ARTICLES ON PRIMARY HEALTH CARE
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Political Context of the Work of International Agencies
A FUNDAMENTAL SHIFT IN THE APPROACH TO
INTERNATIONAL HEALTH BY WHO, UNICEF, AND THE
WORLD BANK: INSTANCES OF THE PRACTICE OF
“INTELLECTUAL FASCISM” AND TOTALITARIANISM
IN SOME ASIAN COUNTRIES
Debabar Banerji
Navarro has used the term “intellectual fascism” to depict the intellectual
situation in the McCarthy era. Intellectual fascism is now more malignant in
the poor countries of the world. The Indian Subcontinent, China, and some
other Asian countries provide the context. The struggles of the working class
culminated in the Alma-Ata Declaration of self-reliance in health by the
peoples of the world. To protect their commercial and political interests,
retribution from the rich countries was sharp and swift, they “invented”
Selective Primary Health Care and used WHO, UNICEF, the World Bank,
and other agencies to let loose on poor countries a barrage of “international
initiatives” as global programs on immunization, AIDS, and tuberculosis.
These programs were astonishingly defective in concept, design, and
implementation. The agencies refused to take note of such criticisms when
they were published by others. They have been fascistic, ahistorical, grossly
unscientific, and Goebbelsian propagandists. The conscience keepers of
public health have mostly kept quiet.
OVERVIEW
Giving a personal account of studies on class, health, and quality of life during
1965-1977 in the United States, Vicente Navarro (1) has brought back chilling
memories of the dreaded McCarthyism which overshadowed almost every facet
of intellectual life in that country. He has, very appropriately, used the term
“intellectual fascism” to describe this phenomenon. The intellectual fascism that
is being practiced by the rich countries of the world on the health services of
the poor, dependent countries is of an even more malignant variety. There is
an unholy nexus between the ruling classes of the rich and the poor countries in
International Journal ol Health Services, Volume 29, Number 2, Pages 227-259, 1999
© 1999, Bay wood Publishing Co., Inc.
227
228 / Banerji
imposing health programs on the poor, because it serves their commercial and
political interests. Even the most cogent, well-documented, and well-argued
observations questioning the scientific validity of these programs are ignored.
Making use of the market-generated information revolution, the rich have brain
washed the helpless masses of the poor to sell their programs. They have also
ignored the fact that health policy formulation is a highly complex process,
requiring optimization of very complex systems. The task becomes even more
complicated when it has to be performed in the context of poor, non-Westem
countries. These considerations have received scant attention from the health pol
icy experts hired by rich countries.
Asia is a huge continent, with extreme variations in geography, population,
ethnic composition, and political commitments. In this report, only the countries
that fall in the “median” positions will be taken into account. Among them,
again, very brief references will be made to the cases of health service develop
ments on the Indian subcontinent and in China to provide a setting for discussion.
Together they account for more than two-fifths of the entire population of the
world, and a much higher proportion of the world’s poor.
The long experience of India in developing its health services has escaped
the attention of scholars from the rich countries, of both the hired and the “pro
gressive” varieties. It has been a most virulent form of intellectual fascism. These
scholars were actively ahistorical, apolitical, and atheoretical. After Independ
ence, India’s ruling class, which had led the freedom struggle against the colonial
rulers, was impelled by the working class to fulfill the promises it had made
while mobilizing them for the struggle. This was the compelling motive force for
its ushering in very ambitious health programs to cover the needs of the unserved
and the underserved during the first two decades of independence, even though
the country faced massive problems.
The situation in China is entirely different from that in India. Significantly, the
two major ideas in public health that emanated from China—the barefoot doctor
and the use of the traditional Chinese systems of medicine in their health ser
vices—are the outcomes of the revolutionary movement, particularly the Long
March. Unfortunately, China also adopted the now well-discredited Soviet
model, which failed to work. Deng Xiaoping’s move to promote “market social
ism” dealt an almost deadly blow to the village commune system, which sus
tained the barefoot doctors.
Other Asian countries such as Sri Lanka, Pakistan, Bangladesh, Malaysia,
Indonesia, Thailand, and the Philippines have also made “progress” in develop
ing their health services. The four last-named countries were among those spe
cially favored by the world capital for stimulating rapid economic growth during
the past two decades. Even at the peak of their growth phase, serious flaws have
been observed in the health services in the form of rapid privatization leading to
gross overcapacity in private hospitals and almost criminal neglect of the poor
because of further decay of the already inadequate health services for poor peo-
Intellectual Fascism and Health / 229
pie. One can well imagine the health and health service consequences of the
severe financial crises that have overtaken these “Tiger” countries since 1997.
The ferment in the development of health services in Asia and elsewhere dur
ing the 1960s and 1970s triggered major changes in World Health Organization
(WHO) policies. The Alma-Ata Declaration on Primary Health Care was the cul
mination of the chain reaction. Apparently for tactical reasons, all the rich coun
tries of the world signed the Declaration. But their retribution for such a dare
devil declaration by the poor was swift and sharp. As if from nowhere, they
“invented” the concept of Selective Primary Health Care (SPHC). A large num
ber of concerned scholars categorically questioned the scientific validity of the
concept, but all failed to make any impression on the exponents of SPHC.
Two main issues stand out from the awesome manifestation of power by the
rich countries in imposing their will on the poor. First, although they lay claim to
being the inheritors of the European Enlightenment, which involves a deep com
mitment to the scientific method, they have shown contemptuous disregard for
these principles whenever scientific data stood in the way of their commercial
and political interests. Second, the bulk of public health scholars, who proclaim
their allegiance to the scientific method and commitment to social justice, found
it worthwhile to remain silent while such active desecration took place.
As a follow-up, the ruling classes of the countries of the world exercised their
control over international organizations such as UNICEF, WHO, and the World
Bank (WB) to get them started with formulating some selected programs as
“global initiatives.” These were bristling with inconsistencies, contradictions,
and patent scientific infirmities. Even the main planks for the formulation of
these initiatives were profoundly flawed. First, how can one have a “prefabri
cated” global initiative given the extreme variations among and often within poor
countries? Second, selection of health problems for action conformed more to
the special interests of the rich countries than the poor. Third, a technocentric
approach to problem-solving was adopted. Fourth, there is an obvious contradic
tion in the scientific bases of the claim that the suggested globe-embracing pro
grams are cost-effective given the profound variations among and within coun
tries. Fifth, by their very nature, international initiatives cannot promote
community self-reliance. Sixth, there is the key question of dependence and
sustainability; “donors” have used their tremendous influence on the pliable rul
ing classes of the poor countries to ensure that the ill-conceived, ill-designed, and
ill-managed global initiatives are given priority over the ongoing work of the
health organizations. Finally, and above all, these programs are the very antithe
ses of the Alma-Ata Declaration.
It is grimly ironic that soon after the leadership given by WHO and UNICEF
in writing one of the brightest chapters in the history of public health practice, in
the form of acceptance of the Alma-Ata Declaration by all countries of the world
in 1978, the ruling classes should have started the international initiatives that
opened one of the darkest chapters. By the early 1980s, UNICEF let loose a bar-
230 / Banerji
rage of global initiatives on the poor countries of the world. WHO and the World
Bank lent the full weight of their considerable prestige and influence in strength
ening this menacing trend in public health thinking and action.
The outbreak of the AIDS epidemic in 1982, which later took the form of a
pandemic, legitimately thrust on WHO the onerous responsibility for action on a
global scale. It developed the Global Programme for AIDS. Despite the bewil
dering variations in the epidemiological behavior of the disease—including its
complex social and cultural dimensions, which required a very flexible approach
to program formulation—the program conformed to a set pattern which was prin
cipally shaped in the United States.
WHO’s declaration of the tuberculosis problem as a “Global Emergency” was
a totally surprising move. The database to justify such a sweeping declaration
was virtually nonexistent. Ironically, allocation of overriding priority to the inter
national initiatives, all down the line, led to the neglect of other services provided
at the peripheral or grassroots level. This included tuberculosis work. WHO had
also launched two other global programs with considerable fanfare. One was the
diarrheal disease control programme and the other was meant to deal with acute
respiratory infections in infants and children. Mercifully, these programs failed
right at the take-off stage. The World Bank had joined WHO to launch yet
another international initiative called the Safe Motherhood Initiative. This too
has a very long way to go.
Some high-profile research administrators got together to set up a global Com
mission on Health Research and Development in 1987. Practice of Essential
National Health Research was the centerpiece of the report. Even the very
scanty materials produced to document progress in its implementation leave little
doubt that the initiatives taken could have little impact on the strengthening of
health services in the countries of the world.
It should come as no surprise that virtually every global initiative taken by
WHO, UNICEF, and the World Bank since the promotion of SPHC by the rich
countries suffered from serious infirmities. Remarkably, even when these
infirmities were pointed out to the organizations, they failed even to enter into
discussion on the issues raised or take any corrective measures. It is not neces
sary here to make a comprehensive critique of all the programs. Only three of the
major ones—on immunization, AIDS, and tuberculosis—will be taken up here,
and these only very briefly.
Even a very broad analysis of the process of policy and program formulation
and implementation of the immunization program (EPI/UPI) reveals that the api
cal organizations of international public health have shown scant regard for some
of the fundamental principles of public health practice. They have dared
to launch a global/universal immunization program without caring to have a rea
sonably reliable epidemiological baseline. They have tended to “homogenize”
the situation; even the 100 or so poor countries have widely varying parameters.
When there is no epidemiological baseline, how is it possible to assess the epide-
Intellectual Fascism and Health / 231
miological impact of the program? Without paying any attention to these vital
infirmities, the WHO/UNICEF/WB establishment has not hesitated to repeat in
1998 the wild claim that: “Today 80 percent of the world’s children receive
this form of protection against childhood diseases during their first year of life.”
WHO and UNICEF had joined the Government of India to get the Indian pro
gram systematically evaluated in 1989. The results were published in the form of
a book, which was widely circulated. The findings seriously questioned the
claims by WHO/UNICEF/WB. Another all-India study conducted in 1992-1993
revealed that at the national level as few as 35.4 percent of eligible children were
fully protected, with the coverage hovering around 9 to 22 percent among many
of the highly populated states with the poorest records of infant mortality. If
the situation is so bad in India, the conditions prevailing in the world’s least
developed countries, and many more, will certainly not be any better.
The same trend was followed when WHO, along with a large number of U.N.
agencies, set out to design the Global Programme for AIDS (GPA), which was
principally directed toward the poor countries. Despite the efforts by WHO/WB
officials and their Indian camp followers to control information and extensively
spread unsubstantiated information, it was possible, as early as in 1992, to bring
out a monograph that called into question a number of critical assumptions in the
formulation of the GPA in India. This too was disregarded.
The justification given by WHO/WB for launching the Global Programme for
Tuberculosis (GPT) is even more fantastic and incredibly contradictory. Out of
the blue, as it were, in the early 1990s, WHO/WB sounded a maximum-alert
alarm bell to proclaim that tuberculosis had become a “Global Emergency” and
the GPT was the way of tackling it. Once again, despite putting on a cloak of
secrecy while selling the program in India, a comprehensive document was pre
pared pointing out major epidemiological, sociological, economic, and organiza
tional and management flaws in the GPT. But this did not deter the authorities
from pushing on with their doomed venture.
A very large area is covered in this report to demonstrate how the imposition
of an enormous, high-priority, prefabricated health service agenda of the rich
countries on the poor ones has virtually decimated the somewhat promising
growth of people-oriented health services in a country such as India. The overrid
ing priority assigned to a Malthusian family planning program for over four
decades by the ruling classes, both national and international, has also had a dev
astating impact on the growth and development of the health services in India. As
described later, Nicholas Demerath, Sr., has given a well-documented account of
the various ways in which India’s family planning program has been influenced
by the U.S. government (U.S. AID) and other U.S. agencies.
In conclusion, let me list just a few of the major areas of distortion. First, the
“public health” practiced by exponents of the international initiatives is starkly
ahistorical. Second, the scientific term “epidemiology,” which forms the
foundation of public health practice, has been grossly misused by the new breed
232 / Banerji
of experts. Third, suppression of information, use of doctored information,
spread of misinformation and disinformation, and lack of effective
evaluation/surveillance are expected outcomes. Fourth, directors-general of two
top public health institutions in India extended their support to the GPT, even
though serious flaws in the program were repeatedly brought to their attention.
After they endorsed the WHO/WB program, they found highly lucrative
positions in WHO. This and many other such instances mark the rock-bottom of
the moral and ethical standards of the parties concerned. Finally, those who are
expected to be the conscience keepers of ethics and morality in public health
practice are perhaps the worst offenders in inflicting such a humiliation on the
poor peoples of the world.
The line of action for those few who still attach high value to intellectual and
moral integrity, and are prepared to pay the sort of price mentioned by Navarro,
emerges from the analysis presented in this report.
INTELLECTUAL FASCISM
Giving a personal account of studies on class, health, and quality of life during
1965-1997 in the United States, Vicente Navarro notes that “terms such as class,
working class (not to mention class struggle), and just plain capitalism were dis
missed as ideological. No serious scholar, aware of the penalty it would carry,
would dare to use these terms” (1, p. 391). He has, to my mind very appropri
ately, used the term “intellectual fascism,” whose “destructive powers could be
even worse than the fascism I had experienced in Spain” (1, p. 392), to describe
this phenomenon.
The intellectual fascism that is being practiced by the rich countries of the
world against the poor, dependent countries is of an even more malignant variety.
In the field of health, to subserve their commercial and political interests, the rul
ing classes of the rich and the poor countries have formed an unholy nexus which
enables them to impose prefabricated, technocentric, dependence-producing
health programs on the poor. These interests are so powerful that even most
cogent, well-documented, and well-argued observations calling into question the
scientific validity of these programs are simply ignored. When it comes to pro
tecting their interests, the special brand of intellectuals/scholars who are hired by
the ruling classes are ruthless, unscrupulous, and nonchalant (2). The Bhopal
tragedy of 1984 (3-10), in which the Union Carbide Corporation got away so
lightly with the consequences of its criminal neglect—which led to the spraying
of the deadly chemical methyl isocyanate on hundreds of thousands of people,
leading to the death of thousands and severe health damage to scores of thou
sands—provides an awe-inspiring case study demonstrating the power of the
nexus of the ruling classes.
The ruling classes of the rich countries have also mobilized a number
of international agencies and myriad bilateral and ‘‘voluntary” agencies or
Intellectual Fascism and Health / 233
nongovernmental organizations to implement their agenda for action.
Suppression of information, doctoring of information, misinformation, and
disinformation have been freely used as means to push their agenda. Making use
of the market-generated information revolution, they have employed the
approach of social marketing (11, 12) to brainwash the helpless masses of the
poor so as to sell their programs. The way in which the “experts” employed by
the World Bank have twisted and distorted the meaning of health policy
formulation almost beyond recognition, by bringing it down to the level of health
financing (13), provides a startling instance of this new brand of scholarship from
the rich countries.
Lest they “forget” the essence of health policy formulation by hiding them
selves in the jungle of the massive, programmed information onslaught, it is
worthwhile to “remind” the hired experts about some of its basic concepts.
(“Man’s struggle against oppression is a struggle between memory and forgetful
ness”—Milan Kundera.) Health policy formulation is a highly complex process,
requiring optimization of very complex systems. For this purpose, epidemiologi
cal, medical and public health, and organizational and management issues are
visualized in their social, cultural, and economic contexts so as to crystallize
them in the form of policies based on constitutional and other types of political
commitments (14). The task becomes even more complicated when it has to be
performed in the context of poor, non-Western countries. Western medicine is,
after all, Western in origin. Furthermore, it has been grafted onto countries that
already had ways of coping with their health problems. The grafting was done
usually against the background of colonial conquest, as in the case of India, or in
blatant imperialistic settings, as in the case of China. Differences in the ecology
of diseases, availability of resources, cultural meanings of health problems and
health practices, formulation of appropriate technologies and economic produc
tion practices are some other important determining factors. These consider
ations have received scant attention from the health policy experts hired by rich
countries (15).
EARLY EFFORTS TO DEVELOP HEALTH SERVICES
IN SOME ASIAN COUNTRIES
Countries of Asia
Asia is a huge continent, with wide variations in geography, population, ethnic
composition, and political commitments. For instance, there are Japan and South
Korea at one extreme, and Nepal, Bhutan, and Afghanistan at the other. Here I
will discuss the role of foreign and international agencies and other organizations
in health policy formulation in terms of those Asian countries occupying median
positions. A very brief reference will be made to the cases of health service
developments on the Indian subcontinent and in China to provide a setting for
234 / Banerji
discussion. Together they account for more than two-fifths of the entire popula
tion of the world, and a much higher proportion of the world’s poor. Besides,
many of the observations made about India and China are also relevant, to vary
ing degrees, to many other Asian countries in “median” positions. It also so hap
pens that information available on development of health service systems in
these other Asian countries is very scanty and often of rather unreliable quality.
Health Service Development on the Indian Subcontinent
The long experience of India in developing its health services has escaped the
attention of scholars from the rich countries, of both the hired and the
“progressive” varieties. Indeed, the former category has actively ostracized the
indigenous scholarship, apparently to create “space” for justifying the agenda
handed down to them by their paymasters; it has been a most virulent form of
intellectual fascism. As pointed out by Navarro (1, 16), and earlier noted by John
McKinlay (17) in a slightly different context, these scholars were actively
ahistorical, apolitical, and atheoretical. Such an approach subserves the class
interests of the rulers. Obviously, this normally would require considerable
elaboration (e.g., 18), but in the present context I will present only a bare outline
of India’s experience.
The British inducted Western medicine in India in the wake of their colonial
conquest in the latter half of the 18th century, primarily to strengthen their
exploitative machinery—the army, the civil service, the European business class,
and a wafer thin, uppermost crust of native collaborators (18). Reciprocally,
this further weakened the native working class, which constituted more than
98 percent of the population. They were further pauperized due to colonial
exploitation, thus further increasing the disease load, and were made to lose
the indigenous coping mechanisms that they had developed over the course of
centuries (18).
As a dialectic response, the people of India launched an anti-colonial freedom
struggle, which became a mass movement, leading to the overthrow of the colo
nial rulers in 1947 (19). The reports of the National Health Sub-committee of the
National Planning Committee of the Indian National Congress in 1940 (20) and
the famous Shore Committee (21) (which, incidentally, was spearheaded by “for
eign” experts such as John Grant and Henry Sigerist) in 1946 provided the basis
for the formation of a blueprint for building an egalitarian health service for free
India.
After Independence, the ruling class, which had led the freedom struggle, was
impelled by those of the working class to fulfill the promises it had made while
mobilizing them for the struggle. This was the motive force for ushering in very
ambitious health programs to cover the needs of the unserved and the
underserved, even though the country faced massive problems—accentuated
severalfold in the wake of Partition. A nationwide network of Primary Health
Intellectual Fascism and Health / 235
Centres (22) for the rural population was established from 1952 to provide inte
grated health services to entire populations, as part of a still more ambitious
Community Development Programme (23). The Primary Health Centres formed
the sheet anchor for developing the other important facets of the health service
system—for example, people-oriented manpower development (24—27), research
(28, 29), regionalization of the health services (30), inclusion of the indigenous
systems of medicine (31), and so on. Very well-designed public health research
on tuberculosis conducted in India had a far-reaching influence on tuberculosis
programs all over the world, including in the rich countries. This research
showed that home treatment is as good as sanatorium treatment (32); that the
BCG vaccine has little protective value, at least for adults (33, 34); that a sub
stantial proportion of tuberculosis patients in a population were already seeking
assistance at Primary Health Centres and other health institutions; and that spu
tum smear examination is the most reliable diagnostic tool (35-37).
The major political upheaval that followed imposition of the National Emer
gency in 1975-1977 was instrumental in adoption of the program of entrusting
“people’s health in people’s hands” (38); using community health workers cho
sen by the people themselves has been another landmark. These movements
culminated in enunciation of the National Health Policy in 1982 (39), which pro
claimed that:
The prevailing policy in regard to education and training of medical and
health personnel, at various levels, has resulted in the development of a cul
tural gap between the people and the personnel providing care. The various
health programmes have, by and large, failed to involve individuals and fam
ilies in establishing a self-reliant community ... the ultimate goal of achiev
ing a satisfactory health status for all our people cannot be secured without
involving the community in the identification of their health needs and prior
ities as well as in the implementation and management of various health and
related programmes.
As discussed later, the approach adopted by the special brand of experts hired
by the rich countries and their camp followers is diametrically opposed to that
envisaged in the National Health Policy. Incidentally, as also pointed out by
Navarro (1), the emphasis on democratization of community health services is
also conspicuously missing in the approach adopted by the erstwhile socialist
countries” (including China) and those European countries that have set up
national health services.
Health Service Development in China
The situation in China is entirely different from that in India. China had the
most blatant form of imperialistic exploitation, as symbolized by the Opium
236 / Banerji
Wars; feudal monarchy; the revolution of 1912; the KMT of Chiang Kai-shek
and their pathetic, supplicant-level dependence relationship with the United
States in almost all spheres; the Japanese war of aggression; the revolutionary
movement by the Chinese Communist Party, including the fabled Long March,
leading to its ultimate victory and establishment of the People’s Republic of
China in 1948.
The United Missions Medical College was China’s first medical college,
started in 1925 (40). In contrast, India had three government-funded medical col
leges by 1835 (41). Significantly, the two major ideas in public health that ema
nated from China—the barefoot doctor and use of the traditional Chinese sys
tems of medicine in the health services (42)—are the outcome of the
revolutionary movement, particularly the Long March. Unfortunately, China also
adopted the now well-discredited Soviet model, which failed to work. In sheer
frustration, Mao had exclaimed, as late as in 1965 (43):
Tell the Ministry of Public Health that it works only for fifteen percent
of the population of the country and this fifteen percent is mainly composed
of gentlemen while the broad masses of peasants do not get medical treat
ment . . . why not change its [Ministry of Public Health’s] name into the
Ministry of Urban Health, the Ministry of Gentlemen’s Health or even the
Ministry of Urban Gentlemen’s Health?
Deng Xiaoping’s move to promote “market socialism” dealt an almost deadly
blow to the village commune system, which sustained the barefoot doctors.
Even though critical of the Soviet model of health services, Navarro (1) has
also observed how the capitalist model adopted by post-Soviet Russia has led
to a disastrous collapse of the health service system of that country. Almost
grudgingly, he also concedes that “the same process is now underway in China.”
It is a profound irony that, having brought about the collapse of the earlier social
ist system, China is now asking for help from WHO’s Division for
Intensive Cooperation with Countries and Peoples in Greatest Need to
solve problems in health financing in connection with re-establishment of
the country’s Rural Cooperative Medical System” (44). China also created a
most embarrassing situation for other countries when it accepted the World
Bank/WHO-supported tuberculosis program with alacrity, turning a blind eye
to the myriad scientific design flaws repeatedly pointed out by scholars from
other countries (45-47). That China should now adopt an openly coercive policy
of one-child families, while earlier it had described the dangers of population
growth as a trait of the capitalist system, is yet another indication of grave
flaws in its population policies and planning. Incidentally, no political leader
would dare even to think of a similar approach for India, for fear of a backlash
from the people.
Intellectual Fascism and Health / 237
The “Tiger” and Other Asian Countries
The state of Kerala in India (population 30 million) (48, 49) and Sri Lanka
(population 16 million) (50) stand out sharply among all the low-income coun
tries in having remarkably good health and mortality statistics. Other Asian coun
tries such as Pakistan, Bangladesh, Malaysia, Indonesia, Thailand, and the Phil
ippines have also made “progress” in developing their health services.
The four last-named countries were among those specially favored by the
world capital for stimulating rapid economic growth during the past two decades.
Even at the peak of their growth phase, serious flaws have been observed in their
health services in the form of rapid privatization leading to gross overcapacity in
private hospitals and almost criminal neglect of the poor because of further decay
of the already inadequate health services for the poor (51). In a recent article,
Barraclough (51) has described how the conglomerate corporations of Malaysia,
which often own plantations, also run the leading private hospitals, using the lat
est technology. He points out the paradox that the workers on the rubber and
palm estates are the poorest in the country. Conforming to laws originating in the
colonial period, the services now being provided to them are “woefully inade
quate and offer little more than treatment of minor ailments and first-aid.” Given
such a situation in 1994 in one particularly “successful” “Tiger” country, one can
well imagine the health and health service consequences of the severe financial
crises that have overtaken these “Tiger” countries since 1997. Although some of
these consequences are already visible in the form of a sharp deterioration in
health and mortality statistics and an acute scarcity and sharp rise in price of
drugs, the full impact of the crises on the health service systems has yet to be sys
tematically assessed.
THE ROAD TO ALMA-ATA AND THE
RESPONSE OF THE RICH
The Alma-Ata Declaration: A Watershed in Public Health Practice
•
This very broad account of the evolution of health service systems in the two
Asian giants, and a mere mention of the state of affairs in many other Asian coun
tries, set the stage for understanding and analyzing the practice of intellectual fas
cism by a syndicate of the world’s ruling classes, with those that are rich and pow
erful setting the agenda for action. The ferment in the development of health
services in Asia and elsewhere in the world during the 1960s and 1970s triggered
major changes in WHO policies. The Alma-Ata Declaration on Primary Health
Care (52) was the culmination of the chain reaction. Health as a fundamental
human right, community self-reliance, intersectoral action for health, social con
trol over health services, use of appropriate technology, encouragement of tradi-
238 / Banerji
tional systems of medicine, essential drugs—these are some components of the
Declaration. It also contained a detailed definition of Primary Health Care.
The Invention of Selective Primary Health Care
Apparently for tactical reasons, all the rich countries of the world signed the
Alma-Ata Declaration even though it shook the very foundations of the conven
tional thinking on international public health as hitherto practiced by these coun
tries. The Declaration marked a watershed. It was also clear to the rich countries
that such a declaration of self-reliance by the poor peoples of the world was
against their class interests. They saw its “subversive” character. Navarro (1) has
described how the use of such radical terminology as “class interests” has long
been seen in the United States as “too ideological,” with the enjoinment that such
things have to be “value free”—forgetting that this is itself a most value-laden
term. The retribution for such a daredevil act as the Alma-Ata Declaration was
swift and sharp.
As if from “nowhere,” the rich nations “invented” the concept of Selective Pri
mary Health Care (53). The justification was that Primary Health Care was good,
but was too ambitious; one therefore should be selective in choosing areas that
are cost-effective. To legitimize such a fragile stand, they got hold of a very
poorly designed, and even more poorly conducted and analyzed, study in Haiti.
The principal author was then an “assistant clinical professor of medicine” at
Harvard. Such a paper would have been rejected out of hand by even the poorest
academic journal in a developing country. That it found ready acceptance for
publication in the prestigious New England Journal of Medicine speaks volumes
about the intensity of intellectual fascism that still prevails in the United States.
More than 80 scholars from schools of tropical medicine and other public
health institutions in Europe and from the United States, Africa, and Asia gath
ered at Antwerp to discuss SPHC. In the Antwerp Declaration (54, 55) they cate
gorically questioned the scientific validity of the concept. Social Science and
Medicine (56) brought out a special issue with a detailed account of the delibera
tions at Antwerp. There were articles on the subject in the Economic and Politi
cal Weekly (Bombay) (57) and the International Journal of Health Services (58).
The Journal of the Indian Medical Association (2) carried a leading article on the
subject. All these and many others (e.g., 59-62) failed to make any impression on
the exponents of SPHC. The latter went on to organize a high-profile meeting
attended by top executives of WHO, UNICEF, the World Bank, and many other
agencies, as well as like-minded persons who called themselves public health
scholars, at Bellagio, Italy (63), thus getting a resounding endorsement for
SPHC. After two years, they organized a similar meeting at Cartagena in Colum
bia (64) (called Bellagio-II) to get a similar endorsement.
Two main issues stand out from the awesome manifestation of power by the
rich countries in imposing their will on the poor. First, although they lay claim to
Intellectual Fascism and Health / 239
being the inheritors of the European Enlightenment, which involves a deep com
mitment to the scientific method, they have shown contemptuous disregard for
these principles whenever scientific data stood in the way of their commercial
and political interests. Second, despite the brave scholars who stood up to the
bullies at Antwerp and at other forums, the bulk of public health scholars, who
proclaim an allegiance to the scientific method and commitment to social justice,
including the Alma-Ata Declaration, found it worthwhile to exercise discre
tion—the better part of valor. They remained silent on the most blatant desecra
tion of scientific principles and methods, presumably to avoid the anger of the
most powerful country and its camp followers. This brand of “intellectuals,” who
belong to the middle class and attained their positions of importance by putting
on a mask of progressivism, can also be said to harbor at least some traits of
intellectual fascism, which they try to hide deep within them. They too need to be
exposed. Where were they when China started its program of enforcing the norm
of a single-child family, or when Indira Gandhi imposed a National Emergency
and let loose a reign of terror, and used force to sterilize millions of people
against their will (65)? The Vietnam “war hero” and then President of the World
Bank, Robert McNamara, visited India at that time and is on record praising
India for its achievement in fighting the menace of population explosion (66).
LETTING LOOSE A BARRAGE OF
INTERNATIONAL INITIATIVES
UNICEF’s Primacy in Imposing International Initiatives
As a follow-up to acceptance of Selective Primary Health Care, the ruling
classes exercised their control over international organizations such as UNICEF,
WHO, and the World Bank to get them started with formulating some selected
programs as “global initiatives” for implementation in the poor countries. The
brief accounts of the evolution of health services in India and China and mention
of some other Asian countries will provide the context for understanding how
different has been the conceptualization, formulation, and implementation
aspects of these initiatives undertaken by the triad (WHO, UNICEF, and the
World Bank). On the basis of this description it is possible to list some major
aspects of their actions.
1. Even the main planks for formulation of these initiatives were profoundly
flawed. How can one have a “prefabricated” global initiative when one takes
into account the extreme variations among and often within the poor countries?
This very obvious determining factor escaped attention, or, more likely, was
deliberately overlooked, when the initiatives were formulated. The situation
bears an uncanny resemblance to the economic “rescue packages” of the Interna
tional Monetary Fund (IMF).
240 / Banerji
2. Selection of health problems for action conformed more to the special inter
ests of the rich countries than to the specific epidemiological situations in the
various poor countries.
3. A technocentric approach to problem-solving was adopted, not because it
provided the “optimal solution” (67, 68), but because this was “friendly” to the
economic interests of the rich countries. The biotechnology, refrigeration, and
drug industries, particularly in the private sector, are some examples. There was,
besides, the opportunity for the creation of high-salaried employment in rich
countries, for hirelings who could then exercise the enormous power bestowed
on them to perform the jobs assigned by their paymasters.
4. There is an obvious contradiction in the specific bases of claims that the sug
gested globe-embracing programs are cost-effective, given the profound variations
among and within countries. Presumably because of this, no serious efforts were
made to assess cost-effectiveness at the time of program formulation. The claim of
cost-effectiveness by once highly respected organizations such as WHO and
UNICEF is an example of the blatant spread of almost manifest disinformation.
The latest instance of this almost deliberate effort to avoid subjecting their assump
tions to objective evaluation comes from the failure of WHO/WB to set up reliable
baseline data on “Annual Rate of Infection” (69) for monitoring the progress of the
huge Global Programme for Tuberculosis which they had launched.
5. By their very nature, international initiatives cannot promote community
self-reliance.
6. Because countries receive a considerable proportion of the funds from out
side, there is the key question of dependence and sustainability—apart from the
real danger of vulnerability to political exploitation by the “donors.”
7. The “donors” have used their tremendous influence on the pliable ruling
classes of the poor countries to get overriding priority assigned to the illconceived, ill-designed, and ill-managed global initiatives at the expense of the
ongoing work of the health organizations. In India, for example, the primacy
given to the programs pushed by the WHO/UNICEF/WB triad, along with an
almost frenzied preoccupation with the family planning program, has had a dev
astating impact on almost every facet of organization, management, and growth
of the health services infrastructure. In the case of China, as (under) stated by
Navarro (1), it was more an overt political decision by the oligarchic ruling class
to shift investment away from the people-based health services; privatization was
the slogan for socialist market orientation.
8. Above all, these programs are the very antitheses of the Alma-Ata Declara
tion and, in the case of India, of its National Health Policy (39), which envisaged
“involving the community in the identification of its health needs and priorities
as well as in the implementation and management of the various health and
related programmes.”
It is grimly ironic that soon after the leadership given by WHO and UNICEF
in writing one of the brightest chapters in public health practice—acceptance of
Intellectual Fascism and Health / 241
the Alma-Ata Declaration in 1978 by all countries of the world—the ruling
classes should have started the international initiatives that opened one of its
darkest chapters. The oppressed peoples of the world will have to pay yet another
installment to their oppressors before their tormentors are again forced to admit
their mistakes and to abandon their ill-conceived misadventures, so that the
oppressed can then resume their long, grinding struggle toward access to peo
ple-oriented services for their populations (57). Using the hindsight of 1998, it is
appalling to find so few who have had the courage of their convictions to call the
bluff of the tormentors of the oppressed.
By the early 1980s, the triad of WHO, UNICEF, and the World Bank had
started to give a global form to the grossly inadequate but politically and eco
nomically important concept of Selective Primary Health Care. UNICEF opened
up a barrage of global initiatives on the poor countries of the world. WHO and
the World Bank lent the full weight of their considerable prestige and influence in
strengthening this menacing trend in public health thinking and action. At first,
UNICEF came up with four areas for “special” attention in child health: Growth
Monitoring, Oral Rehydration, Breast Feeding Promotion, and Immunization
(GOBI) (70, 71). It was soon impelled to add to the list: Fertility Promotion,
Feeding Programme, and Female Development, thus making it GOBI-FFF (72).
Again, it had to backtrack and focus its attention only on immunization. This pro
ject was named the Universal Programme of Immunization (UPI) (73, 74), or
simply the strengthening of WHO’s pre-existing Extended Programme of Immu
nization (EPI) (75). It is not difficult to visualize the impact of such a
fickle-minded approach on the world’s utterly dependent, poorest of the poor
countries. At a later stage, there was yet another turnaround, when one of the six
diseases—poliomyelitis—was singled out for eradication from the globe (76,
77). Thus, the disturbing signals were already there on the quality of care and on
the considerations that had gone into the triad’s drawing up policies and plans for
acting globally to fulfill the responsibility assigned to the three agencies in their
respective constitutions.
In the world of the poor, with virtually no system even to record births and
deaths, not to mention a dependable health information and evaluation system,
“experts” hired by UNICEF, WHO, and many affluent countries of the world
made the pronouncement that six immunizable diseases—tetanus, pertussis,
diphtheria, tuberculosis, poliomyelitis, and measles—account for most deaths
among infants. It was assumed that a massive program of vaccination against
these six diseases would create a strong enough “herd immunity” to eliminate
them as public health problems, if not totally eradicating them within five years,
presumably as in the case of smallpox (74).
To cope with the mind-boggling task of immunizing hundreds of millions of
infants, particularly those living under the most primitive conditions in extremely
remote areas of the very large number of the world’s poorest countries (where,
incidentally, a much higher incidence of the six diseases would be expected).
242 / Banerji
experts from UNICEF/WHO suggested an intensive program of mass communi
cation, using the new technological advances. The globally telecast pop extrava
ganza organized by the Irish pop star Bob Geldof at London’s Wembley Stadium
in the form of “Band Aid,” and later, a still bigger show at the same place under
the label ‘World Aid” (12), are two outstanding instances of appeals to the “char
itable instincts” of the rich to contribute to UNICEF’s crusade against the six dis
eases “to save the lives of the poor.” The rank hypocrisy of the over-affluent rich,
throwing away hundreds of billions of dollars to sustain their vulgar “entertain
ment industry,” could not have been more blatant. There were, incidentally, few
protests from the concerned people of the world at this patently indecent insult to
the poor by the rich. These are the modern-day Marie Antoinettes, the only dif
ference being that their number has swollen to the hundreds of millions, brain
washed by the potent weapons provided by the so-called information revolution.
UNICEF also hired experts from the marketing field and gave the name “social
marketing” to these techniques used to “fight” its crusade against the six dis
eases. Indeed, in order to sell its ideas, particularly to the burgeoning proportion
of the gullible, it claimed that the movement for immunization would lead to
“mass mobilization” of the people of poor countries for other health and develop
ment work (11, 72).
As I will briefly mention later, the propaganda blitz let loose on the poor
countries of the world to promote EPI/UPI has apparently been “forgotten”
within a few years, because it has served the purpose for which it was generated.
The informatics industry, moving fast on the information highways in the rich
countries, has found new pastures for helping to launch new international
crusades against other specific diseases (45). The experts also seem to have
conveniently “forgotten” about the data that had seriously questioned the very
bases of the program (54-62). They, too, seem to have moved on to new pastures,
to carry on new crusades. Public health experts at WHO also fully endorsed the
UNICEF initiative on EPI/UPI, and WHO undertook to use its far-flung
organizational outreach in different countries to push this program (74-76). It has
also undertaken the task of running the global program for eradicating
poliomyelitis by 2000 (77).
The WHO Global Programme for AIDS (GPA)
The outbreak of the AIDS epidemic in 1982, which later took the form of a
pandemic, legitimately thrust on WHO the onerous responsibility for action on a
global scale. It developed the Global Programme for AIDS. Despite the
bewildering variations in the epidemiological behavior of the disease, including
complex social and cultural dimensions that required a very flexible approach to
program formulation, the GPA conformed to a set pattern that was principally
shaped in the United States (78). As pointed out later, this proved to be its
Intellectual Fascism and Health / 243
Achilles’ heel. At a later stage, implementation of the GPA was entrusted to an
inter-agency U.N. organization called UNAIDS.
The WHO/WB Global Programme for Tuberculosis (GPT)
The World Health Organization’s declaration of the tuberculosis problem as a
“Global Emergency” was a totally surprising move. The database to justify such
a sweeping declaration was virtually nonexistent. It has been accepted (e.g.,
35-37, 79) worldwide for more than four decades that public health programs
against tuberculosis are based on general health services, which are expected to
take on the task of diagnosing and treating the bulk of tuberculosis cases in the
poor countries. Ironically, allocation of overriding priority to the international
initiatives, all down the line, led to the neglect of other services provided at the
peripheral or grassroots level. This included tuberculosis work.
What made the very perpetrators of the decline in tuberculosis care work up
such an intense concern for the disease as a public health problem is a useful case
study for scholars interested in a more detailed study of the political economy
of health services. One plausible explanation might be the sudden awakening to
the problem in the United States and other rich countries when their AIDS epi
demics activated the dormant primary foci in many persons with AIDS, and this
led to spread of tuberculosis to others. This triggered alarm bells for the ruling
class, which, in the course of its exponential polarization from the poor, has cre
ated a sterile/sanitized world for itself. An irrational and therefore very malignant
fear of microbes struck terror in the hearts of the rich. One consequence of this
mass hysteria against germs, which received support from the once sober and
highly respected International Union Against Tuberculosis and Lung Disease
(e.g., 45-47,80), was that these unfounded fears (as will be elaborated later) took
the entire world back a century to the days of the long-discarded single-etiology
theory of diseases. What is worse, this observation on tuberculosis in the rich
countries was extrapolated to the entire world. Already, as the AIDS epidemic
seemed to attain a plateau in the rich countries, poor countries were singled out as
the “rich” breeding grounds for a devastating spread of the AIDS pandemic. As
almost a majority of the adult populations in these countries had acquired pri
mary tubercle foci, a fear complex was actively generated to claim that this
would lead to widespread outbreaks of tuberculosis, hence the declaration of the
Global Emergency. Incidentally, subsequent experience has shown that both fears
proved to be unfounded. Black Africa is very much there, in spite of the rapid
phase of spread of AIDS; there is no tuberculosis epidemic even in this region.
The incidence/prevalence of AIDS and tuberculosis is a tiny fraction of what was
predicted by the WHO/WB experts in North Africa, in Central, West, South,
Southeast, and East Asia, and in South America (81, 82). All these facts speak
volumes about the technical competence of those who rule over the destiny of the
world’s health services, particularly in the poor regions.
244 / Banerji
Sticking tenaciously to the single-etiology theory, despite overwhelming evi
dence to the contrary, and the (virtual?) “reality” of the Global Emergency, a
strategy was developed for the GPT. It consisted of making a massive effort to
identify tuberculosis cases in entire populations, then subjecting them to Directly
Observed Treatment with Shortcourse chemotherapy (DOTS) (83). Starting with
China (45, 46), which did not find anything amiss in the DOTS approach, WHO
and the World Bank have come together and managed to successfully “push
through” this approach to the poor countries of the world.
WHO’s Other Efforts to Launch Global Initiatives
The World Health Organization had also launched two other global programs
with considerable fanfare. One was the Diarrheal Disease Control Programme
(84), with Oral Rehydration Treatment as its centerpiece. The other program
was meant to deal with acute respiratory infections in infants and children (85);
it envisaged timely administration of antibacterial drugs to affected children,
using paramedical staff in rural and urban areas. Despite the usual promotional
efforts of WHO/UNICEF/WB, mercifully, these programs failed right at the
take-off stage.
The World Bank had joined WHO to launch yet another international
initiative: the Safe Motherhood Initiative (86). Child survival programs
were later dovetailed with this initiative. Apart from the question of cost
effectiveness, the success of this initiative, like all the preceding ones, depended
on the capacity of the health service systems to undertake the task envisaged
in the program.
Global Initiative in Launching
“Essential National Health Research”
Some high-profile research administrators, who had earlier headed many key
research organizations/committees, both nationally and internationally, in 1987
got together to set up a global Commission on Health Research and Development
(87) . The report of the Commission, and an account of the subsequent follow-up
action and its impact, provide an interesting administrative case study on the
intellectual make-up of the key decision-makers who have dominated the field
worldwide for the past three or more decades. While the Commission had a
self-imposed deadline for its automatic “liquidation” within one year, it could not
present the report until 1991. Practice of Essential National Health Research
(ENHR) was the centerpiece of the report. The Commission took some more
time to hold well-publicized seminars in different parts of the world to promote
the report. It received warm endorsement from government leaders and most of
academia throughout the world, including the prestigious Nobel Symposium
(88) . The Swedish Agency for Research Cooperation with Developing Countries
Intellectual Fascism and Health / 245
(SAREC) (89) and the International Development Research Council of Canada
(IDRC) (90) were among the foremost institutions to promote ENHR and the
other recommendations. The then Executive Director of UNICEF proclaimed
that “in future at least five per cent of UNICEF’s budget will be devoted to
research.” This promise, incidentally, was never kept. SAREC and IDRC also
agreed to provide funds for yet another proposal of the Commission to set up a
two-year task force, with its office located in Geneva, to encourage developing
countries to implement ENHR (88). The materials produced to document prog
ress in the implementation of ENHR (88) leave little doubt that the initiatives
could make little impact on the strengthening of health services in the countries
of the world. The ENHR movement has not achieved anything more substantial
than what was already done by WHO’s Advisory Committees on Medical/Health
Research at the global and regional levels.
SERIOUS INFIRMITIES IN THE GLOBAL
INITIATIVES
It should come as no surprise that virtually every global initiative taken by
WHO, UNICEF, and the World Bank since the promotion of Selective Primary
Health Care by the rich countries suffered from serious infirmities. Remarkably,
even when these infirmities were pointed out to the organizations, they failed
even to enter into discussion on the issues raised, not to mention taking any cor
rective measures. That the infirmities were indeed serious is borne out by the fact
that the programs consistently failed to yield the results expected of them. It is
not necessary here to present a comprehensive critique of all the programs. Only
three of the major ones—the EPI/UPI, GPA, and GPT—will be taken up, and
only very briefly.
Even a very broad analysis of the process of policy and program formulation
and implementation of EPI/UPI reveals that the apical organizations of interna
tional public health have shown scant regard for some of the fundamental princi
ples of public health practice.
1. They have dared to launch a global/universal immunization program with
out caring to have reasonably reliable, global baseline epidemiological data (91).
The specialty of epidemiology should have been the very soul of EPI/UPI. Its
absence has made it “soul-less.”
2. While using their patently unsubstantiated “estimates,” they have tended
to “homogenize” the situation even in the 100 or so poor countries, with their
widely varying parameters affecting the incidence and prevalence of the six tar
get diseases.
3. With no epidemiological baseline, how is it possible to assess the epidemio
logical impact of the program? It could well be argued, “from the other side,”
that the impact, if any, may have been due to the natural histories of the diseases
over time.
246 / Banerji
4. No data have been produced to demonstrate the degree of effectiveness of
the vaccines under the ecological/epidemiological conditions prevailing in the
different countries.
5. No evidence has been produced to justify why the level of “herd immunity”
has been fixed at 85 percent.
6. It is incredible that the program managers claimed that the programs could
have been implemented “satisfactorily” in countries such as Chad and Niger,
not to speak of Sudan, Somalia, and Sierra Leone, or Colombia, Ecuador or Gua
temala. In Asia, Afghanistan, Nepal, Myanmar, Cambodia, and Laos provide the
challenging examples. It requires stupendous logistical capabilities to ensure that
an epidemiologically adequate proportion of infants receive potent doses of the
vaccines in all the countries of the world.
Two academics, specializing in epidemiology, Vance Dietz from the Centers
for Disease Control and Prevention and Felicity Cults from the London School of
Hygiene and Tropical Medicine, have recently produced an article in this Journal
(76) on evaluation of mass immunization campaigns on the basis of a literature
review. The fact that not one of the epidemiological issues raised in the foregoing
discussion—which, incidentally, have been published in the Journal on more
than one occasion—received any mention in their review gives a chilling picture
of the depth to which the practice of public health principles has fallen during the
past three decades. The authors explicitly mentioned that they “did not address
the broader issue of comparing different approaches to the delivery of a strategy
within the context of primary versus selective health care.” Why? They did not
even take up the broader epidemiological, sociological, and organizational and
management issues raised, even when these issues fell within the severely limited
range of the review. In their scheme of things, of course, issues concerning politi
cal economy and the less than academically acceptable role of international and
other foreign agencies, including their own institutions, were considered politi
cally improper.” Either they have become conditioned to follow the line laid
down for them by the dominant intellectual group, or they did not dare deviate
from this for fear of inviting retribution from them.
John Bland and John Clements (74) of the WHO/UNICEF/WB establishment
have not hesitated to repeat the wild claim, as recently as 1998 in the World
Health Forum, that “Today 80 percent of the world’s children receive this form of
protection against childhood diseases during their first year of life,” even though
overwhelming data have clearly pointed to the contrary.
It is remarkable, and to a considerable extent frustrating, that neither academ
ics such as Dietz and Cults nor program managers and experts such as Bland and
Clements cared to take cognizance of the well-designed and well-conducted
evaluation studies carried out in some of the poor countries by “local” scholars.
Dietz and Cults claimed that these findings did not come within the parameters
they had (arbitrarily) set for their literature search. Bland and Clements “blindly”
accepted the government data, without caring to question their validity and reli-
Intellectual Fascism and Health / 247
ability. Indeed, Dietz and Cutts should have noticed that one of the “local” stud
ies has more than once been discussed in some detail in the references cited by
them. These two studies are briefly referred to below.
The EPI/UPI program of India, meant to last five years from 1985, was the
largest in the world. WHO and UNICEF joined the Government of India to get
the program systematically evaluated in 1989. The results were published in the
form of a book, which was widely circulated (92). It showed that the immuniza
tion coverage was less than a fifth in the two-thirds of the population that account
for most of the poor, as well as for most of the infant mortality in the country;
the surveillance system was almost nonexistent. A similar situation existed for
potency tests of the vaccines at the time of inoculation. The book described how
reports of immunization coverage had been exaggerated by 100 percent or more
to please the national and international officers responsible for administering the
program. It also reported at least 56 recorded deaths due to the vaccination pro
cess itself. There was virtually no outcry, nationally or internationally, against
this outrageous consequence of the program. Had even one such death taken
place in a rich country, the entire program would have been halted. An in-depth
study of the program in the State of West Bengal (93) has reinforced the findings
of the national study.
All these startling findings made no impression; there was little follow-up
action or correction of the records and reports. Another all-India study, the
National Family Health Survey (94), was conducted with the involvement of
the U.S. Agency for International Development (U.S. AID) and the East-West
Centre at Honolulu in 1992-1993 (that is, well after “completion” of the time
limit for the EPI/UPI). This study revealed that at the national level as few as
35.4 percent of eligible children were fully protected, with the coverage hovering
around 9 to 22 percent among many of the highly populated states with the poor
est records of infant mortality. In this survey, there was no study of the surveil
lance system, nor was there any check on the potency of the vaccines at the time
of inoculation. Apparently, even these admittedly bare data, which called into
question the effectiveness of EPI/UPI, did not receive the attention of Bland and
Clements (74).
If the situation is so bad in the case of India, which has a fairly extensive net
work of health services at the grassroots level, the situation in Chad, Niger, and
many countries mentioned earlier—as indeed, in all the world’s least developed
countries (44) and many more—will certainly not be any better. What then was
the basis of the claims made by Bland and Clements?
That EPI/UPI was not a temporary aberration becomes clear when one sub
jects the other global initiatives to academic scrutiny. The “malady” seems to
have pervaded the entire academic world of the ruling classes—as, for instance,
was encountered by Navarro (1) when he ventured to study class issues in public
health policy studies in the 1960s. The same trend was followed when WHO,
along with a large number of U.N. agencies, set out to design the Global
Tv.
248 / Banerji
Programme for AIDS, which was principally directed toward the poor countries.
Incidentally, the first Union Budget (1992-1993) (13, 95, 96) after India submit
ted to the IMF conditionalities included a 20 percent slashing of the allocation to
health services (including the tuberculosis program), without accounting for
inflation. However, the World Bank and WHO “assisted” India in setting up the
National AIDS Control Programme (NACP), which accounted for almost a
fourth of the total allocation in the same financial year. Following the now famil
iar line, NACP was formulated under a veil of secrecy and no modification was
permitted unless it got clearance from the World Bank Headquarters in Washing
ton, D.C.
Despite the efforts by WHO/WB officials and their Indian camp followers to
control information and extensively spread unsubstantiated information, it was
possible as early as in 1992 to bring out the monograph Combating AIDS as a
Public Health Problem in India, which questioned a number of critical assump
tions in the formulation of GPA/NACP. Besides addressing matters of interdisci
plinary methodology, the monograph raised issues of comparative epidemiology
by taking up the history of syphilis. Interestingly, Steve Wing (97) has raised
important issues in his article “Whose Epidemiology, Whose Health?” There is
an interesting reference to a comparative analysis of the epidemiological behav
ior of AIDS and syphilis. Among the important issues raised were the profound
implications of AIDS changing from a principally homosexual- associated dis
ease in the rich countries to a heterosexual one in the poor countries; the key
question of the natural history of the disease, as manifested in the differential
incidence in different parts of the world, including among the countries of
Sub-Saharan Africa; cultural, social, and economic parameters of the “risk
groups” which determine the epidemiology of the disease; and the need for for
mulation of suitable strategies for different countries, based on these consider
ations (98-102). From the WHO/WB experts and program managers there was a
stony silence on the issues raised in the monograph. Quite predictably, the objec
tives set before NACP in 1990 remain unfulfilled (103, 104), and very likely
AIDS is set on a course broadly similar to that followed by syphilis as a public
health problem in India over a period of time. A special category of sickness of
mind appears to be afflicting the key decision-makers, who consciously hire an
army of properly sanitized and brainwashed personnel to translate their “sick”
ideas into action. For the oppressed classes and for all those who are prepared to
take up their cause, it appears to be a re-enactment of a form of colonialism, with,
as described by Navarro (1), fascistic overtones.
Justification given by WHO/WB for launching the Global Program for
Tuberculosis is even more fantastic and incredibly contradictory. It is simply
bizarre. Out of the blue, as it were, in the early 1990s, WHO/WB sounded the
maximum-alert bell to proclaim that tuberculosis had become a “Global
Emergency” and the GPT was the way to tackle that emergency (105, 106). How
did a Global Emergency occur? What was WHO/WB doing when this emergency
Intellectual Fascism and Health / 249
was building up? Is it reflected in the Epidemiological Intelligence Reports these
agencies are constitutionally bound to present? Then why did they cut back the
staff of the Tuberculosis Unit at the Headquarters in the 1980s to barely one (45)?
Why didn’t they raise an alarm when the national tuberculosis programs in the
poor countries were being pushed onto the back burner to create “space” for
high-priority programs such as EPI/UPI or NACP, with the already crippled
health services reeling under the impact of brutal cuts imposed by orders of the
IMF? This would be a comical drama had it not been so tragic, costing the lives
of hundreds of thousands of the poor, whose voices were stifled by the ruling
classes.
A streak of steely determination on the part of WHO/WB in imposing the
prefabricated, DOTS-driven agenda of the GPT is reflected in the leading
presentation of a World Health Forum Round Table, which gives the pre-eminent
position to DOTS (83). That even the conversion rates claimed for the new
spectrum of drugs used in DOTS are nothing startling is exposed by comments
made by the veteran tuberculosis worker of the old school, John Crofton, who
was a participant in this Round Table Discussion (79, 83). He stated “We
demonstrated in Edinburgh in the 1950s that 100 percent cure of pulmonary
tuberculosis, with no relapse, could be a reasonable aim (even with the drugs
then available: streptomycin, isoniazid and para-amino salicylic acid).”
The GPT was particularly painful for tuberculosis workers in India, who have
been instrumental in making such a mark in tuberculosis research and action
worldwide over the past four decades. A meeting of key tuberculosis workers
called by the Tuberculosis Association of India and the Government of India in
1992 to discuss the poor state of the country’s National Tuberculosis Programme
came out with well-argued and eminently implementable lines of action (107).
Once again, a comprehensive document was prepared pointing out major
epidemiological, sociological, economic, and administrative flaws in the GPT
(108). To initiate dialogues, this too was extensively circulated to various
agencies by the Voluntary Health Association of India, specifically including the
chief executives of WHO, UNICEF, and the World Bank and aid missions of
some of the major “donors.” However, as in the previous cases, they remained
unmoved; they refused to enter into discussion on scientific aspects of the
program. A detailed account of the efforts made to bring them round to scientific
discussions is also included in this document (108).
The cloak of secrecy shrouding the “selling” of the program to India has been
a particularly unpleasant feature (108). The WHO/WB experts actively avoided
entering into discussion with their counterparts at the National Tuberculosis
Institute, Bangalore, and others actively involved in the conceptualization,
formulation, and implementation of India’s National Tuberculosis Programme.
Instead, they interacted extensively with the then director-general of the Indian
Council of Medical Research, who had been a tuberculosis microbiologist, and
the then director-general of health services of the Government of India, who was
250 / Banerji
a specialist in orthopedics. Both these functionaries were later offered positions
in the South-East Asian Regional Office of WHO.
CONCLUSIONS: A FRIGHTENING SPECTACLE OF DISTORTION OF
THE PRINCIPLES AND PRACTICE OF INTERNATIONAL PUBLIC
HEALTH BY WHO, UNICEF, AND THE WORLD BANK
A very large area has been covered in this report to demonstrate how imposi
tion of an enormous, high-priority, prefabricated health service agenda by the
rich countries on the poor ones has virtually decimated the somewhat promising
growth of people-oriented health services in a country such as India. Poor people
will have to struggle for their right to access to services that are specifically
designed to conform to their epidemiological, sociological, cultural, and eco
nomic requirements. For this purpose, they will not only have to fight the mis
conceived and mismotivated interventions in the form of international initiatives;
their struggle will also include restructuring of the entire health/health service
system to be in tune with their requirements. This will be a long, grinding strug
gle.
It may also be mentioned in passing that the overriding priority assigned to a
Malthusian family planning program for over four decades by the ruling classes,
both national and international (109-116), has also had a devastating impact on
the growth and development of health services in India (114). In his book Birth
Control and Foreign Policy (117), Nicholas Demerath, Sr., has given a well-docu
mented account of the various ways in which India’s family planning program
has been influenced by the U.S. Government (U.S. AID) and other U.S. agencies,
such as the Population Council, the Ford Foundation, the Population Crisis Com
mittee, the Council of Foreign Relations, and programs sponsored by numerous
universities, church organizations, the International Planned Parenthood Federa
tion, and other voluntary associations. So powerful has been the population lobby
in the United States that it forced the publishers, Harper and Row, to hastily with
draw Demerath’s book from bookstore shelves all over the world. It has now
become a collector’s item.
From the standpoint of sociology of knowledge, it is interesting to note that no
other scientific specialty, not even the cousins of public health such as clinical
medicine/surgery, microbiology, and health statistics, has undergone such a
far-reaching distortion. What a macabre situation, reflecting the nature of interna
tional and national power plays of our time. This is indeed the darkest chapter
in the history of public health. In conclusion, five major areas of such distortion
are summarized.
1. The “public health” practiced by exponents of the international initiatives
•» is starkly ahistorical (16, 17). They seem to consider themselves the inventors of
the wheel. So carried away were they with the “new” thinking injected into their
heads by the ruling class that they seemed to have no use for the pioneering work
Intellectual Fascism and Health / 251
in public health done in earlier years by many profound and dedicated scholars.
C. E. A. Winslow’s classic definition of public health way back in 1920 (118);
Henry Sigerist’s emphasis on the history of medicine (119-121) to develop a per
spective for building health services, as in the report of India’s Shore Committee
(21); John Grant’s efforts to promote regionalization of health services and take
public health research and practice to rural field stations (40,122); the pioneering
works of Rene Sand (123), John Ryle (124), and Iago Galdston (125) in giving
content to the important specialty of social medicine; John Gordon’s
pathbreaking field research at Khanna in India on the epidemiology of child mor
tality and morbidity (126); Hugh Leavell’s insightful ideas on the development of
strategies for intervention in the epidemiological behavior of a health problem
based on analysis of its natural history of disease in an individual (127-129);
Edward McGavran’s expose on an epidemiological approach to solving a public
health problem (130); Milton Roemer’s contributions to health manpower devel
opment (131); George Foster’s pioneering work on medical anthropology (132);
P. V. Benjamin and Halfdan Mahler’s dedicated efforts to establish the National
Tuberculosis Programme in India (35) and the latter’s role in getting the
Alma-Ata Declaration on Primary Health Care all over the world—these are but
a few of the works of just some of the pioneers. The public health experts hired
by WHO/WB/UNICEF have been selectively bred and properly programmed to
be unaware, or at least to pretend to their paymasters that they are unaware, of the
work of such pioneers.
2. The scientific term “epidemiology,” which forms the foundation of public
health practice, has been grossly misused by the new breed of experts. On the
basis of the unrepresentative nature of the data used and their highly questionable
reliability and validity, and the very limited data on causative relationship, valid
ity and reliability of impact measurement, and the time trends, we can reject out
of hand the scientific bases of almost all the international initiatives taken by the
triad. Epidemiology, besides, includes the crucial areas of natural histories of dis
eases over time (133-139) and in the individual, as emphasized by Leavell (128).
The experts have chosen simply to ignore other important areas, such as the
social meaning of epidemiological data, the politics and political economy
of health, and concepts of health administration elaborately developed in poor
countries like India for over six decades (18,129). In their zeal to sell their wares,
they have also grossly distorted the concept of health economics, by confusing it
with health financing (13). This amounts to practice of public health quackery.
A similar fate was meted out to a well-established research tool—operational
research (67, 68, 140-146). Developed in the course of World War II, it has very
specific connotations and has enormous application to public health practice,
as it seeks to optimize complex systems. These specifications too were simply
ignored, and operational research has been grossly vulgarized (e.g., 69).
3. Suppression of information, use of doctored information, spread of mis
information and disinformation, and lack of effective evaluation/surveillance are
%
252 / Banerji
expected outcomes when programs are meant to serve power managers, required
by their paymasters to satiate the ever increasing hunger of the marketplace.
4. Directors-general of two top public health institutions in India extended
their support to the GPT, even though serious flaws in the program were
repeatedly brought to their notice. After they endorsed the WHO/WB program,
they found highly lucrative positions in WHO. It is not necessary to speculate
here about other instances. This marks the rock-bottom of the moral and ethical
standards of the practices of the parties concerned.
5. Those who are expected to be the conscience keepers of ethics and morality
in public health practice—teachers in public health schools/institutes, key public
health administrators in national and international institutions, nongovernmental
organizations, and political leaders/activists responsible for safeguarding and
promoting the health of the people—are perhaps the worst offenders in inflicting
such humiliation on the peoples of the world. Apparently attracted by the
financial rewards, many of these professionals actively associated themselves
with the not so ethical and moral ventures. Many others looked the other way,
fearing retribution for exclaiming that the emperor had no clothes. And there
must have been a very substantial number of this “intelligentsia” who could not
move themselves to find out what was happening. The situation certainly did not
compare in depth with that in Hitler’s Germany or even Franco’s Spain, but the
resemblance is uncanny. It shows how cheaply the leaders of the profession
can be bought, to lend their support for patently unscientific, unethical, and
immoral programs which have cost literally hundreds of thousands of lives of
the world’s poor.
The line of action for those few who still attach a high value to intellectual and
moral integrity, and are prepared to pay the sort of price mentioned by Navarro
(1), emerges from the analysis made in this report. The Indian subcontinent and
China must take the responsibility for rediscovering their lost heritage, to set
the tone for alternative, people-oriented health services for the long-exploited,
deprived peoples of the world.
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Direct reprint requests to:
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Who Is WHO?
y
REFLECTIONS ON THE TWENTY-FIFTH ANNIVERSARY
OF THE ALMA-ATA DECLARATION
Debabar Banegi
The Alma-Ata Declaration on Primary Health Care of 1978—based on the
World Health Assembly’s resolution of 1977 on Health for All by the Year
2000—was a watershed in the concepts and practices of public health as
a scientific discipline; it was endorsed by every country in the world, rich
and poor. According to the Declaration, health is a fundamental right, to be
guaranteed by the state; people should be the prime movers in shaping their
health services, using and enlarging upon the capacities developed in their
societies; health services should operate as an integral whole, with promotive,
preventive, curative, and rehabilitative components; and any western medical
technology used in non-westem societies must conform to the cultural, social,
economic, and epidemiological conditions of the individual countries. Since
Alma-Ata, a syndicate of the rich countries and the ruling elites of the poor
countries, aided by the WHO, World Bank, World Trade Organization, and
other international institutions, has done much to overturn the Declaration’s
primary health care initiatives. The WHO’s recent attempt to regain some
credibility, its Commission on Macroeconomics and Health, ignored the
primary health care principles of the Alma-Ata Declaration. A struggle for
these principles will have to be part of the larger struggle, by like-minded
individuals working in individual countries, for a just world order.
The Alma-Ata Declaration on Primary Health Care of 1978 (1), which was
endorsed by all the countries of the world, was a watershed in the concepts and
practices of public health as a scientific discipline. Expectedly, the vision endorsed
at Alma-Ata was the outcome of the power equations that had been forming
within and between countries over the preceding years. India’s vision in 1938
of entrusting “people’s health in people’s hands” (2) during the anti-colonial
struggle, and the emergence in the course of the famous Long March of China’s
vision of developing rural health cooperatives, with the “barefoot doctor” as the
International Journal of Health Services, Volume 33, Number 4, Pages 813-818, 2003
© 2003, Baywood Publishing Co., Inc.
813
814 / Banerji
centerpiece (3), are instances of sociopolitical conditions within individual
countries that inspired such pathbreaking endogenous thinking in public health.
Incidentally, the two countries—India and China—contained an overwhelming
majority of the world’s unserved and underserved people.
Equally expectedly, when the power equation swung massively in favor of a few
rich countries, the poor were made to “forget” the idealism contained in the solemn
declarations made earlier. The changes in China during the past two decades have
virtually wiped out the rural health cooperatives, leaving vast masses of the poor
to their fate. It is a profound irony that, fearing backlash from the poorest of the
poor, the Chinese authorities have now sought assistance from the World Bank to
revive health cooperatives for this population. India suffered a similar fate, but
presumably because of some degree of commitment to democracy, the damage to
the endogenously developed public health system has not been as extensive as
in the case of China.
HIGHLIGHTS OF THE ALMA-ATA DECLARATION
The main principles of the Alma-Ata Declaration can be summarized as follows:
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 regarding
people as almost passive recipients of these technologies, the Declaration
seeks to reverse the relationship by considering people as the prime movers
for shaping their health services. It seeks to strengthen the capacity of the
people to cope with their health problems, a capacity they have developed
through the ages.
3. It visualizes a wider approach to health by strengthening such intersectoral
areas as provision of adequate supplies of potable water, environmental
sanitation, nutritive food, and housing.
4. It calls for social control ofthe health services that are designed to strengthen
people’s coping capacity.
5. It considers health as an integral whole, including promotive, preventive,
curative, and rehabilitative components. Any concept of “selective care”
is antithetical to the concept of primary health care (PHC).
6. Health services should cover the entire population, including the unserved
and the underserved.
7. Those aspects of traditional systems of medicine that have proven effica
cious, or that are the only ones accessible to the people, should be used in
providing PHC.
8. Any choice of western medical technology should conform to the cultural,
social, economic, and epidemiological conditions of individual populations.
Particular care is to be taken to use only essential drugs in generic forms.
e
v
Reflections on Alma-Ata /
815
Ivan Illich, in his book Limits to Medicine (4), stated (perhaps a little exag
geratedly) how, even in the rich countries, “medicine had become a threat to
the people” through what he called the medicalization of life, mystification
of medicine, professionalization of medicine, increasing incidence of medical,
social, and cultural iatrogeneses, and other processes. Later, studying the rapid
market-driven technological developments, he had pointed out (in a personal
communication) the powerful trends in making the practice of medicine a mere
component of a much larger “system” (systematization), which later turned
into even bigger organizations, or “conglomerates” (conglomeratization). More
recently, noting that U.S. doctors have lost much of their say in market-driven
medical practice, John McKinlay and Lisa Marceau (5) have pronounced the
“end of the Golden Age of doctoring.” The PHC approach ensures that such
anomalies do not creep into the practice of medicine.
It may be underlined that PHC is &process. Even the most rudimentary forms of
home remedies or the use of a village bone-setter could form the starting point for
developing PHC. Mahatma Gandhi recognized such limitations of the deprived
sections of the population. In his program of “Constructive Work,” he included
very simple but effective methods of rural sanitation and the use of naturopathy to
protect and promote the health of rural populations in India.
EVOLUTION OF THE ALMA-ATA DECLARATION
The overthrow of colonial rule and rising aspirations of the liberated peoples, the
setting up of democratic forms of government in some of the newly independent
countries, the initiation of the Cold War and formation of the Non-Aligned
Movement—these were some of the most important factors that contributed to
creation of the conditions that impelled the new rulers in these liberated countries
and the newly formed international organizations to pay attention to some of the
urgent problems that faced them. International organizations such as the World
Health Organization and UNICEF and many bilateral agencies came forward to
contribute to improvement of the health status of people in the needy countries.
The availability of so-called silver bullets tempted these organization to launch
special “vertical” or “categorical” programs against some of the major scourges—
such as malaria (DDT and synthetic antimalarials), tuberculosis (BCG vaccina
tion), leprosy (dapsone), filariasis (Hetrazan), and trachoma (Aureomycin). It
took them quite some time to realize that these vertical programs not only were
very expensive but also were failing to yield the expected results. These programs
also hindered the growth of integrated health services. This impelled the agencies
to advocate the integration of health services, then to promote basic health
services, and then to go to individual countries to promote country health planning
and, later, country health programming.
In the mid-1970s the WHO got together with the World Bank to link health
activities with poverty-reduction programs. A World Health Assembly resolution
816
/
Banerji
in 1977 (6), aiming for a program of Health for All through PHC by 2000
(HFA-2000/PHC), set the stage for the International Conference on PHC at
Alma-Ata in 1978.
POST ALMA-ATA SCENARIO
From the early 1980s, exponential changes began in the power equations between
and within the countries of the world. Events such as the end of the Cold War,
enfeebling of the Non-Aligned Movement, and rapidly increasing influence of
the Bretton Woods institutions brought about a sea change in the national and
international commitment to HFA-2000/PHC. As early as 1979, the rich countries
launched what they called Selective Primary Health Care, on the basis of virtually
no scientific data (7). Apparently to make its power fully evident, the syndicate of
the rich countries and the ruling elites of the poor countries forced the two sponsors
of the Alma-Ata Conference—the WHO and UNICEF—to toe the line laid down
by the syndicate. An active effort was made to thoroughly wash away the ideas
generated by the Alma-Ata Declaration, to make “space” for a patently unscien
tific, market-driven agenda for health for the poor countries. It was a massive
assault on the intellect of public health workers; those who conformed to the
syndicate’s line were rewarded; those who dared to disagree were simply ostra
cized (8). Public health was once again turned on its head, with people again
becoming hapless recipients of prefabricated, market-driven, technocentric, and
scientifically very questionable programs imposed by international agencies.
The International Monetary Fund demanded—and got—compliance for funda
mental structural adjustments in the economy of dependent countries. The impact
of these programs on health and health services for the poor was devastating. They
entailed drastic cuts in the already pathetically inadequate public-supported health
budgets. They created space for rapid growth of the private sector in medical
care. They exerted pressure for cost recovery for services provided by some of
the publicly funded health agencies. The pressure to globalize poor countries
on grossly unequal and inequitous terms turned these populations into bonded
laborers in a global village dominated by the syndicate. The World Trade Organi
zation added its bit by forcing patent laws in many poor countries to subserve
the interests of the drug manufacturing giants.
Replacing scientific reasoning and well-researched conclusions by a use of
brute force, the syndicate let loose a torrent of international health initiatives on
the poor countries. As admitted even by the government of India in its Health
Policy announcement of 2002, these initiatives not only have been highly expen
sive but have also further decimated the general health services. Worse still,
they have fallen far short of the objectives for which they were launched. The
Universal Immunization Program, the Global Program on AIDS, the Global
Tuberculosis Control Program, the Pulse Polio Program for polio eradication, and
the Leprosy Elimination Program are examples of the major initiatives taken
!
Reflections on Alma-Ata / 817
during the last decade and a half. Despite the billions of dollars poured into
them, the syndicate-inspired initiatives are becoming a menace to the health and
health services of the world’s poor (9).
In what has turned out to be a desperate bid to regain some credibility, the WHO
managed to interest some ofthe world’s top economists in joining the Commission
on Macroeconomics and Health (CMH) to study the macroeconomics of health
services for the poor people of the world and to make its recommendations (10).
Interestingly, the CMH included the former finance minister of India and the
present leader of the opposition in the upper house of Parliament, Dr. Manmohan
Singh, and the president of the Mitsubishi Bank. The CMH report is being
analyzed at some length, as it provides documentary evidence of the poor level of
scholarship of the members and the secretariat (11).
The report of the CMH is ahistorical, apolitical, and atheoretical. It has adopted
a selective approach to conform to a preconceived ideology. It has ignored the
earlier work done in this field. It has pointedly ignored such major developments
in health services as the Alma-Ata Declaration. This attitude of developing
massive blind spots in its vision has brought the quality of the scholastic work to an
almost rock-bottom level. But it is not surprising that the CMH has developed
such narrow vision in making recommendations on so important a subject.
Its emphatic recommendation for perpetuating vertical programs against such
major communicable diseases as tuberculosis, AIDS, and malaria—on the
grounds that vertical programs have proved convenient in a number of ways to
the “donors”—reveals the real motivations for undertaking an almost openly
ideology-driven agenda. This is a serious warning signal for scholars who would
like to maintain a scientific attitude toward program formulations that would allow
the poor to get the maximum returns from the limited resources.
WHAT IS TO BE DONE?
A struggle for HFA-2000/PHC has to be part of the long and formidable struggle
for a just world order. The focus must be on individual countries. Like-minded
groups from these individual countries must join together to form a global move
ment. Some first, very tentative steps have already been taken:
1. After having their own National Health Assemblies, delegates from many
countries got together in Dhaka in December 2000 to form the People’s
Health Assembly, to adopt a People’s Health Charter. To carry forward the
struggle for health it has formed a People’s Health Movement, which has set
up branches at the continental, national, and subnational levels.
2. The inaugural meeting of the World Social Forum (WSF) was held in Brazil
in 2002. Concern for the health of the poor is an important component of
the activities of the WSF. As a prelude to the second WSF conference, a
meeting of the European Social Forum, attended by 200,000 to 300,000
818
I
Banerji
delegates, was recently held in Florence. An Asian Social Forum was held in
Hyderabad in January 2003.
3. A great deal of credit is due to anti-capitalist activists for organizing
sustained demonstrations, against extremely heavy odds, to register their
protest at major conclaves of rich countries in different parts of the world—
beginning in Seattle and spreading to Gothenburg, Barcelona, Davos,
Calgary, Doha, Genoa, and Melbourne.
4. Another line of struggle will be to use scientific critiques as a weapon to
resist the imposition of the syndicate’s agenda on the poor and to offer an
alternative (8). A “reminder” about the Alma-Ata Declaration is one
such example.
REFERENCES
1. World Health Organization. Primary Health Care: Report of the International Con
ference on Primary Health Care, Alma-Ata, USSR, September 6-12 1978. Geneva,
1978.
2. National Planning Committee, Sub-Committee on National Health. Report, Bombay.
Vohra, 1948.
3. Newell, K. W. Health by the People. World Health Organization, Geneva, 1975.
4. Illich, I. Limits to Medicine. Rupa, Bombay, 1977.
5. McKinlay, J. B., and Marceau, L. D. End ofthe Golden Age of doctoring. Int. J. Health
Serv. 32: 379-416, 2002.
6. World Health Organization. WHO Resolution WHA.32.33. In Handbook of Resolu
tions and Decisions, Vol. 2 (1973-1984). Geneva, 1985.
7. Banerji, D. A manipulated programme. Econ. Polit. Wkly. 15: 151-154, 1980.
8. Banerji, D. Reflections of an Indian scholar. Int. J. Health Serv. 33: 163-169, 2003.
9. Banerji, D. A fundamental shift in the approach to international health by WHO,
UNICEF, and the World Bank: Instances of the practice of “intellectual fascism”
and totalitarianism in some Asian countries. Int. J. Health Serv. 29: 227-259, 1999.
10. World Health Organization. Report on Macroeconomics and Health: Investing in
Health for Economic Development. Geneva, 2001.
11. Baneiji, D. Report of the WHO Commission on Macroeconomics and Health:
A critique. Int. J. Health Serv. 32: 733-754, 2002.
Direct reprint requests to:
Prof. Debabar Banerji
B-43 Panchsheel Enclave
New Delhi 110017
India
e-mail: nhpp@bol.net.in
| EKITOEWLS |
live on Malaria. Les revues de
Fhemisphere Nord furent selectionnees en fonction de leurs
missions et engagement dans
Favancee de la sante publique
et de I’environnement dans les
regions en developpement Les
quatre collaborations etablies
entre revues sont les suivantes:
(1) African Health Sciences et le
BMJ; (2) Ghana MedicalJournal
et The Lancet-, (3) Malawi Medical
Journal et le Journal of the Ameri
can Medical Association ; (4) Mali
Medical, Environmental Health
Perspectives et F American Journal
ofPublic Health. La demiere col
laboration—la notre—est la seule
qui inclut 2 revues de Fhemis
phere Nord, et la seule incluant
une revue francophone.
En juillet 2004, nous nous
sommes reunis au Research Tri
angle Park, en Caroline du nord,
aux Etats-Unis pour commencer
a travailler au succes de Faccomplissement de nos taches contractuelles, qui sont:
1. Identifier les besoins en
equipement du Mali Medical,
puis fournir du materiel informatique et des logiciels aux re-
A Role for
Public Health
History
dactions, ainsi qu’une forma
tion de base au personnel de la
redaction.
2. Identifier les besoins editoriaux du Mali Medical au moyen
des visiles mutuelles de la part
des redacteurs en chef associes,
afin d’observer les methodes de
redaction et d’edition.
3. Offrir une formation d’auteur/
re-lecteur au moyen d’ateliers, en
mettant 1'accent sur les normes
intemationales d’ecriture et les
approches systematiques de
relecture, ouverte a tous les
membres du FAME lors de sommets medico-scientifiques en
Afrique.
4. Offrir une formation et un
support au redacteur en chef et
au directeur du service commer
cial en etablissant des plans pour
des operations d’edition efficaces
et viables grace a une consulta
tion technique et un atelier en
Afrique ouvert a tous les mem
bres du FAME.
5. Developper et entretenir un
site Internet qui permettrait la
publication en ligne du Mali
Medical.
6. Organiser des stages pour les
representants du Mali Medical au
Au cours des annees a venir,
nous evaluerons le succes de
notre initiative d'amelioration de
potentiel au moyen des indicateurs suivants: augmentation
des references au Mali Medical
dans Medline, nombre d’articles
soumis et publics, nombre et efficacite des re-lecteurs locaux, et
ponctualite de publication. Si
nos revues et oi^anisations parte
naires accomplissent nos missions
communes que sont travailler a
Famelioration de la sante
publique et parvenir a 1’egalite
dans la sante pour tous, alors
notre collaboration naissante est
un moyen efficace pour atteindre
ces buts. Notre espoir commun
est que les trois revues exploitent
mieux leur potentiel d’acteurs
Les auteurs remercienl nos organisations
partenaires—I’American Public Health
Association, le Mali Medical Association,
et particuliercment le US National Insti
tute of Environmental Health Sciencespour leur soutien primordial dans cette
entreprise de collaboration.
Mixed in with the rich and varied
articles on global health themes
in this issue of the Journal are 6
articles based on historical re
search. Five of the articles origi
nated in the History Working
Group of the Joint Learning Ini
tiative (JL1) “Human Resources
for Health and Development," a
major international policy and
planning initiative undertaken by
the Rockefeller Foundation and
several partners.1 The sixth, by
Didier Fassin and Anne-Jeanne
Naude, was submitted indepen
dently but fits here nicely along
with the other historical articles.2
The purpose of the Histoiy
Working Group was to con
tribute to the J Li’s overall objec
tives by critically reviewing inter
national public health initiatives
during the 20th century and
uncovering new insights into
their successes and failures.
Members were urged to illumi
nate through historical study the
motives, context, and local com
plexity of these international
programs. Elizabeth Fee and
Marcos Cueto served as cochairs
of the group, and Theodore M.
Brown was senior advisor. From
March 2003 to May 2004 the
group held 2 meetings in Bella
gio, Italy, planned and prepared
papers, and helped to develop
the recommendations of the
final J LI report.
The 5 J LI contributions in this
issue represent current concerns
in the historical study of interna
tional health. For many years,
scholarship in the field focused
on the role played by colonial
and postcolonial medicine, US
philanthropies, and the first inter
national health agencies during
the early decades of the 20th
centuiy.3-8 Few studies examined
developments in international
November 2004, Vol 94, No. 11 | American Journal of Public Health
sein des redactions de 1’Environ
mental Health Perspectives et de
FAmerican Journal ofPublic
Health
7. Mettre au point quatre
compte-rendus systematiques sur
des sujets importants en Afrique
sub-saharienne qui seront pub
lics dans les revues africaines
partenaires a la fois en anglais et
en fran^ais.
d’un changement progressif, et ce
a travers une plus grande com
prehension, la collaboration, la
perspicadte et les relations entre
I’environnement et la sante dans
les pays developpes et en
developpement Nous mettrons a
jour regulierement et simultanement nos trois revues, en anglais
et en fran^ais. Nous souhaitons
etre chacun tenu responsable
pour I'accomplissement des
taches qui nous sont assignees et
Fengagement d’autres partenaires
dans ce combat digne d’etre
mene : trouver des solutions pra
tiques et innovantes pour eliminer les inegalites medicales
passees et presentes et proteger
I’environnement pour les genera
tions futures. ■
Mary E. Northridge, PhD, MPH,
Siaka Sidibe, MD,
ThomasJ. Goehl, PhD
Remerciements
Editorials | 1851
| EDOTHWLS |
health in the second half of the
century. This has begun to
change, and the later period is
now drawing increased attention
from historians, especially be
cause recent decades have been
marked by the tense encounter
of cultures in the context of in
ternational public health, a
changing political climate reflect
ing the vicissitudes of the Cold
War, the emergence of neoliber
alism, and the boom of economic
“globalization.”9"12
Marcos Cueto, in “The Origins
of Primary Health Care and Se
lective Primary Health Care,” un
derscores the dynamics of the
Cold War in the 1970s as the
major contextual source for the
World Health Organization’s
(WHO’s) 1978 Alma-Ata decla
ration on primary health care.13
Cueto suggests that shifts in the
international power balance be
tween the United States and the
Soviet Union, the new assertive
ness of recently decolonized de
veloping nations, and the ascent
of China as a geopolitical player
explain the relative decline of
Western technologically based
approaches and the rise of com
prehensive, grassroots, and socio
political alternatives. The loca
tion of the famous meeting at
Alma-Ata in Soviet Kazakhstan
was itself reflective of the Cold
War context and Soviet versus
Chinese maneuvering. Given the
circumstances, it was no surprise
that "selective primary care," the
alternative to primary health
care promoted by UNICEF,
USAID, and other backers, was
perceived by some as a staged
“counterrevolution."
Socrates Litsios explores other
dimensions of the emergence of
primary health care as WHO
policy in the 1970s. In “The
Christian Medical Commission
and the Development of WHO's
1852 | Editorials
Primary Health Care Approach,”14
he traces 2 streams of thinking
that converged in 1974, when a
critical meeting took place in Ge
neva, Switzerland, between the
staff of the Christian Medical
Commission (CMC) and senior
WHO staff. A few years before,
the CMC had begun to refocus
on preventive services for com
munities at large. Working from
principles of human rights and
distributive justice, CMC leaders
deemphasized technical care
and gave priority to comprehen
sive health care as one part of a
general plan for the develop
ment of society.
Within WHO, Kenneth Newell
and Halfdan T. Mahler began to
shift attention toward plans for
the integration of preventive and
curative care. The World Health
Assembly in May 1973 adopted
a resolution confirming that
countries must develop health
services suited to their needs
and socioeconomic conditions
and use an appropriate level of
technology. This resolution pro
vided the basis for a close col
laboration between the CMC
and WHO, cemented by Mahler’s
election as director general of
WHO and leading ultimately
to Alma-Ata.
Sanjoy Bhattacharya turns
from intra- and interorganizational dynamics to issues of bu
reaucratic complexity and resist
ance in his article, "Uncertain
Advances: A Review of the
Final Phases of the Smallpox
Eradication Program in India,
1960-1980.”15 He explores un
published correspondence to
show that varying levels of pro
grammatic commitment and be
lief, jurisdictional conflicts, and
just plain local sabotage often
undermined the supposedly
smoothly run, carefully orches
trated, and centrally directed
campaign. Bhattacharya docu
ments the ways in which WHO
headquarters in Geneva, the
South East Asia Regional Office
in New Delhi, the Indian central
government, and local Indian
state governments often got in
one another's way and could be
brought into efficient operating re
lationships—for limited periods—
only by concerted diplomacy, fi
nancial blandishments, and
threats of political embarrass
ment. Bhattacharya thus offers
a nuanced account of the final
stages of one of the major inter
national health programs in the
later 20th century and reminds
us that things are rarely as simple
as they are sometimes portrayed
and that politics and public health
are inextricably interwoven.
Stephen J. Kunitz also high
lights the inextricable interweav
ing of politics and public health.
In “The Making and Breaking of
Federated Yugoslavia, and Its Im
pact on Health,”16 he traces the
formation and fragmentation of
the Yugoslav nation, emphasizing
the roles of deep-seated ethnic
tensions, regional economic dis
parities, and the devastating in
flationary consequences of a cal
culated turn to the West.
According to Kunitz, the eruption
of a bloody civil war in 1991
was inevitable, as were the
health consequences of the
downward economic spiral that
led up to it He shows that in the
1980s, as inflation exploded, the
postwar decline in infant mortal
ity stagnated while mortality in
the elderly and mortality due to
cardiovascular disease increased.
Global economics, more than
local ethnic conflict, was the real
villain in the piece, because the
policies of the International Mon
etary Fund led to forced under
spending on social services and
failed to curb inflation, thus lead
ing to deteriorating health and
intensifying ethnic antagonisms.
William Moraskin's article
“The Global Alliance for Vac
cines and Immunization (GAVI):
Is It a New Model for Effective
Public Private Cooperation in In
ternational Public Health?”17
completes the set of JLI contribu
tions in this issue. Muraskin
strongly argues the case that
GAVI, created in late 1999, is
riddled with substantial and
quite possibly fatal flaws that will
undermine the success it has
thus far enjoyed. He contends
that GAVI is an enterprise built
on “top-down globalism" and
that its promoters in the Gates
Foundation, the International
Federation of Pharmaceutical
Manufacturers Association, the
World Bank, and elsewhere push
immunization as a nonnegotiable
goal. The allies recruited into
GAVI by financial inducements
are weak allies at best. They
have their own priorities and
they realize the full extent of the
enormously complex problems
“on the ground," not least of
them the “human capacity prob
lem," which makes it difficult to
implement GAVI initiatives in re
cipient nations. Because of the
top-down imposition of the “pol
icy of the month,” Muraskin ar
gues, it is difficult to respond to
new initiatives without seriously
disrupting existing programs and
priorities. He suggests that a little
humility and a lot more consulta
tion would go a veiy long way.
What are the take-home les
sons of these 5 contributions?
First that international public
health efforts are deeply influ
enced and critically shaped by
their political context. Programs
cannot be created in a vacuum
or applied in isolation. They are
of this world and, like it they
constantly change and thus need
American Journal of Public Health | November 2004, Vol 94. No. 11
| EBTOMLS |
to be frequently renegotiated.
Second, the culture of interna
tional health organizations must
be acknowledged in order to un
derstand what priorities will
emei^e at any particular time
and which will survive intra- and
interagency competition. Pro
grammatic ideas are always con
tested and rise and fall with shift
ing political alliances.
Third, ideas are applied in a
world governed by administrative
and bureaucratic realities. The
translation of plans into actual
programs requires a great deal of
persistence and negotiating skill
to make them real and keep
them functioning. Fourth, inter
national health initiatives must
reckon with deep-seated histori
cal and cultural traditions, local
realities, and global forces. All
play roles in the success and fail
ure of public health activities, and
no success is likely to last forever,
especially when the world
changes in dramatic ways. Fifth,
top-down initiatives cannot ex
pect to succeed without real bot
tom-up support. Because people
at the local level understand how
programs need to function to ad
dress their particular needs, there
can be no simple formula for in
ternational public health success.
A single agenda or set of priori
ties cannot suit all circumstances.
Clearly, there is an important
role for history in global public
health. Studying history carefully
and generalizing from its particu
lars may not necessarily help us
avoid repeating the mistakes of
the past, but by distilling the les
sons of history, we can cer
tainly learn more clearly where
we have been and, as a conse
quence, become more aware of
where we are. ■
Theodore M. Brown, PhD
Elizabeth Fee, PhD
About the Authors
Theodore M. Brown is with the Depart
ment of History and the Department of
Community and Preventive Medicine of
the University of Rochester. Rochester, NY.
Elizabeth Fee is with the History of Medi
cine Division, National Library ofMedi
cine. National Institutes of Health. Be
thesda, Md
Requests for reprints should be sent to
Theodore M. Brown. PhD. Department
of History. University of Rochester,
Rochester, NY 14627 (e-mail: theodore_
brown@urmc.rochester, edu).
This editorial was acceptedJuly 30,
2004.
Acknowtedgment
The authors acknowledge, with grati
tude, support from the Rockefeller Foun
dation through its Joint Learning Initia
tive “Human Resources for Health and
Development'■
References
1. Human Resources for Health and
Development: A Joint Learning Initia
tive. Available at; http://www.rockfound.
org/ Documents/631 /} Ll_Brochure.pdf.
Accessed July 28, 2004.
2. Fassin D, Naude A-J. Plumbism
reinvented: childhood lead poisoning in
France, 1985-1990. Am J Public
Health. 2004;94:1854-1863.
3. Arnold D, ed. Imperial Medicine
and Indigenous Societies. Manchester,
United Kingdom: Manchester University
Press. 1988.
post-war era. Parassitologia. 1998;40:
217-229.
11. Cueto M. El Valor de la Salad: Una
Historia de la Organizacidn Panamericana de la Salud. Washington, DC: Pan
American Health Organization; in press.
12. Rawer HJ. Tropical Medicine in the
Twentieth Century: A History of the Liver
pool School of Tropical Medicine,
1898-1990. New York, NY: Kegan
Paul International; 1999.
13. Cueto M. The origins of primary
health care and selective primary health
care. Am J Public Health. 2004;94.
1864-1874.
14. Litsios S. The Christian Medical
Commission and the development of
the World Health Organization's pri
mary health care approach. Am J Public
Health. 2004;94:1884-1893.
15. Bhatiacharya S. Uncertain ad
vances: a review of the final phases of
the smallpox eradication program in
India, 1960-1980. Am J Public Health.
2004;94:1875-1883.
16. Kunitz SJ. The making and break
ing of Yugoslavia and its impact on
health. Am J Public Health. 2004;
94:1894-1904.
17. Muraskin W. The Global Alliance
for Vaccines and Immunization: is it a
new model for effective public-private
cooperation in international public
health? Am J Public Health. 2004;
94:1922-1925.
4. Cueto M, ed. Missionaries of Sci
ence: The Rockefeller Foundation and
Latin America. Bloomington: Indiana
University Press; 1994.
5. Farley J. Bilharzia: A History ofIm
perial Tropical Medicine. New York, NY:
Cambridge University Press; 1991.
6. Lyons M. The Colonial Disease: A
Social History of Sleeping Sickness in
Northern Zaire, 1900-1940. New York,
NY: Cambridge University Press; 1992.
7. MacLeod R, Lewis M, eds. Disease,
Medicine, and Empire: Perspectives on
Western Medicine and the Experience of
European Expansion. London, United
Kingdom: Routledge; 1988.
8. Weindling P, ed. International
Health Organizations and Movements,
1918-1939. New York, NY: Cambridge
University Press; 1995.
9. Briggs CL, Mantini-Briggs C. Stories
in the Time of Cholera: Racial Profiling
During a Medical Nightmare. Berkeley:
University of California Press; 2003.
10. Packard RM. “No other logical
choice": global malaria eradication and
the politics of international health in the
November 2004, Vol 94, No. 11 | American Journal of Public Health
Editorials | 1853
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PUBLIC HEALTH THEN AND NOW
Hie World Health Organization and the Transition From
International to
Global Public Health
| The term ^global health’1 is rapidly
| replacing the older tenninolagy of “mI ternational Mh.” We describe tite
role of the World Healtli Orgamzafen
(WHO) in both international and global
: healthand ritiietraista Arnone to
i the other. We surest that the term
j “global health” emerged as part of
| larger pcitical and bstenc.il processes,
| hi which WHO found its dominant role
| challenged and began to reposition |
| itself with® a shifting set of power ,
alliances.
Between 1348 and 1598, WHO
moved from being the umjnestioned
leader of international Irealth to being
ar organization in crisis, fating budget
shortfalls and dhinished status,
; especially given the growing influence
; of new and powerful players. We argue
■ feat WHO began to refashion itself as
the coordKiator, strategic planner, and
leader of global health initiatives as a
| strategy of survival in response to this
| transformed international political |
i contexti
62-72. doi!0.2105/AIPH^04.(B831) j
62
| Theoclore M. Brown, PhD, Marcos Cueto, PhD. and Elizabeth Fee, PhD
EVEN A QUICK GLANCE AT THE
titles of books and articles in re
cent medical and public health
literature suggests tiiat an impor
tant transition is under way. The
terms ^global.’ “globalization.”
and their variants are every
where. and in the specific context
of international public health,
'■global" seems to be emerging as
the preferred authoritative term.!
zAs one indicator, the number of
entries in PubMed under die
rubrics “global healtfi" and “inter
national Itealtlf siiows that
“global health" is rapidly on the
rise, seemingly on track to -over
take “international health” in the;
near foture Gable 11 Although
universities, government agendas,
and private phitanflmjpies are all
using the term in hi$tiy visible
ways,2 the origin and meaning of
the term “glolxil healtiT are still
undear
We provide hislnrical insight
into flic emergence of the termi
nology of global health. We be
ll eve that an exanurtation of this
linguistic shift will yield inv|x>rtflnt
hint, and not just information
about fashions and fads in lan
guage use. Our task here is to
Public Health Then and Now i Peer Reviewed f Brown el a!.
prwide a critical analysis of (he
meaning, emergence, and signifi
cance of the term '‘global health’
and to place its growing popular
ity in a broader historical coritext.
In particular, we focus on the role
of the World Health Organization
(WHO) in both international and
global health and as an agent in
the transition from one concept
to the oilier
Let us first define and differen
tiate some essential terms. “Inter
national health’’ was already a
term of considerable currency in
the late 19th and early 20tb. century. when it referred primarily bi*
a focus on tlye control of epi
demics across the boturdaries
between nations (i.<\ “iniemar
tional”). “Intcrgovemmentaj'’
refers to die relationships be
tween the govaTtmenis of sover
eign nations-in this case, with re
gard to the polities and practices
of public health. “Global health”
in general implies considerate^
of the health needs of the people
of the whole planet above the
concerns of particular nations.
The tenn ‘'global” is also associ
ated with the growing impcirtaiK®
of actors beyond go^'cmmental or
intergovernmental organizations
and agencies—for example, the
media, internationally influential
foundations, nongovernmental
oiganizations, and transnational
corpwatiorts. Logically, the terms
“international" ‘■intergovernmen
tal,'’ and “global’’ need not be mu
tually exclusive and in fact can be
understood as comptementary.
Thus, we could say that WHO is
an intetgovcnimenial agency that
exercises international functions
with the goal of improving global
health.
Given these definitions, it
should come as no sinprise that
global health is not entirely an in
vention of the past few years. 'The
tenn "glol'/d” was sometimes used
before the 1990s, as in the
“global malaria eradication pro
gram* lauudied by WHO in the
mid-1950s: a WHO Public Affairs
Conwrattee pamphlet of 1958.
77te World Health Organization. Its
Global Battle Against Diseased a
1971 report for the US Hous<‘ of
Representatives entitled ihe Poli
tics of Global Health4-, and many
studies of the ‘global population
problem" in flic 1970s? But the
term was generally limited and its
American Journal of Public Health i January 2006. Vol 96. No. 1
PUBLIC SMHH THEN AND NOW i
use in official statements and doc
uments sjxjradic at best. Now
there is an increasing frequency'
of references to global health.0 Yet
tire questions remain: How many
have |)a)lirjp»tcd in this shift in
terminology? Do they consider it
trendy, trivial, or trenchant?
Supbida Bunyavanich and
Ruth B. Walkup tried to answer
theae questions and published,
under the provocative title “US
Public Health Leaders Sltift To
ward a New Itadigm of Global
Health,” their report of conversa
tions conducted in 1999 with 29
“international health leaders.” '
'Their respondents fell into 2
groups. About half felt that there
was no need for a new temtinology and that tire label “global
health” was meaningless jargon
The office half thought that there
were profound differences be
tween international health and
global health and that “globaT
clearly meant something transna
tional. Although ffiese respon
dents believed that a major shift
had occuired within the previous
few years, they seemed unable
dearly to articulate or define it.
In 1998, Derek Yach and Dou
glas Bettcher came closer to cap
turing both the essence and the
origin of tire new -global health in
a 2-part article on “'The Global
ization of Public Health” in the
Amencan Journal of Public
Health? They defined the “new
paradigm*’ of globalization as “the
process of increasing economic,
political, and .social interdepend
ence and integration as capital,
goods, persons, concepts, images,
ideas and values cross state
boundaries." The roots of global
ization were long, they said, going
back at least to the 19th centuxy.
but the process was assuming a
new magnitude in the late 20th
century. The globalization of pub
lic health, they argued, had a
January 2006. Vol 96. No. 1
dual aspect, one both promising
and threatening.
In one respect there was eas
ier diffusion of useful technolo
gies and of ideas and values such
as human rigiits. In another, there
were sucii risks as diminished so
cial safety nets; the facWtated
marketing of tefaaeco, alcohol,
and psychoactive drugs; the eas
ier worldwide spread of infec
tious diseases; and the rapid
degradation of the environment,
with dangerous public health
consequences. But Yach and
Bettcher were convinced that
WHO eouM turn these risks into
of^xirtunities. WHO, they ar
gued. could help create more effi
cient information and surveil
lance systems by strengthening its
global monitoring and alert sys
tems, thus creating “global early
warning systems." They believed
that even the most powerffil na
tions would buy into this mw
globally interdependent world
system once these nations real
ized that .sudt involvement was in
tlieir best interest
Despite the hug list of prob
lems and threats, Yach and
Bettcher were latgcly uncritical as
they promoted the virtues of
globftf public health and the leadenship role of WHO. In an edito
rial in flu1 same issue of the Jour
nal. George Silver noted that Yach
and Bettcher worked for WHO
and that their position was similar
to other optimistie stances taken
by WHO officials and advocates.
But WHO, Silver pointed out was
actually in a bad way: “The
WHO’s leuderriiip role has passed
to file fer wealthier and more in
fluential World Bank, and the
WHO’s mission has been dis
persed among otlw UN agen
cies." Wealtliy donor countries^
were billions of dollars in arrears,
and this left the United Nations
and its agencies in “disarray,
American Journal of Public Health
hamstrung by financial constraints
and internal incompetencies, frus
trated by turf wars and crossnatitma) politues.”5* Given these
-realities, Yach and Bcticher's pro
motion of "global public health”
while they were affiliated with
WHO was. to say the least, intrigiiing. Why were these spokes
men for toe much-criticized and
a|jparently hobbled WHO so up
beat about “global” public health?
THE WORLD HEALTH
ORGANIZATION
The Early Years
To better understand Yadi and
Bettcher’s role, and Chat of WHO
WAR ON
“War on the Malaria Mosquito'”
Poster produced by the DMrion of
Public Information, Wodd Health
Organization, Geneva, 195S.
Courtesy of the World Health
Otganization. Source: Prints and
Photographs Collection of the
National Library of Medicine.
THE
MALARIA
MOSQUITO?
Mularia if still the world’s grentest public
health problem. With modern methods it can
be wiped out. This i$ the goal of an interna
tional eradication campaign direetedby WHO.
7
Brown et al. | Peer Reviewed ; Public Health Then and Now j 63
. I
PUBLIC HEALTH THEH fiWD MW
TABLE 1-Number of Articles Retrieved by PubMed, Using “International
Health" and “Global Health” as Search Terms, by Decade: 1950
Through July 2005
International
Global
Decade
Health1
Health’
1950s
1 007
1007
54
1960s
1970$
19te
1990S
2600-JUUM5
3303
3303
8369
8369
56
16924
924
49158
49158
5216952169=
M
1137
M7S
27 794
»?®
‘Picks up variant term eodtngs t«.g.“ir>?£matwiar' afso picks up •irttfenutfonaliK*' and “intemattonaii/ation’';
‘$jS»r skw picks up -gtobaiue" and 'glabalnation’)
-NtsnOer lor 58 miyUtis only.
more generally, it will be helpful
to review the history of die or
ganization horn I948to 1998,
as it moved from being the un
questioned leader of international
health to searching for its place in
the contested world of global
health,
WHO formally began in 1948,
when the First World Health As
sembly in Geneva, Switzerland,
ratified its constitution. The idea
of a permanent institution for in
ternational health can be traced
to the organization in 1902 of
the International Sanitary Office
of the American Republics,
which, some decades later, be
came the lYm American Sanitary
Bureau and eventually the Pan
American Ilealtii Organization.’0
The Roduifeller Foundation, es
pecially its International Health
Division, was also a very signifi
cant player in intemational health
in the early 20fo century.”
Two European-based interna
tional health agencies were also
important One was the Office Intenmtionale d'Hygicne Publique.
which began fimetioning in Paris
in 1907; it concctitrated on sev
eral basic activities related to the
administration of international
sanitary agreements and the
rapid exchange of epidemiologi
cal information.1^ The second
agency, the League of Nations
64
Punhc Health Then and Now Peer Reviewed Brown et al.
Health Organization, began its
woi-k in 1920.n This organiza
tion established its headquarters
in. Geneva, sponsorotl a series of
international commissions on dis
eases, and publMted epidemio
logical intelKgence and tedinical
reports. 'I’he league of Nations
Health Organization was poorly
budgeted and faced covert oppo
sition from other national and in
tcmational organizations, includ
ing the US Public Health Service.
Despite these complications,
which limited die Health Organi
zation ’s effectiventjss. both the
Office Internationale d’Hygiene
Fhiblique and the Health Organi
zation survived through World
War 11 and were present at the
critical postwar moment when
the Future of international health
wuuld be delmed.
An international cpiifercnce in
W45 -approved the creation of
the United Nations and also voted
for the creation of a new special
ized health agency. P&rticjpants at
Hie meeting initially formed a
(xinimission of prominent individ
uals. among whom were Ren6
Sand from Belgiimi. Andrija Stampar from Yugoslavia, and Thomas
Parran from the Unitexl States.
Sand and Suunpar were widely
recognized as diampions of social
medicine, 'fhe ajinmission held
meetings hetwecji 1946 and
early 1948 to plan the new inter
national health organization. Rep
resentatives of the Pan /Amcrim
Sanitary Bureau, svhose leaders
resisted being absorbed by the
new agency', were also involved,
as were leaders of new institu
tions such as the United Nations
Relief and Rehabilitation Adminis
tration (UNRRA).
Against this background, the
linit World Health Assembly met
in Geneva in June 194 8 and for
mally created the World Health
Organization The Office Ihtema-
tianale d i tygiene I'ubliqne. the
League of Nations Heald i Organi
zation. and UNRRA merged info
the new agency. The Pan Ameri
can Sanitary Bureau-then
headed by Fred L. Soper, a for
mer Rockefeller Foundation offi
cial—was aflnwed to retain au
tonomous status as part of a
regionalization scheme.1,1 WHO
formally divided die world into n
series of regions—the Americas.
Southeast Asia. Europe. Eastern
Mediterranean, Western Fhcific,
and Africa—but it did not fully
implement this regionalization
until the 1950s. Although an “in
ternational" and "bitergovemmental” mindset prevailed in the
1940s and 1950s, naming the
new organization the World
Health Organization also raised
sights to a worldwide, “global”
perspective.
'Hie first diredor general of
WHO, Brock Chisholm, was a
Canadian psychiatrist loosely
identified with, foe British social
medidne tradition. The United
States, a main contributor to the
WHO budget, played a contradic
tory role: on the one hand, it sup
ported the UN system with ite
broad worldwide goals, but on
foe other, it was jealous of its sovereignty and maintained the right
to intervene unilateral^ in the
Americas in tile name of national
security. Another problem for
WHO was that its constitution
had to be ratified by nation states,
a slow process: by 1949. only 14
countries had signed on.B
As an intetgovenimentol
agency, WHO had to be respon
sive to the larger political environ
ment. The politics of the Gild
War had a particular salience,
with an umnistakalvlo impact on
WHO policies and personnd.
Thus., when the Soviet Union and
other communist countries
walked out of the U N system and
American Journal of Public Health
January 2005. Vol 96. No. 1
PUBLIC HEALTH THEN AHO NOW !
therefore out of WHO in 1949,
tlie United States and its allies
were easily able to exert a domi
nating influence. In 1953,
Chisholm completed h& term as
director general and was replaced
by die Brazilian Marcolino Candan. Candau, who had worked
under Soper on maiana control in
Brazil, was associated lirst with
(lie “vertical” disease control piograms of d ie Rodtefefier founda
tion and then with their adoption
by the IWi Ameiican Sanitary Bu
reau when Soper moved to that
agency as director.’0 Candau
wriuld be director general of
Wl 10 lor over 20 years. From
1949 until 1956. when the Soviet
Union returned to the UN and
WHO. WHO was closely allied
with US interests.
In 1955. Candau was charged
with overseeing WHO's cam
paign of malaria eradication, ap
proved that year by the World
Ik-alth Assembly. The ambitious
goal of malaria eradication had
been conceived and promoted in
the context of great enthusiasm
and optimism about the ability
of widespread DDT spraying to
kill mosquitos. Aft Randall
Packard has argued, the United
States and its allies believed dial
global malaria eradication would
usher in economic growth and
create overseas markets for US
technology and manufactured
goods?' it would build support
for local governments and their
US supporters and help win
‘hearts and minds’' in die battle
against Communism. Miiroring
then-current development theo
ries. the campaign promoted
technologies brought in from
outside and made no attempt to
enlist the participation of local
populations in planning or imple
mentation. This model of devel
opment assistance fit neatly into
US Cold War efforts to promote
modernization with limited so
cial reform?0
With the return of the Soviet
Union and other communist
countries in lysb, the political
balance in the World Health As
sembly shifted and Candau ac
commodated the changed bal
ance of power. During the 1960s.
malaria eradication was la<-ing se
rious difficulties in the field; ulti
mately, it would suffer colossal
and emlwrassing failures. In
1969, die World Health AssemWy. declaring that it was not feasi
ble to eradicate malaria in many
parts of the world, began a slow
process of reversal, returning once
again to an older malaria control
agenda. ’Phis time, however, there
was a new twist; the 1969 assem
bly emphasized the need to de
velop rural health systems and to
integrate malaria control into gen
era! health services.
Wlxm the Soviet Union re
turned to Wl 10, its representa
tive at the assembly was the na
tional deputy minister of health.
He argued that it was now scicjitificallv fcaabte, socially desir
able, and econoinicaJly worthwhile to attempt to eradicate
smallpox worldwide.* 'Ihe Soviet
Union wanted to make its marl
on global liealth, and Candau.
recognizing the shifting balance
ol power, wax willing to cooper
ate The Soviet Union and Cuba
agreed to provide 25 million and
2 niirtion doses of freezetiried
vaccine, respectively: in 1959.
the World HealUi Assembly com
mitted itself to a global smallpox
eradication program.
In the 1960s, technwal imprewmcnls-jet injectors and bi
furcated ncedles-made die prec
ess of vaersnation much cheaper,
easier, and more effective. The
United States' interest in smallpox
eradication sharjjly incaxuistxi; in
1965. Lyndon Johnson instructed
the US delegation to the World
I leallh Assembly to pledge
Amenran sup|»rt for an interna
lional program to eradicate small
pox frem ifee earth?0 At that
Smallpox Vaccination Program
in Togo, 1&67. Courtesy of the
Centers for Disease Control and
Prevention. Sourcer Public Hearth
Image Library, CDC.
y 1
-
January 2006, Vol 96, No. i i American Journal of Public Health
Grown et si. | Peer Reviewed | Public Health Then and Now
65
PUBLIC HEALTH THEN ANO NOW
lime, despite a decade of marked
progress, the disease was still cndeMic in more than 30 countlies.
In 1967, now with the .support
of the worid’s most powerful
players, WHO launched the
Intensified Smallpox Eradication
Pj-ogram. This program, an inter
national effort ted by the Ameri
can Donald A> Henderson,
would ultimately be stunningly
suca)sslul/’
Alma Ata Conference, 1978.
Courtesy of tf»e Pan American
Health Organization. Source: Office
of Public Information, PAHO.
1
I1 s
The Promise and Perlis of
Primary Health Care,
1973-1993
Withiti WHO. there have al
ways been tensions between so
cial and economic approaches tn
population healtli axKl tedmolog^’or disease-fixajsed approaches.
