared to acute rather than health services, to name only two areas, was not chronic care, often missing the needs of this delivering: poverty and ill-health increased rather population in a serious way. Today, one of than diminished and the gap between haves and every 10 persons is 60 years old or over, total- have-nots, within and between nations, was on ling 629 million people worldwide. By 2050, the the increase (Watkins, 1995). This ‘globalization’ United Nations projects that one of every five has been the subject of critique (Chen and Berlin- persons will be 60 or older, and that by 2150 guer, 2001; Foran, 2003) and Alma Ata should be this ratio will be one of every three persons. By seen by the history of medicine in the twentieth 2050, the actual number of people over the age century as an important milestone in the chal- of 60 is projected to be almost 2 billion, at lenging of the dominant paradigm of medicine which point the population of older persons and health care delivery. At that point in time, will outnumber children (0À14 years) (United part of the contradictions of the document Nations, 2002). The challenge for society at of Alma Ata was that the critique of medicine large and health services in particular is enor- inherent in the approach was seen to apply only mous. Again, a hospital-based system which, to ‘developing’ countries rather than across the given the high cost of modern technology and globe (Macdonald, 1994). health professionals, consumes the greatest This failure to apply the critique and the con- proportion of the health budget is to the detri- sequent primary health care approach to ment of many older people who are in need of ‘developed’ countries in no way diminishes the another approach to care which is less insti- truth of its perspective on developing countries: it tution-based. (Of course, ageing is also a involved an examination of the failure of health phenomenon challenging health systems world- systems to deliver significant change in terms of wide and not just in ‘developed’ countries as is health outcomes in the countries of the third witnessed by the recent WHO initiative of an world. In many of these countries there was evi- integrated response to ‘rapid population age- dence of high infant mortality rates and low life ing’, United Nations Ageing and Life Course expectancy. This was despite many serious Program, undated.) attempts to create a health care system to meet the needs of new nations emerging from periods Again, in all cases, it would be wrong to suggest of colonial discrimination (Banerji, 1985). Access that a primary health care approach would ‘solve’ to the services of these systems was extremely all problems of service delivery, but at least the limited, often to an urban population. The focus orientation of the services would have some was largely on curative institutional care. chance of addressing population need in humane In the document of the conference there is at and effective ways. In all countries, the primary least an implicit questioning of the model of health needs of the population would be health care used to build these systems and a new Downloaded from https://www.cambridge.org/core. IP address: 170.106.33.22, on 28 Sep 2021 at 17:53:19, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1191/1463423604pc218oaPrimary Health Care Research and Development 2004; 5: 284–288 286 John Macdonald

model is outlined. Some characteristics of this in counter-distinction to the selective primary model (which was called ‘primary health care’) are health care model which emerged on the scene well known and can be summarized as follows: immediately following the conference, arguing . Affordable, accessible (on equity lines), appro- that the former, though laudable in intent, was priate care for the particular needs of a given unworkable (Walsh and Warren, 1979). The broad population (this would involve the valuing of health vision of comprehensive primary health local cultures, including non-western health care soon became medicalized by many agencies care systems) (Wass, 1998); (Macdonald, 1994). . Prevention of illness given its due role along- More importantly, perhaps, from a global side treatment; perspective, has been the indifference with which . The role of other sectors which contribute to the primary health care approach has been health to be acknowledged and intersectoral received by what we can call the western world. collaboration for health actively pursued; As Walton pointed out in the 1980s, in both the . People’s participation given a genuine role in UK and in Europe in general, the notions of pri- decision-making (WHO=UNICEF, 1978). mary health care were treated with indifference by those responsible for medical education (Wal- The ‘Primary’ in the name has ever since given ton, 1983; 1985). As mentioned, comprehensive rise to confusion and rather fruitless debate, but primary health care, if noticed at all in the culture there can be no doubt that in its original concep- of western medicine, was relegated to being of rel- tion, it included primary medical care, whether evance in ‘other’ places, so-called developing through doctors, nurses or community health countries. In some countries (like Australia) workers. The term ‘primary’ has linguistically today, the approach is accepted by conventional diverse and even contradictory meanings. In medicine as suitable for Aboriginal health. Abor- Spanish, in particular, some of these are nearly iginal people themselves, with their more holistic opposites. Primario can mean ‘primitive and view of human nature and health, on the other uncivilized’ or ‘principal or first in order or hand, have long since embraced the notion of degree’. As a result of the simplistic and biased primary health care (see, for example, the Mis- perceptions of the experiences on which the con- sion Statement of Aboriginal Health Services, like cept was based, it was easier, more comfortable Wuchopperen, Australia: Wuchopperen, 2003). and safer to accept the former meaning, while the At the beginning of a new century, in a world spirit of Alma Ata clearly embraced the latter. vastly different to that of the 1970s, one can still The declaration states that primary health care confidently assert that the primary health care "forms an integral part both of the country’s model is still relevant in all countries of the world. health system, of which it is the central function Perhaps one will have to see the problems of and main focus, and of the overall social and the health care system in the west get even worse economic development of the community’. It was before alternative models are sought after, just as never seen as an isolated part of the health care the original Alma Ata declaration emerged from system, nor was it limited to marginal, low-cost the realization by many that the model was not treatment for the poor (Tejada de Rivero, 2003). delivering in so-called developing countries. The name also implied referral ‘upwards’ where Primary health care, then, means a system of necessary: a system of health care turned towards medical care and promotion of health focused on people’s needs at the level of the front-line (pri- the health needs of a given community, a whole mary), but with mechanisms of referral in place care system, dealing with the immediate present- to secondary and even tertiary levels when neces- ing problem, but seeking to contribute to strat- sary. Moreover, in addition to this issue of access egies to prevent the problem more ‘upstream’. of ill people to clinical care, the notion of a In no country of the world should hospitals be system which included the fostering of health À filled with older patients with chronic conditions through schools, agriculture, etc., was clearly who could be cared for in less medicalized central to the original idea of Alma Ata and this situations and closer to and sometimes in their aspect often gets referred to as an essential own homes. Nor should hospitals be filled with component of comprehensive health care. This is children with diarrhoeal disease, even less with Downloaded from https://www.cambridge.org/core. IP address: 170.106.33.22, on 28 Sep 2021 at 17:53:19, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/termsPrimary Health Care Research. https://doi.org/10.1191/1463423604pc218oa and Development 2004; 5: 284–288 Primary health care: a global overview 287

