The global project to achieve Health for All through Primary Health Care (PHC) is a profoundly political one. In seeking to address both universal access to health care and the social determinants of health (SDH) it challenges power blocs which have material vested interests in technical approaches to health and development.
The forces that have shaped PHC include Community Oriented Primary Care and the Health Centre Movement, the “basic health services approach,” and nongovernmental and national initiatives that exemplified comprehensive and participatory approaches to health development. The 1978 Alma-Ata Declaration codified these experiences and advocated Health for All by the year 2000 through PHC. It emphasized equitable and appropriate community and primary-level health care as well as intersectoral actions and community participation to address the social and environmental determinants of health. This would need the support of a new international economic order.
The concept of “Selective Primary Health Care” emerged soon after Alma-Ata, privileging a limited set of technical interventions directed at selected groups, notably young children. This was soon operationalized as UNICEF’s Child Survival Revolution. The visionary and comprehensive policy of PHC was further eroded by the 1970s debt crisis and subsequent economic policies including structural adjustment and accelerated neoliberal globalization that deregulated markets and financial flows and reduced state expenditure on public services. This translated, in many countries, as “health sector reform” with a dominant focus on cost efficiency to the detriment of broad developmental approaches to health. More recently this selective approach has been aggravated by the financing of global health through public-private partnerships that fund specific interventions for selected diseases. They have also spawned many “service delivery” NGOs whose activities have often reinforced a biomedical emphasis, supported by large philanthropic funding such as that of the Gates Foundation.
Educational institutions have largely failed to transform their curricula to incorporate the philosophy and application of PHC to inform the practice of students and graduates, perpetuating weakness in its implementation.
Revitalizing PHC requires at least three key steps: improved equity in access to services, a strong focus on intersectoral action (ISA) to address SDH and prioritization of community-based approaches. The third sustainable development goal (SDGs) focuses on health, with universal health coverage (UHC) at its center. While UHC has the potential to enhance equitable access to comprehensive health care with financial protection, realizing this will require public financing based on social solidarity. Groups with vested interests such as private insurance schemes and corporate service providers have already organized against this approach in some countries. The SDGs also provide an opportunity to enhance ISA, since they include social and environmental goals that could also support the scaling up of Community Health Worker programs and enhanced community participation.
However, SDG-8, which proposes high economic growth based substantially on an extractivist model, contradicts the goals for environmental sustainability. Human-induced environmental degradation, climate change, and global warming have emerged as a major threat to health. As presciently observed at Alma-Ata, the success of PHC, and Health for All requires the establishment of a new, ecologically sustainable, economic order.
Community participation in primary health care.