These a|jf.)roaches arc not necessarify incornjiatible, although
they have often been at odds.
The emphasis on one or (he
other waxes and wanes over
time, depending on the larger
balance of power, the changing
S. j
!
mB
facers interact with the health
[>olkyniakhig process.
During the 1960s and 1970s.
changes in WHO were signifi
cantly influenced by a polilica!
context marked by the emer
gence of decolonized African na
tions. the spread of nationalist
and socialist movements, and
new theories of development
dial emphasized hng-term socioemnornic growth rather than
short-tenn technological inter
vention. Rallying within organiza
tions such as the Non-Aligned
Mwenient. developing countries
created the UN Conference
on Trade and Dtwelopmenl.
(UNCTADX whore they argued
vigorously for faimr terms of
trade and more generous financ
ing of development22 in Wash
ington, HC, more liberal politics
succeeded the consemtisni of
Bl
I
a
interests of international players,
tliu intellectual and ideological
commitments of key individuals,
and the way that all of these
■
:
III
■ ill'®
1 i
I;
3;
......
66 ,> Public Health Then and Now Peer Reviewed | Brown et oi.
the 1950s. with die civil rights
movement and other social
movements forcing changes in
national priorities.
'This changing political envi
ronment was reflected in corre
sponding shifts within WHO. In
the 19606. WHO acknowledged
that a strengthened health infra
structure was prerequisite to the
success of malaria control pro
grams, eapedally in Africa- In
1968. Candau called for a com«
pmhensive and integrated plan
for curative and preventive care
services. A Soviet representative
called for an organizational study
of methods for promoting the de
velopment of basic health serv
ices.21 In January 1971, the Exec
utive Board of the World Health
Assembly agreed to undertake
this study, and its results were
presented to flic assembly in
1973.24 Socrates Litsios has dis
cussed many of tlic steps in die
ttwformation of WHO’s ap
proach from an older model of
health services to what would be
come the ’‘Primary Healdi Care*
Mp^nmch.35 This new model
drew upon the thinking and ex
periences of nongovernmental
organizations and medical mis
sionaries working in Africa, Asia,
and Isatin America at the grassroots level. It also gained salienty
from China’s reentry into the
UN in 1973 and the widespread
interest in Chinese “barefoot doc
tors.'’ who were reported to be
tosforming rural health condi
tions. These experiences under
scored die urgency of a. “himary
Health Care’ jjer^M-tiive dial in
cluded the training of community
health workers and the resolution
of basic economic and environ'
mental problems/6
Thcs« new approariies were
spearheaded by Halfdan T
Mahler, a Dane, who served as
director general of WHO from
American Journal ttf Public Health
January 2OO6. Vol 96. No. 1
PUBLIC HEALTH THEN AND NOW
1973 to 1988. Under pressure
from the Soviet delegate to the
executive bound. Mahler agreed
to hold a rrttjor conference on
the organization of health serv
ices in Alma-Ata. in toe Soviet
Union. Mahler was initially reluc
tant because he disagreed wito
toe Soviet Union’s highly centralmd and medicalized approach to
toe provxsion of health services.2'
The Soviet Uniun succeeded in
hosting the September 1978 con
ference. but toe conference itself
reflected Mahlers views much
more closely than it did those
of toe Soviets. The IM’Iaration of
Primary Health Care and the
goal of T lealth for All in tlic
Year 2000" advocated an ‘IntersectoraT and multidimensional
approach to health and socioeco
nomic development, ernphasiz^l
toe use-of Ttppropriate technol
ogy. ’■ and urged active commu
nity participation in health care
and healto education at evety
level.™
David 'fiqada de Rivero has ar
gued that “It is regrettable that af
terward toe impatience of some
international agendes, both UN
and private, and toeir emphasis
on achieving tangible results in
stead of promoting change . . ted
to major distortions of the original
ebnuept of primary' healto care."3**
A number of governments, agen
cies. and individuals saw WHO’s
idealistic view of l-Mmaiy 1 lealth
Care as *unrealistic" and unattain
able. The process of reducing
Alma-Ata’s idealism to a practical
set of tcdmical interventions that
could be imjjlancnled and mea
sured more easily began in 1979
at a small conference-heavily in
fluenced by US ftttendces and
polieies—hdd in Bellagio. Italy,
and sf.xmsorcd by the KockcfeHcr
Foundation, with assistimce from
toe World Bank. Those in atten
dance included tire pesident-of
toe World Bank, the vice presi
dent of toe Ford FoutKiation, tlie
administrator of USAID, and the
executive secretary of UNICEF?10
The Bellagio meeting focused
on an alternative concept to that
articulated at Alma-Ata-‘'Selec
tive Primary Health Care”-which
was Ixiilt on the notion of prag
matic. low-cost iuterveotions that
were limited in senpe and easy to
monitor and evaluate. Thanks
primarily to UNICEF, Selective
Ihimaiy Health Care was soon
ujjerationalized under the
acronym "GOBr (GroMh moni
toring to fight malnutrition in
children. Oral rdiydraban tech
niques to defeat diarrheal dis
eases. Breastfeeding to protect
children, and Immunizations).31
In the 1980s, WHO liad to
reckon with the growing influ
ence of the World Bank. The
bank had initially been formed in
W46 to assist in the recooshuctian of Europe and later ex
panded its mandate to provide,
loans, grants, and technical assis
tance to developing countries. At
first, it funded large uivcsunents
in physical capital and infrastruc
ture; in die. 1970s, liowever, it
began to invest in population con
trol, health, and education, with
an emphasis on pqnilation control.32 lhe World Bank approved
its first loan for family planning
in 1970. In 1979. the World
Bank treated a T’opulation,
1 lealth. and Nutrition Depart
ment and adopted a policy of
funding both stand-alone health
programs and health (components
of other projects.
in its 1980 World Deivlopmait
Kepvrt, toe Bank argued that both
malnutrition and ill health could
be countered by direct guvernmeut action—with World Bank
assistance,31 It also suggested that
improving Irealto and nutrition
could accelerate economic
January 2006, Vol 96. No. 1 > American Journal af Public Health
The Declaration of Primary Health Care
and the goal of “Health for All in the Year
2000" advocated an “inter-sectoral" and
multidimensional approach to health
and socioeconomic development, emphasized
the use of “appropriate technology," and
urged active community participation in health
care and health education at every level.
growtfi. thus providing a good ar
gument for social sector spend
ing. As the Bank began to make
direct loans for health sendees, it
called for more dficient use of
available resenwees and discussed
the roles of the private and public
sectors in financing hedfh care;.
'The Bank favored five markets
and a diminished
for na
tional governments.H In the con
text of widespread indebtedness
by developing countries and in
creasingly scarce resounds for
health expenditures, toe World
Bank’s promotion of ‘■structural
adjustment’’ measure's at toe very*
lime that toe HIV/AIDS epi
demic erupted dirw angry criti
cism but also underscored toe
Banks new influence.
In con trast to toe World
Bank’s increasing authority, in
toe 1980s the prestige of WHO
wfts beginning to diminish. Ono
sign of trouble was the 1982
vote by toe World Health
Assembly to freeze WHO’s
budget55 This was followed
by toe 1985 decision by the
United States to pay only ZO’A?
of its assessed contribution to all
UN agencies and to withhold its
contribution to WHO’s regular
budget, in part as a protest
against WHO’s "f^sential Drug
Program.” which was opposed
by leading US-based pharma
ceutical companies.30 These
events occurred amidst growing
Ufown ct al. | Fwr Reviewed I Public LieaiUi Then and Now : 67
PUBLIC HEALTH THEN ANO NOW
reliance on WHO’s “regular
budget”-drawn from member
states' contributions on the basis
of population size and gross na
tional product—to greatly increased dependence on extrabud
getary funding coming from
donations by multilateral agen
cies or “donor” nations. By the
period 1986-1987. extrabud
getary funds of $437 million had
almost caught up with the regular
budget of $543 million. By the
beginning of the 1990s, extrabudgetary funding had overtaken
the regular budget by $21 mil
lion. contributing 54% of WHO’s
overall budget.
Enoirnous problems for the or
ganizalion followed from this
budgetary' shift. Priorities and
policies were still ostensibly set
by toe World Health Assembly,
which was made up of all mem
ber nations. The assembly, how
Crisis at WHO, 1988-1998
ever, now dominated numerically
The first dtizen of Japan ever
by
pool1 and developing coun
elected to head a UN agency,
tries.
had authojity only over the
Nakajnna rapidly became the
regular
budget, frozen sine® toe
most controversial director gen
early
1980s.
Wealthy donor na
eral in WHO's history. His nomi
tions and multilateral agencies
nation had not tan supported
like toe World Bank could largely
by the United States or by a
call toe shots on toe use of the
number of European and Latin
extrabudgetary funds tlrey con
American countries, and his per
tributed. Thus, they created, in
formance in office did little to as
effort, a series of “vertical’’ pro
suage their doubts. Nakajima did
grams more or less independent
try to launch several important
of toe rest, of WHO's programs
initiatives—on tobacco, global
and decisionmaking stnicture.
disease surveillance, and
'Vhe dilemma for toe OTgaitization
public—private parbtershipswas that although the extrabud
but fierce criticism persisted that
getary funds added to the overall
raised questions about his auto
budget “they [jncreasedj difficul
cratic style and poor manage
ties of coordination and continu
ment. his inability to communi
ity, [caused] unpredictabilify in fi
cate effectively, and , worst of all,
nance, and a great deal of
cronyism and corruption.
dependence on toe satisfaction, ol
Another sy mptom of WHO’s
particular donors,'”’0 as Gill Walt
problems in the late 1980s was
explained.
the growth of “extrabudgetary ”
Fiona Godlee published a se
funding. As Gill Walt of the Lon
ries
of articles in 1994 and 1995
don School of Hygiene and ’ILopithat
built on Walt’s critique.*1
cal Medicine noted, there was a
She concluded with this dire
crucial shift from fmxforainant
tensions between WHO and
UNICEF and other agencies
and the controversy over Selec
live versus Comprehensive Pri
mary 1 lealth Care. As part of a
rancorous public debate con
ducted in the pages of Social
Science and Medicine in 1988,
Kenneth Newell, a highly placed
WHO official and an aixhitect
of Comprehensive Primary’
Health Care, called Selective Pri
mary Healtli Care a “threat...
[thati can be thought of as a
counter-revolution."3 r
In 1988. Mahler’s 15-year
tenure as director general of
WHO came to an end. Unexpect
edly, Hiroshi Nakajima. a Japanese
i^eseardier who had been director
of die WHO Western Pacific Re
gional Office in Manila, was
elected new director general?1*
68 i Public Heaith Then and Now i Peer Reviewed Brown et al.
assessment: "WHO is caught in a
cycle of decline, with donors ex
pressing their lack of faith in its
central management by placing
funds outside the management’s
control. This has prevented
WHO from [developing] ... inte
grated responses to countlies’
long term needs.”41
In the late 1980s and early
1990s, the World Bank moved
confidently into the vacuum cre
ated by an increasingly ineffec
tive WHO. WHO officials were
unable orxawilling to respond to
the new international political
economy structured around neotilxjral approaches to economics,
trade, and politics.42 The Bank
maintained that existing health
systems were often wasteful, inef
ficient, and ineffective, and it ar
gued in favor of greakir reliance
on private-sector health care pro
vision and the reduction of public
involvement in health services
delivery.41
Controversies surrounded die
World Bank's policies ami prac
tices, but there was no doubt that,
by the early 1990s, it had be
come a dominant force in interna •
tional health. The Bank’s greatest
“comparative advanhige” lay in its
ability to mobilize large financial
resources. By 1990, the Bank's
loans for healtli surpassed WHO's
total budget, and by the end of
1996. the Bank's cumulative
lending portfolio in health, nutri
tion, and population had readied
$ 13.5 billion. Yet the Bank recxig
nized that, whereas it had great
economic strengths and influence,
WHO still had considerable tech
nical expertise in matters of
health and medicine. litis was
dearly reflected in the Bank's
widely influential Hbr&/ DwelopwuFnt Report 1993: halting in
Health, in. which credit is given to
WHO, "a full partner with the
World Bank at every step of (he
American Journal of Public Health
.January 2006. Voi 96. No. 1
PUBLIC HEALTH THEN AND NOW
preparation of the Report.”'’4 Cir
cumstances suggested tliat it was
to the advantage of both parties
for the World Bank and WHO to
work together.
WHO EMBRACES
"GLOBAL HEALTH"
This is die context in which
W1 iO began to refashion itself
as a coordinator, strategic plan
ner. and leader of “gicAial health’'
initiatives. In January 1992, the
31 -member Executive Board of
the World Health Assembly de
cided to appoint a “working
group’' to recommend how
WHO could he most effective in
international health work in light
of the “global change” rapidly
overtaking the world. The execu
tive board may have been re
sponding, in part, to die Chib
draft’s Vaccine Initiative.
I>erceived wthin WHO as an at
tempted “coup” by UNICEF, the
World Bank, tlw UN Develop
ment Program, the Rockefeller
Foundation, and sevend other
players seeking to wrest control
of vaccine development.4 ' The
working group’s final report of
May 1993 recommended that
WHO—if it was to maintain lead
ership of the health sector—must
overhaul its fragmented manage
ment of global, regional, and
country programs, diminish the
competition between regular and
extrabudgetary programs, and.
alxivc all. inci'ease the emphasis
within WHO on global healtli is
sues and WHO's coordinating
role in that domain.4''
Until that time, the term
‘’global health” had been used
sporadically and. outside WHO.
usually by people on the political
left, with various “world" agendas.
In 1990. G. A. Gellert of Interna
tional Physkaans f<ir the Preven
tion of Nuclear War had called
&
r jaMMMMl
Hub
for analyses of “global health
interdependence.^7 In the same
year. Milton and Ruth Roemer
argued that further improvements
in “global health" would be de
pendent on the expansion of pub
lic rather Qian private health
services.4* Another strong source
for die tenn “global health" was
the environmental movement es
pecially debates over world envi
ronmental degradation, global
wanning, and their- potentially
devastating effwts on human
health.49
In tlie mid-1990s, a consider
able body of literature was pro
duced on global health threats. In
the United States, a new Centers
for Disease Control and Preven
tion (CDC) journal. Emerging In
fectious Diseases, began publica
tion. and former CDC director
William Fbege started using the
phrase “global Infectious disease
threats’55" In 1997. the Institute
of Medicine’s Board of Interna
tional Health released a report.
Americars Vital Interest in Global
Health ■ Protecttag Our People.
Enhancing Our Ecwurmy. and
Advancing Our International
Interests51 In 1998. the CDC’s
Preventing Emerging Infedious
January 2006. Vol 96, No. 1 i Anreriean Journal of Public Health
Diseases: A Strategyfar the 21st
Century ap|K*areii, followed in
2001 by the Institute of Medi
cine’s /h^pw-th/es on the Depart
ment ofDefense Global Bnergbtg
Infections Surveillance, and Re
sponse System?2 Best-selling
books and news magazines were
full of stories about Ebola and
West Nile virus, resurgent tuberculosis, and the threat of bioter
rorism?’ 1 The message was dear
there was a |xtipable glolxil dis
ease threat
hi 1998, the World Health
Assembly readied outside (he
ranks of WHO for a new leader
who could restore credibility to
the organization and provide it
witli a new vision: Gro Harlem
Biundtland, former prime minis
ter of Norway and a pliysidan
and public health professional
Brundtad brought formidable
expertise to the task. In the
1980$, she had been chair of the
UN World CommisKinn on Envi
ronment and Development and
produced the “Brundtland Re
port," which led to the Earth
Summit of 1992. She was familialwith the global thinking of the en
vironmental nuwernent and had a
broad and clear underslandmg of
Current Director General Jong-wook
Lee with three former DirectorsGeneral at the celebration to
mark the 25th Anniversary of the
Alma Ata Declaration. From left:
G. H. Brundtiand, H. Mahler,
H. Nakajima, Lee JW. Courtesy of
the World Health Organization.
Source: Media Center, WHO.
firdwn el ol. j Peer Reviewed i Public Health Then and How
69
PBBUC HEALTH THEN AND HOW '
the links between health, environ
ment and development
Brundtland was determined to
position W1 IO as an important
player on the g1ol>al stage, move
beyond ministries of health, and
gain a seal al. the table where de
cisions were being made.-' ‘ She
wanted to rdasWon WHO as a
''department of consequeitce’’ *'
able to monitor and influence
other actors on the gloljal scene.
She e&ablisherf a Commission on
Macroeconomics and Health,
chaired by econornfei
Sachs
of Harvard University and induding former ministers of finance
and officers from the Worid Bank,
the Intematimal Monetary Fund,
the World Trade Organization,
and the UN Development Pro
gram, as well as public health
leaders. The commission issued a
njpoit in December 200.1, which
argued that improving health in
developing countries was essential
to their etxjnomic dewlopmcnl50
The report idcntifiwl a set of dis
ease priorities that would require
focused intervention
Brundtland also began to
eases in the world's poorest na
tions. mainly through vaccines
and tintnunizalion programs. ”
Within a few years, some 70
"global hcaltlt partnersh^Js" had
been created.
Brundtkmd’s tenure as director
general was not without blemish
nor free from criticism. Some of
the initiatives credited to her ad
ministration had actitally been
started under Nakajima (for ex
ample. tiie WHO Framework
Conventixin on Ibbaccp Control),
others may be looked upon today
with some skepticism (the Com
from a narrow emphasis on
malaria eradication to a broader
mission on MacroeccMiomics and
Health, Roll Back Malaria), and
still others arguably did not re
ceive enough attention from her
use leadership of an emerging
concern witli “global health51 as
an organizational strategy that
promised survival and. indeed,
administration (Primary Health
Care, HIV/AIDS. Health and
Human Rights, and Child Health)
renewal.
Bui. just as it did not invent
the eratficationist or primary
care agendas, WHO did nol in
vent “global health": other,
larger forces were rcs|xmsiblc.
WHO certainly did help pro
mote interest in global health
and. contributed signilicfl.ntly to
the dissemination of new con
cepts and a new vocabulary. In
that process, it was hoping to ac
Nonetheless, few would dis^xite
the assertion that Brondlland suc
ceeded in achieving her principal
objective, which was to reposition
WHO as a credible and highly
visible contributor to the rapidly
changing field of global health.
strengthen WHO’s financial posi
tion. largely by organizing "global
CONCLUSION
partnemhi^’' and “global funds’’
to bring together “stakeholders’*—
We can now return briefly to
the questions implied at the be
ginning of Uiis aitide: how does
private donors, governments, and
bilateral and multilateral ageu-
interest in the development of
health services and the emerging
concenti'ation on sm allpox eradieatiem. In the 1970s and 1080s.
W110 developed the concept of
Primary Health Care but then
turned from zealous advocacy to
the pragmatic promotion of Se
lective Primary Health Care as
complex changes overtook intraand interarganizational dynam
ics and altered flic international
economic and political-order. In
the 19 90s, WHO aheinpied to
quire. as Yach and Betteher sug
gested in .1998, a restored coor
dinating and leadership role.
Whether WHO’s organizstional
repositioning will serve to
reestablish it as die unques
tioned steward Of the health of
the world's population, and how
cies—to conceritrate on sp«tific
targets (for example. Roll Back
Malaria in 1.998. the Globa! Al*
a historical perspective help us
undenstand the emergence of the
terminology of “global healt h”
and what role did WHO play as
liance for Vaccines and Immu
nization in 1999. and Stop TB in
2001). These were semiautonomous programs bringing in
an agent in its development?
The basic answers derive from
the fed that WHO at various
times in its history alternatively
this mission will be efcted in
practice, remains an open ques
tion at this time. ■
substantial outside funding, often
in (he form of "public-private
partnerships?*7 A veiy significant
led, reflected, and tried to ac
commodate broader changes
and challenges in the ever
shifting world of inlxtmattonal
health, In the 1950s and 1960s.
when changes in biology, eco
nomics, and great power [Mililics
transformed foreign relations
and public health, WHO moved
About the Author
play’trr in these partnerships was
the Bill & Melinda Gates Founda
tion, which committed more than
S1.7 billion between 19.98 and
2000 to an international pro
gram to prevent or eliminate dis-
70 | Public Health Then and Now Peer Reviewed ’ Brown eft al.
'Ihetxkjnf M Brtwn is with the Depurirneni
vf lfalmy and the Departmeiu
uihf and lYeirentme AfetJitim Untt.wyity qf
IMester, Ruaftmter, NY. Matvos
is
with the Tactdtad de Suind Pilbtiaa, ^»ifcnidact IX’rmtrui Cayetano Hwedia, Lima.
I’eru. IRauMi Ire is tpilk the Hisioty of
Medittutr Division. Natiwial Uhniry
Maliivie. Nutiimal Institute of I feaM.
Retkef-da. Md.
Requests for rqjrmts shtfukl be
«»
Mizobeth Rite. fW). Histr/ty qf Medu-we
/Jittsrfrwi X’atttmal Libraiy qf biedickte.
8SOO itodtviUe.
Helhgsdu. Ml)
20974 (e-truiil- eiizMi Jett®
film
This arfide uw furepted faniuirii 11.
2005.
Contribute
AO ftutlws contributed equally to the n?sttarch and writing.
Acknowledgments
The authors an> grateful tn tte- Joint
U^aniing Initiarivr of the &>d«*Hler
Founiiauun, which initially ownuilv
sioiied this article, and to the Global
Health Histw ics Initiative of Un* Work I
Health Organization, which has jjrnvidiH’.l
a suppwtive envimnmenf for rnntinning
otir research.
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Arita. 2denek jovek, and Ivan DaTinovidt (.adnyi. Smallpox and its LSvdica
turn (Geneva: W! 10, 1988).
22 The New Imemaiismal Ecanamu:
Order ‘Ebe North South Dchate. ed.
Jxgdish N. Bhagwati (Cambridge, Mw:
MTF Press, 1977); RoKit L. Rotiwtem,
Cd<M Bargaining: UNCTAD and the
Quest for a Niro IrtteritMitmal Ec&vxnx
Order (Princelore NJ: Princeton Univer
sity Press. 1979).
23. Si>cratas 14t$U». “The- Ixtng and
Difficult Road to Alma Ata; A Pmontil
Rrlhrtion." InlrnustionalJournal of
Health Servwes 32 (2002): 709-732.
24 f kmitrvp Hoard 49£h Sessinn.
WHO<1«m)«M F849/51014 Rev
(Geneva: WHO. 1973). 218; Organisaliimal Study of 'the Execuide Beard on
Methods of f'nmiol.ing the DeveJayinenl of
Basic Health Semicfs. WHO ilanment
RB49AVP/6 (Gauiv-u: WHO. 19721,
19-20.
25. Socrates l.itsic®. “The Christian
Mwlicol CononMan and the Develop
ment of WHO’s Primaiy Health Care
Approach.'1 American Journal afEhibiic
Health 94 (2004k 1884-1893; Utai<*5.
“’I he Long and Diffimi! Road to AlinaAta'
26. John H. Bryant, Health and the DevelopiHg World (fjhaca, NY: Corneil Unr
versify Press 1969); Doctorsfur the Vif
lages: Study ofBund JnM'wdtfps m Seren
fnthnn Medical (rilkgts. ed. Cftrl E. Tay
Ira- (New York: Asia PuHisiiing House.
197(9. Kenneth W Nt-wcfl, Health by the
People (Gcni-va- WHO. 1975). See also
Marrtw Cueta. "The Origins of Primary
Heidlh Carr and Setective Primary
Health Care." Ameritxm Journal uf fStfdic
Hadth 94 (2004); 1864-1874; Utsios.
“The ChustifHi Medical CoimnisxuMi ."
27. See Liteioa. “The Long and Difficult
Road to Ateta-Aia? 716-719.
28. “Dedanitejii uf Alma-Ata. Intcma(ional Cvtifeivnct on .Primary Health
Care, AlrnaAta, USSR. 6-12 September,
1978." available at hiqxZ/wi.wiuho.int/
hpr/NPl-l/dc«^/d<iclara!i«n...alrmata.}:xlf.
arecs-sed April 10, 2004.
29. David A. Tejada de lUwro, “AlinaAta Rovishfidr
in Health
Magazine- The Magariw of the Pan
Amenriin Health Otganiratufn 8 (2003):
1-6 (qsiote on p. 4)
30. Msggir Black, Children Ivnt: The
Story of UNICEF, Hist and Presefd (Ox
ford Oxford I iniversify Press; 1996). and
'I he Chiidrvn and the Nations The Stify if
UNICEFYork-. UNICEF. 1986),
114-140, UNICEF waxix’tttixl in 1946
to assist needy du'kiren in Eiut^w's war
ravaged areas After the enua^ency
endixi, it broadened iLsntissiiMi and con
centrated ipjrnHix^ imi the nmls of ehii
dren In devekprig countries.
31. UNICEF. He Slate ifthe Worlds
Chiktren- 19829^3 (New York: Oxford
Uni versify PntKs. 1983). See also Cueto,
‘Origins of IMrnary Health Care ’
32. Jennifer Prah Ruger. ‘The Chang
ing Me of the World Bank in Global
Health in Historical Rw^xteve,1’ A/mngiwi Jourrutl of Public- Jfmlih 95 (20051
6.0-70.
.33 World Ih-wlrupmeiit ttyxiri 1980
(Washtngtcrk DC. W>rW Bank. 1980)
34 Thtancin^ ifetdlh Servitxs in Dei’ttlaping Gauntries: An Agend/i far iiefarm
(Washington. DC: Workl EtaJik. 1987)
.35 Fiona Godlee, " WHO in Jtatreat; Is
It Losing Ils Ixifluenee?' British Medu:nl
m (1994); 1491 -1491
36. Ibid. 1492.
37. Kermctl) Newell. '’Scteetiv^ Prirnaiy
Itealth On1. The Counter Rtvolution;
Social Sri^ice and Meditdw 26 (1988)
903—906 (quote on p. 9.06).
38. Paul Uvm, “Divided Wbrid Health
Organization Braces for Leadership
Change," Nets' Yorh Ittruts. May 1. 1988,
p. 20.
39. Gill Wall "WHO Under Stress: Implieatkms for Health Polity.’ Health M125-144.
4(1 Ibid, 129.
-IT. FionaGocBee. ‘WHO in Crisis,
BritiNi MedicalJournal 309
(1994): 1424-1428; Gaffer, “WHO in
Retreat’'; Fwa Goffee. “WHO’s Special
Programmes Untternurang From
Above.” tfidish Meduul fourtud 310
(1995). 178-182 (quote on p. 1821.
42. P. Brown. 'The WHO Strikes Mid
life Crisis,” Neto Scientist 133 (1997.1
12: -World Bank s Cure few Donor Fa
tigue titdih-MdaU.' The ImuxiHAZ (July
10. 19931: 63-64; Anthony Zwi, “Introductwin 10 Polky fitatfth: The Wvrkl
Bank and Internatiomd HcaHh " SaHal
Scwik-f unci Mediciw 50 (2000): 167
43, VVodct battk. Hnant-Wfi Health Seri>k.'cs in Develd^ng Countries.
44, WoiitlO^pT^nt^t. 1^3. in
n&uing in Health (WWwr^jon, DC: World
Bank. 199.3), nL-iv {qjidte- «h pp. fli-iv)
45, fw fl full arcouni. sc-e VVilliani
Muntskin. The Mitltis of intematumai
Health The ChihtnnTs
Initiative
(wcl the Single to Develop Vuahnea for
the Third LtWdEA&iiny: Slate Univer
sity of New. York Press. 19981.
48. J3o Stenson and Gbr«n Sterfcy
Brown at ai. Pesr Reviewed i Public Health Then and Now-
71
HiBLIC HEALTH THEN ANO NOW i
■‘VVtal Future WHO’’ Hetthh fbticu 28
(1994): 235-256 (quote on p. 242).
47. G. A. Grllert. "Gktljal Hrjalth Inter
defjerxlcuce and the fnlereatioual HiysidaHH MoverfienL’Voiinw/j/ t/teAmt'iiaat Medical Asam-iittion 204 (14HH));
610—613 (quote on p 610X
48. Milton Roemer and Kuth Roemer.
"Global Health. National Development
and the Rnto of Government” ,‘hnmatn
Journal of PMc Health 80 (1990)'
1188-1192.
49. Sec, for example. Andrew J
Haines. "Global Warming and Health.”
Hriti’ih Medical Journal 302 (1991):
669 -670; Andrew J. Haines, Raul R.
Epstein, and Anrhony .1 McMkbad,
“Gk»T>al IloflTth Watch. Monitoring ImjHids of tuivtronirtenLal Change.’’ The
Lttiuxt 342 (Dceembcr II. 19.93):
1464-1469: Anthony J. McM«bael.
'GlobHl Errvironmental Clumgc and
Human Ifynilaton Hcaltii: A Concep
tual and Sciditific Oidlengr fix' Epide
miology,” lutiTWiMnal Jattmal of Bpide22 (1993); I -8: John M. I^st
"Global Change: Ozone Depletion,
Gtrenhousc Vanning, and Rrhlic
Health," Aitnuid RtshfH1 of Puhlir Health
14 (1993,1; 115-13 tr. AJ MeMidiael,
Ptanciary OiyrkKtd, Clubal I'nvmmtneni/il
Change and the fhxdth of the Jfunuin
Species (Cambndge, lu.iglaixl; Cambridge
Umversily I'ivss. 1993). Anthony J
McMichael. Andtw ]. Humes. R. Sloof,
and 5. Kovats. Climate Cluing and
Human Health (Geneva: WHO, 19961'.
Anthony J McMichael and Andrew
Haines. “Global Ctbnate Chan^L-: The
Potential EITectx on 1 Icalth," Britidi Med
ical Journal 3ln (1997): 805-609.
Fighting Global Blindness
54. Lawrence K. Allrpan. "DS Moves t<»
Replace Japanese Head of WHO.' Aeu1
yitrh Tunes.-December 20,1992. p. 1.
55 Ilona ISckbusrh, “The Develop
ment of International Health I’rioriric*;Atvountabilily Intact?" Social Science. &
Medicine 51 (2000): 979-989 (quote
mi p. 985).
Improving World Vision
Through Cataract Elimination
By SandukRuit, MDt
i
Charles C. Wykoff, MD, D.Phil., MD,
Geoffrey C. Tabin, MD
56 Commission on Mamxjconnmks.
and Health. Macioeconomta und Health
inivsliny tn Health fin f-ctmamn Divelopmerit (Geneva; WHO. 21X11); see also
I toward Wailzkin, "Report of the WHO
ComnuRsion on Marroeconomics and
Health: A -Summary and Crf&pto.’ Vie.
lancet 361 (Februwy 8. 2003):
523-526,
Fiuifisii GimitoMss
.' • . ‘
Vviact '
i
57. Michael A. Reid and E. Jim Pearce.
‘AVhither tlte World I lealth Or^nizatton?t The Medical Jminud of AuHrdlia
IWBim 9-12.
• ir-i’
58. Michael McCarilry. "A Coiwersatiun
With the Leaders of the Gates Fcnmdiation’s Global Health Program? Gordon
IVrkih and William Foege.” The Uncet
356 (July 8. 2(XW); 153-155.
; ■
50 Stephen S. Morse. "Factors in the
kjmergtsice of Infeettwis .Diseases,"
(•inerj’ityj h^'ertiou.^ Diseasten 1 (1995):
7-15 (quote on p. 7).
51. ItwUtute of Medicine. /Imcritw
Viatl lat&^l in Global Health:
Our People. Erdiancing Ottr lieonam/. and
•IriranahR Our Internarionai Inrm^ts
(VV'ashiiigtort. DC; National /Xctfdemy
Press, 1997).
i
'
I
wscul«,«i '
|
J
| | nope rated ca taract is the cause of millions
' Uof cases of visual impairment and
blindness in poor populations throughout
both the developing and the developed world.
This wonderfully written volume shares the
experiences of a team of surgeons who have
demonstrated how the surgical procedures can
be simplified and made more efficient,
. accessible, and far less expensive.
■ ISBH W553 O67 2 ■ spiral bound - ?006
$31.50 APHA Members * 545 Op Nonmembers
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To Order: web www.aphabookstore.org
email apha@pbd.com
fax 888.361 .AP HA
phone. 888.320.APHA M-FSam-Spm EST
.J
52. Bmetgin^
Bwmeduxd Re
search itepwis, ed. flichtad M KiausO
(San Diego; .Amdeinic Press. 1998); Prevenhnff fimeqpnp, hifcdiims Diseases ,4
Simtepif for the 21 st Century (Atlanta:
Centers for Disease Control and Preven
tion. 1998); Perspt.f:livi's on the. Depart
men! of Dtjintse Global ErHeiying Infcc
Cions Surveillamr und Response System.
cd. Philip S Pnidiiriiui, Heather C. O'
Maonaigh. and Richard N Miller (Wash
ington. DC. National Academy Press.
2001).
53 Fw example, laune Garrett, The
Cctming Playa? \'eudy lanerginy Diu^ises
in u IMirld Out vfBalance (New York:
Farrar. Straus und Giroux, 1994).
72 i Public Health Then and Now i Peer Reviewed | Brown et al.
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0277-9536/88 S3.00 + 0.00
Pcrgamon Press pic
Soc. Sei. Med. Vol. 26. No. 9, pp. 957-962, 1988
Printed in Great Britain
GOVERNMENT HEALTH SERVICES VERSUS
COMMUNITY: CONFLICT OR HARMONY
H. T. J. Chabot1* and J. Bremmers2
'Royal Tropical Institute, Mauritskade 63, 1092 AD Amsterdam and 2SNV (Netherlands Development
Organization), The Netherlands
Abstract—From their daily experiences with PHC implementation in Mali, the authors discuss the relation
between the government oriented basic health services (BHS) and the community health services (CHS)
practised at village level. They question the general assumption that the two ‘systems’ work harmoniously
together to improve the health of the rural population.
They argue that the workers within the BHS have little interest in the health of the rural population
for economic reasons, for reasons of training and background, for reasons of their own curative interests
and finally for reasons inherent to the BHS organisation. Thus the BHS are not likely to respond to the
essential needs and problems of the CHS. Some suggestions for what can be done in such a situation are
made.
INTRODUCTION
It is almost ten years since 134 Governments signed
the Alma-Ata Declaration on primary health care
(PHC), in which they described in quite concrete
terms their intentions for the implementation of PHC
in their respective countries. At the time, all these
governments took a serious commitment vis a vis
each other to try to expand and improve the existing
health situation by having the ‘consumers of health
care’ more actively involved. Since then a lot has been
written about PHC and how to implement it [1J.
Participation and an empowering development
strategy are generally considered essential to make
the PHC-philosophy materialise [2, 3]. However little
attention has been given to the role of the State
(especially the Ministry of Health) in trying to have
the rural (and urban) masses participate.
Apart from some exceptions, the general assump
tion underlying the literature seems to be that the role
of the Ministry of Health is to bring health to the
people or at best to have people participate in a
mutual effort to improve the general health situation.
This paper tries to argue a different point of view:
that the interests of the workers in the Ministry of
Health responsible for PHC implementation conflict
with the interests of the people at village level. It will
be argued that this conflict partly explains some of
the failures in PHC-implementation. Although an
image of good versus bad seems difficult to avoid in
this discussion, the reader is asked to keep in mind
that nuances abound and reality is always subtle. At
all levels there are victims and survivors.
The argument will be pursued against the back
ground of Mali, a Francophone country in West
Africa, struck by the general drought problems of the
Sahel region, a country with important donor
commitment and financial support for PHC imple
mentation. After a brief introduction to the socio
political situation in the country and the Malian
health situation, a description will be given of the
Government health services, the community health
activities, and donor health interventions, each with
its different characteristics. The various conflicting
interests will be described and illustrated using case
studies and examples from our experiences in the
field.
Finally we will suggest some possible lines of action
that could be taken to improve the situation.
•Correspondence and requests for reprints should be ad
dressed to: Dr J. Chabot, PHC Unit, Royal Tropical
Institute, Mauritskade 64, 1092 AD Amsterdam, The
Netherlands.
957
SOCIO-POLITICAL SITUATION IN MALI
The history of Mali is marked by mighty and
influential empires, sources of pride which probably
created a basis for a national identity and a collective
consciousness that still defines many of the social
forces in Malian society. But at present Mali figures
among the three poorest countries in the list of
low-income countries mentioned by the World Bank.
The vast Sahelian territory (with no access to the sea),
marked by economic insecurity due to climatic uncer
tainty and desertification, aggravated by a weak
productive structure, makes Mali dependent on
foreign aid for its development.
As elsewhere in Africa, the French presence in Mali
(1908-1960) manifest itself in cultural, economic and
administrative domination. Taxes, the civil-servant
system and the market economy disturbed the tradi
tional ecosystem and started a process of marginal
isation of the Malian peasants. A socialist experience
(1960-1968) and the present-day military Government
have not changed the position of the rural population
in the development process of Mali. Eighty percent of
the eight million people in Mali live in the rural areas.
Their production has to feed themselves as well as the
urban population and it defines the export-potential
of the country. These factors together put heavy
pressures on the peasant population.
On the other side, within Mali’s elite we can
distinguish a fragile alliance between:
958
H T. J. Chabot and J. Brimmers
—the army who controls the population politically.
—the ‘fonctionnairs’ (civil-servants), who are in
charge of the administrative bureaucracy, and
—the merchants who at every level regulate the
flow of money from bottom to top [5].
Although their mutual interests do not always run
parallel (the merchants are often troubled by the
bureaucracy, who in turn are often opposed to the
political authorities due to the low and irregular
payment of salaries), they still succeed together to
present the rural population with the bill for the
economic problems in the country. The peasant
population of around seven million people on the
other hand sees surplus consumed by public institu
tions which are not capable of limiting their running
costs (90% of the state-services rendered remain of
poor quality and are not tailored to their needs). In
short, they find little in return. For a Malian peasant
only the distribution mechanism is tangible and
he/she, wise by prolonged experiences, remains
passive as a sign of rejection of the proposals from
the top (6).
THE HEALTH SITUATION IN MALI
Considering the economic situation of Mali,
the poor health situation becomes self-evident. The
following data only describe this situation in quanti
tative terms (Table 1):
Table 1. Some general data on the Malian health situation
Size
Population (’86)
GNP. capiu (’84)
Health Budget as % of
Nat. Budget (’84)
Money/pp/year for health (’84)
% Rural (’82)
Ration Drs/100,000 population
Birth rate (84)
Death rate (84)
Infant mortality rate
Life expectancy
1,246.000 knf
8.0 million
46,200 FCFA (SI 40)
8.4%
460 FCFA (USSI.—J
80%
24.6 Bamako*
48.0
20,0
60-200 %<,
(National 176 %o)
46 years
(38 rural, 60 Bamako)
(44 male, 48 female)
•Capital city. Source: Basic information Mali: EEC. World Devel
opment Report 86 (WB).
Through its enormous territory (five times the size of
the U.K.), the Government has expanded its health
infrastructure. Manpower was strengthened auto
matically by law as the Government was obliged up
until 1985 to include all the graduates from Medical
School and the various Nursing Schools into their
ranks. However the distribution of personnel did not
follow that of the population (Table 2).
Mali adopted the PHC concept as a national
strategy in 1976 before Alma Ata. Unfortunately, the
Government was not able to translate these concepts
into operational terms, nor did it give those in the
field the training manuals and other necessary
material to support the many village health-workers
that were trained all over the country.
A remarkably uniform approach was adopted by
training two hygieniste/secouriste (HS), and two
accoucheuse traditionelle (AT) per village. Few
people seriously tried to allow for local variations, or
gave thought to the problem of remuneration. This
was left to the 'villagers themselves’ who everybody
assumed would be able to solve this vital issue. Now
we know that broadly speaking they did not, and the
country is faced with the impending failure to imple
ment PHC before the year 2000.
THE MALIAN HEALTH SERVICES
The Malian Health Pyramid shows the different
levels of health infrastructure with corresponding
personnel. From the bottom upwards we see first
community health services (CHS), in principle or
ganised and executed by the villagers themselves,
while supervised and (partly) financed by higher
levels.
At this level health activities in principle are char
acterised by some degree of continuity, a decision
capacity with the existing village authorities (e.g.
village health committee), and an integral approach
to health including curative, preventive and pro
motive aspects. The villages relationship with the
representatives of the state however is ambiguous: on
the one hand they see them coming in the name of the
Ministry of Health, as persons who might improve
their health situation, and thus to be respected; on the
other hand they adopt towards these persons a ‘wait
and see’ approach, that gives them time to judge their
real commitment and their capacity to come with
sensible suggestions.
A great deal depends on the respect and politeness
shown by the health officials, as to how the villagers
will react to the various proposals made to them. We
feel that in most villages it takes between one and
three years even with good relations between the
various partners before some form of self-reliance is
seriously considered.
The next level of the health services is the 'secteur
de base' which is between the village level and the
state organised health infrastructure. In general the
aide soignants (AS) and matrones who work here
come from the area concerned, though they are not
chosen by the villagers. They have a longer training
(on average six months) and are able to handle a
variety of drugs (including injections). They are sup
posed to cover an area of about five to ten villages.
However they are not paid by the Ministry of Health
but through local cooperative funds and/or taxes,
that are paid to them quite irregularly and sometimes
with extremely long time intervals. One of the authors
works in an area where these workers have not
received their salaries for seven months. In such a
situation it is understandable that they will become
small health entrepreneurs, who make their living by
directly charging the sick for their services, doing
private practice sessions in the afternoon.
Table 2. Number and distribution of health personnel in Mali. 1982
Bamako
Doctors
State nurses
Secondary nurses
Midwives
Rural
No.
%
No.
07
•'0
95
252
372
147
42
39
31
64
133
395
828
82
58
61
69
36
Source: Rapport Annuel Medecin Sans Frontiere. 1986.
Total
number
228
647
1200
229
Government health services versus community
Due to their monthly salary they are more related
io the health officials than to the village health
workers (VHW) who they are supposed to supervise.
For this reason we consider them in this paper as
belonging to the BHS. However their position is
ambiguous as their salary is so often lacking and their
background training is quite limited.
Finally the other levels of the health care pyramid,
the arrondissement and cercle level are part of the
BHS that is to say the health infrastructure directed
and controlled by the Ministry of Health, and staffed
by health officials paid by the State. These BHS are
characterised by central decision making and a
straight line of command from top to bottom. One
observes regular transfers decided upon for reasons
inherent to the administration, that do not always
coincide with the needs of the population in the area.
Inherent in this medical administration is a ten
dency to bureaucracy, seen, for example, in the effort
to gather information for its own sake instead of
using it locally for planning and overall management.
One observes also a strong curative bias and a
tendency to define problems in a medical-technical
sense.
Health personnel, whether doctors or nurses, tend
to look down upon village life, as they have not been
trained to analyse it in its social or cultural dimen
sions. When confronted therefore with the necessity
for interventions at village level, solutions and actions
are proposed even before an effort is made to find out
the social-cultural pattern that will have to sustain
and support the proposals. In short a tendency
prevails to reinforce health workers telling people
what to do, rather than discussing with people what
their options are. And their suggestions are of a
medical-technical nature.
DONOR INTERVENTION
It is not the objective of this paper to describe the
various types of donor intervention in the actual
Malian socio-economic situation. At the same time
their role in the health sector cannot be ignored. Here
we will briefly sketch their intermediate role between
the state and the village level.
In general donors seem to try to make the BHS
work effectively for the benefit of the CHS: they often
want the personnel of the BHS to do something
positive for the villagers. To that end they bring in
money (per diems), training, means of transport and
materials, all in an effort to mobilise the health
personnel to do something that is considered good for
the villagers. In a way it looks as if the donors want
the state to do what the sute itself is not able
(interested?) anymore to do.
In this way the donors see their role more and more
limited to provide the incentives to the health staff,
who are themselves not very motivated. However,
staff are prepared to play the game of showing
interest so that money will continue to come .in.
Implicitly it is the hope of many donors that by
paying the nurses for the extra efforts they undertake
in implementing the CHS, in the long run-it-will
become a routine part of their daily work. Very often
time seems to prove this assumption false.
The health personnel from their side see the donor
959
Table 3. Differences between BHS and CHC
Basic health services
Community health care
Central decision making
Top-down line of command
Discussion on content rare
Frequent transfers
Technical and curative
approach (numbers)
Bureaucratic tendencies
Local decision making
Long discussions
Often no harmony
Continuity in approach
Intersectional essential
but no overview
Quality counts more
as an important potential to add to their meagre
salary. As long as the donor is willing to ‘subsidise’
their income through all sorts of allowances, the work
runs quite smoothly. But when these allowances
diminish or disappear, a certain passivity, or even
resistance becomes apparent. And, it should be
stressed, these are all normal daily activities, that are
part of the official workload of a nurse. In short the
attitude of the health staff to community health care
is ambivalent: they have to work harder, suffer
hardship and bear responsibility, but they see their
living-conditions improved with money and material
from the external donors [7].
Looking now for a functional definition of PHC,
it is apparent that PHC embraces both the BHS and
CHS. Within this broad PHC concept we see the
donor as a sort of mediator, trying to have the two
work together as smoothly as possible (Table 3).
CONFLICTING INTERESTS
Most people working for some period of time with
the Ministry of Health trying to improve the func
tioning of the BHS in order to make them better
equipped to implement the CHS, will agree with the
differences mentioned in the previous paragraph.
They probably will argue that this is part of their job,
and that we should continue to prepare better the
health officials for their difficult and arduous tasks.
We will not deny this idea. We do, however, question
the implicit assumption that the interests of the two
health systems run parallel and are complementary to
one another. We would rather argue that the two
systems have often contradictory interests and that
their mutual relation is therefore better described in
terms of an implicit and almost continuous conflict,
in which one side does have substantially more
control over the other, by dominating information,
and the financial and personnel reasons. They need
each other for their daily functioning, but in reality
they are seldom partners in a development process.
The following examples will try to make clear why
the interests of the two systems run in opposite
directions and are not likely to become comple
mentary in the foreseeable future.
1. Mr Tounkara, an elderly nurse in
N’Debougou, Degou region, has started CHS ac
tivities in some villages. He has less free time now and
has spent considerable effort in finding out what the
villagers actually want. Each month he sweats some
litres during supervision and follow-up. For all this
work he will receive the esteem and love of the
villagers, but financially he will not earn a penny
more.
960
H. T. J. Chabot and J. Bremmers
As he docs his work well, he sees even fewer nurse and doctors during their consultation arc not
patients. Some of the sick will now seek treatment affordable for the general population, making west
with the VHW he has just trained. His VHW has ern medicine, without any necessity, the medicine of
become competitive, though not directly in a financial the rich who can afford to pay between 3000 and 7000
way. as he receives a fixed salary per month. However FCFA per illness. A nurse conscious of the financial
over some years, the number of VHWs in the area situation of his patient could easily reduce this ex
could very well affect the number of Mr Tounkara’s penditure to 500-3000 FCFA without changing the
private consultations in the afternoon.
efficacy of his treatment.
In general training VHWs increases the number of
The common practice of prescribing on average
competitors for the sick. Whether this will lead to a four to six drugs at each visit implicitly overestimates
loss of revenue from curative work remains to be the importance of drugs for the treatment of ailments.
seen. As the number of health workers is actually still It seems to advocate a policy of “the more drugs, the
grossly insufficient, this argument will gain in im better the cure”, that is accepted within the BHS. No
portance only over a long period.
wonder that many at least feel that CHS represents
In the meantime other points of contradiction a second-best alternative to modem (read: con
between health workers do emerge, such as the access sumptive) medicine. We suggest this is avoided by
to injectable drugs, which has become an important allowing VHWs access only to cloroquine and
goal for VHWs: it is in this way that they rapidly will aspirin.
become ‘the doctor’ for the village. For midwives the
Traditional medicine offers a more coherent ex
argument is more acute, as the number of deliveries planation of illness at village level, while the BHS
per midwife is low. The auxiliary midwife Fanta (who only provide some basic drugs without any compre
works with Tounkara) complained to us that since hensible explanation. In this way the actual policy
she had trained traditional birth attendants in the does not start to bring the two systems together. At
area she had only done two deliveries in the last best, for the moment they continue to evolve apart.
month. Before she did on the average about 15 Also the emphasis on drugs during the consultations
deliveries per month, which was an important extra is the opposite to the verbal affirmations on the
revenue to her very modest income (20,000 importance of preventive action. As is often the case,
FCFA/month). She had not received her salary for the oral advice is not in line with the practice in the
the last six months. We could only wonder how she dispensary.
At village level, the outcome of all this is a
managed to survive during that period.
2. The nurses utilise conventional training consumptive attitude by the people that look on the
methods with emphasis on the passive copying of BHS as a distributor of some important drugs, while
information while training VHWs. In this way the at the level of the BHS the patients are often grossly
passivity of the system is continued and chances are overcharged for their treatment: for example, the
lost to generate discussions and enhance partici father of little Fode, four years old, showed me a
pation. The trainers are not too keen to create such receipt of a doctor, worth more than 8000 CFA,
a climate, as this might expose their own gaps of while the only problem with the child was a severe
knowledge or even question their authority. Their anaemia. A blood transfusion from an uncle, and
own education is continuously reflected in the efforts iron tablets worth about 300 CFA restored Fode’s
to realise CHS. No wonder that participation or health completely. One wonders whether the doctor
improving village health becomes less important in really had not noticed this marked anaemia.
4. Another difference of interest between the
comparison with the passing on of curative lessons
that often have little applicability to daily reality. two systems lies in what we would call the non
Similarly, within the CHS. it is rare to see the HS serving’ character of the BHS. The remarkably uni
share his knowledge with the people of his village. form approach to the CHS-impIementation has al
Apart from cultural reasons, it might prove more ready been mentioned. Il shows that few have tried
beneficial for his position with the village hierarchy to to find out what the interests and organisationalfinancial capacities of the villagers are. People have
exploit his extra knowledge rather than share it.
Another remarkable contradiction is observable in assumed that two VHWs would be taken care of by
discussions with the nurses on how to integrate the village but few have asked themselves whether
traditional medicine in the daily work of the VHW. village level cohesion really exists or whether a
Many show reluctance and hesitation as to whether family-unit would not have been more prepared to
this is a useful thing to do. In their personal life, support their own VHWs?
Similarly it is not remarkable that all VHWs are
however, it is most likely that their first option is to
treat themselves with home-remedies. In general, male. Few people have seriously given thought to the
therefore, training often continues the dependence of possibility of discussing the option to include women
VHWs on the BHS and brings village care even more in the curative oriented role of the VHW. Again, the
under the (western) control of BHS, rather than BHS have opted for an easy way out of a difficult and
complex problem: how to involve women in CHS.
making it self-reliant.
Nurses support training mainly because of the True, women are difficult to reach, especially by the
allowances that are given during the training-sessions majority of male nurses; they are very often illiterate
which are an important source of revenue for their and therefore need special learning tools, but their
potential to improve the health of groups most at risk
families (18,000 CFA for two weeks training).
3. The curative approach, often of poor quality, (c.g. the children) is much greater than the male
is in itself contradictory to the interest of CHS for VHWs.
Our essential point here is that these different
various reasons. The many drugs prescribed by the
Government health services versus community
■b
options have never been seriously discussed by the
BHS, as potential solutions for major CHS problems.
The actual emphasis on vertical programmes (ex
panded programme immunisation, dianheal control
etc.) is another example where objectives inherent to
the BHS, like ease of implementation and control,
definition of priorities outside the CHS, prevail over
the integrated and participative approach recommen
ded by the Alma-Ata Declaration. As time and means
are limited, the vertical programmes will be in com
petition with the horizontal village-based activities.
Most likely, the coming years will show the prefer
ence of the BHS (and many donors?) for this tech
nical approach.
DISCUSSION
The examples mentioned above try to argue the
conflicting interests of the two health systems in Mali.
For economic reasons, for reasons of training and
background, for reasons of its own curative interests,
and finally for reasons inherent in its own or
ganisation, the basic health services are not likely to
respond to the essential needs and problems of the
CHS. If they seem to do so, it is for reasons of short
term advantages (financial allowances, acquisition of
transport) or to respond to external pressure by the
international community and the various donors,
that ask the country to do something for their
deprived populations. But a real long-term commit
ment that will cost effort, sweat and some financial
input, is not likely in the socio-economic situation of
Mali today.
Unluckily people often forget that PHC is an
integral part of the social-political context. Contra
dictions within society will become apparent within
PHC.
The Malian elite, including the personnel of the
BHS, assume for themselves a positive role in the
process for modernisation. Unconsciously, they look
down at the possibilities of the peasants to make their
own contribution to this process. The peasants can
only protect themselves against the continuous obli
gation to hand over goods and finances by shutting
themselves off from this effort to modernise imposed
by the elite. This in turn for them is proof that their
proposals for development are a waste of time and
effort.
Foreign donors seem to underestimate the com
plexity and depth of the situation. They try to reduce
the failure of PHC to technical and/or financial
constraints, or a lack of modernising efforts by the
peasants. The tendency to vertical programmes and
selective PHC can be considered as examples of this
way of thinking, that in itself reinforces the
conflicting situation. People and donors working in
the health field in Mali should be realistic in their
approach: the BHS are not likely to realise a
capacity-building CHS, that is able to decide and
implement its own health activities. The BHS will not
support such a process but rather shift it towards a
technical-curative health intervention.
The analysis presented above seems pretty grim
and negative. If the BHS are really not interested in
961
the support of a valid CHS, what remains to be done?
Is there still any perspective for action? We think
change is possible with the following caveats in mind:
one has to realise that one’s work within the BHS of
Mali has a limited sphere of influence and as such will
never be able to change the fundamental issues raised
above. If the implications of that statement are
accepted, a strategy should be developed, that aims
at changing the two systems gradually, reciprocally
and similarly, along two major lines:
1. Within the BHS, there are people interested in
change who have valid ideas on what could be done
at village level. As they often do not have the chance
to realise these ideas, it will be important to reinforce
them with all sorts of means: training, training ma
terial, money, strengthening management capabilities
etc. Good initiatives and ideas should be supported,
thus trying to make part of the BHS more geared to
the CHS.
The cooperation with the other sectors of devel
opment, like habitat, agriculture, education and in
dustry should be further reinforced and supported. In
Mali, some of the ‘Operations de Developpement
Rural (ODR)’, offer hopeful initiatives. Those that
have been shown to be reasonably effective in sup
porting village based actions, could eventually take
over some of the deficient functions of the BHS
(drugs supply, training VHWs etc.).
Coordination between donors and non-govern
mental organisations could be essential to demand
from the Malian BHS a more concise policy regard
ing some major aspects:
—Implementation of an essential drug policy,
that excludes the 2000 non-essential drugs
available in the country. This would mean an
important price reduction in the medical treat
ment of the villagers.
—Re-definition of the CHS policy envisaged by
the Ministry, taking the acquired experiences
into account.
—Re-definition of the role and potential of the
intermediate level of ‘Secteur de Base’ as part
of future health development efforts.
—Integration of some major vertical pro
grammes within the general functioning of the
BHS.
As donors very often do not seem to agree on these
issues between themselves, the results of such a
coordination should not be looked at too opti
mistically.
2. At the same time we should try to strengthen
the decision-making capacity of the CHS, by rein
forcing the role of village health committees and
training them in such a way as to make them as
independent as possible from the BHS. Autonomy
for the CHS should be a major objective. Some of the
effective ODRs could play an intermediate role in an
effort to realise this.
In our contacts with the villagers new issues should
be discussed, like the number of VHWs to be trained
and the role of women within the health team. We
should also try to define more clearly the ‘deal’ that
could exist between the BHS and the CHS when
working together, so that both sides know and if
Indian Pediatrics 2001; 38:1129-1143
Child Health Development After Alma Ata Declaration
Pakynathan Chandra
Dr. Pakyanathan Chandra is Executive Director, D. Arul Selvi Community Based Rehabilitation and
Chairman, Tamil Nadu Health Development Forum.
Correspondence to: Dr. Pakynathan Chandra, 'Sornam’, 221-4th Avenue, Indira Nagar, Chennai 600
020, India.
Address given at the 38th National Conference of Indian Academy of Pediatrics, Patna, Bihar on 9th
February 2001 for the Hony. Surg Cmde. Dr. Shanthilal C. Sheth Oration.
Health development includes health care, essential non-specific measures like nutrition, protected water
supply, sanitation, education and economic development. Primary Health Care (PHC) is essential health
care based on practical, scientifically sound and socially acceptable methods. Community involve-ment,
inter sectoral cooperation and approaches to peripheralise health services are the three pillars on which
PHC is being built. Implementing PHC successfully will improve health development. Human progress
and overall development lie in the progress of women and children and the realization of their rights.
Problems of health development and under development are intimately linked.
In the later half of last century important technological advances in medicine were made. Vaccination
against major diseases and therapy for infectious diseases and the technical knowledge to prevent
nutrition deprivation and diseases were available. As a result rapid decline in death rate has occurred.
Inspite of impressive progress in health picture, the prevailing health and nutrition disparities were a
cause for serious concern.
Medical science realized that poverty related social conditions like poor sanitation and housing were
major causes of ill health. Studies have shown that irrespective of medical intervention health status
improved remarkably when basic requirements of health were available. The challenge was primarily a
question of equal access for all. In 1978 for the first time all the Government of the world - Democracies
or Dictatorships, Communists or Capitalists - accepted the principle of PHC officially and promised to
bring them into being in all nations within the next 22 years. This Alma-Ata Declaration accepted that
Health is a Fundamental Human Right. It also accepted that the gross inequalities in health status are
unacceptable. Health for all heralded the vision of a new and better future for all the human family.
To fulfil her commitment of Health for All, India evolved a National Health Policy in 1983. To transfer all
objectives of Health for All, the policy laid down specific goals with quantifiable targets to be achieved.
This commitment did lead to some renewed attempt at achieving these goals. India launched ambitious
campaigns for eradica-tion of communicable diseases, infections and malnutrition. Various policies and
acts introduced earlier and later tried to augment efforts. Few examples in this context include ICDS
(1974) CSSM (1992), The Infant Milk Substitute Act (1992), Pulse Polio Immunization (1997), RCH and
others. The impact of all these interventions to improve health, particularly maternal and child health has
been large. In India decline in vaccine preventable diseases and severe malnutrition of this magnitude
has never been achieved in our setting and certainly not in an equivalent period of time. Still there are
disparities in health. So the achievements of the National Health Policy need critical analysis.
Progress in Maternal and Child Health
A. Mortality and Mobidity in and around Infancy (Table I)
Mortality rates and nutrition status are good indicators to measure the level of health and nutrition care.
This also helps in assessing the overall socioeconomic development.
Still births and deaths within the first week of life are not investigated like infant and neonatal deaths. With
declining infant mortality rate, perinatal mortality is assuming importance as a yardstick of obstetric and
pediatric care before and around the time of birth. There is a wide variation in urban/rural death rates.
References
■
1. Sanders D. The Struggle for Health, United Kingdom, Macmillan Education Ltd.
2. Wener D, Sanders D. The Politics of Primary Health Care and Child Survival, California, Health
Wrights, 1997; pp 82-117.
3. National Coordination Committee Jan Swasthya Sabha, Confronting Commercial-ization in Health
Care. Chennai, South Vision 2000, Annexure 2.
4. National Coordination Committee Jan Swasthya Sabha, What Globalization does to Peoples Health,
Cheanni, South Vision, 2000; p 9.
Government health services versus community
961
the support of a valid CHS, what remains to be done?
Is there still any perspective for action? We think
change is possible with the following caveats in mind:
one has to realise that one’s work within the BHS of
Mali has a limited sphere of influence and as such will
never be able to change the fundamental issues raised
above. If the implications of that statement are
accepted, a strategy should be developed, that aims
at changing the two systems gradually, reciprocally
and similarly, along two major lines:
1. Within the BHS, there are people interested in
change who have valid ideas on what could be done
at village level. As they often do not have the chance
to realise these ideas, it will be important to reinforce
them with all sorts of means: training, training ma
terial, money, strengthening management capabilities
etc. Good initiatives and ideas should be supported,
thus trying to make part of the BHS more geared to
DISCUSSION
the CHS.
The cooperation with the other sectors of devel
The examples mentioned above try to argue the
conflicting interests of the two health systems in Mali. opment, like habitat, agriculture, education and in
For economic reasons, for reasons of training and dustry should be further reinforced and supported. In
background, for reasons of its own curative interests, Mali, some of the ‘Operations de Developpement
and finally for reasons inherent in its own or Rural (ODR)’, offer hopeful initiatives. Those that
ganisation, the basic health services are not likely to have been shown to be reasonably effective in sup
respond to the essential needs and problems of the porting village based actions, could eventually take
CHS. If they seem to do so, it is for reasons of short over some of the deficient functions of the BHS
term advantages (financial allowances, acquisition of (drugs supply, training VHWs etc.).
Coordination between donors and non-govern
transport) or to respond to external pressure by the
international community and the various donors, mental organisations could be essential to demand
that ask the country to do something for their from the Malian BHS a more concise policy regard
deprived populations. But a real long-term commit ing some major aspects:
ment that will cost effort, sweat and some financial
—Implementation of an essential drug policy,
input, is not likely in the socio-economic situation of
that excludes the 2000 non-essential drugs
Mali today.
available in the country. This would mean an
Unluckily people often forget that PHC is an
important price reduction in the medical treat
integral part of the social-political context. Contra
ment of the villagers.
dictions within society will become apparent within
-Re-definition of the CHS policy envisaged by
PHC.
the Ministry, taking the acquired experiences
The Malian elite, including the personnel of the
into account.
BHS, assume for themselves a positive role in the
process for modernisation. Unconsciously, they look
—Re-definition of the role and potential of the
down at the possibilities of the peasants to make their
intermediate level of ‘Secteur de Base’ as part
own contribution to this process. The peasants can
of future health development efforts.
only protect themselves against the continuous obli
—Integration of some major vertical pro
gation to hand over goods and finances by shutting
grammes within the general functioning of the
themselves off from this effort to modernise imposed
BHS.
by the elite. This in turn for them is proof that their
proposals for development are a waste of time and As donors very often do not seem to agree on these
issues between themselves, the results of such a
effort.
Foreign donors seem to underestimate the com coordination should not be looked at too opti
plexity and depth of the situation. They try to reduce mistically.
2. At the same time we should try to strengthen
the failure of PHC to technical and/or financial
the
decision-making
capacity of the CHS, by rein
constraints, or a lack of modernising efforts by the
peasants. The tendency to vertical programmes and forcing the role of village health committees and
selective PHC can be considered as examples of this training them in such a way as to make them as
way of thinking, that in itself reinforces the independent as possible from the BHS. Autonomy
conflicting situation. People and donors working in for the CHS should be a major objective. Some of the
the health field in Mali should be realistic in their effective ODRs could play an intermediate role in an
approach: the BHS are not likely to realise a effort to realise this.
In our contacts with the villagers new issues should
capacity-building CHS, that is able to decide and
implement its own health activities. The BHS will not be discussed, like the number of VHWs to be trained
support such a process but rather shift it towards a and the role of women within the health team. We
should also try to define more clearly the 'deal’ that
technical-curative health intervention.
The analysis presented above seems pretty grim could exist between the BHS and the CHS when
and negative. If the BHS are really not interested in working together, so that both sides know and if
options have never been seriously discussed by the
BHS, as potential solutions for major CHS problems.
The actual emphasis on vertical programmes (ex
panded programme immunisation, diarrheal control
etc.) is another example where objectives inherent to
the BHS, like ease of implementation and control,
definition of priorities outside the CHS, prevail over
the integrated and participative approach recommen
ded by the Alma-Ata Declaration. As time and means
are limited, the vertical programmes will be in com
petition with the horizontal village-based activities.
Most likely, the coming years will show the prefer
ence of the BHS (and many donors?) for this tech
nical approach.
962
H. T. J. Chabot and J. Bremmers
possible respect their mutual agreement. In short an
effective 'methodology of intervention' should be
looked for that defined as clearly as possible the
essential issues that should be discussed while intro
ducing CHS at village level.
The financial supervision of the YHW by the
villagers themselves should rapidly be improved. The
villagers should be able to control the VHW and
decide what to do with the revenues from the sale of
drugs. In a similar way information should be given
to everybody on prices of drugs, and where to get
them more cheaply. In general the financial control of
CHS activities should be clearly laid in the hands of
existing village structures. By these and other
measures, the CHS will perhaps become sufficiently
strong to start a process towards emancipation and
(relative) autonomy.
REFERENCES
1. Scnghor D. Les SSP, revolution ou alibi. Famille Devi.
28, 35-58. 1982.
2. Graaf M. de. Catching fish or liberating man: social
development in Zimbabwe. J. Soc. Devel. Africa 1, 7-26,
1986.
3. Werner D. Village Health Worker. Lackey or Liberator^
Hesperian Foundation, P.O. Box 1692. Palo Alto, CA
94302, U.S.A., 1977.
4. Foster G. M. Community development and primary
health care: their conceptual similarities. \fed. Amhrop.
6, 183-195, 1982.
5. Jacquemot P. et al. Adalis. Le Payson et I'Etat. pp. 17-18.
Editions L’Harmattan. Paris, 1981.
6. Hyden G. /Vo Shortcuts io Progress: African Development
Management in Perspective. Heinemann, London. 1983.
7. Chabot H. T. J. Primary health care will fail if we do not
change our approach. Lancet 340-341. 11 August. 1984.
u
Soc. Set. Med. Vol. 22, No. 10. pp. 1001-1013. 1986
Printed in Great Britain
•>2’7-9536 86 S3.00+0.00
Pergamon Journals Ltd
3
SELECTIVE PRIMARY HEALTH CARE:
A CRITICAL REVIEW OF METHODS AND RESULTS
Jean-Pierre Unger1 and James R. Killingsworth2
'Unile de recherche et d’enseignement en sante publique, Instiiut de Medecine Tropicale Prince Leopold
Nationalestraax 155. 2000 Antwerp, Bclgtum and Stanford Research Instituie International. P O.PBox
1871. Riyadh 11441. Saudi Arabia
Abstract In the aftermath of the Alma Ata conference, three types of Primary Health Care (PHC)
have been tdenufied. Comprehensive PHC (CPHQ and Basic PHC (BPHC) both have a wide scope of
acuities. BPHC however does not include water and sanitation activities. Onlv one vear after the Alma
Ata conferenceCPHC was attacked as not -feasible' and selective PHC (SPHC) was offered as an interim
alternative. SPHC only addresses 5 to 8 diseases, almost all of them falling within the realm of pediatrics
?UrX^e cr\t,calI-v anLaIys« the methods and ’■'Suhs of SPHC. It contrasts the lack of supportive data
tor SPHC and its methodological deficiencies with the extent of its adoption by bilateral cooperation
agencies foundations, academic and research institutions, and international agencies. We suggest that
rather than health factors, the major determinants of this adoption have been political and economical
constraints acting upon decision makers exposed to a similar training in public health
Key words—selective PHC. public health decisions
Selective Primary Health Care (SPHC) has attracted
wide-spread attention as a major alternative to the
Primary Health Care (PHC) concept announced in
the 1978 Alma Ata Conference Declaration [1], The
SPHC strategy emphasizes ‘rationality’ and potential
cost-savings [2], By implication, it challenges govern
ments whose ministries of health joined WHO,
PAHO and UNICEF in formally adopting the pro
gram of the 1978 Alma Ata Declaration. We attempt
here to describe the historical context of this alterna
tive health service approach; to critically analyze its
methods and operational structure; to explore its
empirical foundation; to discuss the implications of
adopting this strategy for the health of developing
country populations; and finally to examine some of
the economic and political reasons for its current
notoriety.
THE ORIGINS OF SELECTIVE PRIMARY
HEALTH CARE
Approaches to health care in LDCs
In the late 1970s, when the Alma Ata Declaration
first was being implemented, the mix of health ser
vices existing in the Third World only approximated
the purity of health system models. These health
service structures could be grouped into three broad
categories tor presentational purposes:
(1) Hospital-oriented medical care;
(2) Vertical or disease-specific programs;
(3) Community-based primary health care.
Hospital-oriented systems. In most developing
countries, health ministry planning and policy agen
cies are dominated by a concern with treating the
sick. The hospital orientation associated with this
curative view has two distinct forms in most LDCs.
One form is a facsimile of European or American
systems. It is urban-based, highly technological and
often includes a major private sector component.
Originally designed to cater to a colonia population,
this system now serves the national or expatriate
middle- and upper-classes.
The other hospital-oriented form targets rural or
peri-urban needs, serves poor population groups, and
is usually state or church operated. In practice, the
hospital sector in LDCs encompasses both forms of
the hospital-oriented system and consumes about
80% of total health care expenditures [3].
Vertical or disease-specific programs. The success
of specific disease control measures that contributed
to the elimination of yellow fever, smallpox and
typhus in North America and Europe in the early
20th century encouraged the growth of vertical cam
paigns. These programs, targeted upon specific LDC
diseases, were recognized as having residual benefits
for the industrialized countries as well (e.g. the con
struction of the Panama Canal and the U.S. military
occupation of Cuba). Large American foundations
(Rockefeller. Ford) joined the U.S. military in the
early development of vertical disease control pro
grams and continue to show interest in this strategy
today.
Early WHO programs, typically vertical in nature,
enhanced the popularity of vertical interventions by
creating time-limited disease eradication programs.
Only the failure of campaigns against malaria and
trypanosomiasis in Africa and Asia (and to a lesser
extent in Latin America) has cast doubt on the ability
of vertical control programs to achieve significant
reductions of suffering and mortality in the long-run.
Community-based primary health care. Just as the
vertically-oriented smallpox campaign was reaching
its successful conclusion, the WHO and its Director^
General, Dr Halidan Mahler, began to advocate a
comprehensive effort to reach the entire world’s
population with horizontally-integrated primary
health care services (PHC). The personal and public
health services of the PHC model sought to improve
health status by the use of health auxiliaries and
1001
1002
Jean-Pierre Lncer and James R. Killingswortw
appropriate health technologies. The model sought to Alma Ata context (CPHC) is “unattainable because
provide acceptable, accessible services based 'upon of the cost and number of personnel required" Pl and
local initiative and maximum levels of communitv (2) even without water and sanitation included basic
participation.
health services (BHS) would cost billions of dollars in
The community-based PHC model was by no the view of the World Bank [2].
means a new notion. For decades, community-based
The operating assumptions of SPHC arc deter
services were advocated by King in Africa and Shaw
mined by one variety of rationalized choice. The
The
!" 2?*5 A membcr of the Bhore Committee
selection of a limited number ( usually 5-10) of health
(1946) John Cram argued for the integration of interventions is established by prioritizing diseases
vertically designed health interventions into a core of importance on I’
the basis of* prevalence, mortality.
more comprehensive health services [4]. Similarly, morbidity data and on ‘the feasibility of controF* As
Hugh Leavell, a Professor at the Harvard School of a result, SPHC health services "concentrate on a
Public Health and Edward MacGaveran, a Dean of ’ ' u
. problems
....................
minimum number of severe
that............
affect lanze
_ _ J *
the North Carolina School of Public Health, have Hl 1 rv-t krtre rn r
numbers of people and ignore interventions of low
firmly supported an integrated PHC approach [4]. questionable or i----_.T__ ".’’. Examples of
unmeasured efficacy
Through the Alma Ata Conference Declaration
interventions that would be ignored
-«?
—— because they
nJVy are
WHO and UNICEF formalized a consensus about
P '' to' control,' are: treatment of tuberculosis.
difficult
tuberculosis,
PHC standards that had already proven themselves
pneumonia, leprosy, trypanosomiasis, meningitis and
? n^uy
W°rld NatiOnS"ivug.ug
By —
acknowledging
helminths. These types of health problems,
r---------- “'mav
that Third World diseases result from poverty and
better be dealt with through the investment in re
that the health care system, “can be a lever for
search", since, in terms of potential benefit, "the cost
increasing social awareness and interest, initiative of research is low”.
and innovation" [I], the conference declaration imim
Warren suggests that the SPHC health services
plied that political commitment toward a reallocation
of scarce resources is required for implementing the structure would be a Christmas tree upon which
ornaments (independent interventions of ‘proven
PHC concept.
efficacy ) might be hung, one by one. The initial
There remains considerable practical debate as to
what constitutes appropriate primary health care in nature of the structure would necessarily emphasize
vaccinations in order to gain the high coverage
developing countries. PHC, by the WHO definition,
(greater than 90 /o) required to interrupt transmission
is broad in scope and includes:
of the major diseases such as measles. Interventions
health education
such as oral rehydration therapy for diarrhea which
food supply and nutrition
require a more stable, community-based health
water and sanitation
service structure would be introduced later on.
maternal and child health programs
Health services such as malaria, chemoprophylaxis
immunizations
or vaccines, schistosomiasis treatment, or other new
prevention and control of locally endemic diseases vaccjnes would be added rationally to the structure
as they become cost-effective in areas where such
treatment of common diseases and injuries
provision of essential drugs.
diseases were of high importance.
Despite its virtual overlap with the initial adoption
Because of its great range, this approach is often
of the PHC concept, the SPHC approach has
called ‘Comprehensive Primary Health Care’
continued to attract support. The American CDC
(CPHC) as distinguished from approaches which
has developed a series of training manuals for ihe
consider water, sanitation and food supply to be
Expanded Program of Immunization (EPI/WHO)
outside the scope of health care system responsibilitv.
and
the Control of Diarrheal Disease Program
The latter view is frequently referred to as ‘Basic
(CDDP'WHO) based on the ‘priority setting’ method
Health Services’ (BHS). Finally, PHC presupposes
(5). Specific CDC international programs emphasize
that its referral and supervisory network will be built
a selective intervention approach.
into a stabile health network.
In late 1982, the U.S. Agency for International
Development (USAID) sent telegrams to all Latin
Selective primary health care
American health stations orienting them to the em
Just as PHC concepts were first being implemented
ployment of the priority-intervention approach when
by Alma Ata signatories, Walsh and Warren
possible. Despite its deep involvement in the PHC
presented the SPHC approach to a joint Ford/ concept at the time of the Alma Ata Conference.
Rockefeller Foundation Symposium on Health Ser
UNICEF’s current health policy, as elaborated in the
vices in Bellagio, Italy. As an alternative to PHC,
selective primary health care would institute, "health December 1982 strategy, reflects a SPHC approach
(6J. A. W. Clausen, in his first health-related pro
care directed at preventing or treating the few dis
nouncement as President of the World Bank, stated
eases that are responsible for the greatest mortality that child mortality in the world could be cut in
and morbidity in less-developed areas and for which
half through the implementation of the new ‘tech
interventions of proved efficacy exist’’ (2J.
nological breakthroughs’ of oral rehydration therapy
Instead of a full health infrastructure based upon and vaccinations by means of an SPHC-like struc
primary health care, the SPHC approached would
ture [7]. In addition, the World Bank appears
reduce the scope of health services in accordance with ready to place billions of dollars behind the SPHC
the findings of cost-effectiveness analysis. Presum
approach: the former World Bank President, Robert
ably. cost-effectiveness analysis justifies a selective S. MacNamara and Dr Jonas Salk recently an
elimination of PHC services since (1) PHC in the
nounced the formation of a world-wide organization
r
i
Selective PHC: a critical review of methods and results
)
devoted to speeding up the application of selective
immunization interventions and diarrhea therapv in
low-mcome countries.
The WHO leadership and other PHC supporters
nave been less than enthusiastic about the SPHC
approach to primary health care. In an April 1983
M^S r/hC W°^ld HeaIth Assemb,y’ Dr Halfden
Mahler. Director-General of the WHO warned;
delTteS’ WhiJe uc have been slriking ahead
uith singleness of purpose in WHO based on your collective
decisions, others appear to have little patience for such
systematic efforts, however democratically they are applied
^ominarn 7/01,tunalc st^s thal ^gative impatience is
looming on the horizon and some of it is already peeping
over and gaimng superficial visibility.... I am referring to
selection by people outside the
• uch initiatives as the selection
•*developing countries of a f~
' •
few isolated
elements of primary
heakh
care for
oarachutino
nrrimplemenmtio'n
■ ..... ™
wundw; or
or the
the
nfze them from
agenltlnro lhcse counln« * immunize them
from above; °orr the
’e
aspect
ofdh?rT
thC concentration
concentralion on
on o-nk
only on
one
others lniri!iti«zA«.
. .
thought for the
others. Initiatives such as these are red herrings?.. With
out building up health infrastructures based on primary
will be dVfl’ ?dUfblC
WUl °n,y
Wasted’ and vou
will be deflected from your path”.
1003
planning methods converge with the political struc
turing of health systems (e.g. activity objectives best
suit centralized health systems while health demand
based planning methods apply readily to systems of
private medicine) and (2) health planning methods
are aIways to some extent ‘structure determinative*.
Of course, the choice of a planning method should
follow from the force and power of the method,
not primarily from its political goodness of fit The
eWxaminPH
SPHC method
inte^l
’ghL °nJy if il Su^rs from major
internal methodological flaws could
could its
its political
political and
and
economic attractiveness account for its enthusiastic
reception.
An exP,oratlon of the SPHC prioritization method
.a .ser,®s of questions about SPHC methodological adequacy. This approach to priorityAtting-one based upon the use of epidemiolosrical
information and extensively used by the American
£RErmUSt Proceed along several lines: 'the wav'ihe
SPHC approach determines its programmatic objec
tives. the SPHC view of resource utilization, and the
planning structure entailed by the application of
bPHC principles (14].
. The
alternative has already been the core
issue ol critical articles. With democracy and equity
as key criteria, Banerji [8,9] has contrasted SPHC Selling SPHC priorilies
methods with those entailed by the development of a
The basic objective of SPHC is the control of
na^°naJ health service. Briscoe [10] followed Walsh diseases
diseases m order to improve the health of a popuand Warren in the acceptance of cost-effectiveness
ahon. Improved health in this case amounts to the
raHking as a major criterion in the assessment of reduction of morbidity, mortality and disability, such
health services but reached dissimilar conclusions reductions being demonstrated by the diminution of
on the exclusion of \water
---- and sanitation activities, disease-specific mortality
' ‘J rate$ among ’prioritv* dis
Others have described the SPHC alternative
eases.
Walsh and Warren «-characterize
the dt'HL
SPHC
’ —a
.
Uai
me
thinly disguised return to technologically-oriented disease prioritization method as follows “in seleorina
vertical health care
j-*5™
'' receive the highest
treatment, four factors
■nnXitf r“ XiXkin82ihas been
leany. a major controversy is brewing with issues
of dollars wi" !* al|ocated for
ce ntng tmlhons of lives hanging in the balance. The
If"! I imi/trtrt
--------- .t •
__
following sections
of this paper offer
both a’conand empirical analysis of the underpinningsj
the selective strategy for primary health care.
METHODOLOGICAL ISSUES REGARDING SPHC
Obviously, quantitative planning is necessary for
any health manager—whether he holds to the ‘SPHC
position or to the ‘Alma Ata spirit’. Since a wide
variety ot quantitative planning methods are avail
able, health managers have options
exercise.
For
____ to
__ __
_
instance, iin the
■' realm of health manpower planning
a manager could assess manpower needs through a
planning base that emphasizes: (1) health needs
°JglCal ,nformaii°n), (2) activity objectives,
( ) health demand or even (4) arbitrary standards
(e.g agent/population ratios) (13, p. 94]. The variety
ot planning methods not only have specific- tech
nical advantages, drawbacks and justifications, they
convey as well a strong political valence.
Planning methods articulate with political struc
tures in at least a two-fold manner: (1) specific
ld be assessed for each diseasi
effica^and^)"
XX'
efficacy
and cost)”. CDC training mndni^J
5
for mid and upper-level EPI program manaXX
fo™ of an equation:'
' 'n the
*
PRIORITY
Importance of Disease
mortality; incidence; disabilitv
4- Likelihood of Success
government commitment; technical
and management factors; public
response.
The SPHC prioritization method is inseparably
integrated into the next step, the selection of an
appropriate health care system for intervention,
Appropriateness turns upon the ’reasonable cost’
an
. ^ -Practicibility
v ‘ ot
-- the
— health
,,i care system in Ques
tion and Walsh and Warren analyze health svstem
structures on the basis of these criteria [2], '
The interventions relevant to the world’s developing areas
which are considered arc comprehensive priman “health
care .basic primary health care. multiple 'diseasendT, TTk” (e-S- inscclicidcs- wa*r supplies), selective
primary health care and research.
This set of objectives appears to follow from the
application of a logically related series of procedural
steps: (1) an objective selection of diseases of great
1004
Jean-Pierri Unger and James R. Killingsworth
importance for an area, (2) their prioritization on the lion or for the re-allocation of resources in the health
basis of whether they can be controlled feasibly and sector of Third World countries.
(3) the creation of a health system around the inter
The •likelihood of success- feature of SPHC and
vention scheme which has been selected.
CDC priority-setting procedures makes evident the
Objective selection of diseases. The characteristics value-laden nature of -feasibility’. The feasibility of
of epidemological data in the less developed world control of a particular disease is as much a function
may jeopardize the validity of the simple and appar of value preferences about health systems as it is a
ently sound SPHC method. Epidemiological data matter of empirical analysis. Immunizable diseases
required tor an initial SPHC prioritization as well and diarrhea treatment, for example, are thought
as for subsequent monitoring of disease-specific ‘feasible’ because they are viewed as diseases that can
mortality rates are of uniformly poor quality in • be effectively managed in a vertically-oriented system.
LDCs. Cause-specific mortality rates are particularly Pneumonia treatment requires the skill of a medical
unreliable due to the lack of adequate diagnostic assistant and a continuous drug distribution network,
measures.
facts which reduce its 'feasibility of control’. On the
A high percentage of causes of mortality cannot other hand, mobile teams are ruled out altogether,
be identified, even when surveillance programs estab since they cannot address the treatment of acute
lished expressly for that purpose have been devel conditions, due to the absence of the mobile team
oped. The 1980 Bangladesh child mortality survey, when the episode occurs.
for example, failed to identify the cause of 44% of
The overall impression created by ‘feasibility of
inlant deaths [15]. In addition, seasonal fluctuations control' in the SPHC method is that it amounts to a
compound the difficulties of analyzing annual rates circular logic. A selective analysis of health care
that summarize mortality. The intermediate aim of organization determines priorities for disease control
reducing disease-specific mortality suffers thus from while it is being claimed that prioritization leads to
data imprecision.
the choice of health care intervention systems.
Related!}', the uncertain weighting scheme used in
Diseases of importance. By the account of Walsh
prioritizing diseases for intervention through the and Warren, medical interventions appropriate to
SPHC method combines conceptual ambiguity with prioritized diseases are stratified, “from the most
data imprecision. Obviously, the product of a rela comprehensive to the most selective-- [2], But the
tively precise parameter and a defective coefficient decision to focus on only 8-10 diseases, regardless of
will be a parameter which is itself defective. Clearly, which diseases are eventually selected, limits health
it is questionable to rely upon this method not only services, predetermines the level of medical inter
for the identification of disease priorities but above vention and concentrates attention on diseases that
all for the designing and planning of the related cause high mortality. Largely ignored are the major
health system.
ity of conditions, i.e. those which cause the bulk of
Feasibility and SPHC objectives. Determining pain, suffering, and disability among a population.
‘feasibility of control' is not simply a matter of
This is true even when appropriate interventions
scientific assessment. Obviously, the absence of a might be available. Although the SPHC approach to
biomedical tool suitable for treatment or prevention ‘importance of disease’ draws upon a definition of
of a condition rules out its control. When a tool is considerable theoretical scope, the practice of SPHC
available, however, its ‘feasibility’ is often a function method [19] leads to an almost exclusive consid
of the health system that uses it. Tuberculosis con eration of diseases which cause high mortality and
trol. for example, it not feasible in a vertically- which enjoy ‘feasibility of control’"
oriented system that uses interval-bound mobile
One important result of the SPHC emphasis on
teams or poorly trained Community Health Workers mortality is an overriding interest in childhood con
(CHWs). Tuberculosis control, on the other hand, ditions. As Julia A. Walsh put the matter [20], -‘since
may be feasible in the context of an integrated CPHC infants and' young children"
w *'*-‘--.1 are at greater risk of
or BHS system where medical assistants practice mortality and morbidity, then health care should be
primary care with the aid of well-crafted treatment primarily directed towards them”. Infants and young
strategies and adequate supervision.
children are at greater risk than most other popu
As SPHC proponents proceed to gauge feasibility lation groups. They represent a large component of
of control, they are often selective in their view of total mortality in LDC's and SPHC appropriately
‘feasible’ health systems. The feasibility of control addresses itself to their pressing problems. While the
permitted by PHC systems is assessed in terms of the SPHC strategy does not by-pass adult disability and
existing state of organization and management in suffering intentionally, the constraints of the SPHC
LDCs, usually called ‘inadequately developed’ and method establish prioritized objectives and preferred
overly exhaustive [16-18]. On the other hand, the intervention schemes that do very little for adult
health system structures involved in determining health problems.
feasibility of control for SPHC systems tend to be
When the 'importance of disease’ measure is fur
judged on the potential efficiency of future tech ther refined, as Berggren et al. [19] and the Ghana
nologies (e.g. new vaccines, single-dose therapies) Health Assessment Team f21] have attempted, the
rather than upon their current or demonstrated SPHC/CDC prioritization approach only serves to
effectiveness.
compound me
the piuu«cins
problems nivoivea
involved m
in concentrating
concentrating
.......................
While potential technological developments appear upon childhood
mortality. Their substitution.3of ‘days
to offer hope for improving health status in the of life lost’ or 'years of life saved’ for total mortality
future, the SPHC literature envisions little prospect figures suggests that a day of life at any age is equally
for improved management, training, and organiza- valued. In consequence, the value of a 7-day-old
A
Selective PHC: a critical review of methods and results
infant with neonatal tetanus is ‘twice’ that of a
20’year-old with tuberculosis. The life expectancy
patterns in most LDCs, however, calls this into
question. Life expectancy in Liberia in 1971 [22], for
example, was only 45 years and the chance of dying
before age 4 was almost 24% in Malawi. Nevertheless
a 25-year-old male’s life expectancy was nearly equal
to that of a person living in a developed nation (38.3
in Liberia, 1971; 47.3 in Canada, 1971) [23].
But even if'days of life lost’ were somehow' ‘prop
erly’ weighted to reflect factual life expectancies, the
SPHC method would still yield a high priority for
childhood mortality diseases due to its focus on 8-10
conditions. The relatively high valuation of children’s
health problems by the SPHC approach raises serious
questions for planning applications of the SPHC
method. Third World communities may hold value
preferences distinctly at odds with an emphasis on
childhood mortality, in part, at least because adult
manpower is indispensable for community survival.
Expected intermediate outcomes for SPHC
Intermediate SPHC goals are almost all related to
a single, general intermediate goal, namely reducing
disease-specific mortality. The methods of SPHC
explicitly assume that a reduction in a certain few
disease-specific mortality rates will result in a reduc
tion of the overall mortality rate for a population.
This assumption is uncertain at best in developing
nations where mortality follows from the myriad
health insults associated with poverty and where
suitable epidemiological information is in very short
supply.
It is likewise questionable whether an attempt to
reduce the disease specific mortality rate of a very few
pathologies can yield success in the reduction of a
population's overall mortality rate. Noting the
difference between diseases registered as the cause of
death and the determinants of death in an area,
Mosley [24] has proposed that child and infant death
has no discrete cause. Childhood mortality is, rather,
the result of a long series of recurrent infections and
deficiencies, particularly deficiencies of food intake.
To overlook the complex nature of childhood mor
tality could lead to: “recommendations for diseaseoriented technical intervention programs that fail to
achieve their goals, a typical example being supple
mentary feeding programs to combat malnutrition'’
[24],
Recent reports from Kasongo, Zaire have under
scored the serious nature of Mosley’s contentions.
These reports suggest that measles vaccination pro
grams which result in a reduction of measles mor
tality may simply shift mortality to other diseases and
conditions without affecting the overall mortality of
the population [25]. The results of the Kasongo
study, it should be noted, are a matter of current
debate [26]. Nevertheless, critics concede the serious
ness of the questions raised and call for further study
of the Kasongo report’s major questions.
The SPHC method, through its focus on medical
interventions of narrow scope aimed at reducing
disease-specific mortality among the children of an
area, appears to overlook the cautionary issue raised
by the Kasongo study. If it is true, that measlesvaccinated, malnourished children perhaps will die of
1005
pneumonia instead of measles, then this disease
specific mortality shift from one disease to another
requires a wider scope of PHC activities.
It should not be thought, however, that measles
vaccination stands alone in raising questions about
SPHC intermediate goals. Oral rehydration is a com
pulsory component of any selective strategy [2, 7, 19]
due to the fact that:
. in most developing coun
tries, diarrheal diseases rank among the top three
‘causes of death’ among infants and young children
along with respiratory diseases and malnutrition”
[24, p. 33]. However, Mosley considers that it is a
great leap of faith to expect that oral rehydration
therapy can reduce the overall mortality rate: . it
becomes evident that a strategy which is directed
toward treatment of the diarrheal cases is likely to be
ineffective, while a strategy which can reduce the
diarrheal incidence may expect to achieve substantial
reduction of mortality” [24, p. 34].
Areas dominated by poverty and malnutrition are
not likely to respond to narrow SPHC activities.
Technical approaches too frequently gloss over this
underlying problem:
. in any PHC program that
takes the narrow technical or ’selective’ approach, an
underlying premise must be that there is no absolute
poverty or severe food shortage in the population”
[24].
These observations about SPHC intermediate
goals are especially pertinent, given the cost
effectiveness contentions that serve as the underlying
SPHC rationale. If SPHC methods target a reduc
tion of disease-specific mortality among children in
resource-poor areas of the world, then selective
disease-control programs are most likely to be used
in the very areas where an unfavorable nutritional
background may doom the SPHC intervention to
failure. As WHO notes, 47% of Asian preschool
children and 30% of African preschool children were
wasted in 1983 (China not included) [27],
SPHC method and resource utilization
Selective methods apparently encourage the
rational use of scarce health resources in developing
countries since a narrow group of activities are
targeted for the control of 5-8 prioritized diseases. In
several major health planning areas, however, the
consequence of using SPHC methods may be a
misuse of scarce resources, not a rational plan for
their conservation.
Physicians and hospitals. With the physician and
hospital-centered elements of most LDC health in
frastructures absorbing 80% or more of developing
country health care budgets, attempts to rationally
introduce primary health care must include referral
functions in overall planning.
However the SPHC approach calls for extremely
limited curative roles through its selectivity. Walsh
and Warren indicate only malaria, diarrhea and
schistosomiasis [2]; UNICEF suggests only diarrhea
and malnutrition [6]; both the GOBI-FF program
and the Deschappelles program [19] propose diar
rhea, malnutrition and tuberculosis as priority dis
ease conditions requiring curative activities. On the
other hand, Walsh and Warren call for "temporary’
controlling for tuberculosis, pneumonia, leprosy, try
panosomiasis, meningitis and helminth [2|. These
1006
Jf.as-Pierr£ Unger and James R. Killingsworth
choices tend to isolate PHC from curative services by
reducing the scope of the curative role to 2 or 3
treatments at the PHC level.
With curative roles focused on only 2-3 disease
conditions, hospital utilization patterns are not likely
to be modified by the creation of a PHC network. It
is significant to note that these utilization patterns arc
known to be unfavorable in the Third World. At
Mityana hospital, for example, a utilization analysis
showed that 40% of those in the wards could have
been treated by ‘self-care’ facilities [28]. The same
hospital showed that, “the average number of out
patient attendances per person per year falls pre
cipitously the greater the distance that separates the
patient's home from the hospital” [28]). The study
concluded that, “Taking services to the people is the
main way of correcting this imbalance" [28].
In Kasongo, the SPHC key interventions are part
of a basic health service package—one emphasizing
both curative and preventive activities. These inter
ventions account for an 85.6% reduction of hospital
admissions due to diarrhea, diptheria, pertussis, tet
anus. malaria, malnutrition and measles in areas
covered by the project. As compared to total excess
hospitalization in areas not covered, this coveragerelated reduction still represents only 28.6% of the
reduction possible through a basic health services
(BHS) package (unpublished data of the Kasongo
Project Team).
The modest Kasongo results were achieved by
medical assistants working in a health center net
work. Of necessity, Village Health Workers (VHWs)
would find it most difficult to apply appropriate
referral criteria. Similarly, mobile teams would not
offer the permanent presence required by curative
activities. In relation to the reduction of excess
hospital utilization, the SPHC results are likely to be
lower than those observed at Kasongo.
As a consequence, hospitals will continue provid
ing primary health care, though access to hospitals
will remain restricted to those living nearby and to
the wealthy. The isolation of primary health care
from curative services encouraged by the SPHC
method will sustain this arrangement.
Physicians raise similar problems. Because of their
relative scarcity, physicians in LDCs must be used
where their skills are needed most. Encouraged by
their Western-training and by the location of hospital
facilities, physicians in developing countries com
monly remain in their nation’s largest cities or they
emigrate to more developed countries.
To meet the test of rational resource allocation in
this regard, SPHC should require the redirection of
physician services from the over-doctored cities to the
doctor-scarce countryside. But the methods of the
selective strategy are not suited to accomplishing
physician redirection. Within the PHC system and
pursuant to the narrow scope of foreseen activities,
an SPHC approach would confine physicians to
extremely simplified, mostly non-medieal work, in
cluding personnel management, supply maintenance,
and limited epidemiological surveillance. A manager
with narrow epidemiological training might function
as well as a physician in such a role.
Since a PHC system would address only 2 to 3
curative activities when operating under SPHC
assumptions, it would not be able to screen
patients, successfully referring patients to levels of
care requiring physician skills. These physicians
would remain within the classical first-level of
curative responsibility.
In consequence, SPHC methods put a double
burden on any attempt to decentralize and redirect
physician skills in LDCs. First, in restricting the
physician's role to a few skill areas, the SPHC
approach tends to rob the physician of motivation to
leave urban areas. Second, by reducing rural inter
ventions to management tasks, SPHC methods dis
courage LDC physicians from incorporating public
health notions of their nations into their day-to-day
activities.
By contrast, Comprehensive Primary Health Care
(CPHC) systems and methods would formalize, stan
dardize and subsequently delegate to medical assist
ants the curative and preventive tasks performed by
a general practitioner. Since such a comprehensive
approach would require that physicians be involved
in carefully analyzing their own work in order to
write strategies and instructions for medical assist
ants. the physicians of developing countries would be
deeply and rationally involved in PHC activities.
Under the CPHC design, this involvement would also
call for regular physician supervision of medical
assistants.
SPHC methods, on the other hand, apparently
deny a role to medical assistants. Disease control
activities limited to less than 10 conditions do not
require the broad skills of a medical assistant. Gen
eral practitioners, like medical assistants, would find
that the SPHC structure offered them no effective
supply system, no regular supervision and virtually
no referral network. Under-utilization of medical
assistants and other general practitioners would be
the likely result of any attempt to supplement SPHC
methods with a more rational use of personnel.
Community health workers. Selective methods give
community health workers (CHWs) a pivotal role.
In fact, the inclusion of CHWs is presumed to be a
rational characteristic of SPHC, one distinguishing
it from strictly vertical programs. In theory, the
CHW links selective interventions with the com
munity, thereby lowering program costs. Though
not described uniformly, village health workers
have as primary tasks the organization of commu
nities for vaccination and the administration of oral
rehydration solutions.
The claim that CHW activities such as these are
comparatively inexpensive does merit examination.
Much of a CHWs resource efficiency stems from the
CHWs short training period and low wages. An
analysis of 52 USAID assisted health care projects
[29]—most of which were designed along the lines of
SPHC concepts—reveals that 86% of the CHWs
involved were trained for less than 2 months. More
than one-half were trained for 2 weeks or less.
While training of this sort obviously lowers direct,
financial costs, the training is not adequate for
many of the tasks identified through the use of
selective disease-prioritization methods [30], Most
targeted SPHC conditions* for example, involve
immunization only. The limited training of CHWs
would not permit them to perform these immun-
Selective PHC: a critical review of methods and results
izations, thus necessitating the use of mobile vacci
nation teams. Field studies conducted in accord with
selective methods, such as those by Berggren et al.
in Haiti [19], rely upon hospital-based activities in
stead of the interventions of CHWs. Only oral re
hydration therapy appears well-suited for the com
petence of the CHW and even this intervention
requires experience and clinical judgment for success
ful case management.
The apparent cost-savings which accrue from the
use of CHWs also must be matched against the
opportunity costs of such volunteers, including time
lost from harvest and cultivation. These losses to
the local economy combined with other pressures,
such as the difficulty CHWs face in gaining commu
nity respect and acceptance, tend to produce a high
level of attrition and turnover among CHWs. In
Nicaragua the rate is reported to exceed 35% [31].
The stress of SPHC upon undertrained village health
workers turns the question of cost-savings into one
about rising long-term costs and the reliability of
undertrained health workers. The statement by
Walsh and Warren that, “these services could be
provided by fixed units or by mobile teams” [2], is a
claim of flexibility not supported by CHW capabili
ties and one that is undercut by program limitations.
In consequence, the selective strategy appears com
pelled to fall back to a first reliance upon mobile
teams at the expense of other health infrastructure
elements.
Vertical structure and selective methods. Because
selective primary health care methods rely upon
the mandatory use of mobile teams, the SPHC
operational structure closely resembles that of a
traditional vertical program [8], Typically vertical
programs are organized along military lines. As a
result, they tend to be isolated units standing apart
from the larger health care structure about them,
both in terms of budget and administrative func
tioning. Verticalist concepts have been characterized
as favoring, “categorically specific, hierarchically
organized, discrete disease control programs” [32],
Although preventive care may be provided by
periodic services, curvative care requires the presence
of a permanent structure. As a result, multiple
health problems are not included within the scope of
effort of the mobile team program. In addition,
vertical schemes overlook the advantage of integrated
preventive and curative health care [33].
The CHW/mobile team structure that SPHC re
quires enjoys neither the increased health team
prestige that results from its curative efforts nor the
improved coverage and effectiveness which belongs to
a system whose personnel gain an increased socio
cultural knowledge of an area as they remain in one
location. Further, vertical structures by their nature
cannot take advantage of information generally
available through CPHC approaches, particularly
the integrated, centralized information that CPHC
systems gather regarding medical histories and
preventive health statuses.
In practice, the costs of vertical intervention struc
tures frequently undermine whatever feasibility exists
in their program design, thereby placing a burden on
other health system structures. As Oscar Gish has
noted: “special campaigns [vertical programs] ab-
1007
sorbed more resources than did the whole of the
country’s health sen-ices located outside the larger
cities and towns” (Note that this statement docs not
refer to a specific country [32, p. 207]).
Finally, SPHC interventions tend to place tight
limits on popular participation in the planning of
programs. They require an extremely close fit be
tween focused goals and the elements of vertical
design so that the selective strategy almost certainly
precludes participatory modification of the health
care agenda created for an area. With participation
reduced or practically eliminated, perceived commu
nity needs—already understated by the SPHC em
phasis upon the problems surrounding childhood
mortality—tend to be overlooked. To ensure that
health problems match-up with the SPHC approach,
community participation is likely to be replaced with
community manipulation.
Quantitatite planning: an alternative to the epi
demiologically based planning approach
As noted above, epidemiologically based planning
is but one specific form of quantitative health plan
ning. An alternative form includes normative con
siderations. Instead of defining health planning
objectives as the reduction of a few disease-specific
mortality rates, these objectives could represent the
commonality between the felt needs of the population
(mostly curative ones) and health needs as defined by
professionals. This more normative approach can be
schematized as follows:
demand
fek needs
objective needs
This is a dynamic scheme which takes the demand
factor into account thus enabling health services to
communicate with people so as to
(1) attempt control of 'irrational- demand
(“irrational” quest for therapies such as vitamines or
injections)
(2) increase the felt needs, that is make people
aware of “objective” needs.
Under this scheme, the fit between the planned health
structures and related health activities could not be
too tight.
A normatively grounded alternative to epidcmiologically quantitative health planning would
stress two characteristics for planned primary health
care systems: (1) they should rely upon polyvalent
health teams and (2) they should consist of suffi
ciently decentralized but fixed units. Pivotal deter
minants of concentration of health professions and
facilities would include the following elements:
(1) geographical accessibility via decentralization
(2) PHC facilities scaled to 'human size'
1008
Jean-Pierre Unger and James R. Killingsworth
(3) consideration of decentralization costs
(4) reduced technical performance linked with
highly decentralized effort
(5) resource constraints.
The normative-quantitative planning alternative
recommends a structure-based planning approach
within which activity objectives would be regionally
and locally established. Such a planning strategy does
not eliminate the need for well-defined priorities. For
example, health center supervision can underscore
the importance of oral rehydration or immunization.
Instead, it advocates quantitative planning on both
professional and local or community criteria.
JLST1FICATION FOR THE SPHC POSITION
Empirical support for the SPHC position is quite
limited since there are only a few field reports avail
able to support its claims. In addition, the cost
savings claimed for the selective approach to primary
health care involve an unorthodox approach to
cost-effectiveness analysis.
Empirical support for SPHC
The SPHC approach formally described by Walsh
and Warren relies upon 7 field reports for its substan
tiation, one of which remains unpublished. Walsh
and Warren first cite a field study from Guatemala.
Gwatkin et al. [34] have suggested that numerous
complications prevented the Guatemala investigators
from reaching unambiguous conclusions.
The Jakhmed (India) project, a second study that
Walsh and Warren cite, cannot be used for substan
tiating the SPHC position since the project under
investigation provided, "...a wide range of nu
trition. health, and family planning services" [34].
This makes the Jakhmed project inappropriate for
bolstering a SPHC viewpoint. Because it was clearly
a simple, vertical program and not a selective one.
the Hanover (Jamaica) project listed by Walsh and
Warren cannot be used as evidence for the value of
SPHC: furthermore it dealt only with malnutrition.
The Walsh and Warren reference to the Ghana
primary health service system is in fact a reference to
a comprehensive not a selective system. Finally, the
Narangwal project [35] cited by Walsh and Warren as
empirical support for SPHC involved projects in 4
villages, each with a different health care activity,
nutrition, curative care with a physician back-up.
nutrition and curative care, and a control village. The
separate Narangwal activities best fit either simple,
vertical intervention formats or coincide with CPHC
functions, not SPHC medical intervention schemes.
In a critique of the studies Walsh and Warren list as
support for the selective strategy, Gish remarks that
the, .. authors [Walsh and Warren] confuse diverse
pilot project research results with World Bank esti
mates [and] with their own data based on [an] African
model area” [32].
Substantiation for the selective disease-control
strategy reduces itself primarily to the field report
from Berggren er al. [19] conducted in the De
schapelles area of Haiti. The results of the Haitian
project are cited as evidence of what a selective
approach ("the same approach advocated in our
paper” [20]) can achieve. Because it is central to the
credibility of the selective strategy for disease control,
it is worth examining the design and empirical claims
of the Berggren et al. study.
Haiii project. The Dcschapelles project prioritized
8 identified disease conditions and then targeted them
for intervention in a small (5x5 km) census tract.
The population of the area was approx. 10.000 and
the tract contained a 150-bcd hospital with a staff of
13 physicians. Before and after medical interventions,
the authors measured disease and age-specific mor
tality rates in the census tract. They concluded that
a selective approach significantly lowered mortality
rates. These claims are open to dispute since the study
exhibits a number of deficiencies. In particular, its
outcome indicators are not controlled, it uses external
standards in a context bereft of external validity, and
the program appears to be more expensive than
SPHC programs.
External standards. Results from the Deschapelles
study are presented by a comparison of death rates
in the targeted area and available national estimates.
Kenneth Warren cites the outcome of this compari
son as evidence for SPHC effectiveness: ’’mortality
rates fell progressively during five years to levels only
one-fourth as high as the national estimates' [20].
The Haiti Project's use of external standards is
open to question in 4 major respects. First, beginning
and final figures of the study are not derived by
similar methods. The beginning figures came from
interviews while the ending ones came from a process
of longitudinal follow-up. Second, during the
project’s first year, the mortality rate for 0-1 age
groups in the Deschapelles area was 55/1000 while
the comparable figure for all Haiti was 146.6 1000
[36, p. 14). a figure almost three times greater than
that of the experimental area. Third, among all areas
of Haiti, the Deschapelles sector showed the lowest
prevalence of Gomez' Stage-1 II malnutrition [37],
still another indication that it was an exceptional
area. Finally, the superiority of agricultural prod
uction in the Artibonite valley, where Deschapelles
is situated, makes it one of Haiti’s superior nee
producing locations.
In consequence, the use of internal comparisons
and beginning-to-end death rate figures suggest that
the selective Haiti program may have had a much
lower impact (if at all) upon the mortality of the
Deschapelles area than a comparison with 1972
national figures would suggest.
Confounding socio-economic factors. Forty-three
per cent of the total mortality decline claimed for the
selective interventions of the Haiti study can be
attributed to malnutrition deaths averted. There are
sound reasons for skepticism concerning this claim.
First, the zone of greatest mortality reduction for the
Deschapelles program falls into the second priority of
diseases listed in the Walsh and Warren version of
SPHC [2]. It is surprizing to see this element of the
Haiti project succeed more markedly than activities
more highly favored by the SPHC strategy, for
example measles or tetanus. Second, the reported
43% decline in malnutrition deaths averted is particu
larly surprizing. Results of a Colombian study [38,
p. 167] indicate that the greatest reductions of infant
mortality rates are to be achieved through supple-
Selective PHC: a critical review of methods and results
1009
mental feeding programs that target pregnant
Empirical adequacy, [n asserting that SPHC is,
women. This was not the approach used in the “potentially the most cost-effective type of medical
Deschapclles field trial, a fact which raises further intervention” [2], Walsh and Warren demarcate an
doubt about tracing malnutrition deaths averted to exceptionally wide scope for their cost-effectiveness
the Haiti project’s selective interventions.
comparisons. They make head-to-head comparisons
Confounding socio-economic factors are perhaps between five approaches: CPHC, BHS, Multiple
at the root of the increasing number of malnutrition Disease-Control Measures, SPHC and research. In so
deaths averted which were reported in the Haiti doing, Walsh and Warren impose considerable strain
study. Despite the fact that Berggren et al. identify a upon the cost and effectiveness data of their report.
series of such factors (housing, food preparation,
First, the cost and effectiveness estimates relied
latrine availability, protected water supplies), they do upon in the Walsh and Warren cost-effectiveness
not show their constancy across time. Even more discussion are heterogeneous and derived from mul
importantly, food availability is not discussed, a fact tiple sources: WHO. the World Bank, bi-lateral field
that raises questions about the degree to which the projects and diverse research programs. Although
study’s overall results are confounded by intervening these cost figures may be completely adequate when
variables.
taken as isolated data, the sweep of the Walsh and
Confounding hospital activities. Findings in the Warren cost analysis leaves numerous un-answered
Haiti study do not adequately control for the impact questions. Were the cost estimates of their study
of Albert Schweitzer Hospital activities upon re reported in the same manner and with equal com
ported mortality rates. The facility was located less pleteness, particularly in the case of estimates about
than 3 km from the surveillance area under study. training, indirect costs at the referral level, and the
With respect to this confounding influence, it is value of volunteer labor [40, pp. 27-49]? Did the
demonstrable that the introduction of prioritized various sources of data rely upon a uniform method
health care activities failed to statistically modify the and rate for discounting reported cost figures? Were
targeted disease-specific deaths as a proportion of the costs discounted at all? Since pilot programs and
overall deaths in the area. A Iwo-taiied Z-test for field studies can change greatly in terms of costs when
proportion (P = 0.2270) does not reject the equality they are ‘scaled-up’ to national levels, it should be
of 1968 and 1972 proportions at the 0.05 level. known whether (and how) national cost estimates
Specifically, the following assertion in the Haiti study were compared with those derived from projects of
must be called into question: “the hospital services smaller scale. How were project and research cost
probably achieved their maximum impact during the figures reconciled?
