Gesundheit für alle – Hintergrund

Twenty Five Years of Primary Health Care

Lessons Learned and Proposals for Revitalisation
 

By David Sanders

•  International Peoples Health Council
• Member of Coordinating Group, Peoples Health Movement
• School of Public Health, University of the Western Cape, South Africa

1. PRIMARY HEALTH CARE – FOCUS AND IMPLICATIONS

The strategy of Primary Health Care, advanced by WHO and UNICEF, was declared by 134 states at Alma Ata in 1978 to be the means to achieve Health for All (HFA) by the Year 2000(7). PHC had strong sociopolitical implications. It explicitly outlined a strategy which 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 PHC, 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(8).

The implications of PHC were recognised, even at the time of the Alma Ata Declaration, 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.

2. MIXED PROGRESS IN GLOBAL HEALTH

Over the past 50 years and even over the last 25 considerable gains in health status have been achieved. Globally, life expectancy at birth has increased from 46 years in the 1950s to approximately 65 years in 1995(1) and the total number of young children dying has been restricted to approximately 12 million instead of a projected 17.5 million(2). Substantial control of certain communicable diseases, notably poliomyelitis, diphtheria, measles, onchocerciasis (river blindness) and dracunculiasis (Guinea worm) has been achieved through immunisation and specific disease control programmes(3). and cardiovascular diseases have decreased in males in industrialised countries, partly because of a decline in smoking(4).

Despite these gains, however, there have been setbacks. Although in aggregate terms child mortality and life expectancy have improved in all regions of the world(5) disaggregation of these data reveals that the gap in mortality rates between rich and poor between and within countries has widened significantly for certain age groups. Furthermore, in a number of Sub-Saharan African (SSA) countries, infant mortality rates (IMR) actually increased in the 1980s under the impact of economic recession, structural adjustment, drought, wars and civil unrest and HIV/AIDS(6).

The past two decades have also witnessed the alarming resurgence and spread of old communicable diseases once thought to be well controlled e.g. cholera, tuberculosis, malaria, yellow fever, trypanosomiasis, dengue etc. while new epidemics, notably HIV/AIDS, threaten this century’s health gains in many, mostly developing, countries. Many developing countries are also experiencing a double disease burden, with cardiovascular diseases, cancers, diabetes, other chronic conditions and violent trauma replacing communicable diseases in some social groups, but in others co-existing with them.

3. PROGRESS AND REVERSALS IN IMPLEMENTATION OF PHC

Implementation of PHC has been rendered difficult as a result of misinterpretation and of changed context. Misinterpretation was rooted even in the Alma Ata document wherein PHC was defined as both a “level of care” and an “approach”: these two different meanings have persisted and perpetuated divergent perceptions and approaches. Thus, in some developed countries and sectors PHC often has been interpreted as primary medical care provided by general doctors, and in developing countries as a cheap, low technology option for poor people(9). Even in countries which embraced PHC as the key to Health For All (HFA), conservative changes in the 1980s in the political and economic context bedevilled its implementation.

There have, however, been significant successes especially in the 1980s, in implementing PHC, although mainly in the development and extension of particular health programmes, rather than in the facilitation of social development though the promotion of an intersectoral approach and community participation(10).

The greatest successes in PHC implementation in developing countries have been in respect of its more medically-related elements. For example, in the 1980s coverage of growing children with the six basic vaccinations increased dramatically from below 40% worldwide to over 70% by 1990. Similarly, access to oral rehydration therapy (ORT) for treatment of diarrhoea expanded over the same decade as did improved access to water and sanitation in some parts of the world.

However, the control of both communicable and non-communicable diseases has proved elusive. In particular HIV/AIDS, T.B. and malaria are affecting rapidly increasing numbers of (especially poor) people worldwide. HIV, which now affects over 40 million people, three-quarters of them in sub-Saharan Africa (SSA), has led to declines in life expectancy in a number of countries. The control of these three diseases and of the chronic diseases, which affect increasingly large numbers of poor people, is complex and clearly requires improved living and working conditions, well-functioning health systems and strong intersectoral coordination and community mobilisation.

However, it is clear that health systems in most developing countries, and especially in SSA have deteriorated in the past ten to fifteen years. This is most starkly illustrated by the decline in vaccination coverage of young children to well below 1990 levels, despite intensive polio vaccination campaigns and the regular measles vaccination campaigns.

3.1 Progress and Setbacks in Implementing the Programme Elements

Since the early 1980’s there has been considerable progress in the coverage of populations with the essential elements (or programmes) of health care.

(Source: WHO 1998B, p 4)

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.

