Primary Health Care Research Paper

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Introduction

This research paper aims to reflect on some of the successes and failures of its implementation over the past 30 years, and attempts a glimpse into the future in terms of some of the key challenges and opportunities.

The Alma Ata Declaration: Background, Focus, And Implications

The concept of primary health care (PHC) evolved during the 1970s, influenced by and influencing the basic needs approach to social development. Informed on the one hand by the disappointments experienced in implementing the basic health services approach, and on the other by the remarkable progress in improving health in China, as well as by the achievements of many small, mostly NGO-inspired, community-based health-care initiatives in developing countries (Newell, 1975), WHO and UNICEF elaborated the strategy of primary health care as the means to achieve Health for All by the Year 2000.

The concept of PHC had strong sociopolitical implications. It explicitly outlined a strategy that would respond more equitably, appropriately, and effectively to basic health-care needs and also address the underlying social, economic, and political causes of poor health. Certain principles were to underpin the PHC approach (PHCA), namely, universal accessibility and coverage on the basis of need; comprehensive care with the emphasis on disease prevention and health promotion; community and individual involvement and self-reliance; intersectoral action for health; and appropriate technology and cost-effectiveness in relation to the available resources. The concept of social justice strongly informed the concept of PHC.

The implications of the PHCA were recognized, even at the time of the Alma Ata Declaration (WHO and UNICEF, 1978), to be far-reaching if the strategy were to be properly applied: the principles would have to be translated into changes not merely in the health sector but also in other social and economic sectors as well as in community structures and processes.

Some of the changes required would include the redistribution of existing resources (financial, material, and human) for health; a reorientation and a broadening of the skills of health personnel to enable them to respond to the challenges of implementing PHC and to work in teams as well as with other sector professionals and communities; and improved design, planning, and management of the health system to facilitate greater community involvement, intersectoral collaboration, and decentralization (adapted from Tarimo and Webster, 1994).

A Balance Sheet Of PHC Implementation: Context And Progress

The Policy Context Of PHC

In the 30 years since the Alma Ata Declaration there has been significant progress in global health with an overall increase in life expectancy. However, rapidly widening inequalities in health experience between and within countries – and even reversals in Africa and the former Soviet Bloc countries – give cause for concern.

These reversals are due to the emergence of new diseases, especially HIV/AIDS, and the resurgence of old ones such as TB, malaria, cholera, and dengue, as well as an alarming rise in the prevalence of noncommunicable diseases and violent trauma – especially among the poor in developing countries.

This disease pattern, and the widening inequalities in health experience, are a reflection of demographic changes together with rapidly widening disparities in socioeconomic status, structural unemployment, increasing pollution of the environment, social disruption, and its exploitation by the drug, alcohol, and tobacco trade (WHO, 1998b). Ultimately, this pattern is a reflection of growing inequalities in wealth between and within countries with the income gap between rich and poor being greater than ever before.

The situation outlined in the preceding paragraphs is a result of a complex history of uneven economic and social development extending over centuries, but progressing much more rapidly over the past 100 years or so, and more recently of what is termed globalization. The latter, ushered in by the debt crisis and structural adjustment programs of the 1970s and 1980s, has been underpinned by policies that have accelerated economic stratification and resulted in chronic underfunding of social services, including the public health infrastructure, especially in rural or peripheral areas.

The Declining Capacity Of Health Systems

The decline in health expenditure since the mid-1980s, and the steady withdrawal by the state from provision of public health services, has resulted in diminished capacity of the health system to respond to the basic health needs of communities.

Technological innovation and globalization have greatly improved communications and information in all countries, and have thus created the potential for improved interventions in health care. However, the widening inequities between rich and poor and between industrialized and developing nations, coupled with the near-collapse of peripheral health services in many developing countries, has meant that such advances benefit only a minority.

Community-level care and programs have also suffered from a decline in support for community health worker schemes, occasioned by a complex of factors which have included observed limitations of such programs (Lehmann and Sanders, 2007), perceived threats by the medical establishment to their hegemony, and financial problems besetting developing country governments and communities.

With less and less money, ministries of health in developing countries have resorted to support from bilateral donors and global health partnerships (GHPs) and initiatives (GHIs), which now largely determine the main lines of action of health programs. This increased reliance on donor aid with its priorities is discussed later in this research paper.

Underfunded government services are, and are perceived to be, deteriorating in quality, with the result that communities are increasingly losing confidence in them and often turning to traditional and private practitioners. In many poor countries declining public sector wages have spawned corruption which has become institutionalized in many health facilities (Bassett et al., 1997).

Different Interpretations Of PHC

A major fault line over the past period – and something which was in fact introduced in the Alma Ata document itself – has been the definition of PHC as both a ‘level of care’ and an ‘approach.’ These two different meanings have persisted and perpetuated divergent perceptions and approaches. Thus, in some industrialized countries and sectors PHC became synonymous with first-line, or primary, medical care provided by general doctors, with the result that PHC has been viewed by many as a cheap, low-technology option for poor people in developing countries (Tarimo and Webster, 1994).

Even in countries that embraced PHC as the key to Health for All (HFA), escalating foreign debt, global economic recession, and reductions in health and social sector spending in the 1980s bedeviled its implementation, leading to the following conclusion: ‘‘It was adopted several years too late for the political and social movements that could have provided support and served as a springboard for development’’.