12 years before the health surveillance and health
Problems also appear in the Walsh and Warren
services began. The impact of health surveillance and effectiveness data as well. By supporting their selec
health services is therefore reflected in the changes in tive strategy on the basis of heterogeneous findings,
mortality rates after 1968" [19].
it remains unclear whether multi-outcome programs
Reliance upon the findings of Berggren et al. were demoted in importance by definitional fiat [40],
as a provisionally adequate defence for selective The decision to compare the effectiveness of research
disease control interventions poses serious difficulties, with primary health care programs designed for field
W'hen the Deschapclles activities were extended to implementation seems equally open to doubt,
three other Haitian areas (each with a population of
The considerable gap between SPHC costs per
10,000 persons), overall mortality rates only slightly capita (1978 S0.25/capita/year) and those reported in
decreased in two of the three while actually increas- *'
the "
Berggren er al.’ field trial (1981 $1.60/capita/year)
ing from 78 to 89/100 in the third [39], Further, it [19] raises still further questions about the empirical
should be noted that the activities introduced by adequacy of SPHC cost-effectiveness comparisons. If
the Haiti use of the SPHC approach fall well within these disparities were projected straightforwardly to
the range of comparable Basic Health Services a national scale, they alone are enough to dampen
(BHS) expenditure levels and cannot easily serve as enthusiasm for the potential cost-savings of the
a normative cost model.
SPHC approach. Finally, it should be noted that
BHS field cost reports [41] disagree with the BHS cost
Cost-effectiveness justifications for SPHC
figures reported by SPHC supporters [2, 42],
Cost-effectiveness analysis is a relatively flexible
Conceptual adequacy. Health planners and
and non-dogmatic mode of economic analysis which decision-makers> are best served by cost-effectiveness
should bolster the contentions of national healthcare analysis when a conceptually clear cost constraint or
strategies. As decision-makers consider careful cost- program objective has been set for the analysis. To
effectiveness analyses, for example, they remain free compare alternatives successfully, cost-effectiveness
to apply variable standards and situation-specific analysis requires compliance with several procedural
criteria in setting priorities and in selecting program requirements:
objectives for their area.
The 1978 Walsh and Warren article sought to link
a clear operational definition (or set of definitions)
SPHC and cost-effectiveness analysis quite directly for the program to be analyzed
[2J. Instead of demonstrating the usefulness of
r
a careful computation
of net costs and net health
cost-effectiveness analysis in the planning of primary effects among the alternatives being compared
health care programs, the Walsh and Warren article
an exact specification of decision rules to guide the
sought to use cost-effectiveness analysis as a selection of preferred alternatives
justification for normative claims, thereby exceeding
a sensitivity analysis to probe areas of uncertainty
the careful limits of the technique.
in the study.
SS.,M. H. 10—B
1010
Jean-Pierre Unger and James R. Killingsworth
The Walsh and Warren comparisons violate these
rules of conceptual adequacy at several points. First,
comparisons between CPHC and SPHC only doubt
fully meet the standards for operational definition.
Second. CPHCs multiple program outcomes require
that it be treated as a cluster of programs, each
scaled-up individually for comparison with the single
programs of BHS and SPHC. In the absence of such
treatment, its net costs and net health effects are
extremely hard to compute.
Third, the teasing out of cost equivalents to form
valid cost-effectiveness ratios would be most chal
lenging in this case, to say the least. Fourth, the
Walsh and Warren report is silent about the sub
ject of a conceptually clear decision rule and makes
no use of sensitivity analysis. The absence of a
sensitivity analysis affects the assessment of alterna
tive approaches adversely. For example, in specific
areas such as water supply, an analysis that allowed
existing expenditures to be redirected away from
inferior water services has shown that long-term
PHC costs decline when water quality is improved
[10]. Finally, the criteria pertinent to broad-scope
cost-effectiveness comparisons (e.g. ‘equity’ and
‘efficacy’) are missing from the Walsh and Warren
report.
Cross-strategy comparisons. Cost-effectiveness
analysis is poorly suited to determining what pro
grams a society should pursue [43], Its forte lies in the
realm of allocative choice, not normative or distribu
tive judgment. Walsh and Warren, however, use the
technique or accomplish cross-strategy comparisons.
In so doing, they reveal normative intentions whose
distorting impact may underlie the conceptual prob
lems of their study. In effect, the Walsh and Warren
use of cost-effectiveness analysis substitutes for mea
surable, comparable program alternatives a group of
proxies for entire health care strategies.
At issue in these comparisons are: choices about
how a population values the existence of a rural
health care infrastructure, about the extent to which
an area’s health care system should be fundamentally
participatory, about the degree to which a health
system should stress objective and extra-local health
criteria rather than the ’felt needs’ of an area, and
about the extent to which health services will be
privately owned and operated. These are valuative
elements in the Walsh and Warren cost-effectiveness
analysis. As integral features of the proxie measures
just noted, they inject value elements that confound
the attempt to make cross-strategy comparisons.
DETERMINANTS OF SPHC ADOPTION
The selective strategy of disease control has
prompted considerable comment and has been well
received by international agencies (World Bank,
UNICEF), academic institutions and research centers
(Centers for Disease Control; Harvard University),
bilateral cooperation agencies (USAID) and private
institutions (Ford and Rockefeller Foundations).
Given the empirical weaknesses, methodological
problems and conceptual difficulties of the SPHC
position, however, it is important to explore some of
the less apparent reasons for SPHCs popular recep
tion and for the magnitude of funding already ear-
marked for its implementation in developing areas.
When this is done, SPHCs widespread appeal seems
to be the coincidental result of constraints and chal
lenges facing influential, independent decision
makers, forces leading them to endorse a primary
health care strategy with strong appeal to their
training in 'classical’ public health.
Political and economic valence of SPHC
The expanding body of pathologies that burden
the population of the Third World are paired
with budget reductions [44] that threaten disaster.
These constraints from the external environment of
international cooperation agencies are matched by
‘internal forces’ of no smaller significance:
1. Results.
Donor agency funding requires “results” within the
period of the agency’s mandate, a pressure which encour
ages short-term planning and readily measured program
objectives; this rules out the measurement of factors such as
the avoidance of suffering and the import of participatory
structures; it also slows the creation of health infrastructure.
2. Privatized Service.
International agencies, recognizing “political realities",
seek to achieve larger macro-economic objectives through
their funding strategies, not the least of which is the
establishment of a uniform economic pattern for the recip
ient nation; this leads to an increasing of the private medical
sector, an expanded donor agency influence over the recip
ient nation's economy, financially and geographically in
accessible private care and a weakening of curative and
preventive service integration (the concept of health service
responsibility for a well-defined population is strained
greatly by rapid expansion of the private, curative sector).
3. Donor Clientel Expansion.
Leading donor agencies recognize that supporting of
medical programs in recipient countries is only one element
in the process of political-economic barter; as donors seek
to expand their number of recipient clients, health con
tributions to individual nations approaches the floor below
which no modification of health care can be achieved.
4. Research and Commercial Outlets
The cooperative activities of funding agencies frequently
aim at the promotion of significant financial and research
outlets for corporations and leading academic institutions of
donor nations; this results in reversed priorities; even before
the benefits of existing technologies are disseminated to
recipient nations, “space age” technologies arc given enthu
siastic support (e.g. vaccines and other fruits of genetic
engineering); the research concerns of donor agencies sup
plant the applied research interests of developing nations
[45].
5. Financial and Institutional Status Quo.
Institutionally, international cooperation agencies and
research institutions seek to respect the financial and institu
tional status quo of recipient nations: this favors the adop
tion of health program strategics placing little constraint
upon national health budgets and making only minimal
demands upon the existing institutions of the recipient
nation.
6. Reduction of Public Expenditures
Despite the seeming paradox, optimizing the costeffectiveness of a health system can entail the introduction
of a new’ level of health care services. The paradox is
only apparent, however, since introducing Village Health
Workers for the sake of cost-effectiveness generally leads to
the dismantling of the health center and dispensary network
of the state. While VHWs reputedly are self-supporting.
Selective PHC; a critical review of methods and results
10H
Table I. Order of the priorities for the study of causes of death according to indices of incidence, importance and vulnerability (Stale
of Aragua. Venezuela. I960)
Causes of death
_____________(ri____________
Dysenlry. gastritis duodenitis, etc. (B6. B36)
Premature births
Influenza, the pneumonias, and bronchitis
(B30. B3I. B32)
Cardiovascular diseases (B22-28)
Pulmonary tuberculosis (Bl)
Transportation accidents (E802-E861)
Other diseases of early childhood (B44)
Tumors (BIS. BI9)
Accidents (excluding transportation)
Coefficient of
incidence
(2)
Coefficient of
importance
(3)
Coefficient of
vulnerability
(4)
Product
(2x3x4)
<S)
Order of
priority
(6)
9.7
8.5
4.4
0.98
1.00
0.97
0.66
0.33
0.33
6.27
2.80
1.40
I
2
3
20.3
2.8
3.9
2.5
6.7
5.3
0.65
0.68
0.82
1.00
0.68
0.75
0.10
0.66
0.23
0.33
0.10
0.10
1.32
4
1.25
5
1.07
6
0.82
7
0.45
8
0.41
9
Note: arranged in accordance with the weighted coefficient of incidence the causes c?
:__ J would appear
;..................
’, order- dysentry;
of death
in lhe;WMWW
following
premature births; other diseases of early childhood: cardiovascular diseases: transportation
accidents;
accidents
.._r--------- ------------ ---------(excluding transportaiion): influenza, etc.: tumors: and pulmonary tuberculosis.
Source: (42. p. 27],
fixed health centers and dispensaries often generate state
expenditures. The overall pattern of replacement is con
sistent with World Bank and International Monetary Fund
and donor policies aimed at “low cost health projects’’ for
PHC [46].
The internal and external constraints upon the
cooperative efforts of international agencies have
combined with the technical training of key decision
makers to encourage an enthusiastic response to
SPHC. Among the features of SPHC which such
agencies find appealing are the following:
Agency Constraint
1. An emphasis upon 'results'
2. Privatization
3. A numerical building of donor agency
clientci
4. The development of commercial and
research outlets
5. A concern for the financial and institu
tional status quo
This widely known effort attempted to put into practice a
fully formed model for health care planning of the sort pul
forward in far more simple form by Drs Walsh and Warren.
After many years of work and the training of several
hundred Latin Americans in the methodology, it was con
cluded in the mid-1970s that planning of this sort was
infeasible and thus to be put aside.
Table 1 summarizes the approach of CENDES
analysis for Araqua State (Venezuela) (50]—an ap
proach quite closely paralleling the method taught 20
Associated Reasons for SPHC Appeal
1. SPHC depends upon ‘objective’ measures and calls for little additional
health infrastructure
SPHC favors a technical agenda whose items have been established by
technical methods
2. By filling in functional blanks left by the private sector (preventive
activities). SPHC implies no competition between public and private
health units [47.48]
SPHC tends to by-pass the issue of population-oriented health service
responsibility
3. SPHC’s claim to be ‘potentially (he most cost-effective’ appeals to the
desire of international and bilateral cooperation agencies to expand their
clienlel
4. SPHC emphasizes prospects for vehicles well-suited for ‘space age’
commercial technologies, e.g. vaccines derived from genetic engineering
rather than prospects for management improvement of existing techniques
SPHC leaves open the option for private sector doctors to refuse standard
treatments, e.g. use of standard pharmaceutical lists [49]; this excludes
from the scope of PHC curative activities (except oral rehydration and
chloroquine)
5. The claims of SPHC assure that it would put almost no strain upon
existing financial or institutional arrangements
SPHC tends to preclude community impact upon the planning and
management of health services, an emphasis which tends to sustain
existing institutional practices and priorities
SPHC requires little fund transfer from hospital to primary health
services.
Training of health system managers; SPHC
The SPHC appeal to international agencies of
cooperation parallels the attraction of health pro
gram managers to the SPHC conceptual structure.
Many of these key decision-makers have an exposure
to past or ‘classical’ approaches to disease control as
a feature of their public health training. Gish, for
example, has noted the similarity between the prior
ities, of SPHC and the CENDES approach [11]:
years later by the CDC (Atlanta) for SPHC-type
prioritizations (Table 2) [51].
The kinship between SPHC and CENDES analysis
is not surprising since the political constraints which
confront program managers and cooperation agency
leaders have been relatively constant in the post
World War II period, as was noted earlier. The
program management view of primary health care
retains its emphasis upon the following:
Jeax-Pierre Unger and James R. Killings worth
1012
Tabic 2. Possible answers to the exercise on establishing priorities (module on national priorities)
Health problem
Overall
importance
Most feasible control measure
Accidents
Diarrhoea
Diphtheria
Lower respiratory infection
Malaria
Measles
Neonatal tetanus
Other neonatal conditions
Pertussis
Poliomyelitis
Skin infection
Tuberculosis
’.'ndernutrition
Moderate
High
.Moderate
High
Moderate
High
Moderate
Moderate
Moderate
Moderate
Low
Moderate
Moderate
First aid; medical diagnosis and treatment; rehabilitation
OR therapy
DPT vaccine
Drug therapy
Drug treatment
Measles vaccine
Tetanus toxoid
Prenatal and delivery care
DPT vaccine
Oral polio vaccine
Good hygiene and health education
BCG vaccine
Education, food supplies and child spacing
Feasibility of
control measure
Overall
priority
Low
Low
High
Moderate
High
Moderate
Hish
High
Moderate
Moderate
Moderate
Low
Moderate
Moderate
High
High
Moderate
Moderate
High
High
LouHigh
High
Moderate
Moderate
Low
Record assessments as high, moderate or tow.
Source: [4J. p. 26).
(1) selection of top-priority pathologies that re
quire epidemiology, surveillance projects and readily
quantified weighting schemes
(2) operational designs that call for the use of
mobile teams
(3) a mobilization of ‘popular-based’ manpower in
accord with anthropological understanding to the
extent that it provides insight about how to increase
popular participation
(4) field evaluation using cost-effectiveness analysis
for single outcome, process evaluation purposes.
Not only do training and field experiences predis
pose program managers to selective interventions
once they reach the level of national health service
management, these forces also lead to a planning of
national health services in terms of program manage
ment concepts—not a health service management
framework:
disease-control strategy are already considerable,
however, it is essential to identify reasons for its ready
adoption by international cooperation agencies and
developing nations. The prime forces appear to be
political and economic in nature, but these
justifications are reinforced by the education and field
experiences of key decision-makers.
Ultimately, the planning and development of pri
mary health services that accord with the 1978 Alma
Ata declaration will require approaches that run
counter to the vertical program characteristics that
typify SPHC. It appears mistaken to create extensive
new financial and human resources commitments for
a SPHC-type campaign. The alternative lies in the
study of methods explicitly connected to the expan
sion of national health services. The methods of
health service development must first be shown to
have clear and demonstrable efficacy for attaining
health for all by the year 2000.
Program Management
Health Services Management
Short-term planning outlook
Planning for program development
Long-term planning outlook
Planning for structural development of health services and functional development
within these structures
Responsibility toward population covered by health services.
Given the political constraints and the program
management perspective derived from successful dis
ease campaigns such as the smallpox effort, the
appeal of SPHC is a rather predictable phenomenon.
This is especially the case, since program managers
tend, with seniority, to obtain tenure in the public
health schools of developed countries. This is not
the case, however, with national health service man
agers hired by LDC public health schools that enjoy
relatively low resource and influence levels.
CONCLUSION
This paper has set forth an historical context for
understanding the current appeal of SPHC for those
who urge its widespread adoption in developing
countries. The weaknesses of its empirical founda
tion, methods and operational structure make dubi
ous the enthusiasm with which SPHC has been
greeted. Since the economic pledges to the SPHC
Acknowledgement—Wc are deeply indebted to Professors
Mercenicr and Van Balen (Institute of Tropical Medicine.
Antwerp) whose knowledge and comments were indispens
able.
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16. Joseph S. C. and Russell S. S. Is primary care the wave
of the future? Soc. Sci. Med. I4C, 137-144. 1980.
17. Warren K. S. Authors reply: comments of Kenneth S.
Warren. 5oc. Sci. Med. 16, 1060, 1982.
18. Evans J. R., Karen L., Hall K. L. and Warford J.
Health care in the developing world: problems of scarciij and choice. New Engl. J. Med. 305, 1121. 1983.
19. Berggren W„ Ewbank D. and Berggren G. Reduction
of mortality in rural Haiti through a primary health care
program. Aeir Engl. J. Med. 304, 1324-1330, 1981.
20. Walsh J. A. A rejoinder To O. Gish and P. A. Berman.
Soc. Sci. Med. 16, 1059-1060. 1982.
21. Ghana Health Assessment Team. A quantitative
method of assessing the health impact of different
diseases in less developed countries. Im. J. Epid. 10,
73-80. 1981.
22. United Nations Demographic Yearbook, 1982, ThirtyFourth Issue. United Nations, New York, 1984.
23. World Health Statistics Annual, Vol. I. WHO, Geneva,
1974.
24. Mosley W H. Will primary health care reduce infant
and child mortality: a critique of some current strategies
with special reference to Africa and Asia. Institut
National d’Etudes Demographiques. Paris, 1983.
25. The Kasongo Project Team. Influence of measles vacci
nation on survival patterns of 7-35 month-old children
in Kasongo. Zaire. Lancet 4, 764-767, 1981.
26. Aaby P., Bush J., Lisse I. M. and Smits A. J. Measles
vaccination and child mortality (Letter to Editor).
Lancet 11, 98. 1981.
27. Keller W. and Fillmore C. W. Prevalence or protein
energy malnutrition. Wld Hlth Statist. Q. 36, No. 2,
1983.
28. King M. (Ed.) Medical Care in Developing Countries:
A Symposium from Makerere. Oxford University Press.
Nairobi. Kenya, 1966.
29. U.S. Agency for International Development. 52
USAID-Assisted Projects. Washington, 1981.
1013
30. Rienks A. and Iskandar P. Primary and indigenous
health care in rural central Dava: a comparison of
process and contents. Hedera Report No. 4, Faculty
of Medicine Gadja Mada University, Indonesia.
1981.
31. Heiby J. R. Enseignements: d’une experience au
Nicaragua. For. Mond. Same 3, 30—33, 1982.
32. Gish O. The political economy of primary health care
and health by the people: an historical exploration Soc
Sci. Med. 13C, 203-211, 1979.
33. Gonzalez L. L. Mass Campaigns and General Health
Services. WHO. Geneva, 1981.
34. Gwatkin D. R., Wilcox J. R. and Wray J. D. Can
interventions make a difference? The policy implications
of field experiment experience. A World Bank Report.
World Bank. Washington. D.C., 1979.
35. Taylor G. E.. Keilman A. A., Parker R L. et al.
Malnutrition infection, growth and development: the
Narangwal experience. Final Report. World Bank,
Washington, D.C., 1978.
36. WHO. World Health Statistics Annual, 1967. Vol. I.
Vital Statistics and Causes of Death. Geneva. 1970.
37. Graitcer P. L. ei al. Haiti nutrition status survey. Bull.
Wld Hlth Org. 5, 757-765, 1980.
38. Mora J. O. Nutritional supplementation and the out
come of pregnancy—III. Perinatal and neonatal mor
tality. Nutr. Rep. Ini. 18, No. 2, 1978.
39. Project Intcgrc de Same et de Population de PetitGoave, Division d’Hygiene Familiale Departement de
la Sante Publique et de la Population. Administratien et
Organisation d'un programme communautairc de same
et de population en milieu rural. Port-au-Prince Haiti
1982.
40. Shepard D. S. and Stoddart G. L. On determining the
efficiency of health programs in developing countries.
Prepared for Workshop on Methods for Health Project
Analysis. McMaster University, Hamilton. Ontario.
1981 (mimeo).
41. Equipe du Project Kasongo. Pour moins d'un dollar par
an For. Mond. Sante 5, 234-238, 1984.
42. Boland R. and Young M. The strategy, cost and
progress of primary health care. Bull. Pan-am. Hlth
Org. 16, 233-41. 1982.
43. Shepard D. S. and Thompson M. S. First principles of
cost-effectiveness analysis of health. Pub!. Hlth Rep. 94,
535-543, 1979.
44. Tarimo E. Good intentions are not enough, tt'id Hlth
For. 5, 319-324, 1984.
45. Microbes for hire. A special, 3-part article. Science 6,
No. 6. 1985.
46. McPherson M. P. (The Administrator of USAID) Aid
and AID (A Letter from the Readers). Commentary 80,
No. 2.
47. New Directions in International Health Cooperation. A
Report to the President, The White House, 1978.
48. USAID Publication. Rethinking A.I.D’s Health Sector
Assistance. Washington. D.C., 1982.
49. WHO. The use of essential drugs. Technical Report
Series No. 685. WHO, Geneva. 1983.
50. Pan American Health Organization. Problems of con
cept and method prepared at the Center for Develop
ment Studies (CENDES) of the Central University of
Venezuela. PAHO Scientific Publications. No. Hl,
1965.
51. WHO. Expanded programme on immunization. Train
ing course on planning and management. Course Facili
tator Guide. WHO, Geneva, 1978.
Indian Pediatrics 2001; 38:1129-1143
Child Health Development After Alma Ata Declaration
Pakynathan Chandra
Dr. Pakyanathan Chandra is Executive Director, D. Arul Selvi Community Based Rehabilitation and
Chairman, Tamil Nadu Health Development Forum.
Correspondence to: Dr. Pakynathan Chandra, ‘Sornam’, 221 -4th Avenue, Indira Nagar, Chennai 600
020, India.
Address given at the 38th National Conference of Indian Academy of Pediatrics, Patna, Bihar on 9th
February 2001 for the Hony. Surg Cmde. Dr. Shanthilal C. Sheth Oration.
Health development includes health care, essential non-specific measures like nutrition, protected water
supply, sanitation, education and economic development. Primary Health Care (PHC) is essential health
care based on practical, scientifically sound and socially acceptable methods. Community involve-ment,
inter sectoral cooperation and approaches to peripheralise health services are the three pillars on which
PHC is being built. Implementing PHC successfully will improve health development. Human progress
and overall development lie in the progress of women and children and the realization of their rights.
Problems of health development and under development are intimately linked.
In the later half of last century important technological advances in medicine were made. Vaccination
against major diseases and therapy for infectious diseases and the technical knowledge to prevent
nutrition deprivation and diseases were available. As a result rapid decline in death rate has occurred.
Inspite of impressive progress in health picture, the prevailing health and nutrition disparities were a
cause for serious concern.
Medical science realized that poverty related social conditions like poor sanitation and housing were
major causes of ill health. Studies have shown that irrespective of medical intervention health status
improved remarkably when basic requirements of health were available. The challenge was primarily a
question of equal access for all. In 1978 for the first time all the Government of the world - Democracies
or Dictatorships, Communists or Capitalists - accepted the principle of PHC officially and promised to
bring them into being in all nations within the next 22 years. This Alma-Ata Declaration accepted that
Health is a Fundamental Human Right. It also accepted that the gross inequalities in health status are
unacceptable. Health for all heralded the vision of a new and better future for all the human family.
To fulfil her commitment of Health for All, India evolved a National Health Policy in 1983. To transfer all
objectives of Health for All, the policy laid down specific goals with quantifiable targets to be achieved.
This commitment did lead to some renewed attempt at achieving these goals. India launched ambitious
campaigns for eradica-tion of communicable diseases, infections and malnutrition. Various policies and
acts introduced earlier and later tried to augment efforts. Few examples in this context include ICDS
(1974) CSSM (1992), The Infant Milk Substitute Act (1992), Pulse Polio Immunization (1997), RCH and
others. The impact of all these interventions to improve health, particularly maternal and child health has
been large. In India decline in vaccine preventable diseases and severe malnutrition of this magnitude
has never been achieved in our setting and certainly not in an equivalent period of time. Still there are
disparities in health. So the achievements of the National Health Policy need critical analysis.
Progress in Maternal and Child Health
A. Mortality and Mobidity in and around Infancy (Table I)
Mortality rates and nutrition status are good indicators to measure the level of health and nutrition care.
This also helps in assessing the overall socioeconomic development.
Still births and deaths within the first week of life are not investigated like infant and neonatal deaths. With
declining infant mortality rate, perinatal mortality is assuming importance as a yardstick of obstetric and
pediatric care before and around the time of birth. There is a wide variation in urban/rural death rates.
References
■
.
■
____________________
1. Sanders D. The Struggle for Health, United Kingdom, Macmillan Education Ltd.
2. Wener D, Sanders D. The Politics of Primary Health Care and Child Survival, California, Health
Wrights, 1997; pp 82-117.
3. National Coordination Committee Jan Swasthya Sabha, Confronting Commercial-ization in Health
Care. Chennai, South Vision 2000, Annexure 2.
4. National Coordination Committee Jan Swasthya Sabha, What Globalization does to Peoples Health,
Cheanni, South Vision, 2000; p 9.
11
PUBLIC HEALTH THEN AND NOW |
The
11If
(f Primary Kedth Care
LUnlGINS
'1
and SELECTIVE Primary Health Care
! Marcos Cueto, PhD
I present a historical study of the
i role played by the World Health Or
ganization and UHICEF in the emeri gence and diffusion of the concept of
■ primary health care during the late j
1970s and early 1980s. I have ana- |
i lyzed these organizations’ political |
context, their leaders, the methodj ologfes and technologies associated
I with the primary health care per: spective. and the debates on the
I meaning of primary health care.
I These debates led to the develop| men! of an alternative, more restricted |
i approach, known as selective primary I
health care. My study examined library |
| and archival sources; I cite examples |
; from Latin America.
I
DURING THE PAST FEW
decades, the concept of primary
health care has had a significant
influence on health workers in
many less-developed countries.
However, there is little under
standing of the origins of the
term. Eyen less is known of the
transition to another version of
primary health care, best known
as selective primary health care.
In this article. I trace these ori
gins and the interaction be
tween 4 crucial factors for inter
national health progrante: the
context in which they appeared,
the actors (personal and institu
tional leaders), the targets that
were set, and the techniques
proposed. I use contemporary
publications, archival informa
tion. and a few interviews to lo
cate the beginnings of these
concepts. 1 emphasize the role
played by die World Health Or
ganization (WHO) arid UNICEF
in primary health care and se
lective primary health care, ’lhe
examples are mainly drawn
from Latin America. The work
is complementary to recent
studies on the origin of primary
health care.'
1864 i Public Health Then and Nov/1 Peer Reviewed I Cueto
BACKGROUND AND
CONTEXT
syringes.
Dining ike finsll decides of lhe
Cold War (the late 1960s and
early 1970s) the US was em
broiled in a crisis of its own
world hegemony-it was in this
jxtlitictil context that the concept
ofyirimary healtli cAre emerged.
By then, the so-called vertical
health approach used in malaria
eradication by US agencies and
the WHO since the late 1950s
were bid ng critidzed. New proposals for health and develop
ment appeared, such as John
IhyanVs book Health and lhe De
veloping World (also published in
Mexico in 1971). in whicli he
questioned the transplantation of
the hospital-based health care
system to developing.countries
and the lack of emphasis on pre
vention. Accoitling to Bryant.
“Large numbets of the world's
jjeople. peiitaps more than half,
have no access to health care at
all. and lor many of the rest, the
care they receive does not an
swer the problems they have ,..
the most serious health needs
am not. be met by teams with
In a similar peraixsctive, CJarl
Tayior, founder and chairman of
the Dq>artmenl of International
Health at Johns Hopkins Univer
sity. edited a book that offered
Indian rural medicine as a gen
eral model for poor countries.1
Another influential work was by
Kenneth W. Newell, a WHO stall
member from 1967. who col
lected and examined lhe experi
ences of medical auxiliaries in
developing countries. In Health
by the People, he aigued that ‘a
strict health sectorial approach
is inefiectiw."4 In addition, the
1974 Canadian I blonde Report
(named after the minister of
health) deempliasized the itftpor*
lance attributed to the quantity of
medical institutions and proposed
4 determinants of health: biology,
health semces, environment and
lifestyles.'’
Other studies, written from
outside the public health commu
nity, were also influential in chal
lenging the assumption that
health resulted from the transferenee of technology or more doc
tors and more servias. lhe
spray guns and vaccinating
American Journal of Public Health 1 November 2004. Vol 94. No. 11
PUBIIC HEALTH THEN O NOW
British historian Thomas Mc
Keown argued that the overall
health of the population was less
related to medical advances than
to standards of living and nutri
tion.1’ More aggressively. Ivan 11lidfs Medical Nemesis contended
that medidne was not only irrele
vant but even detrimental, be
cause medical doctors expropri
ated health from the public. This
book became a bestseller and
was translated into several lan
guages. including Spanish.7
Another important influence,
for primaiy health care Came
from the experience of mission
aries. The Christian Medical
Commission, n specialized organ
ization of the World Council of
Churches and the Lutheran
World Federation, was created in
the late 1960s by medical mis
sionaries working m deyelopihg
countries? The new oiganization
emphasized the training of vil
lage workers at the grassroots
level, equipped with essential
dings and simple methods. In
1970. it created the journal Conlaci. which used the term pri
maiy health care, probably for
the first time. By the mid-1970s.
French and Spanish versions of
the journal appeaivd and its cir
culation readied 10000.
ft is worth noting that John
Bryant and Ori Taylor were
members of the Christian Medical
Cummisrion and tliat in 1974 col
laboration between the commis
sion and toe WHO was formal
ized. In addition, in Newell's
Health by the People, some of the
examples cited were Christian
Medical Commission programs
while others were brought to the
attention of the WHO by commis
sion members. A close collabora
tion between these organizations
was also [wssible because the
WHO headquaiteis in Geneva,
were situated close to the main
office of the World Council of
(□lurches (and 50 WHO staff re
ceived (y>niaci)u
Another important insjjiration
for primary health care was the
global popularity that the mas
sive expansion of rui-al medical
services in Communist China ex
perienced, specially die “bare
foot doctors.” This visibility coindded with China’s entrance
into the United Nations (UN)
system (including the WHO).
The “barefoot doctoi's,” whose
numbers increased dramatically
between the early 1960s
and the Cultural Revolution
(.1964-1976), were a diverse
array of village health workers
who lived in the community
they served, stressed rural rather
titan urban healtli cart1 and pre
ventive rather than (urative
services, and combined Western
and traditional medicines.10
Primary health care was also
favored by a new political context
charaeterizdd by the emergence
ofdecolonized African nations
and the spread ,of national, antiimperialist, and leftist movements
in many less-developed nations.
T hese changes led to new pro
posals on development made by
some industrialized countries.
Mcxiemization was no longer
seen as the replication of the
model of development followed
by the United States or Western
Europe. For example. Prime Min
ister Lester B- Pearson of Canada
and (?.hancellor Witty Brandt of
West Germarty chaired major
commissions on international de
velopment emphasizing long-term
sodoecononiic dmngos instead of
specific technical inteiventions.”
In a corollary decLsion, in 1974
the UN General Assembly
adopted a resolution on die “Es
tablishment of a New Interna
tional Economic Order* to uplift
less-developed countries.12
Novecriber 2004, Vol 94. No. 11 ’ American Journal of PuWic Health
NEW ACTORS AND NEW
HEALTH INTERVENTIONS
New leaders and institutions
embodied the new acadeniic and
political influences. Prominent
among, them was Halfdan T.
Mahler of Denmark, He was
elected the WHO’s director gen
eral in 1973 and was later re
elected for 2 successive 5-year
terms, remaining at its head until
1988. Mahler's background was
not related to malariblogy, the
discipline that dominated inter
national health during the
1950s, His fir-st international ac
tivities were in tubercu lms and
community work in less-devel
oped countries. Between 1950
and 1951. he directed a Red
Cross antituberculosis campaign
in Ecuador and later spent sev
eral years (1951 -I960) in India
as the WHO officer at the Na
tional Tuberculosis Program. In
1962, he Was appoirited Chief of
the Tuberculosis .tlriftnt die
WHO headquariecs.13 In Geneva.
Mahler also directed the WHO
Project on Systems Analysis, a
program that implied improving
national capabilities in health
planningMore importantly, Mahler was
a charismatic figure with a mis
sionary zeal. His father, a Baptist
preacher, helped shape his per
sonality. Many years after his re
tirement from the WHO. he ex
plained that for him. "social
justice’' was a “holy word.”14 The
strong impression he produced in
some people is well illustrated by
a religious activist who met
Mahler in the 1970s: “I felt like a
church mouse in front of an
archbishop.”111
Mahler had excellent relations
with older WHO officers. The
Braziliajt malariologist Marcolino
Candau, the WHO director gen
eral before Mahler, appointed the
o
h
ii
tj
h
HI
ifsS ill
Halfdan X Mahler; director general cf
the WorM Health Organization,
197J-1988.
Cueto Peer Reviewed Public Health Then and Naw
1865
PUBLIC HEALTH THfH Ml) NOW
From the late 1960st there was an increase in WHO projects
related to the development of “basic health services"
(from 85 in 1965 to 156 in 1971). These projects were
the institutional predecessors of the primary health
care programs that would later appear.
Dane as tin assistant director gen
eral in 1970. Thanks to his close
rcliuionship with the WHO’s old
guard, Mahler could ease the
transition ex|)crienced by tills
agency under his command.
Some of these changes occurred
before Mahler assumed die post
of director general. From the late
1960$, there was an increase in
WHO projects related to the de
velopment of “basic heahh serv
iced (from 85 in 1965 to
in
1971).lrt These projects were im
stiUitional predecessors of tlie ptimaiy health care programs that
would later appear. Another early
expression of change was the cre
ation in 1972 of a WHO Division
of Strengthening of Health Ser
vices. Newell, a strong academic
and [Hiblic health voice for pri
mary health care, was ajrpointed
director of this division (Newell’s
career with the WHO started in
1967 as director of tire Division
of Researdi in Epidemiology and
Communications Saaiias).
hi 1973, the year of Mahler’s
appointment as the WHO direc
tor general, die Executive Boand
of WHO issued the report O/g’nnizoitonttl Stiuhj on Methods of
Promoting the Deuelopmetil of
Basie Health Seroices.'’ This re
port was the basis for a redefini
tion of the (xillaboration between
the WHO and UNICEF (which
could be traced to the years im
mediately following World War
H). Mahler established a close
rapport with Henry l^ibouisst;.
UNICEF's executive director be-
1866 i Public Health Then and Now! Peer Reviewed I Cueiu
tween 1965 and 1979. who had
his own rich experience with
community-based initiatives in
health and education. 'The agree
ment produced in 1975 a joint
WHO-UNICEI7 report, Alteniatiw Appritaches to Meeting Btisic
Health Needs in Developing Coun
tries, that was widely dtscasSfed
by these agencies. The term “nlternative'' underlined the short
comings of traditional vertical
programs concentrating on
cific .diseases, hi addition, (he as
sumption that the expansion of
“Western*’ medical systems
would meet the needs of the
Common people was again highly
criticized. According to the docu
ment, the principal causes of
morbidity' in developing coun
tries were malnutrition and vec
tor-borne. respiratory, and diar
rheal diseases, which were
“tliemselves Ute results of pov
erty, squalor and ignorance ***
The report also ejtamined succtesslhl pririwy health care esjxiriences in Bangladesh, Cfrina,
Cuba, India, Niger, Nigeria, Tan
zania, Venezuela, and Yugosla.via
to identify the key faetora in their
success.
'This report shaped WHO
ideas on primary health care.
'Hie 28tli World Health. Assem
bly in 1975 reinforced the trend,
declaring the construction of
“National Programs in primary
healtli care" a matter “of urgent
priority.’' The report Alternative
ApiMtaches became the basts for
a worldwide debate. In the 1976
Work! Health Assembly, Mahler
proposed the goal of “Health for
All by toe Year 2000 ’’ The slo
gan became BP integral part of
primary health care. According
to Mahler, this target required a
radical (’hangc. In a moving
speech that he delivered at toe
1976 assembly, he said that
"Many social evolutions and rev
olutions have taken place be
cause the social structures were
crumbling. 'There are signs that
the scientific and technical struc
tures of public health are also
cnimbling."19 These ideas would
be confirmed ata conference
that took place in toe Soviet
Union.
ALMA-ATA
The landmark event for primaiy health care was the Inter
national Conference on Primary
Health Care that took place at
Alma-Ata from September 6 to
12. 1978. Alma-Ata was the
capital of the Soviet Republic of
Kazakhstan, located in the Asi
atic region of the Soviet Union.
According to one of its organiz
ers, the meeting would tran
scend the “provenance of a
group of health agencies" and
Bex<m moral pressure" for pri
mary healih care.20 A Rosian
co-organizer claimed that “never
before fhavej so many countries
prepared so intensively for an
international confr^rence.”21
The tlien-aiiTent tension
among communist countries
played an important foie in div
selection of the site. Hie Chinese
delegation to die WHO origi
nated the idea of an international
conference on primaiy health
care. Initially, the Soviet Union
opposed the proposal anti de
fended amore medically oriented
approach for hackwaixl countries.
Anterlcan Journal of Public Health ’ November 2004. Vo! 94, No. n
mar HintiH io wb m
) I
i i
However, after noticing that the
primary health care movement
was growing, the Soviet delegate
to the WHO declared in 1974
that his country was eager to
hold the meeting, 'fhe offer also
resulted from tire growing compe
tition between the traditional
communist’parties and the new
proChinese organizations that
emtnged in several developing
countries. However, the proposal
of the Soviet Union had one con
dition: tlx* conference should
take place on Soviet soil. The So
viet Union was willing to fund a
great part of the meeting, offering
$US 2 million.22
For a while, the WHO
searched for an alternative site.
The governments of Iran, Egypt,
and Costa Rica entertained the
idea but finally declined. Nobody
could match the economic offer
of the Soviet. Union, and in the
case of Iran there was fear of po
litical instability. Finally, the
VVI IO accepted the Soviet offer
but asked for a different location
than Moscow, suggesting a
provmcial City. After some nego
tiations Alma-Ata was selected,
partly because of the remarkable
health improvements experi
enced in what was a backward
area during Tsarist Russia. The
event was a small Soviet victqry
in the Cold War.
The conference was attended
by' 3000 delegates from 134
government and 67 interna
tional organizations from all over
the world. Details were carefully
orchestrated by the Peruvian
David Tejada-de-Rivero, the
WHO assistant director general
who was responsible for the
event/ ’ Most of flic delegates
came from the public sector,
specifically from ministries of
health; of 70 Latin American
participants. 97%-were from offi-
cial public health institutions. It
was expected that many ol the
delegates would be planning offi
cers and education experts, who
would be able to implement an
effective intcrscdoribl approach,
but few of them wen?. The meet
ing was also attended by UN and
international agencies such as
the Internadorgd Labor Organi
zation, flu? l-'otxl and Agriculture
Organization, and die Agency for
International Development. Non
governmental organizations, reli
gious movements (including the
Christian Medical Commission),
the Red Cross, Medidis Mundi,
and political movements such as
the Palestine Liberation Organi
zation and the South West Africa
People’s Organization were also
present. However, for political
reasons—the Sino-Soviel conflict
had been worsening sintie the
IQbOs—Qiina was absent.
At the opening ceremony.
Mahler challenged the delegates
with 8 compelling questions that
called for immediate action. Two
of the most audacious were as
feltows.
• Are you ready to introduce,
if necessary, radical changes in
the existing health dcliveiy sys
tem so that it properly supports
[primary health care] as the over
riding health priority?
• Are you ready to light the
political and technical battles re
quired to overcome any social
and economic obstacles and pro
fessional resistance to the univer
sal intitjduction of [primary
health care]?"4
When the conference took
place, primary health care was to
some degree al ready ‘’sold’’ to
rnarry pariicipanVt From 197(5 to
1978. the WHO and UNICEF
oi'gtuiized a series of regional
meetings to discuss ’‘alternative
November 2004. Vol 94. No. 11. American Journal of Public Healtb
approaches." Hie conference's
main document, the Declaration
of Alma-Ata, which was already
known by many participants, was
approved by acclamation. The
term “dedaration'’ suggested high
importance, like other great dec
larations of independence and
human rights. The intention was
to create a universal and bold
statement This was certainly un
usual for a health agency used to
comproniising resolutions. The
slogan “Health for All by flic
Year 2000” was. included as a
prospective view.
Three key ideas permeate the
declaration: “appropriate technologyopposition to medical elit
ism, and the concept of healfli as
a tool for socioeconomic devel
opment. Regarding the first issue,
there was criticism of the nega
tive role of '‘disease-oriented
technology.’’^"’ The term referred
to teclmology, such as body scan
ners or heartdung machines, that
were too sophisticated or expen
sive or were irrelevant to the
common needs of flic poor.
Moreover, the term criticized the
creation of urljan hospitals in de
veloping countries. These institutions were perceived as promot
ing a dependent consumer
culture, benefiting a minority,
and drawing a substantial share
of scarce funds and manpower.
Mahler's used the story of the
sorcerer’s apprentice to illustrate
how heal til technology was out
of “social" control.'2'’ In contrast,
“appropriate" medical technology
was relevant to tire needs of the
people, scientifically sound, and
financially feasible. In addition,
the construction of health posts
in rural areas and shantytowns,
instead of hospital constroefioH,
was emphasized.
The declaration’s second key
idea, criticism of elitism, meant a
Cueto Peer Reviewed Public Health Then and Now
1867
PUBLIC HEALTH THEN AND NOW
disapproval of the overspecializa
tion of health personnel in devel
oping countries and of top-down
health campaigns. Instead, train
ing of lay health personnel and
community participation were
stressed. In addition, tlie need for
working with traditional healers
sudi as shamans and midwives
was emphasized. Finally, die dec
laration linked health and devel
opment. Health worit was per
ceived not as an isolated and
short-lived intervention but as
part of a process of improving
living conditions. Primary health
care was designed as the new
center of the public health sys
tem. This required an intersector
ial approach-several public and
private institutions working to
gether on health issues (e g., on
health education, adequate hous
ing, Safe water, and basic sanita
tion). Moreover, die link between
health and development had po
litical implications. According to
Mahler, health should be an in
strument for development and
not menily a byproduct of eco
nomic progress: “we could ...
became the aixittl garde of an internatioiial conscience for social
development."^
The 32nd WId Health As
sembly that took place in
Geneva in 1979 endorsed the
conference's declaration. The as
sembly approved a resolution
stating that primary health care
was The key io attaining an ac
ceptable level of health for all.’'
In the following years. Mahler
himself became an advocate of
primary health care, writing pa
pers and giving speeelics with
stjxmg titles, such as '‘Health and
Justice’ (197B), “The Political
Struggle for Healtfi'’ (1978),
“'The Meaning of Health for All
by tire Year 2(X)()’’ (1981), and
“Eighteen Years to Go to Health
1868 I Public Health Then and Now i Peer Reviewed | Cueto
for Air (1982).2’ However, liespite the initial enfliusiasm, it
was difltcult to implement pri
mary health care after AlmaAta. About a year after the con
ference took place, a different
interpretation of primary health
care appeared.
SELECTIVE PRIMARY
HEALTH CARE
'The Alma-Ata Declaration
was criticized for being too
broad mid idealistic and having
Wi unrealistic tiHietablc. A com
mon criticism was that the slo
gan “Health for All by 2000"
was not feasible. Conoenied
about the identification of the
most cost-effective health strate
gies, the Rockefdler Foundation
sponsored in 1979 a small con
ference entitled "Health and
Population in Development" at
its Bellagio Conference Center in
Italy. 'The goal of the meeting
was to examine the status and
interrelations of health and pop
ulation programs when the or
ganizers felt “disturbing signs of'
declining interest in papulation
issues.”29 It is noteworthy that
since the 1950s, international
agencies had been active in pop
ulation control and family plan
ning in less-developed countricts.
The inspiration and initial
framework for the meeting came
from the physician John H.
Knowles, president of the Rocke
feller Foundation and editor of
Doing Belter and ['eeluig Worse,
who strongly believed in the
need for more primary care practitioners in die United States?0
(Knowles died a few months be
fore the meeting took place.) l*he
heads of un|x>rtant agencies were
involved in the organization of
die meeting: Robert S. McNa
mara, former secretary of de
fcnse in the Kennedy and John
son administrations, and, since
1968. president of the World
Bank; Maurice Sheng, chairman
of the Canadian International
Development and Research Cen
ter; David Bell, vice president of
the Ford Foundation; and John J.
Gillian, administrator of the VS
Agency for International Devel
opment, among others. The influ
ential McNamara was Vying to
overcome the criticism that the
World Bank had ignored social
poverty and tire fatigue of donor
agencies working in developing
countries. He promoted business
management methods and clear
Sets of goals, and he moved the
World Bank from supporting
large growth projects:aimed at
generating economic growth to
advocating poverty reduction
approaches.”
The conference was based on
a published paper by Julia Walsh
and Kenneth S. Warren entitled
“Selective Primary Health Care,
an Interim Strategy for Disease
Control in Developing Coun
tries.’'32 The paper sought spe
cific causes of death, paying spe
cial attention to the most
common diseases of infants in
developing countries such as di
arrhea and diseases produced by
lack of immutii^tion. The au
thors did not openly criticize the
Alma-Ata Declaration. 1’hey pre
sented an ‘'interim* strategy- or
entity points through which basic
health services could be devel
oped. They also emphasized at
tainable goals and cost-efiective
planning. In the paper, and at
the inecting, selective primary
health care was introduced as
the name of a new perspective.
The term meant a package of
low-cost technical interventions
to tackle the main disease prob
lems of poor countries.
AmeHceb Journal of Public Health | November 2004, Vol 94. No. 11
PUBLIC HEALTH THEN AND NOW
At first, the content of the
package was not completely
clear. For example, in the original
paper, a number of different in
terventions were recommended,
including the administration of
antimalarial drugs for children
(something that later disappeared
from all proposals). However, in
the following years, these inter
ventions were reduced to 4 and
were best known as GOBI, which
stood for growth monitoring, oral
rehydratian techniques, breast
feeding. and immunization.
The first inteivcntion. growth
monitoring of infants, aimed to
identify, at an early stage, chil
dren who were not growing as
tliey should, ft was thought that
tile .solution was proper nutri
tion. The second intervention,
oral rehydration, sought to con
trol infant diaiTheal diseases
with ready-made packets known
as oral rehydration solutions?'
The third intervention empha
sized the protective, psychologi
cal, and nutritional value of giv
ing breastmilk alone to infants
for the first 6 months of their
lives.54 Breastfeeding also was
considered a means for prolong
ing birth intervals. The final in
tervention, immunization, sup
ported vaednation. especially in
early childhood.35
These 4 interventions ap
peared easy to monitor and eval
uate. Moreover, they were meas
urable and had clear targets.
Funding appeared easier to ob
tain because indicators of suc
cess and reporting could be pro
duced more rapidly. In the next
few years, some agencies added
FFF (food supplementation, fe
male literacy, and family plan
ning) to the acronym GOBI, cre
ating GOBl-FFF (the educational
level of young women and moth
ers being considered crucial to
many health programs). Interest
ingly. acute respiratory infec
tions, a major cause of infant
mortality’ in poor countries, were
not included. These were
thought to require the adminis
tration of antibiotics that non
medical practitioners in many of
the affected countries were not
allowed to use.
Selective primary healtii care
attracted tire support of some
donors, scholars, and agencies.
According to some experts, it cre
ated the right balance between
saurity and choice.30 One partic
ipant of the Bellagio meeting that
was greatly influenced by the
new proposal was UNICEF,
James Grant, a Harvard-trained
economist and lawyer, was ftppointed executive director of
UNICEF in January 1980 and
served until Januaiy 1995.37
Under his dynamic leadership,
UNICEF began to back away
from a holistic approach to pri
mary heal tli care. The son of a
Rockefeller Foundation medical
doctor who worked in China,
Grant believed that international
agencies had te do tlreir best
with finite resources and short
lived local political opportunities.
This meant translating general
goals into time-bound specific ac
tions. Like Mahler, he was a
charismatic leader who had an
easy way with both heads of
state and common people. A few
years later. Grant organized a
UNICEF book that proposed a
“children's revolution’’ and ex
plained the 4 inexpensive inter
ventions contained in GOBI38
Mahler never directly con
fronted this different approach
to primaiy healtii care. After
some doubts, Mahler himself at
tended the Bellagio Conference,
and although there is evidence
that he did not get along with
November 2004. Vol 94, No. 11 ! American Journal of Public Health
the new director of UNICEF, he
asked a WHO assistant director
to nourish a good relationship
between the 2 organizations.
However, a debate between the
2 versions on primary health
care was inevitable.'10 Some sup
porters of comprehensive pri
mary health care, as the holistic
or original idea of primary
health care began to be called,
considered selective primary
health care tn he complemen
tary to the Alma-Ma Declara
tion, while others thought it con
tradicted the declaration. Some
members of' the WHO tried to
respond to the accusation that
they had no clear targets. For
Some supporters of comprehen
sive primary health care, as
the holistic or original idea of
primary health care began to be
called, considered selective
primary health care to be
complementary to the Alma-Ata
Declaration, while others thought
it contradicted the declaration.
example, a WHO paper entitled
“Indicators for Monitoring
Progress Towards Health for All”
was prepared at the Tirgent re
quest” of the Executive Board.411
Another publication provided
specific “Heallh for All” goals:
5% of gross national product de
voted to health; more than 90%
of newborn infants weighing
2500 g; an infant mortality rate
of less than 50 per 1000 live
births; a life expectancy over 60
years; local health care units
with at least 20 essential
drugs.41 However, most of the
supporters of primary health
care avoided these indicators.
Cueto i Peer Reviewed . Public Health Then and Now
1869
R MfC HFWTH THEN AN& NOW
SENSE TO
build a
bridge?
Oral rehydration salts pro
moted by selective primary
health care were criticized in
this drawing as a “Band-Aid.”
{Drawing by Alicia Brelsford,
reprinted with permission from
David Werner. David Werner
and David Sanders, with Jason
Weston, Steve Babb, and Bill
Rodriguez, Questioning the
Solution: the Politics of Primary
Health Care and Child Survival,
with an In-Depth Critique of Oral
Rehydratlon Therapy (Palo Alto,
CA: HealthWrights, 19D7J.)
1870
ai-guing that they were unreli
able and failed to demonstrate
the inequities inside poor cquhUies/2 The debate between the
2 versions of primary health
care continued.
THE DEBATE
The supporters of comprehen
sive primary health care accused
selective primary health care of
being a narrow technocentric ap
proach that diverted attention
away from basic health and so
(.’ifx'conomic development, did
not address the social causes of
disease, and resembled verrieal
programs.‘® In addition, critics
said that gixMh monitoring was
difricyli since it required the use
of charts by illiterate mothers
(recording data was not an easy
operation, weighing scales were
frequently deficient, and charts
were subject to misintei-piretation).
Breastfeed ing cojiftorited power
ful food industries. In 1979. it
was estimated that global sales of
Public Health Then and Now . Peer Reviewed Cueto
artificial infant formula were
$2 billion a year fl'hwxi World
nations a<xx>unt<?d for 50% of
the total).44 Companies arguedincorrectly-that infant formulas
had to be used in developing
countries because undernour
ished mothers could not provide
proper nourishment and pro
longed lactation would aggravati?
their health45 In contrast for
health advocates, who launched a
boycott against the Swiss inultmational Nestis one of the main
probleiriS was Hie use of unsafe
water for bottle-feeding in shanty
towns. Ihis fasdnating coutroversy helped to change nugemal
practices in several eoufitries but
did little to excite the eatihuslasm
of donor agencies 46
lb supporters of comprehen
sive primary health cam, onil re
hydration soltitiotis were a BandAid in places where safe water
and sewage systems did not exist
However, tilis intervention, to
gether with immunization, be
came popular with agencies
working in developing coun
tries?7 partly thanks to an impor
tant achievement; the global
eradication of smallpox in 1980.
Beginning .in 1974. the WHO’s
Expanded Program on Immu
nization fought against 6 comra unicable diseases: tutwmulosLs,
measles, diphtheria, pertussis*
tetanus, and polio, setting a tar
get of 80% coverage of infants
or "universal childhood immu
nization” by 1990. Ihis program
contributed to the establishment
of cold-chain equipment, ade
quate sterilization practices, a»lebration of National Vaccination
Days, and expanded systems of
surveillance.48
Imniunization campaigns ac
celerated in the developing
world after the mid-1980s. They
also gained the important sup
port of Rotaiy International49
Colombia, for example, made
immunization a national cnisade.
Starting in 1984. it was strongly
suppc>rted by lhe government
and by hundreds of teachers,
priests, policemen, jotinutlists,
and Red Cross voluntwra.80 In
1975, only 9% of Colombian
children aged younger than J
year were covered with DFf (a
vaccine that protects against
diphtheria, pertussis, and
tetanus, given to children
younger than 7 years old). By
,1989. the figure had risen to
75% and in 1990 to 87%?' In
a corollaiy development, the in
fant mortality rate decreased.
These experiences were instru
mental in overcoming popular
misperceptions such as that varcinatiun had negative side ef
fects, was not necessary for
healthy children, and was not
safe for pregnant women.
However, the achievements of
immunization did not lessen tlie
debate over primary health
Ahiertcan Journal of Public Health
pH c
i
p-
November 2004. Vol 94. No. 1.1
PUBLIC HE41TH THEN AMD NOW
care v Newell, one of the archi
tects of primary health care,
made a harsh criticism; ’’Iseleclive primary1 healtli core] is a
threat and can be diought of as a
c'ounter-revolution. Ratiicr than
an alternative, it... can be de
structive .Its atlractinns to the
professionals and to funding
agencies and gownimeuls look
ing for short-tenn goals are very
a^iarent. It has to be rejected/53
US agencies, the World Bank,
and UNICEF began to prioritize
some aspects of GOBI such as
immunization and oral rehydralion solutions. A$' a result, increasing tension and amtnony
dewloped l>etwcen the WHO
and UNICEF, the 2 founding in
stitutions of primaty health eare,
during the eariy 1980s.'5’’
T he debate between these 2
perspectives evolved wound 3
questions What was the mean
ing of primary health care?
How was primary health care Io
he financed? How was it to be
implemented? The different
meanings, j&peciaUv of coniprehensive primary health care, un
dermined its power. In its more
radical version, primary health
care was au adjunct to social
revolution. Forsome, thus was
undesirable, and Mahler was to
be blamed for transforming the
WHO from a technical into a
politicized oi-gaHrzation.55
Fbr others, however, it was
naive to expect such changes
from the conservative bureaucra
cies of developing countries. Ac
cording to their view, it was sim
plistic to assume that i*nligltemed
experts and bottom-up nmimuiiitv health efforts had n rovolu
tionary potential and the |xTitical power of Hie rural poor was
underestimated. I hey also
thought dial the view of “com
munities'’ as single pyramidal
Structures willing io participate in
health programs alter (heir lead
ers received llu* necessary infor.mktion was idealistic In fact,
they said, these comm unities and
their learning process were usu
ally diverse and complex
in its mildest version, primniy
health care was an addition to
preexisting medical services, a
first medical contact, an exten
sion of health services to rural
areas, or a paiT<age of selective
Itrimarj' healtli care inteiwv
tions. However, none of ttiesc
features could avoid being con
sidered second-quality care, sim
plified technology, or poor health
care for the poor?7 Two corol
lary mticisms from Latin Ameri
can leftist scholars were that '‘primaty* really meant ‘‘primitive"
health care and that it was n
means of social control of the
poor, a debasement of the gold
standard established in AlmaAta. A related question not an
swered was. Is .primary health
care cheeper than traditional
health interx'entions or does it
demand a greater investment? ^
It was not clear just after the
Alma-Ata meeting how primary
health care was going to be fi
nanced. In contrast to other in
ternational campaigns, such as
the global tealaria eradication
program of the TOfiOs, where*
UNICEF and US bilateral awstance providext fuiitting. there
were uo significant resources tn
the WHO for training auxiliary
personnel, improving luitntioti
and drinking water, or avating
new health centers. It was diffi
cult to convince developing
countries to change their already
committed heal tit budgets. A
1986 study examined several es
timates of primary health care in
developing cotmiries (around
US$ 1 bWton) and concluded that
NowinU’f 2004. Vol 94, No. 11 J Amerfcan Journal of Public Health
“the wide range* of costs ... is in
dicative of how little is known
about this are^'*1'
.As a result, most, intemational
agencies were Interested in sliortu*rni tedinkal programs with
dear budgets rather than broadly
defined health programs?1 In ad
dition. during the 1980s many
developing countries confronted
inflation, recession, economic ad
justment jxrficics. and STlffocatfng
foreign debts that began to take
Ulcir toll on public healtli re
sources. A new political context
created by the cmeigtrnt^ of con
servative ntHhliberal tiegimcs in
die main industrialized countries
nwant drastic restrictions in
funds for health aire in develop
ing cwntries. According to
Mahler, during the 1980s, “Too
many totihiries. too many bilat
eral and multilateral agencies,
too many individuals had be
come too disillusioned wilii die
prospects fur genuine human
rlevelopment"^
The changing pohucal context
was also favorable for deeply ingrainrxl cwservadve attitudes
among health professionals. Ihr
example, most luten Ameriean
physicians were trained in med
ical schools that resembled. US
universities, were based in hospi
tals. lived in cities, received a
high income by lrx?al standards,
and belonged to the upper and
U[4)nr-middle classes?’ Tliey per
ceived primary health care as
a n I Hntellccuial. promoting
pragmatic nonseientific solutions
and demanding too many selfsacrifices (few would consider
moving to the rural areas or
shimtylownsL A minority of med
ical doctors who embraced primaiy health care thought that it
should be conducted undec tht?
close supervigfen of qiialifaxl ptofessional personnel Frequently.
Cueto !
Reviewed } Public Health Then and Now < 1.871
PU8UC HEALTH THEN ANO NOW
*
they distrusted lay prnsonnel
working as medical auxiliaries.
In a 1.980 speech. Mahler had
already complained about the
“medical em|jerr>rs" and their
negativism toward primary
hcaltl) care because of false
*ipompc»ts giTuideur."6'’ The txjufrentation made matters worse.
The resistance of medical profes
sionals became more acute since
they feared tang privileges,
pre.stige, and power. Confreutation conlmued since there was
no steady effort to reoiganize
medical education around pri
mary health care or to enhance
the prestige of lay [jersonnel
However, for a genenition of
Latin American medical students,
primary health care became an
introduction to public health and
Mahler a sort of icon.
AntMher problem of prim,ary
healtii care implementation was
real political eonnnftnienL Some
Latin American authoritarian
regimes, such as the militaiy
regime in Argentina, formally en
dorsed the Alma-Ata Declaration
but did not impternent any tangi
ble reform. Because most intermilionaJ agencies favored selec
tive primary health care, many
Latin American ministries of
health created an underfunded
primary health care program in
their fragrnented structures and
concentrated on 1 ur 2 of the
GOBI interventions. As a re
sult. the tension between those
who advocated vertical, diseaseoriented programs and those
who advocated communityoriented programs was accepted
as a.normal state of affafrsDuring the mid-1980s.
Mahler continued his crusade for
a more holistic, primary health
care in different forums. How
ever, he was frequently alone,
since he did not have the full
1872
support of the WHO's bureaucracy. and his allies outside
WHO were not always available.
For example, from 1984 to
1987. an important. US scholar
for primary' health care. Cart
Taytor. left Johns Hopkins and
was a UNICEF repre^entotive in
Cliina. In 1985. Tcjada-de-Rivero.
one of Mahler's main asshtants
at Geneva^ moved permanently
to Peru, where he became miitister' of healilL In 198 8, Mahler
ended a B^term period its direc
tor general of the WHO. Al
though he never officially
launched a rei’lection campaign,
no one apjteared who whs second-in*comman<l nr had suffi
cient energy’ to tap promoting
primary health care against all
odds. In a confwdng election and
an unexpected turn of events,
tfu? Japanese physician Hiroshi
Nakajima. was elected as the new
director general.
Nakajinia lacked the communicatidh skills and charismatic
personality of Ifri predecessor.
I li$ election can be considered to
mark (he end of the first period
of primary’ health can;. The
WHO seemed to trim |>rimary
health care, and most importaotly. the WHO lost its political
profile. In a camllary develop
ment a 1997 I’an .American
Health Organization dotnunent
proposed a new ungcl. or a new
dtwlline. entitled “I leal th for All
in the 21 st-Century/^ Support
ers of a holistic primary health
care- believed that the-.original
pro|tosa! lately remained on the
dmwing boatri^0 a claim still
made today.
CONCLUSION
I Tic history of the origins of
primary healtlv carr; and selective
piimary health ewe analj^ed in
Public Health Then and Nov/1 Peer Reviewed ; Cwito
tliiN article illustrate 2 diverse as*
sumptions in international health
in tiw 20th centiuy- first, there
was a recognition tliat diseases in
Icss-dewloped nations were so
cially and econonikally smtained
and needed a pulitiGal response.
Second, tlicre was an -assumption
that the main dfeeases in poor
Countries were a natural icality
that needed adequate technologi
cal solutions. These 2 ideas were
taken-even before primary
health care—as repix*senting a
dilemma, and one pafo or the
other had to be diosen.
1 have illustrated the crucial
interaction between the context,
tiie actors, the targets, and the
teduiiques. in inicmational
health Primary' health cot and
selective printaiy health care rep
resent dilfetent arrangements of
these 4 factors. In the case of pri
mary health care, the combina
tion can be summarized as the
crisis of Ihe Cold War, the promi
nence of Mahler al the WHO.
the ufopfen god of “Health for
All," and ail unspecific metiindology. ‘Rte combination in the
case of selective primary health
f:ar<i was neo-tiberalism. the
leadership of Grant as head of
UNICEF, the more modest goal
of a "diiktien s revohuion/ and
GOBI interventions.
A lesson of this story is that
the divorce between goals and
tedniiques and the lack of articu
lation between di&nait a*$«ds
ol'ltealth work need to be addressed, A holistic approach, ide*
alisin, tedinical. expertise, and fi
nance should-miist-go together.
Thmi are still pwbfoim of teni(orialily. lack-of flexibility, and
fragmentation in intematinnal
agencies and health programs in
developing cciwtrics. Primary
and vertical programs coex&L
One way to enhance the integra
tion of sound technical interven
tions. socioeconomic develop
ment programs^ and flic training
of human resources for health is
the study ofhtsloiy. «
fibouttiie Author
7?ie duihor ts arith the ttyirtmeni of
Sociom&l^ ^rimces. Schwl f/fruhlic
IfecilSi, M^idad Pmutna ('a^untti
Limti, Peru
^nuildbe. s^tUia
xhtm n«-iu. m ihaMt&a m
Urtwx
'Phis arnd?
2(hD4,
tn0^$ypekQiu])&
txrepied hfardr 13.
ScknwIetlgffleftU
Kewiawh for iltih anwrle, was made possi
ble tiwnks tu the Gawil for Internauonsd KxdMiKgc olSdurfm-lidbrigla
New Century Sriuilars Pixsgnitn '‘Chailength of l lealtb In a Borderless Wurkf
and the joint
Initiative for
Human Rexmirccsfor Health and Deve!optnetil The artodc was completed dur
ing 2004 when the author was a visiting fcllw al the Woodrow Wilson
Coiiter in Wtishitegtofi, DC
Endnotes
1. S. kitsios. ’Tlw- Ixmg and Dininili
K<«lfl te Aln«hAia; A .Wawonal Relk-ctw,* ftuamaitonfilJvumai of ii&tMt $e>'tW 32.
709-732^ S. Lee.
’WHO and the Developing World Tlw?
Context Rir lilpnlogt-." in Hkdm/ Medt(■vie tfs Contested Kfunded^e, od A. Cun
Hingfiarn and B, Andrews (Munchester
Uiiivcndt?4 Press, I9tT7K
24-4S.
2. J. fl. Bryant Healffi mid rhe Ikveloptng Murid (Ithttra. NY: C'orndl Umverity Press, 19(^1. ix -’i,
3. C It Taylor, cd,
the
Villt^es: Siudy of Rim! Inierwlitfn in
Seven InditiH Medico! Crdlt^es LNew
York:' Asia<hiblishing Housi*. 19761
4. K, W. Newell ZWdi dee triple
(Geneva; WorM Health GrganizatkHi
[«. T«J75>. jri.
5. Qinaclian Departinetu of Nammal
IteaWt and VVete. .4 Aw Perspcctiiv
mi the lh‘n!.tli of Ctniiidrinrs
perde /« sarue den Cwtudiens (Otiwwjrn.p, 1074}.
■6. T Mdfenwn. Hie KhnUm Hine, of
f^npulafinnf^ev,’ Y<«1 Atadetnic I’ivss,
rt)76i.
1, I. IHieh. Medicni Nentc^ the Pxpn>
[HiuliMi qflMtk (U»ndon. C&l4er &
BtHfm 19751
Awiericnn Journal of Public Health
Novemt>er 2004, Vol 94, FJo, 11
PUBLIC HtfiLTB IO AND NOW
I
8
G ftiterson. "Hie CMC Story,
1968-1998." Cwtta.-( 161-162 (1998)
3—18.
9. R. Martin. ’■Cliristians Pioneer In
ternational Health Concepts.* availalilc
at http.//vvvw<:<,fo.(jrg/foniin/0011 03.htm. aeerssed March 19, 2004
1(1 V. W. Sidel. 'The Barefoot Doctors
of the I’eojile.'s Republic of China." New
England Journal of Medicine 286
(1972) 1292-1300. See also IL Side!
and V. Sidcl, Health Care and Traditional
Meditine in China. IfiOO-1982 Otottdon: Routledge and Kegan. 1982)
11. L. B, I’eai'son, Bitners tn Developrnent (New York; Praeger. 1969); W
Brandl North-South. A Progwtt for Stn vical(Cambridge. .Mass: Mi l’ Press.
1980).
12. L. A, Hoskins, "'['he New Inteniatiorial Economic Oixlfr: A Bibliugrapluc
Essay." Third World Quarter^/ 3 (#81);
506-527.
13. Hie biographical information is
taken from “fir Hajfdan T. Mahler."
avtelable at http7/ww'w.who.int/
archives;whOSO/cn/direcfors.lum,
accessed March 19. 2004.
14. H, T. Mahler, interview with tite
author. Geneva, May 2t)()2
15. Mac MtGivray (a CMC member)
after a m/teting with Mahler on March
22. 1974. Clled in Paterson. "'Fhe CMC
Story." 13.
lb. V. Djukanovic and IL P. Mach. ed%
Altenuitive Apjnoaches to Meeting Basu
Health Needs of fh/pulations tn Demdop
ing Countries: .4 Joint UNtCEF/WliD
Studg lGcuwa: WHO. 1975). 110
17 "The Work of WHO tn 1972 An
nual Report of the VlirtK-tor General to
tlie World Health Assembly." in WHO
Officwd Records 2(15, 1973. Geneva.
WHO Library.
18. Djukanovic and Mach. Alieritative
Appmaduei, 14.
19. H,T. Mahler. “SixaaJ Perspectives
in Health . Address in Presenting Hh Rvport for 1975 tn die TWcnty>Ninth
Wbild Health Assembly. Geneva. 4
May 1976." 1, Mahler Speeches/l.ectures. Box 1.WH0 Library.
20. ‘Tnteiview with David Tejsido-deRivero." in Hbrid Federation oj lhiblif
I leallh Assk tutiuns, Ctmj'ifmu'e Bulletin I
(1977). 1. ffolda "WHO International
Conference on Pranarv Health Care
1978. November 1977—January 1978.'
P. 21/87/5. WHO Archive. Genevn.
21 D. D Venediktov. "Primary Health
Care; l,css<>n.s From Alma Ata.' World
Health Hnvm 2 (1981) 332-340.
quote from p. 333.
22 "United Nations f xonomic and So-
rial C'oundl. United Nations Ctiildren’s
Fluid. Executive Board. 29 October
1976." Folder “WHO. hiierttatioual Con
ference on Primaty Health Care 1978.
August 1975-Fvbruaiy 1977,"
f7?l,W5. WHO Ardimi.
23. Tcjuda-de-Rivero had great care for
the details of mgamziog the meeting,
shown in Iris lequest for '250 desks
and tables. 500 chairs. 200 typist
desks. 200 typist chairs.” among other
items; 1). Tejada dedtivero to D.
Venediktov, September 20. 1976.
Rikler "VW 10 Intematioiial Conference
on Primary I leallh Can? 1978 August
1975-Fehruaiy 1977." P 21/87/5.
WHO Archive.
24. “Intervention of Director General
of WO. H. Malden" in Wlma Ate
1978. international Conferenex? on Primmy FWth Care. 6-12 September
1978,. Stalements by PaiticipauLs in. the
Plenary Meetings.'' 4-6, ICPIIC/ALA/
78.1 -11. WHO Iabrary. Geneva.
25. See H.T- Mahler, “HealdwA liemystification of Mcdiwil Teclmology.”
Latwet ii (19751: 82.9-833.
26. H. T. Mahler, World Health U
tndwisible: Address to the 'Ihirty-First
World Ileallh Assemb.li/ (Geneva:
WHO. 1978). 4.
27. H. T. Mahler. "WT-lO s Mission Revisited: Address th hxaonting His Re
port for 1974 to the 28th Wtirid Health
Assembly. 15 May 1975,’ K). Mahler
Speeches/Lectures; Box I. WHO Li
brary. Geneva.
1776. Kodcftfdler Archive Cmcer.
Sleepy Hollow. i\T (hereafter RAO-
30. J. IL Knowles, ed..
Better and
Fueling Wante (New York: WAV, Norton
and Co . 1977).
31. J. 11 Knowles to C W&hrfcn. July 6,
1978. [older Tlcaldi nod Population.”
REA, RG A82. Serie? 120. Box 1776.
RAC: MartJia Finnernore. "Redefining
Devdbpineir. at the VUirid Bank.” in IntemMiona! Ifavlopnwnt and the Social
Snente Ensai/s in the Hvftorij and /fylttim
ofKnowledge, cd. E Cooper and R.
Packard IBcrkelev University of Califor
nia Press. 1997).'203-227
32. J. A Walsh and K.S. Whnvn, "Se
lective ftimarj’ Health ('are. an Interim
Strategy for Diswise Control in Devckying Cotmtries.” New England Journal of
.Medicine 3G1 (1979): 967-974; it also
appealed in Sucta! ScieiKV and Medicine
14C (I9&0)! 145M63 as partofan
issue ctevoted to the Bellagio meeting.
33 J. Rutin. “Magjrx'l Bu.Itet: The Wktory of Oral Reliydrution Therajiy.”
Mtrfiad History 38 (19911 363-337.
34. S. Plank.and M.L. Milanese “Infant
Feeding and Infant Mortality in Rural
Chile," fiuliciiti of the. World Health (trganization 48 (1973); 203-210.
35. Ihvlecting the World's Children
Wwmw. and Immumztilum Within Prt
wary Health Cant. Confirrence Report
(New York: Ttockeleller Inundation.
198.4)
36. J. Evans; K. HalL and J. Warforrl.
•'Health Can? in the I'icvdoping World
hnblcms of Scxn.-ity and Choi<x-.” New
England Journal af Medicine 305
(1981); 1117-1127.
28. “WHA32.30, VonnukiVing Strait pcs for Health for all by the Year
2000, World Health Organization.
32nd World llealtli Assembly. Geneva,
7-25 May 1979? available al http://
poJicxewho.int/t^i-bin/ om._ i.sapt.dll?
infobase^\V11 A&softpagt.^Browse.Jra
nie_Pg42. accessed June 25. 2(K)4; H.
T Mahler, “Salud con Juslicia.* Sahtd
Mundial (May 1978); “Wlwtt Is ihmltli
for All?" Wbrld Health (November
1979): 3-5; Mahler, “i he Meanutg of
Henlth for /XII by the Year 2000."
World Health Forum. 2 H9«l); 5-22;
Mahler, "’fhe llilitical Struggle for
Health. Address al the 29th Se.ssfon of
WHO Regional Committee for the
Western ffo.dfic"; Mahler, 'Eighleen
Years to Go to Health for AIL Addrvss
to the 21st Pan American Sanitary Con
ference, Geneva" (fill Maliler articles
from Mahler Speeches/Lectures. Box I.
WHO Library Geneva)
33. UNICEF. I'he Stale of the WaHtfi
Children: 198Z lBB3 ^V York: Ox
ft’rtj Univei-sil.y 1‘i^s. 1983). See also K
&. Warren. "Introduction," in Stmtiifpes
for fSinwiij HeaUh Cure. TfecfciHifrigire
Appmpriateforihe Coirtad of Disease in
the Oavluping Wbtfd cd. j. Walsh and
K S. Wanijn (Qiicagtj: UnivvTsity df
('hicago. 1986), ix-xj; K.S. Warren.
"'Hie Evolution of Selective Bnmary
Health Care.* Social Science and Afedi
cme 2b (1988): 891-808.
29. K KanagaratiHim. 'A Rt’vw-w of
the Bellagio Population and Health Pa
pens." May 9. 1979,1 older 'Health and
Population? Rockefeller Ftnnidaiiun
Ardn'ves (liereaftcr REA). Record Group
(hereafter RG) A$2. Scries 120. Box
39. Examples of die debate are die let
ters sent tn the editor that appeared to
the "Con^spuhdenctr section of the New
England Jouninl of Medici ire 30'2 (1980k
757-759. See also S. Rifkin and G.
Walt. "Why [ lealth Improves-. Germing
November 2004. Vol 94, No 11 | Amencan Journal of Public Health
37. On Grant, wife C. IteUamj. P.
Adamson. S. B. Tacun, ct al../nn Grant.
IJMC& Vhdonanj ^renee. Italy;
UNICEF htnocemi R««?ardi Ceftter.
2001). available al hiij»:/Xtewsw<uriic<,L
org/ alxjuh'w’hix-tedex^bto jfrani.htiiil,
atxessed Majth 19, 2004.
tlie Issues (IniCcrning Comprcheiisive
Primary I leallh Can-' and 'SelectK'c Pnrnmy Heahh Care.’" Samil Science (md
fifafeine 23 <1980)-. 359-566; J P
Unger and j. Kiffing»w>rth. ‘‘Selective Lnwtary I lettlth Care; A Critical Hevtew of
Mttlljtxk and Rcsi.il ts," StMha) Scierux* and
Medicine 10(1986): 1001-1002: the
sjKtial issue -Selective or Comprehen
sive Primaiy Health C/av' vf Social Sci
ence aiu! Mcdirttu! 26(91! 1988>
40. "WHO Indicators for Monitoring
Progn?ss Towards Health for All Discusson Pa|M:.-. Geneva Mardi 17. 1980,''
HPC/MPP/DPE/80.2. WHO Library.
Geneva.
41. ’Prinwy Health: A First Assess
ment," I’eopte ftqport an Priniary Health
C(W (1985): tf-9. WHO Library.
Geneva.
42 Venediktov, “l^ssoite.” 336.
43. 0. Gish, “Selective Primary Care
Old Wine in New Bottles." Sactul Sctencc<ind Mtididne 16 (1982); 1054
44. J. lx Bosi hissaciatc proftssor of
management polity at Boston (Jniwriitj
School of Management! to R Bartley
[editor of (he WTaff Stgnrl jdtinxili, No
vember 13, 1079, Folder “Flic Protec
tion anti Promotion of Breast Feeding.''
CF-NYH-09 D 5-8) Heyward 1011 A
138, L NTOF Archives. New lurk. XY.
45 11 I Sheefild, ‘’Boycott to Save
Lives of Third World Babies.* .Vichtgan
CJirtmide. December 29. 1979 (newspa
per Hij>|>tngi, Folder "'Hie Protection
and Proinnlion of Breastfeedlingf CFKYH-09 D tV»-81 Heyward Tfili
A138 UXICEF .Archives
46 'Crilirhjn Mounts Oyer [/He of
Raby Formulas /Ymcmg World's Poor,'
Wi>diiugtim Pt»l. April 21. 198! [news
paper clijipjijg]. Folder “'Jhe Protection
and Promotioi) ufhieasttefiling;" CFN'YIWB D 05.-81 Heywod foil
A138. UNICEF Archives; ]. E. Post and
IL Baer, ''fhe Internationa Code of
Marketing for Breast Milk Subslitirtes:
Consensus. Compromise and Cohflkl
in (he Infant Formula CanCrovenjy.’
Ar Kcview fnternationul Commisaien
ofJuriata 25 (Pfccmber 1980):
3.2-61; M. B. Bader. '‘Breast-Fading.
The Bole of the Multinational Coqjora
lions tn Latin /Ymcrica,* Jiti^muttonal
jtwmal of Health Serviem 6 (1976).
604-626.
47 During these yeaix most develop
ing couotriis signifiamiiy improved the
coventgr- figures. ‘'Exjwncted Pm-
granwm- on Immunization. November
24. 1978.- Btider ‘WllO-UN'lCl-F joint
Study.’' Cl-NYH-09 D Heyward TWO
;\t2i, UNICEF Archives.
48 T. Hill, R. Kim-Farley, and J
Cueto Peer Reviewed Public Health Then and Now
.1873
I
e
PUBLIC HEftUH W ANO NOW
Rrjhefe. “Bt|wded. l-'n ^rimme o» ln>
ttuuMzatoK A Ckwtf Arhwwd Trwvards
Health fur AO.'«» ftmcfias^ HtuM fitr
\lt ed J. Ruhde. M Chatteijer*. and 0.
MoHcy (Dellii. Oxford Unhwuty fforss.
1993). 403-422.
49. G. N<wa!. ‘ProUfcttriM Ow ffo»gvuy the Futw ’*1 V^wncs,"
tH*s tn ifailth Mmwirte 7 <2002)
8-13.
50. UNICEF.
ih- Arwruti^
far the CMdrttn ttf Z&nje Ikauit^.
1,‘NICEI'. History Sema 85.. Monograph
IV. 1993, UNICEF l.ibmy. New Y.tfk
Cuy
51. F MuOer. 'ParuciptiiKm, Hwriy
and Vtok-net’: Health anti Survival in
America," tit HBtudim# Heultk for
Alt, 103-129.
52. 'Htertt wm' evtm radical critMjim
(.< the ongmal Alma Ata IfeSaratm
such as V. Navarro. "X Critiqur? <4 the
kkdogfoal aiKi Fblfttcul IWtfonji of iht*
WMIy Brandt Report and the WHO
Alm Ata Dectaraisctf ( l&Mk in V.
Navarro. Cnsh. tkalih amt Mrriinne zt
Cntajur tluiKfon: Titvistodt Pubhca&w, tom 212-232
4
39. The cowem ajifteara in some
(INTCEI- docutaenU. sueh as *MeftKV
raruta I mtn UL. Rem. Oeemtajr
22,1977 UtmW Bedridl on Bikfeetn»g oflPranary
Caret'’ Folder
“W1 IO ami UNICEF Fund Rtifctag," CTNYH4MJ U UNICEF Archives
S
B?
0
6|. S, H. Rifkin. F Muller, and V: Ride
rniiiut Tiirrtftry Health Carr. On Mea
suring IVtrtidpatktu ‘ SiKTol 5<w7kv and
H9B»)- 931-940
ti2 H. f. Mahk-r. ‘World Health 2<XMJ
and ffoyond . Address to the 41st World
Health Assembly 3 May 1.984? Mahler
SpecdWlxxctiirtts. Box 1, WHO Ubrary.
03. A. J. RubH, "The Role of Suda! S<3<4jce Rm^rth m Reetut Health P»h
gram-, in ialin Armrim? iMttn Asrcnmn-femn/i fteiaew i (1960) 37-56
53. K W, NewB. “Sderttve Primaiy
Health C^re: The G%mtt?r Revuhttamf
.<XA7«/ Sci^iKt! and Mefhfinr 2b (19881
(juate fmin p 90 b.
54 J<. Goucffldrf. I Chuncr ro Live (N<nv
York MiMIhn Inu-malional. 1991).
25-42.
6.5 Pan Ainrrimn 1 leahh Organizat«»H. Sithtd patv lining m (d Si^(> I rinti
nmwHWWngten. DC I’AHO 19971
55. Mahler htniseh meouom n m H. I
Mahler, ■’lliB fVrfitiatl Sinyggie fw
Hedth; ?kWress of Oh* Ihmior <hi«’.ral
at the 29th Session of the Regional
Cranmfttee for die Western ftuific,
Manila, August 21. 197ft," Mahfer
Sjxwht^/I.jecinmx Bm 1, WHO l>
tswy. Ge»»eva.
66 D. Wenur real D Sunders. Qi^
tKniwg die Sahaion. The llditd'!. of Pri
teary flraith Cfav and Cktld Sareival..
^Vtth an bt-fiejiA Cnliqur of Oral ftditf
drutiwi 'lherafy Ohio Alto, Calif. Health
Riglite. 1997) $<•? ako -Round Tabfo.
IPrimary Health Cartd-What Still
Need* u> Be Dune?' H odd WewM
/iimirt H a990).- 339-3^6.
57 See j. Bwk “FW Contact Shiplifk*d Tedmolf^y or Kisk: Atitai|j8tMMi?
Ik’fbdng I’rwnHty I kaWi Can*," AitKientie MttiKine 65 (W90); R76-<»79.
K3SBCTE
ff NEW '
H from
\\APHA,
’
riCk M Patel “An BewoHlie Evaluafam
uFlkaMi} Fur All." Heukh unit Pidir^ and
PteMWi I H«r 37- 47.
64 H T .Mahler. Ptiniaiii iMbh Care
nn Afttdjfrdii ofSame Cansimint^ «m Addre^ tidteer&t tn the Sf^ral
Una Jiir the Canfemeni i^urt llnnoraru
ih^ree ^t tfr Raffdn T
Univwfty <4
l^agiss Press. IS8Q). W, Mahler
Speeches/Ujctan^ ifox l. WHO 13bnuy'. Geneva
§e. AW, IWr. J M. Wsh. and
&LA, Gmxu “Norttadiw Af^rrosdi to
the Ikfintlion of Primary H«alth Can?,"
WiZSdwk MwKOia/ hmd
54
(1978). 412M3B
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58. See J. Brdih ‘CoiiftmuHiy Mctbcfoe Under IrnjxAriatism: A New Medical
tblfoe.’ htiemttfiottalfoumni nf Iktilfh
SertiKea »(1979); 5-24: M. Testa,
4Atencfon Printaria u primitiva? De
Salad? i« Se^utki^ liinuuLas de .fa&ckin
PmwrKi de la Satud (fhuntw Aim. W
c-iaridn de Mt-dkos Resadetttes del He?*'
pital de Ninos Hjranfo Guuemx 1988.1
75-90, A. llgaldr, ■‘Ideoltuxieiii Dimen
Siam of Communay Ikitieipatiiwi «t
l adn American HmltJt Prcgrams."
eirtl fetter wad Mrrfuw 21 (MStY.
41-53.
J.874 j Public HaeKh Then and Now i Peer Reviewed I Cueto
American Jaurnal of Public Health '; Noventbe? 2004. Yen 94. No. 1.1
Editorials
______
The promise of primary health care
Marcos Cueto1
€
Twenty-seven years after it was
embraced at Alma-Ata (now Almaty,
Kazakhstan), primary health care and
its call for “health for all” still holds
a promise (/). Study of the history of
medicine suggests its worldwide appeal.
Primary health care is the latest expres
sion of a belief that can be traced to
the 19th-century pathologist Rudolf
Virchow: the solution to major human
disease problems resides not only in the
best science available but also in brave
political proposals for social justice and
the improvement of the life of the poor
(2, 3). From this perspective, health is
not only a by-product of social changes
but an instrument to promote such
changes — and health workers are in
the vanguard. History does not follow
a linear path of progress, however:
setbacks, resistance, negotiations and
compromise have existed in the history,
design and practice of primary health
care programmes.
Based on reflections by Socrates
Litsios
and my own research on
the history of primary health care (W5),
I suggest four themes for reconsidera
tion: its meaning, funding, and imple
mentation, and the culture created by
restricted top-down versions of the phi
losophy. First, primary health care has
had several meanings that undermined
its power as a health paradigm. In its
more radical version, the complete re
form of public health structures and the
promotion of major social changes were
envisaged, with primary care as the new
centre of health systems. In contrast,
according to an instrumental interpre
tation, it was merely an entry point,
a temporary relief or an extension of
services to underserved areas {W6}. The
latter interpretation could not avoid
being perceived as second-class care,
“poor” medicine for poor people.
Second, funding for primary
health care has usually been insufficient
and inconsistent (7). In the past few
decades it has been difficult to establish
an effective financial system with clear
indicators that ensures sustained sup
port of community participation and
intersectoral collaboration, to mention
just two important but controversial
project tasks (W).
Third, implementation encoun
tered resistance from health personnel.
Many physicians in less developed
countries were linked to specialized
urban hospitals and traditional medical
schools; they knew much about treat
ment but little about prevention. Many
of them hoped that their expertise
would facilitate upward social mobil
ity (W9). Unless health professionals
and their systems of training are closely
committed, a health programme can
be undermined from within.
Fourth, restricted primary health
interventions reinforced a culture of
survival in developing countries, where
many people believe that public health
is an emergency response embodying
vaccines, drugs, ephemeral training of
lay personnel, or the creation of a health
post. Health work is perceived as a lowvalue, short-lived activity from outside
the community. As a result, a culture
of survival among the poor sustains the
privileges of power among politicians.
The poor continue to struggle to obtain
access to fragmented programmes and
foreign aid in order to relieve pain, delay
death and prot<iect loved ones, while
the elite’s control of limited resources
becomes a source of power in an envi
ronment of scarcity. The combination of
the culture of survival and the privileges
of power reinforces inequity, depen
dency and passivity, all of which are in
compatible with primary health care. It
will take imaginative decision-making to
transform the public health implications
of the culture of survival and recreate a
true primary health care system.
In order to renew the promise of
Alma-Ata, it is crucial to tackle these
four issues and to increase the awareness
of the political contexts in which the
strategy might flourish. The persistence
of neoliberalism, the transition from
an “international” to a “global” frame
work, and the coexistence of the most
terrible expression of human history
(war) and one of the most idealistic (the
Millennium Development Goals) mark
a complex political context, in which
one actor should play a crucial role: the
local health worker. As a recent report
underscored, dramatic changes have
occurred recently in the growth, job in
security and self-assertion of local health
workers (/(?). There have never been
so many health workers in developing
countries with experience in providing
community-oriented care. Many believe
in change from below and have a vested
interest in the integral improvement of
health systems. The old fear of losing
professional privileges is no longer a
concern because these are evaporating.
Mobilizing, empowering and strength
ening these human resources in develop
ing countries are crucial to pursuing
the promise of primary health care. £?■
References
(References prefixed " W" appear in the
web version only, available from www.who.
int/bulletin)
1. Primary health care. Report of the International
Conference on Primary Health Care, Alma-Ata,
USSR, 6-12 September 1978, jointly sponsored
by the World Health Organization and the
United Nations Children's Fund. Geneva: World
Health Organization; 1978 (Health for All
Series, No. 1).
2. McNeely IF. Medicine on a grand scale: Rudolf
Virchow, liberalism and the public health.
London: Wellcome Trust; 2002.
3. Ackerknecht EH. Rudolf Virchow, doctor,
statesman, anthropologist. Madison (Wl),
University of Wisconsin Press; 1953.
7, Patel M. An economic evaluation of Health for
All. Health Policy and Planning 1986; 1:37-47.
10. Joint Learning Initiative. Human resources for
health: overcoming the crisis. Washington (DC):
Communications Development Inc.; 2004.
Administration, Universidad Peruana Cayetano Heredia, Av, Honorio Delgado 430, San Martin de Porres, lima 31. Peru
' Professor, Facultad de Salud Publica y
(email: marc@dnet.com.pe).
Ref. No. 05-022269
Bulletin of the World Health Organization | May 2005, 83 (5)
322
1. Primary health care. Report of the International
Conference on Primary Health Care, Alma-Ata,
USSR, 6-12 September 1978, jointly sponsored
by the World Health Organization and the
United Nations Children's Fund. Geneva: World
Health Organization; 1978 (Health for All
Series, No. 1).
2. McNeely IF. Medicine on a grand scale: Rudolf
Virchow, liberalism and the public health.
London: Wellcome Trust; 2002.
3. Ackerknecht EH. Rudolf Virchow, doctor,
statesman, anthropologist. Madison (Wl),
University of Wisconsin Press; 1953.
4. Litsios S. The long and difficult road to AlmaAta: a personal reflection. International Journal
of Health Services 2002;32:709-32.
5. Cueto M. The origins of primary health care
and selective primary health care. American
Journal of Public Health 2004;94:1864-74.
6. Werner D, Sanders D. Questioning the solution:
the politics of primary health care and child
survival, with an in-depth critique of oral
rehydration therapy. Palo Alto (CA):
HealthWrights; 1997.
7. Patel M. An economic evaluation of Health for
All. Health Policy and Planning 1986; 1:37-47
8. KarkSL. The practice of community-oriented
primary health care. New York: AppletonCentury-Crofts; 1981.
9. Testa M. Pensaren salud. Buenos Aires: Pan
American Health Organization; 1989.
10. Joint Learning Initiative. Human resources for
health: overcoming the crisis. Washington (DC):
Communications Development Inc.; 2004.
Bulletin of the World Health Organization | May 2005, 83 (5)
A
Soc. Sci. Med. Vol. 26. No. 9. pp. 877-878, 1988
Pcrgamon Press pic. Printed in Great Britain
EDITORIAL
THE DEBATE ON SELECTIVE OR COMPREHENSIVE
PRIMARY HEALTH CARE
As many readers of this journal will know the debate concerning the difference between PHC and SPHC has
generated a great deal of discussion. The origins of the debate can be traced to a paper written by Walsh
and Warren in 1979 [1]. They argued that the primary health care approach was too idealistic to be
implemented by most governments. Instead it was more realistic to target scarce resources to control specific
diseases which accounted for the highest mortality and morbidity; which had available low cost technologies
for prevention and treatment; and which had techniques that were cost-effective. This approach was called
selective primary health care.
The discussion about SPHC has not been merely academic. By the mid-1980s it was apparent that several
donor agencies had accepted the line of argument put forward by Walsh and Warren. As a result resources
were increasingly being directed into vertical programmes that sought quick technical solutions to health
problems rather than integrated programmes which addressed a wider range of development issues over the
longer term. It was concern over this trend amongst international agencies that prompted a number of people,
academics, practitioners, agency personnel and donor recipients from both the less developed and the
developed world, to come together to analyse the situation at a meeting in Antwerp in 1985.
Having discussed the SPHC-PHC issue, participants at the Antwerp meeting concluded that an important
next step was “to undertake a programme of fundamental research on primary health care so as to identify
its main features, reinforce them, and make them known". The purpose of this special issue therefore is not
to review the history and development of the debate, which has been done recently [2,3] but to give the reader
an overview of the present status of these discussions and to continue the spirit of the Antwerp meeting by
taking the debate further.
As in the first paper we therefore chose a review summarising the issues which were debated at the Antwerp
meeting. As it is written in French by Grodos and de Bethune, we have included an extended summary in
English by Bichmann.
The remainder of the issue is divided into three sections. Section one focuses on health policy. Section two
examines some of the critical issues identified at the Antwerp meeting. Section three presents five case studies.
In the health policy section four papers reflect different thinking about the concepts. The originators update
their views about SPHC. In his article, Warren gives a historical perspective of the ebbs and flows of the debate
while Walsh argues that the importance of technology in health should not be underestimated. Newell takes
a more combative stand, and argues that the ideas at the core of PHC are revolutionary, and are threatened
by the contrary approaches of SPHC. Concluding this section is a commentary by Mosley, who rejects the
polarisation of SPHC and PHC and suggests a problem-oriented rather than technological or disease oriented
approach that draws together the differences into a ‘middle’ way.
In the second section a number of important issues identified at the Antwerp meeting are addressed. The
first paper by Smith and Bryant explores the debate between vertical and horizontal programmes, and suggests
what the lessons are for the building of a PHC infrastructure. Barker and Green address the issues of financing
PHC and question the existing mechanisms for priority setting and for resource allocation. They suggest that
the technique of economic appraisal reinforces an approach which focuses on specific disease control and
works against involvement of communities in decision making. The third paper in this section by Rifkin,
Muller and Bichman addresses the issue of how to develop methods of assessing the processes involved in
PHC. Here they make a specific attempt to measure participation and suggest indicators for participation in
health care programmes.
Participants at the Antwerp meeting stressed the need for more case studies that analysed the effects of
SPHC or PHC approaches. The following case studies illustrate three major themes encompassed in the
debate. The first analyses the effects of one ‘selective’ approach—growth monitoring. Nabarro and Chinnock
argue that this technique has been used by the international donor agencies as an intervention to promote
the interests of “the agencies, rather than the communities” and doubt that on its own it changes health status.
The second theme examines the effects of developing a comprehensive PHC system. Van Leberghe and
Pangu examine data from the Kasongo Project in Zaire and suggest that by providing integrated
comprehensive health services and a good referral system, hospital admissions (and therefore costs) can be
reduced. Chabot and Bremmer use their experiences in Mali to illustrate the interface between government
and community health services, and the role of donor agencies in the health system, examining the weaknesses
in these relationships.
The final theme confronts the issue of donor agency influence directly. The two papers use UNICEF as
their example, although the points highlighted are just as relevant to other donor agencies. In his paper Wisner
analyses UNICEF’s GOBI-FFF programme and concludes these efforts are likely to undermine the social
basis of comprehensive PHC. Taylor and Jolly, as representatives of UNICEF, address this criticism and go
877
I
878
Editorial
on to argue that the UNICEF approach is to develop priority programmes in such a way as to build on and
strengthen health infrastructures.
In conclusion, the question remains as to whether there is a fundamental conceptual conflict between the
proponents of SPHC and PHC.
Certainly there have been accusations of misrepresentation. On the one hand, advocates of SPHC have felt
aggrieved at the suggestion that they neglect the issues of equity. On the other hand, advocates of PHC believe
they are wrongly accused of ignoring the importance of technology.
There has also undoubtedly been some shifting of position. The debate has generated much thinking about
what PHC can attain, and about the ways of measuring comprehensive PHC. It has fired discussions about
other influences on health, such as education, and also on the political context within which policies are made
[4] and resources are allocated. Both Warren and Mosley now seem to be saying that SPHC and PHC are
falsely juxtaposed—that there is a ‘middle’ way in which selective programmes can be integrated so as to
influence the processes that lead to improvements in health: an evolutionary process within a revolutionary
concept.
However, it is not difficult to reduce PHC itself to a technocratic strategy that ignores the role of the state
(in distributing resources) and continues to see health determined by health service delivery rather than by
overall development [5]. In the wider international scene the most visible effect of a new ‘middle way’ will
be the abandonment by international agencies of the vertical, selective, programmes they have been favouring,
for longer-term development-oriented strategies. As editors of this issue we have put forward some of the
arguments in the debate. As participants in the debate we support the Haikko Declaration on actions for PHC
which suggested that “The need for a broad ‘horizontal’ social and intersectoral approach to health problems
should be reasserted. Vcrticalism should be avoided and selection of programme priorities should be made
mainly locally with popular involvement. Multilateral agencies and bilateral donors should support countries
to develop national health systems based on primary health care” [6].
REFERENCES
I. Walsh J. A. and Warren K. S. Selective primary health care: an interim strategy for disease control in developing
countries. New Engl. J. Med. 301, 18, 1979.
2. Rifkin S. and Walt G. Why health improves: defining the issues concerning ‘comprehensive primary health care’ and
‘selective primary health care’. Soc. Set. Med. 23, 559-566, 1986.
3. Unger J. P. and Killingsworth J. Selective primary health care: a critical view of methods and results. Soc. Sci. Med.
20, 1001-1012, 1986.
4. Halstead S. B. et al. (Eds) Good Health at Low Cost. Rockefeller Foundation, New York, 1985.
5. Barker C. and Turshen M. Primary health care or selective health strategies. Rev. Afr. Pol. Econ. 36, 78-85, 1986.
6. Segall M. and Vienonen M. Haikko declaration on actions for primary health care. Hlth Pol. Pl. 2, 3, 1987.
PUBLIC HEALTH THEN flNB NOW
The Christian Medical Commission and the Development of the
World Health Oi^anization's
Primary Health Care Approach
| Socrates Litsios. ScD
The primary health care approach
was introduced to the World Health
Organization (WHO) Executive Board
in January 1975. In this article, I de
scribe the changes that occurred witfei
WHO leading up to the executive board |
meeting that made it possible for such
a radical approach to health services
to emerge when it did. I also describe
the lesser-known developments that
were taking place in the Christian Med
ical Commission at ttie same time, de
velopments that greatly enhanced the
case for primary health care within
I WHO and its subsequent support by
I nongoYemments! organizations con| cerned witii community health.
!
R
JaaMr
“1T s
Bi
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SI
O
mJ
I
i■ '
11 I
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• ■
• ii
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B
Heafth promoters at the bedside of a
sick child, Chimaltenango Hospital.
1884
Public Health Then and Now ; Peer Reviewed I l..ifs>os
I
American toutnsi erf Public Health i November 2C>04. Vol 94, No 11
PUBLIC KfllTH THEN AHO NOW
THE PERIOD 1968 TO 1975
saw dramatic changes in the pri
orities that governed the work
piugram of the World Health Or
ganization (WHO). For more
Uian a decade, the global malaria
eradication campaign had been
Wl IO s leading program. Initi
ated in the mid-1950s, it was a
strictly vertical program based on
the insecticidal power of DDT.
Only in the early 1960s was it
acknowledged that a health infra
structure was a prerequisite for
(lie success of the program, espe
cially in Africa.
Independent of the malaria
campaign's needs. UNICEF,
wishing to increase available
funding to help governments de
velop health services, sought
technical guidance (rom WHO
for planning such servims. In re
sponse. WI10 prepared in 1964
a short paper outlining broad
principles for the development of
basic health services. 'Fite model,
which followed an outline devel
oped in the early 1950s.1 called
for a hierarchical arrangement of
health facilities staffed by a wide
range of public health disciplines.
As it became evident that
other in 1969. that became
deeply involved in questions con
cerning what countries should do
to improve their health services. 1
then turn to the liistoiy of the
Christian Medical Commission
(CMC), whicli wax addressing
similar questions, but lor totally
different reasons.
The parallel paths of WHO
and the CMC came together only
after Dr Halfdan T Mahler be
came director general of WHO
in July 1.973.1 conclude the arti
cle by describing how coopera
tion between these 2 organha-
these were pajl of tlte "systems
anatysB’ approach dial was very
rnudi in vogue al the time.
In 1969, a new program called
F’roject Systems Analysis was es
tablished in WHO. Its director.
Dr Halfdan 1’ Mahler, a tubercu
losis specialist, had been chief of
the Tuberculosis Unit from 1962
to 1969. Although both pro
grams had many points in com
mon. Mahler’s program was cre
ated as an instrument to change
the way WHO worked with
countries, an orientation that was
outside Newell's mandate.
As it became evident that malaria eradication would not be achieved,
greater priority was given to the development of basic health
services. The then-director of WHO, Dr. Marcolino Candau,
in 1967 noted that 'the success of practically all the Organization's
activities depends upon the effectiveness of these very services.'
lions dewlopcd and how it
influenced tlie formulation of the
primary health care approach.
WHO—SEEDS OF CHANGE
Candau appointed Mahler as
distant director general in Sep
tember 1970. assigning him re
sponsibility for both programs as
well as the divisions concerned
with health care (Organization of
malaria eradication would not be
achieved, greater priority Was
In 1967, a new division was
created in WHO: Research in Epi«
demiolog^' and ConuntuiicatioFLs
Science. Ils director. Dr Kenneth
Health Services and Health Man
power Development)- He was 1
of 5 assistant director generals
who shared rrsponsihility for
given to the development of
N. Newell, was an infectious dis
around 15 technical programs.
basic health services. The thendirector general of WHO, Dr
Marcolino Candau, in 1967
noted that "the success of practi
cally all the Oiganization’s activi
ties depends upon the effective
ness of these very services.n,‘ In
ease epidemiologist Among the
researdi projects developed, one
addressed nestuirch in the organi
zation and stiategy of health ser
vices. Its purpose was "the devel
opment and demonstration of
methods to sliow that a rational
approach to (he formulation of
Although the programs worked
19 68, Candau again highlighted
tlieir importance and called for a
comprehensive health plan,
within which an integrated ap
proach to preventive and cura
tive services could be
developed.3
I begin this article with a de
scription of 2 WHO programs,
one initiated in 1967 and the
heal tii strategies is desirable. |xjssible and efiective.”4 By "rational appreach" was meant the incorpora
tion of epidemiological, ecological,
anti behavihral perspectives into
the health services planning proc
ess, while "methods* included standaixl statistical methods plus math
ematical and simulation modeling;
November 2004. Vai 94. No. 11 i American Journal of Public Health
O
for common goals, each pursued
their objectives following some
what independent paths, thereby
contributing to a liighly frag
mented situation that Mahler’s
program hoped to overcome
through improved project and
program planning methodologies.
In January 1971. the exmitive
board chose the subject of meth
ods of promoting the develop
ment of basic health services for
its next organizational study.5 To
lacilitate this study, the WHO
secretarial prepared a back
ground document for the boaixl's
Litstos | Peer Reviewed j Public Health Then and Now
1885
. PUBLIC HEALTH THEN AND NOW
deliberations in January 1972. It
provided an excellent historical
overview of the subject and iden
tified different ways that WldO
might assist countries—for exam
ple, ’‘Organize a planning and
evaluation section in their ministiy of health,” ’‘train health plan
ners in the establishment and im
plementation of national training
programmes,” and “prepare plans
for the organization and develop
ment of the public health serv
ices.”6 No reference was made to
community particifmtion.
In introducing tills document,
Mahler noted that “there were
sufficient financial and intellec
tual resources available in the
world to meet the basic health
the criteria whereby national
health seivices should be judged
and the role that WHO might
play in assisting member states to
improve their health delivery sys
tems. These criteria were as fol
lows: healtii status, in terras that
induded “fertility, the opportu
nity for proper growth and devel
opment, morbidity, disability and
mortality”; operational factors,
such as coverage and use of
health service: facilities: accepted
technology'; cost; and consumer
approvals
‘The report concluded that no
single or best pattern existed for
develojiing a healtii services
structure capable of providing
wide coverage and meeting the
WHO. the report said, should serve as a 'world health conscience,'
thereby providing a forum where new ideas could be
discussed as well as a 'mechanism which can point to
directions in which Member States should god
aspirations of all peoples.” and
siiggcsted that ‘'tlierc was a need
for an aggressi ve plan for world
wide action to improve tiiis unsaiisfaetoiy situation."'
In 1972, Mahler oversaw the
amalgamation of Newell’s re
search division with the Organi
zation of Heid th Services to cre
ate a new division. Strengthening
of Health Services, with Newell
as director. Newell inherited the
job of secretary to the executi ve
boand’s working group responsi
ble for the prganhational study.
He worked closely with its mem
ber and was deeply involved in
drafting the group's final report
on basic health services, which
was presented to the full execu
tive board in January 1973.
Avoiding the question of what
was meant by basic health serv
ices, the working group identified
1.886 i Public Health Then and Now I Peer Reviewed | Utsios
varying needs of the population
being served: ‘’Each country will
have to possess the national abil
ity to consider its own position
(problems and resources), assess
the aheniativ’es available to it,
decide upon its resource alloca
tion and priorities, and imple
ment its own decisions."*
WHO. tile report said, should
serve as a “world health consciertee,” thereby providing a
forum where new ideas could be
discussed as well as a "mechanism wWch can point to direetiohs in which Member States
should go."10 To fulfill tins role.
WHO needed to make better use
of the resources available to it by
concentrating on those projects
that were likely to. “show major
returns and.. . result in a long
term national capability fer deal
ing with primary problems.’’11
In May 1973. tile 26th World
Health Assembly adopted resolu
tion WFIA26.35, entitled "Orga
nizational Study on Methods of
Promoting the Development of
Basic Health Services.” Among
other things, this resolution con
firmed the high priority to be
given to the development of
healtii services that were “both
accessable and acceptable to die
total population, suited to its
needs and to the socioeconomic
conditions of the country, and at
the level of healtii tedmology
considered necessaty to meet the
problems of that country at a
given time.”12 This wording re
flects the impact of the executive
board s study. (>Hint.ries were
again being reminded tiiat then.'
was no universal model for the
health services that they could or
should aim to develop. They had
to adapt available technologies
to fit the conditions that were
unique to each situation. The
assembly also confirmed tiie
election of Mahler as the next
director general of WHO. the
functions of which he assumed
on July 21, 1973.
Shortly after Mahler became di
rector general. a WHQ/UNICE F
interseo ctamt discussion decided
to seek out ‘promising approaches
to meeting basic health needs”,
among possible diaractpristics to
be considered were “community
involvement tn financing and con
trolling health services, in projects
to solve IcK^al health problems, in
health-related development work,
or other relevant ways.*’13
The search for new approaches
led to 2 important WHO pubfications in early 1975: Alu^rnati^
Approaches to Meeting Basic
Health N&fds of Pttpulatians in Da
vetoping Couidries, edited by V.
Djukanovic and E. P. Mach (staff
membera under Newell), and
American Journal of Public Health | November 2004. Vol 94. No. .1.1
I PUBLIC HEALTH THEN AND NOW
Health by the People, edited by
Newell.14 During the first 18
montlis that Mahler was director
general, the WHO and the CMC
greatly intensified (heir coopera
tion. It is therefore necessary to
backtrack and learn Itow the
CMC eame into being and how
its activities became so important
for WHO in the years that fol
lowed.
ESTABLISHMENT AND
EARLY WORK PROGRAM
OF THE CMC
Lhe CMC was eslabUshed in
1968 as a semiautotiomous
body to assist the World Council
of Churches in its evaluation of
and assistance with church-re
lated medical pnigrams in the
developing world. The dedsion
to create the CMC did not take
place owniight It evolved from
much field work and a series of
consultations. The field work,
which started in late 1963.
showed that churches had con
centrated on hospital and cura
tive services and that these “had
a limited impact” in meeting the
health needs of the people they
were meant to be serving. It was
found that “95^ of church-re
lated work was curative” and ’at
least half of the hospital admis
sions were for preventable conditions![sicF,s
Of particular concern to tire
World Council of Qiurches was
die fact that many of the more
than 1200 hospitals that wen?
run by affiliated associations
were rapidly becoming obsolete
and their ojx’i'ating costs were in
creasing dramatically- What was
needed were “some criteria for
evaluating these programmes”
that would help reorient the di
rection for their fiiture devdoprnentih
Ihe CMC had veiy limited re
sources. It was composed of 25
members and was served b>’ an
executive staff 'consisting of a di
rector and •'not more than three
others.’’’7 It was to engage in sur
veys, data collection, and ‘'re
search into the most appropriate
ways of delivering hcaltli services
which could be relevant to local
needs and the mission and re
sources of the Church" It was
concerned with determining
“what specific or unique -contri
bution to health and medical
services can be offered by the
Two major consultations,
called 'lubingen I (May 1964)
and l ubingen 11 (September
1967) had set the stage for the
work of the CMC Tiibingen
1 reviewed the nature of tile
church's involvement in healing
and the theological roots of such
work. In contrast to the response
of medical missions in the early
pan of the 19th century to the
overwhelming need at that
time, which was “instinctive
without any conscious concern
about its theological justifica
tion,’’ the justification for ciirrent
activities, both medically and
theologically, was still weakly
developed.The church's med
ical staff was trained in medical
care and had little interest in
disease prevention, Which was
considered to be the govern
ment's responsibility.