Child health care provision has increased greatly over the past two decades with the vigorous promotion of certain selected "Child Survival" technologies: growth monitoring, oral rehydration therapy, breastfeeding and immunisation (GOBI). Of these, immunisation has shown the most dramatic improvement, with global coverage of children under one year increasing from 20%(11) in 1980 to 80% by 1990. This impressive progress notwithstanding, there remain areas for concern. These include stagnation in immunisation coverage between 1990 and 1993, and declines in coverage in most regions of the world by 1999(12) 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 programme management(13); and less than 50% coverage of pregnant women with tetanus toxoid vaccine.

The nutrition situation in developing countries remains serious with almost 200 million young children being malnourished and almost a billion people receiving less than their basic daily requirements of energy and protein.

Acute respiratory infection (ARI) and diarrhoeal diseases are the two leading causes of death in children under 5 globally with the overwhelming majority of cases occurring in developing countries. Standardised management guidelines have substantially reduced fatality rates but 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 diarrhoea as a result of minimally improved environmental hygiene and persisting malnutrition(14). More recently, given that 70% of young child deaths can be attributed to diarrhoea, pneumonia, measles, malaria and malnutrition, clinical guidelines for the integrated management of childhood illness (IMCI) have been developed(15).

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.

Table: Maternal Mortality Rate.

(Source: Tarimo & Webster 1994, p 39)

Control of the three most common and serious communicable diseases, tuberculosis (TB), HIV/AIDS and malaria has proved elusive. TB is now responsible for over 25% of avoidable adult deaths worldwide(16) with 95% of cases occurring in developing countries; its prevalence has risen sharply over the past decade-and-a-half as a result of HIV infection, deteriorating socio-economic conditions and poor quality control programmes, together with the emergence of multi-drug resistant organisms. The HIV epidemic has spread rapidly to affect over 40 million individuals, mostly in developing countries, especially Sub-Saharan Africa (SSA), and involves predominantly young adults and children born to HIV-infected women. In some SSA countries gains in survival achieved over the past few decades are being reversed by the effects of HIV infection. The malaria situation remains serious, particularly in SSA 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.

Current strategies for control of these diseases are remarkably similar. TB control programmes rely heavily on directly observed short course chemotherapy (DOTS); HIV control has focused on targeted educational activities and early treatment of STDs; and malaria control on early diagnosis and treatment and selected preventive measures – particularly insecticide treatment of bednets - as part of WHO’s new “roll back malaria” initiative. While the technologies employed in all three cases have evolved considerably in the past decade, sustained success in combating these diseases is unlikely without well-developed health systems, improved living and working environments secured through anti-poverty measures and coordination with health-related economic and social sectors, and active participation by communities in such control campaigns.

The major non-communicable diseases 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, in developing countries. Their complex epidemiology requires better clinical management and lifestyle modification but also actions involving a range of sectors and tied to more fundamental measures, 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 behaviour change towards a broader set of activities termed “health promotion”, which incorporates individual as well as social action(17).

The final programme element to consider is Essential Drugs. While access to essential drugs is much improved approximately two billion people still do not have access to the most important drugs and vaccines(18) and at the same time drugs bills for most countries and their health services are massive, and problems of wastage and irrational drug use remain.

3.2 Progress and Setbacks in Health Systems Development

In the 1980s there was little recognition of the importance of health systems and almost a decade after Alma Ata the activities of various programmes and institutions continued largely to be piece-meal, poorly coordinated, and unevenly distributed. As a result, the concept of the district health system (DHS) was born(19).

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 organised and coordinated. District management structures were envisaged as a focus for decentralisation of political power and resources, increased democracy and equity.

Despite efforts over the past ten years or more, there are few countries where district health systems are functioning fully and effectively(20). There are a number of linked reasons for this: these are related ultimately to the lack of capacity – human and financial – of health services at local levels and an unfavourable broader political and economic environment.

In short, health systems development has been uneven and constrained by fiscal austerity, which has in many countries adversely affected the quantity and quality of human and material resources and logistical support. Efficiency imperatives which have spurred health sector reform and alternative financing approaches in both industrialised and developing countries, have sometimes generated significant innovation but have also often aggravated dysfunctionality and inequity, particularly in developing country health systems(21).

Despite the fact that the successful functioning of health systems depends critically on adequate numbers and competence of personnel who account, in most countries, for approximately 70% of recurrent expenditure on health services, this important area has received inadequate attention in the HFA initiative.

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 is, on the whole, poorly developed(22) and the motivation and competencies of health personnel require considerable strengthening, especially in the non-clinical domains, to implement PHC. 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.

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, has been the substantial failure of most tertiary education health science institutions to adapt their missions and activities to the challenge posed by HFA. Primary health care and public health usually remain marginalised in the formal curriculum and, when present, are often presented in an abstract and theoretical form, with little application to priority health problems and challenges(23).

Further, the training of health professionals mainly at the secondary and tertiary levels of care has meant that health workers are ill-equipped to do primary level work. If health workers are to render comprehensive care at all levels, their practical and theoretical training must be relevant to addressing the needs of the population. It is urgent, therefore, that district-based health teams receive such training(24).

