Primary Health Care

Shifts in Conventional Wisdom

In the early 1970’s, the so-called vertical health approach that was used in smallpox and malaria eradication efforts began to face sharp critique.  Many public health leaders in U.S. agencies and the World Health Organization were dissatisfied with the failure of the Malaria Eradication Campaign and the ‘vertical’ programs upon which this campaign was founded.  Frustrated with the top-down strategies and lack of community participation, more and more people began to adopt an attitude of skepticism regarding western medicine’s tertiary care emphasis in resource-poor areas.  This attitude centered on the realization that the delivery of medical care was a limited part of improving health.  Disillusioned with vertical programming and the limits of technology-based interventions, people began to recognize that social conditions and non-health sector services were vital to population health and well-being.

Under intense criticism, vertical ideologies gave way to new proposals for health and development.  The 1970’s saw a new political will for international development and the re-conceptualization of development activities.  This new conception was termed “Human Development” and emphasized building from the bottom up through the provision of basic primary health services.  In this formula, primary health care (PHC) required a change in socioeconomic status, distribution of resources, a focus on health system development, and emphasis on basic health services.(1)

Another important impetus for primary health care was the large-scale movement of rural medical services in Communist China, especially due to the ‘barefoot doctors’.  These barefoot doctors, who became increasingly popular between the early 1960s and the Cultural Revolution, were a diverse group of village health workers who “lived in the community they worked, emphasized rural rather than urban health care, and preventive rather than curative services”. (2)  The large health gains in China as a result of its community-based health programs and similar approaches elsewhere stood in contrast to the poor results of disease-focused programs.(3)

“Primary health care was also favored by a new political context characterized by the emergence of decolonized African nations and the spread of national, anti-imperialist, and leftist movements in many less-developed nations”.(4)

These changes led to new proposals on development made by some industrialized countries.  In 1974, a United Nations resolution on ‘Establishment of a New International Economic Order’ was issued.  Modernization was no longer seen as the replication of the model of development followed by the United States or Western Europe.  Furthermore, during this time, China began pressing for a conference on Primary Health Care, in order to gain recognition of its own model.  As the consensus on primary health care grew, the USSR took a leading role as they, like China, wanted to highlight a successful system of their own. 

Shifts in Global Health Leadership

New leaders and institutions embodied the academic and political influences of the Primary Health Care movement.  Prominent among them was Halfdan Mahler of Denmark.  Mahler was elected Director General of WHO in 1973 and was later reelected for two successive five-year terms, remaining at its head until 1988.  A respected WHO insider, Mahler worked on Systems Analysis at the World Health Organization and was a strong believer in social justice approaches to global health.  His distaste for ‘medical elitism’ and preference for “participatory and bottom-up” initiatives fed into the growing momentum for Primary Health Care. 

At the 1976 World Health Assembly, Mahler proposed the goal of "Health for All by the Year 2000."  The slogan became an integral part of primary health care. According to Mahler, this target required a radical change.  He said that "Many social evolutions and revolutions have taken place because the social structures were crumbling. There are signs that the scientific and technical structures of public health are also crumbling.”(5)  This and related ideas would be reiterated at the Conference of Alma Ata that took place in the Soviet Union.  Although initially opposed to a Soviet-led Primary Health Care conference as he felt that the USSR model was too top-down, Mahler eventually supported the conference upon recognizing a chance to forward his broader vision.  

International Conference on Primary Health Care

The landmark event for primary health care was the International Conference on Primary Health Care that took place in Alma-Ata from September 6 to 12, 1978 and involved over 3000 delegates from 134 governments and 67 multilaterals/NGOs. Alma-Ata was the capital of the Soviet Republic of Kazakhstan, located in the Asiatic region of the Soviet Union. According to one of its organizers, the meeting would transcend the “provenance of a group of health agencies” and “exert moral pressure” for primary health care.(6)

The Declaration of Alma-Ata that emerged from this conference states that “health… is a fundamental human right and the attainment of the highest possible level of health is a most important world-wide social goal.”(7)  Accordingly, it is one’s moral responsibility to maintain good health and promote the good health of one’s community.

This declaration was one of the first to promote the idea of health as a human right.  It reiterated the realization that health involves far more than the health sector alone can accomplish and called upon governments to build national plans for primary health care infrastructure. Furthermore, the Declaration of Alma-Ata established several main themes:

Challenges of Primary Health Care Model

Yet the model of primary health care that emerged from the Alma-Ata conference had several flaws that would plague the PHC movement.  First, there was no clear definition of what constituted primary health care.  In addition to this vague conception was the need for more defined and realistic goals.  The conference posited no short-term goals besides “Health for All by 2000.”  Furthermore, the ascendency of neo-liberalism began to spoil the political climate for social sector investment. 

It is important to recognize that changing foci in international health are as much tied to changing theoretical perceptions of problems as they are to politics.  In the case of the radical Primary Health Care movement, the new policies and programs in the 1970s developed in reaction to the perceived failure of postwar disease eradication and infrastructure development programs.  Lack of defined goals and strategies meant that primary health care would soon face a backlash in the form of “selective primary health care” and structural adjustment policies.

Go To Module 6: Selective Primary Health Care >>

Footnotes

(1) Magnussen L, Ehiri J, Jolly P. Comprehensive versus selective primary health care: lessons for global health policy. Health Aff. 2004;23(3):167-76.

(2) W.Sidel, "The Barefoot Doctors of the People’s Republic of China," New England Journal of Medicine 286 (1972): 1292–1300. See also R. Sidel and V. Sidel, Health Care and Traditional Medicine in China, 1800–1982 (London: Routledge and Kegan, 1982).

(3) M Cueto, The origins of primary health care and selective primary health care, Am J Public Health 94 (2004), pp. 1864–1874.

(4) Ibid.

(5) H. T. Mahler, "Social Perspectives in Health: Address in Presenting His Report for 1975 to the Twenty-Ninth World Health Assembly, Geneva, 4 May 1976," 1, Mahler Speeches/Lectures, Box 1, WHO Library.

(6) Interview with David Tejada-de-Rivero," in World Federation of Public Health Associations, Conference Bulletin 1 (1977): 1, Folder "WHO International Conference on Primary Health Care 1978, November 1977–January 1978," P/21/87/5, WHO Archive, Geneva.

(7) WHO, "Declaration of Alma Ata: International Conference on Primary Health Care, Alma Ata, USSR, 6–12 September 1978."