The report resulting from
Tiibingen I, The Healing Church.
confirmed that the church did
have a specific task in the field of
healing. The medicalizalion of
the healing art had led to a rift
between the work of "those with
specialized medical training and
the life of the congregation Z The
entire congregation had a part tn
play in healing.2*
November 2004, vol 94, No. 11 | American Journal of Public Healfh
James C. McGilvray. the
CMCs first director, found the
contribution of Dr Robert A.
Lambournc to be "the most sig
nificant" one in the preparatory
stages of Tubingen IL McGilvray
had been involvetl in hospital
and health services ndministmtion since 1940. first when he
was superintendent of the Vel
lore Medical College Hospital in
India and then in various health
administration positions in
Southeast Asia and the United
States.
From Lambourne s reports, a
disturbing picture emerged of
the manner in which modem
care was at odds with the quest
for health and wholeness The
hospital had become a’‘factory
for repair ’ in which the patient
had been broken down into
“pathological parts." The “re
sults of a batt ery of tests’' were
more important “than die- rela
tionship of persons in a thera
peutic encounter."2*
Lamlxnime's concept of
wholeness and health had
strong implications for the cangregation, a position that had
emerged from Tiibingen I. It is
only “when the Christian com
munity serves the sick jMirson in
its midst [diatl if becomes itself
healed and whole.’’22 Going fur
ther, he argued that the healing
congregation accepts the fact
’ dial any one individual group
or nation may not be entitled to
an unlimited use of the re
sources of healing when such
unlimited use will mean less
available resources of healing
for others.*2' Thus. I.amboume's
argument suggested a moral
basts for individuals and com
munities to be involved in any
consideration of how resources
are to be used to promote their
health.
Utsii>$ | Peer Reviewed \ Public Health Then and Now | 1887
PUBLIC HEALTH THEN AND NOW
The theological basis for
health and healing work contin
ued as important points of dis
cussion during the CMC’s first
annual meetings. These were
critical in heJjfing foe conwnission
advise Lire World Council of
Cliurches how to help diurchfunded services to move from
foo provision of medical care to
individuals to the development of
curative and prewntive services
to conanuofoes at large.
'Flie discussions tddk the fonn
of a Yludogite'’ between Dr John
11. Biy’ant, toe itpmmission’s
chairman and a professor of.pub
lic health, and David E. Jenkins,
a comrmssion member and a the
ologian. The last dialogue, whixfo
took place in 1973. demonstrates
well to what degree, even though
there were important difference
of opinion iKtween diem, both
were committed to a dist ribution
of resource^ that improved the
tot of those worst off
Bryant addressed Hie question
of •'health care and justice/24 In
doing so, he applied die notions
of entitlement, natural rights,
positive righto, and distributive
justice to foe question of hitman
health, and developed a series of
tentative ftrinciples:
• Whatever health care and
hcidth services are available
should be equally available to
all. Departure from that equality
of distribution is fjennissible
only if those worst off are made
better off.
- Thm should be a floor or
nunlmum of health services for all.
• Resources alxwe this floor
should 'be distributed according
to need.
• In those instances in which
health care lesources are nondivisiblc or itoressarily uneven,
their distribution should lx? of
advantage to the least favored.2 ’
1888 j Public Health Then and NowPeer Reviewed j U'ts/as
Jenkins approaclied the ques
tion differently. He did not be
lieve. for example, that “the no
tion of human rights is biblical.’’
The Bible is concerned about
“human possibilities, about di
vine activities. and about human
l espuase to divine adivitbsr and
with “obstacles to becoming
human." arid consequently is
much more concerned with “attaeking exploitations, attacking
oppressions, attacking inequalitieSi attacking deprivation than
laying, daw ri^its."2'’
The reflations of both Bryant
and Jenkins supported th<? in
volvement of Christians hi fight
ing inequities. To do so, the CMC
from its inception gave priority to
what it termcxl comprehensive
health eare—^a planned effort for
delivering health and medical
care attempting to meet as many
of the defined needs as possible
with available resources and ac
cording M carefully establishcxf
priorities.’' Such a program
“should nothe developtxl in iso
lation but as the health dimen
sion of general development of
the whole society/47
Given tlic fragmented and
often competing nature of most
church-related programs, the
CMC identified planning as “the
most impdrtartl new dimension
in the fiaid oT health care today"
as a means of exercising “stewaxdship with their resources,’'
Stewardship was required ‘’not
only to achieve the optimum
hadrh cai'e within tmr resomtes.
but equally to see that the results
are (Economically viable in the.
local context^
CMC staff actively W'orked
with various church groups and
voluntary organizations to encourage them U) undertake joim
planning and action with the aim
of promoting a more effective use
of resourexEs. At Ok* same time,
they scairhed for field simafions
that lent themselves “to experimentafion in broad-based communfty health pro^wimes.*’29
Along with members of the com
niissfofli they also searched for
comnmnity-based cxixMiences
around the world Mt would
shed light on how best to develop
programs that were comp'diensive
would offer a spectnmi
of services ranging from treat
ment mid rehabilitation to pre
vention and health promotfon),
were part of a network of serv
ices ranging from the home to
spedalized ii^Ghrtions, and
would incorporate human re
sources ranging from involved
church members to specialist pro
fcssfonals, including auxiliary and
midlevd health workers.M’
Many of the community-based
experiences uncovered were discus$ed at various CMC' meetings
and were written up in the publi
cation CetUact. whose first issue
apfjeared in ^fotenfljer 1970.
Contact was not a regular pub
lication, For the first, few years,
around 6 issues were published
annually. The first issue was a
sunimaxy of a lecture given by
Lamboarne enfitled '‘Secular
and Christian Models of Health
and Salvation.” Issue 4. pub
lished in July 1971. contained
the Bryant-Jt'nkins dialogue held
during the third annual meeting
in June of that year.
Tlarce community-based experiw.es presented to the CMC be
tween 1971 and 1973 proved
critical in WHO’s conceptualiza
tion of primary health care
CRITICAL COMMUNITY
BASED EXPERIENCES
McGilvmy ‘'discovered" the
first project during a survey (in*
American Journal of Public Health i November 2004. Vol 94. No. .1.1
PUBLIC HEALTH THEN AND NOW
dertaken in Indonesia in 1967.31
The project, located in central
Java, was run by Dr Gunawan
Nugroho. Begun in 1963, it fea
tured such innovations as goat
and chicken fanning to increase
the income available to the poor
est members of the community
and the creation of a health fund
tliat aimed at “providing inexpen
sive treatment so that anyone
who was sick could afford to
seek medical care.”32 Educa
tional activities were stressed to
provide individuals will] the in
formation they needed to leant
for themselves what they could
do to improve their health and
that of the community.
Although Nugroho presented
his project to the CMC's annual
meeting in 1971, and Newell
had met him in (lie early 1960s
when he was working in Indone
sia. Newell only learned about
Nugroho's project in late 1973.
Dr Joe Wray, who was tlien witli
the Rockefeller Foundation in
Bangkok, ran into Newell in the
“middle of nowhere” in India
and told him about the project
when he learned thal Newell
was looking for ‘people who
were doing interesting things in
rural health care."1 ‘ Subse
quently, Newell visited Nugroho
and invited him to Geneva in
July 1974 to prepare a chapter
on his project for Health by the
People^4
The second project was also
run by a husband-wife medical
team, Rajanikant and Maybelle
Arole. 'Jlieir project was devel
oped in Jamkhed. India. The
Arolcs sought financial help from
the CMC in 1970. at which time
they described how their initial
attempts at providing curative
services “had done little for the
general health of the community
around us."15
When on tlieir return they
found the project area facing a
severe drought, they helped or
ganize a communify kitchen and
found funding for introducing
tractors in areas where farmers
had lost tlieir cows and for in
stalling deep tube wells. To ex
tend services to nearby villages,
they contacted indigenous practitioners and health workers in tlie
area, helping to shape them into
health teams and to extend the
services offered by inboducing
village health workers.
The Jamkhed project aimed to
establish a viable and effective
health care system that involved
the “community in decisionmak
ing,'' was “planned at grass
roots,” used local resources “to
solve local health prpbteins ” and
provided ‘’total health care not
fragmented care.”3”
Ftajanikant A role' presented
tliair project to the 1972 annual
meeting of the CMC, and it was
written up in Coiitfict. 'fhe WHO
regional offitxi in New Delhi had
not recommended this project
because “it wasn’t an Indian gov
ernment project." However* it
came to the attention of Dr Fid
Brown, who was working for
Djukanovic (the WHO officer
responsible for the alternative ap
proaches study) while on sabbati
cal leave from the. Indiana Uni
versity Medical Center. Brown
gathered the project files from
the CMC (wliicli was just down
the road from the WHO office)
to show' Djukanavic, who then
visited the project and made
anangemenfe for its inclusion in
his study.1'
hi the third critical communitybased ex[>erienc.e. Carroll Behrhorst directed the Chimaltenango
development project in Guate
mala. The use of community
health promoters was one of the
November' 2004. Vol 94. No. 11 j American Journal of Public Health
-Ba™™,
:
'8,
'life*-'®
6
•
w
Mi
Thanks to a mini-dam built by
the community with village labor
and the help of a small loan
from the health center, Sirkandi
village in central Java, Indonesia,
Increased its rice production by
25% In 1 year.
Source. Gunawan Nygroho
Educational activities were stressed
to provide individuals with the information
they needed to learn for themselves
what they could do to improve their
health and that of the community
major Features of this project. Ini
tially selected on the basis of rec
ommendations from local priests
or Peace Corps volunteers, this
approach quickly gave way to
the Formation of community
health committees who took over
this responsibility.
The training of community
health promotel’s was a continuoils activity. They wore •trained in
groups, attending sessions once
weekly For a year before they
weir allowed to dispense medi
cines or give injections. They
could enter the program at any
time; ‘'nearly all of them, even
those who began tlieir training
more than 8 years ago. still come
eveiy week to learn new tech
niques or treatments.*3*
Promoters were also trained as
community catalysts, working in
areas other than curative medi
cine (e.g.. literacy programs; fam-
Lksias j Peer Reviewed ■ Public Health Then and Now
1889
PUBLIC HEMIH THEN MB NOW
il
1
■
w/
■
El
I
-
speculating that WHO miglu
haw felt pressure from toe
Catholic Church on sexual
issues 45 Even before taking over
as director general from Candau.
Mahler was advisiiig VSTIO staff
to read toe Fubruary 1973 issue
of Contact (issue 13). which was
on rural he?alto.',e
The first official sign of efforts
to bring WHO staff together with
CMC staff was a letter from
McGilvray to the commissfon
A farmers’ club gathering
in Jamkhed, India. I
ily planning; the mgahization of
men’s and women's dubs; agri
cultural extension; the intrbduction of new fertilizer, new crops,
and better seet.fr; chicken proj
ects; and improving .animal hus
bandry)?**
Behrliorat presented his proj
ect at the CMC’s 1973 annual
meeting, and it was written up in
Cantact the following year.40
1'here, is no doubt that other
experiences, either then ongoing
or publicized earlier, had anin
fluence on Newell's concepiualizatfon of primary lif&llh care. As
an active member of toe UK so
cial medicine community in toe
1950s. he would have been ex
posed to related concepts and
projects early in his career. He
ww a contemporary of John Cas
sel. whom Newell knew well and
admired: Cassel frequently vis
ited Geneva, where he presented
his latest social epidemiological
research results. These were ac
tively followed and d.frcuRsed by
toe epidemiolqgMs working-in
Newell’s research division.
Cassel’s early career was
"closely inleitwined with [Sidney]
Kark’s.*41 ft is therefore highly
probable that it was he who in
troduced Newell to Kark. who
1890 I Public Health Then and Now | Peer Reviewed i Utsios
Ws Newelfs dinner guest on at
least one occasion before
1973?2 Given Newell's interest
in social medidne and epidemiol
ogy. it is difficult-to imagine that
he did not learn, first from Cassel
and then fixan Kark, of their ear
lier community-oriented primary
care experience in South
Africa.4 ’ Many similarities be
tween primary health care and
Kark’s work in Africa are evi
dent.
WHO AND CMC
JOIN FORCES
By
summer of 1973. the
CMC had bmught to toe world's
atttsitiou many projects that of
fered innovative ways to improve
the health of fiopiilatjotw in de
veloping coiaHrfes. WHO, under
its new leaderdiip. intensified ef
forts to seek alternative ap
proaches to meeting die basic
needs of those same populations.
New leadership was required to
bring about a closer working re
lationship between the CMC and
WHO.44 In (lie Candau-DoroUe
era [of WHO] them wiis a basi
cally hesitant if not negative rela
tion lo religious bodies," said Dr
Hokaji Hellbeig of toe CMC,
members. Dated November 7.,
1973, it sttid that Dr ‘fom Lambo,
the pew deputy director general
of WHO. "is arranging a meeting
between-air staff and several officers of feat organization to ex
plore more effective waj'S of
working together." ’fhat meeting
did not take place until Mardi
22,1974, at which time the small
professional staff of the CMC met
with some 10 senior WHO staff,
including Newell Newell reacted
enthusiastically to the discussion
that took place4' To whai degree
he was already aware of the
CMC before (lie meeting is not
easy to judge. His father had
been a minister who worked for
the World Council of Churches in
Geneva in toe late 1940s or
early 1950s, suggesting that he
might haw had an even deeper
knowledge of their heal to-related
activities than tlihse who worked
with him realized at the time.4*
In any case, he senzed the
tunify offered to work with indi
viduals who clearly shared his
values concerning human and
health development.
Immediately after this meet
ing, Newell met vrito MeGilvray
and Nita tlanow. deputy director
of the CMC. to decide on how to
explore ’’possible collaboration
and the medianisms of action.”*3
A joint working group was estab
lished. with Banw mid Newell
American Journal of Public Health I November 2004, Vol 94, No. 11
PUBLIC HEALTH THEN W NOW i
I
designated as representatives
from the CMC and WHO. re
spectively. The working group
prepared a 6-page statement that
was subsequently approved by
both organizations.50
It was envisaged that a work
ing relationship) could best be
achieved by "joint involvement in
common endeavours” in the do
main of “policy and research, or
research and development en
deavours with particular empha
sis upon healfli delivery systems
at die peripheral fevel.’'*’
Newell attended the CMC an
nual meeting in July 1974, where
the joint statement was dis
cussed. Following the meeting.
McGilvray wrote Mahler that it
was “enthusiastically welcomed
by our membership.”92 In his an
nual report, McGilvray noted that
“cooperation has already begun
at a very practical level? Refer
ring to the inclusion of the 3
projects discussed earlier in the
reports being prepared by WHO,
he expressed his delight “by* Ulis
development, not so much be
cause of die credibility it confers
upon us. as because it signifi
cantly enhances our mutual ef
forts to ensure hetrltli services for
those who are now deprived of
them?53
The 3 community-based proj
ects were incorporated into
Newell's Health by lhe People a
publication that he viewed as “an
extension" of the alternative ap
proaches study,3* Only fire
Jarakhed project had been im
eluded in die publication edited
by Djukanovic and Mad),
Newell classified the case stud
ies from Oiina. Cuba, and Tmzania included in Health by the Peo
ple as examples of changes
introduced al the national level,
while those from Iran, Niger, and
Venezuela represented examples
of changes introduced through
an extension of services piwided
by die existing health services
system He classified the 3
community-based experiences
discussed in the previous section
as local community development
Each example offered something
di’ffei'ent—China, for exan^le,
trained large numbers of parttime health workers (barefoot
doctors), while Venezuela intro
duced what it called “simplified
medicine" and Tanzania mobi
lized its rural population into
“Ujamaa villages” that that were
socialistic in slnicturc and de
signed to encourage jx>pular
participation in development
planning.
While Newell expressed ex
citement at what had been
demonstrated in all of the pro
grams, he was particularly en
thusiastic about the 3 commu
nity development projects. He
contrasted issues such as im
proving tlie productivity of re
source to enable people to eat
and be educated—and rhe sense
of community responsibility,
I ■ : .<
November 2004, Vol 94. No. 11 | American Journal ot Public Health
pride, and dignity obtained by
such action—with the more tra
ditional public hcaldi activities
of malaria control and the provi
sion of water supplies. The chal
lenge for people in the health
field was to accept these wider
developmental goals as legiti
mate ones for them to pursue;
Newell even said (hat “without
them there must be failure."55
PRIMARY HEALTH CARE:
WHO'S NEW APPROACH
TO HEALTH DEVELOPMENT
Resolution WHA27.44,
adopted by the 27th World
Health Assembly in July 1974,
called on WHO to report to the
55th session of the Executive
Board in January 1975 on steps
undertaken by WHO "io assist
governments to direct their
healtli service programmes to
ward their major health objec
tives. with priority being given to
die rapid and effective devdopment of the health deliveiy sys
tem?56 TO provided Mahler
and Newell with the opporturaty
Magdalena Mucia de Cuex at the
dude in an infacroal gathering of
patients, talking abotrt nutrition for
pregnant women.
- T
tv,
I
o
5
Litsias | Peer Reviewed ; Public Health Then and Now ; 1891
PUBLIC HEALTH THEN fiNO NOW
to infroduee primary’ healUi care
m a comprehensive manner,
drawing on the work of (he pre
vious 2 yearn.
The paper presented to the
board, known as document
l:B55/9. argued that the “re
sources available to the commu
nity" needed to be brought into
hannany with "the resources
available to the healtii seniees/
For this to happen, "a radical
departure from conventional
health services approacli is re
quired.'’ one that builds new
setvices "out of a series of pe
ripheral structures that are de
signed for the context they are
to serve.* Such design efforts
should (I) shape primaty health
care "around the life pattern® of
the populationT (2) involve the
local poptilation: (3) place a
“maximum reliance on available
community’ resources” while re
maining witliin cost limitations:
(4) provide for an "integrated
approach of preventive, curative
and promotive services tor both
toe community and the individu<iT; (5) provide tor all interventions to be undertaken "at
the most peripheral practicable
level of the health services by
(he worker most simply trained
for this activity'’; (6) provide for
other echelons of services to
be designed in support of the
needs of the peripheral level;
and (7) be “fully migrated
wfth toe services of the other
sectors involved in community
development''^
Four general courses of na
tional action .were outlined, wall
the expectation that each country
would ns^xand to its need in a
unique manner:
1, rhe development of a new
tier of primary health care;
2. the rapid expansion of exist
ing health services, with priority
being given to primary health
care;
3. the reorientation of existing
health services so as to establish
a unified approach to primary
health care;
4. foe maximum use of ongoing
community activities, espedalfy
devdopmenfetl ones, for foe pro
motion of primary health care?*
invited to speak on this ncca
sion, McGiivray observed. “Utoat
the Commission had learnt from
itsmistakes was rc&ctod in lhe
prind|>les set forth in document
EB§5/9f He went on to urge
foe board to give its -enthusiastic
support for the policy statement
constituted by that document
and pledged Lhe resources of the
commission in implementing1l?n
CONCLUSION
How dramas a dtahge pri
mary health ctin.' was for WHO
can be seen in file contrast be
tween it and the ideas and ap
proaches being jiroinohid strveral
years earlier concerning how best
to develop national health systerns. Instead of the ‘‘toixlowr
pers|xictive of health planning
and systems analysis, priority was
now being given to the Ixrttau|i” a|)piUtclies of eotmnuiiity invoivement and development, but
witlKiul losing, siglu of tlio impor
tance of planning and infonnad
dedstonmaking. 'HiU article doc
uments how and when this shift
look place, but it does not cap
ture the courage that it look for
Mahler to challenge the orgaiMzatinn to rethink its approach to
health services development or
for Newell to respond to that
diaUenge in the way he did.
Once Mahler took command,
he moved quickly to make
known his thinking on how
1.892 j Public Health Then and Not* i Peer Reviewed J Litsfos
healtii services should be devel
oped- In March 1974. for exam
ple, he disciiswxl with Newell’s
senior stall’ how he envisioned
their objectives. He especially
stressed foe objective of
■’purauliugl the idea of commu
nity partidpatfon (and its logical
bottoms-up orientation), to the
maximum degree iJossible."6’1
In January 1975, Newell for
mally created the Primary Health
Care program area, whose mem
bers included those who had
drafted foe report to the exeaitive board. While tiiere was
mixed reaction within WHO to
fob ww priority, a wikle range of
nraigox^ernmental oi^anizations
(NGOs) pined forces in what
scam became the NGO • Commit
tee mi Primary Health Care. This
group of organizations prepared
for the International Conference
on Primruy Health Care held at
Alma-Ala in September 1978 in
an indqxmdcnt manner, (bus
helping to keep WHO on track.
For those of us in WHO comrnitled to the primary health care
approach, working with membens
of tills committee was of prime
importance. At foe i^chofogical
level, the constant positive feed
back felpcd us “keep the feith*
At the professional level, new op
portunities (>|?ened up that led to
projects that woold have been
difficult if not iriipossibfe, to pur
sue tn eartier years.
That primaiy health care tn
time was forced to take second
billing to "sctectivc" primary
health care? in no way detracts
from its importance. The same
reasons that led to it emerging as
a force in public health in the
1970s apply equally, if nut more
so, today. Under new leade«lH|>.
WHO lias recently reintroduced
primary health care onto the
agenda of the governing bodies,
and txmgTOninm.ntaJ voices arc
again pressuring WHO to make
primary health care ifo priority
for toe coming decades?’ I t is
too soon to judge vtoetlier this
will happen. Sadly, however, die
CMC will no longer be involved
with whatever emerges, as it was
uffuctively disestablished in lhe
1990s. ■
About the Aotiior
The ttutimr
ike W)rfd
I^Hcsts ttytinifistetM l>c sent w
Saetvi^:
Sf$, n«'Seifs. M46
lUtuhneK
This ttniek i«is
May 9.
2m
Ackmiedgineflts
I thank the nMewm' of ctidM?r toi-sions
of thb arfidt.1 wtiiMk’ jxwimiis hel|M;<i
inr io loUlly revise .its structure, alkr its
tone, «rni esjwMi on whibr [Hrtnts of
grt’altT Mevttttd? todaj-. I
u-jth thanks the .pnceiMgenirni. cunt
mwits. «nd suggestions I'earivud front Dr
15(1 Bmwn. Dr Jack Bryant. Dr Marcos
Cueto, Dr l lakan Itetlbcig. kanuc
Ncntec, Jane NcweB. Dr Gunawau Nogmbfk
Sknld. Dr jrrn
Dr Carl 'lavlor, and Dr ]».«* Wrxiy I also
thank baefec FMcmo. head of Ki?o»fiK
®jd Archives, WHO; Oiwvb, for mak
ing available cktcwneuh from Hk- VVI lO
Areliivcs,
Endnotes
<Pktrrnitw an Intittlixtilh
for
Amts, SeetMii
ityxrt (;<i»r
wjtftev on
Admimstmiioti
(Gt.'neva;
I lealth Orgaafcatiw
IWHOJ, 1954). WHO Tcehraml Kepart
Series 83.
2. WHO.
Wk uf WHO
Official Rewirtfe No 150.
Geneva, 1967. vu.
3. WHO, 'The Wrk of WHO
19677 OflimJ ftm.rfo No W4
Geneva, 1967, vii.
4 S. Ulsias. “A Pmgffiinim-. for Keseairh w the Organuatsvn and Smegy
oflhjalth ServKts’ ij&prrpresented »t
th WHO Pfreetor Gedcrsls Corder
encuJiHje 25, 196$, WHO Headquar-
!
tfrs. Geneva
5x
Not suggested by (he WHO Scritr
Urine dits study resilhxl from a strewig
jMJsh Ijy the Soviet repretH'nfeiti vv to the
American Journal of Public Health < November 2004,. Vol 94. No. 11
<»
PUBLIC HEfiLTH THEN AND NOW ,
Ixwud, Dr D Ventxiiktov. See S Litaos.
“'Hn-1 .wig and Diffindt Roatl to AlmaAta A IVrsotMl Reflection." hitemutiunul Juunuil yf Healik Servavs .32
(2002). 709-732
b WHO. 'OrganizuhoiiaJ Sttuly of
the Executive Board on Melhods of Protnnttng the Devdopini-m of Baxir
Health Scrviws’ (Geficva WHO. 1972?.
document liB49AVTVfi 19-20
7, VVI10. Executive Itosid 4 9ih Session. decutmurt EB49/SR/14 Rev.
Geneva. 1973.218
8 WHO. Official Rmads No 206.
Annex 11. Geneva. 1973, 105
9. WI IO. Official Rewnis No. 206,
Annex ll. HJ7.
10 WHO. Official Rcioids No. 206.
Annex 11. 108.
11 WHO, Official Reoads No. 206,
Annex 11.10912. Ilandlwok ofRasohtputis und Hect«<>ns of the World Health Assembly and
{fxtxsd.ii'e llotinb Ydkinw 2. 7,973 - /.984
(Geneva WHO, 1985), M
13 Mcmomndum from )’. Dorolle (tiutgmng WHO deputy director general) to
all re^onal directors, July 25. 1973,
WHO Archives, fends Rwmds of the
CcntiTil Registry, third geneiaiton of
Itles. 1955 4983 AVI 10 3). file
N6f ‘.'h18-'77.
Jiis&e iani -Bam for Gunajptuafcjnx a
Health Care Sysiew.' InteniMtmtalJour
nal afHM Service 7 (1977k
707-7W.
2S CMC. Annuttl Rapori 1^73 (Uosst’y.
Swiw’riand; CMC 1973). 32-33.
26. Ibkl. 3S-44.
27 CMCs Jdier of appiiratkin lor
noogownmwrtal r»Kammic«n (NGO)
relnuomhjp with WHO. H?bruar> 3.
1969, WHO Ardiiytjs, f ends ftecuftfe
of the Centml Registry. iWal generation
of Gte& 1953-1983 AVHO.3). file
N6I/348/77.
2B. CMC 1970 Annual Meath)}*,
Btwy. Switzerland. Sopfe'infker 1970,
60.
30. "The Commission's Currw Utwkr$h«Mlmg<its Task” (paper presented at
the atmufll meeting of Oic (ItriMian
Medical Crairrassan. September 2-tk
1968).
47 McGilvray letter from author's persooal M,4.1 remember htong lok! at the
time that Newell was ihe only WBO director present who reacted psRivcIy to
these discussions.
31. MeGifmy, QuestJar Hialth. 57.
4 8. Mrs Jane Newell, written wmwunr
cation, Augtwt 25. 2.003.
33 Dr J. Wray. wriUen tfimmnnk’ii'
(am. July 28. 2003
34. Newell invited Nt^niha tn join
WHO. whirft hc did in late 1974
35 McGtlvw. Qt^t Jhr HetiMi. 60
36 New'cll. Htraitk by the Rrayte. 71
15. J. C. McGilvray. Hie Quest >
Hmltk ttn3 Lt'Wmcss nTihingeii, Germanyr German Instiftiu? for Medical
MiSHitHi. Fiai). XVI J.C McGihtay, “Hie
Intmiaticmal and Ecumenical Dimen
sions of DIFAM’s Contrilmtion to the
Healing Ministry of the Church," May
IS. 199U. 5.
39 IblcMl.
17. CMC. First Meeting. 3.
IS C.M,C. First Meeting. I
19 MeGitvray. Quest Jor Health, y
20 Quoted in McGilvnu. Qu«i/ for
Hetdtb. 13
21 Ihirl.. 25-
22. ibwl.. 25
23. Ibki. 113
24 BrywH. Ipur adafrtal bus paper for
puWicaUon J. Hl ikyam. “Principle trf
37 Rajiintknnt Anrfc. Ctwnct. occa
sional (wper No. 10. August 1972; Dr
t'xl Brown., written wnttnaintcaUati, Au
gust 6. 2003.
38 Newell. Health Ity rl^ l^le. 38
40. Qattffl Behrtrarst. CanttKt, or?w
signal paper No. W.Fcbiwy 1974.1
amM not determine when Newell
learned uftitts prajeti. By early 1975.
os reported in a mating td lhe
tive Committee of the CMC (Jammiy
17-18. 1975). WHO was ‘Gtmsutog
the fH^silwlity of s<.-lting ii training
centre in Qtimaltenan^'i. as it feefe that
there is modi to be fcanrt fmm this
prrijm.’' 'lb the Ixst of my knowledge
tlife never mamiiallMtrl.
41. F M. Brown and K. Fee. 'Sidney
Karh and John Castse’h Social Medtdne
Pmhct rs and South African I litugiv’S?
. \otefKm Journal of PMt Health 92
<2(KI2> 174-1-1745
42. Dr J. .Stromberg, written
cation. Mardi 23. 2004. Srmmbrt^.
who was a social sdentist in WHO aftd
deq>ly involved to promoting commu
nity partidpttoon. was at the dinner
with Kark.
November 2004. Vol 94. No. 11 ! American Journal of Public Health
61. S. Litsios. "Primary Health Care,
WfiO, and iIr- NGO Community," Dt
Wfopmcnl 47 (2(i04).- 57-63
45. Dr Hakan Hellberg, written nmimunicotion. July 22 2003. Hcfiberg
was associale director of the CMC from
1968 to 1972 and subsr^ucigly a scutor WHO Malf member Dr Herat
Dongle we» CandauX dqaKy
46. Dr Jerry Stromberg, writton cammunicaiion. Novemlxer 4. 2003
32. K.W. NmvcH, ed. /»< try the PenKkmeva- WHO. 1975). 103
iNewcfl timed March 18. 1974. in aw
thofs files.
44. The CMC had obtained an NGO
lelattortsfiip with WHO in 1970. but
until 1974. that reJabonsliip hid not dcwlnptxt beyond pemnal ths between
stair rnmilxTs of the 2 organizations
29. CMC l-U'si Meeting, 28
14 Vw« Dfukanovk and Edward 1"
Mach. i-iK. Mternatur .Approocltis (a
lias* Healili Wfah of I^mlo
iwna tn IJt-nckipnig Countries (Getleva:
WHO, 1975k Kenneth VV Newell, nd.
lUtillh int the Ptnpte (Goocvn. WHO.
15173)
Ki. (Jhristitm Medical CtmmtisKkm
(CMC). First Meeting. Geneva. Sepunnber I9«8. I
43: S- L Kark and J. Cassel, ' HkPfraldn Health Cemrv: A Pr^nx'ss Re
port” Saulh A/riean MetfiailJaunKil 26
(1952): 101-104. I31-.l3(i; mprtnlud
in
TAwAA 92
(2002): 1743-1747.’
49. Memaraffctom doted March 2.6,
1974. from Newell to Larrtbo on tlasubim of tlw CMC. WJ10 Archives.
Fomfe Rctwds «»f toe Central lit^istry.
toiirl genmlJun of files. 1955-1983
(VVHO.B), file N6L/348/77
50 The joim Stoteineiil dtiied May
27 1974. took Hie fonn nf a mettwran*
dum trunr Barrow and Newell to
McGihmy nnd .Mahler, WHO ArdnveK
Ponds R»‘«wiis of the CwKrul Ih -gisiry
third geiwmion of Tsk-i., 1955-1983
(VVH0.3J, file N&1/348/77.
B.1. toicUS.
52 Utter dated July 22, 1974, from
MtCilviny m Mahler. WHO Ardih^,
Tttods Rewrdii of tire Central Regstiy.
toittigenerafiun ffffc 1955-1983
(VVTKtl), file NBI/348/77.
53, CMC. Seventh Annua! H^ng.
Meh. Swi^rUndJuJy (974, 3-6.
54. Newll Hyafth by ike fX’ople, xi.
55 IlndUOZ
56 WHO. Handbook of Rrsahitwiot and
Dedfiions of the Hv>r/d H&iltk Assembly
and flxeaidiv lifnird. Vhlimte 2.
1973-1984
57 WHO. T)<Kimienis> fin" 35tli Scpsfon of the EH ~ January 1975. doc-unient I-.B55Z9.
58 toid . 4
59 WHO. A'cjiauim Becord nf 55to
EB.-dmnwni IHV55/SR/6.P 5,
60. S. Htsfox. My Reaction to Meeting
Wfih Dr Mahler & Dr Ching, ADG 13 March 1974 irtemoranduto to
Lilacs | Peer Reviewed I Public Health Then and Now | 1893
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I COMMUNITY ORIENTED PRIMARY CARE |
The Jerusalem Experience: Three Decades of Service, Research,
and Training in Community-Oriented Primary Care
Community*onented primary
care (COPC) developed and
was tested over nearly 3 dec
ades in the Hadassah Com
munity Health Center in Jeru
salem, Israel. Integration of
public health responsibility with
individual-based clinical man
agement of patients formed
the cornerstone of the COPC
approach.
A family medicine practice
and a mother and child pre
ventive service provided the
frameworks for this develop
ment. The health needs of the
community were assessed, pri
orities determined, and inter
vention programs developed
and implemented on the basis
of detailed analysis of the fac
tors responsible for defined
health states. Ongoing health
surveillance facilitated evalu
ation, and the effectiveness; of
interventions In different pop
ulation groups was illustrated.
The center's international
COPC involvement has had ef
fects on primary health care
policy worldwide. (Am J Public
j Health. 2002;92:1717-4721)
| Leon Epstein, MB. ChB, MPH. Jaime Gofin, MD, MPH, Rosa Gofin, MD, MPH, and Yehuda Neumark. PhD. MPH
FOR MORE THAN 25 YEARS
beginning in 1970, the feasibility
of applying the principles of com
munity-oriented primary care
(COPC) was demonstrated in dif
ferent forms of primary health
care practice at the Hadassah
Community Health Center in the
Kiryat HaYovel neighborhood of
western Jerusalem.1,2 COPC was
based on principles of social
medicine developed by Sidney
and Emily Kark in inral South
Africa-in the niid-2Qth cen
tury3-5 and -brought by them to
Israel in 1958.
This pioneer development of
CGPC occurred against the backdrop of 3 major features of pri
mary health care in Israel at that
time. First, the health service pro
viders, with - whom nearly the en
tire population was insured, re
sponded only to demand for
care. Second, primary health care
involved very limited health pro
motion and disease prevention
primary health care services, es
pecially for adults. Third, an ex
tensive network of mother and
child health centers focusing on
preventive services existed
throughout the country', and this
network was organizationally
and fimctionally separate from
the curative care system.
The COPC approach diatgrew
out of primary health care in
Israel and the concepts devel
oped in rural South Africa were
conceptualized as “a continuous
process by which PHC [primary
health care] is provided to a de
fined population on the basis of
its defined health needs by the
planned integration of public
November 2002. Vol 92, No. 11 | American Journal of Publie Health
health with primary care prac
tice.”6 This approach involved a
recognition that, in line with the
World Health Organization defi
nition of health as far more than
absence of disease, health ser
vices should be responsive to
health needs in the widest sense
and should be flexible in their re
sponse to changes in these needs.
In addition, health services’ re
sponsibility is to the health of all
members of the defined commu
nity and the subgroups entitled to
health care, irrespective of
whether or not they seek it Hie
basing of health care planning
and delivery on assessed health
needs was achieved by the intro
duction of epidemiology as aoentral feature of the Hadassah Com
munity Health Center’s practice.
These epidemiological skills
were necessary to answer what
Sidney Kafk labeled the 0five
cardinal questions” that formed
tire strategic basis for the devel
opment of COPC1:
1. What is the community’s
state of health?
2. What are the factors re
sponsible for this health state?
3. What is being done about it?
4- What more can be done, and
what is the expected outcome?
5. What measures are needed
to continue health surveillance of
tire community and to evaluate
the effects of existing programs?
THE COPC CYCLE
In Jerusalem, these concepts
were operationalized in the
CQPC cycle (Figure 1). which en
tails the continuous and repeti
tive performance of various
stages. The COPC cycle begins
with a multistage community diagnosis that includes definition of
the community’s demographic
characteristics, environment.
Community
diagnosis
Reassessment
Prioritization
Evaluation
Detailed problem
assessment
Implementation
Intervention
planning
RGURE 1-The COPC cycle.
Epstein et al. | Peer Reviewed | Comrnuhlty-Oriented Primary Care | 1717
r
....
■
.
'
i eOMMOHSTV-ORiEKTEB PRtttARV CARE
i
M
I
I
■
y
a
health status, and available
health and social services. This
preliminary diagnosis provides
an appraisal of tlie eommunity’s
major healtli-related problems
based on epidemiological and
clinical data and community and
professional input. These identi
fied problems are then prioritized
through application of predeter
mined objective criteria, and a
single health problem (or a set of
problems vvitli common risk fac
tors) is selected as die. priority
target for intervention. The ra
tionale for prioritization is the
unfeasibility of simultaneously in
tervening on a multitude of prob
lems while continuing to provide
high-quality prirnaiy health care
services.
The targeted problem is then
subjected to a detailed assess’
merit Xf> examine its pifeise na
ture and extent in the commu
nity, associated risk factors and
deteiTninants, and options for in
tervention. With this detailed in
formation. an intervention pro
gram (including an evaluation
component) can be developed
and implemented. The stage is
then set for later-reassessment of
the community’s health status,
along with further prioritization,
planning, implementation, and
evaluation of intervention pro
grams. The repetitive nature of
this cycle differentiates the
COPC approach from that of
community-based projects
aimed at a specific disease entity
and conducted over a limited
period.
THE HEALTH CENTER
AND COPC
The Hadassah Community
Health Center opened its doors
in. the mid-1950s7 in an area
populated largely by recent im
migrants from Europe (remnants
of tlie Holocaust) and North
Afiica. 'Die community was char
acterized by diverse ethnic
groups originating from more
than 25 countries. Over the
years, the area rapidly grow fiom
an urban development project to
become an integral part of the
city, with a population of about
15000. The primary care ap
proach that developed in the
health center involved provision
of integrated curative .and pre
ventive care, both dinia based
and home based, to residents of
a geographically defined area of
the nei^iboriiood. This area was
divided into clusters of homes to
which teams of doctors and
nurses were assigned. These
teams,- along with other profes
sionals, also identified and cared
for the social, cultural, and emo
tional health needs of the area’s
residents.
Here we demonstrate the per
formance of the COPC cycle
stages as they were developed
over a period of nearly 3 dec
ades in the 2 clinical practices
that functioned in the Hadassah
Community Health Center: a
comprehensive family medicine
unit and a preventive mother
and child health program. Acade
mic responsibility for these prac
tices fell to the Department of
Social Medicine of the Hadassah
Medical Organization and to the
Hebrew University Faculty of
Medicine.
The clinical teams and the de
partment’s faculty of epidemiologiste, biostatisticians, and behav
ioral scientists were jointly
responsible for developing, im
plementing, and evaluating the
COPC programs. Although all
members of the clinical team had
public health training, tills aca
demic environment provided the
framework for the training of
public health and other profes-
1718 | Ctonvnunity-Onented Primary Care | Peer Reviewed | Epstein et al.
sion&ls and the performance of
applied research.
Community Diagnosis
The community diagnosis was
driven by questions raised by
team members, based on their
clinical experience and review of
patient recojxis; by student proj
ects and theses; and by repeated
community health surveys, for
example, tlie communftydjased
activities of the nurses brought to
light the problem of elderly resi
dents homebound because of
physical or mental linuiatio ns.
The extent, and underlying
causes of the problem were as
sessed, and a clinical and social
welfare support program was de
veloped.2
Similarly, infectious disttastis
were subject to ongoing surveil
lance through the use of “Pickles
chaits” (daily recordings of new
cases of defined diseases).1 and
programs were instituted relating
to identified changes in morbid
ity. A relatively high incidence of
rheumatic .fever came to the
team’s attention as well, leading
to the development of one of the
first cominimity-based prevention
programs irv the family medicine
unit1
As mentioned, student work
and health surveys also con
tributed to tire community diag
nosis. In the mid-1950s, at the
peak of mass immigration to; Is
rael, 2 master’s of public health
(MPH) students wrote their the
ses on the phenomenon of
greater growth retardation in in
fants bom to -new-immigrarit •par
ents from Morocco than in in
fants of Israel-boni parents,
notwithstanding the fact that tlie
former were significantly heavier
at birth.841
Finally, a community health
survey was conducted between
1969 and 1971 in which all of
Um inhabitants of the health cen
ter’s defined catchment area
were interviewed and exam
ined?1’"12 A central finding of the
survey was that cardiovascular
disease accounted for more than
half of adult mortali ty and was a
major cause of hospitalization?'
The data sources just de
scribed formed the basis for
detailed knowledge of the com
munity s health state. Tlie infor
mation gathered also served as
the basefine for tlie subsequent
evaluation of-intervention
programs.
Prioritization
It was clear that not all identi
fied health needs could be simul
taneously targeted for inteiven
tion. Furthermore, all
interventions were to be inte
grated into the ongoing primary
health care activities and were
not to require, additional clinical
manpower or resources. Priori
ties were defined separately in
relation to children and adults,
taking into account identified
health needs and available re
sources.
Tlie findings regarding infant
and child growth and develop
ment led us to identify these ele
ments as tlie major priority in
this age group. 1’hus. the inter
vention needed to focus-on pro
moting growth and development
through supeivision of the preg
nancy, labor, and puerperium
and of tlie first years of tlie
child's life through entry into
school.,’2,4 Similarly, as a result of
the survey findings, priority in
the case of toe adult population
was given to atlierosclerotic car
diovascular disease? 2'M
Detailed Assessment
of Needs
As a means of effecting
changes tn coinnivmity health sta-
American Journal of Public Health | November 2002, Vol 92. No. J.1
COWMUKin-ORBTED PRIMARY CARE
tus, a detailed assessment of the
prioritized health state was re
quired to determine relevant risk
factors and guide the develop
ment of intervention activities.
Community health surveys, clini
cal chart reviews, and summa
tions of relevant literature (in
cluding experiences elsewhere)
provided the basis for regular
meetings Of the health teain (aca
demic and clinical personnel)
arid students in “epiclemiology in
practice” sessions, a community
medicine equivalent of hospital
grand rounds.. At these sessions,
all available information was-.in
corporated'.into planning the in
tervention. These meetings
later became the forum for re
view’s of program performance
and effectiveness.
Childgrowth anti development.
Several factoi-s affecting growth
and development were ifitegrated into the intervention pro
gram.15 For example, one Of the
characteristics related to the
differential development of community gioups was the socioeco
nomic status of parents, espe
cially maternal education level15
Improving social conditions was
beyond the scope of our commu
nity-based intervention program,
but foe primary health care team
identified infants of poorly edu
cated mothers as a high-risk
group -warranting intervention.
Another important observation
was that verbal interaction witfi
very young infants was not conv
monplace among North African
parents. This lack of interaction
was considered to be a con
stituent of those infants’ ob
served deficiencies in intellectua!
devefopment.
Adult aiheroseterotic disease. In
the early 1970s, when COPC
was being developed at the
Hadassah Community Hetilth
Center, international and Israeli
data had defined the major risk
factors related to coronary heart
disease, acute myocardial infarc
tion, and angina pectoris. De
tailed assessments of these fac
tors in our cqmmuiiW revealed
liigh prevalence rates of coforuuy heart disease, hypertension,
obesity, hypercholesterolemia,
and cigarette smoking in- adult
men and women,1’1 These and
ottjer data formed the epidetnior
logical basis for subsequent pro
gram development
Program Planning,
Development, and
Implementation
Intervention planning required
foe articulation of operational
definitions of objectives and ac
tivities. Consideration was given
to logistic implications of the in
terventions, especially with re
gard to additional training and
changes jequired in the function
ing of the health center.
Child growth, and development.
The aim of the cliild inteivention
program was. to prtmdte the
growth and development (PROD)
of infants and toddlei-s and to de
crease gaps between population
groups in this aiea. PROD pro
gram activities included iron sup
plementation,16 promotion of
breast-feeding,17 early stimula
tion.15 and promotion of a healthy
pregnancy and a healthy neona
tal period.13 These activities and
other programs (e,g„ injuiy pre
vention19 and oral health20), in
troduced over time accordfog to
the changing needs Of the popula
tion^ were integrated into the rou
tine mother and child health
clinic functions.1'1
Adult atherosclerotic disease.
'Hie intervention program among
adults addressed the identified
community syndrome of hyper
tension. atherosclerosis, and dia
betes (CHAD). The CHAD pro
November 2002, Vol 92. No; 11 | American Journal of Public Health
gram aimed for risk reduction at
the individual and community
levels.
In the early 1970s, a multifac
torial intervention program was
initiated encompassing all indi
viduals in the community 25
years or older. Medication, diet,
physical activity, and health edu
cation methods were employed
in an attempt to achieve a lowrisk or no-risk status for each
risk factor and to promote
health.21,22 The primary health
care team acted at the primary,
secondary, and tertiary levels of
prevention.
Evaluation and Surveillance
Evaluation activities and ongo
ing surveillance were developed
as inherent components of the in
tervention programs.
PROD. The feasibility and ef
fectiveness of the PROD program
were demonstrated. Review of
specially designed surveillance
records (that became pail of foe
clinical file) revealed that the
early stimulation program im
proved child developniehl in all
maternal education groups and.
reduced gaps across groups. 23
An increase in breast-feeding1'
and a decrease in anemia preva
lence16 were also noted.
CHAD. Routine clinical rec
ords and CHAD prograin rec
ords were reviewed to monitor
activity performance and
changes in risk status. Evalua
tions performed 5 years,24 10
years,25 and 15 years21' after foe
initiation of the intervention
showed the program to be most
effective in relation to hyperten
sion control and reductions in
cigarette smoking.
These examples illustrate the
•successful and effective integrar
tion—and sustainability over 3
decades-of the CO PC approach
in an existing primary health
care clinic. The approach was
flexible enough to adapt to the
changing needs of the commu
nity, modifying existing programs
and introducing new ones ac
cording'.fo clinical and epidemio
logical evidence.
SPREAD OF COPC
THROUGH PROFESSIONAL
TRAINING
The COPC approach is the
focus of afieldfoased workshop
in the Hadassah MPH program.
Since 1960, .more than 1000
health professionals from Israel
and more Oran 75 other coun
tries have participated in tills
workshop.27,28 In addition, hun
dreds ofnursing students, family
medicine and public health resi
dents, and other professionals
have undergone training. Evalua
tions of these workshops by our
international MPH'graduates (3
to 5 years after completing the
program) revealed that more
than half are actively involved in
the application of COFC. princi
ples and methods.
Recent administrative reshuf
fling has resulted in a change in
responsibility for the functioning
of the health center. Whereas in
past years the Kiryat HaYovel
community served as the field
laboratory for the COPC work
shop^ we now select commiimties
throughout the countiy (in col
laboration With local health de
partments) in which our students
perfonn community diagnoses,
conduct detailed assessments of
prioritized health problems, and
develop relevant intervention
programs.
Decades of COPC service, re
search. and training in Jerusalem
set the stage for the develop
ment of collaborative links with
academic and clinical institutions
In countries around the world. In
Epstein el al. | Peer Reviewed | CommunityOrienied Primary Care | 1719
COMMUNITV-ORIENTED PRIMARY CARE
Ute United States, for example, a
COPC workshop is offered
jointly with members of the Jeru
salem faculty at the George
Washington University School of
Public Health and Health Ser
vices. We have also taken the
model back to its country of ori
gin, South Afntja, where a scries
of training workshops were orga
nized in several cities.
In addition, Jaime Gofin has
developed a COPC training pro
gram with the Catalonian Society
of Family Physicians in Spain,
with the participation of more
than 500 family physicians and
nurses. An outcome of this col
laboration has been the incorpo
ration of COPC into the Spanish
National Family Medicine Resi
(enabling integration of routine
clinical practice with epidemio
logical, sodal. and behavioral sci
entific expertise) was.an impor
tant factor contributing-to the
successful application of the com
plete COPC model in our health
center practice. Moreover, the
COPC experience became pail of
tlie program development of
mother and child health centers
in Israel, was tlie basis for a
major hypertension program in
the largest health maintenance
organization in the country,32
and was introduced into family
medicine practice in the northern
region of Israel.33
In conclusion, the Jerusalem
experience has shown the feasi
bility and sustainability of pri
References
1. Kark SL. ed. I^idemialo^ and
Community Medicine. New York, NY:
Ajipleton-Century-Crofts; 1974.
vention pivgnim integrated in a primary
preventive riiild health servioj; evaluu
Cion of fictiviticfs and effectiveness. Gmtnnmity Med. &82;4;302-314
2. Kark SL. The Practice of Community
Oriented Primary Can. New York, NY:
.Afipleton-Ceiituiy'-Crofts; 1981.
16. Gofin R. Adler B, Paltr H. Time
trends of hemogldbin levels and anemia
prevalence in a total, eoimnunity; Ihtblic.
3. Kark SL, Stcuart GW, eds. A Prac
tice of Social Medicine. Etltobuigh. Scot
land: E & $ Livingstone Ltrk 1962.
4. Kark SL. Kark E. Promoting Commumty Health-fwin Pftokla tn Jerusa
lem Juhanwwfcurg. South Africa: Witwatersrand University Press: 1999.
5 Susser M. Pioneering community
oriented primary care. Bull World
Health Organ. 1999;77:436-438.
fi. Community Orienied Primary Care:
A Resource for Developers. London. En
gland King Edward's Hospital Fund for
London; 1994.
7. Mann KJ, Medalie JH. Ueber E.
Green JJ. Guttman )„ Vfe&s to Doctors:
A Medical-Social Study of the .First Six
Yean al a Family Health Center in a De
wloping Community. Jeniaalem. Israel:
Jerusalein /Academic Press; 1970.
dency Program and its applica
tion in 8 primary health care
mary care-public health integra
clinics as demonstration cen
ters.29 In the United Kingdom, a
services and its positive impact,
on community health. The COPC
COPC project was earned out in
17 general practices together
with the King’s Fund.30^
lessons of Pholela and Jerusalem
continue to have relevance for
the primary health care reforms
that are occurring throughout the
world?4’35 «
9. Hug D. A aimmunity program for
promotion of growth and development
(PROD). In: Kark SL, ecl Fpideniiology
and Cctjpnuiuh/Medicine. New York.
NY: Appleton-Ccnttny-Crofis; 1974:
416-417.
About toe Authors
10. Abramson JH. Kark SL, Epstein
IJW, Hopp C, Peritz E, Maki er A A
community health study in Jerusalem;
aims, design, and response. 1stJ Med Sri.
1979;15:725-731.
As mentioned, a central fea
ture of the Jerusalem COPC ex
perience has been the academic
framework within which the in
tervention programs were devel
oped, implemented, and evalu
ated. Had it not been for this
academic backing, one can only
speculate as to whether interna
tional links would have been
forged and whether worldwide
penetration of COPC would have
occurred.
This issue has direct implica
tions with regard to successful
conduct of COPC programs else
where. Although many sites pro
claim to have adopted tlie COPC
model in the delivery of health
care, few, if any, have actually
undertaken the entire COPC
cycle over an extended period of
time. Our experience leads us to
believe that the availability of ap
propriate professional resources
tion in community health
7fie cutlhon are with the Department of So
ria! MetSane. Hadussah Medicdl (hganizatvm. and theHebrew' Univeniiy-Hadassah Braun School ofFtiblic Health and
Gnnmuniiy Medirine. Jerusalem. Israel.
Requests for repfinis should be sent to
Ijwu Epstein, MH, ChB, MPH. Depart
ment
itxilOrganizatidh. PO Box 12000, Jerusa
lem 91120, Israel (e-mail' iconic
hadassah.org.il).
this commentary was aaxptedjune
28, 2002.
Contributors
L Epstein wn.s te^xanstble tor primary
authorsliip and revisions of the commenUuy, The other authors contributed
to revising flic commentary.
Acknowledgments
We wish to pay tribute to al! of the
uiembei'S of the Hadassah Community
Health Center staff who over the years
were an integral pan of the develop
ment and sustainability- of COPC.
1720 i CornmunityOriented Primary Care I Peer Reviev/ed i Epstein et al.
8. Ejistein L.M. Growth in weighi of
infants in foe western region of Jerusa
lem, Israel. ] Troy l^diatr. 1968;14:4-8.
11 Kark SL. Gofin J, Abramson J H. et
al. The prevalence of selected health
charaderistfcs of inert: a eomniuntly
health study in Jerusalem. JsrJ Med Set
I979;t5>732-741.
12. Gofin J. Kark E. M^neipei- N,
Abramson JH, Hopp C., Epstein LM.
Prevaience of selected heatth diaracteristics of women and comparison vdtlt
men: a community healtii survey in Je
rusalem. IsrJ Med Sri. 1981 ;17:
145-159.
13. Abramson JH, Epstein IM Kark E,
Fisdhler B. lite contribution of a Health
survey to a family practice. ScandJ Soc
MtMf. 1973^33-38.
.14. Kark SL, Kark E, Hopp C. Abram
son JH. Epstein LM, Ronen I The con
trol of hypertension, atherosclerotic dis
ease and diabetes: a community
program in a family practice. J R Coll
GenPrvri. 1076:2 6:157-169
15. Palti H. Zllher N. Kark SL A com
munity oriented early stimulation inter
17. Puhi H. Valderrama C, Pognind R.
Jarltoni Y. Kurtzman C. Evaluation of
the effectiveness of a sthictured hreast
feeding promotion program integrated
into a maternal And dtfld health service
in Jerusalem. 1st J Med Sd 1988:2 41
342-348.
18. Gofin R. Balti ll. Adliy B. Bacteriuria far pregnancy and development of
the infant littriy Hinn Deu. 1984:9.
341-346.
19. Gofin R, J3e Leon I), Knisjikowy B,
Pal Li H. Injury prevention prognun to
jirimary care: process evaluation and
surveillance. Inj Pr&j. .1995;U335-339.
20. Sgan Cohen HD. KleinfeldMansbach I. Haver ER, Gofin R Coni
tnunily oriented oral health promotion
for infants to Jerusalem: evaluation of a
preigram
H&dlh Deni.
2001-.61:107-113.
21. Hopp A .aMnamnity program in
primary care for control of cardiovascu
lar risk factors: steps in program devel
opment. hrJ'MeclSii. 1983;19:
748-7-75.
22. Abramson JH, Hqjp C, Gofin J. et
al. A cormnunily pregrajn for (lie con
trol of cardiovascular risk factors: a preliminary evaluation of the effectiveness
of (Ju: CHAD program in Jerusalem
J Communf^y Health 1979:4:3-21.
23. Gofin R. Adler B. Paid H lime
trends of cliild deyetopment in a Jerttsa1cm community. Pdtdiat J^nat Ejhdaniol t996;10-.197-206.
24. Abramson JH. Gofin R, Hopp C.
Gofin J. Donchin M, Habib J. Evaluation
of a comrauriity program for tile control
of cardiovasdilar risk fodors: foe
CHAD program in Jerusalem, I.irJ Med
Sez 1981:17:201-212.
25. Gofin J, Gofin R, Ahrarason JH.
Ban R. len-year evaluation of hyperten
sion, ovenveight, cholesterol and smok
ing control: the CHAD program in Jenisalem. Free Med. 1986;16:304 -312.
26. Abramson JH, Gofin J. Hopp C,
Schein M, Naveh P. I he CHAD pro
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risk factors to a Jerusalem community, a
24-year retrospect, hr J Meet Sri. 1994.
30:106-119.
27 Cfofin J, Matoeiiu'i' N. Kark SL
Community hcaltli in primary care—a
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Ex'aluation of a commimity-oriented pri
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27:28-34.
29. Peray JL, Foz G, Gofin J. COPC in
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30. Gillam S, JofTe M, Miller R, Gray A;
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\)QtAes. Jlrilcrpmfvssional Care. 1998:
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Reis S. Tabenkin H. Practical ^pplications of COPC in family medicine praer
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XROAbS; COPaCeiic 2001
-3.
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2002:92-.1748-r755.
The Community-Oriented Primary Care Experience
in the United Kingdom
The UK National Health
Service has long delivered
public
health
programs
through primary care. How
ever, attempts to promote Sid
ney Kark’s model of commu
nity-oriented primary care
(COPC), based on general
practice populations, have
made only limited headway.
Recent policy develop
ments give COPC new reso
nance. Currently, primary care
trusts are assuming respon
sibility for improving the
health of the populations they
serve, and personal medical
service pilots are tailoring pri
mary care to local needs
under local contracts.
COPC has yielded training
packages and frameworks
that can assist these new or
ganizations in developing, pub
lic health skills and under
standing among a wide range
of primary care professionals.
(Am J-Public Health. 2002;92:
1721-1725)
| Stephen Gillam, MA. MSc, FRGP, FFPHM, MRCGP, and Alan Schamroth, MB, BS. MRCGP
THE EXPERIENCE OF
commiinity-orienled prunaty
citre (COPC) in the United King
dom includes the most compre
hensive attempt since 1^97 to
embed tlie principles of COPC hi
the "new National Health Ser
vice” (NHS) emerging from the
Labour government’s reforms.
Despite a predominantly bio
medical and humanist focus, gen
eral practice in the United King
dom has long been infused by
knowledge and skills traditionally
associated with public health
niedteine.1 The conceptual basis
of COPC can be recognized in
the writings of W
de
scribing the use of epidemiology
in his rural practice in the
1930s.2 Likewise, the Peckham
Pioneer Health Centre, estab
lished before the Second World
War by G. Scott Williamson and
Innes Pearce,3 has been seen as
an antecedent The philosophy of
the center involved piotecting
good health through a confoinatron of individual and family as
sessment and provision of a sup1portive environmenl’1
Throughout tlie past 30 years,
there have been eloquent pleas
for closer working relationships
November 2Q.02, Vol 92. No. 11 | American Journal of Public Health
between public health and pri
mary care professionals. At one
extreme, arguments have advo
cated foe total usurpatibn of pub
lic health doctor?' work by gen
eral practitioners.'3 Most have
envisiOhed the emergence of a
hybrid; the “Community general
practitioner.’” Julian T-idor Hart
has been tlie most visible expo
nent of something akin to Sidney
Kark’s COPC in the United King
dom In a scries of painstaking
studies, be demonstrated the im
pact of “anticipatory" approaches
to the management of cardiovas
cular risk factors bn. his practice
population’s health.6 His practice,
located in a Welsh mining vil
lage, look responsibility for both
community and clinical functions
and held itself accountable to the
population served through such
means as patient committees, am
nual reports, and meetings. He
argued for new alliances be
tween health professionals and
patients as “co-producers of
health.*'7
What injected new vigor into
these debates in the late 1980s
and early 1990s was die reaffir
mation of public health follow
ing the Acheson report and the
Conservative government’s mar
ket-oriented reforms. The for
mer sought to redefine and
strengthen the discipline of pub
lic health medicine after several
decades of decline and presaged
a major expansion in the public
health specialist workforce.8 At
the crux of Toiy reforms was
the introduction of an “internal
market'’ separating the roles of
purchasers (health authorities
and fund-holding general, practi
tioners) from the roles of health
care pro^dei’s. “Fundholders”
could invest savings accrued
through more efficient use of
secondary care in practice
based services. (Fund-holding
general practitioners, generally,
serving populations of al least
7000 patients, were allocated
budgets under the Tories’ inter
nal market for purchase of most
elective hospital care, staffing,
and coverage of prescribing
costs.) As public health doctors
sought to develop strategic plan
ning and purchasing functions
within health authorities, how
ever, fundholders often dis
missed the constraining disci
plines of needs assessment and
service evaluation.9
Gillam.and Schamroth | Peer Reviewed | Cdmrriunity-Orierited Primary Care | 1721
Copyright©2002 EBSCO Publishing
| COMMUNITY-ORIENTED PRIMARY CARE
Community-Oriented Primary Care:
A Path to Community Development
Although community devel
opment and social change are
not explicit goals of commu
nity-oriented primary care
(COPC), they are implicit in
COPC’s emphasis on commu
nity organization and local par
ticipation with health profes
sionals in the assessment of
health problems. These goals
are also implicit in the shared
understanding of health prob
lems’ social, physical, and eco
nomic causes and in the de
sign of COPC interventions.
In the mid-1960s, a com
munity health center in the
Mississippi Delta created pro
grams designed to move be
yond narrowly focused dis
ease-specific Interventions
and address some of the root
causes of community morbid
ity and mortality.
Drawing on the skills of the
community itself, a selfsustaining process of healthrelated social change was ini
tiated, A key program involved
the provision of educational
opportunities. (Am J Public
Health. 2002;92:1713-1716)
| H. Jack Geiger, MD, MSciHyg
EARLY IN HIS CAREER, THE
distinguished social epidemiolo
gist John Cassel worked for a
time as clinical director of tiie
Pholela Health Center, the pio
neering South African program
at which Sidney and Emily Kark
and their colleagues first cre
ated and implemented commu
nity-oriented primary care
(COPC). Their work trans
formed the health status of an
impoverished rural Zulu popula
tion and, ultimately, served as a
worldwide model for the inte
gration of clinical medicine and
public health approaches to in
dividuals and communities.1"4
During a window of opportunity
that opened in the 1950s,
Pholela’s center and a network
of other South African health
centers elabomted the core
goals of COPC: epidemiological
assessment of demographically
defined communities, prioritiza
tion, planned interventions, and
evaluation.5 By decade’s end.
however, these centers had all
been shut down by a rigidly
racist apartheid government.
A few years later. Dr Cassel—
by then a professor at the Uni
versity of North Carolina School
of Public Health-made a return
visit to a Pholela that was even
more deeply impoverished. After
conducting a thoroughly informal
and anecdotal survey, he saw no
signs that the earlier improve
ments in health status had per
sisted. But he was struck by the
target population’s unusually
Itigh levels of educational aspira
tion and educational achieve
ment. (Indeed, one of the health
November 2002. Vol 92. No. 11 I American Journal of Public Health
center’s pediatric patients later
went on to become a physician, a
leader of the African National
Congress in exile, and-after liberation-Nelson Mandela’s first
minister of health.6)
Cassel’s observation illustrates
a goal of COPC-community de
velopment—that the Katka, fully
aware that social, economic, and
environmental circumstances arc
the most powerful determinants
of population health status, un
derstood very well. Although
only occasionally specified in
their publications, it was implicit
in then- programs focusing on
community organization and in
volvement, training and develop
ment of local residents as staff
members, employment of Zulu
nurses as role models, intensive
&
A health center nurse makes a home visit to a stroke-disabled
patient living In a plantation shack near Shelby In Bolivar County,
Mississippi, In 1967. Most such housing Is less substantial than
this. (Photo by Dan Bernstein.)
Geiger I Peer Reviewed I Community-Oriented Primary Care i 1713
COMMUHiTY-ORSENTED PRIMARY CflRf
health education, and environ
mental improvements. Even in
the constrained social and politi
cal circumstances of apartheidera South Africa, such efforts
appaiently had a lasting educa
tional effect.
In the mid-1960s, half a world
away, another—and much big
ger—window of opportunity
opened in the United States. Ihe
"war on poverty” and its federal
implementing agency, the Office
of Economic Opportunity (OEQ),
proposed in principle to address
the root causes of deprivation
and inequality. 'Ihc OEO’s
iaigest arm, the Community Ac
tion Program, was committed to
ideas of community involvement
and program participation. Of
equal importance, the flotuisbing
civil rights movement embodied
bedrock principles of community
empowennent and political and
economic equity. When health
services—and, specifically, COPCbased health centers—were
added to this rich mix, the stage
was set for an experimental test
of the idea that a health program,
in addition to its traditional cura
tive and preventive roles, could
be deliberately fashioned as an
instrument of community devel
opment and as a lever for social
change.
'Phis experiment was con
ducted, in tiie late 1960s and
early 1970s. when Tufts Medical
School proposed the community’
health center model to OEO.
ITie Tufts-Delta Health Center
was tlie first in what is now a na
tional network of more than 900
federally qualified health centei’S.
Qosely modeled on the Pholela
experience,7 it was designed to
serve a primarily African Ameri
can population of 14000 per
sons residing in a deeply impov
erished 500-square-mfle area of
northern Bolivar County in the
"i
fB
««
LU b-J
f
fl
SilM
A typical plantation shack near Alligator, Mississippi, In 1968. A
whole generation Is often missing from the home, as parentsdisplaced by mechanical cotton-harvesting-leave children with
grandparents while they search for other work in northern cities.
(Photo by Dan Bernstein.)
Mississippi Delta. As was the case
with many other areas of the cot
ton-growing della, this was a
population of sharectvppers in
creasingly displaced by mecha
nization and living in crumbling
wooden shacks with no protected
water -supplies, untouched by
.food stamps or commodity sur
plus foods. These families had a
median, income of less than
$900 per year, had a median
level of education of 5 years
(and were exposed to segregated
and inferior schools), and were
suffering the inevitable conse
quences of malnutrition, infant
1714 | Community-Oriented Primary Care I Peer Reviewed | Geiger
mortality, infectious and chronic
diseases, and adult, morbidity
and mortality’.
Detailed descriptions of the
Tufts-Delia Health Center’s per
sonal medical service programs,
outreach services, health educa
tion efforts, and environmental
and other interventions involving
housing, waler supplies and sani
tation, and other public health
approaches have been published
elsewhere.8 0 What is of interest
here is the center’s community
empowerment program.
Witfi tlie guidance of Dr John
Hatch, tlie head of the center’s
community organization depart
ment, 10 local health associa
tions were formed and began to
survey and assess local needs,
nominate people for employ
ment at the center, and plan
satellite centers. Each association
elected a representative to an
overarching organization, the
North Bolivar County Health
Council. The council served as
the health center’s required com
munity advisory board but was
deliberately chartered as a non
profit community development
corporation to broaden the
scope of its work.
Its tint effort was to end the
local racist banking custom that
denied mortgages to Black appli
cants altogether, demanded a
White cosigner, or charged exor
bitant (and illegal) under-thetable interest rates. Members of
the health council visited all of
the local banks and informed
them that the center’s nulliondollar annual funding and cash
flow would be deposited in
whichever bank opened a branch
in a Black community, hired resi
dents as tellers instead of jani
tors, and engaged in fair mort
gage loan practices.
Alter successful completion of
(his process, the local health as
sociations obtained mortgages to
buy buildings for .satellite cen
ters, rented them to tire health
center during the day, used the
rental income to cover (he loan
payments, and used the buildings
as community centers at night.
Local health center staff mem
bers obtained mortgages to build
modest new homes. Next, be
cause there was no public iransportation and few people had
cars, the health counril-on con
tract from rhe health center—es
tablished a bus transportation
system that linked tlic satellites
to tlie health center (and pro
American Journal of Public Health | November 2002, Vol 92, No tl
COMffltimTV-ORlENTED PRIMARY CARE
vided economic mobility lor
workers and shoppers).
Illis was just the beginning.
Subsequently, the council devel
oped a pre-Head Start early
childhood enrichment program
and a nutritional and recre
ational program for isolated el
derly rural residents. In addition,
the council hired a part-time
lawyer to ensure that federal
and state agencies (which had
often ignored Blade communi
ties) provided equitable assis
tance in housing development,
recreational facilities, water sys
tems, and other elements of
physical infrastructure.
Also, by means of a federal
grant and its own budget, the
health council developed a sup
plemental food program. And
when staff of the health center
suggested that local residents
grow vegetable gardens, the
council had a better idea: witli a
foundation grant and help from
the Federation of Southern Coop
eratives, it spun off a new non
profit organization, the North Bo
livar County Fann Co-op, in
which a thousand families pooled
their labor to operate a 600-acre
vegetable fann and share in the
crops. This unique entciprise—
nutritional sharecropping-built
on the agricultural skills people
already possessed.
What made all of tliis possi
ble? One of the principal factors
was ending the isolation that had
kept members of poor rural mi
nority communities cut off from
knowledge of. or help from, such
traditional sources of support as
goveranient agencies, philan
thropic foundations, and universi
ties and professional schools. By
1970. for example, the health
council and health center had
ties to 7 universities, a medical
school, and numerous founda
tions and agencies. In addition, in
...
&
st ■
.
■
■
At a 1968 meeting of the North Bolivar County Health Council at the Delta Health Center, Mound Bayou,
Mississippi, William Finch announces the arrival of a Ford Foundation check that will launch a farming
cooperative to grow vegetables for a malnourished population, (Photo by Dan Bernstein.)
the summer of 1970 alone, the
programs were host to Black and
White student interns from 8
medical schools, 2 nursing
schools, 3 schools of social work,
2 public health schools, and 3
environmental health programs.
As was die case at Pholela,
however, die most important im
pact was educational, in this in
stance in the form of a structured
and multifaceted program. The
health center established an of
fice of education, seeking out
bright and aspiring local high
school and college gi aduates. as
sisting diem with college and
professional school applications,
and providing scholarship infor
mation and university contacts.
At night, health center staff
taught high school equivalency
and college preparatory courses,
both accredited by a local Black
junior college. In the first decade
in which it was in place, this ef
fort produced 7 MDs. 5 PhDs in
hcaldi-related disciplines, 3 envi-
November 2002. Vol 92. No. 11 \ American Journal of Public Health
ronmental engineers, 2 psycholo
gists, substantial numbers of reg
istered nurses and social work
ers, and the first 10 registered
Black sanitarians in Mississippi
history.
One of the physicians re
turned to become the center’s
clinical director, and another re
turned as a staff pediatrician. A
sharecropper's daughter ac
quired a doctorate in social work
and a certificate in health care
management and relumed as
the centers executive director.
(Her successor 8 years later, sim
ilarly well credentialed, had once
been a student in the college
preparatory program.) Other
center staff members completed
short-term intensive training as
medical records librarians, physi
cal therapists, and laboratory
technicians.
Moreover, as John Cassel’s ob
servation at Pholela suggested,
this process has proved to be
self-perpfctuating. Ibday, die
number of Black northern Boli
var County residents and their
next-generation family members
working in health-related disci
plines, at every level from techni
cian to professional, is well over
100. There is anecdotal evidence
to suggest that other health cen
ters. even witlmut special pro
grams of this sort, may have a
similar effect. Local residents
who become center staff mem
bers tend to invest their in
creased earnings in two areas:
better housing and college edu
cation for their children.
The effect is more than eco
nomic, however. Building com
munity-based institutions and re
placing the race- and class-based
isolation of poor anti minority
communities with ties to other
institutions in the huger society
may create a new kind of social
capital that facilitates social
change. This in turn enlarges the
health effects of the traditional
clinical and public health tnter-
Geiger\ Peer Reviewed ■ Community-Oriented Primary Care i 1715
COMMUNITY ORiENTB PRIMARY CASE
ventions that are the core of
COPC. Other community health
centers established in the fii-st
wave of the OEO’s Office of
Health Affairs program similarly
invested vigorously in commu
nity organization, environmental
change, and (in urban areas with
more existing resources) links
with other organizations to cre
ate multisectoral interventions.
There arc two important les
sons to be gained from Ute Mis
sissippi Delta experience. The
first is that communities of the
poor, all too often described
only in terms of pathology, are
in fact rich in potential and
amply supplied with bright and
creative people. The second is
that health services, which have
sanction from the larger society
and salience to the communities
they serve, have the capacity to
attack the root causes of ill
health through community de
velopment and the social change
it engenders.
As at Pholela, after too few
years the window that was open
to expanded programs and com
munity development began to
close. This happened in part be
cause of program costs and in
laj-ger measure because conser
vative national administrations
were (to put it mildly) not overly
interested in community empow
erment and social change. As a
result, health center programs
were squeezed back toward
more traditional roles of deliver
ing personal medical services
and more limited public health
interventions.
Good ideas, however, may be
rediscovered, and the potential is
still there. The North Bolivai*
County Health Council, no
longer in need of university
sponsorship, now owns and oper
ates the freestanding Delta
Health Center, with branches in
2 additional counties, and most
other federally qualified health
centers have analogous commu
nity control and practice ele
ments of COPC. Over the next
few years, the number of com
munity health centers will dou
ble. The recent and growing na
tional interest in community
Cam WtwhingkKi, DC: National Acad
emy Press; 1982.73—114.
9. Geiger HJ. A health center in Mississippi: a case study in social medicine.
In: Corey I-. Saliman SE, Epstein MF.
eds. Medicine m a Changing Society. St.
Ijuris. Mo: CV Mosby Co: 1972:
157-167.
campus partnerships, including
but not limited to health services,
may be a first step in the redis
2nd Edition
covery of community develop
ment as a legitimate goal of
health care interventions. @
About the Author
H.Jack Geiger is with the Department of
Community Health andSodul Medicine,
City University of Hew York Medical
School.
RequesK for
should be sent to
H.Jack Geiger, MD. MSciHyg, City Uni
vetsity ofNew York Medic.nl School, City
College, of New York, 13 8th St at (invent
Avenue New York, NY 10031 (e-mail:
}geigi;r@ige.org).
This commentary was acceptedJune 4,
2002.
CommunityOriented Primary Care:
Health Care for the 21 st Century
Edited by Robert Rhyne, MD, Richard
Bogue, PhD, Gary Kukulka, PhD, and
Hugh Fulmer, MD
4. Philips 1 IT The 19.45 Gluckman
report and (he establishment of South
Africa’s health centers. Am J Public
Health. 1993:83:1037-1039.
This book will give insight into:
• How medicine, health systems, com
munity leaders, and social services
can be supportive as America's pub
lic health practice continues to be
restructured and redefined
• New models of community-oriented
primary care
• Methods and interventions on popu
lation-derived health needs
• Health promotion and disease pre
vention as part of the overall reor
ganization of health services
• Understanding how communityoriented primary care can comple
ment managed care and community
benefit programs
This book teaches skills and techniques
tor implementing a community-oriented
primary care process and topics not
normally taught in health professional
education.
ISBN 0-87553-236-5
19981228 pages I Softcover
5. Kark St, Sleuart G, eds. A Practice
of Social Medicine- Edinburgh, Scotland,
f- & S Lh'ingstone lTd: 1962.
$27.00 APHA Members
$39.00 Nonmembers
plus shipping and handling
References
1. Kark SL. Cassel J. The Pholela
Health Centre: a |Mogress ir*port 5 Afr
Med J 1952:26:101-104, 131-136.
2. Uadi D, Tollman SM. Public health
initiatives in South Africa in the 1940s
and 1950s: lessons for a post-apartheid
era. dm J Public Health. I993 .83'
1043-1050.
3. Susser M. A South African odyssey
iu exmununity health, a mentoir of the
impact of the teaching nl Sidney Kark.
Am J Public Health. 1993:83:
1039-1042.
6. Geiger llj. A piece of my mind
The road out fAMA. 1994:272:1152.
7. Geiger HJ. Conununily-orieaicd
prirnan,’ care: the legacy of Sidney Kark.
Am J Public Healtli.1993-.83:94 6-947
American Public Health Association
Publication Sales
Web: www.apha.org
E-mail: APHA@TASCOl.com
Tel: (301) 893-1894
FAX: (301) 843-0159
COPCOUS
o
AHU.
8. Geiger UJ. llic meaning of com
munity-oriented primary care in the
Ai.nerican context. In: Connor E. Mullan
f", eds. Community Oriented Primary
1716 I Community-Oriented Primary Care I Peer Reviewed i Gefger
American Journal of Public Health | November 2002, Vol 92, No. 11
Copyright©2002 EBSCO Publishing
BMJ 1995;310:178-182 (21 January)
Education and debate
The World Health Organisation: WHO's special
programmes: undermining from above
Fiona Godlee, assistant editor a
a British Medical Journal, London WC1H 9JR
Correspondence to: Department of Ambulatory Care and Prevention, Harvard Medical School, 126
Brookline Avenue, Boston, MA 02215, USA.
Despite the World Health Organisation's spoken commitment to developing integrated
primary health care, its most visible and successful activities are not integrated within
countries; they are its disease specific intervention programmes, such as the Global
Programme on AIDS and the programmes for the control of diarrhoeal and acute
respiratory diseases. The 10 or so special programmes, all but one of which (the
onchocerciasis control programme) are based in Geneva, have found increasing favour
among donors, but critics say that they undermine WHO's attempts to integrate its
activities at country level and discourage countries from developing their own capacity.
WHO's special programmes were set up in response to the perceived need among donors
for something more comprehensive than WHO's regional and country based activities
could offer. The idea is that they boost the organisation's routine activities, using
international and regional expertise and a project based approach to attack specific
diseases or health issues. The special programmes receive no funds from WHO's regular
budget. They are funded from so called extrabudgetary contributions. Because of this they
are not under the control of the director general, the executive board, or the World Health
Assembly. Each special programme has its own director and a management executive
committee made up of donors' representatives.
From the donors' point of view the special programmes have clear advantages over
WHO's non-project based activities. They have well defined aims and strategies; they
have outcome measures, even if most relate to process rather than health indicators, they
are more financially accountable than the rest of WHO; and they are not under the direct
control of the secretariat. This last point has become increasingly important in the past
five years, according to diplomats in Geneva. As donors in Europe, Scandinavia, and
America have become increasingly discontented with the organisation's lack of leadership
and accountability they have concentrated their funding of WHO more and more in
extrabudgetary donations. Extrabudgetary payments to special programmes now make up
over half of the organisation's total income, compared with a quarter in 1972.
The shift to extrabudgetary funding restores to donor countries much of the influence they
lost during the 1970s, when the influx into WHO of countries from the developing world
more than doubled its membership. All countries have equal voting rights at the World
Health Assembly, so groupings of countries from the developing world can now control
the assembly's agenda. By shifting their funds to the special programmes, donors can
influence how their money is spent. A spokesman for one European aid organisation said,
"We invest in these programmes because we have control over what we invest in. If we
don't like what happens we can vote with our cheque book." The arrangement has
advantages for recipient countries too. The regular budget has been frozen in real terms
for the past 13 years, which means that membership payments are falling against
inflation, but extrabudgetary funds keep the money coming in.
The problems of donor power
The change is not without its problems for WHO. Instead of working in a coordinated
way towards a set of centrally agreed goals, the organisation has become an umbrella
within which its independent programmes compete for funds. According to international
aid workers, this reduces WHO's impact and can create confusion and bad feeling.
Recipient countries complain of lack of coordination between different parts of the
organisation.
"Having two types of funding is an important structural weakness," said a staff member in
Geneva. "Programmes are forced to gobegging for money, and they have to compete
with each other, which is absurd. Donors feel more comfortable with this arrangement,
more in control. But because the World Health Assembly doesn't discuss the
extrabudgetary programmes, the multilateral system for setting priorities is effectively
bypassed." Priorities depend on the energy with which each programme lobbies for
support, explained another staff member. Such efforts may be motivated in part by the
desire among specialists on each programme to keep and strengthen their own positions.
"These specialists need the jobs," he said.
WHO's priorities increasingly reflect those of the major donor nations. As Dr Jonathan
Mann, former director of the global programme on AIDS and now director for the
International Centre for AIDS at Harvard, puts it, "The tail is now wagging the dog." The
United States, for example, puts three fifths of its £100m extrabudgetary contributions
into the global programme on AIDS, which is now WHO's largest single programme and
one of the largest in the United Nations. Meanwhile, until recently the United States
refused to donate money to maternal and child health programmes that might advocate
abortion.
Dr Gill Walt of the London School of Hygiene and Tropical Medicine identifies other
problems of "donor power."- Big donors can and do use the threat of withdrawing funds
to exert political pressure. Threats by the United States to withdraw from WHO kept the
Palestine Liberation Organisation from attaining full membership until last year. Also,
donor governments are answerable to their own voters and need to see results. This tends
to encourage them to invest in short term, technically driven programmes and to judge
them by short term outputs (such as the number of immunisations given) rather than long
term outcomes (such as reductions in mortality or improved quality of life).
"Extrabudgetary contributions allow donors to escape from their responsibilities," said
one member of WHO's staff. "They can go for glamorous diseases like AIDS, which grab
the attention of the voting public, but they are not so interested in, say, polio, which is
remote and gives results only in the much longer term." Finally, the shift towards
extrabudgetary donations means that more time at meetings between donor nations and
WHO is now spent debating financial discipline and budgets rather than defining and
formulating policy.-
A recent paper from the Karol inska Institute in Sweden points out another quirk of the
funding of special programmes.- Much of the money donated for research finds its way
back to the donor country. From 1975-89, America gave $33m to the tropical diseases
research programme. Over the same period it received $44.4m from the programme in
research grants. Meanwhile Britain received back over a third of its $43.3m donation to
the programme for research on human reproduction from 1972-92. The authors of the
paper conclude that "the cost effectiveness of transferring large sums of national money
through WHO and back to the country of origin must be questioned."
Need for integration
The special programmes look set to remain a major part of WHO's activities, and WHO is
aware of the need to integrate them into local health care systems if they are to be
sustainable. "Horizontal integration is the main tool for survival of the programmes," said
Dr Anton Fric, medical officer to the expanded programme on immunisation in South
East Asia. "It is especially important if donor funds begin to decline." He believes that the
immunisation programme is now well integrated at central and district level in most
countries in the region and that other programmes will now be able to use the
programme's networks to spread advice on AIDS and maternal and child health.
The immunisation programme has, however, run into problems, largely because WHO
depends on Unicef for its implementation. WHO's initial plan recognised that setting up a
vaccination programme would not only be a valuable intervention in itself but would also
provide vital experience in developing health care systems across the board. But
according to international aid workers, the original principles were lost with Unicef s
decision to work towards the quantitative goal of universal childhood immunisation by
1990. Instead of gradually developing health care infrastructure, as envisaged by the first
director of WHO's immunisation programme, Dr Rafe Henderson, Unicef injected vast
sums of money and external manpower in an attempt to satisfy its donors with visible
results. As 1990 approached and countries in Africa continued to lag behind even the
rescheduled target of 80% vaccine coverage, Unicef poured in resources for mass
vaccination campaigns. Data from Ghana show the result: a massive surge in coverage in
1989-90, allowing Unicef to claim success, but an almost immediate return to levels of
40-50% when the additional resources were removed (see figure). According to Unicef,
coverage in Nigeria has followed the same pattern, peaking at 70% in 1990 and falling to
under 20% in 1994.
MOIM'
-------&CG
---------CWNri*
1
H
120
L^J
* ll<’'
i ioo8
Immunisation coverage in Ghana--an example
showing that, without additional funds for mass
vaccination campaigns (1990), levels are
usually 40-50%
W>’
I SO-
I 70 ’
I to
50- J
40- f
?0'
/
2010
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Harsh lessons unlearnt
The problems besetting the immunisation programme illustrate the pitfalls of single
strategy, top down interventions. Large sections of WHO, and the special programmes in
particular, remain wedded to this approach. Since eradicating smallpox in 1978, and with
the millenium approaching, WHO is understandably keen to do the same with the other
major tropical diseases. The success with smallpox may not, however, be repeatable.
Experts attributed its eradication largely to clear strategic planning but also to specific
characteristics of the disease. Smallpox has no animal reservoir and no subclinical or
carrier state. Its clinical manifestations are clearly recognisable. This meant that cases
could be identified by lay people such as village chiefs, and WHO's staff did not have to
screen individuals. Case monitoring could be done over large areas.
For different reasons, the eradication of polio looks increasingly achievable. The vaccine
virus is secondarily transmitted, especially in endemic areas where there is poor
sanitation. As a result of this multiplication effect, coverage of whole areas can be
achieved without attempting comprehensive individual coverage.
ERADICATING MALARIA
Other diseases are proving less amenable to eradication, and in one famous case, malaria,
intervention has left large areas of the world far worse off than before. The current
malaria pandemic is, says Dr Andrew Spielman of the department of tropical public
health at Harvard, an iatrogenic phenomenon.- WHO's malaria control programme was
set up in 1956. In 1958 the American government announced its plans for an "intensified
effort" against the disease, and unlike WHO's open ended commitment, the Congress
specified a five year time limit. The plan, based on the ideas of Professor Paul Russell of
Harvard University, was to eradicate the disease within the limited three to five year
window of opportunity before resistance to drugs and pesticides set in. Vast sums were
invested in spraying houses with pesticides, the money coming largely from USAID,
America's overseas aid organisation.
The initial success was extraordinary. In Sri Lanka, the annual incidence fell from 1
million in a population of 12 million exposed people in the early 1950s to 18 cases in
1963. Eradication, at least in some areas of the world, seemed guaranteed. But the plan
had been based on the premise that populations were homogeneous and that those who
escaped the spraying programme-itinerant workers, for example-would be equally
spread throughout an area. Professor Russell estimated that covering 80% of houses
would be sufficient. He did not take into account the possibility of clusters of migrant
workers-gem miners in Sri Lanka, for example-who served as an unreachable reservoir
for the parasite. By 1963, the year that USAID was due to pull out of the scheme,
resistance to DDT had arrived, soon to be followed by resistance to the main antimalarial
drugs, and the battle against malaria was lost. WHO was left to pick up the pieces.
WHO's response over the past 20 years has been to retreat into research. Its tropical
diseases research programme, which spends a fifth of its budget on malaria, has had
notable successes. Almost all of the new drugs for treating malaria have come out of
research collaborations funded by WHO, and the programme is now testing drugs and
vaccines for effectiveness and toxicity. Dr Diane Worth, an expert in tropical diseases at
Harvard University, sees this independent validation of products as a vital role for WHO.
But the emphasis still seems to be on finding a single answer, a magic bullet, whether it
be the transgenic mosquito or the malaria vaccine. WHO responds to this criticism by
pointing to the current efforts to integrate the work of separate special programmes like
the tropical diseases research programme and the sick child initiative (box) and to shift
the emphasis towards implementation in the field. Promising though these changes are,
they remain isolated developments within the organisation as a whole.
Sri Lanka now has over 25000 cases of malaria a year. As was recognised when the
eradication programme was launched, failure would carry grave consequences—a nonimmune population exposed to fatal outbreaks with no tools to fight the disease. The
message of the malaria debacle, says Dr Spielman, is that, even with dramatically
effective tools, there is a need to act with restraint. "We need to identify attainable,
worthwhile objectives and then try to act small, to make incremental advances.”
"Eradicationitis"
Despite this harsh lesson, "eradicationitis” remains highly prevalent within WHO. The
organisation's eagerness to follow on from its success with smallpox is evident in other
programmes. According to Dr Diana Lockwood, specialist in leprosy at the Hospital for
Tropical Diseases in London, this has led WHO to overplay its success in controlling
leprosy, with serious consequences for the funding of control and eradication
programmes. "WHO has been very successful in implementing effective antibacterial
treatment for leprosy, but it is naive to think that we can eradicate the disease," she said.
She believes that WHO's approach to leprosy is too short term and places too much
emphasis on drug treatment. "Multiple drug therapy alone is not enough," she said.
"Preventing nerve damage and rehabilitating patientsis just as important. WHO is doing
very little in this area."
Since the early 1980s, when WHO launched its programme to eradicate leprosy by 2000,
the number of active cases has fallen from 7m to 3.1m. These figures suggest that WHO
is well on the way to achieving its target. But by the WHO definition, patients who have
completed a two year course of treatment no longer suffer from leprosy, a definition that
takes no account of longterm disability and recurrence. Other agencies dealing with
leprosy say that WHO's optimistic reports are making it difficult to interest donors in
funding leprosy programmes. "The WHO's announcements that the number of cases is
falling have taken the pressure off governments and donors," said Terry Vasey of Lepra,
the London based leprosy charity.
&
Rehabilitating patients with leprosy is just as
important as using multiple drug therapy to
M eradicate the disease
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The most dangerous pitfail of eradicationitis, however, remains the distortion of
emphasis, from gradual horizontal integration to top down vertical intervention. This is a
criticism levied at the joint WHO and Unicef initiative to eradicate polio by the end of the
century. Dr Giro de Quadros, director of the polio eradication programme in the Americas
has, say aid workers, achieved astonishing results through his singleminded and single
disease oriented approach, but they warn that such a strategy would be highly
inappropriate in Africa, where it would be a bad use of resources to invest heavily in the
top down eradication of a single disease without developing health care infrastructure in
the process.
The vertical approach of most of the special programmes not only undermines WHO's
attempts to integrate its initiatives within countries but has also affected the way recipient
countries organise their health services. A recent study of health policy and organisation
in Ghana concludes that, although the technical concerns of the special programmes have
changed—from smallpox, malaria, and yaws before independence to immunisation,
Guinea worm, and AIDS today-their organisational structures have remained largely
unchanged, and their vertical approach has resulted in separate divisions of the ministry,
each controlling its own cadres of staff and concerned with its own area of intervention.2
Ironically, having been the beneficiaries of donors' discontent over WHO's regional and
country based activities, the special programmes are now themselves being hit. Short of
resigning from the organisation, the main way for donors to press home their concerns
about WHO's lack of effectiveness is to cut their extrabudgetary contributions. Earlier
this month Sweden did just that. One of WHO's most trenchant supporters and the second
biggest overall contributor of extrabudgetary funds after America, Sweden announced
that it was pulling out half of its funding for the special programmes. Other Nordic
countries are considering similar action.
Conclusion
c
WHO is caught in a cycle of decline, with donors expressing their lack of faith in its
central management by placing funds outside the management's control. This has
prevented WHO from coordinating its activities in line with centrally agreed priorities and
has undermined attempts to develop integrated responses to countries' long term needs.
The tendency to give money in extrabudgetary donations was a message to WHO's
leaders, says Dr Jonathan Mann. "It was telling WHO that donors wanted more
accountability and transparency. They wanted more aggressive, concrete, solid work on
important problems. Somehow WHO needs to achieve the same power of response as
these programmes achieve but through the mechanisms of the whole organisation.”
Unless WHO now responds to this message, its hopes of achieving sustainable changes at
country level are slim.
1. Walt G. WHO under stress: implications for health policy. Health Policy
1993;24:125-44. [Medline]
2. Stenson B, Sterky G. What future WHO? Health Policy 1994;28235-56.
3. Epidemiology Unit, Ministry of Health. Annual Report 1992. Accra, Ghana:
MOH, 1993.
4. Spielman A, Kitron U, Pollack R. Time limitation and the role of research in the
worldwide attempt to eradicate malaria. J Med Entomol 1993;30:6-19. [Medline]
5. Bern C, Martines J, de Zoysa I, Glass RI. The magnitude of the global problem of
diarrhoeal disease: a ten year update. Bulletin World Health Organ 1992;70:70514.
6. Tsalikis G. The onchocerciasis control programme in west Africa: a review of
progress. Health Policy and Planning 1993;8:349-59.
7. Cassels A, Janovsky K. A time of change: health policy, planning and
organisation in Ghana. Health Policy and Planning 1992;7:144-54.
9
certificate is proof of success-having
—1 The
eradicated smallpox worldwide, WHO is keen to
I
add other diseases to its books
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The International Federation of Leprosy Associations estimates that 6.5 million people
are currently affected by leprosy worldwide and that, despite multidrug treatment, there
has been no sign of a decline in the number of new cases. A declaration by members of
the federation in July last year emphasised that achieving WHO's current target "does not
mean the end of leprosy or of work on behalf of all those people who are and will be
affected by the disease."
Making things look good
The pressure to eradicate major tropical diseases by the end of the century has brought
with it additional pressures to make the data look good. Aid workers say that they
recognise a degree of mutual self deception when gathering data from local health
workers. One doctor working for a British based aid agency told me that workers in
Ethiopia admitted to falsifying the data on immunisation coverage "because Unicef gave
them so much money, they didn't want to disappoint them."
Shifting goal posts is another sign of the millenium approaching, say aid workers. The
leprosy programme has changed its target from eradication to elimination of the disease
as a public health problem, meaning fewer than one case in 100000 population. Dr
Ebrahim Samba, outgoing director of the onchocerciasis control programme, defends this
approach on the grounds that it is not cost effective to pursue a disease to eradication
when other priorities need resources. He considers the onchocerciasis programme to have
achieved its target now that the prevalence of infection in West Africa is less than 5%
(see box). Some commentators remain concerned, however, that closing the programme
at this stage carries the risk of recurrence.-
£
Top down interventions
Tropical Medicine and International Health
VOLUME 9 NO 6 PP AI-A4 SUPPL JUNE 2004
Editorial: A framework for analysing the relationship between
disease control programmes and basic health care
Bart Criel, Guy Kegels and Patrick Van der Stuyft
Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
Summary
In this paper, we present a framework for analysing the complex relationship between disease control
programmes and basic health care systems. Many of the ideas and concepts presented in this paper were
developed by the staff of the Public Health Department of the Antwerp Institute of Tropical Medicine
(ITM) over the last 20 years. They are thus the product of the reflection of an entire team.
keywords disease control, basic health care, vertical programmes, integration
The difficult relationship between (vertical) disease
control programmes and (horizontal) basic health
care services: an unfulfilled potential?
The relationship between disease control programmes and
basic health care systems has always been, and still is, a
problematic and even tempestuous one. One of the
reasons for this state of affairs lies in the fact that in the
past, too often, protagonists of both approaches took
rigid ideological viewpoints and dug themselves in, each
in their own trenches. Managers of basic health care
systems looked at disease control programmes as a threat
to the values and principles underlying primary health
care. And disease control programme managers consid
ered the defenders of basic health care systems as
dreamers who had forgotten about the need for effect
iveness and impact.
The lack of dialogue, and even respect, between the socalled ‘verticalists’ and ‘horizontalists’ has blurred judge
ment. It is our conviction that this has been a hindrance to
a fruitful collaboration in the interest of patients and
populations whose health would benefit from a more open
relationship and from more exchange. Hence the need to
clarify the terms of the debate.
What is a disease control programme?
A programme can be defined in two ways, which are not
mutually exclusive. The first and rather classical way of
defining a programme is to describe it as a coherent set of
activities conceived to control, possibly eliminate, a given
disease (Cairncross 1997). The identification of this set is,
in principle, the intellectual product of scientific research
and rational planning.
© 2004 Blackwell Publishing Ltd
A second way is to consider a programme as an
institution, with a specific administration, scientific and
technical staff, and logistical and financial resources - the
core business of which it is to control one particular health
problem. Such an institution generally has access to more
resources - often earmarked - than is the case for other
departments or sections in the Ministry of Health. A
programme thus represents an important resource and
opportunity to reduce the burden caused by a given
disease.
But it also is, by the very force of its resources, a
powerful player in national and local health systems (Gish
1992). It has considerable weight on (inter)national and
local decision-making processes, which can then be - more
or less easily - biased in favour of the control of one
particular disease.
Why a programme?
A programme is launched when a health problem is
considered sufficiently important to warrant specific
attention and means to combat it. This decision is taken on
the basis of two types of criteria: on the one hand, objective
and explicit criteria, mainly the importance - its frequency
and severity, and the vulnerability of the disease - i.e. the
availability of an effective treatment. On the other hand, it
is based upon more subjective and implicit criteria related
to the way the disease is ‘perceived’. The social perception
of a disease is in fact a complex issue. It is shaped by a
variety of actors: patient organizations, lobbyists from a
variety of backgrounds (including the pharmaceutical
industry), health care providers, research institutions,
politicians, non governmental organisations, media, etc.
The decision to launch a specific programme is, naturally,
Al
Tropical Medicine and International Health
B. Criel et al.
VOLUME 9 NO 6 PP AI-A4 SUPPL JUNE 2004
Disease control programmes and basic health care
influenced by prevailing international, political, economic
and cultural power relations between the North and the
South.
What is integration about?
In the case of health care, integration usually means that
general health services take the responsibility to operate
specific activities designed to control a health problem.
These services thus become one of several channels for the
programme to implement its activities, which then become
part of the broader package of activities delivered by these
multipurpose general health services (Criel et al. 1997).
It is important to point out that this definition and
many of the other concepts handled when analysing the
issue of integration into general health services also apply
to other sectors than health care. Indeed, a disease control
programme may collaborate with a variety of partners.
For instance, a schoolteacher can speak in his classes
about the prevention of HIV infection; an environmental
health worker can mention the use of bednets in the
prevention of malaria; and a field agricultural worker can
highlight the need for children to have a balanced diet.
Finally, let us not forget that when we talk about
integration, the issue is not integrating (or not)
programmes in their totality; the issue is integrating or
not (some) activities of a programme.
of course it is not. We nevertheless think that the
comparison is useful.
Disease control is disease-centred, a population
dimension prevails, and the basis for the planning of
interventions is need. Basic health care on the other hand
is patient-centred, favours an individual dimension, and
plans its activities starting from the community’s felt needs.
The basis for decision-making in disease control is
epidemiologic evidence, but it is much more complex in the
case of basic health care systems, where the health worker,
ideally, needs to contextualize his decisions so that the
specific and unique character of every single patient is
taken into consideration.
The terms of reference for the evaluation of disease control
activities are straightforward: they focus on the coverage of
the programme and on its epidemiological impact. The
objectives of disease control are relatively easy to quantify.
This is not so in the case of basic health care. In the latter, the
question to be addressed, ultimately, is to assess whether the
health care delivery system is capable to help patients, cured
or not, to cope with their health problem and to carry on with
their lives in a way that is acceptable to them. Finally, the
nature and qualification of the health workers distinguish
disease control from basic health care: in the former
specialists are more prominent, in the latter versatile health
workers constitute the main workforce.
4
Integrate or not? Guiding rules for decision-making
The logic of disease control programmes
and basic health care: a field of tension
Table 1 summarizes the main differences in logic between
disease control programmes and basic health care systems.
A limit of this comparison is that it probably presents
things in an overly simplifying way, as if in reality there
were no situations in between - which of course there are;
or as if the opposition in logic would be absolute - which
To help answer the question whether disease control
activities should be integrated in basic health care services
or not, we wish to present a simple set of guiding rules. It
consists of three straightforward questions. The first
question is whether integration is desirable. Is there an
added value in asking general health services to incorporate
a given disease control activity, or several activities, in
their basic package? In some cases integration is not a
Disease control
programmes
Basic health
care systems
The object
The main dimension
The basis for
planning
The principal basis
for decision-making
A disease
Populational
Need
The patient
Individual
Overlap of demand and need
Evidence
Mix of evidence, patients’
preferences
and constraints, and local context
The terms of
reference
for evaluation
The staff
Programme coverage and
impact on frequency and
severity of disease
Specialists
Is the patient able to carry on with
A2
Table I Disease control programmes vs.
basic health care systems
his life in a way that is acceptable
to him?
Versatile health workers
4
© 2004 Blackwell Publishing Ltd
Tropica! Medicine and International Health
VOLUME 9 NO 6 PP AI-A4 SUPPL JUNE 2OO4
B. Criel et al. Disease control programmes and basic health care
desirable option (Mills 1983). For instance, there is a
strong case for integrating BCG vaccination in general
health care services, but far less so for integrating active
case-finding of African trypanosomiasis (De Brouwere &C
Pangu 1989; Kegels 1995).
A second question is whether integration is possible: can
a generalist perform the tasks properly? A certain degree of
standardization of the task at hand is needed if it is to be
delegated to non-specialists. For instance, passive case
finding and diagnosis of sputum-positive open pulmonary
TB are tasks that can, relatively easily, be standardized.
The diagnosis of leprosy, on the other hand, would be an
example of a task where integration is much more difficult,
especially in low-prevalence situations.
A third question is whether it is opportune to integrate.
Can the general services cope with the additional work
load? Are the general health services functioning suffi
ciently well to host the related new activities (one cannot
integrate activities in something that does not work)? Or
does the policy of integration constitute a genuine oppor
tunity to strengthen the functioning and credibility of the
general health services?
What transpires from this simple set of guiding rules is
that the answer to the question ‘integrate or not? ‘must
necessarily be a contextual one: the answer may differ from
one country to the other, even from one district to the
other. We should thus avoid blanket solutions.
The challenge: optimize the articulation between
the two systems
The challenge ahead is to optimize the articulation between
the two systems. Integration presents opportunities and
threats for both disease control and basic health care
(Table 2). The challenge is to reach an organizational set
up where the threats and dangers of integration are
minimized, and where the opportunities and strengths are
maximized.
For disease control, a powerful opportunity is to extend
the coverage of its programme activities; for basic health
care, the opportunity created by a policy of integration lies
Table 2 Effects of integration
For the disease
control system
For the basic health
care system
Opportunities of
integration
Threats of
integration
Extension in coverage
of programme
activities
Increased capacity to
respond to people’s
felt needs
The disease loses
its privileged
status
Imbalance in the
offer of care
© 2004 Blackwell Publishing Ltd
in the possibilities it creates to improve the general health
services’ capacity to respond to people’s felt needs (Loretti
1989; Criel 1992). When it comes to the threats, the case is
clear for disease control: integration means that the disease
will lose its privileged status and become ‘a disease like any
other’. In the case of basic health care, a major threat is
that the integration of disease control activities will lead to
an imbalance in the offer of care, with a shift of attention
and resources, within the general services themselves,
towards the control of one particular disease. The oppor
tunity cost would soon become detrimental.
Conclusion: Proposals for a fruitful interaction
between disease control systems and
basic health care systems
If we wish to move in the direction of an optimal
relationship between disease control and basic health care,
four general proposals could be kept in mind. A first one
would be to leave the dogmatic discourse behind and to
drop the simplistic (and counter productive) dichotomous
classification of ‘us’ and ‘them’... A second suggestion is
for the people in charge of disease control and basic health
care to recognize the respective strengths and weaknesses
of either approach, and also to acknowledge the intrinsic
field of tension that exists between both systems. The third
suggestion is to accept the need for contextualised solutions
when it comes to integrating some activities of disease
control in basic health care. And finally, a fourth proposal
is for all to accept that basic health care is a human right
and that this right is in agreement with the existence of
disease control programmes together with, not instead of,
general health services.
References
Cairncross S (1997) Vertical health programmes. The Lancet 349
(suppl III), 20-22.
Criel B (1992) L’integration du controle de la tuberculose dans les
soins de sante primaires: ou en sommes-nous? Editorial Annales
de la Societe beige de Mede cine Tropicale 72, 1-3.
Criel B, De Brouwere V & Dugas S (1997) Integration of Vertical
Programmes in Multi-purpose Health Services, Studies in Health
Services Organisation & Policy 3, ITG Press, Antwerp, 37p.
De Brouwere V & Pangu KA (1989) The flexibility of an integ
rated health services in the campaign against Trypanosoma
brucei gambiense trypanosomiasis. Annales de la Societe beige
de Medecine Tropicale 69 (Suppl 1), 221-229.
Gish O (1992) Malaria eradication and the selective approach to
health care: some lessons from Ethiopia. International Journal
of Health Services 22, 179-192.
Kegels G (1995) Development of a methodology for a feasible and
efficient approach to health problems by basic health services in
A3
Tropical Medicine and International Health
B. Criel et al.
VOLUME 9 NO 6 PP AI-A4 SUPPL JUNE 1004
Disease control programmes and basic health care
rural Africa. An application to sleeping sickness. PhD thesis,
University of Antwerp.
Loretti A (1989) Leprosy control: the rationale of integration.
Leprosy Review 60, 306-316.
Mills A (1983) Vertical versus horizontal health programmes in
Africa: idealism, pragmatism, resources and efficiency. Social
Science & Medicine 17, 1971-1981.
Authors
I B. Criel (corresponding author), G. Kegels and P. Van der Stuyft, Department of Public Health, Institute of Tropical Medicine,
! Nationalestraat 155, 2000 Antwerpen, Belgium. Fax: + 32 (0)3 247 62 58; E-mail: bcriel@itg.be, gkegels@itg.be, pvds@itg.be
c
A4
© 2004 Blackwell Publishing Ltd
0277.9536.88 S3.00 + 0.00
Perga mon Press pic
Soc. Sci. Med. Vol. 26. No. 9. pp. 919-929. 1988
Printed in Great Britain
PRIORITY SETTING AND ECONOMIC APPRAISAL:
WHOSE PRIORITIES—THE COMMUNITY
OR THE ECONOMIST?
Andrew Green1 and Carol Barker2
'Lecturer in Health/Development Economics and - Lecturer in Health Planning.
Nuffield Institute for Health Services Studies, 71-75 Clarendon Road, Leeds LS2 9PL, England
Abstract—Scarce resources for health require a process for setting priorities. The exact mechanism chosen
has important implications for the type of priorities and plans set, and in particular their relationship to
the principles of primary health care. One technique increasingly advocated as an aid to priority setting
is economic appraisal. It is argued however that economic appraisal is likely to reinforce a selective
primary health care approach through its espousal of a technocratic medical model and through its hidden
but implicit value judgements. It is suggested that urgent attention is needed to develop approaches to
priority setting that incorporate the strengths of economic appraisal, but that are consistent with
comprehensive primary health care.
It is perhaps salutory to recall that one of the assump are frequently propounded by aid and technical
tions on which the British National Health Service agencies such as UNICEF (through their implicit
was based, was a belief that there existed in any espousal of selective PHC) and the World Bank.
community a finite pool of ill-health, which, through Indeed, it may be largely the use of such techniques
the application of health services, could be reduced in which makes the selective approach to PHC attrac
such a fashion that the need for health care itself tive to these agencies. They create a feeling of secu
would in the long-term decline [1]. Forty years later rity, that allocations have been ‘scientifically’ made;
there are few health service managers who would they provide a simple basis for appraisal and evalu
adhere to that view, recognising instead that whether ation. This special issue warrants emphasis on the
one’s view of health is a narrow medical one, or a particular relationship between such techniques and
broader more holistic view such as that characterised selective PHC. However it is suggested that the
by the WHO definition [2], health demands will contradictions between the unguarded use of such
always outstrip the resources available, even in the techniques and the need for community participation,
(albeit untenable) extreme position in which all of a inter-sectoral collaboration and broader non-medical
country’s resources were devoted to health. Such notions of health make them potentially unsuitable
a view is not limited to underdeveloped countries, for use, in many situations.
Following the original Walsh and Warren paper
whose absolute resource levels are lower, but is
equally applicable to, and accepted by, richer coun that outlined a basis for a selective PHC approach [3],
came two critical responses by Gish [4] and Berman
tries such as the U.S.A.
In a situation of scarcity of resources, there is a [5], both economists, and both concerned amongst
need for means of making choices between competing other things with the misuse of economic techniques.
possibilities, as to how such resources should be used. More recent critiques of, inter alia, the specific eco
How allocative decisions are made has a major nomic content of their original paper have included
effect on the allocation itself, with different priority that of Unger and Killingsworth [6]. Their criticisms,
setting mechanisms leading to very different results. though extremely powerful, were insufficient to halt
This paper examines some of the approaches, and in the rise of selective PHC. This paper builds on and
particular the role of economic techniques in setting fully acknowledges the basis laid by their con
priorities. It suggests that techniques currently in use, tributions. It argues that urgent consideration needs
or suggested for use, are in danger of undermining the to be given to devising approaches to priority setting
strategy of primary health care (PHC) to which and redefining the roles of professionals and their
WHO member states have committed themselves. It techniques in ways that are consistent with and
argues that ’rational’ decision-making models, reinforce PHC, as defined in the Alma-Ata Declara
whether based on epidemiology, economics, social tion.