As summarized above, global economic and social context and policies have been inimical to the implementation of an approach to PHC that emphasizes equity and participatory social development. Despite the above differences in interpretation of the concept of PHC and the changes in the economic and political climate there have been significant successes in implementing PHC. These have, however, been mainly in the development of peripheral health services, rather than in the facilitation of social development through the promotion of an intersectoral approach and community participation, which might lead to improvements in living environments and provision of job opportunities – a philosophy that was at the core of the Alma Ata Declaration.

In the following section we consider the progress that has been made in relation to implementing key aspects of PHC over the past 3 decades.

Progress In Implementing The Eight Program Elements Of PHC

The Alma Ata Declaration suggested that primary health care, at the very least, should include a set of eight basic elements, namely: an adequate supply of safe water and basic sanitation; the promotion of food supply and proper nutrition; maternal and child health care, including family planning; immunization against the major infectious diseases; the prevention and control of locally endemic diseases and appropriate treatment of common diseases and injuries; health education; and the provision of essential drugs. Later, mental health was added as a ninth element of PHC.

Since the early 1980s there has been considerable progress in the coverage of populations with these essential elements of PHC, although the gap between availability in the industrialized and least developed countries is widening as is that between the rich and poor within countries.

In summary, there has been some progress in improving access to water supply and sanitation, although great differences continue to exist between and within countries and social groups. For example, in high-income areas in cities in Asia, Latin America, and sub-Saharan Africa, people have access to several hundred liters of water delivered to their homes, but slum dwellers and people in rural areas have access to less than 20 liters a day, and a little less than half the developing world’s population (2.6 billion) is deprived of sanitation (UNDP, 2006). A welcome development over the past period, however, has been the shift in focus from water quality alone toward a more integrated approach to environmental improvement.

The nutrition situation in developing countries remains serious. According to data from the Food and Agriculture Organization, every day 799 million people in developing countries – about 14% of the world’s population – go hungry (FAO, 2003). Clearly, progress in this area demands not only health sector interventions (e.g., treatment of infectious disease, supplementary feeding, nutrition education) but also effective intersectoral actions to improve living conditions and household food security (Mason et al., 2006).

The most spectacular achievements have been in maternal and child health care and family planning, although maternal health has received far less attention than child health, with levels of maternal mortality and morbidity from largely preventable causes in developing (particularly the least developed) countries remaining unacceptably high. Maternal mortality is the highest in Africa where the lifetime risk of maternal death is 1 in 16 compared with 1 in 2800 in rich countries (WHO, 2005a).

Child health-care provision has increased greatly over the past 2 decades with the vigorous promotion of certain selected ‘Child Survival’ technologies: growth monitoring, oral rehydration therapy (ORT), breastfeeding, and immunization (GOBI). Of these, immunization has shown the most dramatic improvement, with global coverage of children under 1 year increasing from 20% (WHO, 1992, cited in Tarimo and Webster, 1994) in 1980 to 78% by 2005 (WHO, 2006). This impressive progress notwithstanding, there remain areas for concern. These include stagnation in immunization coverage since 1990, with the most difficult-to-reach population being the group experiencing a disproportionate burden of vaccine-preventable disease; the reappearance of diphtheria in the Newly Independent States as a result of vaccine shortage and poor program management; and only 57% coverage of pregnant women with tetanus toxoid vaccine being attained (WHO, 2006).

Acute respiratory infection (ARI) and diarrheal diseases are the two leading causes of death in children under 5 years of age globally. Since the early (in the case of diarrhea) and late 1980s (in the case of ARI) standardized case management guidelines have been developed with rewarding results: however, particularly in the case of diarrhea, the impact has been less than anticipated, due to interrupted and inaccessible supplies of oral rehydration solution, improper usage, and an unabated high incidence of diarrhea as a result of minimally improved environmental hygiene and persisting malnutrition (Werner and Sanders, 1997). Most deaths among under-fives are still attributable to just a handful of conditions and are avoidable through existing interventions, mostly pneumonia (19% of all deaths), diarrhea (18%), malaria (8%), measles (4%), HIV/AIDS (3%), and neonatal conditions, mainly preterm birth, birth asphyxia, and infections (37%) (WHO, 2005a).

Control of the three most common and serious communicable diseases, tuberculosis (TB), HIV/AIDS, and malaria, has proved elusive. TB exacts an annual toll of 8.8 million new cases and 1.6 million deaths worldwide (Maher et al., 2007); its prevalence has risen sharply over the past 2 decades as a result of HIV infection, deteriorating socioeconomic conditions, and poor-quality control programs, together with the emergence of multidrugresistant organisms. Similarly, the HIV epidemic has spread rapidly to affect an estimated 40 million individuals (UNAIDS, 2006), most of whom live in developing countries. In countries hardest hit by HIV, for example, Botswana, Lesotho, South Africa, and Swaziland, there has been a dramatic impact on survival with over 10 years in life expectancy being lost over a short period of time. The malaria situation remains serious, particularly in subSaharan Africa where it imposes high mortality and morbidity levels and a major economic burden from lost productivity and escalating treatment costs as antimalarial drug resistance spreads. Every year, malaria causes approximately 1 million deaths (the majority of which are infants and children in Africa), and between 350 and 500 million people get sick with malaria (The Global Fund, 2006).