Additionally, important aspects of management of human resources, such as mechanisms to ensure greater retention and improved support and supervision, have been given insufficient attention. This has contributed to demoralisation and loss of personnel and inefficient and low quality service provision in the public health sector of many countries(25).

In summary, then, progress in implementation of PHC in developing countries has been greatest in respect of certain of its more medically-related elements (e.g. immunisation, oral rehydration therapy). This strategy of “selective primary health care” – symbolised in the 1980s by GOBI (Growth monitoring, oral rehydration therapy, breastfeeding and immunization) - has reinforced the “medical model” and de-emphasized equitable social and economic development, intersectoral collaboration, community participation and the need to establish sustainable and decentralised structures and systems. Thus, the mixed progress in global health reflects the uneven dissemination of effective and robust health technologies, although often in a context of declining health systems, and in a situation of widening disparities in wealth and widespread poverty, resulting in diminished access for many to the basic needs of food, water, sanitation and housing. Acceleration of pre-existing economic, social and political interdependence has resulted in globalisation, characterised by such instruments of economic integration as Structural Adjustment Programmes and sweeping regulation of trade which threaten the economic sovereignty of poorer nations and in the short run have aggravated inequities(26) (27).

4. PROPOSALS FOR THE REVITALISATION OF PRIMARY HEALTH CARE

4.1 Equitable social investment

In charting the way forward in a world where wealth and health are becoming rapidly and increasingly polarised it is important to reaffirm the centrality of equitable, broad-based and gender-sensitive development and social sector investment in achieving substantial and durable health improvements. This is illustrated by the striking success that has been achieved in social development and health by a few poor countries, notably Sri Lanka, Costa Rica, Cuba, China and Kerala State in India. In these countries mortality and malnutrition rates are much lower and life expectancy much higher than in other countries of similar wealth and, indeed, many much richer countries. An authoritative study of these countries by the Rockefeller Foundation attributed their impressive achievements to a political commitment to equity, secured through strong movements of civil society or social revolution(28). In all cases this resulted in the provision of universal education and an emphasis on primary health care, as well as the assurance of adequate diets through a combination of land reform and consumer food subsidies. That greater equity has been achieved and is associated with better social statistics, whatever the aggregate wealth of a country, is evidenced by the fact that these poor countries have much lower Gini coefficients (an index of relative equality) than neighbouring states.

4.2 Implementing healthy policies and comprehensive programmes

In synergy with equity-oriented social sector investment, a strategy to revitalise PHC requires the complementarity of “bottom-up” comprehensive health programme development and “top-down” policy development and planning. Successful implementation depends on the creation of a facilitatory environment through advocacy, community mobilisation, capacity-building and organisational change backed up by financing and legislation.

Policy development needs to involve those sectors, agencies and social groups critical to achieving better health. Steps include advocating health objectives as integral to socio-economic development, and engaging different sectoral partners and community structures in such a consensual process, which may benefit from setting agreed-upon goals and indicators of progress. Implementation requires functional intersectoral structures, and often laws as well as management instruments and equity-based financing(29).

PHC implementation has often been predominantly facility-based and focused on the curative and preventive components of comprehensive care, while the health promotion movement has stressed the broader social components. The divide between these two initiatives requires urgently to be bridged. Health promotion through Healthy Cities initiatives as well as a focus on other settings, including health districts, can advance the development of healthy policies(30). The success of such multifaceted initiatives depends on organisational change within (especially) government and an openness to the positive potential of community groups.

Whereas health promotion activities commence with a multisectoral focus, programmes originating around diseases or health problems start from a health care response. By addressing priority health problems comprehensively through a combination of rehabilitative, curative, preventive and promotive actions a set of activities common to a number of health programmes will be developed as well as a horizontalised infrastructure. The principles of comprehensive programme development apply to all health problems.

Comprehensive Primary Health Care for some common diseases : a summary framework of priority interventions

Programme design should be based on an assessment of the seriousness of the problem, analysis of its multifaceted and multilevel causation and of the resources that can be mobilised to address it. Minimum or core service components such as the IMCI (Integrated Management of Childhood Illness) guidelines, protocols for clinical management of common diseases etc. should be integral to such comprehensive programmes and replicated at different levels of the health system, including in hospitals(31).

Such programmes need to be integrated into decentralised district systems. This inevitably requires transformation of both management systems and practice. A primary requirement is appropriate and usable health information for planning programmes and monitoring their implementation(32). Where such information is lacking, health systems research – which may be fostered in working relationships with academic departments of public health – may assist decision-making(33).