We stress that we use the term PHC here in the
epidemiology, or, more currently fashionable, a mix
of the three disciplines, obscure built-in value judge broadest sense expressed in the Alma-Ata Declara
ments and hence impose such values over those of the tion—as an approach to the planning and organis
community. Planning systems, if they arc to promote ation of all health services and health promoting
PHC need to adapt to allocative mechanisms that activities with the goal of better health. We do not
allow genuine participation in the setting of priorities, refer only to the primary level of health care, or to
and hence to accept a major change in the role of any list of merely technical actions. While within
‘technicians’ and their techniques. However since the health services the primary level of care is important,
Alma-Ata Declaration, there has been a growing consideration of priority setting must encompass
interest in priority-setting techniques built upon the priorities within a total, integrated health serivce.
disciplines of economics and epidemiology, and these This approach is based on the principle of equity, the
919
'<oran' c -
pRC- ISO
920
Andrew Green and Carol Barker
rejecting the market as a mechanism tended to rely on
technocratic measures of community need, rather
than adapting the notion of ‘wants’. As such they
relied on professional, seemingly objective measures
of need, rather than need as perceived by the commu
nity. For many countries such planning systems are
relatively new. It was not until the late sixties and the
seventies that planning units and formal health plan
ning systems in Ministries of Health in many coun
tries were developed. Even in the U.K. with one of
the earliest public health care systems in a mixed
economy the first attempt at a formal comprehensive
planning system dates from only 1974. 30 years after
1. PRIORITY SETTING APPROACHES
the birth of the National Health Service.
Within planned health systems, the means of deter
A range of approaches to priority setting exist.
Amongst these, two major characteristics can be mining need at the non-clinical level differ. Need has
singled out which have particular implications for long been conceived of as an objective concept mea
PHC—the distinction between needs-based and sureable technically by health professionals. More
demand-based approaches and the role of the indi recently the notion of perceived need has arisen.
vidual or community vis a vis the health professional. Whilst this latter notion corresponds with the prin
ciple of community participation inherent in PHC,
1.1. Demand-based approaches
planning systems based on it are unknown to us.
In almost all systems, need has been categonsed,
Demand-based approaches rest on the assumption
that the operation of a market for the production and first and foremost, by epidemiological assessment.
exchange of health care, is both the most efficient, This approach fails to take into account two im
and the most responsive to individual desires. In portant questions: first, whether knowledge of the
practice such assumptions are extremely questionable importance of various medically-defined conditions
for a number of reasons, which are well-rehearsed in of ill-health helps in planning services aimed to
the health economics literature [7], The most serious positively improve health. Second, whether the most
charges against such a market-based process as a important features of planning strategy, actually vary
means of determining priorities within the context of with different epidemiological profiles. For the mo
PHC, are that: first, the relationship .between the ment however, we will limit discussion to whether or
physician, the individual and the insurer (where not a workable and theoretically sound model of
applicable) is such that in practice the individual has disease-based assessment, is available to the health
little freedom of choice; second, despite the existence planner. This approach may seem to be logically
of insurance schemes, market-based systems are inconsistent, given the questions we have just posed.
grossly inequitable, showing great variation in the However, this type of assessment has become so
accessibility (both physical and financial) of health ubiquitous, and is so widely assumed useful, that the
care to individuals; and thirdly that a free market first task is to look critically at its assumptions and
system is historically predicated on an assumption of limitations. Historically, for most systems the most
providing health care to individuals, rather than to basic measure, apparently attractive in its ease of use,
communities, and as such runs contrary to concepts is the mortality rate, and for planning systems this
of community health and community participation. remains the major criterion of need.
The most immediately obvious drawback to this
(It can be argued that communities exist in the form
of subscribers to particular insurance schemes, but use of mortality rates is that it disregards non-fatal
such a concept of a community, based largely on illness episodes which may be self-limiting but pain
income and with no joint mechanism for decision ful, disabling, or chronic but non-fatal. Such episodes
making holds no similarity to that of the Alma-Ata in fact constitute a major part of the work of health
services. Responses to this have varied including the
notion of community.)
The rejection of the market as the means of argument that as a general measure of community
allocating resources is widespread, and indeed even need, mortality rates are an adequate reflection of
countries such as the U.S.A, which are avowedly free both fatal and non-fatal morbidity (this view is an
market, recognise the need for safety-nets such as assumption of the U.K. general resource allocation
Medicare and Medicaid to ameliorate the worst model RAWP (81) and including attempts to supple
excesses and inequities. In place of the market, plan ment mortality measures with morbidity measures.
ning systems have been developed to allocate re But qualitatively morbidity and mortality are very
sources, and hence set priorities, on criteria other different. Mortality rates reflect absolute states
(whether death occurs from measles or a car-accident,
than demand.
the final result is apparently identical), whereas mor
1.2. Need-based approaches
bidity covers a spectrum of states of ill-health, each
Proponents of planning argue that health care is so with differing characteristics, and not simply com
basic that it cannot be regarded as an exchangeable parable either between themselves, or with mortality
commodity available to the highest bidder, but that rates.
Other criticisms of mortality,'morbidity, arise from
its distribution should be based on need, with re
sources allocated accordingly through a rational the biases inherent in the manner in which such
planning system. Early centralist planning systems in information is routinely collected—through service-
recognition of the need for intersectoral approaches
to the promotion of health, and a broad concept of
health.
The paper is in three sections. First the broad
approaches to priority setting are described. Second,
the paper analyses in more detail economic appraisal,
used in priority-setting, and argues that its underlying
characteristics are such that it is extremely difficult to
use it in a manner consistent with comprehensive
PHC; and lastly the paper suggests a series of issues
in need of wider consideration.
Priority setting and economic appraisal
based returns. Such biases include the translation of
individually perceived needs into professionally de
termined morbidity, and the relationship between
such rates, and the distribution of services. Such
biases are particularly acute in developing countries
with uneven and sparse distribution of services. Fur
thermore none of the procedures for use of mortality/
morbidity rates, take into account the problem that
the use of rather crude measures of rates of ill-health
as observed by the health service, logically serve only
as a data-base for arranging to tackle medically,
those specific conditions of ill-health. This has very
little to do with planning to improve the health status
of a population. In fact it would be conceptually
helpful if we can cease to even try to claim any links
between these two approaches.
In order to unravel such diversity and to explore
the possibilities of non-epidemiologically determined
need, a more basic question about the nature of
health needs answering. What is the view of health
implicit in PHC and how does this relate to that held
by economists and other health professionals? Econ
omists are fond of viewing health (or health care) as
either an investment good or a consumption good. As
the former, health is regarded as an investment in
human capital. A sick person is potentially less
productive than his/her healthy counterpart. Such a
perspective may appear to the health sector, com
peting for resources with other sectors, as an attrac
tive way of making the case for health respectable to
central resource allocating ministries motivated by
economic growth objectives. It is however difficult to
sustain such a view of health as its sole rationale.
Such a view would logically imply priorities for
health care set in such a way that it was not provided
for the elderly or the unemployed, and that in
family-centred economies where workers’ marginal
productivity may be low and where increased levels
of health may not lead to greater productivity, it was
concentrated in urban industrial complexes. Whilst
this scenario may in fact reflect the distribution of
resources in many countries, it is a scenario that few
would, publicly at least, see as desirable, and is clearly
counter to the principles of PHC—in particular
through its implications for equity. A broader variant
on this theme regards health not as an economic
investment but as a social investment. In such cases,
health improvements in certain areas may be seen as
a way of reducing social tensions caused by ill-health
at the family or at the community level (e.g. through
reductions in alcoholism).
Both of these investment orientated approaches
despite the difficulties identified, may through their
apparent objectivity, appear attractive as the basis for
priority setting. But this begs the question, who
makes the value judgements about distribution of
the fruits of additional productivity, and priorities in
social problems? Furthermore, and in some ways yet
more problematic, the resulting health policies will
not (unless great effort is deliberately made) leave
overt the value judgements made. This effectively
removes the policies themselves from the sphere in
which they are properly accessible to public scrutiny.
The third view of health regards it, not as a means
to an end, but as an end in itself, a personal and social
objective, even a right. Priority-setting should then
921
become an exercise to investigate what population
groups require the greatest resources to aid their
struggle for health. Few attempts have been made
to develop a national procedure to implement this
equity-based approach. However valuable efforts
made in this direction in Zimbabwe have been docu
mented [9]. Most usually, the groups are singled out
with no overt justification. A common example is
the treatment as a priority, of mothers (not women)
and children. This particular priority is universally
assumed, and we can find no reference to work
actually arguing the case for or against it. It is there
fore unclear as to whether the judgement reflects
an investment oriented view (the workforce of the
future); a reflection of social prioritisation; or a
medical judgement as to population groups con
sidered most at risk from conditions which, tech
nically speaking, are preventable. Almost equally as
common, at least for less developed countries, is the
singling out of rural communities before urban ones,
many of which are large, desperately poor, and
totally lacking a health care infrastructure. The ratio
nale for this, falls somewhere on the spectrum be
tween political bias and sheer short-sightedness
(those who won’t and those who can’t, see the levels
of need and deprivation in slums and shanty-towns).
1.3. Priority setting planning techniques
A planning methodology on the epidemiological
model would be expected to amass information about
current and future health problems, their effects on
individuals and communities, along with costs of
intervention, and on this basis, set priorities that
would maximise social welfare (or minimise negative
social effects).
Priority-setting techniques have been devised to
put together all the above elements. In 1980, for
example, at a regional UNICEF sponsored workshop
on PHC for Southern Africa, country participants
were asked to rank health problems by categories as
shown in Table 1.
This technique, though including more social vari
ables, is similar to that of the first stage of Walsh and
Warren’s approach [3], and aims at producing a
priority list of diseases, through a combination of
technical expertise (ranking of diseases by relevant
professionals) and political judgement (weighting
either quantitatively or qualitatively the different
criteria to'produce a single composite priority list).
Other techniques have been employed to arrive at
ranked problem or disease lists, including manage
ment techniques, such as Delphi, that aim to reach
consensus amongst individuals and in particular
health professionals with differing initial perceptions.
Others include more structured quantitative tech
niques, based on aggregating performance against
pre-determined criteria, using arithmetic weights [11].
Alongside techniques which aim at categorising
need, are economic techniques concerned with the
costs of intervention. Concern about the costs of
intervention in medical decision-making is relatively
recent. For example, the path-breaking ‘Effectiveness
and efficiency in health services’ [12] by Cochrane,
an epidemiologist concerned about the allocation of
resources into effective, or untested activities, was
only published in 1972. The combination of measures
922
Axdrev, Green and Carol Barker
Table 1. Ranking of disease groups by different factors
Priority
ranking
In-patient
morbidity
Family
disruption
Economic
consequences
I.
Alcoholism
Psychiatric
disorders
Skin diseases
including leprosy
TB
Alcoholism
TB
4
Enteric diseases
Complication of
pregnancy
Respiratory
diseases
TB
Trauma
5.
Malnutrition
STD
Polio
6.
Measles
Skin diseases
including leprosy
3.
Bilharzia
Leprosy
Public and
potential
demand
Malaria
Complication
of pregnancy
Alcoholism
Complication
of pregnancy
Technical
feasibility
of solution
Social
consequences
Suffering
and
disability
Measles
Leprosy
Alcoholism
Leprosy
Polio
Polio
STD
Eye disease
Malnutrition
Psychiatric
disorders
TB
TB
TB
Water-borne disease
(enteric)
Trauma
Both in terms of cost of treatment, and loss of production.
Source. Swaziland Country Report for rpresentation
----------- 1 to the Nampula Primary Health Ca:re Workshop—Nampula. April 1980. quoted (10).
of successful intervention against medically defined the ability to heavily influence, if
not determine.
need (hence concepts of effectiveness) and cost (hence priorities.
concepts of efficiency) form the basis of economic
appraisal.
For these reasons, such approaches to pnority setting
Economic appraisal has over the last decade, be run counter to the philosophy of PHC. and in
come viewed increasingly as an attractive framework particular to its wider, holistic concept of health, its
for incorporating the needs-based variants described recognition of the need for broader approaches to
above, and hence as a valuable, if not essential, means health provision that reduce boundaries both be
of assisting in determining priorities, and has been tween agencies, and within agencies between vertical
heavily adopted by the epidemiological school of programmes, and most importantly the need to
planning. Closer examination of the techniques of place the responsibility for determination of priorities
economic appraisal however, demonstrate some of the firmly in the hands of the communities.
The next section sets out briefly a critique of the
dangers of indiscriminate use of such techniques.
The most well-known attempt to formalise such methodology of economic appraisal as currently used
techniques into a system within developing countries as a technique for priority setting, and as exemplified
was the PAHO-CENDES planning system [131 by the select!vist school.
which was highly structured, extremely quantified
and based on concepts of economic appraisal. Its
2. ECONOMIC APPRAISAL IN PRIORITY SETTING
development in the sixties involved a massive in
As a result of the apparent inexorable logic con
vestment in and commitment to the system itself,
relying as it did on large numbers of trained man tained in each of a series of steps, techniques of
power and extensive information. As a cohesive economic appraisal are extremely seductive. Various
methodology PAHO-CENDES collapsed, in part as techniques exist (see Carrin [14] for review of main
a result of the unrealistic resource requirements of methods), but the two suggested most widely are cost
operating the system, in part with the realisation that benefit and cost effectiveness analysis. The technique
such comprehensive planning is unworkable. More of cost benefit analysis (CBA) was adopted for the
recently however, less technically ambitious attempts public sector from the fields of industrial and com
to introduce “rationing by rationality’ have been mercial appraisal, with adaptation of discounted
introduced, usually also based on a variant of eco cash flow techniques to suit the broader social objec
nomic appraisal. The most well-known of these, and tives (hence social CBA). Essentially the technique
the subject of this journal issue is selective primary identifies measures in money terms and compares the
health care, as proposed by Walsh and Warren. Their advantages/benefits and disadvantages/costs to deter
approach suggests a simple criterion for prioritisation mine the relative worth/cost benefit ratio of different
cost per life saved, and is a prime example of options, including, ideally, that of doing nothing, i.e.
inappropriate use of economic appraisal as discussed maintaining the status quo.
The transfer of such techniques from the private
further below.
All the above such approaches are deceptively sector to the public sector, is seemingly easiest in
attractive, employing a blend of rational analysis to areas such as public transport or nationalised indus
demonstrate their technical objectivity and neutrality, tries, where the most obvious benefits are increased
and quantified data to show their roots in reality. productivity. In such fields CBA flourishes. However
Unfortunately their present use is inconsistent with in sectors or more specifically projects, which have
outcomes that are not primarily or uniquely related
the tenets of PHC for two main reasons:
to productivity gains, and are hence less easy to value
(a) They reinforce a medical model of health, in money terms, an alternative economic appraisal
through their emphasis on disease-based outcome technique may be suggested. Cost-effectiveness ana
measures, and leading logically to a uertical, disease lysis (CEA) accepts the difficulty of money valuation
based, programme approach.
of outputs such as health improvement, and instead
(b) They provide the planning bureaucracy with compares the cost per outcome of different inter-
Priority setting and economic appraisal
923
rare. The commonest use of CBA is at the single
project level, where a well-defined relationship be
tween inputs and output apparently exists.
2.1.2. Identify costs and benefits. The second step in
an appraisal consists of the identification of the
specific costs and benefits that are associated with the
intervention. The major difficulty at this step lies in
2.1. Cost benefit analysis
the drawing of boundaries around the problem. Any
Figure 1 sets out the main steps in a CBA.
2.1.1. Identify options for appraisal. The first step in intervention creates a series of ripples, with those
a CBA is the identification of the options themselves. closest to the intervention being stronger. The cut-off
In theory, all possible alternative options should be point, as to which effects are included, may have
examined as competing demands for resources. In implications for the appraisal. In theory all effects
practice this is palpably impossible, and judgements should be included but in practice a judgement is
have to be made to exclude the majority of possi required as to which effects are so minimal as to not
bilities. Some of these exclusions are made on affect the appraisal.
A separate, but related issue, is that of ‘whose costs
grounds of political judgement, or technical fea
sibility, whilst others may be excluded on the basis of and benefits’. Costs can be classified as falling on the
crude ‘back of the envelope’ appraisals. Clearly how initiating agency, other agencies and the public. In
ever the process of determining which options are theory, the distinguishing feature between a public
appraised carries with it tremendous potential for sector social CBA and a private sector appraisal is
influencing the final outcome—both by excluding that the former is concerned with the effects to the
possibly viable alternatives, and by, in the final society as a whole, whilst the latter is only concerned
shortlist, presenting a ‘good’ project next to a clearly with the effects on the firm itself. Thus a private
sector appraisal would not be concerned with distri
unacceptable or ‘bad’ project.
Appraisals can in theory be carried out at any butional issues (e.g. who bought the product, or the
level—from determining at the macro level the ideal effects on income distribution of their workers’
mix between allocation of resources to health services wages), or with costs arising from the production that
and other contenders; to determining at the micro fell on others (e.g. pollution), whilst a public sector
level, choice of techniques such as whether disposable appraisal should. Similarly, within the health sector,
syringes are better than re-usable ones. In practice a private health service appraisal would concern itself
however the choice of level for appraisal is con only with those costs that fell on itself, whereas a
strained by a methodological need to identify the public health service appraisal should examine the
specific costs and benefits associated with the inter costs to both the health service and the community.
vention. The broader an intervention, the harder it The degree to which such social costs and benefits, as
becomes to identify such consequences. The extreme, opposed to private costs and benefits are included,
of determining resource allocation between sectors at can dramatically change the appraisal. Such social
the national level, or within the health sector of costs either to the user or other agencies may be
resources for hospitals rather than primary health identified at the early stages of an appraisal. In
care services, are as a result of their multiple out practice, however it is common to find appraisals that
comes, so difficult to measure that sectoral appraisals either ignore them, or identify them but fail to value
are virtually unknown, and programme appraisals them. Two reasons can be discerned for this. First,
methodologically it can be extremely difficult to
identify and then value such effects. Second, the
budgetary systems of many countries reinforce a
predominantly single agency, or private firm outlook.
Identify options for appraisal
Within the U.K., for example, the transfer of the care
of suitable patients from long-stay hospital to domi
ciliary settings is a stated public policy. The impli
Identify costs and benefits
cations of such a policy on agency costs however are
for each option
that health service hospital costs may drop, but
community based costs of both the health service,
other agencies and the community itself will rise.
Value costs and benefits
Whilst overall it may be argued that the balance of
social benefits over social costs is greater under such
a policy, in practice the implementation in the U.K.
has not gone smoothly due in part to rigid institu
Discount costs and benefits
tional barriers between sectors. In such an environ
ment, where budgetary transfers between agencies are
difficult, incorporation of other agency costs into an
Compare costs and benefits
appraisal may be resisted, in the knowledge that no
using sensitivity analysis
compensatory transfer is likely.
The above describes the situation presently per
taining, partly as a result of budgetary systems in
Apply decision criteria
many countries. The integration of budgets, intro
duction of compensatory transfers or creation of
special inter-agency budgets could overcome some
Fig. I
ventions (e.g. the cost per life saved). Though such an
approach sidesteps some of the problems of valuing
benefits, it shares with CBA many other problems
and is inherently less powerful as a priority setting
tool. These techniques will be examined in turn.
Andrew Green and Carol Barker
924
of the reluctance to include third party costs in that are not. are left to be considered alongside the
appraisals, and the economist has an important role •valued’ effects. Whilst such an approach is clearly
both accurate and honest, it considerably emasculates
to play in helping to design such systems.
A more serious, and methodologically more com the technique and leaves open the question of how
plex, concern, however, relates to the types of benefits such intangibles are incorporated into the decision
and costs chosen. Table 2 sets out the usual categories criteria.
There are, at the valuation stage, a variety of
of costs and benefits that a health project may
consider. Such costs and benefits are firmly linked possibilities for building into the equation, other
to an epidemiological input-output model. Indeed concerns and which demonstrate the reliance on
this mirrors a wider concern in health planning over value judgements. Outside the health sector, ‘shadow
the last decade with effectiveness and efficiency—the prices’ are commonly used to correct for apparent
desire to relate services to outcomes, as measured in distortions in the market which lead to the level of
medical terms, through mortality/morbidity changes. prices and wages failing to reflect the real costs to the
Wider benefits of, for example participation in the economy. Concern about the distributional effects
process of health care planning and delivery are of projects, particularly those considered to be di
rectly productive, may be built in to allow national
rarely considered.
objectives concerning equity or regional growth to be
2.1.3. Value costs and benefits. Once costs and
benefits have been identified, they need to be valued considered. Such corrections of the market value of
in money terms, in order for direct comparisons to be costs and benefits demonstrate the potential ability of
made. It is at this stage that most methodological project appraisal to respond to social/political value
judgements. Failure to adopt such corrective mech
difficulties lie and where criticism is most vocal.
There are two types of difficulty with valuing costs anism does not of course imply greater objectivity,
and benefits. Firstly, information systems are rarely but acceptance of the values inherent in existing
routinely geared to providing relevant information, distortions.
2.1.4. Discounting. Having identified and valued
e.g. on consumer travel costs, and though some of
this information is obtainable through other methods costs and benefits, the next step is to discount them.
such as surveys, the cost of providing the information In a typical project, the costs and benefits will occur
itself may be significant, particularly where informa over a period of time. The technique of discounting
tion management skills are scarce. More important allows the stream of costs and benefits to be added
though are the difficulties associated with valuing the by applying a differential weighting to each year to
benefits (other than productivity gain) of saving life, reflect a view of the future. Typically a discount rate
and reducing pain and suffering. Various methods of between 5 and 12% may be chosen, which implies
exist [15], ranging from analysis of life insurance that a benefit of £100 in year 1 is equivalent to (at
premiums, to analysis of peoples’ behaviour in, for a discount rate of 10%) a benefit of £110 in year 2
example, the trade-off between lower aircraft ticket or £121 in year 3. The choice of the public sector
prices and the associated greater risk of aircraft discount rate is often made by a central ministry, and
accidents. Ultimately however such methods are reflects various linked factors including the current
based, however ingenious the method, on measuring interest rate and society’s view of investment as
the value individuals or society place on such out opposed to present consumption. The choice of dis
comes. Whose values are to be measured and how count rate can easily change the nature of an
such values are to be weighted are essentially political appraisal—a high discount rate favouring projects
questions, for which the economist has no expertise with early benefits compared to costs. Table 3 demon
strates the effect of discount rates of 5 and 10% on
to offer.
One device common to appraisals where such a hypothetical stream of valued benefits and costs.
Whilst there is clearly a valid argument for the use
difficulties are met, is the introduction of unquantifiable intangibles. In such appraisals, those costs and of a discount rate to reflect the opportunity cost of
benefits that are measurable, are quantified and those capital, it should be noted that such calculations are
Tabic 2. Costs and benefits commonly identified in economic appraisal of a health project
Benefits
Costs
To the individualifamily;community
Decrease in
Mortality
Morbidity’
rates
rates
Leading to
Increase in productivity
Loss of production during treatment
Reduction in pain, grief and suffering
Treatment pain, grief and suffering
Reduction in caring costs
to services, environmental
Increase in caring costs, travel costs to services
Creation of employment
To agencies
Reduction in future costs
Service provision costs
•N.B. Morbidity contrasts with mortality in that mortality is considered a disbenefit in itself,
whereas morbidity is a disbenefit through its secondary effects (some of which are
secondary effects of mortality also).
Priority setting and economic appraisal
925
Table 3. Discount example
Year 0
0% discount rate
Benfits
Costs
0
100
Year 1
Year 2
Year 3
Year 4
Totals
12
40
50
100
50
~50
135
10
287
260
125
27
-100
-38
50
-10
0
-100
11
-48
36
-45
86
-43
III
-8
244
-244
Net (benefits - costs)
10% discount rate
Benefits
Costs
-100
-37
-9
43
103
0
0
-100
II
-45
33
-41
92
-7
21'1
-231
Net (benefits — costs)
-100
-34
-8
75
-38
~37
85
— 20
Net (benefits — costs)
5% discount rate
Benefits
Costs
often themselves based on the operations of a dis There is often, in such situations, a severe and
torted money market. Furthermore whilst it is dangerous temptation to ignore intangibles, concen
equally clear that as individuals we view the future as trating on the quantified and valued effects which
of less importance than the present (partly as a result decision criteria can be applied.
of uncertainty), there is an equally valid argument
that a social view, as exercised in a public sector 2.2. Cost-effectiveness analysis
appraisal should defend the interests of future popu
CEA is at first sight an attractive alternative
lations, and should deliberately take a long term to CBA. Where difficulties exist in attaching money
view.
values to benefits, CEA may be used which measures
The choice of discount rate therefore cannot be the cost per outcome, and allows comparison be
seen as being a technical choice, but one of consider tween projects by seeking interventions with the
able political importance.
lowest cost per outcome. Whilst this clearly circum
2.1.5. Appraisal. The last stage in an appraisal vents some of the methodological difficulties of CBA,
brings together the costs and benefits by comparing it introduces its own set of problems.
their present values (values after discounting). The
The major difficulty it faces stems from the need
appraisal in a CBA is of two kinds. Firstly, an to have a single outcome measure, which is common
appraisal of a project on its own can indicate to those interventions being compared. For it to
whether, compared with the ever existent option of measure the effectiveness of a service the outcome
doing nothing, it is worth carrying out. Secondly, it should be in terms of health objectives; if not, the
should be compared to all other possible alternatives analysis is reduced to measuring efficiency in service
to determine whether it is the best use of resources. provision alone. The simplest outcome measure used
Even at this stage however, ambiguity arises from is deaths averted, which can be made more soph
at least three sources.
isticated by measuring life-years saved. (Which of
Firstly the appraisal may be affected by the choice these is chosen depends on such normative assump
of appraisal criteria. Methodological uncertainty may tions as to whether the life of a 60-year-old is equally
exist as to whether to view certain consequences as important to that of a 5-year-old or how the life of
costs or benefits [16]. A reduction in future health a 2-year-old with measles and leukaemia is compared
service costs for example may be regarded as a to the life of a 2-year-old with measles alone.) How
benefit, or as a negative cost. The choice of appraisal ever comparison, using such indicators, between
criteria [e.g. net present value (the difference between death from different causes fails to distinguish be
benefits and costs) or the benefit to cost ratio] can, in tween the different processes of dying (cancer versus
such instances, affect an appraisal result.
road accidents for example). Many interventions
Furthermore, one of the comparative problems within the health field are of course not life-saving
between projects arises through the scale of a project. but concerned with alleviating pain and discomfort,
A small scale project may have a higher benefit-.cost and returning someone to a ‘normal’ state of health
ratio than a larger project, but because of its scale, a as soon as possible. Measures such as days of sick
lower net present value. The choice of decision crite ness averted or working days lost may be used to
ria is clearly important.
measure this. However such measures are qualitat
Secondly, attempts to scale up small projects to ively different from those related to death (as opposed
make them of equivalent size to larger projects is to dying) in that whilst death is absolute, different
fraught with dangers of determining average costs illnesses are viewed qualitatively differently (flu
which may alter with the scale of the project.
versus schizophrenia for example).
The third and major difficulty lies in comparison
Attempts have been made to provide composite
between valued benefits and costs on which appraisal measures, in ordinal if not cardinal terms, of different
criteria can be levied, and intangibles. The very mixes of pain, death and disability. These include
difficulties that resulted in a decision not to value such measures such as healthy days of life lost [17]
intangibles raises similar difficulties in making com and more recently the Quality Adjusted Life Years
parisons both between different intangibles them (QUALYS) [18]. Amongst these measures two
selves, and between intangibles and ‘valued’ effects. approaches can be discerned; firstly an attempt to set
926
Andrew Green and Carol Barker
up medically based indices that provide standards aware of the difficulties in applying the results of such
against which specific illness can be compared (e.g. studies within the field of priority setting. In particu
can the patient feed him/herself). Whilst such an lar they are aware of the following general problems
approach is attractive in its apparent objectivity, it that the preceding has highlighted:
provides no means of comparing between two ill
(a) That appraisal techniques, tend to reinforce a
nesses with different ratings and different incidences.
medical model of health through their emphasis
The second set of approaches such as QUALYS
on disease, and their methodological diffi
try to face up to such value judgements by basing
culties of comparing multi-input, multi-output
measurements of the different qualities of life associ
programmes; hence they are often project
ated with different states of illness, on community
rather than programme orientated, and where
assessments, and hence offer the greatest hope for
they are programme orientated they tend to
community involvement in such value judgements.
appraise
vertical programmes.
However, it is still methodologically in its infancy,
(b) Economic appraisal requires value judgements
and more importantly, through its reliance on mor
to be made about:
tality rates and its disease-specific nature, is still based
—
national objectives;
on a medical model of health. There are also im
—which groups, if any. are to be favoured (e.g.
portant questions of value judgement inherent in the
regional, income, disease, age);
methodology—most importantly that of who makes
—the future compared to the present;
the assessments.
—whose costs/bencfils are to be included;
The present state of the art however, both in
—weighting to be given to tangible compared
developing and more developed countries, is that
to intangible effects.
CEAs are almost invariably based on simple outcome
Frequently
such value judgements arc made
measures. Such measures are either highly restrictive,
without the active participation of commu
or open to misuse. This stems from the need to
nities, either because of the difficulties of so
compare interventions which result in similar out
doing, or because of a mistaken belief that they
comes. This can be a powerful tool at the level of
are technical rather than political decisions.
determining the most efficient way of dealing with a
(c) The process of economic appraisal is open to
specified health problem, but as such is essentially
misuse as a ‘black box’ technique, by providing
concerned with questions of ‘how’ not questions of
the planning bureaucracy with the means to
'what'—process not prioritisation. Alternatively, as
heavily influence, if not determine, priorities,
in the Welsh and Warren approach, comparisons are
through its control of the mechanism, e.g.
made between programmes with different outcomes,
through initial judgements required as to which
and as such blur potential differences in the type of
areas appraisal should focus on, and its par
outcome.
ameters.
A further problem exists however, in that the need
for simple outcome measures forces consideration of These potential characteristics run counter to the
disease strategies rather than health strategies. How philosophy of primary health care and in particular
ever as Unger and Killingworth [6], amongst others, its broad concept of health, its emphasis on multi
point out. the effect of a reduction in disease-specific sectoral activities, and its clear requirement for com
mortality, as a result of medical interventions, on the munity involvement in priority setting.
The above has deliberately used the word ‘poten
health of a community is far from clear, particularly
in poverty situations where deaths averted from one tial’. Most economists would argue that they are
disease, are replaced by another. Whilst epidemio professionals carrying out a technique which is avail
logists and economists concentrate on such medical able for use by planners or the community alike,
disease based input-output analyses, the wider objec and into which any set of value judgements can
tives of health improvement are likely to be over be inserted. Furthermore they would argue that
looked. This is one of the fundamental criticisms of appraisal techniques are not in themselves decisionthe selective PHC approach, but can be seen in many making techniques, but aids to decision-making.
CEAs. The direction of the relationship between the Whilst strictly true, paradoxically in practice those
medical model of health and appraisal techniques, is appraisals which deliberately attempt to set out the
unclear and can only be speculated on. It is likely assumptions made, are often the least accessible to
however that the emergence of economic appraisal the non-economist planner, politician or community.
into the health field, was at a time of strong medical If such appraisal techniques are to be reoriented
dominance, and for economics to gain a foot-hold, towards PHC, they must be made more accessible,
acceptance of such an approach was inevitable. Since and more relevant non-medical measures of output
then however, the apparent methodological need in devised. The final section re-examines the process of
appraisal for simple input-output relationships as priority-setting and looks at possible roles for eco
conveniently provided by the medical model has nomic appraisal within it.
provided a false synergy between them. Lastly, CEA
shares with CBA a number of similar considerations
3. PRIORITY SETTING AS A PROCESS
of value judgements as outlined earlier.
The setting of priorities is no new phenomenon
2.3. Economic appraisal and priority setting
being as it is a necessary consequence of scarcity
The preceding has outlined briefly the approaches of resources. However the last 20 years has seen
of CBA and CEA appraisal techniques. Most econo a growing formalisation of the process as part of a
mists involved in carrying out appraisals are well wider interest in and development of planning sys-
•W.-
Priority setting and economic appraisal
terns and an extension of the scope and scale of
services particularly in the post-independence period
for many underdeveloped countries. Early formal
plans were often heavily norm-based and institu
tionally-focused with capital developments providing
a focal point for growth. Increasing interest in
the effectiveness of services (resulting from a mixture
of the need to convince donors, and the growing
strength and synergy between medical epidemiology
and economics), led to public emphasis on preventive
services and was reflected in moves to set plan
objectives in terms of health status improvement (or
more accurately reduction in incidence of specific
disease), rather than service targets per se. However
despite public emphasis on non-hospital activities,
the major proportion of resources continued to be
allocated in that direction. Two main reasons can be
discerned for this: firstly the late sixties was a period
of growth in Ministry of Health budgets for many
developing countries, allowing the parallel growth
of hospital and non-hospital activities. However the
difference in size of the resource base from which
each started and the greater capacity for imple
mentation within the hospital sector meant that
hospitals not only continued to grow, but to increase
the overall proportion of resources. Secondly, where
there was strong competition for resources, the size of
the hospital sector, coupled with its political appeal,
allowed ‘rational priority setting’ as formally set out
in plan documents to be overturned.
The inability of epidemiologically determined
plans stressing preventive activities and in particular
single disease strategies to be fully implemented,
should be interpreted not simply as the result of a
shortage of resources, but rather as a demonstration
that priority setting is not and cannot be a ‘rational
objective’ process, but is ultimately concerned with
power relations and value judgements. This can be
further demonstrated by the observation that plans
rarely deal with reallocation of existing resources—
however inefficient or ineffective they are, but with
allocation of additional resources—a tacit recog
nition of power structures. Such an observance of
the status quo was an explicit part of the PAHO-
CENDES method. Yet even this degree of sophisti
cation is denied within the selective approach to
PHC, which is essentially ahistorical, forgetting that
anything existed before.
The resources that were allocated to preventive
activities in the sixties and seventies were largely
channelled into single disease campaigns (TB, small
pox, malaria, schistosomiasis etc.), both resulting
from, and reinforcing, the epidemiological model of
priority setting.
The resource constraints arising from the recession
of the late seventies, concentrated interest in planning
and priority setting and added to the epidemiolog
ical model, stronger economic perspective and inter
est in economic techniques, together with increased
demands on information about health or illness and
service provision. Shortages of economic, epidemio
logical and statistical skills inevitably resulted in their
concentration at ministry level and greater potential
for top-down medical technocratic planning.
However other trends were running counter to
this. First, realisation of links between poverty and
health, suggested that broader strategies were re
quired if health (albeit defined in medical terms) was
to be improved. Second, many countries concerned at
their slow progress in implementing developments in
the rural sector saw a way forward in decentralis
ation. Third, and in part, connected with decentral
isation were moves in the health sector towards
community participation, both as a resource pro
vider, but more importantly as an end in itself.
These strands culminated for the health sector in
the Alma-Ata Declaration and commitment by signa
tories to PHC involving a broader concept of health,
recognition of the need for an integrated multi sec
toral approach, equity and community participation
as a right, and necessity.
The implications of PHC for the process of
priority-setting as compared to that prevailing are
major, and are demonstrated in Fig. 2.
The tensions set up in many countries by the
concept of PHC are understandable when viewed in
this context, for PHC calls not so much for medical
change as for social change, with major shifts in
Econ./epidem. approach
PHC
Communities participate in proactive
process as a right, and to the end
of positive production of health.
Communities participate in a
reactive process to release
resources.
Recognition of links between poverty
and health implies need for ability
to switch resources between sectors.
Medical model reinforces sectoral
boundaries.
Broad concept of health incorporating
not only physiological concerns, but
relationship to society.
Concept of health as measured by
inverse relationship to disease
episodes.
Equity reflecting both access to
health care and other services, and
social structure.
Equity reflecting access and
utilisation of services.
Fig. 2
927
928
Andrew Green and Carol Barker
power structures. Responses to these tensions have
varied from analyses that PHC is unachievable out
side a socialist framework [19], to attempts to dress
up previous medical models and call them PHC—
as Walsh and Warren did. This latter approach is'
clearly attractive to many health professionals as a
means of accommodating their own technocratic
training, and side stepping the fundamental question
of empowering communities. These tensions, though
present in all aspects of a PHC strategy from its
development to its implementation, are perhaps
most polarised in the area of priority setting. It is
paradoxical therefore that little analysis and research
has gone into the process and the role of professionals
and their techniques vis a vis the community. Docu
ments outlining WHO’s MPNHD [20] for example
are remarkably vague in their description of this
process and it is assumed that professionals will
continue with a similar role to that occupied in the
pre-PHC days of medical epidemiology.
Since the Alma-Ata Declaration, interest in com
munity participation has largely focused on training
of CHWs (by professionals). However participation
of communities is absolutely constrained by existing
and prevailing structures of priority setting. Atten
tion needs to be given to the interface between
communities and professionals, and the use of tech
niques such as economic appraisal.
To argue the preceding however is not to argue the
disposal of professionals, bur rather to suggest that
in developing PHC strategies explicit recognition is
required that priority setting concerns value judge
ments. As such it is the province of the communities
and politicians and cannot be left in the hands of
planners and their superficially attractive techniques.
A shift in the role of professionals in relation to
communities is required; with the general principle of
accountability by professionals to communities being
paramount. However it must be recognised that
different types of priority decisions exist with the
nature of the professional’s role altering accordingly.
The following sets out some preliminary thoughts as
to the nature of such decisions, and hence the charac
teristics of the role of the professional, within a PHC
context.
3.1. National level
Al lhe national level, allocation of resources needs
to respond to three criteria: equity, need-based allo
cation. health before health care.
3.1.1. Equity. Determination of equity is a socio
political judgement. However inasmuch as a country
has adopted the Alma-Ata concepts of PHC, it has
already made a formal political decision to promote
equity, aiming for equal distribution of access to
services on the basis of need.
Working against this effort will be, of course, the
practical consideration of existing resource distribu
tion and the political strength of those presently
enjoying a large share of the cake.
There has been pioneering work done [9] in some
countries to identify existing patterns of resource
allocation; and economists have an important role
to play in this activity. However for the majority of
countries, such analyses are incomplete due in part
to both a lack of awareness of the need to evaluate
the role of, inter alia the private sector, and a lack of
appropriately categorised data.
3.1.2. Need-based allocation. Given the strong links
between poverty and health, distribution of resources
should be based, not on medical indicators, as in
traditional epidemiological models (such as RAWP)
but on social-epidemiological models that reflect
these causal links and are disaggregated on a social
rather than purely geographical basis. Identification
and measurement of relevant socio-economic indi
cators should be an important research item.
3.1.3. Health before health care. Resource allo
cation from the national level down, must recognise
lhe need for an inter-sectoral approach, and at local
levels, the necessary ability to shift resources between
sectors. Few budgetary systems allow such shifts; and
yet this ability is one of the essential prerequisites for
successful decentralisation.
If health is indeed the goal, priorities have to be
identified not only at the level of primary care, but
first, at the level of the total budget; primary care
which becomes merely another vertical programme
is an organisational phenomenon closer to selective
PHC then to that described in the Alma-Ata Declara
tion.
3.2. Local levels
At local levels, the allocative mechanism that cor
responds most closely to PHC would require control
by the community and ability to shift resources
between sectors. At this level the role of the profes
sional would be in the fields of providing information
at the request of communities, i.e. both listening to.
and discussing with, communities. Professionals need
to be able to respond to priorities from communities
being formulated either in medical status terms (e.g.
reduction in deaths from measles), or in service terms
(e.g. provision of water supplies or clinic services).
Appraisal techniques need developing that are acces
sible to communities, and that respond to their needs
rather than those of lhe lechnique.
3.3. Within the service
As we said at the beginning of this paper, however,
the epidemiological model of planning must be ques
tioned on further grounds—if we take the goals of
PHC seriously, are epidemiological values the im
portant ones for health management? Is allocation
really between diseases, many of which health ser
vices cannot cure, and many of which a national
health service strategy would safely put in the hands
of a reasonably well-trained multi-purpose health
auxiliary, provided that such a person had access
to drugs and a referral system. For the purpose of
studying techniques currently used, we have laid
aside the question of which types of criteria are
important. We would wish to argue that a real life
health manager will only concern him/herself (if left
alone to develop a rational plan) at the margins,
with specific diseases. The categories of choice which
are actually important, include: mix of manpower/
professionals; training; weights of services al the
tertiary/secondary/primary levels; amount of re
sources allocated to improvement of the community
participation process itself; emphasis on health care
infrastructure and operations, emphasis given to staff
Priority setting and economic appraisal
motivation. These are the decisions which the com
munity cannot directly address, but which the profes
sional manager, having understood the community(ies)’s demands, can incorporate into plans for a
comprehensive primary health care approach.
Once the service priorities have been identified,
there is a clear role for appraisal, and in particular
cost-effectiveness studies, to determine the optimal
means of provision. Such appraisals however, again
require a process of demystification, and must be
structured in such a way that communities and all
levels of health worker can be involved in the process.
4. CONCLUSION
The paper has argued that since Alma-Ata, two
contradictory strands have emerged within the field
of priority setting. PHC clearly recognises that prior
ities need to be set by communities, whilst the struc
tures and techniques that existed prior to Alma-Ata,
and which reinforce biases towards single disease,
medically orientated, professionally determined stra
tegies remain. Economic appraisal is gaining in pop
ularity as an ‘aid’ to priority-setting and yet its
application is often open to misuse and manipulation.
Arguments for selective PHC are couched in such
terms and are examples of the failure of PHC to
develop alternative community orientated priority
setting processes.
Acknowledgements—The authors would like to acknowl
edge valuable comments on an earlier draft by Dr Unger,
and an anonymous referee. Any errors of judgement or fact
that remain are of course their own.
REFERENCES
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Health (Edited by Robertson M.), 1979; or Sorkin A.
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8. Resource Allocation Working Party. Sharing Resources
for Health in England. HMSO, London, 1976.
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national strategy. Soc. Sci. Med. 17, 1947-1960. 1983.
10. Green A. Health, population and development. In
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lation and Development, 1980.
11. See for example Blum H. Generics for the 80s, pp.
155-160. Human Science Press, New York, 1981.
12. Cochrane A. L. Effectiveness and Efficiency, Random
Reflections on Health Services. London Nuffield Pro
vincial Hospitals Trusts, 1972.
13. For a description of the PAHO-CENDES method
see Hilleboe H. et al. Approaches to National Health
Planning. Public Health Papers No. 46, pp. 52-68.
WHO. Geneva. 1972.
14. Carrin G. Economic Evaluation of Health Care in Devel
oping Countries. Croom Helm, London, 1984.
15. For a discussion of the main methods see Mooney G.
The Valuation of Human Life. Macmillan, New York,
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appraisals see Drummond M. F. Principles of Economic
Appraisal in Health Care, pp. 59-65. Oxford Medical
Publications, OUP, 1980.
17. Ghana Health Assessment Project Team. A quantitative
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73-80, 1981.
18. Williams A. Economics of coronary artery bypass graft
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19. Navarro V. A critique of the ideological and political
positions of the Willy Brandt Report and the WHO
Alma Ata Declaration. Soc. Sci. Med. 18, 467-474,
1984.
20. Managerial Process for National Health Development :
Guiding Principles. WHO, Geneva, 1981.
L
Available online at www.sciencedirect.com
SCIENCE
DI RECT’
IheaIth policy
1*
ELSEVIER
Health Policy xxx (2006) xxx-xxx
www.elsevier.com/locate/healthpol
Primary Health Care and England: The coming
of age of Alma Ata?
Andrew Green3’*, Duncan Rossa,b, Tolib Mirzoev3
a
International Health Planning, Nuffield Centre for International Health and Development, University of Leeds, UK
b Performance Improvement and Information, East Yorkshire and Yorkshire Wolds and Coast PCTs, UK
Abstract
The Alma Ata Declaration is now 28 years old. This article uses its framework to assess the changes that have occurred in
recent years in the English health system. It summarises the health reform changes that have occurred internationally and those
in the English health system in two eras, pre- and post-1997 - when the Labour Party came to power. It concludes that linked
forces of managerialism and consumerism have had an impact on the health system which has undergone a number of structural
changes in recent years. It suggests that the original Alma Ata focus on equity is being modified by the concept of choice. The
tensions between central priorities, often reflected in targets, and local accountability and needs are explored. There appears to be
a greater interest in seeking genuine health (rather than solely health care) change, with attendant public health and partnership
policies, however the gap between policy and practice still needs to be bridged, and questions as to the appropriate locus and
leadership for health promotion activities addressed. However there have been numerous institutional changes which carry the
danger of distracting from the purpose of achieving health change, and which continue to raise questions as to the appropriateness
of a market model for health. Finally the paper argues that the PHC framework of Alma Ata remains a useful framework for
assessing health systems, but needs to be tailored to, and prioritised within, a political dynamic.
© 2006 Elsevier Ireland Ltd. All rights reserved.
Keywords: Alma Ala; Primary Health Care; Public health; Health systems
1. Introduction
Two years ago, the 25th anniversary of the Alma
Ata Declaration passed quietly. Yet for many health
systems, especially in low-income countries, Alma
Ata with its Primary Health Care (PHC) strategy was
* Corresponding author. Tel.: +44 113 343 6947;
fax: +44 113 343 6997.
E-mail address: a.t.green@leeds.ac.uk (A. Green).
influential in setting the health policy agenda during
the 1980s. In contrast, in high-income health systems,
such as the UK, the Primary Health Care strategy was
ignored as irrelevant on the presumption that primary
level services were already well-developed. Although
referred to as “the cornerstone of health services system
in the United Kingdom as well as in many countries”
[1] the interpretation of PHC as a focus on services,
ignored, as we shall argue, the wider universal princi
ples underpinning Alma Ata [2]
0168-8510/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved,
doi: 10.1016/j .healthpol .2006.02.007
HEAP-1871; No. of Pages 21
2
A. Green el al. /Health Policy xxx (2006) xxx-xxx
However by the 1990s the Alma Ata polices were
overshadowed by policy fascination with health sector
structures and reforms. Indeed in some parts of WHO,
its original sponsor, it was even regarded as an historic
process with little current relevance. Yet the agenda
set by Alma Ata is re-emerging albeit hesitantly in
key international policy organisations including WHO
[3-6].
This article assesses the current health policies and
system in England [7] against the PHC approach. It
starts by summarising the key elements of Alma Ata,
and analyses the historical shifts that have occurred
since then. It then assesses the current health system
in England using the PHC principles and concludes by
identifying future challenges.
2. The Alma Ata Declaration and subsequent
international policy developments
The Alma Ata Declaration was signed in 1978 by
health ministers at an international conference organ
ised by WHO and UNICEF [8]. It set out a strategy
for attaining Health for All which included two dis
tinct levels of thinking - an operational set of services
and a number of principles. The operational set of ser
vices at the primary level which ranged from provision
of immunisations through to adequate nutrition and
water supplies), were seen by more advanced health
systems as being already in place. The principles, on
which we focus in this article, however, can be argued
as universal and equally applicable to developed indus
trial societies as to low-income rural economies. These
principles were;
• attention to equity has to be at the heart of health
strategies both for reasons of principle and for sus
tainability;
• decisions about health care services should be made
with the involvement of communities both for rea
sons of justice and in order to ensure that services
are appropriate and acceptable;
• health strategies have to incorporate a preventive
approach alongside the more widespread curative
focus both on grounds of efficiency and appropri
ateness of approach;
• the wide determinants of health require health pro
moting strategies that are intersectoral and much
wider than the more traditional narrow medical care
focus of many health strategies;
• the inevitable shortfall between resources available
for health and the total needs of any population
reinforces the need for adoption of appropriate tech
nology in health strategies.
Implicit, particularly in the second of these, was a
principle that decisions should be made as locally as
possible, i.e. that decentralisation of decision-making
was important. This was seen as a response to bureau
cratic centralism and as such having the potential to
promote greater efficiency, and allow greater identifi
cation and response to locally determined needs. This
‘principle’ became more explicit in the late 1980s and
1990s [9].
Alma Ata had a strong influence on policy agendas
in developing country health sectors. However imple
mentation of the Primary Health Care principles was
more variable [10-12] though its influence can be seen
in common policy themes such as the development
of community health workers, and the adoption of
essential drug lists. However by the beginning of
the 1990s there was a sense of disillusion in many
low-income health systems and international agencies
at the failure to make major inroads into the poor health
status of many marginalized groups. Attention focused
on the causes of this failure and in particular the
health system structures and led to a decade in which
a, if not the, key policy focus for many developing
countries shifted from PHC to health sector reform
[13,14]. This was consistent with a wider focus, in
part ideologically driven by New Right thinking, par
ticularly in high-income countries, on reducing, or at
least changing, the role of the public sector in the area
of welfare. This policy focus was shared, and indeed
led by, a number of industrialised health systems and in particular the UK with the reforms initiated by
British Prime Minister Margaret Thatcher [15-17].
The reforms generally contained the following
elements:
• introduction of market principles of distinction
between the functions of supply and demand leading
to a purchaser-provider split;
• enhanced role for the private sector as providers of
health care, potentially purchased by public sector
commissioning authorities;
ARTICLE
A. Green et al. /Health Policy xxx (2006) xxx-xxx
• attention to approaches to prioritisation with partic
ular emphasis on economic approaches;
• financing of health care with increased interest in
individual financing of health care rather than col
lective responsibility;
• decentralisation of decision-making powers both to
lower administrative levels and to hospital institu
tions;
• introduction of private sector approaches to man
agement (including the concept of leadership, and
greater interest in incentives) in contrast with previ
ous top-down command and control lines of author
ity.
*
With the exception of decentralisation the above
reform paradigm can be contrasted with that of the
Alma Ata PHS principles. For example, financing
reforms emphasised the individual rather than commu
nity - a key aspect of PHC; efficiency rather than equity
were key drivers; and the reforms focused on the role
of the health service rather than the wider determinants
of health.
The international reform process has, in the last
5 years, shifted away from a formulaic set of com
mon elements to a more organic and context-specific
approach. This is reflected in the change in terminology
away from health sector reform to health system devel
opment. Within the structures themselves, emphasis is
placed on issues of governance or, as WHO termed
it, stewardship [18] Indeed there has appeared to be,
within WHO, a renaissance of the concepts of PHC
as symptomised by the call for a return to PHC prin
ciples by the new WHO Director-General [3] though
the degree of commitment to this has been questioned
[6,19].
The last important shift to recognise as part of the
policy development process over the last decade, has
been the increased interest in evidence-based policymaking exemplified by the focus by WHO at the recent
Mexico summit on health systems research and its role
in policy-making [20].
Whilst Alma Ata was the dominant policy influence
in the 1980s for low-income countries, this was less the
case in industrialised countries where PHS was seen
as established services. However there were various
significant initiatives within Europe and in particular
the European Health for All targets [21 ] and the Healthy
City movements [22] which were clearly influenced by
3
Box 1: Selected key dates In the
English health system
1980
1984
1990
1992
1992
1993
1997
1998
2000
2000
2002
2003
Although not officially acknowledged, Black
Report was a first attempt to highlight health
inequalities in this period
Introduction of principles of general
management to the NHS following the
Griffith's report. Contracting out services
Policy initiatives to increase utilisation of
private sector - tax relief on the premium
cost of individual private medical insurance
to people of 60+ years
Publication of "Health of the Nation" - the
first attempt to introduce public health
targets
Introduction of Patient's Charter for England
and Wales, which set out 10 rights to which
every patient was entitled
Conservative Government began NHS
Reforms with introduction of GP
fund-holding, private sector management
techniques in the NHS, greater emphasis on
health needs, health promotion and public
health
Election of Labour Government with
ideological shift towards wider determinants
of health, which resulted in various
multi-sectoral initiatives at all levels
Neighbourhood Renewal Strategyintroduction of multi-sectoral approaches at
the local level covering five sectors (health,
police, education, business and voluntary
sector)
New Local Government Act gave new
powers to Local Authorities to promote
'well-being'
Labour Government introduced new NHS
Plan targeting inequalities-reducing waiting
times, enhancing role of PHC level and
putting emphasis on health needsestablishment of PHC Trusts, etc.
Department of Health launches a new
initiative 'Shifting the Balance of Power'
which provided more commissioning power
to PCTs and the merging of District Health
Authorities to Strategic Health Authorities
with a performance management role.
Department of Health Regional offices
abolished and Regional Directors of Public
Health move to Government Offices as part
of government initiative to decentralise
public sector and put greater emphasis on
health promotion and public health
Further decentralisation establishing
Foundation Hospital Trusts
J
9
- Sw % W
4
1
A. Green et al. /Health Policy xxx (2006) xxx-xxx
2004
2004
Multisectoralism at the national level Government requirement to develop Public
Sector Agreements on cross-cutting
objectives
Government publishes Public Health White
Paper 'Choosing health' which places
greater emphasis on individual choice on
improving lifestyles behaviour
the PHC philosophy. However, as we have seen, there
was far more congruence in the 1990s between lowand high-income country health sector policies with a
shared focus on structural reforms.
We consider that the PHC principles provide a robust
framework by which to assess health systems and we
use this framework to explore the degree to which a
PHC revival is occurring in the English health system.
We start by a brief outline of the key features of the
changes to the English health systems over the last two
decades as an important contextual background to the
current structures and policies. Box 1 summarises the
key dates.
3. Primary Health Care and England - changes
since Alma Ata
3.1. History of UK reforms prior to 1997
The Alma Ata Declaration virtually coincided with
the election of the centre-right Conservative Govern
ment that was to remain in power until 1997. Following
an initial laissez-faire health policy during its first term,
elements of market reform were increasingly intro
duced into the UK health sector. These reforms were
driven by an ideological belief in the benefits of private
over state sector provision, and the power of the mar
ket to improve efficiency. They also focused on how
to increase the funding base for the health sector and
then, more importantly, how the constrained resources
available to the health sector could be more efficiently
utilised.
Although care remained free at the point of initial
access, various user charges were imposed to increase
resource generation, most controversially for prescrip
tions and eye assessments (which still remain for cer
tain groups). Efficiency was focused on, with an under-
lying belief that increased market competition would
produce this, echoing, and indeed, in part leading the
global health sector reform movement described ear
lier. A number of different policy components were
included, several proving politically contentious. Key
components included firstly the introduction of a split
between purchasing (or as it later became known, com
missioning) of health care and provision of health
care. Provider units were split from the previously
integrated local health authorities and established as
semi-autonomous hospital and community health ser
vice trusts. Services were then purchased from trusts
through contracts. A second component was a shift
in the roles of the public and private sectors with
encouragement to private agencies, including the vol
untary sector, to provide a range of services. This was
seen most directly in the incentives offered, through
tax relief, for older people to take out private health
care insurance [23]. Encouragement (such as increased
scope for private practice in the revisions of NHS
consultant’s contracts, town and country legislation
favouring private sector development, relaxing controls
over private hospitals, adjusted taxation and insurance
schemes) was given to the placing of contracts with the
private sector [24]. A third component was decentrali
sation policies ostensibly in response to concerns over
excessive, irresponsive and bureaucratic central control
(it can be argued that decentralisation also provided
a convenient means of diffusing political embarrass
ment with the NHS at the national level) with greater
power being given to lower levels in the health sector
through deconcentration. The most significant element
of this was the establishment of general practice (GP)
fund holding in the mid 1990s, in which local groups
of primary care physicians were allocated budgets to
purchase certain hospital and community services on
behalf of their patients.
Wider public health, and particularly efforts to
reduce poverty and its consequences on health, received
little direct attention by policy makers. Instead, the
so-called ‘trickle down’ effect was relied upon to
ensure that socially excluded and deprived groups
in the population benefited, indirectly, by the wealth
creation of others. Similarly, there was little inter
est in ‘health inequalities’ despite the publication of
the Black Report [25]. This report had been commis
sioned by the previous (Labour) Government in 1977,
to assess health inequalities and to make recommen-
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A. Green et al. / Health Policy xxx (2006) xxx-xxx
4
dations for action. It, and the subsequent ‘Whitehead
Report’ [26,27], demonstrated both that people from
lower socio-economic groups were less healthy and
more likely to die prematurely than those from more
affluent groups, and that the gap was widening. Black
made a number of recommendations to tackle inequali
ties, mainly through progressive tax and benefits, along
with special action zones for the most deprived areas
and excluded groups. However the new Conservative
Government rejected its findings; indeed the report
was never formally published. During the 1980s and
1990s, this inequality widened [28-30]. For example,
by the early 1990s, death rates were almost three times
higher among unskilled groups as they were for profes
sional groups comparing to two-fold difference in early
1970s; in 1999/2001, the difference between areas with
the highest and lowest life expectancy at birth was 9.5
years for boys and 6.9 years for girls [31].
The publication of ‘Health of the Nation’, in 1992
[32], was the first attempt by a British Government to
set health targets. Whilst these focused on the major
disease groups (coronary heart disease, stroke, cancer
and accidents) there was al last some recognition of
health inequalities, though no target was set and the
term ‘variations’ was preferred to ‘inequalities’.
Health promotion also received little attention by
policy-makers at this time. One exception to this was
the high profile media campaign against HIV/AIDS in
1986/1987. Although controversial at the time, with its
emphasis on a mass ‘blanket’ campaign and on pro
moting changes in personal habit through fear, it is
generally regarded now as successful in raising aware
ness [33,34]. The Health Education Council, the body
responsible for setting health education policy and
which had led this campaign, came under pressure from
the Conservative Government on their approaches to
sexual health and community development. This pol
icy difference led the Government to take more direct
control of health education policy, by abolishing the
council and setting up a new Health Education Author
ity in early 1987.
The purchaser-provider split resulted in a fragmen
tation of Health Promotion and Public Health Ser
vices. Furthermore, in the context of continual bud
get restraints, health promotion was also seen by both
purchasers and providers as an easy target for cuts.
However after the 1993 reforms, which formally estab
lished purchasing health authorities, the opportunity
5
arose for purchasing to be based on health gain giving
a potentially greater impetus to the science of ‘needs
assessment’. This became recognised as a key function
for new authorities-based on the utilitarian approach of
achieving the greatest gain to meet health needs of a
given population [35].
With a growing emphasis on both consumerism and
managerialism in health care, health boards of pur
chasing health authorities recruited lay and business
non-executive directors. The first represented a new
approach towards local\public representation and the
ethos of consumer responsiveness and listening exer
cises [36] and can be criticised for breaking the earlier
link with democratic control through local authority
representation. The second indicated a shift from pub
lic sector management towards greater private sector
management techniques.
3.2. The English health system since 1997
The striking thing about the election of the New
Labour Government in 1997 was the initial policy con
tinuity with that of the previous Conservative regime.
Whilst the ideological commitment certainly shifted to
a greater concern with equity and a reinvigoration of a
publicly funded national health service, the mechanism
continued to be one of market orientation.
The recent approach to health policy, has been
founded upon four central tenets:
• setting of defined standards for the delivery of health
services and health improvement, linked to strength
ened public accountability through regulatory mech
anisms;
• decentralisation of health management and decision
making;
• flexibility of health service delivery through the
introduction of new contractual mechanisms;
• choice exercised by patients in the quality, range and
location of care given to them.
An initial reaction against what were seen as
excesses of the market approach, led to the ending
of subsidisation of private health insurance and GP
fund-holding and the creation of primary care groups
(PCGs). However, the fundamentals of the market
approach remained; most notably through the reten
tion of the purchaser/provider split. An initial coolness
towards the private sector was replaced however by
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A. Green el al. /Health Policy xxx (2006) xxx-xxx
a belief that the private sector could drive state sector
efficiency gain by attacking the perceived constraints of
professional cartels and the introduction of more mod
ern health delivery processes. Decentralisation was
most dramatically evidenced by complete devolution
of health sector responsibility to the new administra
tions in Scotland, Wales and Northern Ireland. Since
devolved administrations were established in Scotland
and Wales, the government has also pursued greater
autonomy for the English Regions. Following pilots
in devolving economic development policies to Gov
ernment Offices in these Regions, the Government set
out an agenda to devolve various functions from 1999.
This included public health with the move of Regional
Directors of Public Health to Regional Government
Offices in 2002. This provided a new opportunity to
tackle the wider determinants of health such as eco
nomic regeneration, education and community safety
working [37,38].
Under a new health minister, and with media focus
on long waiting times and health care quality, the Gov
ernment launched its NHS Plan in 2000 [39]. This
included pledges to boost NHS funding to tackle wait
ing times, give greater weight to the primary care
level through the conversion of Primary Care Groups
(PCGs) to Trusts (the latter with greater authority), a
plan to tackle health inequalities and ‘codification’ of
service and health improvement targets into the Plan
ning and Priorities framework. In England, Primary
Care Trusts were established covering populations of
around 150,000 people. These now control 75% of
total state health care resources, with a broad remit to
improve the health of their population, purchase hos
pital services and provide primary care services. In
2002 former district health authorities were merged to
form ‘strategic health authorities’ covering populations
of 1.3-4 million and with a performance management
function for both primary and hospital care trusts. The
Labour Government which was re-elected in 2001 sub
sequently made a commitment to boost health service
expenditure to the European average, and to reform
services to meet NHS Plan targets, particularly waiting
times for major surgery, and access to services.
In 2003 the Government gave hospitals greater
autonomy through the establishment of Foundation
Hospital Trusts (FTs). They remain part of the NHS
and are subject to NHS inspection and regulation via
Monitor (a non-departmental public body established
under the Health and Social Care (Community Health
and Standards) Act 2003, responsible for authorising,
monitoring and regulating NHS Foundation Trusts).
However FTs operate outside central control and have
accountability to local members who elect a Board of
Governors. Some FTs have up to 6000 members - a
possibly unexpected level of local interest, although it is
still too early to evaluate the effectiveness and genuine
representativeness of this type of public involvement.
They are funded through a process which links income
directly to the amount of activity undertaken within
a national tariff system. FTs can access capital mar
kets based on their ability to service debt. This places
very direct incentives to maximise business opportuni
ties to improve services. The utility and affordability
of additional activity remains a concern at present. One
danger of the move to FT status is the shift to private
sector accounting standards which potentially exposes
historic debt built up in organisations, although in the
ory this should be dealt with during the FT approvals
process.
A significant difference between pre- and post-1997
policy has been an apparent recognition that health
improvement requires action on the wider determinants
of health. Almost all such determinants are outwith the
immediate control of the health sector, and thus there
has been emphasis upon multi-sectoral working. An
initial exclusive focus on area (community) based ini
tiatives such as Health Action Zones, Surestart, and
Structural Regeneration, has given way to local govern
ment multi-agency partnerships, called Local Strategic
Partnerships, to co-ordinate strategy and implementa
tion. These provided, for the first time since the 1970s,
formal structures to work tackle wider determinants
of health with an emphasis on community and Local
Authority involvement.
The emphasis on efficiency has not mitigated the
realisation that the effectiveness of the health sector is
critically tied to the overall level of resources invested
in it. This has led, since 2000, to substantial planned
investment. Between 2002 and 2006 £34 billion, a 43%
increase in real terms in health services is planned [40].
However it is clear that, as a result of factors such as
changing technology, wage inflation and changes in
working practice, this is unlikely to lead to a compa
rable increase in outputs. Between 1995 and 2003, for
example, health inputs grew by 80% at current prices
(or between 32 and 39% with pay and price inflation
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A. Green et al. /Health Policy xxx (2006) xxx-xxx
removed) whilst health output has been estimated to
have grown by 28% [41].
There has always been recognition that unless the
vast majority of the population remain loyal to the
NHS, support will inevitably wane leading to a two-tier
service giving greater inequality in access and health
outcomes. As such, policy has been geared towards
maintaining public confidence and trust in the NHS.
This has had effects on the willingness of individuals
and corporations to subscribe to private health insur
ance, leading to price deflation in the private sector
and service reorganisation with, for example, BUPA (a
leading private sector health provider) selling 9 out of
its total 35 hospitals in summer 2005 [42].
4. Assessment of current health system in
England
We turn now to assess, against the above back
ground, the current health system using the PHC prin
ciples as an evaluative framework.
4.1. Equity’
The English healthcare system espouses objectives
of equity, usually expressed as equality of access for
equal need. The right to access is established in com
mon law and any health organisation denying it would
face judicial challenge. The attainment of this objec
tive needs to be assessed by the degree of equity
achieved in the distribution of resources, the outputs
of health services and outcomes in terms of health
improvement.
4.1.1. Distribution of resources
The allocation of financial resources continues to
be based on refinement of the Resource Allocation
Working Party (RAWP) formula first introduced in
1976 [43]. This is calculated on the basis of population
weighted by proxies of health need including demo
graphic profiles, and, despite some criticism [44,45]
this formula is generally accepted as equitable [46].
Since 2002, allocations have been made directly to Pri
mary Care Trusts (PCTs). The comparison of present
allocation versus ‘ideal’ target allocation gives an indi
cation of the degree of inequity. The policy set for
the period 2002-2005 moves all PCTs towards their
7
target allocation, through a combination of a capped
increase for over-resourced districts of around 8.5%
per annum (still well in excess of inflation) and sig
nificantly greater increases of up to 14% for under
resourced districts. The effect of this will be that at the
end of the period only four (of 302) PCTs are antici
pated to remain more than 10% under target, and eleven
PCTs more than 10% over target [47].
Similarly, there has been recognition of the inequity
of distribution of human and physical resources. The
NHS Plan [39] sets challenging objectives for increas
ing the number of health care staff. Targets have been
set for strategic health authorities in proportion to the
base differential from national comparator benchmarks
for specific cadres e.g. numbers of community nurses
or hospital consultants. The rationale for such targets
can, however, be questioned especially as health service
modernisation drives skill-mix changes making histori
cally based comparators, focusing on the availability of
single professions, difficult to interpret. Specific finan
cial incentives were introduced through ‘golden hellos’
to encourage GPs to take up appointments in more
deprived areas. However the effectiveness of these
in contributing to greater equity was limited and the
scheme was withdrawn in April 2005. This reflects a
shift towards addressing resource management issues
at local rather than national level, and a realisation that
equity of outputs and outcomes are of greater impor
tance than attempted national micro-management of
inputs.
Strategic health authorities allocate capital
resources to trusts, although the majority of capital in
the health service is now controversially raised through
private finance initiatives (PFI) with concerns both
about privatisation of the NHS and about potential for
overextension of recurrent commitments. Allocation
of public capital is dependent upon a variety of factors,
such as existing building stock, making direct equity
analysis complex. The most glaring examples of
estates inequity occur within primary care services, in
inner city areas. To respond to this, legislation has been
enacted to allow the establishment of Local Investment
Finance Trusts (Ln?T), a public/private partnership
focused on producing increased capital resources for
community-based services. It remains too early to
evaluate the effectiveness of such initiatives, though it
has attracted criticism including a concern that this is
likely to result in for-profit ownership and leasing of
ill
8
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A. Green et al. / Health Policy xxx (2006) xxx-xxx
primary care facilities with potential for misalignment
with population health needs [48],
4.1.2. Health care outputs
Any assessment of health system outputs faces a
bewildering range of potential measures that reflect
the controversy around overall system productivity. In
terms of assessment against the equity principle of
PHC, we focus on two-attainment of equality of access
as measured by the proxy of waiting times and attain
ment of equal geographical quality of health servicesthe end of what is called ‘postcode prescribing’.
Waiting lists are the most tangible symptom of
inequity within and between the public and private
health sectors in England. Eradication of waiting lists
has therefore become a policy priority to promote
equity and maintain public confidence in a publicly
funded health service. The NHS Plan set out annual
milestones towards eradication of waits in excess of 3
months for outpatients and 6 months for in-patients by
the end of 2005. Substantial progress has been made
to reduce waiting lists both in total size and, more
importantly, length of waiting time. There has been a
reduction from a peak of 1.3 million people on NHS
waiting lists in April 1998, to 857,221 in October 2004
[49]. Within this figure there is a significant reduction
in those waiting in excess of 6 months falling from
264,000 in March 2000 to 69,638 in October 2004.
The waiting time ceiling target has also reduced from
a maximum of 18 months to 9 months [50]. Although
there have been examples of outliers from the general
levels of improvement across the country, these varia
tions have been usually within a few percentage points
of overall attainment.
Attention is also now being paid to the, often hid
den, issue of waiting times for primary care services.
According to the NHS plan, by the year 2004 all
patients are expected to have access to GP within 48
hours and a health professional within 24 hours [39].
Whilst at the end of 2001 40% of PCTs were finding
it hard to meet these interim targets, particularly the
second one [51], by 2003/2004 the majority (79% and
84%, respectively) of general practices were meeting
these key targets [52]. The Minister of Health stated
that “97% of patients are now able to see a GP within
two days” [53]. The Commission for Health Improve
ment, however, has criticised PCTs as “.. .technically
meeting their target while actually not achieving the
underlying goal”; PCTs were not offering any appoint
ments in advance of 48 hours [54], an example of the
dangers of the perverse managerial incentives built into
such targets. The importance of this is illustrated by the
fact that political attention (with particular embarrass
ment for the Prime Minister who appeared unaware
of the issue) was focused on this particular issue in
the last election. Policy objectives for the future focus
on waiting for diagnostic tests and times from referral
to treatment (including any need for diagnostic tests).
Whilst this may be desirable in promoting patient care,
it does have the effect of further diverting priorities
towards acute care provision and away from chronic
care such as in learning disability.
Stronger central policy definition and regulation,
through for example the development of National Ser
vice Frameworks (these are long term strategies for
improving specific areas of care, by setting measurable
goals and lime frames) is aimed at reducing varia
tion in the quality of health service delivery across the
country. Although variance still exists [55] there is evi
dence through the assessments in clinical governance
reviews and annual performance assessment ratings by
the Healthcare Commission that quality is improving
and variance reducing [56].
4.1.3. Health outcome inequalities and equality
and diversity policies
The Labour government has given high priority in
its policies to reducing the levels of inequity in health
experience alongside an objective of improving general
health levels. A recent report monitoring progress on
inequalities suggests mixed results in terms of achieve
ment against these policies [57]. On the positive side
progress is reported on child poverty and housing and
in some specific disease areas. However for two key
indicators - inequalities by social class in infant mortal
ity and life expectancy have widened. The independent
monitoring group also calls attention to need for greater
focus on other forms of inequality including by ethnic
ity. The following explores the details of this.
One important proxy measure of population health
is average life expectancy at birth. Throughout the
1980s to the present, there was steady increase in
life expectancy [58]. However, significant gaps in
life expectancy remain, both geographically and
between socio-economic and ethnic groups [59-61]
- for example, there is a two-fold difference in infant
/ J 3
:
4. Green et al. / Health Policy xxx (2006) xxx-xxx
mortality by social class [62]. Generally whilst average
population health improves, persistent gaps in health
experience between the rich and poor remain and in
some cases are even widening [63,31]. Health Action
Zones were created in 1998-1999 in 26 areas across
England particularly challenged by poor health and
lower life expectancy - largely in the post-industrial
urban areas in the North of England and London.
Persistent inequalities were acknowledged in subse
quent initiatives such as ‘Programme for Action’ and
‘Spearheads’ and ‘Communities for Health’ launched
with the publication of the Public Health White Paper
in 2004 [50]. All these initiatives have a common
theme-to provide extra resources for community devel
opment and cross sector activities, particularly across
the Local Government departments such as education,
community safety and regeneration, recognising the
wider determinant of ill health. However, whilst all
these initiatives had been positively received by PCTs
and the public health community, the timescales for
reversing the trends in life expectancy will require
political commitment for many years.
One important and persistent area of health inequal
ity has been for minority ethnic groups. Despite many
national and local initiatives, poor health inequalities
persist [62]. For example, perinatal mortality within
communities with Pakistani and Caribbean origins is
almost double the national average [64]. Furthermore,
recent widespread criticism of ‘institutional racism’ in
some areas of public service, has led the government
to launch a new programme to promote diversity and
mentorship.
In summary, it can be seen that there is now more
apparent interest in inequalities than previously. How
ever, unsurprisingly, the health inequalities are signif
icantly a function of wider forces outside the direct
control of the NHS, and raises major challenges for the
NHS at different levels in its growing health promotion
responsibilities as discussed later.
4.2. Participation and decentralisation
Increasing levels of participation and decentralisa
tion have been central objectives of recent English
health policy [65-67]. In addition to the necessity to
maintain a balance between strategic and local pri
orities within partnerships between NHS and local
authorities [68], there continues however to be tension
9
between the participation of individuals and patients
versus the participation of communities.
4.2.1. Participation
In the early 2000s, UK legislation promoted the par
ticipation of patients and community in health [69],
with the expectation that this will ultimately improve
accountability [70]. Problems remain however in devel
oping effective relationships between NHS and the
public to secure accountability [71].
A number of models of participation for community
accountability and involvement in planning of health
services have been tried. From 1974 to 2003 Commu
nity Health Councils (CHCs) which were non-elected
bodies had statutory rights to be consulted on changes
to the health service. In late 2003 the CHCs were abol
ished as part of the wider changes in the NHS [72] with
the aim to increase public involvement in the NHS via
the establishment of alternative means of community
involvement such as Overview and Scrutiny Commit
tees and Patients’ Forums. The rationale appeared to be
a desire to align patient inputs with specific health care
organisations but this can be questioned on the grounds
that the public does not necessarily view health care in
such organisationally constrained terms.
Another model involves non-executive representa
tion on the boards of healthcare organisations, such as
NHS trust boards; however their line of accountability
is clear - to the Board chair and through him/her to the
Strategic Health Authority. This raises questions as to
the accountability of such representatives unless there
is a clear link to democratic processes such as local
government. As we have seen, FTs include a member
ship element designed to provide a form of community
accountability, but still untested. The role of the public
in healthcare inspection processes has been strength
ened through, for example, the use of lay assessors in
the visits of the Healthcare Commission (a body set
up to monitor health care quality and practice) and the
annual quality assessment process recently required in
all general practices, though their genuine involvement
in the process remains to be evaluated.
Increased scrutiny of health services, in particular
the effectiveness of their processes for public involve
ment, is also a function of the recently established
Patient Forums which link a group of local residents to
their healthcare organisation. An explicit role has also
been established for local publicly elected authorities to
10
A. Green el al. /Health Policy xxx (2006) xxx-xxx
question directly the running of district health services.
Citizen’s juries, another form of public involvement in
health decision-making, have been commented on pos
itively [73,74] and legislation has been enacted which
requires healthcare organisations to consult formally
with the public on all major changes to service provi
sion [75].
Additional initiatives include analysis of health
which includes public perceptions of health and health
services. A national patient survey, which can be dis
aggregated to district level, has been conducted since
2002. This has yielded information on local priorities.
More immediate and direct feedback from the public
is provided by the Patient Advice and Liaison Ser
vice (PALS) established in all healthcare organisations.
PALS provides mechanism for the public both to seek
advice on using health services, and to register concerns
about the delivery of health services. Information from
PALS has proved more sensitive and reliable to track
the quality of service provision than the more tradi
tional reliance on formal complaints [76].
In 2001 the Modernisation Agency was set up
to spear-head dissemination of health improvement
methodology across the NHS [77], The stated objective
was to place the patient at the centre of redesign efforts.
To enable this, tools such as patient led process map
ping and the use of patient questionnaires and histories
have been encouraged within the service. These pro
vide opportunities to analyse services from a patient,
rather than medical, perspective. Although a number
of discreet examples of improvement can be identified,
the overall impact is less easy to quantify. Patient sur
veys indicate a fairly constant level of approval rating
for quality of care since they were initiated in 2002
[78,79].
ipation through choice is seen by policy-makers as an
important driver in making services more responsive
to individual wishes and preferences.
Choice as a policy initiative has become closely
aligned with efforts to diversify provision through
encouraging a greater range and plurality (public and
private) of providers. As well as promoting choice, the
rationale for plurality is also seen as enhancing con
testability between health services, which is perceived
as encouraging efficiency. The most tangible result of
plurality policies has been the introduction of indepen
dent sector run treatment centres and an objective to
increase significantly the volume of private sector pro
vision contracted by the NHS over the next 3 years [81].
There are however a number of criticisms made of the
dangers of such pluralism and the potential for growing
privatisation [82,83]. In particular, growing numbers of
private providers could change the balance of power in
the medium term with concomitant potential for “rapid
cost inflation, rising transaction costs in managing the
market, and an inability of governments adequately to
regulate the private sector” [84].
Increasing choice by driving appropriateness and
efficiency is also perceived in some quarters as pro
moting equity, as summarised by a recent statement
from the health minister:
4.2.2. Choice
Choice is a policy theme that places the individual
and the decisions they take about the quality, range
and location of care available to them at the centre
of the healthcare dynamic [80]. This gives increasing
importance in policy to individual consumerism as
contrasted with the PHC approach to community
participation. However, for choice to be genuine, a
real set of different and accessible care options needs
to be available. Patients can then assess their choices
by trading off various known access and quality
parameters weighted by their individual values. Partic-
There are, however, several potential negative
aspects to the focus on choice. Firstly, the ability of
patients to exercise genuine choice is adversely affected
by levels of deprivation, e.g. access to transport to move
to alternative providers. Thus more affluent and articu
late groups potentially seize differential benefits. This
is exacerbated by the growing ability of certain groups
to access information through sources such as the
internet, which may provide selective social empow
erment. Secondly, an almost inevitable consequence
of increased competition is failure of some providers.
This may have significant effects on local access in
The post-war welfare state was characterised by a
belief that services could deliver equality through
the provision of the same services to everyone. What
became clear is that different people have different
needs and that uniformity ofprovision fails to provide
equity of provision for people with different needs.
Different provision suited to different needs will
encourage equity [85].
A. Green et al. / Health Policy xxx (2006) xxx-xxx
affected areas. The implications of this have yet to be
tested.
It remains too early to judge the success of the
‘choice’ initiative, but it provides a new perspective
on, and interpretation of, individual participation driv
ing other aspects of PHC.
In summary, the last few years has seen a num
ber of new initiatives in the area of community and
individual participation in decision-making in the NHS
with attempts to operationalise the rights of the public
to be consulted, with mechanisms to provide greater
accountability. This coincides with, or indeed may be
driven by, heightened expectations by the public as
to their rights within health and health care delivery,
which is likely to grow. At the community level, there
remain doubts as the representativeness and genuine
accountability processes, given the lack of links to a
democratic process. At the individual level, partici
pation is being increasingly interpreted as providing
alternatives for choice, which raises questions as to the
genuine nature of the choices for certain social groups,
and a different interpretation to that of the original
Alma Ata Declaration which focused on community
inputs to decision making rather than individual roles
and responsibilities.
4.2.3. Decentralisation
At the core of efforts to promote decentralisation
has been the establishment of Primary Care Trusts
(PCTs) with the functions of improving health both
through public health responsibilities and the provision
of health services either directly or through commis
sioning. Underpinning this was the need to work in part
nership with other organisations, notably local author
ities and many PCTs are seen to be . .developing
partnerships more effectively than any of their NHS
predecessors” [86]. It is important to recognise how
ever, that while an overt rationale for decentralisation
is a desire to allow central government to focus on key
policy levels such as regulation and standardisation,
this paradoxically may lead to greater centralisation.
Furthermore, some analysts have argued that the ori
gins of the current decentralisation in the Thatcher
reforms were based in a political desire to shift respon
sibility for the failings of the NHS away from central
government.
When first established PCTs were seen as pow
erful entities in shaping both the future provision of
11
health services and efforts to implement health pro
moting initiatives, through a strong community basis,
and a primary care view on the design of health ser
vices. The effectiveness of PCTs in leading commis
sioning has, however, been increasingly questioned due
to the continuing dominance of large hospitals and
inadequate capacity of PCTs to successfully perform
public health function [87]. Recent policy guidance
has given greater emphasis to decentralisation within
PCTs [88,89] through the introduction of practice
based commissioning to enable primary care physi
cians and patients to have a direct influence on service
commissioning.
However, since 1997, the scope for genuine self
determination of local bodies remains restricted, as a
result of the large number of centrally driven targets,
and performance management approach. In response
to this, financial and target setting systems are being
reformed to support local target setting as the next log
ical stage in supporting local determination. This is
seen in two policy areas.
Firstly, greater power and autonomy for local gov
ernment is being sought [90]. One of the early manifes
tations of this is ‘Local Area Agreements’ being piloted
in 21 local authorities, to release nearly all previously
earmarked funding for local determination. Health is
one of three ‘blocks, together with ‘children and young
people’ and ‘stronger safer communities’. However
a central hand remains present with local organisa
tions needing to demonstrate that they can deliver on
nationally set targets within budget, before being given
greater responsibility — the concept of ‘earned auton
omy’.
Secondly, attention is also shifting towards a greater
development of locally determined health targets. All
PCTs are required to agree a range of targets for local
health plans. As long as these comply with a national
prioritisation framework and can be seen to be suf
ficiently challenging, then PCTs have the power to
determine them. However, the usefulness of this power
is questionable as pursuit of national targets usually
consumes all resources available at local level.
In conclusion, there are clear tensions between the
desires of national politicians to drive change through
centrally imposed targets, and to allow greater freedom
at the local level to determine and respond to their own
priorities, with the latter clearly being closely related
to the conceptualisation and approach to local partic-
12
A. Green et al. / Health Policy xxx (2006) xxx -xxx
ipation discussed in the previous section. What is the
balance between accountability upwards to the national
level and accountability downwards to the community?
[91] As Peckham reminds us, Butler pointed out 10
years ago: “it is still not clear whether the NHS is a
central service that is locally managed or a local service
operating within central guidelines” [92], The manage
ment of these tensions remains an ongoing political
challenge.
4.3. Prevention and health promotion
In recent years has been greater emphasis on pre
vention and promotion. This can be viewed at different
levels - that of general government policy concerning
the determinants of health, and the specific activities of
the health agencies. In the next section we examine the
institutional arrangements for intersectoral activities in
pursuit of a public health agenda.
4.3.1. National health promoting policies
Since 1997, the Government has embarked on
a more progressive (though still cautious) tax and
incomes policies and more socially inclusive policies.
There is some evidence that the increasing gap between
lower income groups and other groups has halted and
in some areas, is narrowing [93]. However data is
mixed. The economic and social gap between London/Southern England and the post industrial North
(the so called North-South divide) is reported to have
widened on a number of economic and social indicators
[94-96]. Efforts to address these persistent inequali
ties have intensified since 2002. For example there is
renewed effort to ensure open access to higher edu
cation, assistance for public services in areas of high
deprivation, economic regeneration policies and access
to NHS services through the use of health equity
audits which are designed to influence local alloca
tive and service improvement decisions. Audits [97]
are expected/designed to identify how fairly services or
other resources are distributed in relation to the health
needs of different groups and areas, and the priority
action to provide services relative to need.
In 2002 and 2004 the government published reports
into NHS financing and opportunities for preventing
ill health-the Wanless Reports [98,99] which criticised
public policy in the area of prevention and accused the
NHS for its emphasis on acute care. Interestingly this
report originated from the finance ministry in recogni
tion of the high cost of failing to achieve a public health
policy. It predicted an exponential year on year increase
in the demand for health services and outlined scenar
ios on how this increase in cost could be prevented or
contained. It recommended that only when individuals
are fully engaged in their health can there be any oppor
tunity to prevent ill-health. The report was welcomed
by the health sector and public health community,
although critics point out that the report emphasises
individual choice rather than wider community and
government action [100,101], The Government sub
sequently consulted and published its Public Health
White Paper Choosing Health [50]. This attempts to
define the role of individuals and communities and
government in public health policy in the 21st century
and states that its prime objective is to empower indi
viduals to make healthy choices about their lifestyles.
The government’s role is seen as creating an environ
ment which will enable disadvantaged people to make
healthier choices and to protect those (such as children)
who cannot make choices themselves. At the national
level there have been various institutions aimed at
providing health promotion leadership, of which the
most recent, the Health Development Agency, recently
merged with the National Institute for Clinical Excel
lence to become the new National Institute for Health
and Clinical Excellence (to continue to be known as
NICE). This is intended to reflect the need to advise on
good practice in health promotion as well as continuing
to assess and issue guidance on clinical procedures and
treatments.
The Government’s Public Health White Paper [50]
contains proposals to introduce smoke-free public
places by 2008. There is, however, a loophole-pubs
and bars which do not serve prepared food will be able
to allow smoking on their premises1. The BMA in a
recent study found that 9 of out 10 towns and cities
with the highest proportion of ‘non-food’ pubs are in
the north of England or the Midlands [102]. This sug
gests further differences in health status contradicting
to Government’s policy to reduce health inequalities.
Following the terrorist attacks of 9/11, the govern
ment increased investment in public health services
to prepare for new threats to the public’s health from
1 An interesting, and politically significant, difference from other
parts of the UK and in particular Northern Ireland and Scotland.
n
-4. Green et al. / Health Policy xxx (2006) xxx-xxx
nuclear, chemical or biological weapons. In England,
this was one of the reasons for re-organising the com
municable disease control and emergency planning
functions, which were fragmented at local and national
levels into a Health Protection Agency. Although this
investment has been in a narrow field within public
health, this increased awareness and investment has
had some spin-offs in other areas of public health, par
ticularly in communicable diseases such as STI and
HIV/AIDS.
4.3.2. Role of PCTs in prevention
Each PCT is now required to promote the health
of its population - a shift from the traditional general
practice patient-centred approach. Health promotion’s
organisational location within primary care has meant
its re-focusing at this level, on health improvement for
defined populations. Health promotion services have
enjoyed a renaissance with this focus and have engaged
in area-based initiatives such as Health Action Zones
(HAZs) [103]. However one downside of this has been
the loss of a co-ordinated approach in large conur
bations where previously functions such as commu
nicable disease control were led from a wider level.
Furthermore, the continued political attention to tar
gets such as waiting lists for acute care, inevitably put
pressures on PCTs to respond to these, at the cost of
attention to wider preventive activities.
One of the implications of the principles of Alma
Ata was the need to integrate promotion, prevention,
curative and rehabilitative services at the primary care
level. To address this integrated approach to prevention
National Service Frameworks (NSFs) have been pro
duced for heart disease, cancer, diabetes, older people
and child services amongst others. A defined set of
proposals now exist to move towards a single holistic
approach to health and health care. Whilst certain
variations exist, NSFs appear to have been successful
in focusing attention and initiating service improve
ment. Indeed one of the functions of the NSFs is to
provide explicit standards to help with equity goals,
given as we have seen that in 1990s there were major
inequities in provision and use of health services in
England [104].
Concern exists however that resultant services, such
as smoking cessation, whilst improving overall levels
of health still suffer from differential access and effec
tiveness leading to widening health inequalities.
13
The, above suggests that there has been a greater
interest in public health and personal prevention than in
previous decades. However, a significant gap between
policy and practice continues to exist and to reflect the
dominance of acute care thinking in the NHS. There
clearly remain areas where public health and preventive
policies are less strong than would be desirable, both in
terms of national initiatives (such as smoking legisla
tion) and at the local level in terms of co-ordination of
activities. This raises in itself questions as to whether
the NHS (or any similar health care service) can trans
form itself into a lead health promoting agency or
whether such leadership is more feasible from a differ
ent organisational location within government and we
turn now to an examination of the relationships between
different sectoral actors in health promotion.
4.4. Multisectoralism
The principle of multisectoralism is derived from a
desire to promote good health by focusing on the deter
minants of health, and as such is closely related to the
previous section. Here we examine particular mech
anisms at different levels for enhancing collaborative
work across sectors.
4.4.1. Local partnerships
In 2001 the Government launched a Strategy for
Neighbourhood Renewal [105]. Five sectors (health,
police, education, business and the voluntary sector)
are required to work with local authorities to establish
and manage Local Strategic Partnerships (LSPs). All
areas arc required to establish LSPs, but the Strategy
also identified 88 most deprived LA areas ear marked
for additional funding to support local work. Nearly
all PCTs participate in LSPs-many with specific local
health objectives.
Increasing attention is being paid to formal arrange
ments to link health with directly related areas of public
sector provision. The potential to establish Care Trusts
fusing health and social care has existed for several
years, but this power has only been availed by a lim
ited number of organisations. Much more significant
are the implications flowing from the Children’s Act
(2004) which require the establishment of Children’s
Trusts in all local authority area under a single Director
of Children s Services. Although at a fairly early stage
of implementation and with significant potential for
14
A. Green et al. /Health Policy xxx (2006) xxx-xxx
local flexibility it is already clear that health, social and
educational services for children will have to become
increasingly integrated over the coming years. Knockon impact into models for adults and older people is
likely.
4.4.2. Regional partnerships
Government Offices, alongside Regional Develop
ment Agencies (RDAs) and Assemblies act as a key
partnership at this level. Nine Government Offices exist
in England and through the provision of the White
Paper “Your Region Your Choice’ (2002) allow for
these organisations to work in partnership on cross sec
tor planning at a regional level. Through the Regional
Directors of Public Health a number have agreed part
nership frameworks and plans to tackle health inequal
ities. Also at Government Office level, other partner
ships have developed with the voluntary sector, busi
nesses, education (learning skills councils), the envi
ronment (Countryside Agency) sport (Sports Boards),
and culture, which have led to incorporation of health
improvement objectives into other sector strategies.
For example, most regions now have regional hous
ing strategies which require meeting population health
needs for new housing development - particularly
warm affordable housing in deprived areas. Similarly
sporting strategies now incorporate health improve
ment as a key aim through improving participation in
sport and leisure. However as in many areas of govern
ment policy implementation at the regional level, there
is a lack of robust research on the effectiveness of these
partnerships.
c
c.
4.4.3. National Government Partnerships
During 2004, the Government issued its 3 years
Comprehensive Spending Review, which includes
spending plans for each department. The Treasury
requires each department to make ‘Public Sector
Agreements (PSAs) on cross cutting objectives. Public
health, for the first time, is a key theme in this review.
Each Department is required to establish new part
nership arrangements across Whitehall. For example
there is obesity PSA, which requires the Departments
of Health, Culture, Media and Sport and Education and
Science to collaborate to reduce the obesity epidemic
(through education, access to leisure and sporting facil
ities and health promotion). These partnership agree
ments are new in tackling upstream wider determinants
of health at Central Government level; their impact is
still to be assessed.
The preceding sections on prevention and multisectoralism have indicated a weakness in the Alma Ata
framework. The rationale for a multisectoral approach
is, of course, the opportunity for action on the wider
social determinants of health, and as such, a major
opportunity for health promotion. Assessing the two
criteria together, suggests that there has been a signif
icant increase in interest in health promotion in recent
years both within the health care system and in other
parts of government. Interestingly some of this has been
driven by an economic agenda. The impact of this new
emphasis and its institutional mechanisms however
remains to be evaluated, including the ability of PCTs to
take on a genuine broad population-based role and the
ability of government to provide sufficient incentives to
obtain genuine cross-agency working. Underlying all
of this are questions as to the ability and indeed will
ingness of the NHS, given its history of focus on acute
care, to lead on a health (rather than health care) agenda
[106]. At the national level, the major thrust towards
public health has emanated from Treasury concerns
over the economic cost of preventable illness. Further
more, political considerations have led, to reluctance to
“challenge powerful commercial interests that under
mine public health” [107]. At the local level, despite
a number of important partnership initiatives, the fre
quent reorganisations of the health service have not
helped to allow the emergence of genuine and sustain
able partnerships on a health agenda.
4.5. Appropriate technology
Health technology is potentially an all encompass
ing concept. For the purposes of this paper it is taken
to be the set of techniques, drugs, materials, equipment
and procedures used by health care professionals in
delivering health care to patients and the systems within
which such care is delivered. Appropriateness is a more
problematic term to define and encompasses criteria
such as relevance, safety, cost, usability, feasibility,
community and cultural acceptability. Some of these
have already been considered elsewhere in this paper.
As a highly advanced increasingly post-industrial
economy within which many health technologies have
been adopted with a well-trained workforce, many
aspects of appropriateness appear well met at a general
ilBOi
I
A. Green el al. / Health Policy xxx (2006) xxx-xxx
4
I
level. Although not expressed in the direct terminology
of appropriateness, concern for maximising the effi
ciency and effectiveness of healthcare technology has
been an important facet of recent health policy. There
has been a focus both on individual technologies and
their location within healthcare processes.
The Wanless Report [98] highlighted three particu
lar aspects:
• the continuing importance of NICE in examining
newer technologies and older technologies and prac
tices which may no longer be appropriate or cost
effective;
• extension of National Service Frameworks to other
areas of the NHS, to include estimates of the
resources - in terms of the staff, equipment and other
technologies and subsequent financial needs - nec
essary for their delivery;
• recognition that a key priority is the need for effec
tive investment in Information and Communication
Technology (ICT) with a major programme being
required to establish the infrastructure and to ensure
that common standards are established.
4.5.1. Healthcare Technology Assessment
The need for effective health care interventions,
which provide the maximum benefit appropriate to the
resources has led to the development of a National Insti
tute for Health and Clinical Excellence (NICE) which
makes recommendations to government and clinicians
on the most effective treatments available.
Currently, NICE produces three types of guidance:
• technology appraisals - guidance on the use of new
and existing medicines and treatments;
• clinical guidelines — guidance on the appropriate
treatment and care of people with specific diseases
and conditions;
• interventional procedures - guidance on whether
interventional procedures used for diagnosis or treat
ment are safe enough and work well enough for
routine use.
A significant proportion of interventions is assessed
as not appropriate for support and therefore should
not be made available within the NHS. The recent
plans to incorporate the Health Development Agency
into NICE will mean that similar approaches will be
adopted for public health interventions.
C
15
NICE appears to have attained a high level of
influence and credibility within the health sector, in
determining the health technology assessment and dis
semination process and thus its appropriateness within
England. Its explicit rulings may also provide a focus
for lobbying by interest groups as has been shown
recently in public debate over the provision of cancer
drugs.
4.5.2. Information and communication technology
The publication of the Wanless report in 2002 led
to the production of a new national strategy for ICT
[108J. Three main objectives were set to:
• support the patient and the delivery of services
designed around the patient, quickly, conveniently
and seamlessly;
• support staff through effective electronic communi
cations, better learning and knowledge management,
cutting the time to find essential information (notes,
test results) and make specialised expertise more
accessible;
• improve management and delivery of services by
providing good quality data to support NSFs, clinical
audit, governance and management information.
Implementation through the National Programme
for Information Technology (NPfIT) has focused on:
• greater central control over the specification, pro
curement, resource management, performance man
agement and delivery of the information and IT
agenda;
• development of the infrastructure, including improv
ing broadband capacity, giving central storage
(allowing sharing and analysis) of all health infor
mation;
• development of key applications which allow effec
tive integration of care around the patient.
Implicit within this was recognition that current ICT
had been inadequate in delivering appropriate technol
ogy. The previous decentralised approach had led to
a multiplicity of systems standards and applications,
making effective system communication and integra
tion virtually impossible.
Substantial controversy has surrounded the imple
mentation of the NPfIT over recent years. Major con
cerns have focused on cost, programme feasibility, con
fidentiality of records and resistance of professional
16
A. Green ei al. /Health Policy xxx (2006) XXX-X.KX
groups to adopt new technologies and working prac
tices. Although progress is being made in establishing
the core infrastructure, many of the anticipated benefits
for staff and patients remain unrealised.
Attention has also focused on improving levels of
patient access to healthcare information through both
telephone and internet routes. A national telephone
access point - NHS Direct - provides advice on han
dling medical problems based on standardised care
algorithms. Efforts to introduce telecare remain at early
stage, except in certain vulnerable groups [109] and
highly rural locations.
This discussion has focused on two critical aspects
of health technology: assessment processes and the
importance of ICT in delivering modern integrated
healthcare. These suggest that concerns about, and
delivery of, appropriate healthcare is an increasingly
important aspect of health policy.
5. Conclusions
This article has provided an assessment of the cur
rent English health system against the Alma Ata PHC
principles. There are two broad areas of conclusion.
The first relating to the English health system and the
second concerning the PHC principles.
5.1. Assessment of the English health system
4
Although within the English health system, the per
ception and understanding of Primary Health Care as
a specific strategy has often been limited, the vari
ous principles which underpin PHC are in fact largely
implicit within health policy. The English system has
come some way from its days of excessive secondary
care dominance of health services and the internal mar
ket of the 1980s, although significant elements of the
market still exist.
Clearly health policy has evolved, and is cur
rently located, within a socio-political context that
has changed substantially over the past 25 years. Two
linked forces: consumerism and market management
can be seen to have had a significant impact on the inter
pretation of PHC within the English healthcare system.
The rising importance of consumerism can be seen
to have led directly to increased attention to choice
in the type and range of healthcare, based on individu-
ahsed rather than community needs and rights of users.
Logically such choice can only be meaningful if a range
of diverse providers exists and is genuinely accessi
ble to all social groups. To avoid significant potential
inequities such a market needs to be tightly managed
with a clear centrally defined system of pricing and
standards. Indeed whether choice requires a ‘market’
as such, is open to question. This at first sight para
doxical need for tight national systemic regulation in
defence of local choice is an example of the wider ten
sion that is evident in the recent history of the English
health system - between a desire to drive reforms cen
trally and to allow greater decentralisation.
Yet the ability to exercise choice, both in terms
of service access and health promoting interventions,
is directly linked to social factors. This explains the
increasing paradox in English health; rapidly improv
ing health service outputs, processes and overall health
outcome indicators, alongside widening equity gaps.
There is a real danger that the new emphasis on choice
(unrealisable for some) may result in further widen
ing inequities. Closely related to this are questions as
to the relative roles of the state and the individual,
with difficult balances to be made between the roles
of individuals as individual actors in pursuit of their
own health, the roles of individuals as part of a wider
community making decisions as the nature of priori
ties and services and the roles of the state in leading
and responding to democratic processes. This tension
is well illustrated in the policy area of smoking in
public places, and which has led to different political
responses in England from Scotland.
Improvements in outputs have come at substantial
cost and increasing concern has been voiced about the
overall efficiency of the health service. This led to the
initiation of the Gershon Review [110] which recom
mended reductions in non-service overhead costs by
15%. As well as ineffective managerial structures, a
significant driver has been rising unit labour costs. New
contractual arrangements for all major staff groups,
most significantly for general practitioners and hospital
consultants, have not resulted in the expected improved
productivity. Weaknesses in organisational design and
human resources policy pose significant risks to the
attainment of sustainable PHC based services.
Underpinning all of the above however is a more
direct question as to the appropriateness of a mar
ket model in health. The Thatcher reforms introduced
f
A. Green et al. /Health Policy xxx (2006) xxx-xxx
a market into the British health delivery system and
subsequent reforms have essentially responded in one
way or another to this paradigm. Some commentators
[111] have argued strongly, that this market philosophy
should be rejected; and that this does not need to imply
a return to old ‘command and control’ approaches to
the NHS. Instead it is argued that a third way is required
which addresses the needs for reform without resorting
to market principles and drawing on principles of mutu
alism (idem). We have not addressed this issue directly
in this paper, but it is clearly a critical one. Indeed alter
native models for structuring the health service will
inevitably have implications for the principles of pri
mary care that we have examined, such as participation.
The original concept of participation by communities
in decisions was intended to be more than the sum of
individual participation in their own health care needs.
A market approach to health care emphasises the indi
vidual as a consumer rather than as a member of a
community. Such more communally based participa
tion is not easy to see in the English health system.
Whilst, the new roles for Local Government in pub
lic health, identified in the Public Health White Paper,
may provide an opportunity for more local democratic
accountability for health, PCTs and FTs are not, in any
sense, democratic and cannot be argued to be repre
sentative in any sense of the wider community. This
remains a major challenge.
One particular aspect of this relates to the contin
uing tension between the setting of central policy, as
expressed by central targets, and local policies to reflect
community needs and interests which is evident within
the present system.
One of the major policy shifts that does however
seem to be appearing within the English health system
is greater attention to the wider determinants of health
rather than a narrower healthcare agenda. The criti
cal question is whether these policies can be turned
into practice. If this is genuinely implemented and sus
tained, then this could provide a set of experiences for
other countries that struggle to move beyond the nar
row and medically dominated interpretation of health
policy. Policies to regenerate deprived areas economi
cally and socially will have a direct impact on health.
Similarly, health promoting schools and workplaces are
likely to provide opportunity for heath improvement
outside the direct responsibility of traditional health
care systems. However there is some evidence that the
17
government may not have the desire to show political
leadership in some areas of public health promotion
and where necessary challenge commercial or indeed
professional interests. Linked to this are questions as
to the most appropriate focus for leadership in pub
lic health and whether the current structures allow the
genuine development of sustainable partnerships for
interventions on the wider determinants of health.
Lastly the last 15 years of reform of the English
health system has been characterised by a combination
of changes in the structure of the system accompanied
by a proliferation of institutional responses to policy
challenges. As one commentator has suggested this has
been a “phenomenon of ‘dynamics without change’”
[112]. Indeed, as this article is finalised, a further round
of reforms is being prepared for implementation. This
is to some degree paradoxical given the political stabil
ity which would have suggested the ability to develop
a single cohesive approach. There would appear to be
a real danger that such the frequent institutional recon
figurations have the danger of masking, and indeed
detracting from the underlying objectives and princi
ples of any health system, and in particular those of
PHC.
5.2. Primary Health Care as a framework
The dichotomies and tensions within and between
AA principles are well illustrated by the experience
of the English healthcare system. This illustrates the
need to recognise that political value judgements will
always be required to prioritise the AA elements giving
the implementation of PHC a particular and changing
interpretation.
The exercise has not only identified traditional ten
sions in any health care system (such as equity versus
efficiency and central targets versus local autonomy)
but interesting new tensions which need further explo
ration.
For example Alma Ata does not identify the role
of government in health improvement and individual
choice. Indeed it could be argued that there is a para
dox in this paper in that we have focused on the public
sector responses to ill-health. However implicit in the
interpretations of the PHS principles is the need for
state action, and given the endorsement by health min
isters, such a focus is regarded as appropriate. The
English White Paper attempts to define the boundaries
as
18
A. Green et al. /Health Policy xxx (2006) xxx-xxx
of government and individual responsibility for a 21st
century Western society. It states that individual must
take responsibility for making personal healthy choices
and that communities and government has a role in
creating the right conditions for healthier choices, par
ticularly if those conditions encourage poor healthy
lifestyles. This particular boundary may not be accept
able within all societies. However it does provide an
example of the sort of policy concerning the role of
government that is required.
Indeed, the degree to which a market orientated
health care system can support the attainment of PHC
objectives presents an interesting challenge to conven
tional PHC thinking.
Finally, we consider that an exercise such as this
is worthwhile is tracking progress and we believe that
further mapping by other countries will shed light on
useful comparisons.
Acknowledgements
The authors wish to acknowledge invaluable com
ments both from anonymous referees and from Paul
Johnstone, Regional Director of Public Health, and Vis
iting Professor of Public Health, University of Leeds
and Professor David Hunter, University of Durham.
Any remaining errors of fact or interpretation are of
course, our own.
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GLOBAL HEALTH
JI
Health for all beyond 2000: the demise of the Alma-Ata Declaration
and primary health care in developing countries
John J Hall and Richard Taylor
The Conference strongly reaffirms that health, which is a
state of complete physical, mental, and social wellbeing, and
not merely the absence of disease or infirmity, is a funda
mental human right and that the attainment of the highest
possible level of health is a most important world-wide social
goal whose realization requires the action of many other
social and economic sectors in addition to the health sector
— Alma-Ata Declaration, 1978.1
Access to BASIC HEALTH SERVICES was affirmed as a
fundamental human right by the Declaration of Alma-Ata in
1978.1 The reality is that, in 2002, more than 30 years later,
many people in resource-poor settings still do not have
equitable access to even basic services. In many places this
gap is widening.2
J
The 1960s and 1970s was, for many developing countries,
an era of newly won independence from former colonial
powers. This independence was accompanied by an enthusi
asm to provide high-standard healthcare, education and
other services for the people. Governments moved to estab
lish teaching hospitals and medical and nursing schools,
often with the assistance of donor nations. These tertiary
services consumed the largest portion of the country’s
healthcare budget, and were available mostly in urban areas,
creating access problems for the predominantly rural socie
ties. Healthcare services to the rural majority were supplied
by missionary hospitals and clinics, or by “touring services”
provided from urban hospitals. There was a wide variety of
services of varying standard and quality in the rural areas.
Most of the population still visited traditional healers.3
By the 1970s, the morbidity and mortality for rural
communities was not improving, and in some places they
deteriorated.3’4 In places where people did have access to
services, cultural beliefs about illness meant those services
were not being accessed.3,4
Further developments, such as oral rehydration solutions,
showed that early and appropriate intervention by carers
and village volunteers could avoid referral and admission to
hospital,5,6 and, if combined with an effectively organised
vaccination program, would address the major causes of
death and illness.7
Facut^.pT
, NSW, Australia^
I
vitebe.
th^authQr5,
T.
>
$
’A
b PHC did not achieve its goals for several reasons, including
the refusal of experts and politicians in developed countries
to accept the principle that communities should plan and
implement their own heathcare services.
6 January 2003
a It is time to abandon economic ideology and determine
the methods that will provide access to basic healthcare
services for all people.
MJA 2003; 178: 17-20
In the 1960s and 1970s, China, Tanzania, Sudan and
Venezuela initiated successful programs to deliver a basic
but comprehensive program of primary care health services
covering poor rural populations.3,4 From these programs
came the name “primary health care”. Papua New Guinea
had a similar comprehensive program in place for some
years.8’9 This new methodology for healthcare service deliv
ery incorporated a questioning of top-down approaches and
the role of the medical profession in healthcare provision.
During the 1970s, a synthesis of these concepts was
undertaken by the World Health Organization (WHO) and
UNICEF. It addressed the need for a fundamental change
in the delivery of healthcare services in developing coun
tries, with an emphasis on equity and access at affordable
cost, and emphasising prevention while still providing
appropriate curative services. This took place in an era
where the pre-eminent role of government in the provision
of health, education and welfare services was taken for
granted in most developed countries, and when there still
existed large countries with socialist economies, such as the
USSR and China.
The Foundations of Primary Health Care:
Alma-Ata
,
(A27), Syd^y; NS^^20Q6■JA^siraiia.’^’^■
Vol 178
ia The model formally adopted for providing healthcare
services was “primary health care” (PHC), which involved
universal, community-based preventive and curative
services, with substantial community involvement.
University
’’S
MJA
» Access to basic health services was affirmed as a
fundamental human right in the Declaration of Alma-Ata
in 1978.
a Changes in economic philosophy led to the replacement of
PHC by “Health Sector Reform”, based on market forces and
the economic benefits of better health.