Current strategies for control of these diseases are multifaceted and remarkably similar. Given these synergies and the magnitude of the dual epidemics of HIV and TB, global partnerships like The Global Fund to Fight AIDS, Tuberculosis and Malaria, The Stop TB Partnership, and Roll Back Malaria were established.

Technologies employed in all three cases have evolved considerably in the past decade, for example, improved short-course anti-TB drug regimens, the syndromic management of sexually transmitted infections (STIs), increased access to antiretroviral therapy (ART), and geographic information systems to assist in targeting malaria vector control. However, sustained success in combating these diseases is unlikely without well-developed health systems, improved living and working environments secured through antipoverty measures and coordination with health-related economic and social sectors, and active participation by communities in such control campaigns. Indeed, a recent review has pointed out the lack of evidence for effectiveness of directly observed therapy – short course (DOTS) in the absence of a well-functioning health service and community engagement (Volmink and Garner, 1997).

The major noncommunicable diseases (NCDs) such as cardiovascular disease, cancers, diabetes, and mental illness, together with violence and injuries, contribute significantly to the burden of disease in developed and, increasingly, developing countries. The WHO estimates that currently 60% of all deaths are caused by NCDs. Reflecting increasing contamination of the food chain and the environment by chemical, hormonal, and radioactive pollution, most cancers are on the increase in both developed and developing countries, an exception being lung cancer, which is declining among men and the younger generations in developed countries as a result of reduced tobacco consumption; the reverse is generally true for women everywhere, as well as for developing countries where smoking is on the increase. Diabetes, too, has become much more common globally, reflecting inappropriate dietary patterns and exercise habits. Cardiovascular disease is now becoming more common in developing countries but has declined dramatically in most developed countries: here smoking reduction, particularly among men, has been a major factor.

The high prevalence of mental illness and the increasing incidence of violence and injury reflect marked changes in living and working environments which are characterized by rapid, squalid, and stressful urbanization, structural unemployment, and increasingly visible disparities within most societies. In recognition of the burden of mental disorders and their costs in human, social, and economic terms, the WHO developed a set of recommendations for action, many of which incorporated the principles of PHC (WHO, 2001).

The complex epidemiology of noncommunicable diseases reveals starkly the inadequacy of control measures based on a narrow medical-technical approach which in the past relied heavily on a combination of medical measures and individually directed health education. It is clear that a wide-ranging set of actions, involving a range of sectors and tied to more fundamental measures, is necessary for sustainable impact.

Thus it is that the understanding and application of health education, one of the elements of PHC, has evolved significantly from a preoccupation with individual behavior change toward a broader set of activities termed health promotion, whose scope has been elaborated at international conferences beginning with Ottawa (1986), and most recently in Bangkok (2005) and which incorporates individual as well as social action.

The final program element to consider is essential drugs. Since 1978, when the Action Program on Essential Drugs was established, great progress has been made. By 1990, 64 countries had installed operational essential drugs programs, 28 were developing such programs, and at least 68 had formulated national drug policies (Tarimo and Webster, 1994).

By 2002, at least 156 countries in total had adopted national essential drugs lists and over 100 countries had national policies in place or under development. Despite this, however, approximately two billion people still do not have regular access to essential medicines (Quick et al., 2002). At the same time the drugs bills for most countries and their health services remain massive, and wastage and irrational drug use in public and especially private sectors remain problems. Despite the introduction of an Essential Medicines List for Children, there is still a great need for comprehensive national policies and actions covering procurement and quality control, distribution, and rational prescribing and dispensing, as well as consumer education.

Progress In Health Systems Development

Support at the national level for the reorientation of existing facilities and personnel has been visible in many countries where large numbers of workshops on PHC have been organized for health workers, and organizational structures developed to facilitate PHC implementation. Logistic support for health services in terms of drugs, equipment, vehicles, and communications has frequently been inadequate, often determined by the overall level of development of the country, except where special (often donor-provided) resources have been allocated, as in the case of immunization and diarrheal-disease control programs (Tarimo and Webster, 1994).

In recognition of the fact that, almost a decade after Alma Ata, the activities of various programs and institutions largely continued to be piecemeal and poorly coordinated, and that health services often remained concentrated in particular areas, leaving large population groups with little or no access to health care, the concept of the district health system (DHS) was born. The DHS has been promoted as the unit within which the implementation of primary health care by the health and health-related sectors (public and private) and communities can be best organized and coordinated. District management structures were envisaged as a focus for decentralization of political power and resources, increased democracy, and equity.

Notwithstanding their potential as a mechanism for decentralized health systems management, Tarimo and Webster (1994) suggested that despite efforts over the previous 10 years or more, there were few countries where district health systems were functioning fully and effectively. In part this was seen as a result of many interventions being externally funded and based on ‘blue print’ models which did not create local ownership of the district system or a sense of commitment among those responsible for implementing the changes.

While the recognition at Alma Ata of the importance of health services research and operational studies has stimulated skills development, training materials production, and even health systems research studies, investment in and utilization of findings from these activities remain weak. Often this results from the lack of relevance of this research and/or the noninvolvement of decision-making cadres in its planning and conduct and the application of inappropriate methodologies.

