Selective Primary Health Care

Selective Primary Health Care

In response to the vagueness of primary health care and the conference of Alma Ata, an alternative movement began to gain momentum.  This movement, termed Selective Primary Health Care (SPHC), emphasized the cost-effectiveness of vertical programs with measurable results.  In addition, an important part of selective primary health care was the creation of political will for funding opportunities.  

One year after the Alma Alta declaration, Julia Walsh and Kenneth Warren presented selective primary health care as an "interim" strategy to begin the process of primary health care implementation.(1)  They argued that the best way to improve health was to fight disease based on cost-effective medical interventions.  Although they acknowledged that the goal set at Alma Ata was admirable, they contended that resource constraints made its scope unattainable.  Their agenda for selective primary health care is illustrated below in an excerpt from their report:

“A flexible program delivered by either fixed or mobile units might include measles and diphtheria-pertussis-tetanus vaccination, treatment for febrile malaria and oral rehydration for diarrhea in children, and tetanus toxoid and encouragement of breast feeding in mothers. Other interventions might be added on the basis of regional needs and new developments. For major diseases for which control measures are inadequate, research is an inexpensive approach on the basis of cost per infected person per year.”(2)

 GOBI-FFF

Selective primary health care as conceived in the Walsh-Warren article proposed a selective attack on the most severe public health problems.  It was thought that this narrow and focused attack would maximize health improvements in developing countries.  For example, SPHC identified four factors to guide the selection of target diseases for prevention and treatment: prevalence, morbidity, mortality, and feasibility of control.

Thus, rather than primary health care’s broad emphasis on development and sustainability of health systems, SPHC focused on four vertical programs: growth monitoring, oral rehydration therapy, breastfeeding, and immunization (GOBI).(3)  Family planning, female education, and food supplementation (FFF) were added later.  “These interventions appeared easy to monitor and evaluate.   Moreover, they were measurable and had clear targets”.(4)   Thus, funding was easier to obtain because indicators of success and reporting could be produced more rapidly.
SPHC’s narrow selection of specific conditions abandoned Alma Ata’s broad focus on social equity and health systems development.  This divergence from the lofty goals of Alma Ata to a selective approach sparked more than two decades of debate:

“The advocates of highly selected and specific health interventions have ignored, or put on one side, the ideas which are at the core of what could be described as the primary health care revolution. They are in this sense counter revolutionaries.” (5)

Medicine vs. Public health

Throughout the history of global health efforts there has been a recurring tension between medicine (treatment) and public health (prevention).  This tension emerged with the therapeutic revolution which brought about profound changes and gave rise to potent drugs and powerful pharmaceutical companies.  The therapeutic revolution also fostered a culture of biomedical superiority, promoting medicalization and overlooking important social factors that contribute to health and illness.(6)  For example, in Penicillin: Triumph and Tragedy, Robert Bud argues that penicillin was seen as a miracle drug that not only cured illnesses but also saved entire societies from political and economic collapse.(7)  Bud points out that because of these new drugs, “infection now came to be seen as a technical problem susceptible to a pharmaceutical solution,” and consumption of these drugs grew exponentially and remorselessly. 

Yet this early faith in biomedicine was soon replaced by a growing discomfort with vertical, technology-driven interventions.  As realization of the importance of social and economic factors grew, people became suspicious of medicine’s quick-fix mentality.  This backlash culminated in the primary health care movement in which basic health services and preventive activities were promoted above all others.  As discussed above, the overemphasis on vague preventive strategies created a backlash of its own, exemplified by the ideologies of selective primary health care. 

A continuous theme throughout these debates has been the tension between medical interventions and public health efforts.(8)  This has taken many forms including: SPHC vs. PHC, vertical vs. horizontal programs, malaria vs. smallpox eradications efforts, and more.  The debate posits opposing ideologies: to improve health it is necessary to provide either “more physicians, hospitals, expanded diagnostic testing, and access to medication” or promote “patient education, and prevention aimed at addressing basic needs”. 

This traditional opposition has created a false dichotomy between public health and medicine, forcing a choice between one and the other.  The truth is that focusing on medical interventions over basic health infrastructure is an ineffective way to improve health, both domestically and internationally.  At the same time, the denial of effective medical care and so-called “vertical interventions” is a violation of the right to access available and effective treatments.  It must be realized that medical treatment does not have to come at the expense of public health initiatives.  In order to be effective, we must take a “diagonal approach” in which health efforts incorporate both medical interventions and preventive public health activities.  

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Footnotes

(1) J. Walsh and K. Warren, "Selective Primary Health Care: An Interim Strategy for Disease Control in Developing Countries," New England Journal of Medicine 301, no. 18 (1979): 967–974.

(2) Ibid.

(3) J.Ruxin, "Magical Bullet: The History of Oral Rehydration Therapy," Medical History 38 (1991): 363–397.

(4) M Cueto, The origins of primary health care and selective primary health care, Am J Public Health94 (2004), pp. 1864–1874.

(5) K. W.Newell, "Selective Primary Health Care: The Counter Revolution," Social Science and Medicine 26 (1988): 903–906.

(6) Edmund Pellegrino. "The Sociocultural Impact of Twentieth-Century Therapeutics". The Therapeutic Revolution. Philadelphia: Univ. Penn Press, 1979.

(7) Robert Bud. Penicillin, Triumph and Tragedy. New York: Oxford University Press, Introduction and pp. 75-112.

(8) Brandt, Allan. “Antagonism and Accommodation: Interpreting the Relationship Between Public Health and Medicine in the United States During the 20th Century.” American Journal of Public Health 90 (2000) 707-715.