malnutrition: conditions which could and should rarely welded into an integrated vision, an over- be dealt with in a primary health care system arching framework in the way Alma Ata at the community level. In both scenarios (of attempted. childhood diseases and of ageing conditions of The moral arguments of Alma Ata, involving ill-health), hospitals and their resources would be exhortations to address inequalities in health have used more appropriately for those conditions proved largely ineffectual. In the twenty-first cen- which cannot be dealt with at the level of the tury perhaps the main driver of change will be community. economic rationalism. As one Canadian com- There is, implicitly, in the primary health care mentator, recasting primary health care in the vision, a critique of western health care systems. vocabulary of a population health approach, puts it: The critique suggests that, left to itself, a typical ... western-type health care system can easily No one with an interest in health care develop along lines which might mean the impro- can afford to be ignorant of the population vement of different aspects of medical technology health approach. It is the conceptual ground ... and even medical practice, without necessarily for health reform today The latter half effecting the improvement of health status of of this century has seen an evolution in communities or even having this as its major pre- approaches to health that began with com- occupation. Specifically, the mindset inculcated passion, and was driven on by combined by such a health system allows the perpetuation forces of improved understanding, increased of the draining of funds into technical medicine health care costs, and decreased dollars (Ah to the neglect of the creation of healthy environ- Shene, 1997). ments. The separation means the perpetuation of In the west, there is a great deal of interest the dominance of the ‘downstream’ approach. in ecological perspectives and it is easy to argue There is no doubt that in many countries this is that the primary health care approach repre- what is happening. Where is the vision of another sents an ecological=population health point of way? The answer is outlined in the primary health view, in which the main task of health systems care approach. is to create healthy environments (Macdonald, It is interesting to ask: why has primary health 1999). This line of thinking is given great cre- care never or not yet been accepted in western soci- dence by the work done on the ‘social determi- eties? Even where there has been acknowledgement nants of health’. Until relatively recently, the of the logic of the arguments for a better balance call for more emphasis on prevention and for a between high-tech institutional care and com- more equitable and rational balance in the dis- munity-based care and between treatment and pre- tribution of the health dollar has been seen as a vention and policy statements been made in moral imperative. Indeed it is, there should be a support of comprehensive primary health care, the better balance, for example, between treatment reality is often policies and practice based on a and prevention, but especially in the last dec- dualistic way of thinking and acting, a continuation ade, there has arisen a body of scientific evi- of the division between treatment and pre- dence which should be drawn into the debate. vention=promotion which has been the hallmark of The work on the ‘social determinants of health’ western health care in the twentieth century. This is (Kawachi, 2000; Marmot and Wilkinson, 1999; despite some token acknowledgement of the need WHO, 1998) increasingly adds weight to the for community care and prevention. It is also of arguments against the irrationality of an over- note that the ‘three pillars’ of the primary health emphasis on medical technical interventions to care movement: participation, intersectoral collab- the neglect of the health-enhancing or health-threat- oration and the addressing of equity issues (Mac- ening contexts in which people live out their lives. donald, 1994) do appear, increasingly, as We have to think and plan the management of preoccupations of concerned commentators on health, not just the management of disease. health and critics of health services (see, for We have to recommit to primary health care, example, the excellent work on inequalities in unashamedly. We need not reject it but need to health: Kawachi (2000) and Wilkinson (1996) to find new ways of keeping its principles and apply- name only two), but these preoccupations are ing them to the contexts of today. Downloaded from https://www.cambridge.org/core. IP address: 170.106.33.22, on 28 Sep 2021 at 17:53:19, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1191/1463423604pc218oaPrimary Health Care Research and Development 2004; 5: 284–288 288 John Macdonald

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Downloaded from https://www.cambridge.org/core. IP address: 170.106.33.22, on 28 Sep 2021 at 17:53:19, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/termsPrimary Health Care Research. https://doi.org/10.1191/1463423604pc218oa and Development 2004; 5: 284–288