Fiscal austerity, which has been a feature of the global economic crisis of the past 3 decades, demands greater value for money. Together with rising unemployment and changes in the labor market, changes in demographic and social trends, and rapid technological advances with major cost implications for health services, it has, over the past 2 decades, driven a process of health sector reform in industrialized and developing countries. The implications of this have been felt at the district level.

Although there is no consistently applied, universal health-care reform package, it essentially includes the following: the restructuring of national health agencies; better planning and more efficient implementation strategies and monitoring systems; the introduction of user fees for public health services; the establishment of health insurance schemes; introducing managed competition among service providers; and working with the private sector through contracting, regulating, and franchising different private providers (Cassels, 1995).

Whereas the above aims appear rational in their conception, the reform process has evolved at different rates and to different extents in different countries and it is difficult to generalize about the success of its implementation. It appears that in many, especially developing, countries the rhetoric of implementation often masks the truth that fundamental change has not occurred (Mills, 1998). Piecemeal approaches have sometimes aggravated inequities (as with user fees in several countries) (Kutzin, 1995), or have led to a deterioration of local health services as decentralization of responsibility has occurred, mostly without the accompanying decentralization of resources and enhancement of local capacity.

Furthermore, the focus on cost-effective and efficient ‘delivery’ of ‘health-care packages’ threatens to aggravate the neglect of the process of health development and reinforce the technicist emphasis seen with selective PHC.

The emergence in the 2000s of a plethora of GHPs or GHIs – such as the Global Alliance on Vaccines and Immunizations (GAVI), the Global Fund to Fight AIDS, TB and Malaria (GFATM), the World Bank Multicountry AIDS Program (MAP), and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) – have reinforced the selective approach to PHC: under pressure to show rapid results, they have developed country-wide, disease specific funding mechanisms which are vertically implemented and managed. Although there is little evidence to date on the system-wide effects of the disease-specific GHIs, there is a concern that these target-driven, performance-based funding mechanisms may put pressure on countries to ‘‘pursue low-hanging fruit and focus on more easily reached target populations (Brugha et al., 2005) and politically high-profile treatment campaigns, thereby exacerbating inequities and neglecting population-wide public health programs.

Although the rationale is compelling for decentralization of implementation and management of PHC to a self-contained geographic area, the DHS is potentially being misappropriated by those concerned with the technical aspects of management (e.g., information systems, management development) rather than with its role in developing comprehensive services within subdistricts (Tarimo and Webster, 1994). The DHS was, after all, conceived as a means to better organize and support integrated and comprehensive PHC.

In some contexts – particularly in hierarchical and nonegalitarian societies – there has been strong, and even violent, opposition to PHC efforts where they have been seen to be succeeding, and/or are perceived to be a subversive and even revolutionary social enterprise (Heggenhougen, 1984).

Progress With Human Resources For Primary Health Care

The successful functioning of health systems depends crucially on adequate numbers and competence of personnel who account, in most countries, for at least 70% of recurrent expenditure on health services. Consequently, not only does human resource development (HRD) assume a place of priority but is also a primary step in health systems development.

Since 1978 there has been a considerable expansion in health human resources, particularly at the ‘auxiliary’ or ‘paramedical’ level in developing countries and, especially in the immediate post Alma Ata period, in the community health worker cadre. Despite this, many poor countries, especially the least developed, have too few health workers to provide universal coverage, and in all countries there continues to be significant maldistribution of, and imbalances between, various types of health workers.

Teamwork to implement PHC is on the whole poorly developed and the motivation and competencies of health personnel require considerable strengthening, especially in the nonclinical domains. Also, greater involvement of traditional practitioners in the health system has been advocated in some countries: achievements in this regard have been limited, with the notable exceptions of China and India where progress largely antedated Alma Ata.

If education and training are to serve the development of comprehensive and integrated health systems, then the PHCA, with its clinical and public health components, needs to permeate much more strongly most health professional education. There is, however, in most tertiary health science educational programs an unfortunate separation between the clinical health care and public health components. The latter is often marginalized in the formal curriculum and, when present, is usually presented in an abstract and theoretical form. Indeed, the substantial failure of most tertiary education health science institutions to adapt their missions and activities to the challenge posed by HFA has probably been one of the most significant impediments to the successful implementation of PHC, and a major reason for the continued dominance of specialist and hospital-based health care in many countries.

There are also many aspects of the management of human resources which are critical to the functioning of the health system and to which insufficient attention has been given. These include satisfactory remuneration, positive work environments, and good supportive systems ( Joint Learning Initiative, 2004) so as to specifically address the retention of skilled health workers in the context of their migration from low to high-income countries, as well as the provision of ongoing support and supervision of health personnel. Neglect of these has contributed to demoralization and loss of personnel and inefficient and low-quality service provision in the public health sectors of many countries (Bassett et al., 1997).