Background
1’
ABSTRACT
The Declaration of Alma-Ata formally adopted primary
health care (PHC) as the means for providing a comprehen
sive, universal, equitable and affordable healthcare service
17
GLOBAL HEALTH
for all countries. It was unanimously adopted by all WHO
member countries at Alma-Ata in the former Kazak Soviet
Republic in September 1978.1
Primary health care is essential health care based on
practical, scientifically sound and socially acceptable meth
ods and technology made universally accessible to individu
als and families in the community through their full
participation and at a cost the community and 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 both 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 community. It is the
first level of contact of individuals, the family and commu
nity with the national health system bringing health care as
close as possible to where people live and work, and
constitutes the first element of a continuing health care
process — Alma Ata Declaration, 1978.1
PHC envisaged universal coverage of basic services such
as education on methods of preventing and controlling
prevailing health problems; promotion of food security and
proper nutrition; adequate safe water supply and basic
sanitation; maternal and child health, including family
planning; vaccination; prevention and control of locally
endemic diseases; appropriate treatment of common dis
eases and injuries; and provision of essential drugs. The
emphasis changed from the larger hospital to that of com
munity-based delivery of services with a balance of costeffective preventive and curative programs. The approach
was intersectoral, involving agriculture extension officers,
schoolteachers, women’s groups, youth groups and minis
ters of religion, etc. The community, through its leaders,
was to be involved in the planning and implementation of its
own healthcare services through community Primary Health
Committees. Where Western-trained doctors and nurses
were not available. Village Health Workers were to be
trained and used as a formal part of the healthcare system.10
The conference went so far as to address the economic
and political steps needed to fund the initiative:
An acceptable level of health for all people of the world by
the year 2000 can be attained through a fuller and better use
of the world’s resources, a considerable part of which is now
spent on armaments and military conflicts. A genuine policy
of independence, peace, detente and disarmament could
and should release additional resources that could be
devoted to peaceful aims and in particular to the accelera
tion of social and economic development of which primary
health care, as an essential part, should be allotted its proper
share — Alma-Ata Declaration, 1978.1
National governments throughout the world adopted
PHC as their official blueprint for total population coverage
with essential PHC services. Goals and targets were set for
Achieving Health For All by the Year 2000.10 Some of these
goals were that:
h at least 5% of gross national product should be spent on
health;
n at least 90% of children should have a weight for age that
corresponds to the reference values;
18
a safe water should be available in the home or within 15
minutes’ walking distance, and adequate sanitary facilities
should be available in the home or immediate vicinity;
■ people should have access to trained personnel for
attending pregnancy and childbirth; and
a child care should be available up to at least one year of
age.
In the initial stages, nurses and health extension officers
(who had skills allowing them to undertake procedures
previously the domain of doctors) were trained to work in
community health centres, which covered the population.
They were given balanced training in clinical and preventive
PHC interventions. Where there were gaps in the healthcare
system, village health workers were trained in a limited
number of skills to fill these gaps. Community representa
tives, through Village Primary Health Care Committees,
were supposed to have a central role in planning and
overseeing their healthcare services.10 Adequate supervision
to ensure service quality, essential drugs, vaccines and
equipment, especially at the most peripheral levels, was
envisaged.
Almost as soon as the Alma-Ata Conference was over,
PHC was under attack. Politicians and aid experts from
developed countries could not accept the core PHC princi
ple that communities in developing countries would have
responsibility for planning and implementing their own
healthcare services. A new concept of “Selective Primary
Health Care” (SPHC)11 advocated providing only PHC
interventions that contributed most to reducing child (< 5
years) mortality in developing countries. The advocates of
SPHC argued that comprehensive PHC was too idealistic,
expensive and unachievable in its goals of achieving total
population coverage. By focusing on growth monitoring,
oral rehydration solutions, breastfeeding and immunisation,
greater gains in reducing infant mortality rates could be
achieved at reduced cost.11
In effect, SPHC took the decision-making power and
control central to PHC away from the communities and
delivered it to foreign consultants with technical expertise in
these specific areas. These technical experts, often employed
by the funding agencies, were subject to the policies of their
agencies, not the communities. SPHC reintroduced vertical
programs at the cost of comprehensive PHC.12’13
The PHC versus SPHC debate continued throughout the
1980s.
There were other reasons why PHC did not achieve
Health For All by the Year 2000.14
a Many ordinary people felt PHC was a cheap form of
healthcare and, if they were able to, they bypassed this level
to attend secondary and tertiary centres because of a lack of
staff and essential medicines at the PHC level.
a Civil war, natural disasters and, more recently, HIV
affected the ability of PHC to maintain comprehensive
services, especially in many sub-Saharan countries.
■ Political commitment was not sustained after the initial
euphoria of Alma-Ata. In many cases PHC became a jargon
term used as a slogan, and little else. The rhetoric was not
backed with the necessary reforms.14 Agencies were content
if countries adopted PHC as a policy, and did not assess
MJA
Vol 178
6 January 2003
J
GLOBAL HEALTH
$
J
actual practice. Politicians saw PHC as a way to reduce
expenditure in health and lacked the political will to ensure
that services were equitably shared and distributed. Most
healthcare resources continue to be directed to the large
urban-based hospitals.
as Issues of governance and corruption in the use of
resources resulted in donors becoming very wary of funding
comprehensive, broad-based programs. Vertical, definable,
time-limited programs that could be changed every few
years suited both donor agencies and governments.
Health Sector Reform: The World Bank Report, 1993
1
1
Changes in political and economic philosophy in the late
1980s and 1990s marked a major change in how govern
ment services were delivered throughout the world. These
reforms had their roots in the economic reforms of North
America and Europe. Emphasis was placed on reducing
government involvement in all aspects of society. Market
forces became the dominant model for service delivery.
The fall of the socialist eastern European bloc and China’s
adoption of many aspects of liberal economics were major
features of this period.
Governments in resource-poor countries, which had
already reduced their expenditure on health as their foreign
debt mounted in the 1980s and 1990s, now had to contend
with the new economic philosophy. International donors
insisted these governments adopt the market-driven eco
nomic reforms if they were to receive foreign aid and debt
relief.
It was against this background that the World Bank’s
World Development Report of 1993, “Investing in Health”,
was undertaken.15 It reflected a marked change in the
orientation of how healthcare services in resource-poor
countries would be delivered. The report makes little use of
the term “Primary Health Care”. It considers the delivery of
healthcare services in terms of the economic benefit that
improved health could deliver, and sees health improvement
mainly in terms of improvement of human capital for
development, rather than as a consequence and fruit of
development. The report is mostly about healthcare sector
activities in improving health, and gives scant recognition to
the role of other sectors, which contrasts with the original
PHC’s multisectoral approach.
This World Bank approach became known as Health
Sector Reform. This heralded an emphasis on using the
private sector to deliver healthcare services while reducing
or removing government services. User pays, cost recovery,
private health insurance, and public-private partnerships
became the focus for delivery of healthcare services.
Although the report does discuss in detail the issues of
market failure, externalities, inequity and the importance of
public goods, its conclusions fail to fully reflect these
concerns in matters of policies and recommendations. How
these reforms are implemented in situations of absolute
poverty and to indigent populations is not explained.
Further, Health Sector Reform was and is seen in devel
oping countries as being imposed by economists from North
America and Europe. As a policy it has not been debated
MJA
I
1
Vol 178
6 January 2003
Case study: the Gambia18
In the Gambia, in west Africa, a study by the United Kingdom
Medical Research Council of 40 villages beginning in 1981 over a
15-year period compared infant and child mortality between
villages with and without primary health care (PHC). Extra services
to the PHC villages included a paid Community Health Nurse for
about every five villages, as well as a Village Health Worker and a
trained Traditional Birth Attendant. Maternal and child health
services with a vaccination program were accessible to residents in
both PHC and non-PHC villages. There were marked improvements
in infant and child (<5 years) mortality in both PHC and non-PHC
villages.
After the establishment of PHC in 1983, infant mortality in the PHC
villages dropped from 134/1000 in 1982-1983 to 69/1000 in 19921994, and from 155/1000 to 91/1000 in the non-PHC villages over
the same period. The change in death rates for children aged 1-4
years between the two groups was not as marked.
Supervision of the PHC system weakened after 1994, and infant
mortality rates in the PHC villages rose to 89/1000 in 1994-1996.
The rates in non-PHC villages fell to 78/1000 for the same period.
Mortality rates rose significantly when PHC services were
weakened.
and unanimously agreed to, as PHC was at Alma-Ata.
Communities in developing countries do not have a say
directly or indirectly in their health services. There is no
sense of this new approach promoting equity in accessing
even the most basic of services, let alone the benefits of
modern medical advances. Rather, there is a sense of
inequity, marginalisation and frustration.
Since the 1993 report, the World Bank and other similar
agencies have made little reference to PHC as endorsed at
Alma-Ata. WHO continued to use the terminology through
out the 1990s. It conducted reviews and held meetings16
assessing and attempting to strengthen progress towards
Health for All by the Year 2000.
The “World Health Report 2000, Health Systems:
Improving Performance” marked the end of WHO’s use of
PHC as the means for the delivery of healthcare services in
resource-poor countries. This report puts the failure of
PHC to achieve its goal down to inadequate funding and
insufficient training and equipment for healthcare workers
at all levels. This resulted in either a total lack of services at
the community level, or services of such poor quality that
people had no option but to bypass the primary-level
providers, resulting in a failure of the referral system within
the PHC hierarchy.17
But what has been the basis for abandoning PHC other
than a change in economic and political philosophy? As the
study from the Gambia shows (Box),18 PHC does bring
about reductions in infant mortality when implemented
with sufficient resources. Further, worldwide vaccination
coverage rates for measles have risen from less than 20% in
1980 to now cover 80% of the world’s population, and
measles cases have fallen from more than four million in
1980 to be now less than 0.8 million annually.19 There is
strong evidence that infant mortality rates in resource-poor
countries have continued to drop at a steady rate since
1990.20 There are strong indications that PHC has and can
bring about marked gains in health.
19
GLOBAL HEALTH
I he future: health beyond 2000
Given the enormous economic and political sway of the
World Bank, the Health Sector Reform methodology will
continue in the immediate future as the vehicle for health
care service delivery, especially in countries having struc
tural adjustment programs imposed on them
However, this is not unquestioned. Health Sector
Reform is criticised as being driven by economic and
political ideology.13 There is little provision for ensuring
equity in access to services, especially for people living in
absolute poverty or the indigent. As Whitehead et al point
out, “The actual outcomes of previous and current mar
ket-oriented reforms have often been contrary to stated
objectives, as economic access for poor people has declined
and total costs have increased”.21 Ten years on, is it not
time that Health Sector Reform also underwent thorough
review?
Advocates of PHC are drawn largely from non-government organisations, academics and community groups
within developing countries who argue that PHC was not
given a chance to establish itself as a viable system or
methodology.22 Once the economic and political implica
tions of the Alma-Ata Declaration were recognised, it was
not given a chance to survive politically or economically.
A reasonable criticism of PHC is that it did not establish
whether it was actually bringing about a quantifiable
change in the health of populations in the early 1990s. Its
data, analysis and evaluation systems were weak at a time
when there was a demand for evidence-based demonstra
tions in health status. But was this sufficient reason to stifle
a methodology that gave a sense of participation in and
equity of access to a healthcare service over which commu
nities had some control?
It is time to put political and economic ideology aside
and determine the methodology that will yield the greatest
gains and provide access to even the most basic of services
for All People Beyond the Year 2000.
Competing interests
None identified.
References
1. Declaration of Alma-Ata. International Conference on Primary Health Care. Alma-
Ata, USSR, 6-12 September 1978. Available at <http://www.who.int/hpr/archive/
docs/almaata.html>.
2. Braveman P, Tarimo E. Social inequalities in health within countries: not only an
issue for affluent nations. Soc Sci Med 2002; 54; 1621-1635.
3. Bennett F. Primary health care and developing countries. Soc Sci Med 1979;
13A: 505-514.
4. Benyoussef A. Christian B. Health care in developing countries. Soc Sci Med
1977;11:399-408.
5. Oral glucose/electrolyte therapy for acute diarrhoea [editorial]. Lancet 1975; 1: 79.
6. Pierce N, Hirschhorn N. Oral fluid — a simple weapon against dehydration in
diarrhoea: how it works and how to use it. WHO Chron 1977; 31: 87-93.
7. The Mahler revolution [editorial], BMJ 1977; 1: 1117-1118
8. Spencer M. Public health in Papua New Guinea. 1870-1939. ACITHN Mono
graph No. 2. Brisbane: University of Queensland. 1999.
9. Dennon D. Public health in Papua New Guinea: medical possibility and social
constraint 1884-1984. Cambridge: Cambridge University Press, 1989
10. World Health Organization global strategy for health for all by the year 2000
Geneva: WHO, 1981.
11. Warren K, The evolution of selective primary health care. Soc Sci Med 1988; 26:
891-898.
12. Unger J, Killlngsworth J. Selective primary health care: a critical review of
methods and results. Soc Sci Med 1986; 22: 1001-1013.
13. Werner D. Health hazard: user fees. New Internationalist 2001; 3l(Jan): 22-23.
14. Tarimo E. Webster EG. Primary health care concepts and challenges in a
changing world Alma-Ata revisited. ARA Paper Number 7 (WHO/ARA/CC/97.1).
Geneva: WHO, 1997.
15. World Bank. World development report 1993: investing in health. New York:
Oxford University Press, 1993.
Conclusion
As the world reviews healthcare services beyond 2000,23
work continues on reducing health inequities for poor
people. Concern is being expressed that people living in
absolute poverty still do not have access to basic services or
a healthy environment.2 As economic development
improves the incomes and standards of living in many
developing countries, an increasing gap is opening up
between the rich and the poor and this is associated with
inequitable access to healthcare services. There are now
calls to give voice to the poor so they have a greater say
in how healthcare services are delivered.24 But, then, isn’t
this PHC?
Further, as we reflect on recent world events, surely we
must address the underlying causes. The United States is
prepared to spend SUS 100 billion on a war in Iraq,25,26 but
only contribute SUS200 million to the Global Fund to
Fight AIDS, Tuberculosis and Malaria. If those funds were
expended on the provision of an equitable and comprehen
sive PHC system and the relief of the massive debt burden,
this would be a major step in addressing the prevailing
sense of frustration in resource-poor countries.
20
16. Primary Health Care 21: 'Everybodys Business". An international meeting
celebrating 20 years after Alma-Ata. Almaty. Kazakhstan. 27-28 November 1998
Geneva: WHO. 1998.
17. World Health Organization. The World Health Report 2000. Health systems:
improving performance. Geneva: WHO. 2000. Available at <http://www.who.int/
wh r2001/2001/archi ves/2000/en/contents. htm >.
18. Hill A, MacLeod W. Joof D. et al. Decline of mortality in children in rural Gambia:
the influence of village-level primary health care. Trop Med Int Health 2000- 5
107-118.
19. World Health Organization. Global measles vaccine coverage and reported
cases, 1980-1999. May 2000. Available at http://www.who.int/vaccines-surveillance/graphics/htmls/measlescascov.htm (accessed 15 Oct 2002).
20. Rutstein S. Factors associated with trends in infant and child mortality in
developing countries during the 1990s. Bull World Health Oman 2000- 78
1256-1270.
21 Whitehead M, Dahlgen G, Evans T. Equity and health sector reforrhs: can lowincome countries escape the medical poverty trap? Lancet 2001; 358: 833-836
22. Chowdhury Z, Rowson M. The people’s health assembly. BMJ 2000; 321
1361-1362.
23. Zwi A, Yach D. International health in the 21st century: trends and challenges
Soc Sci Med 2002; 54: 1615-1620.
24. Mehrotra A, Jarrett S. Improving basic health service delivery in low-.ncome
countries: “voice" to the poor. Sog Sci Med 2002; 54: 1685-1690.
25. Sachs J. Weapons of mass salvation. The Economist 2002; Oct 20: 73-74.
26. Kleinert S. What are the world's priorities? Lancet 2002; 360: 1118.
(Received 28 Oct 2002. accepted 7 Nov 2002)
MJA
Vol 178
□
6 January 2003
A
J.
LOT®
COMMUNITY-ORIENTED PRIMARY
CARE AND PRIMARY HEALTH CARE
J
J
J
J
2
Nowadays there is a renewed interest in the
role of primary care as an essential compo
nent of the delivery of health care. Cueto’s
article on the role of the World Health Organi
zation (WHO) in the emergence of primary
health care’ is timely indeed and stimulates
discussion about this dimension of health care.
We wish to direct attention to an approach
not mentioned in Cueto’s article that is taught,
practiced, and written about extensively—the
community-oriented primary care (COPC)
model. The recent application and evaluation
of COPC in various countries was reported
in several articles published in the November
2002 issue of the Journal.
The conceptual roots of COPC were intro
duced and developed in the 1940s by Sidney
Kark and Emily Kark in a rural area of South
Africa. As family physicians, the Karks imple
mented a comprehensive approach to care, tak
ing into account the socioeconomic and cultural
determinants of health, identifying health needs,
and providing health care to the total commu
nity. Their pioneering work, integrating preven
tive and curative care with significant commu
nity involvement, created a service network of a
kind scarcely known then in that continent, with
more than 40 community health centers estab
lished in different regions of the country.2 The
Letters to the editor rearing to a recentJournal
article are encouraged up to 3 months after the
article’s appearance. By submitting a letter to
the editor, the author gives permissionfor its
publication in theJournal Letters should not
duplicate material being published or submitted
elsewhere. The editors reserve the right to edit
and abridge letters and to publish responses.
Text is limited to 400 words and 10 refer
ences. Submit online at www.ajph.orgfor
immediate Web posting, oratsubmitajph.org
for later print publication Online responses are
automatically consideredforprint publication
Queries should be addressed to the department
editor, Jennifer A. Edis, PhD, atjae33@
columbia.edu
Karks and their team developed this approach
further at the Community Health Center of the
Hadassah School of Public Health and Commu
nity Medicine in Jerusalem.3
In Sidney Kark’s book Epidemiology and
Community Medicine published in 1974, be
fore Alma Ata), he speaks of “community
medicine and primary health care as a unified
practice.”4^75 This approach, which later was
denominated COPC,5 is considered an expres
sion of the Alma Ata spirit6-7
In our COPC teadung,8 we have had fre
quent discussions with international public
health students, mainly Africans, concerning
the similarities and differences between
COPC and the primary health care approach
of WHO. As an explicit expression of the role
played by COPC in the development of the
WHO primary health care approach, Litsios
notes (also in the November 2004 issue of
the Journal) that there is evidence of “many
similarities between primary health care and
Kark’s work in Africa."9^1890>
The renewed interest in primary care is
particularly appropriate because primary care
is the component of health services that ad
dresses most of the health problems arising
in a community, and when it is enhanced by
a community orientation, it can be considered
public health at the local level.10 ■
Jaime Gofin, MD, MPH
Rosa Gofin, MD, MPH
About the Authors
77» aulhors are with Hebrew Urwersity-Hadassah School
of Public Health and Community Medicine,Jerusalem, Israel
Requests for reprints should be sent to Jaime Cofin, MD.
MPH. Hadassah School ofPublic Health, PO Box 12272,
Jerusalem 91120, Israel (e-mail: jaime@md.huji.ac.il).
doiI0.2105/AJPH.2004.060822
References
4. Kark SL Epidemiology and Community Medicine
New York, NY: Appleton-Century-Crofts; 1974.
5. Kark SL The Practice of Community Oriented
Primary Health Care. New York, NY: Appleton-CenturyCrofts; 1981.
6. Susser M. Pioneering community-oriented primary
care. Bull World Health Organ. 1999;77:436-438.
7. Ashton J. Public health and primary care: towards
a common agenda. Public Health. 1990;104:387-398.
8. Gofin J. Planning the teaching of community
health (COPC) in an MPH program. Public Health Rev.
2002:30:293-301.
9. Litsios S. The Christian Medical Commission and
the development of the World Health Organization-s
primary health care approach. Am J Public Health.
2004;94:1884-1893.
10. Kark SL, Kark E, Abramson JH, Gofin J, eds.
Atencion Primaria Orientada a la Comunidad [in Span
ish]. Barcelona: Ediciones DOYMA SA; 1994.
CUETO RESPONDS
I am grateful for Gofin and Gofin’s letter men
tioning an important dimension of primary
health care that I did not examine in my article.
One reason for its absence is that I did not find
the term “community-oriented primary health
care” very frequently in the archival materials of
the late 1970s and early 1980s of the World
Health Organization, the United Nations Chil
dren’s Fund, the Rockefeller Foundation, and the
Ban American Health Organization My article
was the first result of 2 years' investigation based
on the archives of these official health agencies.
My research is ongoing, and I am certain that in
the future I will find many remarkable cases of
community-oriented primary health care that
may have been missed by the official agencies.
I very much agree with Gofin and Gofin
that the work of Sidney and Emily Kark is
crucial for anyone interested in primary
health care. Their letter suggests the need for
more research on the history of primary
health care, and I thank them for it ■
1. Cueto M. The origins of primary health care and
selective primary health care. Am J Public Health.
2004;94:1864-1874.
2. Tollman SM. Community oriented primary care:
origins, evolution, applications. Soc Sci Med. 1991 ;32:
633-642.
3. Kark SL, Kark E. Promoting Community Health:
From Pholela to Jerusalem. Johannesburg, South Africa:
Witwatersrand University Press; 1999.
May 2005. Vol 95, No. 5 | American Journal of Public Health
Marcos Cueto, PhD
About the Author
Requests for reprints should be sent to Marcos Cueto, PhD,
Facultad de Sahid Pilblica, Universidad Peruana Cayetano
Heredia, Avenida Honorio Delgado 430, Lima 31, Peru
(e-mail: mcueto@upch.edu.pe).
doi:!0.2105/AJPH2005.062521
Letters | 757
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€
Soc. Sd. Med. Vol. 39, No. 4. pp. 455-458, 1994
Copyright © 1994 Elsevier Science Ltd
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EDITORIAL
PRIMARY HEALTH CARE AND THE HOSPITAL:
INCOMPATIBLE ORGANISATIONAL CONCEPTS?
Laurence Malcolm
3
Primary health care (PHC), in one form or another,
has become a key policy priority in the health systems
of most countries, both developing as well as devel
oped. This new approach, formally launched with
great expectations at the Alma-Ata Conference in
1978, was seen to be the key strategy by which Health
for All would be achieved [1,2]. In describing events
leading up to Alma-Ata, Newell [2] refers to a report
to the 1973 Executive Board of WHO on major
health service problems of inadequate coverage, gaps
in health status within and between countries, rapidly
rising costs and a feeling of helplessness on the part
of consumers. This report led the Board to conclude
that these problems were “symptoms of a wide and
deep seated error in the way health services are
provided” [2], Newell [2] states that debates on this
report led directly to the emergence of the WHO
concept of PHC and to Alma-Ata in 1978.
Despite widely held expectations of what this new
approach might achieve, progress towards health
systems based upon PHC, with its emphasis upon
social justice, a broad concept of health, intersectoral
integration and participation by communities in de
veloping comprehensive, equitable and holistic treat
ment and preventive services has been slow [3]. While
recent reports have drawn attention to increasing
political commitment to Health for All and signifi
cant gains achieved globally in life expectancy [3,4],
they have also noted the widening gap in health status
between rich and poor countries and an increase in
both communicable and non-communicable disease.
Health systems in all countries continue to be domi
nated by hospitals and provider groups with priorities
largely determined by increasing demands and expec
tations for tertiary and high technology type services
[4]. Is the ‘deep-seated error’ that concerned WHO in
1973 still present? The problems of 20 years ago
certainly are and in greater measure. Is the problem
the continued recognition of the hospital as a key
organisational entity of health systems particularly
when its goals appear to be in fundamental conflict
with those of PHC? Is there an alternative to hospi
tals?
PHC continues to be bedeviled by both conceptual
confusion and operational uncertainty [5-8]. Con-
ceptually, PHC has been seen to be polarised between
two extreme viewpoints [2,9, 10]. The ‘comprehensivists* take the somewhat fundamentalist position
that PHC is largely an approach, a philosophy and
strategy for reorienting health systems and eschew its
implementation as a service to be organised and
managed [11,12]. At the opposite pole are the ‘selectivists’ who advocate the implementation of frag
ments of PHC, so-called vertical programmes such as
immunisation, family planning, cervical screening,
etc., detached from the other components of PHC
including generalist ser/ice provision [9, 10]. These
problems are particularly evident in developing
countries through the influence of donor agencies
but are also important in developed countries’
programmes. Such approaches do little to develop
an integrated and sustainable infrastructure for
PHC.
A number of compromises to these somewhat
extreme positions have been advocated [13—15]. The
position of WHO itself has been somewhat unclear.
Its publications over the years, representing the views
of participants in various expert committees, study
groups etc., have seen it as inclusive of a philosophy
concerned with equity and social justice, a strategy
concerned with intersectoral collaboration, a level of
care including being the point of first contact with the
health system and a set of at least eight activities,
including the provision of clinical services [16-19].
But this broad spectrum view has done little to
clarify the operational aspects of PHC. PHC has been
variously equated with community-based care, with
primary medical care or more often just called pri
mary care [20,21]. Starfield sees PHC as evolving
from primary medical care with a progressive shift
towards the goals of Alma-Ata [21], In practice most
countries, indifferent to or unimpressed with the
conceptual debate, are implementing some form of
PHC inclusive of some of the basic elements although
tending to focus more upon the clinical and preven
tive aspects rather than broader strategic concerns.
But few countries have seen PHC as an organis
ational strategy, a key subsystem of the health system
to be organised and managed in its own right.
Consequently it remains largely a disjointed set of
455
1
456
Editorial
fragmented provider and community groupings with
little collective power to influence decision making.
While there may be a desirable idealism in PHC as
a philosophy and an approach to reorienting health
systems little progress might be expected having
regard to the realities of the power structures influ
encing health systems. In short hospitals have been
empowered to dominate health systems by being
recognised as organisational and managerial entities.
By contrast PHC has been disempowered by being
denied such status.
Most decisions about PHC see it as complementing
hospital-based services [17-19]. However, this pre
sumes that, in contrast to the hospital, PHC is
largely, if not entirely, community-based care. But
community-based care can include specialised care
such as provision of mental health services, disability
services and public health engineering services which,
even in the broadest sense, could not realistically be
called PHC. On the other hand, there are many
hospital-based activities which could be classified as
PHC including the basic services provided within the
district in many developing countries. PHC could
also include the services provided by smaller commu
nity-type hospitals in developed countries. It also
logically includes the services of primary care
providers such as general practitioners and midwives
undertaking maternity and other type care even in
larger hospitals.
To what extent does this conceptual and organis
ational confusion stem from the continuing accep
tance of the hospital as an organisational entity?
Almost all health systems are divided organisation
ally and managerially into hospital-based services on
the one hand and community-based services on the
other [22, 23]. But while there are strengths in hospi
tals as organisational entities, including their clearly
defined architectural boundaries, their ability to co
ordinate services under one roof, their being a base
for education and training and being valued as an
important resource by communities, they have many
weaknesses. These include their ability to dominate
health systems in almost all countries and to absorb
resources from less powerful and often poorly organ
ised PHC and community services. Their goals are
largely focused on the development of specialised
activities, they may become a ‘fortress’ to protect
those working inside their walls from responding to
the needs of the community and they may become a
‘prison’ for those needing to undertake community
based activities. A significant volume of health re
sources is tied up in plant and equipment.
However, the overiding problem of hospitals, as
organisational entities, is that they fragment the
continuum of care, the delivery of integrated services
which should be inclusive of both hospital- as well as
community-based care. A mental health service, for
example, should be an integrated entity inclusive of
psychiatric wards of a general hospital, the mental
hospital of an area, where it exists, and community-
based mental health services including those provided
by a range of agencies [24].
An alternative view to this ‘anatomical’ or loca
tional division of health systems into hospital-based
services on the one hand and community-based ser
vices on the other is a ‘physiological’ or functional
approach to health care organisation [22]. Based on
a systems approach this involves dividing the health
system more fundamentally, not on location but on
level, into PHC on the one hand and secondary
health care on the other. In this division PHC is not
only a level of care. It is also care which can be
generalist, holistic, continuing and comprehensive.
This contrasts with secondary care which is special
ised, dealing with only one aspect of the person’s
needs and is episodic [22],
Under this model, hospitals and community ser
vices, as organisational divisions of health systems,
would be replaced by service programmes or subsys
tems of the health system. Such services, medical,
surgical, child health, mental health, etc., as well as
PHC, would have both a community- as well as a
hospital-based component. PHC would be the infra
structure service underpinning all others [22], As
such, PHC may be inclusive of services provided by
general practitioners and other PHC providers,
nurses, social workers, etc., as well as preventive and
health promotive activities. In a smaller locality it
may include the hospital-based services which are
essentially just PHC. As an organised entity PHC
could become the budgetholder for referral to sec
ondary care and thus become a practical strategy for
shifting the balance of care from secondary to pri
mary. In developing countries a PHC service could
include the general outpatients section of the district
or regional hospital as well as the urban and rural
health centres.
PHC, as an accountable service, could develop
closer relationships with communities and establish
significant community participation and even owner
ship of such a service. It would be able to argue, on
the grounds of equity, for a fairer share of the health
resources for a defined population to be distributed
to localities and groups in greatest need in an area.
An accountable, managed PHC service could also
support such projects as healthy cities, thus demon
strating, in a practical way, its involvement in inter
sectoral action.
Such a service would appear, at least at this
operational level, to fulfil many of the requirements
of the ‘comprehensivists’. Furthermore, as an inte
grated, comprehensive and holistic service, it can be
contracted to for the delivery of a wider range of
treatment and preventive programmes. It thus estab
lishes a sustainable infrastrucure for the ongoing
provision of such services, thus satisfying the de
mands of the ‘selectivists’.
But is this just a theoretical concept with little basis
in practical reality. The integrated continuum of
hospital- and community-based care which has been
€
Editorial
successfully implemented in mental health services in
a number of countries is one example of this model
[24] . Evidence is emerging from developments in New
Zealand’s health system, which has possibly been
through more organisational reform than any other
developed country, that services have largely replaced
hospitals as the key organisational units of the health
system [23,24]. In a recent survey, 58% of top
managers of New Zealand’s area health boards
agreed with the statement that services had replaced
hospitals as organisational entities [25]. Only 23%
disagreed. Furthermore, 93% stated that there were
advantages in managing services rather than hospitals
[25] .
The most recent reorganisation, implemented on 1
July 1993, put in place crown health enterprises
(CHEs) as the main delivery units of the public health
system [26]. CHEs, like the previous area health
boards, which were fully implemented only in 1989,
are still largely population-based delivery systems,
providing comprehensive treatment and preventive
services [25]. Most have been organised along ser
vices lines with service managers for mental health,
elderly, medicine, surgery, child health and, in in
creasing numbers of CHEs, for PHC. Managers of
PHC are responsible for such community-based ac
tivities as community support services, sexual health
services, social work, health promotion, community
hospitals and, to an increasing extent, liaison with the
privately provided general practitioner services. In
creasingly, general practitioners are becoming ac
countable, through collective independent practice
associations, for contracting with the four newly
formed regional health authorities (RHAs). These
RHAs have the potential to be the most integrated
purchasing system of any developed country with
responsibility for the purchasing of public and pri
vately provided government-funded services, hospital
and community, secondary and primary, health and
disability services.
While it is too early to be confident that an
integrated, comprehensive PHC service will emerge
from these new structures, a trend towards this is
occurring. This is possible because, for the large part,
New Zealand has replaced hospitals with service
programmes as organisational entities. This opens the
way for PHC to emerge, not just a service division but
a key service underpinning all others. It is able, in so
doing, to influence the balance of both hospital and
community services on the one hand and secondary
and primary services on the other. It also provides an
accountability entity for moving towards integration
and for closer relationships with communities and
consumers through community budgetholding.
An integrated, comprehensive, managed PHC ser
vice, underpinning a set of secondary care services,
which means going beyond hospitals as organis
ational entities, may be the key to solving some of the
basic problems facing all health systems and achiev
ing better progress towards Health for All.
G
Aa'
457
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14. Mosley W. H. Is there a middle way? Categorical
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*
' HEALTH POLICY AND PLANNING; 16(3): 221-230
© Oxford University Press 2001
Review article
Community participation in health: perpetual allure, persistent
challenge
LYNN M MORGAN
Department of Sociology and Anthropology, Mount Holyoke College, South Hadley, MA, USA
The concept of community participation continues to capture the attention of international health policy
makers and analysts nearly a quarter of a century after it was formally introduced at the Alma Ata Confer
ence. This paper reviews trends in the participation literature of the 1990s, drawing examples primarily from
Latin America. The following topics are discussed: sustainability, new methods for operationalizing and
evaluating participation, the significance of local and cultural variability in determining outcomes, partici
patory self-determination as raised in the social movements literature, the increasing importance of inter
sectoral linkages, and continuing impediments posed by biomedical ideologies and systems. While the
rhetoric and practice of participation have become fully integrated into mainstream health and development
discourses, the paper concludes that ideological and political disagreements continue to divide pragmatists,
who favour utilitarian models of participation, from activists, who prefer empowerment models.
Introduction
J
This paper1 reviews recent trends and debates concerning the
concept of community participation in health, focusing on
new ideas that were added to the debate during the 1990s, and
focusing specifically on examples drawn from Latin America.
There, as elsewhere, participation has captured the attention
of health planners, policymakers and activists, and become
well entrenched in mainstream health discourse. This wide
spread consensus about the importance of participation
follows years of disagreement about what it meant and how
best to create participation. Twenty-five years after the for
malization of the concept at the Alma Ata Conference in
1978, advocates of participation tend to have a greater
appreciation of the difficulty and complexities involved in
enhancing participation than they did then. The analytic com
plexities, definitional disputes, and operational challenges
have been thoroughly (even exhaustively) discussed and
illustrated through case studies. Today, a middle ground
has opened for researchers who focus on methodologies
for monitoring and assessing participation and for making
sure that the principle is woven into policy and planning at
district and national levels in addition to international levels
(Chambers 1995; Kahssay and Oakley 1999).
Because so much of the debate over participation involves
conversations between anthropologists and epidemiologists,
this paper will also address how the concept has been ana
lyzed by anthropologists and other social scientists, and by
epidemiologists, health service managers and policymakers.
While their approaches often overlap, anthropologists are
more typically concerned with conceptual issues such as what
the concept means to those involved in implementation, while
epidemiologists, managers and policymakers are often con
cerned with how to operationalize, implement and measure
levels of participation.
The definitional divide: utilitarian and
empowerment models
Community participation in health has traditionally been
defined according to one of two distinct perspectives. Firstly, it
can be a utilitarian effort on the part of donors or governments
to use community resources (land, labour and money) to offset
the costs of providing services. Nelson and Wright describe this
as ‘participation as a means (to accomplish the aims of a project
more efficiently, effectively, or cheaply)’ (1995 [1986], p. 1;
emphasis in original). In the most recent and comprehensive
World Health Organization (WHO) publication on the
subject, Kahssay and Oakley describe one of the interpre
tations of participation as ‘collaboration’, in which people
‘voluntarily, or as a result of some persuasion or incentive,
agree to collaborate with an externally determined develop
ment project, often by contributing their labour and other
resources in return for some expected benefit’ (1999, p. 5; see
Morgan 1993; Bronfman and Gleizer 1994 for reviews of
this literature). On the other hand, participation can be
defined as an empowerment tool through which local com
munities take responsibility for diagnosing and working to
solve their own health and development problems. Nelson and
Wright describe this as ‘participation as an end, (where the
222
Lynn M Morgan
community or group sets up a process to control its own
development)’ (1995, p. 1); others describe this as an
empowerment approach, or as people-centered development.
Each of these definitions itself encapsulates a range of mean
ings; for example, empowerment may be defined as simply
allowing community representatives a seat at the table where
policy decisions are made, or it may mean a process of democ
ratization whereby governments become more open and
responsive to the needs of disenfranchised citizens. Some pro
ponents herald participation for its cost-sharing potential and
its contribution toward building sustainable programmes.
Others emphasize the need for effective partnerships
between government and citizenry, and yet others stress the
prospects for democracy that would follow if governments
were accountable to citizens. How can one phrase carry so
many definitions?
The proliferation of meanings attached to the phrase ‘com
munity participation in health’ (also called ‘popular partici
pation’, ‘social participation’ and ‘community involvement’)
has allowed it to be analyzed as a political symbol capable of
being simultaneously employed by a variety of actors to
advance conflicting goals, precisely because it means different
things to different people (Morgan 1993). Chambers lists as
one of the definitions of participation its ‘cosmetic’ value, its
ability ‘to make whatever is proposed look good’ (Chambers
1995, p. 30). Participation quickly became a regular feature of
international health discourse in part because the word
sounds so appealing and desirable, which may also explain
why it was so heartily endorsed at Alma Ata. It is now an
essential element of community health and other develop
ment programmes sponsored by NGOs and international
donors.
That participation has been institutionalized in mainstream
development discourse is evident in the fact that the World
Bank has adopted the concept. After publishing several docu
ments about participation over the last decade, the World
Bank defines it as: ‘a process through which stakeholders
influence and share control over development initiatives and
the decisions and resources which affect them’ (World Bank
1996). The Bank defines ‘stakeholders’ not as the poor or dis
advantaged, as we might imagine based on the discussion thus
far, but as all those who ‘could affect the outcome of a pro
posed Bank intervention or be affected by it’. This includes
‘borrowers, that is, elected officials, line agency staff, local
government officials’, ‘indirectly affected groups, such as
non-governmental organizations (NGOs), private sector
organizations, and so forth’, as well as ‘Bank management,
staff, and shareholders’. The Bank notes that these powerful
stakeholders might oppose Bank efforts if attempts are made
to bypass them. The decision to define ‘stakeholders’ in this
way, they say, ‘is a decision that we have made consciously,
and one that has potentially important implications for the
way the Bank works’ (World Bank 1996). Sceptics might
argue that the Bank’s definition co-opts the concept of ‘par
ticipation’, using it to put a rosy face on business as usual.
They might argue that we should all be sceptical of using
organizations like the World Bank as major actors in attempts
to strengthen civil society, at the same time that states (in the
neoliberal economic model) are being asked to step back.
The danger with this model, as Jelin notes for NGOs and
international financial institutions in general, is that they ‘do
not have a built-in mechanism of accountability’; they claim
various constituencies (including, in the case of the Bank, the
rich AND the poor), but they are accountable to none of
them (Jelin 1998, p. 412; see also Mayo and Craig 1995). At
the very least, though, the Bank’s definition acknowledges
what many others have said: participation is about power.
Power struggles are, to many analysts, crucial to the long-term
viability of participatory endeavours. Susan Rifkin, one of the
world’s foremost experts on participation in health, argues
that participation programmes have often failed to meet
expectations precisely because they were ‘conceived in a par
adigm which views community participation as a magic bullet
to solve problems rooted both in health and political power’
(1996, p. 79). Struggles over power are not necessarily
destructive; Chambers points out that, ‘Conflict can be an
essential and creative factor in change for the better’ (Cham
bers 1998, p. xviii). In order for conflict to be productive,
however, planners and policymakers need to anticipate it and
devise mechanisms to accommodate it. Participation pro
grammes that cannot cope with disputes over power are likely
to fall short of expectations.
Paradoxically, neither of the two most widely used notions of
participation calls for it to be initiated entirely by community
members; each entails some degree of outside motivation.
‘Encouraging participation is something that practically by
definition comes from above or outside’ (Uphoff et al. 1998,
p. 83). Even Robert Chambers, whose respectful approach to
community work has won admiration in international health
circles, admits that participation is never consensual, at least
in the short run, for many projects (Chambers 1998, p. xviii).
Many proponents of the empowerment approach to partici
pation would like to ignore the uncomfortable fact that par
ticipation may require outside prompting; they would rather
see spontaneous, self-generating conscientization and partici
patory action on the part of poor community members.
Increasingly, however, they are willing to acknowledge that
marginalized or disenfranchised communities are powerless
to effect participation precisely because they have no power,
and that outsiders might succeed in fostering community
mobilization if they act with great sensitivity and humility.
‘A complex of factors, varying from country to country as
well as community to community, maintains a political,
economic, and social status quo that keeps the large
majority of rural people from having much voice in or
control over their lives. Poverty, prejudice, despair,
paternalism, local power structures, legal and regulatory
restrictions, adverse past experiences, and other forces
commonly discourage people from playing more active
roles in changing their circumstances and opportunities.
Yet there are encouraging examples of emergent local
activism and institutional development that can change
the participation equation.’ (Uphoff et al. 1998, p. 83)
Today, facilitators and policymakers are more willing to
assume the responsibility that is entailed by their desire to
C'
Community participation in health
enhance participation. This means that they must take greater
responsibility for planning the kind of participation they want
to encourage. Guidebooks for participation planners often
emphasize that project planners must begin by having
detailed discussions about their own goals and definitions of
participation before taking the concept to the field.
Frits Muller, a well-respected activist and theorist of partici
pation who has worked in Latin America, expands the dis
cussion of participation beyond definitional issues to include
hierarchies of power in Latin America. He does not agree
that participation needs to be initiated by outsiders; partici
pation, he says, emerges when citizens demand that the state
include them. His perspective is apparent in the first two sen
tences of his book: ‘Latin America is characterized by the
grand inequality that exists between rich and poor, mestizos
and indios, city and countryside, man and woman. These
inequalities are so obvious and so repugnant that no one can
remain unmoved; not the visitor, and certainly not any of
those who suffer’ (Muller 1991, p. 13). The problem of poor
health in Latin America, he says, is largely attributable to the
marginalization of certain sectors of the population. Only
about 15% of the population can afford to buy private
medical care, another 15% enjoy either state-subsidized or
private insurance, and 70% have to rely on state-provided
health services. Of those 70%, about half do not have access
to medical care even in the event of an emergency. In this
context, he says, participation is not a state- or NGO-initiated
effort, but a local reaction to desperate living conditions:
‘This kind of participation forms part of a survival strategy for
marginalized people, expressed in traditional health services
and in the demands for decent services they make of the Min
istry of Health. It finds expression in, among other things, the
soup kitchens, the glass of milk programs, school lunches,
mothers groups and neighborhood and peasant health
organizations; these are the specific manifestations of opposi
tion in our unequal societies’ (Muller 1991, p. 16). If we con
trast Muller’s perspective with that offered by the World
Bank, for example, we can see that there are still great dis
crepancies over the way that participation is defined and prac
ticed, even 25 years after the optimism generated by the Alma
Ata Conference.
New ideas about participation in the 1990s
5
Much has changed since Alma Ata. The remainder of this
paper reviews some of the new language and concepts that
have influenced the discussion pertaining to participation
generally, as well as to participation in health, in the past
decade. The first section deals with the notion of ‘sustainabil
ity’, which entered development discourse in the 1990s and
prompted theorists to discuss whether participation was a
product or a process. Those who advocated participation as a
product (often for pragmatic reasons, including the need for
donor accountability) were keen to develop methods to oper
ationalize and evaluate participation; this is the topic of the
second section. The tendency to systematize and opera
tionalize participation was counterbalanced by those who
emphasized the importance of local context; the third section
reviews discussions about culture, context and the state. It
includes a brief review of lessons learned from fine-grained
223
case studies of participatory initiatives. The literature on
social movements in Latin America has not yet been fully
incorporated into the discourse on participation in health, but
the fourth section argues that the social movements literature
offers useful analytic insights. The fifth and sixth sections,
respectively, review the emerging consensus that intersec
toral collaboration is essential to successful community-based
health programmes, and that biomedical training and the
hierarchical structure of medical practice is a barrier to par
ticipation. The paper concludes that notions of participation
are infinitely more nuanced and complex today than they
were a decade ago, yet many of the same fundamental ideo
logical divisions remain.
Sustainability and process
Sustainability was one of the big international development
buzzwords of the 1990s, so perhaps it was inevitable that the
term would be applied to health programming and partici
pation (LaFond 1995). Like ‘participation’, the term ‘sustain
ability’ has multiple meanings. For donors, it may mean that
project costs can be borne by locals without further inter
national aid; for policymakers it may mean that the initiative
in question (such as participation in health) has to be con
tinually reinvented and reinvigorated in order to stand the
test of time. Uphoff et al. caution that the term is ‘highly
favored these days by governments and donor agencies’ and
that it is ‘often used in overblown ways and [is] easily over
stated’ (Uphoff et al. 1998, p. 196). The marriage of the con
cepts of ‘sustainability’ and ‘participation’ has led analysts to
add sustainability criteria to the list of points on which par
ticipation will be evaluated.
In response to this challenge, analysts of participation have
stressed that participation is a continuous process. Questions
about sustainability raise questions about how to define a pro
gramme and how to determine the point at which it should be
assessed. In response to the question about defining pro
grammes, Krishna et al. (1997) emphasize that blueprint
models rarely work and that participatory initiatives must be
adaptable to local situations. Canned or cookbook models of
participation are thus rarely ‘sustainable’, if we understand
that to mean static and unchanging. As for the question of
assessment, Kalinsky and colleagues note that participatory
programmes are often evaluated in the literature on an ‘all or
nothing’ basis; they have either succeeded or failed (Kalinsky
et al. 1993, p. 11). If participation is a process, however, it is
difficult to know whether and when a programme has finally
reached its endpoint. Analysts today tend to stress that par
ticipation is not a product or a time-delimited project; rather,
it needs to be ‘continuous, sustained and locally grounded’
(Krishna et al. 1997, p. 5).
Participation can be sustainable only as long as the relevant
actors remain committed, and the sociopolitical and econ
omic environments remain conducive, to the process. Process
has therefore emerged as the sine qua non of participatory
endeavours: ‘The key issue [in the first steps of project
development] is the notion of process and the fact that
community participation is not merely an input to the project
but the basis upon which it will operate. Furthermore,
224
Lynn M Morgan
participation cannot be assumed but has to be systematically
encouraged, and means have to be created to make it effec
tive’ (Oakley et al. 1999, p. 117). Processual understandings
of participation make sense to those interested in theory and
implementation, but they can compound the challenges of
operationalization, measurement and assessment.
Operationalization and evaluation
WHO and UNICEF were the multilateral sponsors of com
munity participation in health, and their names are still
strongly associated with the concept. The WHO’s most
recent document on the subject, Community involvement in
health development: a review of the concept and practice, pro
poses that participatory thinking needs to be institutional
ized at district levels in national ministries of health
(Kahssay and Oakley 1999). The authors argue that partici
pation efforts in the 1980s and 1990s often bypassed national
and district levels of health planning and policymaking. Par
ticipation was originally introduced as an international
mandate, yet as part of the primary health care strategy it
was often implemented at local levels. National ministries of
health did not usually enlist the support of clinicians and
other health professionals, nor did they seek the support of
institutions that were not directly involved in primary health
care. Consequently, Kahssay and Oakley say, there is still a
great deal of resistance to participation among health pro
fessionals and institutions, especially at district levels. If
these important constituencies continue to be excluded, par
ticipation will likely never become fully accepted and will
always meet resistance. They argue, therefore, that project
level commitment to community participation, while import
ant, is insufficient to insure the sustainability of the concept;
that what they call ‘community involvement in health (CIH)’
should be regarded as a principle rather than a programme.
In order for participation to be sustainable, it must extend
beyond the local (or project) level. ‘For CIH this is the key
issue; it is not just a question of people’s participation in
health activities or health projects but, more importantly,
their involvement in district-level health services which is
crucial to sustainable health development’ (Kahssay and
Oakley 1999, p. 18; emphasis in original).
Sceptics may argue that Kahssay and Oakley have taken an
overly technocratic view of the concept of health partici
pation, leading to a self-fulfilling call for professional training
and development workshops, educational and curricular
reform, and capacity building among health clinicians, plan
ners, managers and labour organizations. The authors
demonstrate familiarity with the political and situational
complexities of participation, but in comparison to earfier
documents, the implications of their analysis are specific to
the health sector and do not emphasize the value of building
democratic institutions or citizens. In this sense, the latest
document to emerge from WHO can be analyzed within a
larger global sociopolitical and economic framework; once
the appearance of democracy was restored to most Latin
American countries, the rhetoric of participation could be
transformed into a reformist, technocratic project and shed its
radical connotations. If this document is read as a portent of
trends in health participation, we might expect international
health agencies to adopt policies and support programmes
that are more pragmatic and less idealistic.
Critiques aside, development planners are often under pres
sure to systematize and generalize concepts such as par
ticipation, so that other planners and technicians can
‘consciously include this principle in their programme plans
and evaluations’ (Rifkin et al. 1988, p. 931), learning from
them and thereby ostensibly maximizing their own chances
for success. Donors usually also require that projects be
evaluated. During the 1990s, these pressures led to a rapid
proliferation of new methodologies and techniques both for
assessing rural health and development needs, and for design
ing implementation, intervention and evaluation pro
grammes. Oakley and colleagues, for example, have worked
on a methodology for enhancing community involvement in
health which entails training staff and setting up mechanisms
at the project level to monitor participation and to evaluate
its effect (Oakley et al. 1999, p. 115). A full review of these
approaches is beyond the scope of this paper, but it is import
ant to mention the proliferation of rapid appraisal techniques
and participatory action research methodologies (Nichter
1984; Scrimshaw and Hurtado 1987; Fals-Borda and Rahman
1991; Manderson and Aaby 1992). Developed during the
1980s, these approaches turned into a booming business
opportunity for qualitative researchers who generated a veri
table mountain of books, documents and reports directed at
community researchers (Rahman 1993). Analysts are quite
cognizant of the multiple dilemmas posed by these trends:
‘The situation today [1996] reveals two paradoxes in par
ticipatory development. The first involves the standard
ization of approaches. This trend contradicts one of the
original aims, to move away from the limitations of
blueprint planning and implementation towards more
flexible and context-specific methodologies. A second,
related, paradox lies in the technical, rather than
empowerment-oriented, use of “participatory” methods.
A manual and method-oriented mania has led many to
claim successful participatory development, despite only
a superficial understanding of the underlying empower
ment principles that were at the root of much pioneering
work.’ (Guijt and Shah 1998, p. 5; see also Rifkin et al.
1988)
Given the divisions within and outside the development
establishment, anyone who watched the debates over partici
pation in the 1980s could well have predicted the situation
that would emerge in the 1990s. Just as ‘community’ is not a
monolithic entity, neither is the development establishment,
which contains within it both the propensity to standardize
and to adapt to local circumstances. The tendency during the
1990s to pay heed to qualitative research was a positive event
for anthropologists and other social scientists, who were
finally able to bring local meanings and alternative social
movements into mainstream conversations within the
development establishment. Furthermore, the work provided
for social scientists by the enthusiastic reaction to partici
patory research methodologies has allowed social science
perspectives, theories, ideologies and politics (various though
these are) to be debated throughout the development
J ■
Community participation in health
enterprise. Consequently, the paradoxes articulated by Guijt
and Shah will likely not be resolved; they will continue to co
exist because the competing exigencies of development
demand a coterie of responses.
For example, donors are often pressured to operationalize
community participation, even while they recognize that ‘par
ticipatory processes do not necessarily follow structural, pre
determined and linear directions. Participation cannot be
seen merely as an input to a project, but as an underlying
operational principle which should underpin all project
activities’ (Oakley et al. 1999, p. 114). The penchant for oper
ationalization and evaluation exists in spite of its recognized
limitations. Donors often realize that it is hard to measure
participation when participation is so hard to define. They
recognize that it is difficult to measure a ‘process’ that has no
fixed endpoint. They may recognize an additional paradox:
the evaluation of participatory programmes often lacks com
munity participation (Kalinsky et al. 1993, p. 12). Experience
has shown that, even in the case of ‘successful’ projects, there
is no guarantee that what worked in one situation will work
in another, or will work in the future. The uniqueness of each
participatory project resists the systematizing requirements
of operationalization and evaluation.
Nevertheless, Rifkin et al. (1988) point out that the pro
fessionals who control the allocation of resources will not
necessarily be inclined to support participatory initiatives
unless the benefits can be demonstrated to them. Their
matrix for measuring participation is a useful first step in the
process of convincing the sceptical of the utility of partici
pation; meanwhile, other pragmatic efforts to combine quan
titative and qualitative approaches to community health
have been tried, such as the census-based, impact-oriented
approach recently implemented in Bolivia (Perry et al.
1999). The tendency to operationalize and measure partici
pation was offset, however, by a countervailing trend to
tailor participation to specific local, cultural and state
contexts.
Culture, context and the state
s
J
Anthropological research into community participation in
health has emphasized the importance of context. As Muller
(1991: 26) says, ‘Participation is an ambiguous concept
because it cannot be defined outside of a social context’.
‘Context’, from an anthropological perspective, refers to the
social relations and matrices of power through which partici
pation must be effected. ‘Culture’ emphasizes the importance
of understanding what participation means within a particu
lar setting, beyond the bounded, formal political system and
institutional structures. This does not mean, however, that a
focus on culture need be apolitical. Anthropologists do not
perceive ‘culture’ and ‘politics’ as two separate entities, but
rather as ‘simultaneous and inextricably bound aspects of
social reality’ (Alvarez et al. 1998, p. 4). They note that
because participation usually involves a set of material
demands (a redistribution of resources), its meanings will
inevitably be contested, both at the level of rhetoric and in
social practice. Anthropologists are often incorporated into
the planning, implementation and evaluation of participatory
225
endeavours because their observational skills and techniques
are able to elicit the multiple (and often conflicting) meanings
associated with particular development initiatives. They
have, therefore, become the designated experts in com
munity-level analysis of community participation.
Idiosyncratic local contexts are the sites where programmes
succeed or founder. As Oakley et al. stated, ‘Culture is not an
obstacle to community participation, but it must be under
stood before participation is externally imposed’ (1999, p.
123). This was the anthropologist’s cue. For many years,
anthropologists were cast as experts in ‘the local’. They were
called in to evaluate initiatives in situ. Can a given initiative
be successfully implemented in a particular setting? What are
the factors that facilitate or impede it? Does it result in the
desired outcome? Who decides what the desired outcome is?
The answer to many of these questions is presumed to lie in
‘culture’ (often glossed as ‘local’). In 1992, Linda Stone
reviewed the understandings of culture that have been util
ized in the participation literature. Culture, she says, was initi
ally viewed in one of two ways:
‘One view, held primarily by planners and health project
personnel, saw culture as a set of “beliefs” and
“customs” which were potential “obstacles” to the intro
duction of new health measures and ideas. A second
view, sponsored primarily but not exclusively by social
scientists, saw “culture” in the realm of health as “local
knowledge” (indigenous medicine) on the one hand, and
local “strategies” for securing health care on the other.
Both groups, however, tended to regard local culture as
fairly static.’ (Stone 1992, p. 410)
There were a number of reasons why these understandings of
culture fell into disfavour. Stone mentions that the relation
ship between traditional and modem medicine proved more
complex and adaptable than many had predicted, and that
communities exposed to primary health care often expressed
a preference for curative care, which had not been predicted.
More attentive now to the creative dynamism of culture,
anthropological studies of participation of the 1980s and
1990s began to emphasize ‘political relationships and pro
cesses’ (Stone 1992, p. 413). Ugalde and Morgan, among
many others, showed that community participation in Latin
America in the early 1980s was often motivated by ideological
and political factors that had little to do with improving
health. Furthermore, participation programmes often took a
patronizing attitude toward local communities, which were
often regarded as passive and incapable of organizing them
selves (Morgan 1990; Ugalde 1993; Zakus 1998; see also
Woelk 1992). Stone says that this emphasis was important
because it ‘encourages an encompassing framework within
which all levels of a health system can be simultaneously
incorporated’ (Stone 1992, p. 413), allowing for the inte
gration of macro and micro level analysis. Social scientists
began to study the meanings of participation among inter
national and national experts, consultants, agencies and insti
tutions, as well as among rural and poor people (Justice 1986;
Foster 1987; Morgan 1993; Barrett 1996). They have shown
that international health agencies have a near-hegemonic
control over the definition of health problems and solutions
226
Lynn M Morgan
worldwide. Consequently, they have become bloated bureau
cratic machines, burdened by the vicissitudes of global poli
tics, over-dependent on ‘top-down’ planning, and prone to
faddish trends (Werner 1993).
Concomitantly, anthropologists began to look at the effects of
ethnic and gender (in addition to class) stratification on par
ticipatory initiatives. They expanded traditional anthropo
logical critiques of the supposedly monolithic ‘community’,
pointing to the effects of institutionalized stratification and
discrimination on keeping certain people excluded, even as
others were encouraged to participate.
‘The cutting edge of development practice in the 1990s is
described in terms of “participation”, “communitydriven action”, and “empowerment”. The broad aim of
participatory development is to increase the involve
ment of socially and economically marginalized people
in decision-making over their own lives. The assumption
is that participatory approaches empower local people
with the skills and confidence to analyse their situation,
reach consensus, make decisions and take action, so as to
improve their circumstances. The ultimate goal is more
equitable and sustainable development.’ (Guijt and Shah
1998, p.l)
This model is flawed, Guijt and Shah say, because ‘many par
ticipatory development initiatives do not deal well with the
complexity of community differences, including age, econ
omic, religious,- caste, ethnic, and, in particular, gender’
(1998, p. 1). They argue that development planners should
not treat ‘the community’ as a benign entity with shared
goals and values, because the relationships within particular
communities can isolate or even harm some individuals and
groups. In this sense, all development projects should con
sider the impact that they have on reinforcing or undermin
ing existing identities within stratified socioeconomic
contexts.
If context is everything, then the case study format is essen
tial to presenting, analyzing and comparing experiences
within and between countries and regions. Case studies both
reinforce and reflect the assertion that participation is con
tingent upon local contexts. Even the most cursory review of
the 1990s literature on participation turns up case studies
from Argentina (Kalinsky et al. 1993); Brazil (Dias 1998);
Central America (Barrett 1996); Costa Rica (Morgan 1993);
El Salvador (Smith-Nonini 1997); England (Jewkes and
Murcott 1996); Nicaragua, Peru, Colombia, and Guatemala
(Muller 1991); Mexico (Sherraden and Wallace 1992; Ras
mussen-Cruz et al. 1993; Zakus 1998); Africa (Toure 1994),
including South Africa (Botes and Van Rensburg 2000);
Turkey (Tatar 1996); and many others (Oakley 1991; Nelson
and Wright 1995). Case studies can provide important lessons
about the range of factors that might influence participation,
but if ‘context is everything’ then case studies should not and
cannot be used to predict what might happen in a different
context. Nevertheless, case studies are vital for a variety of
reasons. They allow new ideas to be tested and results to be
compared and disseminated. They are useful to people
designing their own programmes in different settings because
they allow them to anticipate problems and implement pro
cedures that worked elsewhere. During the 1980s, for
example, a number of case studies were published about
Nicaragua, which were later invoked by British policymakers
trying to democratize decision-making in the British Health
Service (Crowley, undated).
Epidemiologists and policymakers working at international
levels are not satisfied with case studies alone, however,
because they need to formulate or derive principles of com
munity participation that can be generalized and applied
across a variety of national and political environments. To
accomplish this goal, they must extrapolate from individual
cases and summarize the results. This task has been accom
plished for rural development literature (not just health, per
se) in two recent volumes by Krishna et al. (1997) and Uphoff
et al. (1998). The first volume includes case studies from a
variety of rural development projects, emphasizing the emic,
or participants’, perspective on events. The second volume
contains the etic, or analysts’, evaluation of events, focusing
on the factors conducive to success ‘through amicable and
respectful collaboration between external and community
actors’ (Uphoff et al.1998, p. viii). The authors are not overly
optimistic about the prospects for success of rural develop
ment projects, which they note have often failed due to ‘the
ways that governments, donor and international agencies,
and some nongovernmental organizations usually proceed’
(1998, p. viii). According to the authors, impediments to par
ticipatory projects include changes in the development para
digm used by governments and donors to ‘neoclassical
economic logic’, which led to structural adjustment and pri
vatization, trickle-down theories, etc. in the 1980s and 1990s.
Uphoff et al. (1998, p. 2) say that, ‘Although this doctrine is
still dominant, there is some evolving thinking that poverty
alleviation needs to be resurrected as a prime concern, with
concern for sustainable development now legitimating the
incorporation of environmental considerations into policy
and planning’. Impediments also include changing environ
ments: increased urbanization, population growth, landless
ness and unemployment, and environmental degradation
(Uphoff et al. 1998, p. 2-3).
Zakus’ (1998) case study of community participation in
health in Oaxaca, Mexico, during the 1980s, provides a useful
theoretical perspective for analyzing and comparing partici
pation across national contexts. Zakus utilizes the ‘resource
dependency model’ to argue that the Mexican Ministry of
Health set up participatory initiatives because it was under
tremendous internal and international pressure to expand
health services. Because the Ministry lacked sufficient
resources to extend services itself, it looked to the surround
ing environment for additional resources and ‘ironically . . .
[found them] in the under served communities themselves’
(Zakus 1998, p. 487). Through a close evaluation of the struc
ture and implementation of the programme, Zakus concludes
that the Ministry did not grant power or decision-making
authority to communities; furthermore, it co-opted partici
pants (including communities and health workers) and failed
to provide adequate training or supervision (Zakus 1998, p.
491). The resource dependency approach, Zakus argues, can
help to identify and to anticipate organizational impediments
Community participation in health
to participation, in hopes that similar failures can be avoided
in future programmes.
The social movements literature
5
J
In addition to the resource dependency model and other
analytic frameworks for analyzing participation, the 1990s
saw the emergence of a literature focused on social move
ments. The social movements literature examines how
culture and politics are intertwined, that is, how they consti
tute each other; it provides another way to analyze the inter
sections of popular mobilization and government action in
the post-1990s era. Elizabeth Jelin says it was unclear whether
participatory movements in Latin America were ‘new’ in the
1970s and 1980s, or were merely a response to ‘the closing of
institutionalized channels of participation’ caused by dicta
torships, civil war and repression (Jelin 1998, p. 405). Like
wise, the return to democratic rule may not have had the
salutary effect on participation envisioned by some authors.
Jelin (1998, p. 405) says the return to democratic rule ‘implied
giving priority to political parties and making a renewed com
mitment to institution building, a trend that emphasized the
construction of institutions within the political system, guided
by the logic of “governability”. This effort often clashes with
the less institutionalized collective means of expressing old
and new social demands, and even with the more partici
patory pressures in the process of democratization.’ Mean
while, income inequalities and poverty are on the rise in Latin
America. The return to democracy is publicly heralded;
support for formal democracy is ‘a hegemonic discourse’, but
it is accompanied by the impoverishment of a large segment
of the population, caused by inequitable economic relations
(Jelin 1998, p. 408).
Jelin’s analysis has interesting implications for participation
in health. It implies that participation stalls in conditions in
which there is a modicum of civilian participation in public
life, in which reformist governments channel dissident voices
into political parties, in which formal democratic govern
ments do not need separate participatory initiatives because
the presumption is that the entire government is purportedly
devoted to democratic participation, in which people have
not (yet) organized themselves against the apathy and dis
illusionment that accompanies the spiral into deeper poverty.
1
Poststructural critiques of development published in the
1990s also provided new frameworks for analyzing partici
pation (Ferguson 1990; Escobar 1995). Poststructuralists
would analyze ‘participation’ as a site of struggle over the
causes and solutions to poverty and underdevelopment. On
one hand, participation became a hegemonic discourse only
because it was promulgated by powerful international donors
and financial institutions that have an interest in representing
‘low participation’ as an impediment to development. As
James Ferguson (1990) argues in The anti-politics machine,
development agencies prefer to identify problems for which
they can devise technical (rather than political) solutions. On
the other hand, the rhetoric of participation can be used to
advance claims on power by a variety of groups, using ‘par
ticipation’ to justify tactics that had previously been excluded
from the political arena.
227
The poststructuralist critiques call for close examination of
the relationship between historical events and social actions.
They might ask, for example, what effect neoliberal economic
policies and increasing privatization of government functions
had on participation and community action. Under what con
ditions do impoverished communities become passive and
apathetic? Under what conditions do they mobilize to protest
the withdrawal of government services and accountability?
How can a discourse such as ‘participation in health’ be coopted (in a process similar to what Sonia Alvarez described
for Latin American feminist NGOs) in ‘a move toward
policy-focused activities, issue-specialization, and resource
concentration among the more technically adept, transna
tionalized and professionalized NGOs’ (Alvarez 1998)? The
cultural politics of co-optation are also discussed by Eric
Dudley, who writes:
‘Participation used to be the rallying cry of radicals; its
presence is now effectively obligatory in all policy docu
ments and project proposals from the international
donors and implementing agencies. Community partici
pation may have won the war of words but, beyond the
rhetoric, its success is less evident. Part of the problem is
clearly political. True participation is a threat to power
ful and vested interests.’ (Dudley 1993, p. 7)
A poststructuralist analysis would propose that international
donors and development agencies win a major political battle
by claiming to understand the many meanings of participation,
while at the same time synthesizing those meanings into a
single definition that goes on to dominate participation dis
course. The World Bank example cited at the beginning of this
paper shows how an international donor can wield its con
siderable authority to define participation in self-serving terms.
Thus far, we have discussed trends that affected general par
ticipation discourses during the 1990s. The remaining sections
of this paper focus specifically on trends related to community
participation in health.
The intersectoral nexus
In the years following Alma Ata, participatory initiatives
were often directed at primary health care programmes. Ana
lysts quickly realized, however, that community members
often defined health broadly. They identified impediments to
good health that reached far beyond the health sector to
encompass other issues including housing, employment and
land tenure (see Asthana, undated; Morgan 1993). Further
more, donors and governments recognized that they could
not resolve many of the most pressing primary health prob
lems without also addressing other aspects of development,
including (in addition to the above) education, water and san
itation, agriculture and the environment, and economic
development. Nowadays, advocates of community partici
pation in health expect that participatory initiatives directed
at one sector will have ramifications in others. Participation
‘in health’ is hardly ever just ‘in health’ (Kalinsky et al. 1993).
Health has never been easily compartmentalized; partici
pation is even less likely to be confined to one developmental
228
Lynn M Morgan
sector. In fact, some argue that the goal of participation is to
ripple throughout a society, having a positive effect on
democracy-building. Another consequence of this trend is
that ideas about ‘community participation’ and empower
ment have captivated the interest of development experts,
activists, and educators far beyond the primary care sector.
Community participation is now discussed with reference to
health education (Cardaci 1997; Arenas-Monreal et al. 1999)
and disease control (Manderson 1992; Briceno-Leon 1998).
Advocates of the utilitarian and empowerment models agree
that intersectoriality is both desirable and necessary.
Biomedicine as an impediment
Proponents of both empowerment and utilitarian models
also agree that biomedical training and the hierarchical prac
tice of medicine can impede participatory initiatives. John
Macdonald offers an extreme rendition of this argument
when he suggests that allopathic medicine is by its very
nature non-participatory. Doctors are trained to be authori
tarian; they are taught to retain the power to diagnose, pre
scribe and cure (and to target diseases rather than people).
Therefore they do not know how to promote participation.
Macdonald offers his analysis as a corrective to studies of
health participation that focus on structural impediments.
While he admits that there is considerable structural opposi
tion to participation, he wants to highlight ‘the great strength
of medical opposition to participation which mirrors and in
a sense is part of the social and political opposition to a
strong PHC [primary health care] with its emphasis on real
participation and a move towards equity’ (Macdonald 1993,
p. 105).
Macdonald’s analysis is important for our purposes because it
offers one explanation for the tension between anthropologi
cal and epidemiological approaches. Epidemiologists, Mac
donald says, are similarly tainted by the biomedical model
that informs their training (see also Blum 1995). This explains
why we rarely hear such terms as ‘participatory epidemiol
ogy’, which:
‘do not fit with what we have come to understand to be
the scope and method of the work of epidemiologists.
According to their training, they are ready to analyse
data on morbidity and mortality and to suggest correla
tions and trends. But they have much less preparation in
the skills of asking community members about their per
ceptions of their needs, what they think of the services
provided, or the skills necessary to enable the com
munity to be involved in future planning. Western scien
tific medicine sees the community as the aggregation of
the (sick or potentially sick) individuals in it. It equips its
practitioners to diagnose and tell, not to listen and plan
in partnership.’ (Macdonald 1993, p. 103)
Macdonald tends to exaggerate his case, overlooking the
work of social epidemiologists who work alongside com
munity members to define and resolve health problems, and
who are committed to health services research and popular,
public health education (American College of Epidemiology
1998; McKnight 1999). Nevertheless, his argument could be
applied to Kahssay and Oakley’s case for community involve
ment in health. Their approach is rhetorically sophisticated
but programmatically modest. Kahssay and Oakley empha
size the intersections between participation and health sector
reform, arguing that community involvement needs to
become a central component of national health systems
through intervention with policymakers. This could be seen
as a pragmatic response to earlier attempts that placed
responsibility solely on community members, when in fact
those people rarely had the power to effect dramatic struc
tural change. Kahssay and Oakley, by contrast, turn the onus
of responsibility back onto those who control the allocation
of resources. Their final recommendations are directed not
toward community mobilization, but toward the need to
incorporate community involvement ‘principles’ into health
sector planning and evaluation. Critics might point out that
this makes their analysis similar to that offered by the World
Bank, which redefined participatory initiatives to direct
attention away from the poor and toward ‘stakeholders’.
This approach, while posing less of a threat to the status quo,
is fraught with problems and dilutes the transformative
potential of participatory rhetoric and programmes (Zakus
1998).
Pragmatists, activists and the persistent
challenge of participation
Responses to the analytic complexities and persistent chal
lenges of participation a quarter of a century after Alma Ata
include both pragmatic and activist proposals. Pragmatists
point out that participation has been ‘talked to death’. They
doubt there is much new to say about it, yet they note; with
some urgency that development problems are deeper and
more pressing than ever. Dudley says, ‘The challenge is now
to get beyond the general principle and determine the practicahties of how participation fits into a larger picture of effec
tive aid for just and sustainable development’ (Dudley 1993,
p. 159). The pragmatic response has been offered as a justifi
able response to cynicism and disillusionment (see Woelk
1992, p. 419), in spite of charges of utilitarianism. Pragmatists
argue that even compromised, utilitarian action is better than
the alternatives: to hold onto the romantic hope for a utopian
democracy, to give up in frustration, to allow governments
and donor agencies to focus on economic growth at the
expense of poverty alleviation, or to allow governments to
dump responsibility for rural development onto local com
munities with impunity. Pragmatists favour an approach of
respectful collaboration among donors, community represen
tatives, and governments (when possible) to achieve mutual
goals. Pragmatic solutions require policymakers, managers
and planners to identify the elements critical to success, which
include ‘novel ideas and strong value commitments that
outside resources could support and make more productive,
once a significant learning process is initiated and carried
through’ (Krishna et al. 1997, p. 3). Pragmatists are convinced
that the poor will be better served by accepting self-reliance
as a strategy rather than waiting for government or donor
assistance.
In contrast to the pragmatists, activists argue that a sustained
commitment to social justice and genuine democratic process
)
Community participation in health
is more important than ever. In a world ideologically and
economically dominated by globalization and transnational
capitalism, there can be no excuse for ignoring the underlying
causes of the desperate poverty that affects an ever-greater
proportion of the world’s population. There is too much at
stake in this context for ‘community participation1 to be
offered as a panacea for health and development problems.
Activists argue that empowerment is essential; it is increas
ingly important, they say, to identify and dismantle the politi
cal, economic and social arrangements that foster increasing
disparities between the rich and healthy, and the poor and ill.
The activist agenda calls for supporting and strengthening
collective social movements that share these goals. Activists
do not want to see participation reinvented as a toned-down,
moderate form of continuing education for professionals or
of small-scale village programmes. They want to retain and
strengthen the movement’s devotion to empowerment
models, in which conflict is stimulated with the goal of achiev
ing a more equitable distribution of power.
The complexities of participation are better understood
today, and the possibilities for pragmatic compromise more
widely accepted by a generation of seasoned planners, prac
titioners and analysts. Yet disagreements about participation
persist, to a large extent rehearsing and reiterating the orig
inal schisms between empowerment and utilitarian models.
Meanwhile, participation continues to be at once alluring
and challenging, promising and vexing, necessary and
elusive.
Endnotes
1 A different version of this paper will appear in Portuguese in
Abordagens Antropolbgicas em Epidemiologia. Coimbra CEA, Jr,
Trostle JA (eds). Rio de Janeiro, Brazil: Editora Fiocruz.
Forthcoming.
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Acknowledgements
I would like to thank James Trostle and Carlos Coimbra for calling
this essay into existence, and the reviewers for their comments on an
earlier draft.
Biography
Lynn M Morgan is Professor of Anthropology at Mount Holyoke
College in Massachusetts, USA. She holds a PhD in Medical
Anthropology from the University of California, Berkeley and San
Francisco. She is the author of Community Participation in Health:
The Politics of Primary Care in Costa Rica (Cambridge, 1993), and
co-editor of Fetal Subjects, Feminist Positions (University of Penn
sylvania Press, 1999). Recent articles about reproductive ideologies
and practices in Ecuador and the United States have been published
in edited collections and in Ethos: Journal of the Society for Psycho
logical Anthropology, Feminist Studies, and Hypatia: A Journal of
Feminist Philosophy. She is currently completing a book manuscript
about the social history of human embryo collecting in the early 20th
century.
Correspondence: Lynn M Morgan, Professor of Anthropology,
Department of Sociology and Anthropology, Mount Holyoke
College, 50 College Street, South Hadley, MA 01075-1426, USA.
Email: lmmorgan@mtholyoke.edu
0277-9536.88 53.00 + 0.00
Soc. Sci. Med. Vol. 26. No. 9. pp. 903-906. 1988
Printed in Great Britain
Pcrgamon Press pic
SELECTIVE PRIMARY HEALTH CARE:
THE COUNTER REVOLUTION
Kenneth W. Newell
Department of International Community Health, Liverpool School of Tropical Medicine.
Liverpool L3 5QA, England
Abstract—Primary health care in the WHO sense was triggered indirectly by the failure of the Malaria
Eradication Programme. The response to this failure was an ideological change which considered that
health services were not purely a way of delivering health care interventions to people but were something
important to individuals and groups in their own right. Key changes of this idea called primary health
care were linked to qualities such as power, ownership, equity and dignity. Such an ideological change
involves the evolution of new forms to reflect the changes in content and some of these structures still
require development.
. .
The advocates of highly selected and specific health interventions plus the managerial processes to
implement them have ignored, or put on one side, the ideas which are at the core of what could be
described as the primary health care revolution. They are in this sense counter revolutionaries.
3
Key words—primary health care, selective primary health care, equity
J
a programme and the long knives were out looking
Most of us have difficulties in describing a success.
We are aware of the conditional clauses we would for technical, political and administrative scapegoats
have to use to describe a successful person. Few to blame. The conclusion which was most widely and .
would say it was the richest person, or the one who comfortably drawn from these malaria debates was
had the most children, the person with the greatest that while there were technical reasons for the
difficulties in malaria eradication the most domin
apparent power, or even the one who states that he
ating cause of failure was the lack of a complete
had reached the peak of all his aspirations. We all
have heard of the unhappy millionaire, the miserable continuing health service infrastructure which could
reach
every household and remain in place. This
leader, the near vegetable who exists in a cloud
t
‘ * h care infrastructure did not have to be very
cuckoo land of apparent achievement and yet exists health
sophisticated and the degree, of completeness of its
in personal and social squalor.
The definition and description of health involves coverage and its stability were more important than
similar problems for very similar reasons. There are its level of technical competence.
With such a conclusion, WHO was almost forced
so many facets that have to be seen together and there
is no objective way of judging whether one mix is to look more deeply into the distribution, form, and
better or worse than another. Two individuals can roles of ‘basic health services’ (as such services were
then often called). This w^s done by the Executive
have two very different mixes and each may be the
ideal for that particular person. Because of the div Board of WHO proposing, carrying out, and report
ersity of acceptable outcomes, the promoters of suc ing on an ‘Organizational Study on the Methods of
cess (or health) feel forced to concentrate on trying Promoting the Development of Basic Health Serand unexpected
to prevent failures (or disease). Unfortunately, when vices’ [2]. The report was a surprising
.
one follows this line of reasoning one almost inevita- document. An appreciation of the present position [2,
crisis on the point of
bly is led to the idea that if we can prevent, abolish, p. 106) describes a “
** major
j
or remove enough aspects of failure, the result will be developing’’ in the developedI as well as in the third
world. lt
states that
to be widespread
a success. This is not valid reasoning. Certainly, it v_LL
'----L ‘ “there appears
?_
..................
must be ‘good’ to abolish or control diseases but (his dissatisfaction of populations about their
healthi ser
does not inevitably lead to health or to what people vices for varying reasons’’. A number of causes (of
dissatisfaction) are listed and include:
necessarily want.
—“a failure to meet the expectations of the popu
Philosophic dilemmas such as the above sometimes
resurface and become the starting points of new lations;
—an inability of the health services to deliver a
initiatives, and primary health care (PHC) as ex
pressed by WHO could be said to have had its genesis level of national coverage adequate to meet the stated
from the implications of failure rather than from any demands and the changing needs of different soci
vision of success. It is worth remembering that PHC eties;
—a wide gap (which, is not closing) in health status
started in the late 1960s and early 1970s. This was the
between countries and between different groups
era dominated by the thinking of people such as Ren£
Dubos (I) whose ‘Man Adapting’ was almost com within countries;
_rapidly rising costs without a visible and mean
pulsory reading for anyone interested in the bio
ingful improvement in services;
medical sciences. In the same era WHO and many
—a feeling of helplessness on the part of the
countries were struggling to face the implications of
consumer,
who feels (rightly or wrongly) that the
the failure of malaria eradication as an idea and as
903
0
&
904
Ktsneth W. Newell
health services and the personnel within them are
progressing along an uncontrollable path of their
own which may be satisfying to the health professions
but which is not what is most wanted by the con
sumer.”
A number of reasons for the above were explored
further and the report concludes that ‘‘they are
possibly symptoms of a wide and deep-seated error in
the way health services are provided”. When the
report describes what should be the content of basic
health services, it denies that any collective or world
list of health service actions should exist. ‘‘Physicians
cannot say that persons with this or that condition,
for which a health intervention is possible, should be
given first priority or that another disease should be
left alone to be dealt with later.” Instead it suggests
that it is the responsibility of the health sciences to
describe possible interventions and their implications
and costs, but not to choose.
I have quoted at length extracts from this report
for two reasons. Firstly because it turned objectives
for a health service upside down by saying that its
structure and content should not be dominated by a
form required for malaria eradication, or any other
disease control measure, but for quite different soci
etal reasons. Secondly, because the debates on this
report by the Executive Board of WHO and within
the following World Health Assembly led up to the
idea of PHC as expressed by WHO.
During these debates it was the representatives of
the industrial world who first rose to their feet and
stated that the report described their health system
problems. This was followed later by similar state
ments from representatives from the developing
world. In the debate on the implications of the report,
the examples quoted were not limited to disease states
of deprived societies but included occupational
hazards, pollution, traffic accidents, and drug addic
tion as often as malaria, child and maternal mortality
or communicable diseases. The issues moved on from
the right of every individual to have access to health
care towards the realities that the form that the health
system took was not just of epidemiological, fiscal or
managerial relevance and that both the long and
short term objectives, and who should decide, were of
fundamental importance. The imminent crisis that
was being described and the criticisms of the existing
health care scene were not directed towards the
present health status of populations or to particular
disease states but to the indignity of health and health
care being ‘owned’ by special groups and the form
and objectives of these systems being imposed on
populations on quasi-rational grounds. The report
was unexpected and revolutionary because it de
scribed health systems as failures because people were
dissatisfied with their ideology and form—not be
cause they were unsuited for malaria eradication.
The evolution of a statement consistent with these
ideas has been slow and tortuous and is far from
being completed. As with any radical shift in ideol
ogy, the steps from ideology to applications and
methods of implementation present real difficulties.
Even a definition seems to start with essential or core
qualities rather than a proper statement giving
boundaries and direction. The first attempt to de
scribe a revised system, given by WHO the code name
of PHC, followed the Joint WHO'UNICEF study of
success [3], This was in a paper presented to the 1975
World Health Assembly (4). Here PHC was described
rather than defined and seven qualities or principles
were proposed. These included the design of a PHC
system around the life patterns of the population, the
need for total health systems to be designed to
support the needs of the periphery, the acceptance
that many primary causes of ill-health were based on
factors such as poverty, deprivation and environ
mental abuse, the need for active participation (own
ership) of health systems by local populations, and
equity. These principles were accepted by the Assem
bly, and led to the meeting in Alma Ata in 1978.
Large, formal international meetings of national
representatives have their own peculiar needs. It is
difficult for a representative to return home and
report on an ideology. What is wanted is a pro
gramme. At Alma Ata, almost inevitably the empha
sis moved from what is wrong, and why, to what can
health services do, and how can success be measured.
Lists started to appear of health status problems
which needed to be dealt with and they included the
expected, including maternal and child mortality,
water and sanitation, health education, fertility, and
the communicable diseases. It can fairly be said that
it would be surprising if such widespread horrors
were not on such a list. However, the risk of such an
activity is that when you start with any list, the entire
reasoning starts to change and the list becomes the
objective.
It can be said that ‘selective primary health care’
(SPHC) may possibly have started from the lists of
Alma Atas rather than from the Walsh-Warren article
in 1979 [6]. There seems little difference in principle
between an international forum selecting a group of
disease and intervention priorities and saying we will
try and implement these throughout the world, from
a different group making a different selection based
on the cost and effectiveness of interventions and
saying do these things first because they work. Both
groups are putting forward health status objectives as
goals and are cither saying use PHC principles to
implement our choices (if they are cheaper, more
effective or more acceptable) or let us design a
different series of delivery systems which could opti
mize our goals and leave the more general goals to
some later date when such luxuries can be afforded.
To the convinced PHC advocate such SPHC pro
posals are not PHC at ail but are the antithesis of it.
They are disease control programmes which are
ideologically similar to the malaria eradication disas
ter and are a regression to the very qualities of
imposed systems which were described in the Or
ganisational Study. The selected initial lists are ex
pressed as ‘interim’ objectives but even if these items
were solved they could then be followed by another
list using similar logic, ad infinitum. In no way do they
share the objectives of PHC and the apparently
preferred vertical programme management structure
is very different from the horizontal decentralisation
which is an essential component of a PHC form. The
choices are those of the technologists and managers
(national and international); ‘ownership’ rests with
the programmes; mechanisms are designed for the job
and not for the system; objectives and outcomes are
J
1
J
3
'J
Selective primary health care
905
short term rather than primary causes or barriers of intolerable that they should continue when effective
- --» built-in
assumptions that the prob- technologies and sufficient resources exist to deal with
change; there are
I
lems and outcomes are those of the people and the them if they are used wisely and with proper manage, w.v is the preferable one for all societies; and ment. Success to the SPHC will come when every
technology
the programmes'support the existing resource gather- child is immunised at the right time, every child is fed,
*
Jand
ing and distribution patterns
and’-------may increase
de so on.
Another way of illustrating the two choices is by
pendency.
(7) that the solution for a malnourished child
Such statements can easily be misinterpreted. The saying
, ...
1960s and 1970s were not only the time of the is the provision of proper food (SPHC). The advocate
appearance of PHC but were also the era of smallpox of PHC will reply that a healthy village or family
eradication. This success story of modem medicine feeds its children. The differences between SPHC and
_ and was
— —
-r pHC are not just variants on a single theme or
was selected internationally
implemented
ustaglrighly specific methods designed exclusively for technological^ fights between scientists. The differthe programme. It would be difficult to find anyone ences are real and are of crucial importance.
A different line of argument used by some is that
now who does not applaud this programme and who
is not satisfied with the result. But the main health PHC is an ideological dream but that it does not
problems of both the poor and the rich countries do work and is difficult or impossible to implement,
not fall into the same category as smallpox. The especially in those countries which are poor and have
health problems of today, when viewed by the profes more arbitrary political systems. In such circum
sionals or the people, are ones requiring continuing stances, which is best—a PHC system which does not
action cohort by cohort, person by person, and day fully work or a series of vertical programmes directed
to day. There are few health advances which do not towards identifiable consumers? A response to such a
have to be weighed against disadvantages and oppor question must take into account that central PHC
tunity costs which are important to individuals and ideas such as equity and decentralisation are not
accepted in any sector of some countries. They may
to societies. SPHC and PHC are not similar.
The clash between PHC and SPHC is real even even be viewed as political threats. Most resources
though the points of conflict are not the obvious may be purposely directed to the cities, or to special
ones. Both sides in the argument accept that poverty, groups such as civil servants or the army. Fragmen
deprivation, malnutrition, lack of education, the sta tation may be a real threat to a newly independent
tus of women, environmental hazards and a gross country and decentralisation may appear to encour
maldistribution of resources are among the primary age it. Factors such as these may be some of the
causes of much ill-health and that these things need reasons why PHC is rejected or accepted in name but
to be faced directly in their own right. SPHC takes not in reality. With such factors being possibly
no responsibility for attempting to alter them and present it would be unreasonable to expect PHC to
PHC may only influence them indirectly or margin- be immediately and completely implementable everyally. Similarly, both sides equally accept that many where at once. Evolution is possible as well as
(or most) infant, child, and maternal deaths and some revolution and' if would seem more sensible to work
other illnesses and deaths can be directly prevented or slowly in the direction of a long-term solution than
influenced by existing interventions which can be to build structures which are for the moment and
cheap and effective. Both sides are aware that these impossible to justify in the long term. In such couninterventions are only being applied to a minority of tries, forward movement may be slow and fragile and
the world’s risk populations.
can so easily be stopped or destroyed by misplaced
These agreements may seem to be so all-embracing actions. The accounts which are now becoming availthat the differences must be only marginal. They are able from Africa and Asia of the destructive effects at
not. If the objectives and who decides them as well as the district and peripheral levels of the health system
the form are opposed, then the similarities rather by processes such as preferential field allowances to
than the differences are of little account. PHC advo- workers participating in vertical EPI programmes are
cates feel that, even if the list of actions and inter so dramatic that they cannot be ignored. They must
ventions put forward by SPHC are applied to a total be viewed as the national expressions of technical
population, the health system may still be classed as SPHC decisions tied to international or bilateral
a failure. If what results is still an oppression, does resources in New York, London, Geneva or else
not deal with that society’s priorities, and is inconsis where and are signs that the battle is not just
tent with the way of life and the dignity of that ideological but is one which will have its ultimate
population, then it is not successful. Such a statement expression in villages and homes,
can be reversed to say that a PHC system can still be
classed as successful even if some of the illnesses and
deaths targeted by SPHC continue to occur if that
CONCLUSION
society truly has a choice but decides to take up other
There are moments of history when unplanned and
priorities knowing the implications. This mayjseem
strange but surely it is no different from an industrial apparently irrelevant events present the opportunity
to rchange.
country accepting a certain level of disability and to
“ view ourselves in a different way and tn
death as a consequence of traffic accidents or The events of the 1960s and 1970s not only made
visible the magnitude of the health problems facing
pollution.
This is completely different from the SPHC view the majority of the world’s people but gave us the
that the targeted health priorities are an abomination opportunity to discuss publicly some of the ab
because they are so easily dealt with, and it is surdities of our health systems and the objectives we
SSM
906
Kenneth w. Newell
were working towards. If health is not definable
except in a fluffy way, can never be completely
attainable by individuals or groups, and will always
involve a play off between risks and aspirations, then
why do we continue to act as if disease and death
control equals health? There is no objective way of
using the scientific method to choose between these
issues, to select this rather than that illness for action,
to say that the death of a child is somehow worse
than that of an adult, or to selectively direct public
resources to one set of individuals rather than to
another. These are inevitably value judgements. Only
society can choose and if a society has rights one of
them must be the right to know what the choices are,
to have access to those choices in an acceptable way,
and to understand the consequences or implications
of the decisions.
The continuing evolution of PHC is the nearest
thing that we have at present which reflects these
rights. It is likely that it will take a long time and
many ineffective attempts before it is possible to get
it to work properly. The PHC failures may need to
be ruthlessly destroyed but the movements towards
workable forms have to be protected and encour
aged. SPHC is a threat and can be thought of as a
counter revolution. Rather than an alternative, it is
a form of health service feudalism which can be
destructive rather than an alternative. Its attractions
to the professionals and to funding agencies and
governments looking for short term goals are very
apparent, k has to be rejected, but for the right
reasons.
No one can justify the mismanagement, logistic
incompetence, and conceptual confusion of many
so-called PHC systems which make many of the
interventions selected by SPHC inaccessible to the
people who might very well choose them if they had
the opportunity. But if these are corrected in the
wrong way, they may result in pathetic substitutes for
the real thing if the main objectives and qualities of
PHC arc forgotton or put on one side.
REFERENCES
1. Dubos R. Man Adapting. Yale University Press. Newhaven, 1965.
2. Organizational Study on Methods of Promoting the
Development of Basic Health Services. Official Records
No. 206. WHO. Geneva, 1973.
3. Djukanovic V. and Mach E. P. (Eds) Alternative
Approaches to Meeting Basic Health Needs in Devel
oping Countries. WHO. Geneva. 1975.
4. WHO. Promotion of National Health Services, Paper for
WHA A29/9, April, 1975.
5. Primary Health Care. A Joint Report by the Director
General of WHO and the Executive Director of
UNICEF. WHO. New York. 1978.
6. Walsh J. A. and Warren K. S. Selective primary health
care—an interim strategy for disease control in devel
oping countries. zVgw Engl. J. Med. 301. 18. 1979.
7. Newell K. W. (Ed.) Health by (he People. WHO.
Geneva, 1973.
Soc. Sci. Med. Vol. 22. No 10. pp 1001 -101 3. 1986
Printed in Great Britain
<)ri-95}6 86 S?.OO +0.00
Pergamon Journals Lid
SELECTIVE PRIMARY HEALTH CARE:
A CRITICAL REVIEW OF METHODS AND RESULTS
Jean-Pierre Unger1 and James R. Killingsworth2
’Unite de recherche ci d'enseignement en sante publiquc, Institut de Medecine Tropicale Prince Leopold.
Nationalcstraat 155. 2000 Antwerp, Belgium and Stanford Research Institute International, PO. Box
1871. Riyadh 11441. Saudi Arabia
g
Abstract—In the aftermath of the Alma Ata conference, three types of Primary Health Care (PHC).
have been identified. Comprehensive PHC (CPHC) and Basic PHC (BPHC) both have a wide scope of
activities. BPHC however does not include water and sanitation activities. Only one year after the Alma
Ata conference. CPHC was attacked as not ‘feasible’ and selective PHC (SPHC) was offered as an interim
alternative. SPHC only addresses 5 to 8 diseases, almost all of them falling within the realm of pediatrics.
Our article critically analyses the methods and results of SPHC. It contrasts the lack of supportive data
for SPHC and its methodological deficiencies with the extent of its adoption by bilateral cooperation
agencies, foundations, academic and research institutions, and international agencies. We suggest that
rather than health factors, the major determinants of this adoption have been political and economical
constraints acting upon decision makers exposed to a similar training in public health.
Key words—selective PHC. public health decisions
Selective Primary Health Care (SPHC) has attracted
wide*spread attention as a major alternative to the
Primary Health Care (PHC) concept announced in
the 1978 Alma Ata Conference Declaration [1]. The
SPHC strategy emphasizes ‘rationality’ and potential
cost-savings [2]. By implication, it challenges govern
ments whose ministries of health joined WHO,
PAHO and UNICEF in formally adopting the pro
gram of the 1978 Alma Ata Declaration. We attempt
here to describe the historical context of this alterna
tive health service approach; to critically analyze its
methods and operational structure; to explore its
empirical foundation; to discuss the implications of
adopting this strategy for the health of developing
country populations; and finally to examine some of
the economic and political reasons for its current
notoriety.
THE ORIGINS OF SELECTIVE PRIMARY
HEALTH CARE
Approaches to health care in LDCs
In the late 1970s, when the Alma Ata Declaration
first was being implemented, the mix of health ser
vices existing in the Third World only approximated
the purity of health system models. These health
service structures could be grouped into three broad
categories for presentational purposes:
(1) Hospital-oriented medical care;
(2) Vertical or disease-specific programs;
(3) Community-based primary health care.
Hospital-oriented systems. In most developing
countries, health ministry planning and policy agen
cies are dominated by a concern with treating the
sick. The hospital orientation associated with this
curative view has two distinct forms in most LDCs.
One form is a facsimile of European or American
systems. It is urban-based, highly technological and
often includes a major private sector component.
Originally designed to cater to a coIonia population,
this system now serves the national or expatriate
middle- and upper-classes.
The other hospital-oriented form targets rural or
peri-urban needs, serves poor population groups, and
is usually state or church operated. In practice, the
hospital sector in LDCs encompasses both forms of
the hospital-oriented system and consumes about
80% of total health care expenditures [3].
Vertical or disease-specific programs. The success
of specific disease control measures that contributed
to the elimination of yellow fever, smallpox and
typhus in North America and Europe in the early
20th century encouraged the growth of vertical cam
paigns. These programs, targeted upon specific LDC
diseases, were recognized as having residual benefits
for the industrialized countries as well (e.g. the con
struction of the Panama Canal and the U.S. military
occupation of Cuba). Large American foundations
(Rockefeller. Ford) joined the U.S. military in the
early development of vertical disease control pro
grams and continue to show interest in this strategy
today.
Early WHO programs, typically vertical in nature,
enhanced the popularity of vertical interventions by
creating time-limited disease eradication programs.
Only the failure of campaigns against malaria and
trypanosomiasis in Africa and Asia (and to a lesser
extent in Latin America) has cast doubt on the ability
of vertical control programs to achieve significant
reductions of suffering and mortality in the long-run.
Community-based primary health care. Just as the
vertically-oriented smallpox campaign was reaching
its successful conclusion, the WHO and its DirectorGeneral, Dr Halfdan Mahler, began to advocate a
comprehensive effort to reach the entire world's
population with horizontally-integrated primary
health care services (PHC). The personal and public
health services of the PHC model sought to improve
health status by the use of health auxiliaries and
1001
<■>-
1002
Jean-Pierre C’\GEk and James R. K.illi>gsworth
appropriate health technologies. The model sought to
provide acceptable, accessible services based upon
local initiative and maximum levels of community
participation.
The community-based PHC model was by no
means a new notion. For decades, community-based
services were advocated by King in Africa and Shaw
in India. As a member of the Shore Committee
(1946). John Grant argued for the integration of
vertically designed health interventions into a core of
more comprehensive health services [4). Similarly,
Hugh Leave!!, a Professor at the Harvard School of
Public Health and Edward MacGaveran, a Dean of
, the North Carolina School of Public Health, have
firmly supported an integrated PHC approach (4).
Through the Alma Ata Conference Declaration,
WHO and UNICEF formalized a consensus about
PHC standards that had already proven themselves
in many Third World Nations. By acknowledging
that Third World diseases result from poverty and
that the health care system, “can be a lever for
increasing social awareness and interest, initiative
and innovation” ((], the conference declaration im
plied that political commitment toward a reallocation
of scarce resources is required for implementing the
PHC concept.
There remains considerable practical debate as to
what constitutes appropriate primary health care in
developing countries. PHC, by the WHO definition,
is broad in scope and includes:
health education
food supply and nutrition
water and sanitation
maternal and child health programs
immunizations
prevention and control of locally endemic diseases
treatment of common diseases and injuries
provision of essential drugs.
Because of its great range, this approach is often
called ’Comprehensive Primary Health Care’
(CPHC) as distinguished from approaches which
consider water, sanitation and food supply to be
outside the scope of health care system responsibility.
The latter view is frequently referred to as ‘Basic
Health Services’ (BHS). Finally, PHC presupposes
that its referral and supervisory network will be built
into a stabile health network.
Selective primary health care
Just as PHC concepts were first being implemented
by Alma Ata signatories, Walsh and Warren
presented the SPHC approach to a joint Ford/
Rockefeller Foundation Symposium on Health Ser
vices in Bellagio, Italy. As an alternative to PHC,
selective primary health care would institute, “health
care directed at preventing or treating the few dis
eases that are responsible for the greatest mortality
and morbidity in less-developed areas and for which
interventions of proved efficacy exist” [2j.
Instead of a full health infrastructure based upon
primary health care, the SPHC approached would
reduce the scope of health services in accordance with
the findings of cost-effectiveness analysis. Presum
ably. cost-effectiveness analysis justifies a selective
elimination of PHC services since (1) PHC in the
Alma Ata context (CPHC) is "unattainable because
of the cost and number of personnel required" [2] and
(2) even without water and sanitation included, basic
health services (BHS) would cost billions of dollars in
the view' of the World Bank (2],
The operating assumptions of SPHC are deter
mined by one variety of rationalized choice. The
selection of a limited number (usually 5-10) of health
interventions is established by prioritizing diseases of
importance on the basis of prevalence, mortality,
morbidity data and on ‘the feasibility of control*. As
a result, SPHC health services '‘concentrate on a
minimum number of severe problems that affect large
numbers of people and ignore interventions of low
questionable or unmeasured efficacy’’. Examples of
interventions that would be ignored because they are
difficult to control, are: treatment of tuberculosis,
pneumonia, leprosy, trypanosomiasis, meningitis and
helminths. These types of health problems, “may
better be dealt with through the investment in re
search", since, in terms of potential benefit, ‘’the cost
of research is low”.
Warren suggests that the SPHC health services
structure would be a Christmas tree upon which
ornaments (independent interventions of ‘proven
efficacy’) might be hung, one by one. The initial
nature of the structure would necessarily emphasize
vaccinations in order to gain the high coverage
(greater than 90%) required to interrupt transmission
of the major diseases such as measles. Interventions
such as oral rehydration therapy for diarrhea which
require a more stable, community-based health
service structure would be introduced later on.
Health services such as malaria, chemoprophylaxis
or vaccines, schistosomiasis treatment, or other new
vaccines would be added rationally to the structure
as they become cost-effective in areas where such
diseases were of high importance.
Despite its virtual overlap with the initial adoption
of the PHC concept, the SPHC approach has
continued to attract support. The American CDC
has developed a series of training manuals for the
Expanded Program of Immunization (EPI/WHO)
and the Control of Diarrheal Disease Program
(CDDP/WHO) based on the ‘priority setting* method
[5] . Specific CDC international programs emphasize
a selective intervention approach.
In late 1982, the U.S. Agency for International
Development (USAID) sent telegrams to all Latin
American health stations orienting them to the em
ployment of the priority-in tervention approach when
possible. Despite its deep involvement in the PHC
concept at the lime of the Alma Ata Conference,
UNICEF’s current health policy, as elaborated in the
December 1982 strategy, reflects a SPHC approach
[6]. A. W. Clausen, in his first health-related pro
nouncement as President of the World Bank, stated
that child mortality in the world could be cut in
half through the implementation of the new ‘tech
nological breakthroughs’ of oral rehydration therapy
and vaccinations by means of an SPHC-like struc
ture [7]. In addition, the World Bank appears
ready to place billions of dollars behind the SPHC
approach: the former World Bank President. Robert
S. MacNamara and Dr Jonas Salk recently an
nounced the formation of a world-wide organization
1
3
9
Selective PHC: a critical review of methods and results
devoted to speeding up the application of selective
immunization interventions and diarrhea therapy in
low-income countries.
The WHO leadership and other PHC supporters
have been less than enthusiastic about the SPHC
approach to primary health care. In an April 1983
address to the World Health Assembly, Dr Halfden
Mahler. Director-General of the WHO warned:
■Honorable delegates, while we have been striking ahead
with singleness of purpose in WHO based on your collective
decisions, others appear to have little patience for such
systematic efforts, however democratically they are applied.
There are unfortunate signs that negative impatience is
looming on the horizon and some of it is already peeping
over and gaining superficial visibility .... 1 am referring to
such initiatives as the selection by people outside the
developing countries of a few isolated elements of primary
health care for implementation in these countries: or the
parachuting of foreign agents into these countries to immu
nize them from above; or the concentration on only one
aspect of diarrheal disease control without thought for the
others. Initiatives such as these are red herrings.... With
out building up health infrastructures based on primary
health care, valuable energy will only be wasted, and you
will be deflected from your path".
The SPHC alternative has already been the core
issue of critical articles. With democracy and equity
as key criteria, Banerji [8, 9] has contrasted SPHC
methods with those entailed by the development of a
national health service. Briscoe (10) followed Walsh
and Warren in the acceptance of cost-effectiveness
ranking as a major criterion in the assessment of
health services but reached dissimilar conclusions
on the exclusion of water and sanitation activities.
Others have described the SPHC alternative as a
thinly disguised return to technologically-oriented
vertical health care programs (ll). Also the
cost-effectiveness technology used to justify SPHC
as a system of rational choice-making has been
questioned with respect to its validity [12].
Clearly, a major controversy is brewing with issues
about how billions of dollars will be allocated for
international health services and with choices con
cerning millions of lives hanging in the balance. The
following sections of this paper offer both a con
ceptual and empirical analysis of the underpinnings
of the selective strategy for primary health care.
METHODOLOGICAL ISSUES REGARDING SPHC
3
^7;.
U-
I
Obviously, quantitative planning is necessary for
any health manager—whether he holds to the 'SPHC
position or to the ‘Alma Ata spirit’. Since a wide
variety of quantitative planning methods are avail
able, health managers have options to exercise. For
instance, in the realm of health manpower planning
a manager could assess manpower needs through a
planning base that emphasizes: (1) health needs
(epidemiological information), (2) activity objectives,
(3) health demand or even (4) arbitrary standards
(e.g. agent/population ratios) (13, p. 94). The variety
of planning methods not only have specific- tech
nical advantages, drawbacks and justifications, they
convey as well a strong political valence.
Planning methods articulate with political struc
tures in at least a two-fold manner: (1) specific
1003
planning methods converge with the political struc
turing of health systems (e.g. activity objectives best
suit centralized health systems while health demand
based planning methods apply readily to systems of
private medicine) and (2) health planning methods
are always to some extent ‘structure determinative'.
Of course, the choice of a planning method should
follow from the force and power of the method,
not primarily from its political goodness of fit. The
wide-spread appeal of the SPHC method must be
examined in this light. Only if it suffers from major
internal methodological flaws could its political and
economic attractiveness account for its enthusiastic
reception.
An exploration of the SPHC prioritization method
raises a series of questions about SPHC meth
odological adequacy. This approach to priority
setting—one based upon the use of epidemiological
information and extensively used by the American
CDC—must proceed along several lines: the way the
SPHC approach determines its programmatic objec
tives, the SPHC view of resource utilization, and the
planning structure entailed by the application of
SPHC principles (14).
Setting SPHC priorities
The basic objective of SPHC is the control of
diseases in order to improve the health of a popu
lation. Improved health in this case amounts to the
reduction of morbidity, mortality and disability, such
reductions being demonstrated by the diminution of
disease-specific mortality rates among •priority' dis
eases. Walsh and Warren characterize the SPHC
disease prioritization method as follows, "in selecting
the health problems that should receive the highest
priorities for prevention and treatment, four factors
should be assessed for each disease: prevalence, mor
bidity, mortality, and feasibility of control (including
efficacy and cost)”. CDC training modules prepared
for mid and upper-level EPI program managers use
the same method only summarized concisely in the
form of an equation:
PRIORITY = Importance of Disease
mortality; incidence; disability
+ Likelihood of Success
government commitment; technical
and management factors; public
response.
The SPHC prioritization method is inseparably
integrated into the next step, the selection of an
appropriate health care system for intervention.
Appropriateness turns upon the 'reasonable cost’
and ‘practicibility’ of the health care system in ques
tion and Walsh and Warren analyze health system
structures on the basis of these criteria [2],
The interventions relevant to the world's developing areas
which are considered are comprehensive primary health
care... basic primary health care... multiple disease
control measures (e.g. insecticides, water supplies), selective
primary health care and research.
This set of objectives appears to follow from the
application of a logically related series of procedural
steps: (1) an objective selection of diseases of great
1004
Jean-Pierre Unger and James R. Kilungsworth
importance for an area. (2) their prioritization on the
basis of whether they can be controlled feasibly and
(3) the creation of a health system around the inter
vention scheme which has been selected.
Objective selection of diseases. The characteristics
of epidemological data in the less developed world
may jeopardize the validity of the simple and appar
ently sound SPHC method. Epidemiological data
required for an initial SPHC prioritization as well
as for subsequent monitoring of disease-specific
mortality rates are of uniformly poor quality in
LDCs. Cause-specific mortality rates are particularly
unreliable due to the lack of adequate diagnostic
measures.
A high percentage of causes of mortality cannot
be identified, even when surveillance programs estab
lished expressly for that purpose have been devel
oped. The 1980 Bangladesh child mortality survey,
for example, failed to identify the cause of 44% of
infant deaths [15]. In addition, seasonal fluctuations
compound the difficulties of analyzing annual rates
that summarize mortality. The intermediate aim of
reducing disease-specific mortality suffers thus from
data imprecision.
Relatedly, the uncertain weighting scheme used in
prioritizing diseases for intervention through the
SPHC method combines conceptual ambiguity with
data imprecision. Obviously, the product of a rela
tively precise parameter and a defective coefficient
will be a parameter which is itself defective. Clearly,
it is questionable to rely upon this method not only
for the identification of disease priorities but above
all for the designing and planning of the related
health system.
Feasibility and SPHC objectives. Determining
‘feasibility of control’ is not simply a matter of
scientific assessment. Obviously, the absence of a
biomedical tool suitable for treatment or prevention
of a condition rules out its control. When a tool is
available, however, its ‘feasibility’ is often a function
of the health system that uses it. Tuberculosis con
trol. for example, it not feasible in a verticallyoriented system that uses interval-bound mobile
teams or poorly trained Community Health Workers
(CHWs). Tuberculosis control, on the other hand,
may be feasible in the context of an integrated CPHC
or BHS system where medical assistants practice
primary care with the aid of well-crafted treatment
strategies and adequate supervision.
As SPHC proponents proceed to gauge feasibility
of control, they are often selective in their view of
‘feasible’ health systems. The feasibility of control
permitted by PHC systems is assessed in terms of the
existing state of organization and management in
LDCs, usually called 'inadequately developed’ and
overly exhaustive [16-18], On the other hand, the
health system structures involved in determining
feasibility of control for SPHC systems tend to be
judged on the potential efficiency of future tech
nologies (e.g. new vaccines, single-dose therapies)
rather than upon their current or demonstrated
effectiveness.
While potential technological developments appear
to offer hope for improving health status in the
future, the SPHC literature envisions little prospect
for improved management, training, and organiza-
don or for the re-allocation of resources in the health
sector of Third World countries.
The 'likelihood of success’ feature of SPHC and
CDC priority-setting procedures makes evident the
value-laden nature of ‘feasibility’. The feasibility of
control of a particular disease is as much a function
of value preferences about health systems as it is a
matter of empirical analysis. Immunizable diseases
and diarrhea treatment for example, are thought
‘feasible’ because they are viewed as diseases that can
be effectively managed in a vertically-oriented system.
Pneumonia treatment requires the skill of a medical
assistant and a continuous drug distribution network,
facts which reduce its 'feasibility of controT. On the
other hand, mobile teams are ruled out altogether,
since they cannot address the treatment of acute
conditions, due to the absence of the mobile team
when the episode occurs.
The overall impression created by 'feasibility of
control’ in the SPHC method is that it amounts to a
circular logic. A selective analysis of health care
organization determines priorities for disease control
while it is being claimed that prioritization leads to
the choice of health care intervention systems.
Diseases of importance. By the account of Walsh
and Warren, medical interventions appropriate to
prioritized diseases are stratified, “from the most
comprehensive to the most selective” [2]. But the
decision to focus on only 8-10 diseases, regardless of
which diseases are eventually selected, limits health
services, predetermines the level of medical inter
vention and concentrates attention on diseases that
cause high mortality. Largely ignored are the major
ity of conditions, i.e. those which cause the bulk of
pain, suffering, and disability among a population.
