Revitalising primary health care: Challenges for WHO in the new millennium

A People's Health Movement (PHM) Dialogue paper

Core principles

The term 'Primary Health Care' is defined and used in different ways. WHO's revitalisation of PHC must be based on a definition as broad and ambitious as that described in the Alma Ata Declaration and embedded in the social processes detailed there. It must incorporate all of the following:

A systems-wide approach that incorporates more than just primary level health care. It must reflect an approach that includes and co-ordinates public health interventions, health promotion activities and hospital services, with referrals to district and tertiary centres.

• A health system that is progressively financed, inclusive and equitable. A PHC approach is not limited to merely providing a 'basic' or 'minimal' package of care for the poor. Instead it strives to reduce the impact of socio-economic injustice by designing a single system of health care for all that provides access and care according to need and fairness.
• A comprehensive approach which addresses the social, political and economic determinants of health and implements multi-sectoral action to improve health – not just healthcare.
• A community empowerment approach which enables individuals, families and communities to act towards improving their health and the conditions they live in, especially for those who are most disadvantaged.
• A health system based on the 'Right to Health' recognising the entitlements of citizens.
• The appropriate use of technology sensitive to local contexts and people's traditional culture - helping people learn to combine the best and reject the worst of both traditional and modern medicine.

New challenges for primary health care

Since the formulation of the 1978 Alma Ata Declaration, new challenges have emerged which must be addressed in any effort to revitalise the PHC concept. These include:

The proliferation and dominance of selective health care programmes

Selective health care programmes are often characterised by a top-down and vertical approach to health care. Such programmes often fragment and disorganise the wider health system (especially by drawing away resources), treat patients as passive recipients of medical care and ignore the broader social, economic and political determinants of health. While there may always be a need for focused programmes and specialist health workers, the current balance between narrow (often disease-specific) programmes and integrated health care is skewed.

• In order to revitalise PHC, there needs to be a revitalisation of the District Health System model which allows for more integrated, community-driven and bottom-up health planning and provision - and more efficient implementation of specialist programs when appropriate. There must be a renewal of the role of community health workers to extend coverage at the local level and act as advocates for their communities.

Global public private partnerships

Global public private partnerships bring new financial resources to address health challenges but, up to now, these initiatives have further reinforced selective programmes by focusing on technocratic solutions to single issues, without addressing the determinants of health or the needs of health systems. Such programmes often employ narrow cost-effectiveness analysis (which ignore benefits to other sectors from health improvement) and undermine PHC systems. In addition, they raise concerns about sustainability and accountability.

• These partnerships need to be reoriented towards more horizontally integrated sector-wide approaches that build health systems; respond to local needs; and build new relationships with civil society, people's organisations and social movements - reasserting the central place of democratic, participatory decision-making in all health services.

The new market economy in health

The last thirty years has seen increasing privatisation and commercialisation of health systems across the world. This has undermined public sector health systems; eroded ethical standards of behaviour among health workers and trust between communities and the health system; and exacerbated inequity and disparities in access to health care.

• There is a profound need in many countries to strengthen the public sector and the 'public ethic' of service provision; direct the existing private sector towards serving the needs of the public as a whole; and reduce the presence of profit-seeking and commercial initiatives that currently harm many interactions between people and health care providers.

Unfair globalisation

Globalisation presents opportunities for increased sharing of knowledge and information and greater co-ordination of efforts at the global level to address the determinants of health. However, globalisation also presents new threats to health such as increased trade in unhealthy commodities and in health workers ("brain drain") - undermining the ability of many poor countries to support PHC systems. Furthermore, global inequalities mean that many poor countries lack any hope of sustainable domestic funding for their health systems and are therefore increasingly reliant on external sources of funding.

• A revitalised PHC strategy must address the globalised nature of the health worker labour market and provide a framework to generate new global pools of finance that ensure an adequate resource base for the health systems of all countries - including compensating poor countries for their labour losses.

Intellectual property

In recent years, the scope and length of patents has increased greatly. These developments represent a profound transformation of patterns of ownership within society, with major implications for the development of technology for the treatment of disease. While technology offers tremendous potential to improve health, it is sobering to recall that many of the most useful technologies available in 1978, at the time of Alma Ata, are still unavailable to most people. The implementation of intellectual property rules often makes new life-saving medications unaffordable to the people who need them most.

• Addressing the challenges to PHC requires universal access to essential medicines. This will require confronting emerging trade and patent regimes to be people-friendly rather than market-oriented and supporting countries to make full and appropriate use of the flexibilities in TRIPS to make necessary drugs available to all who need them.

Other new challenges

Finally, in the three decades since Alma Ata, the global health situation has changed drastically. The planet's ability to support human health is at great risk from unsustainable development; inequities have increased between and within countries; access to food, education, water, shelter, sanitation and employment are still inadequate for many; the challenges of poverty, gender inequity and social exclusion continue; both communicable and non-communicable disease epidemics challenge health systems; and war, violence and conflict abound.

• Any renewal of primary health care, while reiterating the core principles, must address these new challenges at local, national, regional and global levels, and bring the health of marginalised groups to the centre of the commitment to 'Health for All'.

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