Summary

While progress in implementing the PHC strategy in developing countries has been greatest in respect to certain of its more medically related elements, the narrow and technicist focus characterizing what has been termed the selective PHC approach (Walsh and Warren, 1979) has at best delayed, and at worst undermined, the implementation of the comprehensive strategy codified at Alma Ata. The adoption in developing countries of certain selected interventions – such as ORT and GOBI – created the centerpiece of UNICEF’s Child Survival Revolution, which, it was argued, would be the ‘leading edge’ of PHC ushering in a more comprehensive approach at a later stage. The relative neglect of the other PHC program elements and the shift of emphasis away from equitable social and economic development, intersectoral collaboration, and community participation, as well as the need to set up sustainable district-level structures, all suited the prevailing conservative winds of the 1980s (Rifkin and Walt, 1986). It gave donors and governments a way of avoiding the fuzzier and more radical challenges of tackling inequalities and the underlying causes of ill health.

A key thrust of later health sector reforms is the quest for technical efficiency. This aims to improve spending on health by proposing a ‘package’ of public health interventions and a ‘package’ of essential clinical services, the content of which is determined by what are regarded as cost-effective interventions. This approach is, in effect, a more elaborate version of the selective PHC approach, virtually neglecting intersectoral work and community involvement.

Proponents of the selective approach point to the impressive increases in immunization coverage, the declines in infant mortality in many countries, and the successful eradication of polio from the Americas. However, notwithstanding these successes, questions have been raised about the sustainability of mass immunization campaigns (Hall and Cutts, 1993), the effectiveness of health-facility-based growth monitoring (Chopra and Sanders, 1997), and the appropriateness of ORT when promoted as expensive and often inaccessible sachets or packets and without a corresponding emphasis on nutrition, water, and sanitation (Werner and Sanders, 1997). Evaluations at both national and provincial levels have found that it is only when core service activities (such as the child survival technologies, DOTS, and use of management guidelines for common diseases) are embedded in a more comprehensive approach (which includes strengthening health systems, engaging health-related sectors, and involving local communities) that real and sustainable improvements in the health status of populations are seen (Gutierrez et al., 1996).

The Revitalization Of Primary Health Care

In advocating primary health care, the Alma Ata Declaration affirms that health is determined mainly by factors lying outside the medical or public health services. Countries that have achieved the greatest and most durable improvements in health are usually those with a commitment to equitable development that is broad-based and multisectoral. Good empirical evidence for this comes, for example, from a set of poor developing countries – the ‘Good Health at Low Cost’ examples of Sri Lanka, China, Costa Rica, and Kerala State in India. These countries demonstrated that investment in the social sectors, and particularly in women’s education, health, and welfare, had a significant positive impact on the health and social indicators of the whole population (Halstead et al., 1985).

To realize the equity essential for a healthy society, evidence suggests that a strong, organized demand for government responsiveness and accountability to social needs is crucial. Tacit recognition of this important dynamic informed the Alma Ata call for strong community participation. To achieve and sustain the political will to meet all people’s basic needs, and to regulate the activities of the private sector, a process that involves citizen participation is essential. In fact, analysts have noted that such political commitment was achieved in Costa Rica through a long history of egalitarian principles and democracy, in Kerala through agitation by disadvantaged political groups, and through social revolution in China (Halstead et al., 1985). Robust community involvement is important not only in securing greater government responsiveness to social needs but also in providing an active, conscious, and organized population so critical to the design, implementation, and sustainability of comprehensive health systems.

Given that the current global sociopolitical environment is markedly different from that of the late 1970s and is not generally supportive of a basic needs approach to social development, a number of strategies need to be employed – in different combinations depending on the particular situation – to revitalize PHC and drive forward the HFA initiative. Reflecting the dialectical relationship between strong, organized community demand and government responsiveness and accountability, these strategies are complementary and are ‘bottom-up’ (e.g., community-based program development) as well as ‘top down’ (e.g., policy development and planning).

The PHC approach is based on the understanding that health improvement results from a reduction in both the effects of disease (morbidity and mortality) and its incidence, as well as from a general increase in social wellbeing. The effects of disease may be modified by successful treatment and rehabilitation and its incidence may be reduced by preventive measures. Well-being may be promoted by improved social environments created by the harnessing of popular and political will and effective intersectoral action.

Of particular relevance to the development of comprehensive health systems is the clause in the Alma Ata Declaration stating that PHC ‘‘addresses the main health problems in the community, providing promotive, preventive, therapeutic and rehabilitative services accordingly.’’

Comprehensive health systems include, therefore, both therapeutic and rehabilitative components to address the effects of health problems, a preventive component to address the immediate and underlying causative factors that operate at the level of the individual, and a promotive component which addresses the more basic causes which operate usually at the level of society.

For example, using the example of diarrhea in children, and starting with a disease focus, oral rehydration and nutritional support are required immediately, followed by a process of nutritional rehabilitation so as to restore the child to a state of well-being. However, these interventions need to be complemented with health education about the importance of hand washing, food hygiene, breastfeeding, and immunization. Coupled with such preventive measures ought to be broader, developmental interventions such as the promotion of improved child care, household food security, and access to water and sanitation so as to comprehensively address the root causes of diarrhea in children.

Strategies for comprehensively tackling such health problems can be grouped essentially under two, complementary headings: promoting healthy policies and plans, and developing comprehensive community-based programs. Success of these strategies depends on the creation of a facilitatory environment through such actions as advocacy, community mobilization, capacity-building, organizational change, financing, and legislation.