This is true even when appropriate interventions
might be available. Although the SPHC approach to
‘importance of disease' draws upon a definition of
considerable theoretical scope, the practice of SPHC
method [191 leads to an almost exclusive consid
eration of diseases which cause high mortality and
which enjoy ‘feasibility of control’.
One important result of the SPHC emphasis on
mortality is an overriding interest in childhood con
ditions. As Julia A. Walsh put the matter [20], “since
infants and young children are at greater risk of
mortality and morbidity, then health care should be
primarily directed towards them". Infants and young
children are at greater risk than most other popu
lation groups. They represent a large component of
total mortality in LDC’s and SPHC appropriately
addresses itself to their pressing problems. While the
SPHC strategy does not by-pass adult disability and
suffering intentionally, the constraints of the SPHC
method establish prioritized objectives and preferred
intervention schemes that do very little for adult
health problems.
When the ‘importance of disease’ measure is fur
ther refined, as Berggren ei al. (19) and the Ghana
Health Assessment Team [21] have attempted, the
SPHC/CDC prioritization approach only serves to
compound the problems involved in concentrating
upon childhood mortality. Their substitution of'days
of life lost’ or ‘years of life saved’ for total mortality
figures suggests that a day of life at any age is equally
valued. In consequence, the value of a 7-day-old
Selective PHC: a critical review of methods and results
infant with neonatal tetanus is ‘twice’ that of a
20-year-old with tuberculosis. The life expectancy
patterns in most LDCs, however, calls this into
question. Life expectancy in Liberia in 1971 [22], for
example, was only 45 years and the chance of dying
before age 4 was almost 24% in Malawi. Nevertheless
a 25-year-old male's life expectancy was nearly equal
to that of a person living in a developed nation (38.3
in Liberia, 1971; 47.3 in Canada, 1971) [23].
But even if’days of life lost’ were somehow’ ‘prop
erly’ weighted to reflect factual life expectancies, the
SPHC method would still yield a high priority for
childhood mortality diseases due to its focus on 8-10
conditions. The relatively high valuation of children’s
health problems by the SPHC approach raises serious
questions for planning applications of the SPHC
method. Third World communities may hold value
preferences distinctly at odds with an emphasis on
childhood mortality, in part, at least because adult
manpower is indispensable for community survival.
f'?
■f.’S!,
Expected intermediate outcomes for SPHC
Intermediate SPHC goals are almost all related to
a single, general intermediate goal, namely reducing
disease-specific mortality. The methods of SPHC
explicitly assume that a reduction in a certain few
disease-specific mortality rates will result in a reduc
tion of the overall mortality rate for a population.
This assumption is uncertain at best in developing
nations where mortality follows from the myriad
health insults associated with poverty and where
suitable epidemiological information is in very short
supply.
Il is likewise questionable whether an attempt to
reduce the disease specific mortality rate of a very few
pathologies can yield success in the reduction of a
population's overall mortality rate. Noting the
difference between diseases registered as the cause of
death and the determinants of death in an area,
Mosley [24] has proposed that child and infant death
has no discrete cause. Childhood mortality is, rather,
the result of a long series of recurrent infections and
deficiencies, particularly deficiencies of food intake.
To overlook the complex nature of childhood mor
tality could lead to: “recommendations for diseaseoriented technical intervention programs that fail to
achieve their goals, a typical example being supple
mentary feeding programs to combat malnutrition”
[24].
Recent reports from Kasongo, Zaire have under
scored the serious nature of Mosley’s contentions.
These reports suggest that measles vaccination pro
grams which result in a reduction of measles mor
tality may simply shift mortality to other diseases and
conditions without affecting the overall mortality of
the population [25]. The results of the Kasongo
study, it should be noted, are a matter of current
debate [26], Nevertheless, critics concede the serious
ness of the questions raised and call for further study
of the Kasongo report’s major questions.
The SPHC method, through its focus on medical
interventions of narrow scope aimed at reducing
disease-specific mortality among the children of an
area, appears to overlook the cautionary issue raised
by the Kasongo study. If it is true, that measlesvaccinated, malnourished children perhaps will die of
1005
pneumonia instead of measles, then this disease
specific mortality shift from one disease to another
requires a wider scope of PHC activities.
k should not be thought, however, that measles
vaccination stands alone in raising questions about
SPHC intermediate goals. Oral rehydration is a com
pulsory component of any selective strategy [2. 7, 19]
due to the fact that: “... in most developing coun
tries, diarrheal diseases rank among the top three
‘causes of death’ among infants and young children
along with respiratory diseases and malnutrition”
[24, p. 33]. However, .Mosley considers that it is a
great leap of faith to expect that oral rehydration
therapy can reduce the overall mortality rate:
. it
becomes evident that a strategy which is directed
toward treatment of the diarrheal cases is likely to be
ineffective, while a strategy which can reduce the
diarrheal incidence may expect to achieve substantial
reduction of mortality” [24, p. 34].
Areas dominated by poverty and malnutrition are
not likely to respond to narrow SPHC activities.
Technical approaches too frequently gloss over this
underlying problem: “.. . in any PHC program that
takes the narrow technical or ‘selective’ approach, an
underlying premise must be that there is no absolute
poverty or severe food shortage in the population”
[24]These observations about SPHC intermediate
goals are especially pertinent, given the cost
effectiveness contentions that serve as the underlying
SPHC rationale. If SPHC methods target a reduc
tion of disease-specific mortality among children in
resource-poor areas of the world, then selective
disease-control programs are most likely to be used
in the very areas where an unfavorable nutritional
background may doom the SPHC intervention to
failure. As WHO notes, 47% of Asian preschool
children and 30% of African preschool children were
wasted in 1983 (China not included) (27J.
SPHC method and resource utilization
Selective methods apparently encourage the
rational use of scarce health resources in developing
countries since a narrow group of activities are
targeted for the control of 5-8 prioritized diseases. In
several major health planning areas, however, the
consequence of using SPHC methods may be a
misuse of scarce resources, not a rational plan for
their conservation.
Physicians and hospitals. With the physician and
hospital-centered elements of most LDC health in
frastructures absorbing 80% or more of developing
country health care budgets, attempts to rationally
introduce primary health care must include referral
functions in overall planning.
However the SPHC approach calls for extremely
limited curative roles through its selectivity. Walsh
and Warren indicate only malaria, diarrhea and
schistosomiasis [2]; UNICEF suggests only diarrhea
and malnutrition [6]; both the GOBI-FF program
and the Deschappelles program [19] propose diar
rhea, malnutrition and tuberculosis as priority dis
ease conditions requiring curative activities. On the
other hand, Walsh and Warren call for ‘temporary’
controlling for tuberculosis, pneumonia, leprosy, try
panosomiasis, meningitis and helminth [2]. These
1006
Jean-Pierre Unger, and James R. Ki lungs worth
choices lend io isolate PHC from curative services by assumptions, it would not be able to screen
reducing the scope of the curative role to 2 or 3 patients, successfully referring patients to levels of
treatments at the PHC level.
care requiring physician skills. These physicians
With curative roles focused on only 2-3 disease would remain within the classical first-level of
conditions, hospital utilization patterns are not likely curative responsibility.
to be modified by the creation of a PHC network. It
In consequence, SPHC methods put a double
is significant to note that these utilization patterns are burden on any attempt to decentralize and redirect
known to be unfavorable in the Third World. At physician skills in LDCs. First, in restricting the
Vlityana hospital, for example, a utilization analysis physician's role to a few skill areas, the SPHC
showed that 40% of those in the wards could have approach tends to rob the physician of motivation to
been treated by ‘self-care’ facilities [28]. The same leave urban areas. Second, by reducing rural inter
hospital showed that, “the average number of out ventions to management tasks, SPHC methods dis
patient attendances per person per year falls pre courage LDC physicians from incorporating public
cipitously the greater the distance that separates the health notions of their nations into their day-to-day
patient’s home from the hospital" [28]). The study activities.
concluded that, ‘"Taking services to the people is the
By contrast. Comprehensive Primary Health Care
main way of correcting this imbalance" [28].
(CPHC) systems and methods would formalize, stan
In Kasongo, the SPHC key interventions are part dardize and subsequently delegate to medical assist
of a basic health service package—one emphasizing ants the curative and preventive tasks performed by
both curative and preventive activities. These inter a general practitioner. Since such a comprehensive
ventions account for an 85.6% reduction of hospital approach would require that physicians be involved
admissions due to diarrhea, diptheria, pertussis, tet in carefully analyzing their own work in order to
anus, malaria, malnutrition and measles in areas write strategies and instructions for medical assist
covered by the project. As compared to total excess ants, the physicians of developing countries would be
hospitalization in areas not covered, this coverage- deeply and rationally involved in PHC activities.
related reduction still represents only 28.6% of the Under the CPHC design, this involvement would also
reduction possible through a basic health services call for regular physician supervision of medical
(BHS) package (unpublished data of the Kasongo assistants.
Project Team).
SPHC methods, on the other hand, apparently
The modest Kasongo results were achieved by deny a role to medical assistants. Disease control
medical assistants working in a health center net activities limited to less than 10 conditions do not
work. Of necessity. Village Health Workers (VHWs) require the broad skills of a medical assistant. Gen
would find it most difficult to apply appropriate eral practitioners, like medical assistants, would find
referral criteria. Similarly, mobile teams would not that the SPHC structure offered them no effective
offer the permanent presence required by curative supply system, no regular supervision and virtually
activities. In relation to the reduction of excess no referral network. Under-utilization of medical
hospital utilization, the SPHC results are likely to be assistants and other general practitioners would be
lower than those observed at Kasongo.
the likely result of any attempt to supplement SPHC
As a consequence, hospitals will continue provid methods with a more rational use of personnel.
ing primary health care, though access to hospitals
Community health workers. Selective methods give
will remain restricted to those living nearby and to community health workers (CHWs) a pivotal role.
the wealthy. The isolation of primary health care In fact, the inclusion of CHWs is presumed to be a
from curative services encouraged by the SPHC rational characteristic of SPHC, one distinguishing
method will sustain this arrangement.
it from strictly vertical programs. In theory, the
Physicians raise similar problems. Because of their CHW links selective interventions with the com
relative scarcity, physicians in LDCs must be used munity, thereby lowering program costs. Though
where their skills are needed most. Encouraged by not described uniformly, village health workers
their Western-training and by the location of hospital have as primary tasks the organization of commu
facilities, physicians in developing countries com nities for vaccination and the administration of oral
monly remain in their nation’s largest cities or they rehydration solutions.
emigrate to more developed countries.
The claim that CHW activities such as these are
To meet the test of rational resource allocation in comparatively inexpensive does merit examination.
this regard, SPHC should require the redirection of Much of a CHWs resource efficiency stems from the
physician services from the over-doctored cities to the CHWs short training period and low wages. An
doctor-scarce countryside. But the methods of the analysis of 52 USAID assisted health care projects
selective strategy are not suited to accomplishing [29]—most of which were designed along the lines of
physician redirection. Within the PHC system and SPHC concepts—reveals that 86% of the CHWs
pursuant io the narrow scope of foreseen activities, involved were trained for less than 2 months. More
an SPHC approach would confine physicians to than one-half were trained for 2 weeks or less.
extremely simplified, mostly non-medical work, in
While training of this sort obviously lowers direct,
cluding personnel management, supply maintenance, financial costs, the training is not adequate for
and limited epidemiological surveillance. A manager many of the tasks identified through the use of
with narrow epidemiological training might function selective disease-prioritization methods [30]. Most
as well as a physician in such a role.
targeted SPHC conditions, for example, involve
Since a PHC system would address only 2 to 3 immunization only. The limited training of CHWs
curative activities when operating under SPHC would not permit them to perform these immun-
V
3
1
s’
Selective PHC: a critical review of methods and results
1007
izations. thus necessitating the use of mobile vacci sorbed more resources than did the whole ot the
nation teams. Field studies conducted in accord with country’s health services located outside the larger
selective methods, such as those by Berggren et at. cities and towns” (Note that this statement docs not
in Haiti [19], rely upon hospital-based activities in refer to a specific country [32. p. 207]).
Finally, SPHC interventions tend to place tight
stead of the interventions of CHWs. Only oral re
hydration therapy appears well-suited for the com limits on popular participation in the planning of
petence of the CHW and even this intervention programs. They require an extremely close fit be
requires experience and clinical judgment for success tween focused goals and the elements of vertical
design so that the selective strategy almost certainly
ful case management.
The apparent cost-savings which accrue from the precludes participatory modification of the health
use of CHWs also must be matched against the care agenda created for an area. With participation
opportunity costs of such volunteers, including time reduced or practically eliminated, perceived commu
lost from harvest and cultivation. These losses to nity needs—already understated by the SPHC em
the local economy combined with other pressures, phasis upon the problems surrounding childhood
such as the difficulty CHWs face in gaining commu mortality—tend to be overlooked. To ensure that
nity respect and acceptance, tend to produce a high health problems match-up with the SPHC approach,
level of attrition and turnover among CHWs, In community participation is likely to be replaced with
Nicaragua the rate is reported to exceed 35% [31]. community manipulation.
The stress of SPHC upon undertrained village health Quantitative planning: an alternative to the epiworkers turns the question of cost-savings into one demiologically based planning approach
about rising long-term costs and the reliability of
As noted above, epidemiologically based planning
undertrained health workers. The statement by
is
but one specific form of quantitative health plan
Walsh and Warren that, ‘These services could be
provided by fixed units or by mobile teams” (2J, is a ning. An alternative form includes normative con
claim of flexibility not supported by CHW capabili siderations. Instead of defining health planning
ties and one that is undercut by program limitations. objectives as the reduction of a few disease-specific
In consequence, the selective strategy appears com mortality rates, these objectives could represent the
pelled to fall back to a first reliance upon mobile commonality between the felt needs of the population
teams at the expense of other health infrastructure (mostly curative ones) and health needs as defined by
professionals. This more normative approach can be
elements.
Vertical structure and selective methods. Because schematized as follows:
selective primary health care methods rely upon
demand
the mandatory use of mobile teams, the SPHC
operational structure closely resembles that of a
traditional vertical program [8]. Typically vertical
programs are organized along military lines. As a
felt needs
result, they tend to be isolated units standing apart
from the larger health care structure about them,
both in terms of budget and administrative func
objective needs
tioning. Verticalist concepts have been characterized
as favoring, “categorically specific, hierarchically
organized, discrete disease control programs” [32].
Although preventive care may be provided by
periodic services, curvative care requires the presence This is a dynamic scheme which takes the demand
of a permanent structure. As a result, multiple factor into account thus enabling health services to
health problems are not included within the scope of communicate with people so as to
effort of the mobile team program. In addition,
(1) attempt control of ‘irrational’ demand
vertical schemes overlook the advantage of integrated (“irrational” quest for therapies such as vitamines or
preventive and curative health care [33].
injections)
The CHW/mobile team structure that SPHC re
(2) increase the felt needs, that is make people
quires enjoys neither the increased health team
prestige that results from its curative efforts nor the aware of “objective” needs.
improved coverage and effectiveness which belongs to Under this scheme, the fit between the planned health
a system whose personnel gain an increased socio structures and related health activities could not be
cultural knowledge of an area as they remain in one too tight.
location. Further, vertical structures by their nature
A normatively grounded alternative to epicannot take advantage of information generally dcmiologically quantitative health planning would
available through CPHC approaches, particularly stress two characteristics for planned primary health
the integrated, centralized information that CPHC care systems: (I) they should rely upon polyvalent
systems gather regarding medical histories and health teams and (2) they should consist of suffi
preventive health statuses.
ciently decentralized but fixed units. Pivotal deter
In practice, the costs of vertical intervention struc minants of concentration of health professions and
tures frequently undermine whatever feasibility exists facilities would include the following elements:
in their program design, thereby placing a burden on
(1) geographical accessibility via decentralization
other health system structures. As Oscar Gish has
(2) PHC facilities scaled to human size’
noted: "special campaigns [vertical programs] ab
1008
Jean-Pierre Lsger and James R. Kjllisgsworth
(3) consideration of decentralization costs
G) reduced technical performance linked with
highly decentralized effort
(5) resource constraints.
The' normative-quantitative planning alternative
___j_
-------------------.-.
•,
recommends
a_ structure-based
planning
approach
within which activity objectives would be regionally
and locally established. Such a planning strategy does
not eliminate the need for well-defined priorities. For
example, health center supervision can underscore
the importance of oral rchydration or immunization.
Instead, it advocates quantitative planning on both
professional and local or community criteria.
u
j
JVSTinCATlON FOR THE SPHC POSITION
Empirical support for the SPHC position is quite
limited since there are only a few field reports avail
able to support its claims. In addition, the cost
savings claimed for the selective approach to primary
health care involve an unorthodox approach to
cost-effectiveness analysis.
Empirical support for SPHC
The SPHC approach formally described by Walsh
and Warren relies upon 7 field reports for its substan
tiation, one of which remains unpublished. Walsh
and Warren first cite a field study from Guatemala.
Gwatkin et al. [34] have suggested that numerous
complications prevented the Guatemala investigators
from reaching unambiguous conclusions.
The Jakhmed (India) project, a second study that
Walsh and Warren cite, cannot be used for substan
tiating the SPHC position since the project under
investigation provided, "...a wide range of nu
trition. health, and family planning services” [34].
This makes the Jakhmed project inappropriate for
bolstering a SPHC viewpoint. Because it was clearly
a simple, vertical program and not a selective one,
the Hanover (Jamaica) project listed by Walsh and
Warren cannot be used as evidence for the value of
SPHC: furthermore it dealt only with malnutrition.
The Walsh and Warren reference to the Ghana
primary health service system is in fact a reference to
a comprehensive not a selective system. Finally, the
Narangwal project [35] cited by Walsh and Warren as
empirical support for SPHC involved projects in 4
villages, each with a different health care activity:
nutrition, curative care with a physician back-up,
nutrition and curative care, and a control village. The
separate Narangwal activities best fit either simple,
vertical intervention formats or coincide with CPHC
functions, not SPHC medical intervention schemes.
In a critique of the studies Walsh and Warren list as
support for the selective strategy, Gish remarks that
the. ". .. authors [Walsh and Warren] confuse diverse
pilot project research results with World Bank esti
mates [and] with their own data based on [an] African
model area” [32].
Substantiation for the selective disease-control
strategy reduces itself primarily to the field report
from Berggren et at. [19] conducted in the Dcschapelles area of Haiti. The results of the Haitian
project are cited as evidence of what a selective
approach ("the same approach advocated in our
paper” [20]) can achieve. Because it is central to the
credibility of the selective strategy for disease control,
it is worth examining the design and empirical claims
of the Berggren et al. study.
Haiti project. The Deschapelles project prioritized
8 identified disease conditions and then targeted them
for intervention in a small (5 x 5 km) census tract.
The population of the area was approx. 10.000 and
the tract contained a 150-bed hospital with a staff of
13 physicians. Before and after medical interventions,
the authors measured disease and age-specific mor
tality rates in the census tract. They concluded that
a selective approach significantly lowered mortality
rates. These claims are open to dispute since the study
exhibits a number of deficiencies. In particular, its
outcome indicators are not controlled, it uses external
standards in a context bereft of external validity, and
the program appears to be more expensive than
SPHC programs.
External standards. Results from the Deschapelles
study are presented by a comparison of death rates
in the targeted area and available national estimates.
Kenneth Warren cites the outcome of this compari
son as evidence for SPHC effectiveness: ''mortality
rates fell progressively during five years to levels only
one-fourth as high as the national estimates'* [20].
The Haiti Project’s use of external standards is
open to question in 4 major respects. First, beginning
and final figures of the study are not derived by
similar methods. The beginning figures came from
interviews while the ending ones came from a process
of longitudinal follow-up. Second, during the
project's first year, the mortality rate for 0-1 age
groups in the Deschapelles area was 55/1000 while
the comparable figure for all Haiti was 146.6'1000
[36, p. 14], a figure almost three times greater than
that of the experimental area. Third, among all areas
of Haiti, the Deschapelles sector showed the lowest
prevalence of Gomez' Stage-HI malnutrition [37],
still another indication that it was an exceptional
area. Finally, the superiority of agricultural prod
uction in the Artibonite valley, where Deschapelles
is situated, makes it one of Haiti's superior rice
producing locations.
In consequence, the use of internal comparisons
and beginning-to-end death rate figures suggest that
the selective Haiti program may have had a much
lower impact (if at all) upon the mortality of the
Deschapelles area than a comparison with 1972
national figures would suggest.
Confounding socio-economic factors. Forty-three
per cent of the total mortality decline claimed for the
selective interventions of the Haiti study can be
attributed to malnutrition deaths averted. There are
sound reasons for skepticism concerning this claim.
First, the zone of greatest mortality reduction for the
Deschapelles program falls into the second priority of
diseases listed in the Walsh and Warren version of
SPHC [2]. It is surprizing to see this element of the
Haiti project succeed more markedly than activities
more highly favored by the SPHC strategy, for
example measles or tetanus. Second, the reported
43% decline in malnutrition deaths averted is particu
larly surprizing. Results of a Colombian study [38.
p. I67J indicate that the greatest reductions of infant
mortality rates are to be achieved through supple-
Selective PHC: a critical review of methods and results
)
9.
£
menial feeding programs that target pregnant
women. This was not the approach used in the
Deschapelles field trial, a fact which raises further
doubt about tracing malnutrition deaths averted to
the Haiti project’s selective interventions.
Confounding socio-economic factors are perhaps
at the root of the increasing number of malnutrition
deaths averted which were reported in the Haiti
study. Despite the fact that Berggren et al. identify a
series of such factors (housing, food preparation,
latrine availability, protected waler supplies), they do
not show their constancy across time. Even more
importantly, food availability is not discussed, a fact
that raises questions about the degree to which the
study’s overall results are confounded by intervening
variables.
Confounding hospital activities. Findings in the
Haiti study do not adequately control for the impact
of Albert Schweitzer Hospital activities upon re
ported mortality rates. The facility was located less
than 3 km from the surveillance area under study.
With respect to this confounding influence, it is
demonstrable that the introduction of prioritized
health care activities failed to statistically modify the
targeted disease-specific deaths as a proportion of
overall deaths in the area. A two-tailed Z-test for
proportion (? = 0.2270) does not reject the equality
of 1968 and 1972 proportions at the 0.05 level.
Specifically, the following assertion in the Haiti study
must be called into question: "the hospital services
probably achieved their maximum impact during the
12 years before the health surveillance and health
services began. The impact of health surveillance and
health services is therefore reflected in the changes in
mortality rates after 1968'’ [19].
Reliance upon the findings of Berggren er al.
as a provisionally adequate defence for selective
disease control interventions poses serious difficulties.
When the Deschapelles activities were extended to
three other Haitian areas (each with a population of
10,000 persons), overall mortality rates only slightly
decreased in two of the three while actually increas
ing from 78 to 89/100 in the third [39]. Further, it
should be noted that the activities introduced by
the Haiti use of the SPHC approach fall well within
the range of comparable Basic Health Services
(BHS) expenditure levels and cannot easily serve as
a normative cost model.
Cost-effectiveness justifications for SPHC
Cost-effectiveness analysis is a relatively flexible
and non-dogmatic mode of economic analysis which
should bolster the contentions of national health care
strategies. As decision-makers consider careful costeffectiveness analyses, for example, they remain free
to apply variable standards and situation-specific
criteria in setting priorities and in selecting program
objectives for their area.
The 1978 Walsh and Warren article sought to link
SPHC and cost-effectiveness analysis quite directly
[2J. Instead of demonstrating the usefulness of
cost-effectiveness analysis in the planning of primary
health care programs, the Walsh and Warren article
sought to use cost-effectiveness analysis as a
justification for normative claims, thereby exceeding
the careful limits of the technique.
S.S.M. 12.10—8
st
1
1009
Empirical adequacy. In asserting that SPHC is.
"potentially the most cost-effective type of medical
intervention" [2], Walsh and Warren demarcate an
exceptionally wide scope for their cost-effectiveness
comparisons. They make head-to-head comparisons
between five approaches: CPHC. BHS, Multiple
Disease-Control Measures, SPHC and research. In so
doing, Walsh and Warren impose considerable strain
upon the cost and effectiveness data of their report.
First, the cost and effectiveness estimates relied
upon in the Walsh and Warren cost-effectiveness
discussion are heterogeneous and derived from mul
tiple sources: WHO, the World Bank, bi-lateral field
projects and diverse research programs. Although
these cost figures may be completely adequate when
taken as isolated data, the sweep of the Walsh and
Warren cost analysis leaves numerous un-answered
questions. Were the cost estimates of their study
reported in the same manner and with equal com
pleteness, particularly in the case of estimates about
training, indirect costs at the referral level, and the
value of volunteer labor [40, pp. 27—49]? Did the
various sources of data rely upon a uniform method
and rate for discounting reported cost figures? Were
the costs discounted at all? Since pilot programs and
field studies can change greatly in terms of costs when
they are ‘scaled-up’ to national levels, it should be
known whether (and how) national cost estimates
were compared with those derived from projects of
smaller scale. How were project and research cost
figures reconciled?
Problems also appear in the Walsh and Warren
effectiveness data as well. By supporting their selec
tive strategy on the basis of heterogeneous findings,
it remains unclear whether multi-outcome programs
were demoted in importance by definitional fiat (40).
The decision to compare the effectiveness of research
with primary health care programs designed for field
implementation seems equally open to doubt.
The considerable gap between SPHC costs per
capita (1978 50.25/capita/year) and those reported in
the Berggren er al. field trial (1981 $J.60/capita/year)
[19] raises still further questions about (he empirical
adequacy of SPHC cost-effectiveness comparisons. If
these disparities were projected straightforwardly to
a national scale, they alone are enough to dampen
enthusiasm for the potential cost-savings ot the
SPHC approach. Finally, it should be noted that
BHS field cost reports [41] disagree with the BHS cost
figures reported by SPHC supporters (2, 42].
Conceptual adequacy. Health planners and
decision-makers are best served by cost-effectiveness
analysis when a conceptually clear cost constraint or
program objective has been set for the analysis. To
compare alternatives successfully, cost-effectiveness
analysis requires compliance with several procedural
requirements:
a clear operational definition (or set of definitions)
for the program to be analyzed
a careful computation of net costs and net health
effects among the alternatives being compared
an exact specification of decision rules to guide the
selection of preferred alternatives
a sensitivity analysis to probe areas of uncertainty
in the study.
1010
Jeas-Pierre Unger and James R. Killings'a.'ORTH
The Walsh and Warren comparisons violate these
rules of conceptual adequacy at several points. First,
comparisons between CPHC and SPHC only doubt
fully meet the standards for operational definition.
Second. CPHCs multiple program outcomes require
that it be treated as a cluster of programs, each
scaled-up individually for comparison with the single
programs of BHS and SPHC. In the absence of such
treatment, its net costs and net health effects are
extremely hard to compute.
Third, the teasing out of cost equivalents to form
valid cost-effectiveness ratios would be most chal
lenging in this case, to say the least. Fourth, the
Walsh and Warren report is silent about the sub
ject of a conceptually clear decision rule and makes
no use of sensitivity analysis. The absence of a
sensitivity analysis affects the assessment of alterna
tive approaches adversely. For example, in specific
areas such as water supply, an analysis that allowed
existing expenditures to be redirected away from
inferior water services has shown that long-term
PHC costs decline when water quality is improved
(10}. Finally, the criteria pertinent to broad-scope
cost-effectiveness comparisons (e.g. ‘equity’ and
efficacy’) are missing from the Walsh and Warren
report.
Cross-strategy comparisons. Cost-effectiveness
analysis is poorly suited to determining what pro
grams a society should pursue [43]. Its forte lies in the
realm of allocative choice, not normative or distribu
tive judgment. Walsh and Warren, however, use the
technique or accomplish cross-strategy comparisons.
In so doing, they reveal normative intentions whose
distorting impact may underlie the conceptual prob
lems of their study. In effect, the Walsh and Warren
use of cost-effectiveness analysis substitutes for mea
surable. comparable program alternatives a group of
proxies for entire health care strategies.
At issue in these comparisons are: choices about
how a population values the existence of a rural
health care infrastructure, about the extent to which
an area’s health care system should be fundamentally
participatory, about the degree to which a health
system should stress objective and extra-local health
criteria rather than the ‘felt needs’ of an area, and
about the extent to which health services will be
privately owned and operated. These are valuative
elements in the Walsh and Warren cost-effectiveness
analysis. As integral features of the proxic measures
just noted, they inject value elements that confound
the attempt to make cross-strategy comparisons.
DETERMINANTS OF SPHC ADOPTION
The selective strategy of disease control has
prompted considerable comment and has been well
received by international agencies (World Bank,
UNICEF), academic institutions and research centers
(Centers for Disease Control: Harvard University),
bilateral cooperation agencies (USAID) and private
institutions (Ford and Rockefeller Foundations).
Given the empirical weaknesses, methodological
problems and conceptual difficulties of the SPHC
position, however, it is important to explore some of
the less apparent reasons for SPHCs popular recep
tion and for the magnitude of funding already ear-
marked for its implementation in developing areas.
When this is done, SPHCs widespread appeal seems
to be the coincidental result of constraints and chal
lenges facing influential, independent decision
makers, forces leading them to endorse a primary
health care strategy with strong appeal io their
training in ‘classical' public health.
Political and economic valence of SPHC
The expanding body of pathologies that burden
the population of the Third World are paired
with budget reductions [44] that threaten disaster.
These constraints from the external environment of
international cooperation agencies are matched by
‘internal forces’ of no smaller significance:
1. Results.
Donor agency funding requires “results” within the
period of the agency’s mandate, a pressure which encour
ages short-term planning and readily measured program
objectives; this rules out the measurement of factors such as
the avoidance of suffering and the import of participatory
structures; it also slows the creation of health infrastructure.
2. Privjtized Service.
International agencies, recognizing “political realities”,
seek to achieve larger macro-economic objectives through
their funding strategies, not the least of which is the
establishment of a uniform economic pattern for the recip
ient nation; this leads to an increasing of rhe private medical
sector, an expanded donor agency influence over the recip
ient nation’s economy, financially and geographically in
accessible private care and a weakening of curative and
preventive service integration (the concept of health service
responsibility for a well-defined population is strained
greatly by rapid expansion of the private, curative sector).
3. Donor Clientel Expansion.
Leading donor agencies recognize that supporting of
medical programs in recipient countries is only one element
in the process of political-economic barter; as donors seek
to expand their number of recipient clients, health con
tributions to individual nations approaches the floor below
which no modification of health care can be achieved.
4. Research and Commercial Outlets
The cooperative activities of funding agencies frequently
aim at the promotion of significant financial and research
outlets for corporations and leading academic institutions of
donor nations; this results in reversed priorities; even before
the benefits of existing technologies are disseminated to
recipient nations, “space age” technologies arc given enthu
siastic support (e.g. vaccines and other fruits of genetic
engineering); the research concerns of donor agencies sup
plant the applied research interests of developing nations
[45].
5. Financial and Institutional Status Quo.
Institutionally, international cooperation agencies and
research institutions seek to respect the financial and institu
tional status quo of recipient nations: this favors the adop
tion of health program strategies placing little constraint
upon national health budgets and making only minimal
demands upon the existing institutions of the recipient
nation.
6. Reduction of Public Expenditures
Despite the seeming paradox, optimizing the costcffcctivencss of a health system can entail (he introduction
of a new level of health care services. The paradox is
only apparent, however, since introducing Village Health
Workers for the sake of cost-effectiveness generally leads to
the dismantling of the health center and dispensary network
of the state. While VHWs reputedly are self-supporting.
Selective PHC: a critical review of methods and results
1011
Table I. Order of die priorities for the study of causes of death according to indices of incidence, importance and vulnerability (Stale
of Aragua. Venezuela, I960)
Causes of death
_________ m_________
Djsentry, gastritis duodenitis, etc. (B6. B36)
Premature births
Influenza, the pneumonias, and bronchitis
(B30. B3I. B32)
Cardiovascular diseases (B22-28)
Pulmonary tuberculosis (Bl)
Transportation accidents (E802-E86I)
Other diseases of early childhood (B44)
Tumors (BIS, BI9)
Accidents (excluding transportation)
Coefficient of
incidence
(2)
Coefficient of
importance
(3)
Coefficient of
vulnerability
H)
Product
(2x3x4)
(5)
Order of
prionty
<6)
9.7
8.5
4.4
0.98
1.00
0.97
0.66
0.33
0.33
6.27
2.80
1.40
1
2
3
20.3
2.8
3.9
2.5
6.7
55
0.65
0.68
0.83
1.00
0.68
0.75
0.10
0.66
0.33
0.33
0.10
0.10
1.32
1.25
1.07
0.82
0.45
0.41
4
5
6
7
8
9
Note: arranged in accordance with the weighted coefficient of incidence the causes of death would appear in the following order, dysentry;
premature births; other diseases of early childhood: cardiovascular diseases: transportation accidents; accidents (excluding transporiaiion): influenza, etc : tumors; and pulmonary tuberculosis.
Source: (42. p. 27],
3
3
J*
fixed health centers and dispensaries often generate state
expenditures. The overall pattern of replacement is con
sistent with World Bank and International Monetary Fund
and donor policies aimed at “low cost health projects” for
PHC [46].
The internal and external constraints upon the
cooperative efforts of international agencies have
combined with the technical training of key decision
makers to encourage an enthusiastic response to
SPHC. Among the features of SPHC which such
agencies find appealing are the following:
Agency Constraint
1. An emphasis upon ‘results*
2. Privatization
3. A numerical building of donor agency
clientci
4. The development of commercial and
research outlets
5. A concern for the financial and institu
tional status quo
L
£
Table 1 summarizes the approach of CENDES
analysis for Araqua State (Venezuela) (50}—an ap
proach quite closely paralleling the method taught 20
Associated Reasons for SPHC Appeal
1. SPHC depends upon ’objective' measures and calls for little additional
health infrastructure
SPHC favors a technical agenda whose items have been established by
technical methods
2. By filling in functional blanks left by the private sector (preventive
activities), SPHC implies no competition between public and private
health units [47,48]
SPHC tends to by-pass the issue of population-oriented health service
responsibility
3. SPHC’s claim to be ‘potentially the most cost-effective’ appeals to the
desire of international and bilateral cooperation agencies to expand their
clienlel
4. SPHC emphasizes prospects for vehicles well-suited for ’space age’
commercial technologies, e.g. vaccines derived from genetic engineering
rather than prospects for management improvement of existing techniques
SPHC leaves open the option for private sector doctors to refuse standard
treatments, e g. use of standard pharmaceutical lists [49]; this excludes
from the scope of PHC curative activities (except oral rehydration and
chloroquine)
5. The claims of SPHC assure that it would put almost no strain upon
existing financial or institutional arrangements
SPHC tends to preclude community impact upon the planning and
management of health services, an emphasis which tends to sustain
existing institutional practices and priorities
SPHC requires little fund transfer from hospital to primary health
services.
Training of health system managers; SPHC
The SPHC appeal to international agencies of
cooperation parallels the attraction of health pro
gram managers to the SPHC conceptual structure.
Many of these key decision-makers have an exposure
to past or ‘classical’ approaches to disease control as
a feature of their public health training. Gish, for
example, has noted the similarity between the prior
ities. of SPHC and the CENDES approach [11]:
J
This widely known effort attempted to put into practice a
fully formed model for health care planning of the sort pul
forward in far more simple form by Drs Walsh and Warren.
After many years of work and the training of several
hundred Latin Americans in the methodology, it was con
cluded in the mid-1970s that planning of this sort was
infeasible and thus to be put aside.
years later by the CDC (Atlanta) for SPHC-type
prioritizations (Table 2) [51].
The kinship between SPHC and CENDES analysis
is not surprising since the political constraints which
confront program managers and cooperation agency
leaders have been relatively constant in the postWorld War II period, as was noted earlier. The
program management view of primary health care
retains its emphasis upon the following:
1012
Jean-Pierre Unger and James R. Kjlljngsworth
Table 2. Possible answers to the exercise on establishing priorities (module on national priorities»
Overall
Feasibility of
Overall
Health proWern
importance
Most feasible control measure
control measure
priority
Accidents
Moderate
First aid; medical diagnosis and treatment; rehabilitation
LowLow
Diarrhoea
High
OR therapy
High
High
Diphtheria
Moderate
DPT vaccine
High
Moderate
Louer respiratory infection
High
Drug therapy
Moderate
High
Malaria
Moderate
Drug treatment
Moderate
Moderate
Measles
High
Measles vaccine
High
High
Neonatal tetanus
Moderate
Tetanus toxoid
High
High
Other neonatal conditions
Moderate
Prenatal and delivery care
LouModerate
Pertussis
Moderate
DPT vaccine
High
Moderate
Poliomyelitis
Moderate
Oral polio vaccine
High
Moderate
Skin infection
Low
Good hygiene and health education
Low
Moderate
Tuberculosis
Moderate
BCG vaccine
Moderate
Moderate
’ .'ndemutrition
Moderate
Education, food supplies and child sparing
Low
Moderate
Record assessments as high, moderate or low.
Source: (43. p. 26].
(1) selection of top-priority pathologies that re
quire epidemiology, surveillance projects and readily
quantified weighting schemes
(2) operational designs that call for the use of
mobile teams
(3) a mobilization of‘popular-based’ manpower in
accord with anthropological understanding to the
extent that it provides insight about how to increase
popular participation
(4) field evaluation using cost-effectiveness analysis
for single outcome, process evaluation purposes.
Not only do training and field experiences predis
pose program managers to selective interventions
once they reach the level of national health service
management, these forces also lead to a planning of
national health services in terms of program manage
ment concepts—not a health service management
framework:
Program Management
Short-term planning outlook
Planning for program development
disease-control strategy are already considerable,
however, it is essential to identify reasons for its ready
adoption by international cooperation agencies and
developing nations. The prime forces appear to be
political and economic in nature, but these
justifications are reinforced by the education and field
experiences of key decision-makers.
Ultimately, the planning and development of pri
mary health services that accord with the 1978 Alma
Ata declaration will require approaches that run
counter to the vertical program characteristics that
typify SPHC. It appears mistaken to create extensive
new financial and human resources commitments for
a SPHC-type campaign. The alternative lies in the
study of methods explicitly connected to the expan
sion of national health services. The methods of
health service development must first be shown to
have clear and demonstrable efficacy for attaining
health for all by the year 2000.
Health Services Management
Long-term planning outlook
Planning for structural development of health services and funclional development
within these structures
Responsibility toward population covered by health services.
Given the political constraints and the program
management perspective derived from successful dis
ease campaigns such as the smallpox effort, the
appeal of SPHC is a rather predictable phenomenon.
This is especially the case, since program managers
tend, with seniority, to obtain tenure in the public
health schools of developed countries. This is not
the case, however, with national health service man
agers hired by LDC public health schools that enjoy
relatively low resource and influence levels.
CONCLUSION
This paper has set forth an historical context for
understanding the current appeal of SPHC for those
who urge its widespread adoption in developing
countries. The weaknesses of its empirical founda
tion, methods and operational structure make dubi
ous the enthusiasm with which SPHC has been
greeted. Since the economic pledges to the SPHC
Acknowledgemem—We are deeply indebted to Professors
Mercenicr and Van Balen (Institute of Tropical Medicine.
Antwerp) whose knowledge and comments were indispens
able.
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1965.
A Symposium from Makerere. Oxford University Press.
51. WHO. Expanded programme on immunization. Train
Nairobi. Kenya. 1966.
ing course on planning and management. Course Facili
29. U.S. Agency for International Development. 52
tator Guide. WHO, Geneva, 1978.
USAID-Assisted Projects. Washington, 1981.
&
3
VOL 341: FEB 13, 1993
THE LANCET
44)9
Alma Ata revisited
3
e
c
L
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L
The central Asian republics1 present several
paradoxes in health care; they give women up to one
year’s paid leave after delivery but mothers seldom
breast feed; they have one doctor for 200 people but a
high maternal mortality rate; and they have modest
birth rates but a low use of contraception. To explore
these issues and look for solutions the US Agency for
International Development (USAID) sponsored a
seminar in Alma Ata last month on Maternal and
Child Health. Medical leaders and parliamentarians
from
Kazakhstan,
Kirghiztan,
Tajikistan,
Turkmenistan, and Uzbekistan were represented.
These newly independent nations contain 50-6 million
people. Education is universal and of a high standard,
but there are many environmental problems. As many
as 80% of women are anaemic and hepatitis is
common. There is no record of human
immunodeficiency virus infection yet.
Before the break-up of the Soviet Union, all aspects
of health and nutrition were centrally planned and
even breastfeeding was organised according to the
“Moscow regimen”. Every state still has a network of
milk kitchens, and rigid diagnostic screening practices
end up categorising the overwhelming majority of
women as sick. Antenatal care consists of twelve visits
and women stay in hospital for a week after a normal
delivery. Yet many women complain about
impersonal and even callous treatment and
presumably it is this perception of services, with
consequent low uptake, together with inadequate
access in some areas, that accounts for the high
maternal mortality rate per 100 000 live births
(Uzbekistan: 65, Turkmenistan: 134). Even more
worrying, the maternal mortality rate is rising in
several republics and has jumped by one third in
Kazakhstan since 1987.
The central Asian republics have always had a
higher fertility than the rest of the former Soviet
Union (total fertility rates 2-3 in urban areas and 3-4
in rural), although it is much lower than in their
Moslem neighbours such as Afghanistan and
Pakistan. Only about 15% of couples use any modem
method of contraception. Again, Moscow set
inflexible rules: after two caesarean sections women
had their tubes tied without their consent but those
who requested sterilisation were refused and the pill
was regarded as dangerous. Supplies of contraceptives
remain grossly inadequate and abortion rates are high
(25-60 per 100 live births). Although outpatient
vacuum aspiration abortion was originally developed'
in the Soviet bloc, women in the Asian republics still
have dilatation and curettage procedures and spend
two nights in hospital. The most widely used
contraceptive is the intrauterine device. In Uzbekistan
there has been a major effort to increase its use and this
is the only republic where the maternal mortality rate
has fallen (78 in 1989, 55 in 1992).
The USAID seminar provided a welcome
opportunity to begin the transition from a centrally
planned medical system to local decisions based on
scientific research—a change that national leaders are
well placed and eager to make. It was agreed to adopt
World Health Organization standards for defining
vital statistics and the five republics plan to work
together on such things as a common drug registration
policy. A client-centred approach to maternity care is
needed, with more involvement of women in decisions
about their care. There was unanimous agreement
that a family member should be allowed to stay with
the woman during labour, and on the desirability of
rooming-in of newborn babies. Even in the areas with
very high environmental pollution from pesticides
and nitrates breastfeeding was still seen as preferable
to bottle feeding (local research showed bottlefed
babies have five times as many infections as their
breastfed counterparts). One republic has begun to
offer voluntary sterilisation and it should be relatively
easy to replace dilatation and curettage by vacuum
aspiration for first trimester abortions.
The people of the former Soviet Union face a
difficult transition from a centrally planned economy
to a free market and they need and deserve short-term
assistance from the West. What was probably not
needed was the recent donation of 1483 tons of
powdered milk by the American Red Cross to
Turkmenistan—a country where half the homes have
no running water. Most of the $6 -5 million cost would
have been better spent on contraceptives, which
would undoubtedly save a great many abortions, or on
iron and folic acid tablets to prevent anaemia.
The Lancet
1. Chen LC, Rhode JE, Jolly R. A looming crisisrhealth in the Central Asian
Republics. Lancet 1992; 339: 1465-67.
Soc. Sci.
Vol. 26. No. 9. pp. 931-940, 1988
Printed in Great Britain. All rights resen/ed
0277-9536 38 53 00+0.00
Copyright e 1988 Pergamon Press pic
J
PRIMARY HEALTH CARE: ON MEASURING PARTICIPATION
Susan B. Rifkin,'* Frits Muller2 and Wolfgang Bichmann1
. -'s-.,.. a.™.,
'
Heidelberg, F.R.G.
concentrate on the assessment of particinatio^ A mrthnH J
•h
Cqua ,mP°rtancc. the authors
9
5
S r=«amh'C'Pat'°n
™ -hich is
m ^al for
Key H^-^omprehensive primary health care, community participation, measurements
g
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4,v
INTRODUCTION
health programmes in terms of service delivery and
vfirSt.decade in which primary health care
health status alone remain strong. In part, it may be
(PHC) has been the accepted policy of over 150
argued that one reason is that there are few ideas of
nations grows to a close, the future of this policy is
a pragmatic nature by which to assess participation
and equity.
still very much uncertain. The promises of a radically
better life for those whose needs were greatest re
This paper is a beginning to give a form to the
mains an illusive goal and the vision of both authors
* ----------&- enable policy
principle of -participation
that-----might
and signatories of the Alma Ata declaration threatens makers,
. . , planners
. . and beneficiaries
.ntScariss to consciously
e
*platitude.
----- There **.v
include this principle in their programme plans and
to remain a mere
are ssMiMjr
many itaavili
reasons
for this
of the most
most important
important is
is the
the
eva!uatlons- Participation cannot be divorced from
...situation. One
— -•
unrealistic expectations of policy makers, planners
As thc framcwork develops, therefore, equity
and beneficiaries concerning how health improves 11]
. a constanl» if not explicit, factor.
Traditionally expectations about health imIs. il realistic t0 believe that an analytical frameprovements have been linked to inputs and outputs WOrk t0 assess Participation can be developed? There
of medical services (more recently termed ‘health arf ar8uments to suggest it is not [3,4]. Whatever the
services’ to include preventive care) and/or impact in va,ld!ty of these views, there, on the other hand,
terms of health status. The development decades of ren}a,ns a major problem. Decisions about allothe 1960s and 1970s which gave birth to PHC and the cat,ons.of resources for PHC are often in the hands
basic neeas
needs’ [2]
°f 7ied’ca,,y trained people. Until those who have to
uasic
izj concepts, put forward an analysis
services; maI? decisions • about resources also have framewhich related better health not only to health services
but also to the existing socio-economic conditions. It works by whlch to understand and judge their efforts
was argued that health improved not merely by the t0 extend PHC beyond service delivery, it is likely
provision of health services but in addition by the thcy wiU continuc to expect health to be related
distribution of available resources based on the prim
ma,nIy t0
Provision of services and choose policiple of equity and by the involvement of beneficiaries
and acdons that reflect this view. For this reason
in decisions about care based on the principle of
11 *
t0 attempt to develop a framework in
participation.
which professionals can see benefits of efforts iu
to
Despite the acceptance of these arguments by those
support participation, alter their expectations accordmgly
resources and’ time
to developing
who adhere to the Alma Ata declaration on PHC
V and allocate
’
*-----------------’
this approach. Until those who have control of
traditional vlews which judge the success or failure of
resources are convinced that partic
and desirable concept, it is likely to remain relegated
’Correspondence should be addressed to: Susan B. Rifkin,
to rhetoric.
Department of International Community Health, Liver
This paper presents a methodology by which as
pool School of Tropical Medicine, Pembroke Place
sessment of participation in health programmes can
Liverpool L3 5QA, England.
be undertaken. It sets out to provide a tool to assist
931
(...
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932
Susan B. Rifkin et al.
those involved in PHC programmes to describe par
ticipation in their programme and upon that basis
plan their future actions. It takes as its starting point
the conclusion of a previous work by one of the
authors which suggests that broader participation is
gained by developing a wider range of activities [5].
It does not set out to validate the crucial role of
equity and participation in PHC as these arguments
have been accepted by the signatories of the Alma
Ata declaration. Nor does it attempt to present an
argument that more participation is ‘good’ or ‘bad’
as this tool is descriptive and not judgemental.
The paper is divided into five parts. In the first
section, we will review past efforts in measuring PHC
by frameworks other than those which only examine
the improvement in health status and in measuring
participation. Part two discusses the conceptual
framework for assessing participation. Part three
discusses the analytical framework. Part four presents
the methodology. Part five describes a case study
using the analysis. The final section presents the
conclusions. The appendix includes some questions
to suggest how the indicators might be placed.
OF OUTCOMES, IMPACT AND PROCESS INDICATORS
Health improvements, as we have mentioned, have
traditionally been measured in terms of causal re
lationships. Evaluations have described inputs then
looked for the results in terms of specific outcomes
and overall impact (usually health status). These
measurements are characterised as being quantitative
rather than qualitative and static rather than
dynamic (6). In other words, they describe a specific
situation at a given time in terms of numbers. With
the broadening of analysis that linked health im
provements to overall economic development, the
confines of the traditional approach have become
apparent. It, thus far, has proved not possible to give
a number to individual perceptions of changes in the
quality of life or to quantify the relationship of
specific changes such as the correlation of the number
of educational facilities to improved income. Nor is
it possible, as we have already suggested, to quantify
the relationship of available health services with
improved health status.
Recognition of these difficulties has been expressed
by those involved in evaluating both development
and health programmes. There is still no satisfactory
method by which to measure social and economic
change. Dudley Seers in his classic essay on “The
Meaning of Development” discusses in detail some of
the problems with identifying indicators highlighting
the need to take into account social, economic and
political systems. In view of this analysis, it is easy to
see why quantitative, static measurements are
ephemeral [7],
Attempts to quantify relationships in the health
field, for instance, for specific interventions such as
nutrition programmes or family planning similarly
have been unsatisfactory. The search for direct cor
relations between interventions and health im
provements for large populations based on the bio
medical research model so far has proved futile. In
their often quoted study of 10 small scale pro-
grammes, Gwatkin er al. concluded that even tthough
’
evidence suggested selected interventions improved
the health and nutrition of target groups, the effects
of these interventions on health improvements did
not depend solely on the inputs but also on how the
inputs were administered (8], Isley studied the re
lationship between rural development strategies and
their health and nutrition effects on fertility and also
found that direct causal relationships between inputs
and effects were not possible to identify (9J.
The above studies illustrate the constraints of an
approach which uses a tightly designed study to
identify critical factors for health improvements. To
help overcome these problems, Mosley and Chen
offer the “proximate determinants” framework [10]
combining social science analysis with the bio
medical model. These proximate determinants which
include maternal health factors, environmental fac
tors, nutritional factors, injury and personal illness
control are quantifiable and combined with socio
economic measures can be put forward to identify
children at risk. Although the framework accounts
for non-medica) influences upon health, the deter
minants still remain static as they do not assess
changes over time and still view health improvements
in terms of defined causal relationships.
The weaknesses of assessing economic devel
opment and health improvements in terms of linear
causal relationships and/or through tightly controlled
studies are magnified when trying to assess commu
nity participation [4). These efforts are complicated
not only by lack of a clear definition of the termi
nology but also by the specific cultural, historical,
social, economic and political environments in which
they take place. As a result parameters of such
assessments, in an attempt to become globally appli
cable, become merely vague or basically descriptive.
The World Health Organisation, for example, in its
publication concerning indicators for progress to
ward ‘Health for All by the year 2000’ states that
community involvement (the term it prefers to com
munity participation because it implies active rather
than passive engagement in health activities) can be
assessed by the level of involvement in and the degree
of decentralisation in decision-making as well as the
development of effective mechanisms for expression
of people’s needs and demands [11], When Palmer
and Anderson attempted to apply this framework to
assessing community participation in WHO’s West
ern Pacific Region, they concluded ways to measure
participation are too new and too infrequently used
to be precise (12).
In attempting to provide a strong conceptual and
evaluative framework, Muller in his analysis of case
studies in Latin America uses the ‘basic needs' frame
work and argues that society must be analysed in
terms of inequalities [13). He says that there are those
who have full access to the benefits of society,
including health services and who fully participate in
decision-making. And there are those who are not.
Within this framework, the provision of services to
and increasing participation in national decision
making of those who had no access to services or to
power or control he calls social participation. In the
development of health care programmes, a more
targeted form of participation is present which relates
J
- V
PHC: on measuring participation
to involvement in the health care programmes. This
he calls direct participation. His studies look at the
linkage between the two types of participation. In
developing the latter concept, however, he relies on
the description of the development of situations
specific to a given community. His work gives case
study comparisons which cannot be generalised to
programmes in different areas.
Agudeio (14) building on Muller puts forward an
analysis for comparing participation between pro
grammes. By assigning numbers to rank participation
in a specific range of activities in the areas of (1)
management, (2) the range and completeness of
participation in terms of the number of community
‘agents’ present and operating and (3) community
support and financing, he suggests that a standard of
participation can be articulated. With a standard,
programmes can be compared. Agudeio, however,
leaves no means by which to assess participation in
decision-making, a crucial factor in PHC, and no way
by which to assess the process by which participation
takes place. In addition, his framework is not flexible
enough to account for change or reverses in the
programme with the probable result that many of
these will be overlooked by those using the evalu
ation. In his attempts to quantify the problem, he
becomes entrapped in the limitations found in the
bio-medical research model which we have discussed
above.
This wide range of experiences in seeking to evalu
ate both health improvements and community par
ticipation suggests that an alternative is needed.
Rather than looking for measures which show where
programme development is in relation to a specific,
static standard, it is perhaps better to seek a relative
measure. Studies have suggested that a method by
which to assess the process of programme devel
opment is needed [15-17]. The development of pro
cess indicators is critical to the understanding of
health improvements and community participation
defined in the ‘basic needs' and PHC strategies of the
recent UN development decades.
933
article (19) where he suggests that this definition is
critical if health plans are to be more realistic and
effective.
A third definition of community which is im
portant to health professionals is that of target
populations or ‘at risk’ groups. This definition is
rooted in the epidemiological view of community. In
PHC, in terms of equity, effectiveness and efficiency,
groups of people need to be identified so that re
sources can be allocated to the greatest effect. It is
therefore important to take into account this aspect
of health concerns in seeking a realistic definition.
The term participation also has a wide range of
meanings (20). In reviewing these definitions, three
characteristics appear to be common to all. The first
is that participation must be active. The implication
is that the mere receiving of services does not consti
tute participation. (We have noted previously WHO’s
use of the word ‘involvement’ to place emphasis on
this characteristic.) The second is that participation
involves choice. Participation implies the right and
responsibility of people to make choices and there
fore, explicitly or implicitly, to have power over
decisions which affect their lives. The third is that the
choice must have the possibility of being effective.
This suggests that mechanisms are in place or can be
created to allow the choice to be implemented.
Based on these considerations, we can suggest a
definition of community participation which takes
into account the geographic, common interests and
epidemiological meanings as well as the character
istics of participation we have described. Community
participation is a social process whereby specific
groups with shared needs living in a defined geo
graphic area actively pursue identification of their
needs, take decisions and establish mechanisms to
meet these needs. In the context of PHC, this process
is one which focuses on the ability of these groups to
improve their health and health care and by exer
cising effective decisions to force the shift in resources
with a view to achieving equity.
DESCRIBING THE ANALYTICAL FRAMEWORK
DEVELOPING A CONCEPTUAL FRAMEWORK
J
5
3
B
4i<
To assess participation in a health programme we
can suggest the use of indicators which in any specific
programme will tell us whether participation has
become narrower, broader or remained unchanged.
The development of these indicators depend, firstly,
on a clear understanding of the use of the terms
‘community’ and ‘participation’.
Midgley (18) suggests that community has had two
meanings in the health/development literature. The
first is that which defines community in geographic
terms. Community is a group of people living in the
same defined area sharing the same basic values and
organisation. This definition is the one most often
used in the health literature.
The second definition is that which says a commu
nity is a group of people sharing the same basic
interests. The interests change from time to time with
the consequence that the actual members of the
‘community’ change from time to time. This
definition of community and its implications for
health policy has been explored by Ugalde in an
On the basis of this definition and in recognition of
the need to examine process rather than impact of
community participation in health programmes we
can suggest the following framework.
We can take the factors which influence par
ticipation identified by Rifkin [5] in a paper which
analysed over 100 case studies. These factors are: (1)
needs assessment, (2) leadership, (3) organisation, (4)
resource mobilisation, (5) management, (6) focus on
the poor. For each factor, except the last, we can
develop a continuum with wide participation (com
munity people plan, implement and evaluate the
programme using professionals as resources) at one
end and narrow participation (professionals take all
decisions, no lay participation) at the other. We then
can divide the continuum into a series of points and
place a mark at the point which most closely de
scribes participation in the health programme we are
assessing. Upon this basis, we can define process
indicators for participation in health care pro
grammes as the width of participation on the con
tinuum of each of these factors. We can use these
934
Susan B. Rjfkln et ai.
indicators to compare differences in participation (1)
at a different time in the same programme. (2) by
different assessors of the same programme, (3) by
different participants in the same programme.
A word needs to be said about the sixth factor—
focus on the poor. It is difficult to conven this factor
to an indicator for two reasons. Firstly, as an indi
cator for participation it also must be viewed as an
indicator for equity. The whole question of the
assessment of equity is recognised as key to PHC but
is beyond the scope of this paper. As we later note,
it is a vital area for future research. Secondly, based
on personal field experience of the authors and of
others, it is very difficult to firstly, identify the very
poor in any given community and secondly, to define
activities which truly reflect a long term shift of
resources to improve the plight of the most impover
ished. For these reasons, the sixth factor is not
included as a factor in assessing participation in the
present framework.
When a mark has been placed on the continuum
these marks can be connected in a spoke
configuration which brings them together at the base
where participation is the most narrow. The first
point at this end of the continuum is not at the point
where the spokes connect because we recognise that
in any community there already exists some par
ticipation which people undertake to meet their
health needs Figure I gives an illustration. By plac
ing the appropriate mark on each continuum and
connecting these marks, we can show the degree of
breadth of participation to describe a baseline which
provides for a comparative assessment either at a
later time or by other assessors. The differences
between the baseline and other assessments will show
what movement has taken place and whether it is
great or small. From the narrow links near the base,
as participation becomes broader, the links which
cross the sections, fan out and widen.
Figure 2 shows a programme where the baseline
has been done. Figure 3 is an example where
difference between the baseline and another assess
ment either over time or by different assessors can be
V
1
Manage)iment
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2
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Fig. 1
A
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4
5
1
/
Fig- 2
V
Managemen’
5
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^5^1
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Fig. 3
seen. In the penultimate section, the indicators have
been used for an actual case study to illustrate this
analysis.
Rather than assessing community participation in
health care in a linear relationship or in terms of a
standard, these indicators allow us to assess health
programmes in a varied relationship accounting for
both progressive and retrogressive periods and ana
lysing relative change.
To re-iterate, these indicators do not value wider
community participation as ‘good’ or ‘bad’ nor do
they correlate community participation with im
proved health status. They are intended to describe
changes and show the processes of participation in
specific health programmes. They take as their start
ing points that health improves through community
participation and that broad participation builds on
a wide range of activities and involvement of many
different community groups.
These indicators are developed to assess par
ticipation in health programmes. Increasing the
breadth of participation along the continuum means
increasing involvement of the community in health
programmes in terms of direct participation. Whether
J
PHC: on measuring participation
J
or not this means increasing social participation de
pends on the nature of existing inequalities in a given
society which may be along the lines of economic
classes, social classes, tribes, gender, etc. In other
words, this question focuses on the question of
equity. Muller has in his work suggested some indi
cators for social participation [13] which include
awareness of the interpretation of health problems
and their causes, awareness-building, and the exis
tence of organisation(s) to change the unacceptable
existing situation. As social realities are different
among communities and countries and as theoretical
frameworks for analysis are also different, a global
conceptual analysis is difficult to make. The indi
cators discussed in this paper do not link the breadth
of participation to social participation. We again
repeat that we are aware to the importance of making
this linkage and define it as a critical area for future
research.
3
DEFINING THE METHODOLOGY
a
©
u
&
©
c
As we stated, the purpose of this assessment is to
define the movement of the process of participation
in health care programmes. Using the definition of
participation we have earlier suggested and recog
nising limitations which may be imposed on par
ticipation by the government [18] a mark will be
placed along the continuum to tell us how wide or
narrow the process is at any given time.
To collect information which will decide where the
point will be plotted, ‘action/research’ [21] may be
used in which the programme planners, the health
team and the beneficiaries all play a role. Through
‘participant/observation’, data can be collected. We
have included in the appendix a list of questions
which might be useful to help define each indicator in
a specific health programme (Appendix 1).
Once information is obtained, a decision as to
where to place the mark needs to be made. The
discussions about this decision can be as valuable as
the final decision. It is not crucial to find the precise
point for the mark. Rather the objective is to find a
point which can be used as a point for comparison at
a later time. Once all the marks have been placed,
they can be connected to give a broad picture of the
extent and scope of participation in the programme.
The first phase of the assessment is now completed.
The process indicators for participation provide the
baseline by which future assessments can be made.
These assessments can be carried out by the same
team, by a new team or a new assessor. As a means
of developing participatory evaluation [22], they also
can be carried out by a range of programme par
ticipants to see if the assessment by programme
planners differs from community assessment.
The new assessments will show changes in par
ticipation in the programme or will show areas where
no perceived change has taken place. They will also
show where participation has tended to become more
broad or more narrow. Based on these assessments,
planners and beneficiaries can decide what next pro
gramme steps might be in relation to participation.
They also may reflect on this assessment as a learning
exercise to better understand the process of par-
935
ticipation and how it develops or why it does not
develop in a given health programme.
USING PARTICIPATION INDICATORS:
A CASE STUDY
In his fieldwork in, Nepal Bichmann [23] made
experimental use of the process indicator framework
described above.
The setting
Rural health programmes in Nepal are not unlike
those in other parts of the world, where village health
committees and community health workers form the
main formal mechanisms for community par
ticipation in health care. Health services of a western
type have been evolving in Nepal only slowly until the
thirties [24]. A Ministry of Health was created in 1956,
but Nepal’s health sector has been characterised for
a long time by the existence of poorly coordinated
vertical programmes and the involvement of a multi
tude of foreign donor agencies [25]. The need for
integration of all these programmes promoted the
concept of ‘integrated health services’ and a special
division was formed in the Ministry of Health for that
purpose. The Sixth Five Year Plan, furthermore,
announced a country-wide system of locally recruited
employed village health workers (VHW), who, later
on, were supplemented by voluntary community
health leaders (CHL) and traditional birth atten
dants. Several studies revealed, however, that there
existed a large gap between the villagers’ perspectives
on health and those of national PHC planners and
international consultants [25, 26], The low quality of
curative health services in remote areas has been a
long standing concern in many communities.
In the present government health system, curative
and preventive health services are modelled according
to the district health care approach [27]. In contrast
to the situation in many other developing countries,
however, Nepal’s Decentralisation Act (1982) is a
clear committment to the decentralisation of govern
ment structures as it establishes the legal prerequisites
for decentralised planning. In the health sector health
committees have been created at different levels of the
administrative system in order to guarantee commu
nity involvement—especially at health post and ward
level, i.e. in the basic administrative units of the
communities. Whereas the Ward Health Committees
(WHC) in the district studied on average were not
busy, the Health Post Committees—under the strong
leadership of the local Health Post-in-charge—met
regularly, a fact which therefore might not be an
indication of strong community involvement but
rather one of consequent management by the profes
sionals.
Data collection and analysis
Using participant observation and semi-structured
interviews with carefully selected key informants
from both the health services and the community,
Bichmann drew a profile of the breadth of commu
nity participation present in the Kaski District of
Nepal in a poor mountainous part of the country. As
already mentioned, wide community participation
was an aim of the health programme. Individual
o
RANKS
Narrow,
nothing
1
Restricted,
small
2
i. Leadership (L)
[wealthy minority-variety of
interests]
One-sided (i.c. wealthy
minority; imposing
ward-chairman; health
staff assumes leadership;
or: inexistence of
hetcreogcncous WHC.
2, Organisation (0)
[created by
planners -community
organisfition)
Mean, fair
3
Open,
much good
4
Wide very
much excellent
5
WHC not functioning,
but CHL works
independent of social
interest groups.
WHC functioning under
the leadership of an
independent CHL.
Active WHC, taking
initiative.
WHC fully represents
variety of interests in
community and
controls CHL
activities.
WHC imposed by health
services and inactive.
WHC imposed by health
services, but developed
some activities.
WHC imposed by health
services, but became fully
active.
WHC actively
cooperating with other
community organisations.
Existing community
organisations have
been involved in
creating WHC.
3. Resource Mobilisation (RM)
[small commitment 4- limited
control-good
commitment + commited
controlj
Small amount of
resources raised by
community. No fees for
services. WHC docs not
decide on any resource
allocation.
Fees for services. WHC
has no control over
utilisation of money
collected.
Community fund raising
periodically, but no
involvement in control of
expenditure.
Community fund raising
periodically and WHC
controls utilisation of
funds.
Considerable amount
of resources raised by
fees or otherwise.
WHC allocates the
money collected.
4. Management (M)
[professional
induced-community
interests]
Induced by health
services. CHL only
supervised by health
staff.
CHL manages
independently with some
involvement of WHC.
Supervision only by
health staff.
WHC self-managed
without control of
CHL’s activities.
WHC self-managed and
involved in supervision
of CHL.
CHL responsible to
WHC and actively
supervised by WHC.
5. Needs Assessment (NA)
[professional
view-community involved]
Imposed from outside
with medical,
professional point of
view (CHL, VHW,
HP-slaff); or; Latrine
building programme
imposed on community.
Medical point of view
dominates an
‘educational’ approach.
Community interests are
also considered.
CHL is active
representative of
community views and
assesses the needs.
WHC is actively
representing community
views and assesses the
needs.
Community members
in general arc
involved in needs
assessment.
Indicator
[rangej
VHW = village health worker; WHC — ward health committee; CHL — community health leader; HP — health post.
Fig. 4. Ranking scale for six process indicators for community participation.
I
D3
H-
PHC: on measuring participation
ority of health staff, previous negative experience
with community development programmes, and lack
of orientation, sensitisation and training of both
health professionals and community members.
4
■u
c
3 -
g
o
o
2
1
121
L
NA
I
0
RM
I
M
Process indicotors
Fig. 5. Degree of CI achieved in Kaski district
J
'J
J
interviews were carried out with 20CHLs and 21
elected community leaders in the hamlets of the
health post areas served. The interview data were
analysed using a matrix (Fig. 4), which assigned
relative ranks to each of the five above-mentioned
factors using a 5-point scale. Thus every single inter
view produced a subjective measure of the degree of
participation achieved as reflected in the five factors
considered.
Averages of the ranking of indicators were calcu
lated per group of respondents, per health post area
and per district. Interesting differences in the assess
ment by different groups of community informants
were obvious and could later on be analysed in depth.
The district average of the degree of participation
achieved—as expressed by the totality of community
key informants—was visualised using a bar chart
(Fig. 5). Using the visualisation developed above, the
plotting of data of Fig. 5 would result in a spider’s
web as shown in Fig. 6.
In this case study, the conclusion to be drawn from
using this framework of process indicators was that
the degree of community participation achieved was
still rather low, even though the structure, or
ganisation and management of the district health
services was excellent in comparison with the situ
ation in other parts of the country. It was suspected
that reasons for this low achievement have to be
sought in factors such as social structure, lack of
financial committment of the government, sup
pression of community initiatives, attitudes of superi-
1
J
5
Management
4
a”
1
Fig. 6
SSM
»—£
937
Limitations
It was not possible to get interviewees to recall how
the participation in the programme might have
looked at its inception. For this reason changes in the
participation process could not be assessed. However,
it was possible to describe the present situation thus
providing a baseline for future assessments which
focus on changes.
Conclusion
The cited case study provides an example of how
the assessment of process indicators of community
participation in health might be used. Although
programmes vary widely, for each specific situation
similar matrices can be developed in order to identify
formal and informal mechanisms of participation.
The result of the case study provides a useful baseline
assessment which can be used by other persons,
assessors, health staff or community members, when
planning for a comparative assessment at a later
stage. This baseline might also stimulate debate
within other concerned groups. The assessment uses
relative values. It does not pretend to be ‘correct’ and
therefore, does not pretend to be a method for
defining participation in terms of a standard.
CONCLUSION
In this paper, we have presented a framework and
methodology for assessing community participation
in any specific health care programme. We have
defined process indicators as indicators which show
how wide participation is on a continuum of each of
the major factors which influence participation. We
have described how to identify and use these indi
cators to assess participation in these programmes.
Finally, we have presented an example of how these
indicators can be used in practice.
As we have continually stressed, process indicators
are not used to quantify or standardise changes. They
do not tell us whether community participation is
‘better’ or ‘worse’. Rather their value is two-fold.
Firstly, they describe differences in community par
ticipation in a health programme over time and by
different people. Secondly, and equally important,
they serve as a departure for discussions about com
munity participation which can help us to understand
the process better and which can help the people
involved in the programmes to achieve better results
by allowing for greater involvement.
This presentation is one of the first steps in begin
ning to develop practical, useful tools for under
standing community participation in health pro
grammes. We would very much appreciate hearing
from those of you who try it in your own pro
grammes. We would also appreciate any comments
and criticisms.
Acknowledgements—The authors wish to thank the follow
ing people for their comments, assistance and inspiration:
E. Barnett. P. R. Payne, C. Roberts, G. Walt and members
Susan B. Rjfkin et al.
938
of the Department of International Community Health,
Liverpool School of Tropical Medicine.
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12. Palmer C. T. and Anderson M. J. Assessing the devel
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14. Agudelo C. A. Community participation in health
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15. Bethune X. de and the P. H. R. T. U. Health and
Community. Report of a Seminar held at the Institute of
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on Primary Health Care and its Alternative, Selective
Activities on Health Status. Institute of Tropical Medi
cine, Antwerp, 1985.
16. Chowdhury A. M. Evaluating community ORT pro
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17. Nordsjo C. and Williams K. UNICEF Programme Audit
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Nairobi. 1986.
18. Community Participation. Social Development and the
State (Edited by MidgJey J.). Methuen. London. 1986.
19. Ugalde A. Ideological dimensions of community par
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21. 41-53. 1985.
20. Oakley P. and Marsden D. Approaches to Participation
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21. Mercenier P. and Prevot M. Guidelines for a Research
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22. Feuerstein M. T. Partners in Evaluation: Evaluating
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tries. Macmillan. London, 1984.
APPENDIX 1
Questions to help determine the plotting of participation
indicators:
Note: The following is a description of the broad frame
work of each of the five participation indicators. After
explaining the two extreme points, a list of relevant ques
tions is presented. These questions are not given as a
checklist for finding the position of the indicators. Rather
they are given as guidelines for evaluators to enable them to
develop their own questions for each specific programme. It
will be quickly realised that the answers to these questions
are not always easily obtained nor easily analysed. These
difficulties should not be underestimated. However, the
point to be plotted on the continuum does not have to be
precise but rather comparative. As experience is gained, a
backlog of knowledge will be colleced to make this task
easier.
Needs Assessment
The introduction of a health programme reflects judge
ments about the health needs of people living in a certain
area and decisions to act upon those needs. Needs assess
ment can be made by professionals using their training and
past experience cither to project possible problems or carry
out surveys in order to plan actions. Professional assessment
alone places the indicator at the narrow end of the spectrum.
It moves toward broader participation *ith actions that
involve community members in research and analysis of
needs. Questions to assess participation might include:
—How were health needs identified?
—Did the identification include only health service needs
or other health needs?
—What role, it any, was foreseen for community people
in conducting needs assessments, in analysing health
needs?
—Were surveys used? Who designed the surveys and who
conducted them?
4<\-.
939
PHC: on measuring participation
—Were the surveys used merely to get information or also
to initiate discussions with various possible
beneficiaries?
—Were potential beneficiaries involved in analysing the
results?
—Was the assessment used to further involve the
beneficiaries in future plans and programmes?
—Was only one assessment made or is it an exercise for
change, review and further involvement of community
people in programme plans?
—How were the results of the assessment used in the
planning of the programme?
—If community people were involved in the assessment,
did they continue to be involved in the implementation?
—Was the assessment used to strengthen beneficiaries
role in decision-making about the programme?
—Was it able to include various representatives from the
wide range of possible beneficiaries for which the health
programme was designed?
Leadership
It is necessary to examine who the existing leadership
represents, how does the leadership act on the interest of
various community groups, especially the poor and how
responsive arc the leaders to change. Narrow participation
is present if the leadership represents only the small and
wealthy minority and continues to act only in their interest.
The indicator moves toward the wider end if the leadership
represents the variety of interests present in its constituen
cies.
—Which groups does the leadership represent and how
does it represent these groups?
—How was the leadership chosen and how has it
changed?
—Is the leadership paternalistic and/or dictatorial limi
ting the prospects for wider participation by various
groups in the community?
—Does a charismatic leader exist who might not allow
mechanisms for continuity to be developed?
—How docs the leadership respond to the poor and
marginalised people, i.e. peasants, labourers, un
employed, women?
—How does the leadership respond to demands of out
side organisations in terms of gaining resources for the
poor as well as the better off?
—Have most of the decisions by the leadership resulted
in improvements of the majority of the people, for only
the elites, for the poor?
—What was the attitude of the leadership toward the
introduction of a health programme and what was the
attitude of the leadership to health before the pro
gramme was introduced?
Organisation
/" ■
kj
i-
L
z
f
c
If the health programme is to be Community based, the
organisations must exist among the community people to
implement the programme. If programme planners and
professionals do not use community organisations, experi
ence suggests programmes will find it difficult to succeed.
Programmes with community organisations created by
planners will see the indicator for this activity placed at the
narrow end of the continuum. Where community or
ganisations exist, include a broad constituency and incorpo
rate or create their own mechanisms for introducing health
programmes, the mark will fall near the broad end of the
continuum. Questions which might be asked to determine
this point are some of the following;
—How were organisations focusing on health needs
development?
—What is the relationship of the health professionals’ to
these organisations—do they have a decision-making
role and if so, how important is that role?
—If new organisations were created, how do they relate
to existing organisation(s)?
—How does the organisation(s) get resources?
—What kind of input do the resource holders have in the
organisation(s). is it a large decision-making role?
—Has the representation and the focus of the or
ganisations) changed since it was created, if so, how
and to whose benefit?
—Who staffs
the
organisation(s)—professionals,
beneficiaries and which beneficiaries (elites or the
poor)?
—Can the organisation(s) meet needs other than provid
ing health services if other needs have been identified?
—Is the organisation^) flexible and able to respond to
change or is it rigid fearing a change in control?
Resource Mobilisation
In the PHC philosophy, self-reliance in terms of both
resources and responsibility for programmes is a major goal.
While mobilising indigenous resources is a symbol of com
mitment to a specific programme, all too often it also has
been seen as a way in which governments can be relieved of
allocating their scare resources to these areas. If this situ
ation exists, the commitment of resources limits the ability
of participants to decide on allocations which have been
defined by outsiders rather than enhance their control over
programmes. Thus the indicator for resource mobilisation
not only must take account of the commitment of commu
nity resources but also the flexibility which can be exercised
in deciding how these resources can be used. A point at the
narrow end of the spectrum therefore would be one which
showed a programme with a small commitment of indige
nous resources (money, manpower, materials) and/or lim
ited decisions about how local resources are allocated.
Questions to suggest where the indicator is to be placed
must reflect both these concerns. They might include:
—What have beneficiaries contributed?
—What percentage of total requirements come from these
groups?
—What arc the resources being used to support?
—Have these resources been allocated for support of
parts of the programme which in other circumstances
would be covered by government allocations?
—Who has decided how indigenous resources should be
used?
—Do all groups that contribute have a decision-making
role?
—How do the poor benefit from allocations to which,
because of their poverty, they can make little con
tribution?
—Can resources raised to suppon a health programme be
used to support more than health services?
—How are mechanisms developed to decide about allo
cations and are they flexible or rigid?
—How are resources mobilised from the community?
—Which groups influence mobilisation and how do they
do it?
—Whose interests are being served in both the mobi
lisation and allocation of these resources?
Management
Management includes not only the management of the
organisations responsible< for the programme but also the
management of the programme itself. Decisions and man
agement structures which favour the professionals and
planners indicate narrow participation and those which
favour the wide range of community people widen the
scope. To assess this indicator, we may ask:
—What is the line of responsibility for management and
what are the roles of beneficiaries, particularly commu-
940
Susan B. Rifkin ei al.
nity health workers (CHWs) if present in the pro
gramme?
—For instance, are the CHWs responsible to community
organisation(s) or programme managers?
—Has the decision-making structures changed both from
the beginning and from the baseline to favour certain
groups and which groups are favoured?
—Have the management structures expanded to broaden
the decision-making groups, have they been able to
integrate needs which are not health needs?
§
. J
0277.9536.88 $3.00 + 0.00
Sw. Sa. Mol. Vol. 26. No. 9. pp. 909-917. 1988
Printed in Great Britain
Pergamon Press pic
BUILDING THE INFRASTRUCTURE FOR PRIMARY
HEALTH CARE: AN OVERVIEW OF VERTICAL AND
INTEGRATED APPROACHES
Duane L. Smith1 and John H. Bryant2
‘District Health Systems, Division of Strengthening of Health Services, World Health Organization. 1211
Geneva 27, Switzerland and 2Chairman, Department of Community Health Sciences. Faculty of Health
Science. Aga Khan University, P.O. Box 3500, Karachi 5. Pakistan
Abstract—In the past four decades there has been a succession of different approaches to the development
of infrastructure for the delivery of health services. There have been striking similarities among these
approaches in both direction and timing in many different countries, particularly in the developing world.
While the general trend has been strongly in the direction of a more comprehensive, integrated health
infrastructure, there have been important regressions from this path. It is suggested that (he recent
attention given to the delivery of ‘selective’ packages of interventions has often diverted energy and
resources from the essential task of developing comprehensive, efficient and effective health services.
This paper begins with an historical review of trends in the development of health services infrastructure
in recent decades. It proceeds to analyse the implications for the organization of health services and for
resource allocation when the health services infrastructure is viewed as part of a health system based on
primary health care.
Finally, we maintain that district health systems based on primary health care provide an excellent
practical model for health development, including an appropriate health system infrastructure. Within this
model the concerns with accelerating the application of known and effective technologies and the concerns
with strengthening of community involvement and intersectoral action for health are both accommodated.
The district health system provides a realistic setting for dialogue and planning involving both
professionals and non-profcssionals concerned with health and social development.
Key words—health infrastructure, PHC, vertical programmes, selective PHC, district health system
INTRODUCTION
S-
<
C;
Much of the debate in recent years concerning ‘selec
tive primary health care' has arisen from a conflict
between two different perspectives on improving
health. These perspectives have been elaborated in
detail in recent articles (1, 2). Common to both is a
belief that it is possible to improve health on a much
wider scale than is currently being done by making
better use of existing financial and human resources,
including non-professionals and community or
ganizations, and by wider application of existing
technology.
The differences, which frequently seem exaggerated
and misconstrued, are not mainly a conflict over what
needs to be done, although there are differences in
this area, but over who decides on the sequence and
priorities, and who are the most important actors in
the process.
But the diversionary effects of a selective approach
on the development of a sustainable and efficient
health services infrastructure have often been over
looked. In its most dramatic form, this is exemplified
by the fear that ‘selective PHC might mean establish
ing parallel health delivery systems for the imple
mentation of the ‘selected’ interventions, creating yet
another ‘vertical* programme structure. There is little
evidence that this has happened on a large scale.
A second common fear is that a selective approach
would concentrate scarce resources on only a few
selected interventions, leaving those unfortunate
enough to suffer from diseases not on the ‘selected*
list, such as malaria or tuberculosis, without recourse.
This concern has been increasingly expressed by
many health system managers, particularly in the
poorer developing countries. They have indicated
that the additional resources being targeted by exter
nal donor agencies for certain ‘selective’ programmes
often have the undesirable effect of diverting the time
and attention, particularly of peripheral health
workers, away from other priority programmes such
as antenatal care and environmental health.
Thus the renewed concentration on ‘delivery’ of a
narrow range of interventions has diverted both
attention and resources away from the essential tasks
of strengthening the capabilities of both health insti
tutions and people at all levels to plan, implement
and monitor a broad range of essential health activi
ties. This diversion began about the same time as
primary health care initiatives focused increased at
tention on the training of community health workers
and the development of community-based health
activities. These activities were unfortunately them
selves often relatively isolated from the organized
health services, and in some countries took the form
of a separate ‘vertical’ primary health care pro
gramme.
The importance of a strong linkage between com
munity health activities and health services has been
widely recognized for some time [31. However, the
growing experience in community-based primary
health care has underlined the point that if the
potential of the primary health care approach is to be
realized, greater attention must be given to the inter909
910
Duaxe L. Smith and John H. Bryant
face between communities and the health services,
along with stronger efforts to alter the perspectives
and actions of health workers, especially at the
periphery of the health services. It is increasingly
apparent that in order to make better use of existing
health resources, the role of health facilities such as
clinics, health centres and hospitals needs to be
expanded and strengthened in at least two com
plementary directions:
—expanding their involvement with and support
of communities and community based health
activities, including reallocation of greater time
and resources for these activities;
—increasing their ability to plan, prioritize and
monitor their ongoing activities, and to adapt
uuuvnai (and unvi
uatiuuai) pia.413
UilUliUC^
national
international)
plans dllLi
and priorities
to local needs and circumstances, with the involvement of local organizations and people in
this process.
The above observations rightly point to a ineed for
renewed attention to the development of the health
services infrastructure per se and not just to a few
‘priority’ programmes.
By health services infrastructure, we mean the struc
tures, functions and resources required to provide a
range of health programmes and services—facilities,
manpower, management, information, logistics,
transport and supplies. It is through an appropriately
organized infrastructure that health care programmes
can be effectively implemented. The health services
infrastructure has often included numerous poorly
coordinated components such as independent public
and private infrastructures, a variety of semiautonomous specialized elements such as ‘vertical’
programmes.
A health system comprises the inter-related ele
ments that contribute to health in homes, com
munities and workplaces, including the physical and
psychosocial environment, the health services, and
health-related sectors. The health system therefore
includes a variety of infrastructural elements includ
ing health services, community organizations and
numerous health-related infrastructural elements,
working together towards common goals. Both the
health services infrastructure and the health system
are usually organized at various levels from the
community to the national level.
The principles of primary health care demand
movement from the traditional model of diverse and
poorly related health services infrastructures towards
a more comprehensive health system based on pri
mary health care. Throughout this paper, we will
attempt to maintain a clear distinction between these
two terms.
A germinal event for coalescence of ideas con
cerning the importance of the health services in
frastructure, and its evolution towards a health
system based on primary health care, was a WHO
meeting which took place in New Delhi in June 1984
[4J. The participants were largely Ministry of Health
officials with senior managerial responsibilities for
the operational implementation of primary health
care in their own countries. This meeting reviewed the
patterns of development of health infrastructure over
the last several decades with particular regard to the
progression from vertical towards integrated health
services infrastructures. The historical information
presented in the next three sections is based largely on
country studies and discussions from that meeting.
global trends in health services
infrastrlctlre development
The development of national health systems during
the past three decades has been marked by two major
trends, which vary in their inter-relatedncss from
country to country.
The first was the establishment of ‘vertical' pro
grammes for the control of specific priority health
problems, each with its own specialized infrastructure
staffed by uni-purpose
workers. The programmes
.
k
o
a8a*nSl ,yaws ^nd malana- and the global smallpox
eradication
crad,cal,on effort
cfforl are among
amonS the more successful
examples of this approach.
The second was the development and expansion of
general health services infrastructure designed for the
provision of curative services with a variable range of
preventive services. They were at first largely
hospital-based and often urban-oriented, but they
have become increasingly accessible to national
populations, though often still with a strong curative
orientation. The limitations of these basic health
services in reaching non-urban populations, and their
weak attention to promotive and preventive health
care, provided the underlying stimulus for the devel
opment of the primary health care approach.
Since the WHO/UNICEF Conference on Primary
Health Care at Alma-Ata in 1978, the trend toward
more integrated health services infrastructure has
accelerated dramatically, through the expansion and
strengthening of health facilities, emphasis on pri
ority activities such as immunization, and especially
the training of community health workers and the
involvement of communities in health efforts; these
have made it possible, more and more, to reach
unserved populations with primary health care
services.
Although, in general, health decision-makers ac
cept the idea of comprehensive primary health care
with its multiple components, there have been many
difficulties in making the transition from semiautonomous vertical programmes, alongside a
general health infrastructure, to an integrated in
frastructure capable of providing both general and
specialized health care effectively to entire popu
lations in relation to their main needs. These
difficulties have included a variety of hurdles to be
overcome: administrative integration of personnel,
finances, supplies and information; training and re
orientation of uni-purpose workers to carry out a
broader range of activities; ensuring the effective
maintenance of desired special programme activities;
and mediating among the various persons and groups
affected by the changing roles and power re
lationships caused by the integration progress.
These operational difficulties within countries have
often been compounded by the continued inter
national debate on the merits and demerits of vertical
and integrated approaches to the organization of
health programmes, and the continuing preference of
some donor agencies for the support of specialized
Building the infrastructure for PHC
Predominantly vertical programmes: the 1950s and
1960s
The period after World War II brought a rapid
increase of vertical programmes for disease con
trol. The predominant targets were communicable
diseases—malaria, yaws, tuberculosis, schistoso
miasis—but other problems also were attacked in this
way, particularly population growth and mal
nutrition. There were clear reasons for this wave of
vertical programmes: new technology and a strong
interest in bringing under control some of the major
scourges of mankind (though at times there was more
faith in the technology and programmes than proved
to be warranted, as in the expectations for malaria
THE EVOLUTION OF COUNTRY HEALTH
eradication).
SERVICES INFRASTRUCTURE
International donors in this period often insisted
A striking aspect of the evolution of primary health on independent vertical programmes, each with its
care around the world has been the extent to which specific focus, because of the lack in most countries
the trends and major milestones have appeared in of institutions capable of reaching the large popu
similar forms and at nearly the same times during lations required for effective control efforts. Indeed in
recent decades. The main shifts in emphasis, first, this period many countries had no widespread health
towards vertical programmes and, later, towards service infrastructure, even for basic curative services.
integrated programmes, occurred in many different With the focus on disease-oriented programme pri
countries within only a few years. The global his orities, it is probable that there was also a general
torical factors that gave rise to these particular lack of appreciation, then as now, of the importance
approaches, and then stimulated the subsequent of the health services infrastructure per se as a
changes, form a basis for understanding some of the prerequisite for the development of more widespread
current problems that countries face, both indi and comprehensive services.
vidually as they try to implement their own health
The vertical approach brought substantial ad
strategies, and collectively as members of WHO in vances in the control of a number of diseases, and this
pursuing the goal of health for all.
undoubtedly contributed to the considerable im
The main events can be grouped into three his provements in health that have occurred over the past
torical periods. This grouping provides a framework several decades. Nonetheless, it gradually became
for understanding the evolutionary path of recent apparent that multiple vertical programmes as a
decades and the major issues that influenced it.
long-term approach entailed serious inefficiencies and
reduncancies. Some countries had more than 10
separate and largely autonomous vertical pro
Predominantly curative period: pre-World War fl
grammes, and at the same time had to cope with
In the late 1800s health services were generally very many health problems for which there were no
sparsely distributed and limited in effect. In the programmes at all. Reservations were expressed.
developing countries they were often provided by Broader visions of the health services were described.
missionaries or by the early forerunners of colonial or Experiments began.
national health services. Occasionally there appeared
One of the most notable of the early statements of
an event that was extremely important in the devel the need for integrated and comprehensive ap
opment of public health, such as the initiation of proaches to health services and manpower devel
yellow fever control programmes in Brazil in the opment was the Bhore Report in India in 1946.
1890s (one of the first examples of what was to be Kenya’s health services were oriented toward com
called a vertical programme), and the discovery by prehensive services based on an expanding network
Ross in India in 1898 of the role of the mosquito in of health centres from the 1950s onward. Indonesia
malaria transmission, providing the scientific basis ran its first pilot effort at integrated services in 1958.
for subsequent malaria control effects.
The Philippines were exploring integrated systems
After the turn of the century curative services in the same period. Thus the first probes towards
became more widespread. The construction of the integrated approaches had already begun to appear
Kenya-Uganda railway around 1910 led to the pro in the 1950s and 1960s, though they attracted little
vision of rudimentary health services for the workers, attention, perhaps because of the still limited in
whose health was constantly threatened by the en frastructure of general health services. However, with
vironment of East Africa. In India, in the 1930s, increasing awareness of the costs and limitations of
tuberculosis was treated largely in sanatoria, follow vertical programmes, and the concomitant increasing
ing the pattern in Great Britain and Europe. During public and governmental desire for more widespread
these years the emphasis was on medical care, though and comprehensive health services, integration be
with a steadily increasing understanding of the par came the focus of another wave of policy change in
ticular problems of tropical diseases. But in the the early 1970s.
background a base of scientific knowledge was grad
ually building up, which would allow a more wide Transition from vertical programmes to integrated
spread attack in the second half of the 20th century PHC: 1970s-80s
The probes and explorations of more comprehenon many common endemic diseases.
programmes with autonomous infrastructures con
centrating on a single set of activities, which can be
insulated from the broader demands of the general
health services.
In order to shed further light on the question of
how countries can progress towards a more rational
use of resources and a more effective implementation
of all the essential elements of primary health care,
an attempt was made to review the evolution of
the health services infrastructure in a number of
countries.
V
o
t:
G
c
c
G
64
9U
912
Duast L. Smith and John H. Bryant
sive and integrated services spread. Each country except leprosy from the district level downward.
took its own path, but there was undoubtedly some Malaysia is retaining its vertical structures in the
international awareness of the issues, and some learn central regions, but integrating most programmes in
ing from one another in this process. A number of the more remote provinces. Ethiopia is taking major
countries had already laid the conceptual and admin steps to bring together its various vertical pro
istrative groundwork in the 1950s and 1960s. They grammes into a more integrated system starting from
were then able to shift to integrated programmes as the national level.
a major policy step, such as happened in Finland and
In the course of this transition, countries have
Indonesia in 1972, and India in 1974.
encountered various problems, obstacles, and un
WHO and UNICEF convened the International foreseen events. For example, changes have been
Conference on Primary Health Care at Alma Ata in required in manpower training to assure the neces
1978. The Declaration of Alma At reaffirmed the sary technical knowledge as workers shift from single
social target of Health for All by the Year 2000, and purpose to multipurpose roles. Establishment of new
specified primary health care as “the key to attaining administrative relationships have often been compli
this target as part of development in the spirit of cated in practice because of continuing allegiance to
social justice" [5]. Where did this signal event fit into previous vertical programme supervisors and objec
the historical sequence outlined above?
tives at the expense of newly assumed responsibilities.
The basic commitment to equity and justice in But at the same time these difficulties have pointed
health services was already gaining hold in many the way to new solutions, providing leverage for
countries, and the efforts to implement effective ver other constructive changes across a series of pro
tical programmes, and then to make the transition to grammes, especially where the skills and knowledge
integrated approaches, had begun some time before of well-established vertical programmes in areas such
Alma Ata. Indeed, the remarkable success of the as management and supervision could be applied to
Alma Ata Conference and the elaboration of strat a wider range of primary health care activities.
egies of health for all was probably in great part due
Both vertical programmes and general health ser
to the groundwork laid previously in a number of vices covering large populations require extensive
countries. Nonetheless, it is also likely that the com support systems: a network of facilities, supplies,
mitment of countries, collectively within WHO, to transport and personnel; an information system,
health for all, has been largely responsible for the including surveillance of problems and target popu
substantial subsequent progress towards universal lations and a capacity for monitoring progress; man
coverage with effective services through imple power development, including training, deployment,
mentation of primary health care.
and supervision; and general management capabili
Following Alma Ata, the policy direction toward ties including plannning and evaluation. Given the
full integration with a health system based on pri complexity and costs of these support system require
mary health care was reinforced, but operational ments, countries have often had difficult choices
realities required a step by step process and much between the high cost of providing adequate support
time.
for effective programmes and the risks of limiting
In this period, integrated programmes were ‘sold their population coverage. This dilemma is exto and approved by planning and finance ministries acerbated when several vertical programmes multiply
as more cost-effective approaches to organization of both the redundancies in support systems and the
health services. At the same time, however, consider associated costs.
able expansion of health services infrastructure was
The most serious deficiency in many developing
still required in many countries to provide adequate countries during this transitional decade of the 1970s
population coverage. This led to considerable con was the lack of an adequate infrastructure for pri
cern later as the extension of more services to larger mary health care. This continues to be a weakness in
numbers of people brought requests for ever higher some even today. An adequate, integrated and
budget allocations, rather than the expected savings. effective infrastructure is a crucial requirement for a
It was also not at all clear that integrated PHC health system based on primary health care. The need
services would be able to maintain the ground that for duplication of support services is eliminated by
had been gained through the vertical programmes, the shift from vertical programmes to an integrated
particularly as available resources were spread more organizational structure. But the mirastructure
infrastructure rethinly to cover more activities. Malaria control in quircd
quired for
for primary
primary health
health care
care isis necessarily
necessarily more
India, for example, regressed considerably during the complex than that needed for a vertical programme,
early phases of integration. However, it was also clear as it must provide effective coordination and support
that the goal of universal coverage with a full range for multiple and often diverse programme activities.
of effective services would not be attained by means
Another important function required of a health
of purely vertical programmes; integrated pro system based on primary health care is rhe establish
grammes were the only realistic choice available, ment and nurturing of close relations between com
though the way to achieve these was less clear.
munities and health services, so that communities can
Countries now are taking various paths toward become fully involved in protecting and promoting
integrated health systems. Indonesia, for instance, is their own health. The recent global economic crisis
concentrating within its health services on a ‘cluster’ has made it even more clear that governments have,
of programmes related to child care so as to have an and will continue to have, only a limited capacity for
assured impact on infant mortality, while some of its the provision of health services to their populations.
other disease control programmes remain predomi It is equally clear that the primary health care
nantly vertical. India has integrated all programmes approach demands a much broader attack on the
913
Building the infrastructure for PHC
Integrated Health Services
Intrastructure
Notional
level
?C«n«rol coordination
Provlnci ol
level
District
level
Malaria
General
health
services
Fig. I. Vertical independent infrastructures.
L'
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various determinants of health which lie outside the
traditional concerns of the health services. This in
turn demands new forms of dialogue between com
munities, health professionals, and social and politi
cal groups to mobilize the necessary action on many
fronts for health and social development.
Despite the progress towards an integrated health
services infrastructure, and the wide expansion of
community-based health programmes in many devel
oping countries, progress in realizing the Alma Ata
visions of community involvement and intersectoral
action for health has been relatively limited. This is
largely because of difficulties in establishing and
maintaining adequate dialogue and social control
between the health services, other sectors and
community-based health programmes within a co
ordinated health system based on shared social goals
and aspirations [6. 7).
The problem of establishing more effective linkages
between communities and the health services will be
dealt with further in the final section of this paper.
The following section, however, will look at some of
the practical solutions adopted by countries which
have tried to make the transition from vertical to
integrated programmes, with particular regard to the
organizational options in the structure of the health
services.
ORGANIZATIONAL ASPECTS OF THE TRANSITION
FROM VERTICAL PROGRAMMES TOWARDS INTEGRATED
PRIMARY HEALTH CARE SERVICES
Variations of vertical and integrated arrangements
The transition from vertical programmes towards
integrated PHC services is characterized by different
and changing mixtures of vertical and integrated
components. One such mixture is a group of vertical
programmes, with their own lines of command, staff
and supplies, from centre to periphery, alongside a
more generally integrated health services infra
structure. Figure 1 illustrates how programmes on
malaria and family planning often run in parallel with
general health services. In a more integrated form
(Fig. 2), separate programmes are incorporated into
an integrated set of primary health care services,
although some programme components continue to
provide specialized staff and support for the inte
grated components in order to ensure their continued
effectiveness.
There are many variations among these mixtures.
The most important points, however, are first, the
vertical programmes have often established functions
and infrastructures which arc separate from those of
the general health services. Secondly, primary health
care programmes, which depend on a general health
infrastructure to provide services to the community,
need continuing support from specialized units at
higher levels within that infrastructure, even where
services are fully integrated at the peripheral levels.
Some of the existing mixtures reflect systems still in
transition; others represent a stable equilibrium. In
teresting questions arise: What are appropriate link
ages between vertical programmes and integrated
services? How much specialized support is appropri
ate for integrated primary health care programmes, and
how far towards the periphery should this support
continue to be provided by specialist personnel re
stricted to only a limited range of functions, as
opposed to generalists with special training as neces
sary? These questions call for an analysis of the
organizational structures and relationship of national
health systems at all levels, including such matters as
administrative lines of authority, functions, finance
and budget, information, and supplies.
Health system infrastructure in support of primary
health cafe
The health system infrastructure needed for pri
mary health care is comprised of the physical struc
tures and the functional capacities needed to support
all primary health care activities. This includes health
services infrastructure such as facilities, including
equipment; supplies and communications; health
manpower, including education, training and super
vision; planning, management and evaluation;
Vertical
Independent Infrastructures
; Control Integration
fp
Malaria
:::::: Provincial Integration
Integrated District Health System:
J Integrated Peripheral Services::
I
Integrated services
Fig. 2. Integrated health services infrastructure.
914
Duane L. Smith and John H. Bryant
Primary health care programme elements
Functional infrastructure
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Fig. 3. A conceptual model of a comprehensive health system based on the principles of primary health
care. World Health
Heal th Organization. Hospitals and Health for All. Report of a WHO Expert Committee on
the Role of Hospitals at the First Referral Level. WHO, Geneva. 1987. Technical Report Series No 774
p. 21.
financing; information systems, including health sur
veillance and programme monitoring; and possibly
action-oriented research. It is the infrastructure
which makes it possible to assess a population's
health problems, to extend health care to commu
nities and to people and groups with special needs, to
ensure that manpower is deployed according to need,
and to monitor the effectiveness of programmes.
In addition to the health services infrastructure,
the health system also includes health-related in
frastructure of other sectors and the more informal
community infrastructure including local leaders,
health committees, voluntary organizations, and
community health workers, inter alia. It is the latter
which through its interaction with the health services
enables communities to become fully involved in the
planning and implementation of health activities in a
health system based on primary health care. Both the
Building the infrastructure for PHC
health services and the community infrastructure
must be adequately developed, and working together,
to provide an adequate infrastructure for primary
health care.
The range of needed structures and functional
capacities is as yet only partly developed in most
health systems. The possibilities of achieving health
for all depend largely upon further development of
this infrastructure, and improvement of its
effectiveness.
Infrastructure levels. The infrastructure has com
ponents at all levels of the system—central, pro
vincial, district, and community, by whatever names
they may be called. A primary health care system
isolated from central policies, technical support and
logistic systems cannot be expected to function
effectively. Figure 3 depicts these relationships
schematically.
Health services reorganization. Virtually every ele
ment of the health services infrastructure can be
brought into play in support of primary health care.
It can facilitate epidemiological surveillance and the
determination of target groups, short-term training
for health manpower, preparation for new initiatives,
active participation of community leaders and village
groups, and the efficient provision of supplies. With
out an effective health services infrastructure, pri
mary health care programmes would be seriously
hampered. This realization has led to the review and
reorganization of health service structures in a
number of countries.
In Kenya, where primary health care programmes are
fully integrated under the ‘district focus’ for rural devel
opment, the infrastructure has been extended to provide
relatively broad coverage of the population. Aided by recent
efforts to strengthen district planning and management, the
system can focus on priority needs, and teams of health
workers are trained together in a network of eight rural
health training centres.
The State of Sdo Paulo, Brazil, is well advanced in a major
health development with a hierarchical organization based
on the health needs of a largely urban population. It is
essentially an epidemiologically oriented health system
which is trying to focus greater attention on the needs of the
disadvantaged urban poor. Great attention is being given to
the development of the infrastructure, including proposals
under considerations for integrating the social security and
public health institutions into a more efficient system.
J
£
*
Community role in health system infrastructure. It
should be emphasized that unlike the view of the
health services infrastructure prior to Alma Ata, the
health system infrastructure as outlined here includes
individuals, families and communities as integral
partners with the health services and other sectors.
The community can be involved in planning surveil
lance, training, supervision, monitoring and sharing
in the provision of resources for primary health care
activities. This infrastructure ideally provides the
framework for regular interaction among community
structures, including relations with social and politi
cal groups, non-govemmental organizations, and
both public and private sector health institutions at
various levels.
In Indonesia communities are actively involved in primary
health care through close interaction with health centres,
selection of village kaders (community health workers).
1
915
involvement of village councils, and self-help activities. Such
activities are often included in village community health
development efforts.
In the State of Gujarai, India, the panchayat (the equiv
alent of a village council) exercises authority over local
primary health care, including some health personnel
(health guides) and budget. Thus the interaction of the
community with the government health services in planning,
budgeting, implementing and evaluating health programmes
is very close. Voluntary organizations also play a strong role
in supporting or implementing health programmes with the
framework of the health system.
In Finland the tradition of local self-government is strong
and long-standing. Interactions between local and national
government, and between local government and the health
infrastructure, are highly dynamic, with well-established
guidelines for shared decision-making.
Intersectoral linkages for health. Finally, the health
system infrastructure, directly and through its re
lations with communities and primary health care
programmes, includes interaction with the social and
economic development infrastructure. This inter
action is focused on a more concerted effort to
influence the many promotive and preventive activi
ties capable of influencing health in a positive way
through acting on behavioural, social, environmental
and economic causes of ill health. A variety of
approaches can be used, ranging from policy analysis
and dialogue, legislation and regulation, and social
marketing to collaborative development of edu
cational materials or coordinated community devel
opment action at the local level.
SETTING PRIORITIES AND ALLOCATING
RESOURCES FOR PHC
The setting of priorities and the related allocation
of resources usually, or at least often, ignores the
infrastructure, focusing instead on selecting from
among primary health care programmes. An excep
tion is the frequent readiness to expend money on
buildings and equipment, often coupled with a regret
table reluctance, particularly in poorer countries, to
finance the operating costs essential for ensuring their
effective use.
A central point in the management of primary
health care is to make the best use of resources.
Attention must be given to the entire community or
population, not only to certain privileged groups. The
practical question is how to promote health within
the context of general development, and to achieve
maximum reduction of suffering within the resources
available.
With equity as the guideline- total coverage taking
into account differential need -criteria used in alloeating resources often refer to such factors as: the
magnitude of the problem (its prevalence and
seriousness, based on epidemiological findings); its
effects on the underprivileged; the extent of com
munity concern; technological and organizational
feasibility of effective action; costs; and the im
portance of the problem in the overall framework of
national development.
The idea of cost-effectiveness of programmes is
inherent in these criteria. However, it needs to be
understood that there is frequently conflict between
cost-effectiveness and equity: the people most in need
916
□last L. Smith and John H. Bryant
are often the most costly to reach. It is often argued siderablc inputs into education, with similar levels for
that the dominant criterion should be equity, within both sexes; some means of assuring adequate nutrition
the limits of resource availablity. But it is more for everyone; and health services accessible to all and
difficult to translate this principle into useful practical working efficiently, usually because of popular pres
guidelines for resource allocation, beyond obvious sure, and providing antenatal and postnatal health
examples such as avoiding concentration on high- services, fully trained birth attendants, and universal
tech hospital equipment in countries with high mor immunisation [11. p. 208].
tality from preventable diseases, etc. There are, how
After looking again at a larger group of countries
ever. some practical tools for assessing equity in with similar, but less dramatic progress, Caldwell
terms of indicators of coverage with certain primary notes the importance in these countries of a broad
health care services, which should find increasing consensus on social goals, and the important role
application in planning and resource allocations [8]. played by an enlightened local community in making
Much of the recent emphasis on cost-effectiveness demands upon and requiring accountability from the
and the related international trends in resource allo local health services to the community. He goes on to
cation towards ‘selective’ primary health case have remark that the most striking needs are the further
been based on evidence from isolated studies of ance offemale autonomy and increasing the efficiency
specific interventions. These studies have largely of the local health services.
ignored the health services infrastructure and the
The above study has been cited because it seems to
factors which contribute to or inhibit its effectiveness. underline and illustrate well several of the key points
They tend also to focus on only a few interventions, of this paper: the need to look beyond the health
with little effort to look at opportunity costs of services alone in order to improve health; the im
alternative activities, or at the dynamics and require portant roles to be played by communities and other
ments of social and organizational change in altering sectors, as part of the health system: and the need to
the behaviour of individuals or institutions.
focus greater attention on strengthening the health
This is certainly in large part due to the real services infrastructure within the health system.
limitations of available scientific methodologies,
If we have now reached some consensus on this
which require isolating the parts from the whole in approach, how might we then proceed in more
order to increase our understanding of their func practical terms?
tioning. But the operational realities are that “pro
vision of primary health care is a far more complex
and cumbersome process than is reflected by current
DISTRICT HEALTH SYSTEMS BASED ON
strategies” [9]. The same author goes on to underline
PRIMARY HEALTH CARE: THE OPERATIONAL
a number of important issues including both tech
LOCUS FOR INTEGRATION
nical factors, such as the limitations of impact indi
cators and the problems of assessing interventions
In May 1986, the 39th World Health Assembly
with multiple effects (female literacy, for example), adopted a resolution calling on countries to place
and behavioural factors which influence demand for more emphasis on strengthening district health sys
and utilization of available services.
tems based on primary health care. This call for
On a still broader scale, are the well-known link action reflected the growing awareness among coun
ages between health status and a wide range of tries that a major obstacle to achieving health for all
socio-economic indicators. One of the most hopeful is weak organization and management, particularly
lessons from the extensive literature on this subject is at the local and intermediate levels of the health
that a broad attack on social determinants of ill system.
health might be mounted with good effect even in the
A district health system based on primary health
face of very limited economic resources.
care may be considered to be the ‘local* operational
Some of the evidence is well summarized in a recent framework required for the implementation of pri
report based on the experience in mortality reduction mary health care as defined at Alma Ata and dis
in China, Costa Rica, India’s Kerala State, and Sri cussed above. It is an integral part of the national
Lanka [10]. In these cases, the combination of polit health system, comprising a population living within
ical commitment to change, and social policies provid a clearly delineated administrative or geographical
ing for a broadly based development effort with area, whether urban or rural. It includes all insti
substantial inputs in the areas of education, health tutions and individuals providing health care in the
services and nutrition, seemed to be the most im- district,
.... whether o
governmental,t social security, nonportant determinants of accelerated progress. Indeed governmental, private or traditional
the experiences of these countries are among those
A district health system, therefore, consists of a
upon which the primary health care approach was large variety of inter-related elements that contribute
built.
to health. It includes self-care as well as all health care
An important extension to this information is the workers and facilities, up to and including com
study conducted by Caldwell to assess the extent to munity and district hospitals, and laboratory and
which the experiences of these countries which had other diagnostic and logistic support services.
achieved “Good Health at Low Cost” might be
The characteristics of a district health system
followed by other poor countries (11). Based on a should reflect the principles of primary health care on
detailed analysis of the changes in Costa Rica, Kerala which it is based: equitable use of resources in
and Sri Lanka during their period of mortality tran relation to need; total population coverage; emphasis
sition, a number of key conditions for their progress on health promotion and disease prevention; inter
seemed to emerge; sufficient female autonomy', con- sectoral action: community involvement; comprehen-
a
Building the infrastructure for PHC
1
7
>
*-
917
sive and integrated services; effective and efficient must be carried out. Perhaps if the balance can be
management.
redressed in this way, it will be possible to both
The district is well situated to play a pivotal role accelerate targeted primary health care actions and
in matching local needs and priorities with national increase the effectiveness of the health system, while
policy guidelines and resource allocations. Playing avoiding the twin pitfalls of "planning without
this role effectively requires adequate decentralization
people’, and ‘participation without progress’.
of both responsibility and resources. Both com
munity involvement and intersectoral action can take Acknowledgements—The authors acknowledge with grati
place at various levels within the district health tude the support and encouragement of Dr E. Tarimo
system. Mechanisms and opportunities for such dia Director, SHS, WHO, Geneva. The participants of the
logue already exist within districts in most countries. consultation on operational issues in the transition from
It is also here that the multitude of special pro yenteal programmes toward integrated primary health care
in New Delhi in 1985 provided the major inputs and
grammes found at the national level often falls on the
stimulus for the historical review above, and their
shoulders of a small team charged with numerous
contributions are gratefully acknowledged, while full
responsibilities for promotive, preventive, curative
responsibility for any inaccuracies in the information
and rehabilitative services for a local community. It
abstracted here rests fully with the authors.
is thus here that integration usually occurs by neces
The views expressed in this article are the sole re
sity, if not by choice. It is also often at the health
sponsibility of the authors, and do not necessarily reflect the
centre or clinic that the conflicting demands of many
views of the World Health Organization or the*Aga Khan
University.
specialized programmes are resolved, for better or for
worse, by arbitrary decisions, frequently made with
out benefit of careful planning or epidemiologic
analysis.
