PHA-Exchange> PHC: a reminder of its principles

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From: "DBanerjee" <nhpp at bol.net.in>
PRIMARY HEALTH CARE: AN OVERVIEW
DEBABAR BANERJI
Guest Lecture for National Seminar on Health For All in the New
Millenium, NIHFW, February 24-26, 2003.
(Professor Emeritus, Centre of Social Medicine and Community Health,
Jawaharlal Nehru University)

A WATERSHED IN PUBLIC HEALTH


The concept of Primary Health Care (PHC), which was approved by the
World
Health Assembly in 1977 and endorsed at the International Conference on
Primary Health Care at Alma Ata in 1978, marks a watershed in the
discipline
of public health. It had virtually turned the discipline up side down,
as it
were; technology, administrative practices were subordinated to the
needs of
the people.  Halfdan Mahler, the then Director-General of WHO, had
rightly
labelled it as a revolution. He had also acknowledged that the work
done in
India had substantially contributed to the development of the concept
of
PHC.

The concept of Primary Health Care has to be distinguished from the
concept
of a  Primary Health Centre in India. Failure to do so has very often
led to
trivialisation of the concept of Primary Health Care. The ideas behind
setting up Primary Health Centres can be considered as a component of
the
concept of Primary Health Care.

Reference to the term, primary health care, is made in the
Director-General'
s report to the 53rd meeting of the WHO Executive Board as early as in
January 1975, proclaiming that `primary health care services at the
community level is seen as the only way in which the health services
can
develop rapidly and effectively'. He had enunciated seven guiding
principles
for this purpose:

1. to shape PHC `around the life pattern of the population';
2. for involvement of the local population;
3. for `maximum reliance on the available community resources', while
remaining within cost limitations;
4. for an `integrated approach to preventive, curative and promotive
services for both community and for the individual';
5. for all interventions to be undertaken `at the most peripheral
practicable level of the health services by the worker most simply
trained
for this activity';
6. for other echelons of services to be designed  in support of the
needs of
the peripheral level; and,
7. for PHC services to be `fully integrated with the services of the
other
sectors involved in community development'.

By the time of the Alma Ata Conference on PHC had taken its now well
known
form, it was seen as the `key to attaining' the target of health for
all by
the year 2000 (HFA-2000/PHC). Only the outstanding elements of the
Declaration are being presented below:

 I The Conference strongly reaffirms that health is a fundamental human
right and that the attainment of the highest level of human health is
the
most important social goal and whose realization requires action in
many
other social and economic sectors in addition to the health sector.

 II The existing gross inequality in health status of the people
particularly, between developed and developing countries and as well as
within countries is politically, socially and economically unacceptable
and
is, therefore, of common concern to all countries.

 III. Economic and social development is of basic importance to the
fullest
attainment of health for all and to the reduction of the gap between
developing and developed countries. The promotion and protection of the
health of the people is essential for sustained social and economic
development and contributes to better quality of life and to world
peace.

 IV. The people have the right and duty to participate individually and
collectively in the planning and implementation of their health care.

 V. Governments have a responsibility for the health of their people
which
can only be fulfilled by the provision of adequate health and social
measures. A main social target of governments, international
organizations
and the whole world community in the coming decades should be
attainment by
all the people of the world by the year 2000 of a level of health that
will
permit them to live a socially and economically productive life.
Primary
health care is the key to attaining this target as a part of
development in
the spirit of social justice.

 VI. Primary health care is essential health care based on practical,
scientifically sound and socially acceptable methods and technology
universally made accessible to individuals and families in the
community
through their full participation and at a cost the community and the
country
can afford to maintain at every stage of their development in the
spirit of
self-reliance and self-determination. It forms an integral part of the
country's health system, of which it is the central function and main
focus,
and of the overall social and economic development of the country. The
first
level of  individuals, family and the community with the national
health
system bringing health care as close as possible to where people live
and
work and constitute the first of the continuing health care process.

Primary health care
 1. reflects and evolves from the economic conditions and
socio-cultural and
political characteristics of the country and its communities and is
based on
application of the relevant results of social, biomedical and health
services research and public health experience,
 2.addressses the main health problems in the community, providing
promotive, preventive, curative and rehabilitative services
accordingly,
 3. includes at least: education concerning prevailing health problems
and
methods of preventing and controlling them; promotion of food supply
and
nutrition; adequate supply of safe water and sanitation; maternal and
child
health care, including family planning; immunization against major
infectious diseases; prevention and control of local endemic diseases
and
injuries; and provision of essential drugs,
 4. Involves, in addition to the health sector, all related aspects of
national and community development, in particular agriculture, animal
husbandry, food, industry, education, housing, public works,
communication
and other sectors, and demands the coordinated efforts of all those
sectors,
 5. requires and promotes maximum community and individual
self-reliance and
participation in the planning, organization, operation and control of
primary health care, making fullest use of local, national and other
available resources, and to this end develops through appropriate
education
the ability of the community to participate,
 6. should be sustained by integrated, functional and mutually
supportive
referral systems, leading to progressive improvement of comprehensive
health
care to all, giving priority to those most in need,
7. relies, at local and referral levels, on health workers, including
physicians, nurses, midwives, auxiliaries, as needed, suitably trained
socially and technically, to work as a health team and to respond to
the
expressed health needs of the community.

The foregoing quotations from official WHO documents (unavoidably
repetitive) show  how revolutionary have indeed been the ideas which
culminated from the Alma Ata Declaration on Primary Health Care. These
ideas
are being put together below in a summary form:

 1.Health is considered as a fundamental right. The state has the
responsibility to enforce this right.

2. Instead of starting with various types of health technologies and
considering people as almost passive recipients for them, the
Declaration
sought to reverse the relationship by considering people as the prime
movers
for shaping their health services. It sought to strengthen the capacity
of
the people to cope with their health problems which they have developed
through ages.

3, It also visualised a wider approach to health by strengthening such
intersectoral areas as ensuring adequate supply of potable water,
environmental sanitation, nutritive food and housing.

4. It called for social control of the health services that are meant
to
strengthen people's coping capacity.

5. It considered health as an intergral whole, including promotive,
preventive, curative and rehabilitative components. Any concept of
`selective care' was considered antithetical to the concept of PHC.

6. Health services ought to cover the entire population, including the
underserved and the unserved.

7. Those aspects of traditional systems of medicine, which are proven
to be efficacious or which are the only one accessible to the people,
ought
to be used in providing PHC.

8. Choice of Western medical technology should conform to the cultural,
social, economic and epidemiological conditions prevailing in
countries.

9. Particular care is to be taken to use only essential drugs.

It may be emphasised that PHC is a PROCESS; it provides a road map for
developing heath service in different countries of the world. Health
service development in India is taken up here as a case study.

 [The case study is available by contacting the author directly].