Developing And Promoting Healthy Policies And Plans

The choice between various policy options must be made on the basis of an ethical framework or a clear set of values and principles: these are essentially those enunciated in the Alma Ata Declaration with emphasis on equity in health and participation in decision making about matters that affect both individual and societal health.

Governments and international organizations have a responsibility to ensure the conditions and opportunities to enable present and future generations to exercise these rights. Public health problems, and therefore necessary responses, are becoming increasingly global. Consequently, the need for strong global leadership is crucial, along with a strong advocacy role. An agency, such as the WHO, should assume this responsibility: it should take the lead in analyzing and publicizing the negative impact globalization and neoliberal policies are having on vulnerable groups. It should spearhead moves to limit health hazards aggravated by globalization, including trade in dangerous substances such as tobacco, alcohol, and narcotics, and the arms trade. At the same time, WHO should demonstrate and promote the benefits of equitable development in the realization of HFA – which includes strong investment in the social sectors. It should vigorously promote health as a human right and give support to governments in building their capacities in policy, planning, and advocacy. At the time of writing this research paper, WHO is showing a renewed interest in PHC.

In a similar manner, governments should, in developing health policies and plans, give serious consideration to employing a process that engages as partners those sectors, agencies, and social groups critical to the achievement of better health. The first step is creating awareness of the need to make health objectives part of the broader process of socioeconomic development. Since ‘health’ and ‘medicine’ have become virtually synonymous in the popular consciousness, it is important to convey the understanding that ill health results from unhealthy living and working conditions, from the failure of society to equitably provide health-promoting conditions, and not merely from a biological organism. It then becomes obvious that health problems are the result of multisectoral failure and that their solution cannot lie in health care alone, but requires comprehensive and intersectoral actions. Such advocacy needs to be illustrated by a demonstration of health inequities and their social determinants, and needs to be directed in a user-friendly fashion at all prospective partners, especially underprivileged communities and their political representatives. The importance of addressing these factors and understanding the role of other sectors in health improvement has led to the appointment by WHO of a Commission on Social Determinants of Health in 2005. Here the media also have an important role to play.

The policy development process must be as transparent and inclusive as possible to secure broader understanding and greater ownership of the policies. Developing consensus by initiating a dialogue with the public and enlisting their support can contribute to the continuity and sustainability of policies for health. The setting of goals and indicators (for different levels) through a participatory process can be valuable in defining policy objectives more specifically, allowing progress to be monitored by partners and affected communities, and can assist in popularizing public health issues. Such processes can help focus partners on the scope and rationale for the policy, and on their roles in implementation, and become a rallying point around which civil society can mobilize and demand accountability.

Following a PHC approach, the formulation and implementation of health policies thus requires new alliances with different sectors, voluntary organizations, and public and private bodies. The health sector needs to take leadership in prioritizing health in other sectors: here the establishment of functional intersectoral structures is desirable.

The implementation of policies may require different actions at different levels. These include laws on financial and management instruments, and, importantly, on mechanisms to involve networks within civil society. Financing should be equity based to ensure that underprivileged groups are not excluded from health care for economic reasons. Resources should be allocated according to need rather than for services actually delivered. The monitoring and evaluation of progress in policy implementation ought to be done in such a way as to embrace a sense of accountability – with the progress toward goals being presented to elected bodies or displayed in the mass media.

The Development Of Comprehensive, Community-Based Programs

The implementation of PHC has too often focused on the (often facility-based) therapeutic and preventive components of comprehensive care, while the promotive aspect, which focuses on the broader social determinants of health, is often neglected. This gap urgently needs to be bridged, as they are clearly indivisible in the process of health development.

Much experience has been gained internationally in the development of comprehensive and integrated programs to combat undernutrition: these experiences can provide useful lessons for other programs (Mason et al., 2006).

The principles of comprehensive program development apply to all health problems, whether specific communicable (e.g, diarrhea) or noncommunicable diseases (e.g., ischemic heart disease) or health-related problems (e.g., gender-based violence).

Once the priority health problems in a district have been identified, the first step in program development is to conduct a situation analysis. This should identify the prevalence and distribution of the problem, its causes, and potential resources, including community capacities and strengths, which can be mobilized, and actions that can be undertaken to address the problem. The more effective programs have taken this approach, involving health workers, other sectors’ workers, and the community in the three phases of program development, namely, assessment of the nature and extent of the problem, analysis of its multilevel causation, and action to address the linked causes.

Clearly, the specific combination of actions making up a comprehensive program will vary from situation to situation. However, there are certain principles that should inform program design, one of which is the deliberate linking of actions that address causative factors operating at different levels. So, for example, in a nutrition program any intervention around dietary inadequacy (immediate level of causation) should also address household food insecurity (underlying level of causation). Thus, the choice of food supplement should be based not only on its nutrient value but also on its availability, cost, and cultivability and/or purchasability. The careful choice of an appropriate food supplement should be reinforced as an educational action in order to positively influence food habits and feeding practices. Clearly this principle of linking therapeutic or rehabilitative (feeding), preventive (nutrition education), and promotive actions (improved household food security) could and should be applied to health programs other than nutrition.

In addition, a nutrition program will include a minimum of core health service activities (mostly facility based) including effective growth monitoring and promotion, the integrated management of childhood illness, the promotion of breastfeeding, the promotion of energy, and nutrient-dense weaning diets based on commonly available local foods.