Most district level health personnel will be based in sub-district facilities such as health centres and clinics. Health centres should be the focal point for comprehensive PHC : personnel teams will therefore need a combination of clinical skills and skills in participatory programme development(34). Their success can be enhanced by working with and through community health workers: the role of this cadre needs to be re-examined, given their undoubted historical and potential contribution.

Since equity is core to the policy of HFA and current socio-economic and health sector trends are aggravating inequities, capacity to monitor equity in health and health care needs to be strengthened(35).

A prerequisite for the realisation of HFA is sufficient numbers and effective performance of health personnel in all phases of health systems development. The PHCA needs to strongly inform both curriculum content in all the health sciences as well as the process of, and choice of venues for, learning. Learners at undergraduate and postgraduate level need to be equipped with a broader range of competencies than hitherto has been the case(36). Expansion of continuing education and training is urgent if system change is to be achieved in the near future. Relevance will be enhanced through problem-oriented and practice-based approaches, preferably involving multidisciplinary teams. To give effect to such changes, teaching staff in many countries also require urgent strengthening of knowledge and skills(37). Retention of personnel in the public sector is increasingly difficult during the current economic crisis. Urgent attention needs to be given to implementing measures – incentives and regulations - to halt this loss from the public health sector of precious human resources(38).

5. CONCLUSIONS

It is clear that progress towards 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 programmes 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.

In terms of implementation, the challenge is to revitalize Primary Health Care by drawing together the best of the PHC experience and the best of the HP initiative as well as important associated activities such as those around Local Agenda 21. Here the lessons learned in implementing Healthy Cities projects need to be applied more widely.

The time is long overdue for energetically translating policies into actions. The main actions should centre around the development of well managed and comprehensive programmes involving the health sector, other sectors and communities. The process needs to be structured into well-functioning district systems which require, in most countries, to be considerably strengthened, particularly at the household, community and primary levels. Here comprehensive health centres 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 decentralised 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 draw upon, and simultaneously reorientate, 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 is crucial. The engagement of communities in health development needs to be pursued with much more commitment and focus. Here the identification of well-functioning organs of civil society, whether or not they presently are active in the health sector, needs to be urgently pursued.

In promoting the above move from policy to action, WHO has to play a much bolder role in: advocating for equity and legislation to facilitate its achievement; pointing out the dangers to health of globalization and liberalisation; stressing the importance of partnerships between the health sector and other sectors; integrating its own internal structures and activities to ensure that comprehensive PHC programmes are developed; entering into partnerships with and influencing other multilateral and bilateral agencies and donors as well as non-governmental organisations and professional bodies towards a common vision of PHC; and arguing for major investment in health, especially in human resource development, without which HFA will remain a mere statement of intent.

REFERENCES

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7. Source: WHO and UNICEF, Report of the International Conference on Primary Health Care Alma-Ata, USSR, 6-12 September 1978.
8. Adapted from Tarimo & Webster (1994), op. cit., p 3.
9. Tarimo & Webster (1994), op. cit., p 88.
10. WHO (1998A), op. cit., p 145.
11. WHO (1992), cited in Tarimo & Webster (1994), op. cit., p 43.
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13. WHO (1995), cited in Tarimo & Webster, (1994), op. cit., p 44.
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23. White, K.L. (1991). Healing the Schism: Epidemiology, Medicine and the Public’s Health. Heidelberg: Springer- Vrlag. cited in Zwi, A., Zwarenstein, M., Tollman, S. & Sanders, D. (1994) ‘The introverted medical school – time to rethink medical education?’, South African Medical Journal, 84(7), pp 424-426.
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25. Bassett, M.T., Bijlmakers, L. & Sanders, D. (1997). ‘Professionalism, Patient Satisfaction and Quality of Health Care: Experience during Zimbabwe’s Structural Adjustment Programme’, Social Science Medicine, 45 (12), pp. 1845 – 1852.
26. Speth, J.G.. UNDP, 29/06/94, quoted in the Social Summit Seen From the South, P 31. Norwegian Summit for Environment and Development, 1995, cited in Werner & Sanders, (1997), op. cit, p 87.
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31. Sanders, D. (1997) “Success factors in community-based nutrition programmes”, cited in: Food and Nutrition Bulletin, Volume 20, Number 3, September 1999, pages 307-314.
32. Vaughan, J.P. & Morrow, R.H. (eds) (1989). Manual of Epidemiology for District Health Management. Geneva: World Health Organisation.
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35. World Health Organisation (WHO)(1998D). Final Report of Meeting on Policy-orientated Monitoring of Equity in Health and Health Care. Geneva, 29th September – 3rd October 1997. (Document WHO/ARA/98.2). Geneva: World Health Organisation
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37. World Health Organisation (WHO) (1996C). Reviewing and Reorientating the Basoc Nursing Curriculum. Copenhagen: WHO Regional Office for Europe.
38. Tarimo & Webster (1994), op. cit., p 55.

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