Similar minimum or core service components can also be identified for other health programs, for example, activities in the Safe Motherhood Initiative, the integrated management of childhood illnesses (IMCI), DOTS, technical guidelines for the management of common noncommunicable diseases, and so forth. There is an advantage in standardizing and replicating these core activities in health facilities at different levels, thus reinforcing their practice throughout the health system.

The District Health System, Subdistricts, And Health Centers

As mentioned earlier, there are at a local level in most countries a number of health programs, often vertically organized and centrally administered, with specialized staff who perform only program-specific functions. The development of comprehensive programs that are integrated into a decentralized district service inevitably requires transformation of both management systems and health worker practice. Making the transition from a centralized bureaucratic system to a decentralized, client-oriented organizational culture calls for a significant investment in the reorientation and development of the existing management systems, structures, and capacity of health personnel. District-level staff must be trained in order to support decentralized development of comprehensive programs with clear roles, goals, and procedures.

To properly undertake the challenge of health development, health personnel need to be able to gather and use appropriate health information for planning programs as well as for monitoring and evaluating their implementation.

Interventions in this field are seen as a very cost-effective technical and financial investment (World Bank, 1993). However, there has not been adequate effort to develop, implement, and use locally relevant health and management information systems, and there is still transmission of raw data to the national level without informing district management. District-level staff therefore have to make major decisions based on estimates, and very often they lack the skills needed to do so. Even when routinely collected information is available and relevant, subdistrict and district managers often have difficulty in getting access to it because of resource constraints, unintelligibility of technical jargon, and general lack of empowerment. As a result, these personnel have only limited opportunity to learn from new ideas and from the data concerning their work.

There have been a number of attempts to set up appropriate information systems which have led to improvements in data collection, the improved relevance of information, and improved supervision. However, these have generally been small-scale projects which have not been replicated on a larger scale. There needs to be increased support for taking these small projects to scale and developing ‘bottom-up’ models of information systems that are relevant for the service provider, that support the management decisions of the district manager, and yet feed into the overall information needs of higher levels.

Where information for planning and program or system development or improvement is lacking, health systems research is an important tool to assist decision making (Tarimo and Webster, 1994). There is now significant experience in using the ‘district problem-solving’ approach, where health personnel identify priority health system problems and are guided in the development of research approaches to identify their causes and fashion appropriate solutions (Varkevisser et al., 1991). Here there is an important opportunity for academic departments of public health to develop productive working relationships with the health sector and at the same time strengthen the relevance of their educational efforts.

Some district managers and district-level personnel will be based at the district center or hospital, but in most situations the majority will be located in health centers (HCs) or clinics in subdistricts. HCs are or should be the focal point within the DHS for comprehensive PHC: they should provide quality care as well as facilitate the promotion of the community’s health. This implies that, apart from their clinical skills, the health center team should have the ability to identify and forge alliances with other health workers (e.g., general practitioners, traditional healers, community or village health workers), other sectors, and nongovernmental and community-based organizations and structures. For this, both subdistrict and district-level staff need skills in advocacy, negotiation, and compromise (WHO, 1997a).

In the 1970s and 1980s an important role was given to community health workers (CHWs) in the implementation of PHC. Indeed, many of the ‘model’ PHC initiatives relied extensively on CHWs for their successful operation. One of the strongest features of CHWs is that they are not merely a technical means of extending basic health care to peripheral communities and households, but occupy an advocacy and social mobilization role, enrolling the conscious involvement of communities and other sectors in health development. As a result of a number of factors noted earlier, many of these programs have proved difficult to sustain, and CHW programs have disappeared from many countries or have been significantly weakened. In the recent past there has been renewed interest in CHWs and lay health workers, partly in response to the critical shortage of health-care personnel and partly as a result of the increasing health-care burden imposed by the HIV epidemic (Lehmann and Sanders, 2007).

Such HCs and clinics should, ideally, be managed locally by boards with a majority of local residents. This would allow them to identify, analyze, and take action in partnership with their communities on local public health issues. Such actions could include the formation of patients’ groups on particular health issues (e.g., diabetes, hypertension), establishing health education groups, and working with other sectors such as housing, education, welfare, and transport to assess the potential for changing their operations so that they are more likely to promote health.

Monitoring Equity In Health And Health Care

Equity is core to the policy of Health for All. As noted earlier, reductions in public health and social services in many countries are one of the contributing factors leading to growing inequities in health. To more successfully advocate for equity in health and health care among international organizations, governments, donors, and professional organizations, ministries of health need to be able to demonstrate any social differentials in access to health resources or in health outcomes. Their capacity to routinely monitor equity in health and health care needs to be strengthened through the use of simple yet valid approaches, using where possible existing data sources from all relevant sectors (McCoy et al., 2003).

Human Resource Development For Primary Health Care

Sufficient numbers and effective performance of health personnel in all phases of health systems development – policy development and advocacy, planning, implementation, management and evaluation – is fundamental to, almost a prerequisite for, the realization of HFA. In recent years there has been increased recognition of the importance of human resources for health (HRH), impelled primarily by Africa’s health crisis and the inability of health systems to adequately respond. A large research and advocacy project, the Joint Learning Initiative ( JLI), undertaken early in the decade, has resulted in greater attention to – and resources for – human resource development ( Joint Learning Initiative, 2004).

In human resource planning, the dominant approach of employing ‘norms’ to calculate numbers of health personnel required needs to be supplanted by one that considers not only their numbers, but, more important, the competencies of personnel required to implement PHC (Green, 1992).

With regard to education and training of health personnel, the PHCA needs to inform both the curriculum content and the process and choice of venues of learning. There is accumulating evidence that problem-oriented and practice-based approaches result in more relevant learning, and in the acquisition of problem-solving skills, both necessary attributes for the successful development of systems based on the PHCA. If health workers are to contribute to a health system that enables people to assume more responsibility for their own health, then their training must expose them to the practice of comprehensive programming at the district level and to the social issues at the community level.

The above suggestions for education reform apply equally to all categories of health personnel, as well as to undergraduate and postgraduate training. It has long been acknowledged that nurses play a pivotal role in the PHC team, and constitute the largest category of health personnel in most countries. Endorsement of such educational reforms and their fuller elaboration and promotion by countries’ nursing leadership is critically important for progress toward HFA (WHO, 1997b).

In most countries, health science educational institutions have not resulted in curriculum reform along the lines described above. Although there are indications that some have embarked or will embark on such a course, there will probably still be a significant delay before sufficient ‘new’ graduates are available to work in and transform the health system. Clearly, if the implementation of comprehensive PHC is to be achieved during the next decades, the process of curriculum reform in the educational institutions needs to be accelerated and accompanied by a massive program of capacity development of personnel already working in the health system. In short, the current HFA imperative demands the rapid expansion of continuing education activities, whether through in-service learning programs conducted on site within a district, or through postgraduate training programs offered by academic institutions.

Any PHC-related training should also include personnel from other health-related sectors as well as community members: capacity development for these constituencies has generally been neglected and has weakened the growth of both community participation and intersectoral involvement in health development.

Human resource management problems referred to earlier cannot be solved within the health sector alone, but will require more fundamental interventions in the economy and in the public sector. However, some important intrasectoral measures should be promoted; these can be grouped broadly into incentives and regulations. Among the possible incentives are: continuing education, including the possibility of formal certification and qualification for promotion; additional pay and accelerated promotion as well as allowances for children’s schooling for serving in remote and underserved areas; and honorary academic appointments carrying both financial and other privileges. Possible regulations include: limitations on the licensing of private medical facilities; control over public sector workers’ involvement in private practice; and compulsory service in underserved areas for specified periods after graduation (Tarimo and Webster, 1994).

In implementing a PHC approach, health workers require a range of skills: they need to be able to work across disciplines and sectors, to be knowledgeable about both primary health care and public health, and to have a strong commitment to community participation. In addition, the day-to-day management of human resources – acknowledged to be critically important for the effective functioning of district health systems – is an area that also requires considerable investment and should be a priority training issue.

Conclusions

It is clear that progress toward Health for All has been uneven. Gains already achieved are under threat from a complex and accelerating process of globalization and neoliberal economic policies which are impacting negatively on the livelihoods and health of an increasing percentage of the world’s population and the large majority in developing countries. Although the global PHC initiative has been successful in disseminating a number of effective technologies and programs that have reduced substantially the impact of certain (mostly infectious) diseases, its intersectoral focus and social mobilizing roles – which are the keys to its sustainability – have been neglected, not only in the discourse but also in implementation.

Government health ministries need to enthusiastically enter into partnerships with other sectors, agencies, and communities to develop intersectoral policies that address the determinants of inequities and ill health. The policy development process needs to be inclusive, dynamic, and transparent, and supported by legislation and financial commitments.

The time is long overdue for energetically translating policies into actions. The main actions should center around the development of well-managed and comprehensive programs involving the health sector, other sectors, and communities. The process needs to be structured into well-functioning district systems, which, in most countries, must be considerably strengthened, particularly at the household, community, and primary levels. Here comprehensive health centers and their personnel should be a focus of effort and investment and the reinstatement of community health worker schemes should be seriously considered.

The successful development of decentralized health systems will require targeted investment in infrastructure, personnel, and management and information systems. A key primary step is capacity development of district personnel through training and guided health systems research. Such human resource development must be practice-based and problem-oriented, and must draw on, and simultaneously reorient, educational institutions and professional bodies.

Clearly, the implementation and sustenance of comprehensive PHC requires inputs and skills that demand resources, expertise, and experience not sufficiently present in the health sector in many countries. Here partnerships with NGOs and expertise in various aspects of community development are crucial. The engagement of communities in health development needs to be pursued with much more commitment and focus. The identification of well-functioning organs of civil society, whether or not they are presently active in the health sector, should be urgently pursued.

In promoting the move from policy to action, the global health community needs to be much bolder in: advocating for equity and legislation to facilitate its achievement; pointing out the dangers to health of globalization and liberalization; and stressing the importance of partnerships between the health sector and other sectors to ensure that comprehensive PHC programs are developed. The WHO must assume greater responsibility for influencing other multilateral and bilateral agencies and donors, as well as NGOs and professional bodies, toward a common vision of PHC, and must argue for a major investment in health, especially in human resource development, without which HFA will remain a mere statement of intent.

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