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It is obvious that while the type of district health
system outlined above may be conceptually appeal
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Recently, a conference on Strengthening District
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concluded that communities and all sectors, including
9. Chen L. C. Primary health care in developing countries:
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Held at the Bellagio Conference Center, Bellagio, Italy,
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29 April-2 May. 1985. The Rockefeller Foundation,
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primary health care seems to provide a viable means
11. Caldwell J. C. Routes to low mortality in poor counto work towards a better balance between the current
tries. Popln Devi. Rev. 12, 171-220, 1986.
concentration on intensifying specific programmes,
12. Report of the Interregional Melting on Strengthening
and the need for greater strengthening of the infra
District Health Systems Based on Primary Health Care.
structure through which these and other activities
Harare, Zimbabwe. August 1987 WHO. Geneva. 1987.
0277-9536/88 53.00+ 0.00
Pcrgamon Press pic
Soc. Sci. Med. Vol. 26. No. 9. pp 971-977. 1988
Printed in Great Britain
THE STRAW MEN OF PRIMARY HEALTH CARE
Carl Taylor and Richard Jolly
UNICEF, UNICEF House, 3 UN Plaza, New York. NY 10017, U.S.A.
3
Abstract—The following paper discusses the progress made in providing primary health care (PHC) to
the developing world in the 10 yean following the joint WHO/UNICEF International Conference on
Primary Health Care held at Alma Ata, U.S.S.R., in 1978. UNICEF is now 12 years from the goal to
provide Health for All by the Year 2000. In this context, the authors describe UNICEF’s ‘country
programming approach’ to PHC as part of the child survival and development revolution (CSDR).
articulated by the agency in 1982. A polarization between the two concepts of‘selective’ and ‘comprehen
sive’ PHC is examined in the light of quotations from the original conference document which set forth
strategics and priorities. The authors, a consultant and a staff member of UNICEF, respond to criticism
of the agency in this regard by drawing directly on UNICEFs own work in the field and its record of
success, even at a time when developing countries are battling severe economic constraints and health
budgets are being slashed—a contingency not foreseen at Alma Ata. V/HO evaluations of both the
Expanded Program on Immunization (EPI) and oral rchydration therapy (ORT) show that accelerated
programs develop best when underpinned by a good health infrastructure. The challenge is to develop
priority programs in such a way as to build on or strengthen this infrastructure. Flexibility is the key in
adapting national priorities to local programs. The point is made that international agencies should be
careful to limit themselves to advocacy and support. The authors conclude by discussing some major
points that require further debate and analysis, including the final and most fundamental question—how
can we ensure true equity in reaching those in greatest need?
Key words—primary health care, selective, comprehensive, Health for All
J
3
One of the most wasteful of human endeavors is the
tendency described in the allegory of beating on straw
men that we have created ourselves rather than
tackling our real antagonists.
The battle between ‘selective’ and ‘comprehensive’
primary care (SPHC vs CPHC) has all the elements
for becoming a focus for such a self-satisfying war.
Battle lines have been drawn up, banners and slogans
identified, challenges and insinuations have been
hurled and further recruitment and mobilization is,
apparently, under way. The irony of the battle is that
those involved share many of the same objectives and
values—a concern with poverty eradication, equity,
community participation, with ‘democratizing, and
‘demcdicalizing’ health, with making the goals of
Alma Ata a current reality, not merely a distant hope
[1]. As history shows, however, such common con
victions are no guarantee of harmony and may
actually serve to inflame the conflict. Religious cru
sades are all the fiercer when fighting what is seen as
heresy at home rather than the enemy abroad.
We do not feel we are overdramatizing the problem
or emphasizing imagined risks. We are concerned
that one recent conference concluded that a “cam
paign against this (selective PHC) approach
should be launched, on the grounds that selective
care will not improve health, particularly not in the
countries normally targeted where the roots of illhealth lie in poverty” (2J. To the extent that the
confrontation diverts time and attention from-more
substantive action, the suffering that results will
continue to be in the lives of those in greatest need
in developing countries. The poor and vulnerable
who have always been on the margins of any form of
health care, will still not have access to services that
971
D
might have reached them. If we can agree on the basic
issues we could open the way for more relevant
research, writing, debate and action.
It is in no way our intention to stifle debate. We
assume that all who are engaged in the cunent
confrontation would agree that it would be preferable
to stop fighting from entrenched battle lines and
repeating old arguments. Our appeal is that we focus
not on buttressing existing stylized positions but on
moving from these to empirical analysis of issues. The
real preoccupation should be with promoting Health
for AJ1 as part of a general, poverty-alleviating devel
opment strategy.
An increasing number of developing countries are
sustaining the severest economic constraints and cut
backs in half a century. Per capita income has
declined in two-thirds of the countries of Africa and
Latin America since 1980. Health budgets in most of
these countries have been cut in half and have been
reduced more than public expenditure as a whole.
Little of this reduction of total resources was envis
aged at the time of Alma Ata. It poses a major change
of
< context, within which the goals of Alma Au still
need to be pursued if progress is to be made.
An encouraging development is that, in the 1980s,
a diversity of countries have tried different ap
proaches to accelerate health action, mobilizing re
sources
and people in ways markedly different from
:
those tried earlier. At the same time, major changes
1have been taking place in the health systems of
<countries such as China which had earlier set the
imodels on which the Alma Ata view of PHC had
been built. More such practical experimentation is
ineeded. This empirical experience deserves careful
;analysis leading to lessons, guidelines and strategies
972
Carl Taylor and Richard Jolly
for reaching the goals of Health for AH by the year
2000.
This note attempts to define potential areas of
convergence and possible directions for future action.
We do this first by noting some polarizations that
seem exaggerated. Then we pose some empirical
questions requiring analysis and research which
might lead to policy and action. Since UNICEF is
obviously a party to the debate, we have included
references to UNICEF’s own experience and pro
grams. But first, we return to Alma Ata and how the
issue of selectivity in PHC was treated in the back
ground document.
PRIORITY SETTING IN THE
ALMA ATA DOCUMENTATION
The concept of ‘selective primary health care’ was
built into the original definition of PHC in the
background document for the Alma Ata conference.
This is important to underline, since this point has
often been misinterpreted, especially by proponents
of SPHC arguing that CPHC ignored the need for
exphen pnonties.
Thus, the first straw man to be created after Alma
Ata was based on the mistaken assumption that
CPHC services were supposed to try to implement all
eight components of PHC equally and at the same
time. This misinterpretation was criticized repeatedly
by proponents of campaign approaches. The straw
man assumed that PHC proponents were totally
naive—which indeed was sometimes said in so many
words. In a country with limited resources it is
obviously impossible to do everything at once. The
need for setting priorities was fundamental to all
versions of country health programming and the
managerial process for primary health care that have
guided implementation efforts.
It seems obvious from statements made by these
critics of PHC that they had never bothered to read
the Alma Ata documents but had substituted their
own iinterpretations of the shorthand slogans used to
generate political suppon. Incidentally, this process
of mobilizing political will was remarkably successful
because within one year over 100 countries had
legislated policies accepting the principles of Alma
Ata. This was a necessary step before moving on to
implementation. A few quotations from the official
publication on Alma Ata will help to clarify the issue.
On page 74, item 117: “The national programme may
begin in selected parts of the country, provided that all are
covered as soon as possible. It may also start with only a
limited number of the components of primary health care,
provided that the others are added in the course
of time. The
------------------essential feature is that it should be extended progressively,
in both geographical coverage and content, until it covers all
the population with all essential components.” On page 75,
item 118: “However, if it is not possible to implement
strategies in accordance with a strictly rational process of
decision-making, a pragmatic approach may have to be
adopted in order to seize every opportunity to introduce
primary health care whenever and wherever possible" [3],
It should be evident that most of the atfacks on
CPHC from proponents of SPHC have been directed
against a set of assumptions which are very different
from the middle ground charted in the Alma Ata
documentation. Most of the rationale for SPHC was
already included as part of phased progress towards
CPHC.
OTHER MISLEADING POINTS
OF POLARIZATION
Selectivity versus comprehensiveness is only the
beginning of a misleading list of polarizations. Just as
Alma Ata recognized the need to be both comprehen
sive in goals and strategy and somewhat selective in
choosing tactics and specific program interventions,
so many of the other points of debate have been
misleadingly polarized. For instance:
Vertical vs horizontal
Most health systems embody elements of both
verticality and horizontality, and both are needed.
Health education and promotion through the mass
media of radio and television almost by definition
tend to become a vertical activity. Health centers tend
to be organized horizontally—though almost always
,
... and. drug
.
with some support (e.g.
training
supply),. h
is a sstraw
traw man construct to imply that programs
L ,J *be ““always
’
*horizontal,
*
should
never vertical". We
need, however, to ensure the necessarily vertical
aspects of organization remain responsive to local
views and realities.
Top-down vs bottom-up approaches
This also is a misleading polarization, though there
is currently much justification for stressing
bottom-up approaches, because of the overwhelming
predominance of top-down perspectives in decision
making. But recognition of the need to offset this bias
does not justify the tendency to deny a need for
overall ‘macro-planning’.
Planned vs participatory approaches
Experience in many countries confirms that there
is generally a cluster of similar health problems which
should have high priority. The community is usually
aware of the problems but they frequently do not
know that solutions are available or can be mobil
ized. The pneumonia-diarrhea complex has for over
20 years been recognized to include the two con
ditions that are the first and second causes of death
in most poor communities [4]. The six diseases
targeted by EPI, especially measles and neonatal
tetanus, also cause many deaths and can be readily
prevented. Problems associated with maternal care
and the synergism of malnutrition and common
infections have almost universal priority. It is a straw
man argument to suggest that it was the intention at
Alma Ata to recommend that community demand
would somehow spontaneously mobilize local control
programs to attack such priority problems in an
efficient way. The whole process of national health
planning which has been carefully promoted by WHO
has provided a framework for setting priorities.
Planning is greatly influenced by the size of the
population group where a priority problem occurs.
Because of economies of scale, the larger the admin
istrative unit the greater the efficiency of imple
menting a control program. Where problems are
common in large population groups it is relatively
5
The straw men of primary health care
easy to mobilize support. This is especially true of
support from national and international sources. A
major factor in obtaining such support is the demon
stration that inexpensive and simplified interventions
are available that make it possible to control priority
problems within the resource limitations of devel
oping countries.
3
1
r‘<
w
"Technological, magic-bullet approaches" versus
"building organizational structures"
Polarization over this issue is not merely mis
leading but dangerous. On the one hand, new tech
nologies are important and effective and they need to
be more widely promoted than they are [5]. Immu
nization on average still reaches under 50% of chil
dren and pregnant mothers; ORT is still used in less
than 20% of children with diarrhea; new technologies
for diagnosing acute respiratory infections (ARI) are
used even less. Malaria, AIDS and a host of common
health problems require technological research to
produce low-cost, widely applicable solutions. It is a
straw man argument to decry these technologies
because of their "use by the ruling class in third world
countries to achieve visible and dramatic im
provements in health and to divert attention away
from the lack of basic survival needs”. However, the
issue is more realistically stated in the same paper as
"the health improvements brought about by, say,
immunisation or the use of ORT or for that matter
growth charts or nutritional supplements can only be
sustained by the availability of food, water and
shelter and the political and economic power to
obtain them” [6]. Technologies alone will not make
much difference. Knowledge of when and how to use
new methods must be disseminated widely, along
with appropriate supplies and equipment. Personnel
and family members must be trained. AH this requires
organization and tackling issues of access, cost and
inequality. This process of organization will include
the building of PHC structures. These management
variables have to be promoted along with em
powering people to solve their own problems.
It is counterproductive to pose the issues as tech
nology versus building infrastructure. Recent experi
ence in countries (left and right) show that promotion
of technological approaches has often substantively
helped to accelerate the building of PHC infra
structure. By making specific the purpose and con
tributions of particular service activities in promoting
health goals, it has been possible to increase the
competence and self-confidence of health personnel
along with their credibility and public support.
UNICEF EXPERIENCE
Since UNICEF has sometimes been criticized as a
leading culprit in this controversy, it seems appropri
ate to refer to UNICEF experience directly.
A quotation from the Review of African Political
Economy may make clear the nature of the changes:
'“‘The Politics of the Debate
Despite the impressive array of criticisms that have been
mounted against the selective approach to health care, most
of the important international agencies are presently favour
ing that approach in financing aid projects to the health
J
9^
V&
973
sector. The most visible and notable example is that of
UNICEF, who co-sponsored with WHO the Alma-Ata
Conference, and yet whose own activities since then have
been increasingly selective, reduced to the promotion of
single activities/techniques such as ora! rehydrationin
isolation.*’
In replying to such criticism it should be made clear
that UNICEF has never wished to align itself with
either position in this confrontation—but rather as
this paper argues, to focus on what can be done in a
practical way to tackle major child health problems.
The activism and decentralization that has always
marked UNICEF’s work also necessarily leads to
pragmatism. This is characterized by a willingness to
try the approach, if it works go ahead, if it does not
work try something else. In different parts of the
world many alternatives have been tried, tested and
modified.
A number of internal tensions have resulted from
this process based on decentralized decision making,
especially among those within the organization who
hold different points of view. Some of these tensions
reflect reluctance to change within a bureaucracy
when it is challenged to implement new priorities.
The promotional and mobilizing rhetoric of GOBIFFF was sometimes misinterpreted as setting up rigid
requirements for field implementation [7]. Certainly,
internal doubts about the child survival and devel
opment revolution (CSDR) thrust and priorities have
greatly diminished in the last 2 years, as positive
results have been seen and as it has become clear that
establishing UNICEF-wide goals need not conflict
with constructing country programs sensitive to
national needs, thinking and priorities. Other doubts
arose over the use of statistical estimates of deaths
averted from EPI and ORT, which were never in
tended as precise epidemiological projections but
were presented in order to stimulate public awareness
and interest. They serve the same function as the
slogan ‘Health for All by the Year 2000’, which has
helped decision makers to firm up their commitment
to equity in health care.
The potential for a “veritable child survival and
development revolution” was first articulated at
UNICEF headquarters in 1982. At this meeting, the
GOBI-FFF interventions were identified as having
widespread applicability for reducing infant and child
mortality and improving child health and welfare in
the vast majority of developing countries. From the
early stages, a major concern was that the package be
a focus for priority but not exclusive action and that
all activities be designed as part of strengthening
PHC. In fact, for interna! purposes, UNICEF some
times refers to the concept of “EPI to the third
power” to indicate that the goal of universal child
immunization should be achieved in three
dimensions—the first power being to reach effective
universal coverage of EPI services, the second to
make them sustainable and the third power being to
spread the linkages with other elements of PHC.
UNICEF has, however, been aware that the
greatest weakness of current CSDR efforts has been
that generally insufficient attention has been paid to
long-range objectives in the pressure to get
something/anything started fast. Predictably, some
EPI campaigns have peaked and subsequent coverage
974
Carl Taylor and Richard Jolly
somewhat declined (though in no case to date, to
of just over 20% of total program expenditure by
below pre-campaign levels of coverage). The chall
1989-90, before tapering down in the 1990s as recur
enge remains to take advantage of the social mobi
rent support becomes increasingly incorporated into
lization that promoted the accelerated effort to main
national health budgets. These proportions can be
tain coverage at a higher level than it had been
compared wtih UNICEF's total expenditure on
before. The emphasis now being given to sustain
’health care (about
''
37% in 1986) andon
.....................................................
18%
water,
cr. •
ability reflects a learning process in which subsequent
9% on education and 5% on nutrition in the
generations of workers have to learn for themselves
year. Even these proponions are imisleading
* ‘ ‘
since
by making the same sort of mistakes made by their
they suggest separate programs and actions in each
predecessors.
area, while UNICEF pursues and stresses an inte
From 1981 to 1986, immunization and the use of
grated, multisectoral approach.
oral rehydration salts (ORS) in the developing world
The fact is that far more has been achieved than
have each increased dramatically, with immunization
would have been predicted by even the most opti
coverage in developing countries expanding from
mistic proponents of CSDR. It is probably a pretty
around 25% in 1981 to about 50% in 1986, and ORT
good batting average that two of the main inter
use from less than 1 % of the population to around
ventions have done well while the other two have
50% in 1986. At a time when health budgets and
been slow. Certainly, the CSDR rhetoric has been
many health activities have been cut, these increases
highly effective for generating political commitment
by over 300% in mainstream components of PHC are
and social mobilization, but not in a narrow fashion.
remarkable for at least three reasons: they represent
Rarely, if ever before, has so much attention been
a movement against a downward trend in health
generated for children in so short a period of time.
activities over the period; they imply a significant
There is a chance that a global ethic of concern for
restructuring of activity and usually of financial
children can be made a continuing development
expenditure on health (since foreign aid has usually
focus.
provided for a minority share of the total expenditure
A striking feature of current prospects is that the
on these items); and they represent a clear acceler
experience (and dialogue) of the past 10 years has
ation over past trends in these areas of activity and,
produced a better basis for an operational consensus
in most countries, over past growth of PHC activity
for action than some of us would have thought
as a whole. Equally important, in many countries this
possible a few years ago. At a second meeting of a
expansion has been part of a process going far
scientific advisory group at UNICEF in June 1987,
beyond the health services in their traditional sense.
four and a half years after the first ‘GOBI meeting’,
As documented in a succession of UNICEF reports
there was a tendency at first for confrontation be^tate
C^e ^or^'5 Children (1985, 1986 and
tween those who said that the focus on EPI and ORT
1987, in particular) a process of social mobilization
should not be diluted and those who said it was time
has been set in motion which is involving a wide
to go beyond GOBI-FFF. Some of the sterile old
range of groups and organizations—political, gov arguments promoting polarization were being trotted
ernmental, nongovernmental, churches, youth
out. Fortunately, the focus of discussion shifted, and
groups, national and international—many not pre a consensus emerged that it was time to build on the
viously involved in health activities.
tremendous foundation of agreement that has
It is important to stress that in no way does
evolved from practical experience in field activities,
UNICEF see these impressive developments as the
rather than continuing theoretical arguments in
simple result of its own efforts. The very goals of searching for universal principles. WHO evaluations
universal immunization and, more recently, of uni
of both EPI and OR.T have shown clearly that
versal access to and knowledge of ORT originated
accelerated programs have developed best where
in WHO, and were subsequently endorsed by
there was a good health infrastructure. The challenge
UNICEF’s Executive Board, UNICEF has in
remains to learn how to develop priority programs in
creasingly been one of a wide number of national and
such a way as to build on or strengthen this in
international agencies committed to this core of frastructure. It was agreed that ‘‘priority does not
activities within PHC. WHO itself has units focused
mean exclusivity” and that flexibility is needed in
on EPI and diarrhea disease control; the Red Cross
adapting national priorities to local programs. It was
has concentrated on a Child Alive Program, the
also readily agreed that ultimately all decisions about
World Council of Churches on CSDR and Rotary
priorities must be made by countries themselves and
International on the Polio Plus Program.
that international agencies should be careful to limit
Similarly, several of the international aid agencies
themselves to advocacy and support.
have provided basic support for GOBI-FFF activ
UNICEF has long practiced a "country pro
ities, notably USAID (support for ORT), CIDA and
gramming approach”. In each country, a 3- to 5-year
the Italian government (support for EPI).
program of support is prepared in close collaboration
Lest this focusing of support be interpreted as an
with country officials over an I8-month or 2-year
exclusive concern, it must be made clear that most of
period. This begins with a situation analysis, which
these agencies have also continued a considerable
includes the general problems and needs of children
in that country, and how they are being corrected. In
range of other support for health and other-devel
opment activities. The share of UNICEF’s program
addition to collaboration with government agencies,
support for immunization and ORT has’ risen
appropriate parts of the analysis are done by univer
sharply—but to only 16% of total program ex
sity or other specialized groups within the country.
penditure in 1986. Future forecasts suggest that ex
The purpose is both to have a solid basis of under
penditure on these activities may rise to a maximum
standing within which UNICEF’s country program
The straw men of primary health care
of support can be prepared and to raise awareness of
key problems of children in the country in a way
which stimulates advocacy and action.
UNICEFs country programs cover a wide range
of activities in addition to health. Indeed, in spite of
great acceleration of UNICEF’s efforts in support of
immunization and ORT, program expenditure on
these activities is not projected to rise much above
20% (from the current 16%). In terms of total
expenditure, UNICEF is still spending more on low
cost water schemes than on immunization and almost
as much on education as on these activities.
UNICEF’s experience shows the value of mobil
izing opinion and action for child survival and devel
opment activities. Social mobilization has been a
conscious and increasing thrust of program action
since the launch of CSDR at the end of 1982. The
State of the World's Children report, UNICEF’s
flagship publication, issued in 41 languages and
300,000 copies each year, has been used to promote
awareness of the potential gains from simple and
cost-effective interventions, providing care as near
as possible to people’s homes. The results of this
mobilization—and the efforts of many governments,
NGOs and international agencies—can be seen in the
increase in funding, focus, use and immunization
coverage achieved over the last 5 years. The increase
in ORS use has risen dramatically from 1982 to 1986.
WHO’s own statistics of officially recorded morbidity
show a marked decline in the prevalence of polio,
tetanus and measles in most countries.
But lest there be too much emphasis on UNICEF’s
role, it is important to stress that the goals underlying
UNICEF’s mobilization of action towards universal
child immunization and universal awareness and
access to ORT were not UNICEF’s but those of the
World Health Assembly and ministers of health in
different parts of the world. The goal of universal
immunization was originally posed by the World
Health Assembly in 1977, and the declaration of 1986
as Immunization Year for Africa and the re
endorsement of universal immunization in Africa by
1990 were made by the African ministers of health,
meeting under WHO auspices in Brazzaville, Congo,
in 1986.
3
3
3
Q
MAJOR POINTS REQUIRING FURTHER
DEBATE AND ANALYSIS
From the perspective of UNICEF some major
questions require resolution soon. A systematic pro
cess is needed to bring together field personnel and
those who can contribute specific scientific and man
agement expertise. The focus should be not only on
what can be done now, but also on the long-range
implications of current action.
The most urgent question is how to achieve longrun sustainability of accelerated programs as they
evolve. This includes:
—sustainable PHC infrastructures;
—maintaining intersectoral cooperation;
—sustained motivation and commitment, ’at
grass-roots worker and volunteer level as well
as among political and administrative national
policy makers;
975
—financial sustainability, especially during the
present period of scarce resources (sustaining
CSDR faces the same constraints as the more
general question of financial sustainability for
PHC as a whole).
Secondly, what is the role of national mobilization
in generating new awareness of health needs and the
potential of building a new alliance for health? What
are the limits and limitations of social mobilization
and how best can such mobilization efforts be inte
grated with the normal ongoing work of PHC? What
are the best mechanisms for getting bureaucracies,
research institutions, national ministries and inter
national agencies like WHO and UNICEF to move
with consistency and purposeful direction towards
agreed goals? How can we take advantage of present
opportunities to use practical scientific knowledge to
empower those in greatest need? In order to do this,
people with expertise will have to give up doctrinaire
positions and adapt flexibly to changing conditions.
A subsidiary question relating to social mobilization
and communications is how to ensure that the neces
sary simplification of messages does not lead to
over-simplification resulting in narrowness of action.
A third question in trying to balance top-down
and bottom-up planning is how to relate objective
priority setting by experts to community-felt need.
New practical mechanisms need to be developed that
can be used in defining the problems that are most
important and can be most readily solved.
A fourth question is to improve understanding of
how correlative risk influences child survival. It is
often the same children in a community who are most
susceptible to infections and malnutrition. If they are
saved from death by immunization or any other
specific intervention, how does this influence their
future health? Risk may be greater because of the
increased probability that they will die from another
health problem simply because they are poor and live
in a hazardous environment. On the other hand, risk
may be reduced because the sequelae of an infection
such as measles are numerous and have long-term
synergistic effects on other conditions. The inter
actions need to be worked out.
The fifth question is, what can be done to ensure
that program acceleration leads to the broadening of
action and extension into other health and devel
opment activities? Abundant experience has shown
the limitations of vertical programs which have often
been started at the insistence of international donors
so that they can monitor the flow of their dollars and
take credit for their impact. Overly circumscribed
activities have tended to leave countries with en
trenched bureaucracies that resist eventual inte
gration into PHC. Over the years, most countries
have developed such hierarchies, and we need to learn
how to encourage them to work together.
Sixth, an important set of questions relates to how
and where priority setting should be done. Most
current definitions of SPHC fit well with the Alma
Ata document as summarized in this paper, except
for disagreement about the process of setting pri
orities. Most proponents of SPHC and all advocates
of vertical campaigns must rely on centralized prior
ity setting. For international donors, this central-
976
CalKL Taylor and Richard Jolly
ization means that they will set priorities in Geneva,
New York or the capital city where the donor agency
is based. Those whose field orientation includes a
primary commitment to community participation
have tended to construct a straw man that anyone
holding a different point of view is automatically
considered to be imposing interventions on the com
munity without their involvement in the decision
process. They reject any central control as a con
tinuation of past patterns of promoting dependence
rather than self-reliance. They describe the use of
terms such as community participation or social
mobilization as part of a campaign approach as being
a devious process of community manipulation by
outside forces. We need better ways of balancing
top-down and bottom-up priority setting.
The final and perhaps most fundamental question
is how to ensure true equity in reaching those in
greatest need. This goes well beyond issues of equal
coverage. Rather than traditional bureaucratic con
cerns about equalizing input, a more cost-effective
approach may be to focus on outcome. This will
require means to identify those in greatest need and
at most risk. A new approach to surveillance may be
needed to evolve social indicators to monitor pockets
where health problems are concentrated. Public funds
can then be focused where they will make the greatest
difference in improving the health of the community.
But the political ramifications of such an egali
tarian approach to affirmative action are manifestly
complex.
Ten years after Alma Ata and 12 years before the
year 2000 we can move forward with more assurance
based on the great achievements of recent years. A
major contribution of Alma Ata was to turn around
by 180 degrees the political posture of leaders in
many developing countries who had previously been
obsessed with imitating the hospital-based, doctorcontrolled health services of many industrialized
countries. It has taken longer to get reallocation of
funds to follow the rhetoric. It has been hard also for
health professionals to make the sharp break needed
in promoting new policies of using simple health
technology, auxiliary personnel and efficient man
agement to make services cost-effective, and to
accept community involvement and intersectoral
co-operation.
The most important contribution of the
PHC/Health for All by the Year 2000 movement has
been to gel acceptance of the fundamental principle
of equity in health care—emphasizing the ‘All’ in the
slogan. Using the foundation of the political will
generated by commitment to PHC in developing
countries it has, in the past 5 years, been possible to
accelerate implementation by focusing on important
priority interventions as part of CSDR. As activities
such as EPI develop greater sustainability within
PHC there should evolve a process through which
combinations of interventions and their relative' pri
orities will vary and shift in adapting to local con
ditions. The progress achieved in the last 10 years
provides a basis for hope that Health for-All will
become a reality for the poor and deprived of the
world by the year 2000.
REFE REXES
1. WHO/UNICEF. International Conference on Primary
Health Care, Alma Ata, U.S.S.R.. September 1978,
WHO, Geneva.
2. Barker C. and Turshcn M. Primary health care or
selective health strategies. Rev. Afrn Polit. Econ. 36, 78.
September 1986.
3. On p. 57, item 62: “Once priorities are decided on.
decisions have to be taken concerning the methods and
techniques to be employed. These have to be acceptable
both to those who use them and to those on whom they
will be used. Further decisions have to be taken on the
composition and degree of skill of the health team
providing primary health care. Should this be composed
of health workers each providing the same range of
services, or by a mixture of health workers each provid
ing different kinds of service? Are there to be part-time
or full-time health workers or a combination of both?
Will they have prospects for advancing in their career
and how will this be organized and controlled? Should
volunteers be mobilized?'’
On p. 58, item 67: "Primary health care aims at
proriding the whole population with essential health
care. Population coverage has often been expressed in
terms of a numerical ratio between services for provid
ing health care and the population to be served. Such
ratios are often misleading. It is necessary to relate the
specific components of health care being provided to
■ those who require them—for example, to relate the
provision of child care to the total number of children
in the community, female as well as male, in order to
make sure that such care is in fact available to all
children. Even then, such ratios express the mere exist
ence or availability of services and in no way show to
what extent they have been used, let alone correctly
used. To be used they have to be properly accesible.”
On p. 54. item 52: “Strategies have to be devised to
translate policies into practice; a useful process for this
purpose has come to be known as Country Health
Programming, which consists essentially of assessing the
country’s health problems in their socioeconomic con
text, identifying areas susceptible to change and formu
lating priority programmes to induce such change.”
On p. 55, item 57: “Strengthened by this guidance and
information (from central planning), members of the
community are better equipped to participate fully in
the formulation of their primary health care pro
grammes, by analysing their known health problems,
taking decisions on priorities, making local adaptations
of national solutions, and establishing their own com
munity organizations and support and control mech
anisms."
On p. 56, item 61: “In determining priorities, what arc
the best ways of ensuring that the voice of the whole
community is heard? And once priorities have been
determined, are they to be given effect all at once or in
stages? The answer to this last question will of course
depend on the resources available; decisions have to be
taken concerning the generation of local resources in
cash and land, and assessments made of the resources
potentially available from the other levels of the health
system and from the central government.”
Finally, on p. 79, the last item 133: “In conclusion,
international commitment to primary health care
should be oriented to support national primary health
care programmes by creating a positive climate of
opinion; by facilitating the exchange of expertise, tech
nology and information through technical co-operation
among developing countries and between industrialized
and developing countries; and by encouraging proper
r1- '
J
The straw men of primary health care
orientation of financial resources. However, all inter
national agencies, non-governmental organizations and
countries providing support have to be aware that the
purpose of their efforts is, in the long run. to enable
countries themselves to apply primary health care as
part of their overall development and in the spirit of
self-reliance.”
4 McDermott W. Modern medicine and the demographic
disease pattern of overly traditional societies: a tech
nological misfit. J. med. Educ. 41, 137-174, September
1966.
J
J
3
•©
5
U-
977
5. Grant J. P. State of the World's Children 1987.
UNICEF, New York. 1987.
6. Banetji D. Technocentric approach to health. Econ.
Polit. Wkly 21, 1233-1235. 12 July. 1986.
7. GOBI-FFF. Growth monitoring and promotion of
child growth; oral rehydration therapy to tackle de
hydration from diarrhea; breast-feeding and better
weaning; immunization plus family (birth spacing) and
food supplementation Female education, the third F,
was added in 1983. a year after GOBI-FF was first
articulated.
Tropical Medicine and International Health
VOLUME 9 NO 6 PP A21-A16 SUPPL JUNE 2OO4
Disease control in primary health care: a historical perspective
Harrie Van Balen
Formerly Institute of Tropical Medicine, Antwerpen, Belgium
Summary
1
The effectiveness of disease control by mobile teams decreased when countries became independent.
Early case-finding and continuity of care require permanently accessible health care facilities where
rationalization by professionals and participation of the users are well balanced. The Primary Health
Care concept, a plea for this equilibrium, has been discredited by different types of misapplication.
Correctly functioning and accessible first line health services, completed by a referral level, are a
precondition for effective participation of the users. Where ‘ideal health districts’ cannot be realized, a
form of steady exchanges between generalists and the specialists of the referral level has lead to diverse
‘functional districts’.
keywords disease control, primary health care, health policy, systems approach, health district,
users participation
Evolution of vertical structures for the control
of endemic diseases
In the 1950s, scientific advances fed the great hope that
disease could be overcome if modern health care and
medical technology were made available to all people.
Before 1950, yellow fever was already under control as an
effective vaccine offered protection for at least 10 years.
Several very rational control programmes of endemic
diseases had been consigned to vertical structures, often
with the aim of eradicating those diseases. This indeed led
to the eradication of smallpox - possible because human
beings were the only reservoirs and the attack rate of the
disease was relatively low.
The malaria eradication programme of the 1960s,
striving to definitively interrupt the transmission of the
parasite, turned out to be too ambitious. The mosquito
control programmes still have to be executed by specific
structures and the adequate and timely treatment of cases
still requires permanently accessible health care facilities.
Until recently, the prospect of the eradication of polio
myelitis was deemed possible. It is now doubted that polio
can be eradicated globally within a few years, in which case
the routine immunization has to be continued (Razum
2002).
In the 1950s, mobile teams drastically reduced the
incidence of sleeping sickness by active compulsory detec
tion and treatment of new cases but, in a democratic
setting, preventive measures imposed on people without
A22
I*
their consent could hardly be maintained. During the
1960s, active case finding by mobile teams deteriorated
into a yearly passive case finding. Once simple serological
screening tests became available, the advantage of perma
nently accessible facilities became obvious: the delay of
detection amongst patients with symptoms could be
reduced and by focussing on high-risk groups, the periodic
outreach clinics were able to actively detect infected cases
(Kegels 1995). This potential of greater effectiveness and
efficiency was not considered and the orientation of specific
human and material resources to vertical structures was
maintained.
The multicausal deterioration of people’s health, above
all if conditioned by poverty, is hardly influenced by
isolated immunization campaigns (Kasongo Project Team
1981). It requires a combination of vaccination with
early treatment of prevailing ailments and nutritional
rehabilitation.
Above all, a study on early case finding and treatment of
tuberculosis patients (Banerji &: Andersen 1963) conducted
in 1960 in Bangalore, showed that easy access to credible
health care facilities, alertness of the practitioner, good
communication, counselling and retrieval of defaulters are
far more important for the result than the maximization of
the technical components of the diagnosis and treatment.
The conclusions of this study are applicable to practically
all disease-specific programmes.
So in the early 1960s, there were compelling arguments
for the allocation of more resources to the organization of
© 2004 Blackwell Publishing Ltd
Tropical Medicine and International Health
H. Van Balen
VOLUME 9 NO 6 PP A22-AZ6 SUPPL JUNE 2004
Disease control in PHC
permanently accessible adequate multi-function health care
facilities, as an essential contribution to the efficient
control of endemic diseases.
Evolution of the general health services
This did not preclude most newly independent countries
from maintaining the broad lines of the inherited health
services: expensive hospitals and a network of dispensaries
conceived as the second best solution for people who lived
too far away from a hospital where ‘really good care’ was
provided.
The activities organized in those services were based on
health needs determined by medical experts while the
public had to accept what was proposed. Yet people did
not react as health workers thought they should: they
consulted late, they did not adhere to the treatment,
they disregarded preventive advice pertaining to hygiene,
systematic screening or lifestyle. Meanwhile their
demand for care, responding to the problems they were
worrying about, was met by drug hawkers, drugstore
keepers and ‘healers’. In the meantime, the community
development movement of the 1950s and 1960s had
emerged, encouraging communities to identify their
needs and find solutions themselves in all areas of
social life, including health (Van Balen & Van Dormael
1999).
During the 1970s, in rich and poor countries, field
experiences in health care, where individual patients as
well as population groups were viewed as active partners,
have shown the relevancy to cope with the felt needs of the
people, to cope with their own knowledge, with their
ability to deal with health problems and with their overall
subjective aspirations (Newell 1975).
The Alma Ata Declaration
Those field experiments and research on the optimization
of health care inspired the Alma Ata Declaration on
PHC, adopted in 1978 by the WHO. PHC was seen as a
component of overall development based on social
justice. The concept responded not only to the need for
accessible and trustworthy facilities, but also to the social
pressure to strike a satisfactory balance between the
participation of the population and the rationalization of
the care.
Article V of the Declaration describes PHC as ‘essential
health care based on practical, scientifically sound and
socially accepted methods and technology, made univer
sally accessible to individuals and families in the com
munity through their full participation and at a cost that
the community can afford to maintain at every stage of
© 2004 Blackwell Pubfishing Ltd
their development in the spirit of self-reliance and selfdetermination’. Hence the importance ‘to bring health
care as close as possible to where people live and work’ in
order to improve ‘the first level of contact of individuals,
the family and community with the national health
system, which constitutes the first element of a continuing
health care process’ (WHO/UNICEF 1978).
The place of disease control in PHC-inspired
health systems
The implementation of PHC as defined in Alma Ata
entails substantial change in health care. Organizing basic
health services, one has to take into account that their
prime objective is not epidemiological but social: the
reduction of health problems impeding human well-being.
The timely detection, cure and care of endemic diseases
and relevant personalized preventive care and advice is
thus their main role in disease control. Therefore, the
decentralized first line health services have to be
strengthened. Technically they should perform well.
Moreover, they should generate an interface, a
channel of communication, for interaction with the
individual users, their family and representative groups
of the population it serves. Such an interface makes it
possible to take into account the demand and the
know how of the people and to negotiate their
contribution as well to the solution of their problem
as to a better functioning of the health centre (Van Balen
1990, 1994).
The network of health centres has to be backed by a
referral level. Mahler (1981) claimed that a health system
based on primary health care cannot exist without hospi
tals for the continuity of care requiring techniques which
cannot be realized adequately at the first line (Mahler
1981; Van Lerberghe & Lafort 1990). In Harare, the
WHO formulated recommendations for the realization of
such health systems: the integrated health districts (WHO
1987). Ideally, the district health system was to be
managed by a direction committee, accountable to the
target population. In several countries health care
services have been patiently oriented that way, sufficiently
to show that the system can play the expected role in
disease control as long as the indispensable resources are
available.
In countries where doctors were too few in number to be
assigned to health centres, experiments have shown that it
was possible to delegate clinical functions to less qualified
staff without detriment to the clinical quality of the care
(Kasongo Project Team 1980). When budgets became
insufficient, they were completed with affordable cost
sharing patient charges (Pangu 1988).
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Tropical Medicine and International Health
H. Van Balen
Disease control in PHC
In the 1980s, there were comprehensive training pro
grammes in Thies (Senegal), Kinshasa and Dogondoutchi
(Niger), which prepared medical doctors for the role of
district medical officer and saw to a follow-up on the job in
order to enable young doctors to manage or at least to
coordinate, in a team, the components of a coherent system
(Unger 1989, 1995). Unfortunately funding to the above
scheme was withdrawn.
The PHC concept discredited
1
3
j
Several governments, funding agencies and NGOs, eager to
obtain ‘instant success’, have failed to notice the com
plexity of the proposed change and the time needed, for the
appropriation, by the actors involved, of an acceptable
expression of the conceptual model. Many of the early
initiatives, dealing with only one aspect of the system, were
harmful for the evolution towards an integrated system.
Moreover, successful local initiatives were, for political
reasons, too rapidly extended to a national level (Berman
et al. 1987). The multiplication of village health workers,
seen as the magic bullet, did indeed increase the geographic
accessibility but did not bring along effective care,
complementary to what people were able to do for
themselves. Similar programmes, defined at national (or
even international) level were pushed through at a local
level, often including a fake interface. As a consequence,
neither system adjustment nor adaptation to local situa
tions was possible.
In many countries, PHC became a vertical programme
with its own structure, alongside the apparently undis
turbed ‘modern’ health services and the existing traditional
health care (Senghor 1984). The enormous amount of
money spent on this simplistic interpretation of PHC, was
held back from the strengthening and multiplication of
health centres.
In the 1980s and 1990s, the budgets of the first-line
health services went down. In some places a productive
interaction between representatives of the population and
the health staff succeeded in the mobilization of local
resources. But the top-down imposition of local health
committees did not automatically lead to an increase of
resources for the health service. Too often the mobilized
resources were diverted to the committee itself. Not
everywhere does the population demand to be involved in
the development of the health service; for them, health is
but one concern amongst others. In such situations, the first
step to be taken is the establishment of an adequate health
service which enables users to judge in practical terms what
is being offered to them.
The adoption of the Bamako initiative has undoubtedly
contributed to an increase of the income of the first line
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VOLUME 9 NO 6 PP AZ2-A16 SUPPL JUNE 2OO4
health services. But as an isolated measure, the raising of
the income proportionally to the sale of drugs often
boosted the dependence on drugs.
In order to cope with smaller budgets, Walsh and
Warren (1980) proposed ‘selective primary health
care’ as an interim strategy for disease control in
developing countries. How could health personnel, not
bothering about the felt need of the population, boost
dialogue and participation? When the budgets of mobile
teams went down, in some places proposals were
made to integrate their activities in the existing basic
services but without allocating a supplement to their
budget. It became clear that without resources these
tasks could not be performed correctly by those basic
services.
Another initiative was the allocation of important
premiums to health centre staff for tasks related to specific
diseases or problems but taking too much of their time,
prejudicing other activities of the centre and hence its
credibility. Sometimes single-purpose personnel was
allocated to the centre for these tasks. Often this was
counterproductive for the real integration of disease
control because it disrupted teamwork.
Workshops and seminars have been organized in order
to train the personnel of general health services in the
control of specific diseases or problems. Generally
speaking, the instructions took into account neither the real
context in which that personnel worked nor the other tasks
they had to perform.
In many countries ‘integrated health districts’ were
officially recognized even if there was not the least trace
of a system. The time and effort it takes to change an
established hospital-centred approach into an ‘integrated
systems approach’ was underestimated. It is indeed not
self-evident to reconcile the approach of the specialist,
who aims for maximum use of available technologies,
with the approach of a general practitioner, who talks to
a patient to see which effort he or she is prepared to make
in view of the improvement that can be expected and
keeping in mind the patient’s other priorities. Therefore,
formal arrangements where the staff of the district office
and the medical staff of the hospital, joined in a direction
committee, organize the complementarity of the levels of
care for the control of diseases, are exceptional. Such a
committees can only work adequately if the staff is
competent, experienced and motivated. It is therefore
illogical that their remunerations is budgeted so ridicu
lously low that even were they to be found, they could
not be maintained at this level. In contrast, funding
agencies offer very high salaries to this type of staff for
the implementation of vertical programmes in specialized
structures.
© 2004 Blackwell Publishing Ltd
Tropical Medicine and International Health
H. Van Balen
VOLUME 9 NO 6 PP AXX-AX6 SUPPL JUNE 2004
Disease control in PHC
Effective control of endemic diseases requires
a trade-off between investments in specific
programmes and investments in general health
services
The alternation of technocratic and populist excesses show
that we certainly have underestimated the complexity of an
integrated health care system and the difficulty and cost to
implement it. We also underestimated the conservatism of
the medical establishment and the time the appropriation
of the change by the actors involved requires in diverse
circumstances.
The basic health service has to play its obvious role in
disease control: personalized curative and preventive care.
Therefore, we first of all have to create conditions which
can enhance the development of the system: correctly
functioning and accessible health centres and referral
levels. Indeed, an accessible and effective therapeutic
service meets with public approval worldwide. If the
performance of the service enables users to judge the
advantages of what is being offered in practical terms, the
reinforcement of the system by individual or collective
participation will be more likely.
A platform for steady exchanges between the existing
staff of the first-line and of the referral level, ‘involving the
specialists responsible for the implementation of the
disease-specific programmes’, can orient their activities
towards a performing integrated system. By a common
analysis of the diseases and problems to be tackled, by
understanding the complementarity of each other’s role in
the control of diseases it can bring about an agreement on
the distribution of tasks. It must not necessarily lead to a
formal geographically defined district. In the last two
decades workable flexible health systems, realizing such
kind of exchanges, came into being: e.g. SILOS {sistemas
locales de salud) in Latin America (Paganini & Capote Mir
1990); l’espace sanitaire coherent in urban settings in West
Africa (Grodos & Tonglet 2002); the experimental SYLOS
{syst'eme local de sante ) which started in Belgium in the
mid-1990s (Unger et al. 2000).
Carried out in diverse ways, the PHC concept becomes
more inspiring. It also shows the need for never-ending
health systems research in a continuously changing envi
ronment (Grodos & Mercenier 2000).
References
Van Balen H (1990) An adequate interface with the community:
the contribution of the basic health services. In: Implemen
ting Primary Health Care; Experiences since Alma-Ata
(eds P Streefland 8c J Chabot). Royal Tropical Institute,
Amsterdam, pp. 21-31.
Van Balen H (1994) The Kasongo project: a case study in
community participation. Tropical Doctor 24, 13-16.
Van Balen H &c Van Dormael M (1999) Health service profes
sionals and users. International Social Science Journal.
Banerji D &c Andersen S (1963) A sociological study of
awareness of symptoms among persons with pulmonary
tuberculosis. Bulletin of the World Health Organisation 29
665-683.
Berman PA, Gwatkin DR 8c Burger SE (1987) Community-based
health workers: head start or false start towards health for all?
Social Science and Medicine, 25, 443-459.
Grodos D 8c Mercenier P (2000) Health Systems Research: a
clearer methodology for more effective action. In: Studies in
Health Service Organisation and Policy, Vol. 15. ITG Press,
Antwerp.
Grodos D 8c Tonglet R (2002) Maitriser un espace sanitaire co
herent et performant dans les villes d’Afrique subsaharienne: le
district de santea 1’epreuve. Tropical Medicine and International
Health 7, 977-992.
Kasongo Project Team (1981) The Kasongo project. Annales de la
Sociit6 Beige de Mtdecine Tropicale, 61 (Suppl), 5-54.
Kasongo Project Team (1981) Influence of measles vaccination on
survival pattern of 7-35 month old children in Kasongo, Zaire.
Lancet I, 764-767.
Kegels G (1995) Development of a methodology for a feasible and
efficient approach to health problems by basic health services in
rural Africa. An application to sleeping sickness {Trypanosoma
brucei gambiense). PhD thesis, Universitaire Instellingen,
Antwerpen.
Mahler H (1981) The Role of Hospitals in Primary Health Care.
Conference Aga Khan Foundation and World Health Organi
sation, Karachi.
Newell KW (1975) ‘Health by the People’ Edit. World Health
Organisation, Geneva.
Paganini JM 8c Capote Mir R (eds) (1990) Los Sistemas locales de
Salud, Publication Cientifica, vol. 519. Organization Panamericana de la Salud, Washington.
Pangu KA (1988) La 'Sante pour Tous’ d’ici Van 2000: c’est
possible. These de Doctorat, Universite libre de Bruxelles.
Razum O (2002) A farewell to polio vaccination? Not anytime
soon. Tropical Medicine and International Health 7, 10471052.
Senghor D (1984) ‘Les soins de sante primaires. Revolution ou
alibi?’. Famille et Developpement 28, 34-58.
Unger JP (1989) The training of district medical officers in the
organisation of health services: a methodology tested in Senegal.
Health and Policy Planning 4, 148-156.
Unger JP (1995) The training of general practitioners in developing
countries. Annales de la Sociite Beige de Medecine Tropicale 75
(Suppl 1), 7-90.
Unger JP, Van Dormael M, Unger J, Van der Vennet J 8c Roland
M (2000) Les systemes locaux de sante, un element de reponse a
la arise du secteur de la sante en Belgique? Sante Conjugute 20,
13-55.
Van Lerberghe W 8c Lafort Y (1990) The Role of the Hospital in
the District, SHS/CC/90.2. World Health Organisation, Geneva.
-J
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H. Van Balen Disease control in PHC
Walsh JA & Warren KS (1980) Selective Primary Health Care: an
interim strategy for disease control in developing countries.
Social Science and Medicine 14C:145-163.
World Health Organisation (1987) Report of the Interregional
Meeting on Strengthening Health Systems Based on Primary
Health Care; Harare, Zimbabwe, 3-7 August 1987. World
Health Organisation, Geneva.
WHO/UNICEF (1978) Primary Health Care. Report of the
International Conference on Primary Health Care, Alma Ata,
6-12 September 1978, World Health Organisation, Geneva.
Author
Prof. em. Harrie Van Balen, Formerly Institute of Tropical Medicine, Antwerpen, Belgium. Tel.: + 32-3-2390320;
E-mail: harrie.vanbalen@belgacom.net or isa@itg.be
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0277-9536 90 S3.00 + 0.00
Copyright C 1990 Pergamon Press pic
Soc. Set. Med. Vol. 30. No. 9. pp. 1025-1034. 1990
Printed in Great Britain. All rights reserved
PRIMARY HEALTH CARE IN A MULTI-LEVEL
PERSPECTIVE: TOWARDS A RESEARCH AGENDA
Sjaak van der Geest,' Johan D. Speckmann2 and Pieter H. Streefland3
'Anthropological-Sociological Centre, University of Amsterdam. OZ Achterburgwal 185.
1012 DK Amsterdam, institute for Cultural Anthropology, University of Leiden, Wassenaarseweg 52.
2333 AK Leiden and ’Primary Health Care Group, Royal Tropical Institute, Mauritskade 63,
1092 AD Amsterdam, The Netherlands
1
Abstract—The authors propose to view primary health care (PHC) from a multi-level perspective.
Studying how PHC is conceived and implemented at different levels of social organization (e.g. in
international agencies, national governments, regional centres of health care and local communities)
will reveal which interests may be competing in the planning and execution of what broadly and
conveniently is called ‘PHC’. Mapping out these conflicting views and interests will contribute towards
a better understanding of how PHC works or why it does not work and provide suggestions for a more
effective and equitable PHC. Five themes are proposed for a multi-level research approach: (1) vertical
versus horizontal organization of PHC; (2) the role of medical personnel in PHC; (3) the distribution of
pharmaceuticals; (4) the integration of traditional medicine in PHC; and (5) family planning.
$
Key words—primary health care, multi-level perspective, research
INTRODUCTION
j
}
The idea of primary health care (PHC) as a strategy
to attain ‘health for all by the year 2000’ was received
enthusiastically at Alma Ata at the time. However the
critics started raising their voices almost from the
very beginning [1]. One of the main complaints, and
the most threatening to PHC’s existence, was that
the PHC concept was unrealistic. The comprehensive
and community-based health care approach was
believed to be too idealistic and not feasible. Tangible
decreases in morbidity and mortality rates were
seldom reported. A PHC success story, comparable
to the eradication of smallpox for example, has not
yet been written.
Most of the criticisms were heard in the debates on
selective versus comprehensive, and vertical versus
horizontal PHC [2]. Today, more than 10 years
after Alma Ata, PHC is in real danger. Some of the
WHO’s paymasters and donors of public health
programmes are chafing at PHC’s slow pace and its
revolutionary rhetoric. They seem to favour a verti
cal, ‘no-nonsense’ approach going after quick results.
At the same time, important shifts have taken place
at the WHO and the consequences these will have for
the organization’s policy are still being awaited.
In this paper we investigate the possible sources
of problems surrounding PHC by looking at PHC
from a ‘multi-level perspective’ (see next section). The
immediate reason for undertaking this exploration
was the contrast between the unanimous approval of
PHC at the Alma Ata conference and the following
confusion about its meaning. Countless reports and
publications on PHC programmes in many countries
have made it clear that PHC can mean all sorts of
things to different people in different positions in
the political hierarchy. Consequently, Alma Ata has
generated a great variety of programmes and activi
ties on all of which the ‘PHC’ label has been pinned.
S.S.M )0»—G
J
but which in fact may even prove to be in conflict
with one another.
The confusion about the concept’s meaning and
the contradictions in the PHC policy are. however,
not formless. They seem to have a logic of their own.
It is our intention to give a rough sketch of the
different forms and meanings of PHC by departing
from a multi-level perspective; that is, we will exam
ine how PHC is perceived and implemented at differ
ent levels of social integration. Our contention is that
‘PHC’ could not succeed because it never really
existed as a concrete strategy agreed to by its sup
posed supporters. PHC as a global movement system
atically avoided the different views and interests of
the participants—in fact, needed to ignore them so
that a global movement could take place. The multi
level perspective enables us to illuminate and analyse
the underlying processes that led to the present state
of *PHC’. This paper provides suggestions for inter
disciplinary and comparative research into problems
in PHC policy.
MULTI-LEVEL PERSPECTIVE
Social research has often been confined to a single
level of social organization. For anthropologists this
level was usually that of the village community.
Influences from beyond this level were generally
excluded from the researcher’s area of attention.
With growing state intervention in rural societies
and the increase of global economic interdependence,
this one-sided interest became more and more
problematic and prevented a deeper insight into the
social developments in local communities. Con
versely, researchers studying processes of state forma
tion and other macrosocial themes often did not
consider sufficiently the influence of developments
at lower levels. In order to simplify the research,
1025
1026
Sjaak van der Geest et al.
social reality was often made, as it were, one
dimensional.
The multi-level perspective, which is a reaction
against this one-sidedness, insists that the object of
research should not be isolated but rather seen as
linked to ‘higher’ and ‘lower’ levels of social organi
zation. It could, therefore, also be called ‘linkages
perspective’. The assumption is that developments
at the various levels are linked to one another and
that the nature of these linkages has to be studied in
order to understand properly what takes place at a
specific level. The word ‘level’, a metaphor, refers in
particular to the international, national, regional and
local tiers of social organization [3j. The term ‘link
age’. it should be noted, does not refer to political
power alone. Of equal importance are aspects of
’descending cultural values’: opinions and customs
held by elites, and which are gradually becoming
part of the social code of larger groups in society. For
that matter, it is not only a question of ‘linkages’
extending from ‘the top’ to ‘the bottom’. Influence
spreading from one level to another can also start
from the bottom.
What we call ‘linkage’ will almost always be
some form of communication transmitted by man or
by material means and moving from one level
to another. Information, in its widest sense, is dis
tributed over the various levels of society by people
and objects, particularly by commodities. Underlying
the multi-level perspective is the assumption that
what is carried around does not remain the same
thing during its journey. The meanings of concepts
and objects, of words and institutions change as
they move from one level to another. So the main
concern of those applying a multi-level perspective
is to reveal the different meanings of phenomena
carrying the same name at different levels of social
organization.
In the multi-level perspective we are particularly
concerned with vertical linkages. But there is also an
interest in horizontal linkages. This interest presents
itself in a multi-sectoral approach breaking with the
tradition of dividing reality into fields of scientific
disciplines such as economy, politics, religion, lan
guage and health. Finally, interest in the historical
context is growing, phenomena are being considered
in their development through time. One could there
fore speak of vertical, horizontal and time linkages.
Here we shall mainly focus our attention on vertical
linkages [4].
The subject of this paper. PHC, lends itself partic
ularly well to a multi-level perspective. PHC is, after
all, a subject which occupies people at all levels.
Furthermore, it seems to be a ‘vehicle’, as we shall see
later, with which governments try to exert influence
on lower levels. One could say that PHC material and
personnel themselves constitute linkages between the
various levels in the health care system.
PHC AT DIFFERENT LEVELS
A general assessment of PHC at different levels of
social integration is not really possible. The differ
ences between countries are too great. Therefore the
following exposition can only be exploratory and
fragmentary. The examples quoted come mainly from
a few countries in which the authors have conducted
research: Nepal, Cameroon and Somalia. Examples
from The Netherlands are sometimes used to com
pare experiences in developing countries with those in
a highly industrialized society.
International organizations
PHC is not a new concept. However in 1978 it
began to receive more attention as a response to the
immense health problems, in Third World countries
in particular. For the WHO, PHC was in the first
place a correction of the old model of hospital-based
and urban-centred curative health care. The PHC
plan was an attempt to adjust the achievements of
medicine to the economic reality of the countries
concerned. It was hoped that this objective would be
attained by emphasizing the importance of disease
prevention and by drawing the attention of local
communities to their own possibilities of preventing
illness. Furthermore, it was pointed out in the docu
ment that certain outside curative services could be
provided much more cheaply than had been the case
so far. Much of this care could also be provided by
low-skilled health workers instead of highly quali
fied doctors. PHC should be an integration of two
approaches: first, community-based health care, that
is by and for the community, provided to the greatest
possible extent with the community’s own means and,
therefore, including traditional health care; second,
basic health services, that is the lowest level of
health care organized, financed and controlled by the
government or by private institutions. In broad out
line the PHC document was a plea for prevention and
for the greatest possible self-reliance in the field of
health care. The principal components of PHC were
summed up as follows:
. . . promotion of proper nutrition and an adequate supply
of safe water: basic sanitation, maternal and child care,
including family planning; immunization against the major
infectious diseases; prevention and control of locally
endemic diseases; education concerning prevailing health
problems and the methods of preventing and controlling
them; and appropriate treatment for common diseases and
injuries [5, p. 2).
Apart from the WHO and UNICEF, many other
organizations are involved in implementing PHC
policy, bilaterally or multilaterally, by financing or
carrying out projects. They include public as well as
private organizations. The latter sometimes have a
religious affiliation.
The emphasis on community participation is
significant. Stone (6J has suggested that the way this
concept is (was?) promoted by international donor
organizations reflects Western notions of self-reliance
and equality. Community participation is understood
as the people’s “adoption of an attitude of selfreliance and faith in their own powers to better their
lives through ‘self-help’ and ‘taking initiatives’” [6,
p. 212]. Indeed, Western cultural values of individual
ism seem to dominate these organizations which may
be ‘international’ but are not yet ‘inter-cultural’.
Stone shows that rural people in Nepal have quite
different ideas about ‘community participation’. For
them it means: obeying orders from above to con
tribute land, money or labour to a specific develop-
PHC in a multi-level perspective
3
ment project. In their situation, a Western-type of
self-reliance would amount to social and economic
suicide. In the Nepalese village community inter
dependence seems the best strategy for survival. Stone
remarks: “Rather than seeking self-reliance and a
sense of ‘mastery over their own destiny’, perhaps
villagers would welcome a greater sense of meaning
ful interdependence and exchange with outside devel
opment agencies and institutions” [6, p. 211]. In
addition, as we shall see in the next section, national
authorities may apply yet another definition of ‘com
munity participation’. Many governments will prob
ably favour political and socio-economic dependence
for their population rather than the Western ideal of
self-reliance. It seems likely, therefore, that one of the
basic concepts of the Alma Ata strategy is a Western
cultural value that may not be shared at all by those
involved in the PHC enterprise at lower levels of
social organization.
In a survey of the failures of community participa
tion in PHC throughout the Latin American con
tinent, Ugalde [7] criticizes the political objectives
behind the international—mainly U.S.A.—support
for these programmes. He summarizes his argu
ment as follows: “... through symbolic participation,
international agencies had two purposes in mind:
(I) the legitimization of low quality care for the
poor, also known as primary health; and (2) the
generation of much needed support from the masses
for the liberal democracies and authoritarian regimes
of the region” (7, p. 41]. In his view, PHC is not
only a political tool in the hands of national govern
ments (as we shall argue in the next section) but also
in those of organizations at the international level,
where certain countries may be able to sway the
policy.
To make things still more complex, the PHC policy
of the international organizations has not remained
unchanged in the past years. The emphasis,
which was at first placed on the population’s
participation and self-reliance, has been shifted
here and there towards a more marketing-like
strategy; the original comprehensive approach is
now faced with competition from more selective
approaches. Examples of this development are
the GOBI approach (Growth monitoring. Oral
rehydration, Breastfeeding and Immunization),
‘FFF’ (Family spacing, Food supplements and
Female education) and a growing emphasis on
water and sanitation. Another development that
should be mentioned is the cautious but increasing
value accorded to traditional healers. It can perhaps
be stated that the following characteristics still
broadly determine the policy of the WHO, of
UNICEF and of other supranational organizations
and donors:
a. PHC is based on considerations of medical
rationality and efficiency. It is hoped that via
PHC, Third World health statistics will im
prove. The principal objective is to reduce mor
bidity and mortality rates.
b. At the same time the very limited resources of
the governments of Third World countries are
taken into account. Therefore, the second char
acteristic is that PHC is based on economic
z'?'
''-i
ae
1027
considerations. After all, medical rationality is
dependent on material possibilities.
Furthermore, it is of importance that the WHO
and UNICEF are bound to abstain from
making political statements openly criticizing a
particular government. Yet the concept of PHC
is political because emphasizing general im
provement of health conditions has immediate
political implications. However, these implica
tions are not mentioned. The PHC document is
openly apolitical, as most other WHO and
UNICEF publications are. As a matter of
fact, most aid organizations avoid political
pronouncements, usually for tactical reasons,
exceptions being a few private organizations.
d. It seems contradictory that, on the one hand,
PHC is offered and promoted from the top and,
on the other, community participation at the
bottom is urged.
The plea for community participation carries
another contradiction, for is it not the case that
the most urgent problems of local communities
and the solutions to the same problems have
been defined at the top? As we have seen, the
PHC document recommends self-reliance and
more attention to prevention as a solution.
However, it is odd that the plea for self-reliance
does not come from those who should become
self-reliant but from the international health
planners.
The state
The most important transformation PHC is
undergoing at national government level is that it
is becoming a political topic. Many Third World
countries are young nations in which it is difficult to
propagate the ideal of unification among the whole
population. This applies mostly to African nations,
but even in these countries where the concept of a
unified nation is already understood by the popula
tion, local governments are still confronted with large
cultural, ethnic and linguistic variations, which are
difficult to unify (8]. Another obstacle in the process
of state formation is the poor economic situation of
many countries. Consequently, a large part of the
population often lives in poverty. If, as Rousseau
states, the raison d’etre of the state is “the salvation
and the prosperity of its members’’, then many
young states risk contradicting themselves. After all,
they are not always in a position to guarantee an
acceptable subsistence level for their populations.
For national governments encountering so many
problems in their efforts to introduce the concept of
one nation and to establish the authority of the
state in the local communities, health care seems an
attractive vehicle to spread state influence. Western
biomedical care, which has proved its popular appeal
in most non-Western societies, undermines self-re
liance. Almost everywhere Western medicine seems to
succeed in displacing local medical traditions based
on self-help and to make people dependent on highly
specialized knowledge (9). At the same time Western
medicine tends to be so expensive that it cannot be
applied by local groups trying to restore their auto
nomy. By supplying the villages with medical care,
the state appears in its most favourable light as a
1028
Sjaak van der. Geest et al.
bringer of provisions which the community cannot
itself provide. Advanced technology and high costs
are the reasons that this type of health care can only
be organized by very wealthy professional institutions
such as the state itself.
However, in practice it is quite a different matter.
Many national governments do not succeed or are
not interested in taking advantage of the political
opportunities of health care. The costs appear to be
too high and the physicians, whose training they have
financed, often disappear abroad or remain in the big
cities where the financial situation is more attractive.
In addition, in many countries the position of the
Ministry of Health in the governmental bureaucracy
seems to be rather weak. And frequently, govern
ments are not even interested in using PHC as a
political tool. Salim [10, p. 308] points out that PHC
is not attractive to politicians, .. because it takes a
long time to show results and because the benefits are
not easily calculated. Consequently, primary health
care is among the first activities to be cut when
government revenues decline.” Generally politicians
who want to build up a clientele by promising
rewards to their supporters, prefer to give impressive
evidence of something that can be realized within
their period of office, which is usually about 5 years.
PHC does not suit that purpose. The fact that most
PHC activities are especially directed towards rural
communities can be another reason for their low
priority; the rural population does not usually pose a
threat to the government nor does it need political
favours to keep quiet. The likely result is that public
health care, particularly in the rural areas, finds itself
in dire straits and is disliked by the local population.
Especially when well-functioning private medical
services are available in addition to the inadequate
public provisions, public health care will provide
negative political publicity for the government. It
then proves that the government is not capable of
performing its most essential task. Especially in
Africa and Latin America, where many private insti
tutions (churches and NGOs) are active in the area
of medical care (and education), this development
is frequently seen. However, in many Asian countries
as well, public health service is often regarded as a
second-rate choice by the population. Even in a more
prosperous country such as The Netherlands the
state does not always guarantee every medical provi
sion. In recent years, the Dutch government has, for
example, tried to economize on all kinds of medical
costs by withdrawing from some sectors of health
care, leaving them in the hands of volunteers and/or
commercial organizations.
As we have just mentioned, the failure to distribute
health care provisions effectively to all sections of
the population was one factor that led to the PHC
concept, according to which the ambition to make
expensive specialist curative provisions available
everywhere should be abandoned. Only the most
indispensable (and affordable) services should be
provided by the state and apart from those the
population should learn to look after itself as best
as it can, for instance by means of disease preven
tion. This ‘solution’ places national governments in a
peculiar quandary. On the one hand, PHC appeals to
them because it shows them a way out of the impasse
which health care has reached. On the other hand,
achieving one of the PHC's main objectives (greater
self-dependence by the people) could constitute a
threat to the concept of a unified state [11].
The present estimate is that many governments in
developing countries have adopted the PHC concept
without giving much substance to the aims of auto
nomy. By officially including PHC in government
policy, by training people, by setting up programmes
and providing resources, the state has incorporated
PHC into the existing health care system. PHC is
not so much an ‘antidote’ to a maladjusted and
overly expensive health care system but rather an
extension of it. In most cases it is still organized
from the top and carried out by professional workers
from the state, with the help of outside finances.
In this way PHC becomes a means of subordination
which can be used to reach social and political
consensus. Werner’s [12, p. 47] distinction between
‘community-supportive’ and ‘community-oppressive’
PHC still provides an apt description of the state’s
dilemma:
Community-supportive programmes or functions are
those that favourably influence the long-range welfare of
the community, that help it stand on its own feet, that
genuinely encourage responsibility, initiative, decision
making and self-reliance at the community level, that build
upon dignity.
Community-oppressive programmes or functions are
those which, while invariably giving lip-service to the above
aspects of community input, are fundamentally authori
tarian, paternalistic or are structured and carried out in such
a way that they effectively encourage greater dependency,
servility and unquestioning acceptance of outside regula
tions and decisions and in the long run cripple the dynamics
of the community.
The latter strategy is financially advantageous to the
state in two respects. At the level of the local popu
lation the state hopes to be able to economize on
personnel and material resources and to present this
cut-back as a qualitative improvement of health care;
after all this is PHC. At the top, at the level of the
international organizations, it hopes to acquire more
financial aid by using PHC as a banner. In that light
it is obvious that the concept of PHC can be over
stretched. Summing up, it can perhaps be said that at
the level of the national government, PHC has three
particular characteristics:
a. Medical: the objective is to expand the ‘cover
age’ of medical provisions and to push back the
mortality and morbidity rates.
b. Political: the medical improvements brought
about by state-initiated PHC must increase the
political credibility of the government.
c. Financial: via PHC the government hopes to
reduce its expenditure (for basic health care)
and to increase its revenue (with international
aid).
Professional health workers
Those who want to gain an impression of what
PHC means for health care personnel, should ask
themselves what opportunities there are for health
workers to become dedicated to PHC and what
their interests arc in implementing a PHC policy.
J
PHC in a multi-level perspective
3
&
1
There seem to be at least five reasons why doctors,
nurses and other health care staff have little interest
in PHC.
First, the government offers them insufficient
opportunities to perform the preventive and informa
tive tasks expected of them. If the curative services
function badly, those who provide them are likely to
lose their credibility as health counsellors. They are
not able to mobilize the local community for preven
tive measures, because the people are not prepared
to listen to health workers who cannot even offer
adequate curative care.
Second, PHC has little financial appeal to health
workers. Doctors and nurses in government service
often earn an extra income by providing curative care
privately (formally or informally). In a well-to-do
environment this additional income can rise to a
multiple of the official salary. An appointment to a
PHC project, however, is likely to deprive doctors
and nurses of this opportunity, mainly because they
will probably be posted to a poor rural area. An
additional disadvantage is that they are supposed to
concentrate on preventive services for which the
population is unwilling to pay.
Third, doctors and other health workers have
usually not been trained to provide preventive health
care and have little professional interest in it [13].
Many doctors are not interested in health but in
disease. A serious disease presents a challenge, while
an improvement in diet or drinking-water has little
appeal. Such objectives are regarded as less interest
ing. The same applies, to a lesser degree, to nurses.
Fourth, conscientious performance of a PHC task
is rarely beneficial to the career of a health worker.
Those who want to carve out a career for themselves
have to steer away from the periphery where PHC is
usually found. Higher functions fall to those who
have succeeded in finding a position in the adminis
trative centres or who have specialized.
Finally, health workers are often opposed to a
PHC function for all sorts of personal reasons such
as primitive living conditions in rural areas, attitude
of their relatives and limited educational opportuni
ties for their children [14].
To sum up, health workers may assume a negative
attitude towards PHC because of the following impli
cations:
a. Frustration in their work, because they do not
get sufficient support from the government and
because the population is not interested in their
message.
b. Reduction of income.
c. Medically the work is uninteresting.
d. The consequences for their career are negative.
e. Personal problems within the family.
The population
In the section dealing with PHC policies at the
highest level, that is at the level of the WHO, World
Bank and UNICEF, it was stated that these organi
zations tend to determine the needs and wishes of
local communities. But what do those concerned have
to say?
Research into primary health care needs of local
communities is scarce. Although medical anthropol-
<3
1029
ogy has already established a respectable tradition in
the study of lay opinions about illness and health, it
seems that this subject has been largely avoided in
PHC research. One explanation could be that policy
makers anticipated the findings of such research and
did not know how to put them into practice. Conse
quently, the emphasis on prevention and on the
greatest possible autonomy in health care should not
be seen as an evaluation of the real desires of local
population groups but as an indication of what they
are supposed to want. Here the concept, already
mentioned, of ‘descending cultural values’ applies.
Some ‘messages’ reaching the periphery are picked
up, others are rejected. The effectiveness of modern
curative drugs, for example, is widely recognized and
ever larger groups of the population are wanting
them. Hence the opposition to any government policy
which recommends prevention and withholds mod
em drugs. It illustrates the contradiction pointed out
earlier in this paper: the local community is told to
become more independent.
Although only little research has been done into
the PHC client's perspective, Bloom’s conclusion
seem plausible: “Clients’ perceived needs may vary
widely from planners’ epidemiological definition
of needs’’ [15, p. 8]. Justice [16] comes to a similar
conclusion. She describes how unaware international
organizations were of the problems and cultural
conventions of villagers in Nepal and how this lack
of knowledge led to PHC initiatives which failed
completely to fit in with the culture and needs of the
local population. We will confine ourselves to three
examples of local opinions which deviate from the
PHC objectives that exist at a higher level of social
organization.
During her research in Nepal, Stone [17] examined
closely the question of what the villagers themselves
regarded as their most urgent needs. Apparently
they were not at all pleased at the strong emphasis
on prevention which, in addition, was provided at the
expense of curative aid:
... it is not only that the PHC ‘package' fails to deliver what
the people really want by way of modern health ‘services’,
but also that the package itself runs the risk of being
perceived as largely unneeded and irrelevant to the majority
of people it is intended to serve. During my... household
interviews covering the work of village health workers, one
woman’s comment was typical: “He comes, he writes things
down. He tells us to do this and that. What benefit is there
to us?” Another man remarked: “It is his job to come here.
I do not mind. But when we are sick, there is nothing he can
do.”
PHC is perhaps forced to ignore local priorities for curative
services since it cannot deliver them in good quality on a
wide scale [17, p. 296].
In another quotation the villagers' exasperation at
not being given curative aid by PHC workers is
even more strongly expressed. One of the workers
relates:
Sometimes they get angry. One woman when I measured her
child's arm .... we saw the child was too thin. She got
angry and said: “Then why don’t you do something? You
come to show me my child is not good like this and then
you do nothing!” (16, p. 297).
A PHC project in South Cameroon which at first
was primarily oriented towards prevention and
1030
Smak van der Geest ei al.
education-cum-awareness ‘developed’ after some
lime into an almost purely curative service, not
differing very much from a pharmacy on wheels
where people could buy their medicine. Ironically,
both parties, the medical staff and the villagers,
appeared to be reasonably satisfied with this proce
dure [18].
A second contradiction between a population’s
needs and PHC objectives, which Stone also dis
cusses, lies in the assumption made by PHC officials
that people consider health to be their greatest con
cern. It is quite possible the people in question beg to
differ and regard their deplorable living circum
stances as problem number one because they rightly
believe that poverty is the principal cause of all kinds
of disease. Indeed, this opinion is in agreement with
the official formulation of PHC in the Alma Ata
document. The “Intersectoral Action for Health”
report [19] gives a most detailed description of this
point of view and has translated it into 19 recommen
dations. The sixth recommendation, for example,
reads as follows:
Governments should:
formulate comprehensive agriculture and health policies,
covering all aspects of development of human and natural
resources and actively supported by coherent strategies
including:
—joint diagnosis of the food and nutrition situation from
agricultural and health points of view;
—explicit statement of health goals in agricultural develop
ment plans and programmes, particularly when there is
likely to be a conflict between health and production
objectives;
—systematic analysis and assessment of the nutritional and
health impact of agricultural policies and projects and of
the process of resource allocation [18, p. 131],
How these broad statements should be translated into
concrete action in a PHC project is, however, not
at all clear. Village health workers usually have no
other choice than to ‘stick to their guns’ and try to
solve immediate health problems. At this point the
PHC supply no longer meets the demands of the
villagers. The fact of the matter is that the villagers
often know exactly what they want: instant financial
aid, not improvements in agriculture in 5 years’ time
or more. They are faced with so many immediate
problems that they cannot afford the long term
view. For the same reasons they are relatively unin
terested in improvements for the whole community
but first want help for themselves and their close
relatives. Rather than ‘preventive’ help for their
financial problems they require an immediate ‘solu
tion’, however narrow-minded that may appear to a
‘rational* outsider.
Huyts [20], in her study of two community health
projects in South Cameroon, writes that the popula
tion cooperated with her because it expected personal
benefits (gifts, work, free medicine and ‘connections’)
in return. Sanitary improvements for the village
interested these people much less. It does not seem
an exaggeration to claim that the villagers, in having
such expectations (direct advantages), actually react
in exactly the same way to PHC as do those involved
in it at other levels: the experts in the international
organizations earn a comfortable living from PHC;
national governments try to acquire more develop-
ment funds via PHC (which would also bring private
gains to state officials); health workers adopt a
reserved attitude because there is little money in PHC
for them; and villagers hope to become ‘better off’
with it.
The third example of conflicting expectations is
closely linked with the two mentioned earlier. The
stimulation of greater self-reliance may be no more
than the concern of a foreign project staff hailing
the Western ideal of individual independence. Or it
can be a strategy by which a government tries to
rid itself of certain burdens in a decent and inter
nationally accepted manner. Such self-reliance is
not always liked by the villagers. They may rightly
gain the impression that highlighting self-reliance is a
euphemism for leaving them to fend for themselves.
In particular, the recommendation that they should
have more faith in traditional medical knowledge and
skills does not ring true to the villagers, who for years
have been told that those traditional methods are
useless or even dangerous. The same villagers have
meanwhile come to the conclusion that the curative
methods of modern medicine have quicker and more
effective results than their own traditional methods.
If they are forced to take up the ‘old’ methods again
they feel they are being fobbed off with inferior
quality health care. That is not the way they want to
become ‘self-reliant’. They are demanding their share
of the national facilities and will not accept that the
right to have doctors, hospitals and proper medicines
is reserved to the urban population.
That same contradiction within PHC can be found
in The Netherlands. Bensing [20], for instance, has
pointed out that only healthy people are willing to
assume greater responsibility for their own health.
The sick and the weak, on the other hand, will ask for
more care from professional medical workers. The
enthusiasm for ‘volunteer aid’ is also greatest among
those who do not have anyone in need in their
immediate vicinity. And patients’ associations do not
appear to be pressing for more autonomy in their
campaigns but rather to be aiming for greater medical
dependence and for more advanced diagnostic and
therapeutic techniques. Those who worry about their
health and welfare see more self-reliance not as an
improvement but as a threat to their situation.
In summary it can be said that the population often
expects something quite different from PHC than
has been planned for it at higher levels. The three
principal conflicts are probably:
a. People ask for curative instead of preventative
aid.
b. People expect material advantages.
c. People do not want self-reliance if it means they
will be left to fend for themselves.
A broad and hypothetical sketch has thus been given
of the changes which the concept of PHC may
undergo at the various levels of social organization.
Research will have to prove whether and how these
conflicting views occur in specific PHC settings. A
multi-level approach seems to be a suitable strategy
for revealing the more hidden problems of present
PHC policies via the analysis of the divergent—and
sometimes conflicting—views and interests at the
<different levels of social organization.
PHC in a multi-level perspective
RESEARCH THEMES
1
Research into problems of PHC from a multi-level
perspective will mostly not focus on PHC in general
nor on all levels at which PHC is planned and
implemented. It is more likely that research will be
limited to a few levels or that a choice is made for
a certain aspect of PHC. In the next section five
such aspects will be outlined as possible themes of
research. The key question will be to what extent
greater understanding can be gained of processes of
conceptualization and implementation of PHC by
studying the theme at different levels of social organi
zation. In all five themes to be presented here ques
tions about the local community’s perception of and
participation in PHC, as opposed to perceptions
and involvements at other levels, seem particularly
relevant.
Vertical organization and horizontal integration
$
Since the Second World War, programmes
combating infectious diseases such as malaria, small
pox and tuberculosis have always been well-known
variants of specific organizational modes of interna
tional and national health programmes. The objec
tives and the means regarded as necessary to realize
them are determined at the top of the organization
pyramid and further specified and translated into
quantitative targets at lower levels of decision
making. In general the programmes are rigid, with
clear-cut divisions of tasks and authority between
levels of organization and leave little room for
regional variations.
In other fields of health care, such as immuniza
tion, family planning and provision of drinkingwater, large-scale vertical programmes have also
been drawn up. Such programmes are internationally
oriented. Multilateral organizations such as the
World Bank and UNICEF were, and still are, responsible for taking the initiative, for financing and
implementation, for providing training material and
stimulating the necessary research. Vertical pro
grammes can be very attractive to planners and top
managers. However, in practice, the coexistence of a
number of such specific programmes and of the
regular national health programme can easily lead to
practical problems. Thus a vertical programme can
be successful on a narrow front but at the same
time—for example by monopolizing the best trained
and most dedicated personnel—prevent progress on
a broader front.
In the 1970s it gradually became clear that a broad,
horizontal, integrated approach offered better per
spectives for a lasting improvement in public health
than a conglomerate of various vertical programmes.
From 1978—and before that in a few countries like
China and India—the so-called PHC programmes
were created on a large scale. In these programmes
the principle of horizontal integration of health care
covering a variety of activities occupied an important
a
i
U'
I
place. In recent years, however, many donor organi
zations and policy-makers have become somewhat
impatient with the slow progress within PHC and
seem to want to go back to a vertical approach [22].
Research from a multi-level perspective can shed a
new *light
’w’t on this issue. Important questions are:
1031
What criteria are used to measure the effects of PHC
at various levels of health planning and how are these
criteria regarded by a population directly involved
in PHC activities? Other crucial questions are: To
what extent have international donor organizations
dropped ‘self-reliance’ as a cultural ideal and the final
goal of development? What are the political and
economic interests of the organizations behind the
present shift of emphasis toward selective PHC?
How is this new emphasis translated from the supra
national level to the national governments? And
finally, what PHC approach should be recommended
as the most ‘effective’, viewed from a multi-level
perspective? It may be advisable for this type of
research to concentrate on selected parts of health
policy, such as immunization or diarrhoeal disease
control.
The role of medical personnel in PHC
Various researchers have drawn attention to the
'trained incapacity* of medical personnel in PHC and
in rural health care in general. The ‘incapacity’ of
doctors in particular seems to be due to insufficient
medical training and to the difference in educational
level between doctors and villagers. In an exploratory
study on this issue in Somalia, Buschkens [14] draws
attention to differences in life style between doctors
and villagers and emphasizes differences in upbring
ing, religion and social aspirations.
The unwillingness and ‘incapacity’ of doctors and
other medical personnel to serve in PHC is not the
only problem. A more serious issue seems to be that
their activities can pose a direct threat to one of
the basic principles of PHC, the stimulation of self
dependence in the field of health care. Doctors in
particular are viewed by the local community as
representatives of a higher level of social organiza
tion. They embody,, „
as it were, the links between
different societal levels. By providing professional
.
curative help, they can deprive
the villagers of a
serious motivation to seek self-dependence. The
conflict between the availability of a doctor and the
self-dependence principle in PHC stems from a lack
of insight into the problematic relations between the
different levels of organization in health care.
Lower-skilled health workers may feel caught
between two levels of health care organization. They
do not receive the support and material resources
from above to carry out their work and, partly as a
result, are not accepted by the local population
(23, 24). Curiously this fundamental conflict within
PHC has as yet hardly been brought up from this
angle in the numerous publications and reports about
PHC.
Distribution and use of medicines
The role of medicines in PHC is problematic and
controversial. The popularity of Western medicines is
bound up with cultural perceptions of effectiveness
and with technological dependence. The effective
functioning of pharmaceutical distribution channels
depends mainly on the smoothness of operation of
the linkages between the various levels of organiza
tion. The kind of medicines obtainable or used in
local communities depends on a complicated proce
dure based on such factors as commercial interests of
1032
Sjaak van der Geest ei al.
pharmaceutical companies, the economic situation
of the importing country, the medical opinions and
personal interests of national policy-makers, the
quality of the distribution system, the attitudes of
doctors and other health staff with regard to the
prescription of medicines and the cultural concep
tions and financial resources of villagers.
As a result of the relations between the various
levels of organization, the knowledge of Western
medicines is widespread but their distribution is not
always so. Even in peripheral communities people are
familiar with the efficacy of these products and ask
for them. Their own curative methods are increas
ingly regarded as inferior and therefore discarded.
However, the medicines themselves penetrate insuffi
ciently into the periphery. Their distribution breaks
down at higher levels where interested parties receive
a disproportionate share at the expense of the rural
areas. The great faith in Western medicines and their
limited availability often makes the demand for them
even greater. Efforts to set up a PHC programme
with a ‘low supply of medicines' and with a strong
emphasis on prevention therefore meet with a great
deal of distrust, the result of which can be a complete
rejection of PHC programmes.
Finally, like doctors and other health workers,
medicines produced externally introduce a form of
dependence into local communities which can conflict
with the basic aims of PHC. Pharmaceuticals are
themselves linkages. They move from one level to
another, bringing with them not only the medically
defined therapeutic substances they contain, but also
crucial social and cultural aspects such as money
value (price), information about use (or lack of such
information), political and economic dependence and
meaning. These aspects (price, information, meaning)
are likely to change considerably during a medicine’s
‘journey' from level to level. Prices may, for example,
rise sharply at the local level and a doctor’s or
salesman's ideas about pharmaceuticals may differ
considerably from those of an ordinary patient. The
individuals involved in the transaction and trans
portation of medicines are also ‘linkages’; they are
like agents acting between different levels of social
organization. The most relevant ‘actor-linkages’ are
pharmaceutical representatives, government health
personnel, health workers, shopkeepers (including
pharmacists) and patients. By following the drugs
themselves and the individuals involved in their trans
action we hope to gain a better understanding of how
dependency, or self-reliance, is created in the context
of PHC.
Traditional medicine
In the Alma Ata document [5, p. 33] collaboration
with traditional medical practitioners is recom
mended in the following terms:
Traditional medical practitioners and birth attendants are
found in most societies. They arc often part of the local
community, culture and traditions, and continue to have
high social standing in many places, exerting considerable
influence on local health practices. With the support of the
formal health system, these indigenous practitioners can
become important allies in organizing efforts to improve the
health of the community. Some communities may select
them as community health workers. It is therefore well
worthwhile exploring the possibilities of engaging them in
primary health care and of training them accordingly.
In addition, the WHO [24] has devoted a report to
the integration of Western and traditional medicine.
Optimism about possible cooperation between repre
sentatives of different medical cultures also predomi
nates in a collection of articles (25), published under
the auspices of the WHO.
Although some scepticism about traditional
medicine still exists, the idea seems to prevail interna
tionally that additional training and involvement of
traditional practitioners can make up the great short
age of personnel in PHC or at least ease it. Another
advantage is that traditional practitioners will be less
inclined to leave their community than specially
trained health workers who are likely to seek further
career opportunities elsewhere after they have com
pleted their training. Their close relationship with
their fellow-villagers is yet another advantage.
At the national level lip service is quite often paid
to this passage in the WHO document. Promotion of
traditional medicine frequently serves the purpose of
national and cultural self-awareness. In practice there
is hardly any question of real collaboration and
exchange between modern and traditional medicine
in the framework of PHC [26]. Health workers within
the biomedical system are generally opposed to the
idea of collaboration, whereas traditional practi
tioners are often more responsive. They expect an
increase in prestige and income through their associ
ation with the official health care system.
As yet, little is known about the reaction of local
population groups to the incorporation of traditional
medicine into PHC. While they have long been
accustomed to Western and traditional medicine be
ing used side by side, they are likely to see themselves
fobbed off with second rate provisions when tradi
tional practitioners are mobilized as village health
workers.
Critical observers have shown divisions of opinion
on the plea for reassessment of traditional medicine.
Some have criticized it as being romantic and un
scientific [27] and a questionable method of econo
mizing. Others are of the opinion that the WHO’s
guidelines are only a beginning and are still char
acterized by ethnocentrism and scientism. They take
the view that policy-makers still make too extensive
use of the biomedical yardstick when evaluating
traditional medicine. Research into opinions and
practices concerning traditional medicine and PHC at
different levels of integration will doubtlessly lead
to more policy-relevant conclusions.
Family planning
Although family planning is mentioned only once
in the Alma Ata document as a component of PHC,
it is definitely regarded as an essential item in most
PHC programmes [28]. Family planning is thought
about very differently at the various levels of social
organization. At the level of the international organi
zations anti-natal and neo-Malthusian opinions pre
dominate. National governments have often adopted
this view—sometimes voluntarily, sometimes under
pressure—but are not very successful in selling it to
the population.
.5
’’K
)
The interests of the peasants and urban poor
with regard to children differ fundamentally from
the views of government leaders, which are tuned
towards the national economy and political stability.
The views of representatives of international organizations are again directed towards other ‘dangers’
such as ecological disaster and international stability.
A study of the views on and interests in family
planning at the various levels will provide insight into
the successes and failures, as well as the future
possibilities of family planning as a part of PHC.
CONCLUSION
)
1
i'V
5
1
1033
PHC in a multi-level perspective
Reports and articles on PHC clearly show that
PHC has no fixed meaning. At different levels of
social organization people appear to have different
interests in PHC and, consequently also have differ
ent ideas about it. There is no such thing as a
world-wide PHC concept. We will have to be satisfied
with a non-definition. PHC is what people say it is.
Research into problems in the functioning of PHC
should not overlook this semantic confusion.
In this article we have proposed to take this
confusion as a point of departure for research. Expos
ing the absence of a common definition of‘PHC’ and
tracing back this absence to a lack of common
interests in it, is the main contribution a multi-level
research approach can make towards a better under
standing of how ‘PHC’ works and why it so often
does not work.
Is it possible, however, to formulate a critique of
PHC if we do not agree on a definition? The con
fusion surrounding the concept of PHC at various
levels of social organization also affects this paper.
If international institutions, national governments,
health workers and local communities have their own
definition of PHC, why not social researchers? Are
they not cultural beings with their own ideas and
interests?
The somewhat schizophrenic position we have
taken is indeed that PHC has no fixed meaning.
At the same time, however, we have measured its
functioning against the Alma Ata definition, not
because we accept that definition is the only true one,
but because it is the one to which participants have
pledged their allegiance.
But we also have our own ideas on PHC, shaped
by our cultural background. These have prompted
the questions raised in this paper. We cannot antici
pate the results of a multi-level study, but one
conclusion seems almost certain: PHC cannot be
separated from its political meanings. If we agree on
a programmatic definition of PHC as “democratiza
tion of health care” (29), it will be clear that the ideal
cannot be achieved as long as the political reality
allows people so little room to pursue their own views
and interests.
Acknowledgements—A different version of this article
served as a position paper for an international seminar on
PHC research, in November 1988. in Wassenaar, The
Netherlands. The position paper appeared under the collec
tive authorship of the Dutch research group ‘Linkages,
Medical Systems Research’. Thirty participants from vari
ous developing countries (India, Indonesia, Peru, The
Philippines, Somalia and Zimbabwe) and from the The
Netherlands commented on the text through reaction papers
which were discussed at the seminar. We would like to thank
all the participants, in particular M. Colpa, who contributed
to the present text with their criticisms and suggestions. We
are also grateful to an anonymous reviewer who sent us
some useful comments and to W. de Rijke and M. J. Collins
who helped prepare this English version.
REFERENCES
1. One of the first signs of opposition to the Alma Ata
version of PHC was: Walsh J. A. and Warren S. K.
Selective primary health care: an interim strategy for
disease control in developing countries. New Engl. J.
Med. 301, 18, 1979.
2. The literature accompanying the debate is too vast to be
cited here. We limit ourselves to the most important
contributions: Gish O. Selective primary health care:
old wine in new bottles. Soc. Set. Med. 16, 1049-1053,
1982; Berman P. A. Selective primary health care: is
efficient sufficient? Soc. Sci. Med. 16, 1054-1058, 1982;
Rifkin S. B. and Walt G. Why health improves: defining
the issues concerning ‘comprehensive primary health
care’ and ‘selective primary health care’. Soc. Sci. Med.
23, 559-566, 1986; Chen L. C. Primary health care in
developing countries: overcoming operational, techni
cal, and social barriers. The Lancet 1260-1265, Nov.
1986; Rifkin S. and Walt G. (Eds) Selective or compre
hensive primary health care? Special Issue of Soc. Sci.
Med. 26, No. 9, 1988. An overview of the debate is
presented in Warren S. K. The evolution of selective
primary health care. Soc. Sci. Med. 26, 891-898, 1988.
3. See Wolters W. Levels and linkages: an alternative
analytical approach to development problems. Nether
lands Ret . Devi. Stud. 1, 39-54; and DeWalt B. R. and
Pelto P. J. Micro and Macro Levels of Analysis in
Anthropology: Issues in Theory and Research. Westview
Press, Boulder, CO, 1985.
4. Since 1984, cultural anthropologists and development
sociologists from seven Dutch universities and two
research institutes have combined their efforts to
develop this ‘linkages perspective’ and to use it in
the design of" a common research project on problems
of development. The research group has divided itself
into four subgroups concentrating on: (1) the state,
(2) rural development, (3) urban development, and
(4) health care. The fourth subgroup organized the
seminar at which this text was presented as a position
paper (see Acknowledgements). The aim of the seminar
was to develop an outline for an international and
comparative research on PHC from a multi-level per
spective.
5. WHO/UNICEF. Primary Health Care. A Joint Report.
WHO, Geneva, 1978.
6. Stone L. Cultural crossroads of community participa
tion in development: a case from Nepal. Hum. Org. 48,
206-213, 1989. In the same article Stone sketches the
conflicting views on ‘development’. The international
staff of a project in Nepal sees development as people’s
growing ability to “take matters into their own hands",
but for the villagers “development is something that
comes from outside."
7. Ugalde A. Ideological dimensions of community partic
ipation in Latin American health programs. Soc. Sci.
Med. 21, 41-53, 1985.
8. Sec e.g. Geertz C. The integrative revolution: primordial
sentiments and civil politics in the new states. In The
Interpretation of Cultures, pp. 255-310. Basic Books,
New York, 1973.
9. For an example of such a process in Nepal, see:
Streefland P. H. The frontier of modem Western
medicine in Nepal. Soc. Sci. Med. 20, 150-161, 1985.
1034
Sjaak van der Geest et al.
10. Salim E. Primary health care belongs in the mainstream
of development. Wld Hlth Forum 9, 307-309, 1988.
11. The contradictory role of the state in the implemen
tation of PHC is also shown in four Middle-American
case studies in: Morgan L. M. (Ed.) The political
economy of primary health care in Costa Rica,
Guatemala, Nicaragua, and El Salvador. Med. Anthrop.
Q. NS 3, No. 3, 1989. In her introduction Morgan
refers to the Guatemalan case: “On the one hand,
Guatemala’s leaders wanted to comply with interna
tional mandates, but on the other hand, the politicizing
effects of PHC programs have been instrumental in
undermining the fragile support for the military regime
in the countryside.” She concludes: “PHC can be both
a boon and a threat to the established political order”
(p. 228). That ambiguity is the state’s problem with
PHC.
12. Werner D. The village health worker: lackey or libera
tor? Wld Hlth Forum 2, 42-68, 1981.
13. See also Farah A. A. and Buschkens W. F. L.
Community-oriented training in Mogadishu, Somalia.
Newsletter 7, 7-8, 1987.
14. See Buschkens W. F. L. De levensstijl van Somalische
artsen en de ontwikkeling van de gezondheidszorg.
In Levensstijlen: resulta ten van een Leids onderzoeksprogramma (Edited by Nas P. J. M. and van den
Eerenbeemt F.), pp. 86-95. ICA-publicatie 79, Leiden,
1987.
15. Bloom A. Introduction: the client’s perspective in pri
mary health care. Med. Anthrop. 9, 7-10, 1985.
16. Justice J. The bureaucratic context of international
health: a social scientist’s view. Soc. Sei. Med. 25,
1301-1306, 1987.
17. Stone L. Primary health care for whom? Village
perspectives from Nepal. Soc. Sci. Med. 22, 293-302,
1986.
18. Van der Geest S. The secondary importance of primary
health care in South Cameroon. Cult. Med. Psychiat. 6,
365-383. 1982.
19. WHO. Intersectoral Action for Health. WHO, Geneva
1986.
20. Huyts M. ’Community organization’ comme methode
d’in terven lion dans un projet sanitaire. Universite
Agronomique, Wageningen (Rapport du stage), 1979.
21. Sensing J. Wie wil in Nederland primary health care?
(Who wants PHC in The Netherlands?). Medisch Con
tact 39. 141-146, 1984.
22. Taylor and Jolly, both attached to UNICEF, have
criticized the horizontal-vertical debate and called it a
‘misleading polarization’. They argue that the original
Alma Ata document recommends a combined selective
and comprehensive approach in PHC. Taylor C. and
Jolly R. The strawmen of primary health care. Soc. Sci.
Med. 26, 971-977. 1988.
23. For two examples (in Cameroon and Mali respectively)
sec: Hours B. L'etat sorcier. Sante publique et societe
au Cameroon. Harmattan, Paris, 1985; Chabot H. T. J.
and Bremmers J. Government health services versus
community: conflict or harmony? Soc. Sci. Med. 26,
957-962. 1988.
24. WHO. The Promotion and Development of Traditional
Medicine. TRS 622. WHO, Geneva, 1978.
25. Bannerman R. H. el al. (Eds) Traditional Medicine and
Health Coverage. WHO, Geneva, 1983.
26. Pillsbury B. Policy and evaluation perspectives on tradi
tional health practitioners in national health systems.
Soc. Sci. Med. 16, 1825-1834, 1982.
27. See e.g. Velimirovic 0. Traditional medicine is not
primary health care. Curare 7, 61-79. 1984.
28. Taylor C. E. and Parker R. L. Integrating primary
health care services: evidence from Narangal, India.
Hlth Policy Plann. 2, 150-161, 1987.
29. This definition was suggested by D. Banerji at the
fnternational Seminar on PHC Research, Nov. 1988.
>
-’s
5^
Journal of Community Health, Vol. 30, No. 3, June 2005 (© 2005)
DOI: 10.1007/sl 0900-004-1960-4
<•
-V
HOW DO WE DETERMINE WHETHER COMMUNITY
HEALTH WORKERS ARE COST-EFFECTIVE? SOME
CORE METHODOLOGICAL ISSUES
Damian G. Walker, MSc; Stephen Jan, PhD
1
ABSTRACT: Since the Alma-Ata Conference in 1978 reiterated the goal
of “Health for All by the Year 2000”, health service delivery programs
promoting the primary health care approach using community health
workers (CHWs) have been established in many developing countries.
These programs are expected to improve the cost-effectiveness of
health care systems by reaching large numbers of previously underseived people with high-impact basic services at low cost. However,
there is a dearth of data on the cost-effectiveness of CHW programs to
confirm these views. This may be because conventional approaches to
economic evaluation, particularly cost-effectiveness, tend not to capture
the institutional features of CHW programs. Therefore, this paper aims
to examine the means by which economic methods can be extended to
provide evidence regarding the cost-effectiveness of CHWs in develop
ing countries.
KEY WORDS: community health workers; cost-effectiveness; review.
INTRODUCTION
5
>
Since the Alma-Ata Conference in 1978 reiterated the goal of
“Health for All by the Year 2000”, health service delivery programs pro
moting the primary health care approach using community health work
ers (CHWs) have been established in many developing countries.1
Services provided by these workers are seen to be more appropriate to
the health needs of populations than those of clinic-based services, to be
less expensive and to foster self-reliance and local participation.
Furthermore, because CHWs are more accessible and acceptable to
Damian Walker is a Research Fellow in Health Economics, and Stephen Jan is a Lecturer
in Health Economics, both at the London School of Hygiene and Tropical Medicine.
The authors are members of the Health Economics and Financing Program (HEFP),
which is supported by program funds from the Department for International Development, UK
(DFID).
Requests for reprints should be addressed to Damian Walker, M.Sc, Health Economics and
Financing Program, Health Policy Unit, Department of Public Health and Policy, London School of
Hygiene 8c Tropical Medicine, Keppel Street, London, WC1E 7HT, UK; e-mail: damian.walker@lshtm .ac.uk
ft
J*
221
0094-5145/05/0600-0221/0 © 2005 Springer Sdence+Business Media, Inc.
*»
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1?
222 JOURNAL OF COMMUNITY HEALTH
clients in their communities, they aim to improve the overall coverage of
services as well as equity, i.e. increased service use by poorer individuals
and households.2 In short, these programs are expected to improve the
cost-effectiveness of health care systems by reaching large numbers of
previously under-served people with high-impact basic services at low
cost.33 Gilson et al.4 argue that CHWs represent an important health
resource whose potential in providing and extending a reasonable level
of health care to undeserved populations must be fully tapped. However,
given the stated importance of CHW there is a surprising lack of data on
the cost-effectiveness of CHW programs to confirm these views.
Possibly one explanation is that the nature of CHW poses prob
lems for conventional forms of economic analysis. The value of such
activity — its appropriateness to a particular population or community —
is influenced heavily by institutional factors such as altruism, volunteer
ism, community norms, reciprocity and duty and these tend not to be
reflected well in estimates of cost-effectiveness. However, CHW does
involve the use of limited social resources and thus there are compelling
reasons for some form of economic evaluation to establish whether
such resources are deployed efficiently. As a consequence, methods for
building in some of these aspects of institutional change are important
in enabling economic evaluation to better capture the full value of these
programs.
This paper aims to critically review methods that have been used
previously to examine the cost-effectiveness of CHW, with an emphasis
on developing countries. The second section sets out some of the specific
objectives of CHW programs. The third section examines the scope of
conventional forms of economic evaluation and the methodological
issues related to the valuation of costs and outcomes in CHW. The fourth
section reviews the existing cost-effectiveness evidence-base highlighting
some of its limitations and methodological shortcomings. The discussion,
in section 5, considers how economic evaluation can be extended to
incorporate factors, important to CHW that erstwhile have not been wellrecognized in the economic evaluation literature. Some brief conclusions
are drawn in the final section.
' J
SPECIFIC OBJECTIVES OF CHW
In evaluating a CHW program, an important initial step is the
identification of its objectives. Economic evaluation, if it is to be
policy-relevant, needs to be matched to the actual objectives of the
If
□Damian G. Walker and Stephen Jan 223
program. This section outlines the potential objectives of CHW recogniz
ing that these will vary across settings:
3
• Health gain: such as lives saved, years of life gained, etc. Intermedi
ate health measures such as reduction of risky behaviour,
attendance at antenatal clinic, may be seen as useful tracers for
change in health status, particularly given the methodological dif
ficulties associated with measuring and attributing change in
health status to an intervention.
• Individual non-health benefits: there are likely to be a number of
non-health benefits to individuals such as process of care and the
information resulting from CHW intervention, its cultural appro
priateness and the degree of autonomy afforded patients in the
treatment process.
• Social non-health benefits, this relates to changes in the wider com
munity resulting from the program, e.g. community empower
ment, sustainability, economic benefits such as employment and
production gains. In practice, some of these outcomes may have
positive or negative values.
It is evident from this list that the objectives of such programs do
not neatly fit into uni-dimensional measures of health that tend to be
used in cost-effectiveness studies. The next section examines in more
detail the scope of such analyses.
THE ROLE OF COST-EFFECTIVENESS ANALYSIS
Cost-effectiveness analysis (CEA) is a form of economic evaluation
that involves the estimation of cost alongside a measure of outcome (typi
cally health gain).5 Estimates of cost-effectiveness for a particular health
intervention, say in terms of cost per life saved, when compared with that
of another, indicate where funds could be allocated to maximize health
gain.
Applied to the evaluation of community-based health programs
it enables a decision-maker to choose between two or more modes of
delivery for the same intervention (e.g., hospital- versus clinic-based
care6) in order to. identify which represents the most efficient, or
“cost-effective”, use of resources. In making such comparisons, it is
relevant to examine both costs and outcomes of switching between
alternatives, i.e. the incremental cost and outcomes of CHW relative to
224 JOURNAL OF COMMUNITY HEALTH
a stated alternative, which is sometimes a “do nothing” option (e.g„
see Wang”ombe7).
In terms of the incremental costs of CHW programs, a compari
son with hospital-based care would need to highlight not only changes in
resource use to the health sector but also those to patients and the wider
community. For instance in a study of tuberculosis (TB) control compar
ing DOTS in the community with hospital care, it was noted that signifi
cantly lower costs were incurred for the former.6 However, it can
sometimes be unclear the extent to which such cost savings result simply
from costs shifted from the health sector to the community. An impor
tant issue that needs to be explored in such studies is therefore the distri
bution, or burden, of costs. Although a “do nothing” option would on
the face of it be less costly than a CHW program, there may in the long
term be potential downstream cost savings that result from the effective
operation of such a program. An evaluation would ideally be sensitive to
this although it is not typically the case that CEA is sufficiently broad in
scope to capture these effects.
Another major issue is the use of volunteer labor in community
health work. Although such labor is nominally “free”, in principle it has
an economic cost because it is a resource that has alternative, valuable
uses. The cost of such labor thus ideally should be based on a “shadow
price” reflecting prevailing wage rates (e.g, San Sebastian et al.8—see
below). The argument for such valuations is generalizability to other, per
haps more typical, settings where such labor may need to be remuner
ated (see section 4 for further discussion).
Estimating the outcomes from CHW would entail deriving some
measure of health gain (e.g., life years saved) or an intermediate measure
reflecting change in health risk (e.g., improved attendance at antenatal
clinics). The usual difficulties, particularly in relation to detecting health
gain attributable to the program, include inevitable time lags and controlhng for confounders. These problems of attribution, however, are
general to all forms of evaluation and thus will not be addressed further
in this paper.
REVIEW OF EVIDENCE
This paper examines three areas where there has been some liter
ature on the economics of CHW programs: primary health care; vaccina
tion services; and TB control programs. The review is by no means
comprehensive. Its aim is simply to give a sense of the parameters with
Damian G. Walker and Stephen Jan 225
which economic evaluations of CHW tend to be set and how such find
ings are presented.
Primary Health Care
3
One of the first papers to evaluate the value for money of CHW
programs was published by Wang’ombe7 in 1984. The project consisted of
CHWs, trained for 12 weeks and deployed in two locations in Kenya’s
Western Province, to provide basic health care and health promotion. A
cost-benefit analysis (CBA) was performed using the willingness-to-pay
approach to compare the costs and benefits of the project. The evaluation
illustrated a large net present value and a benefit-cost ratio of between
9.36 and 9.85, depending on the choice of discount rate. The author con
cluded that the results were “...strongly in favor of decentralization of pri
mary health care on similar lines in the rest of the country”.
More recently Makan and Bachman9 undertook an economic
analysis of CHW programs in the Western Cape Province of South Africa.
Their study evaluated the costs of five CHW programs delivering primary
health care services and one CHW training center. The authors observed
that the CHW unit costs were comparable to those of other health ser
vices, although they noted that such a comparison fails to account for dif
ferences in disease severity and professional training. Unfortunately, a
failure to assess the effectiveness of the programs did not allow for an
evaluation of cost-effectiveness.
Immunization Services
'S
c
£
e.
In a recent review of the effects and costs of expanding the cover
age of immunization services in developing countries, one of the inter
ventions with the highest impact on full coverage was CHWs.10 The
employment of CHWs in outreach programs was evaluated in relatively
small but diverse communities, e.g. urban areas of Mexico11 and commu
nities in rural Ecuador.8 The involvement of communities improved ser
vices as it meant that houses were located with precision, they were
registered and the days of vaccination chosen to suit parents. San Sebas
tian et al.8 was one of only two studies for which cost-effectiveness was
also evaluated. The use of CHWs was reported to be more cost-effective
than outreach teams involving health staff. Some of the reasons posited
for this were the isolation of this community, the employment of CHWs
yielded both significant cost savings and a service more in tune with the
needs of the community.
226 JOURNAL OF COMMUNITY HEALTH
Tuberculosis Control Programs
There has been a number of recent studies comparing the cost
and cost-effectiveness of community-based care with other strategies for
TB. Wilkinson et al.6 illustrated that the cost to both health service and
patient can be substantially reduced by using community-based directly
observed therapy (short-course) for TB control in South Africa. They
found that this strategy was more cost-effective than hospitalization or
sanatorium care on a cost per patient cured basis. Other studies have
found similar findings. For example, Floyd et al.12 compared strategies
for new smear-positive pulmonary patients and for new smear-negative
pulmonary patients concluding with a strong argument for expansion of
decentralization and community-based DOTS in Malawi. Comparable
findings have been reported elsewhere in Africa, e.g. Kenya 13 Uganda14
and South Africa.15
Another recent study in rural Bangladesh compared the cost
effectiveness of a NGO-provided TB control program involving CHWs
with a government program involving regular health staff. The cost per
patient cured was $64 in die NGO program compared to $96 for the gov
ernment one. Similarly, a study conducted alongside a clinical trial in
three sites in Pakistan was undertaken to establish the cost-effectiveness
of different strategies for implementing DOTS.17 Patients were randomly
allocated to one of three arms: DOTS with direct observation by health
workers (at health centers or by CHWs); DOTS with direct observation
by family members; and DOTS without direct observation. The clinical
trial found no statistically significant difference in cure rate for the differ
ent arms. However, the economic analysis found that direct observation
by health center-based health workers (the model recommended by the
World Health Organization and International Union against Tuberculosis
and Lung Disease) was the least cost-effective of the strategies tested in
terms of cost per case cured ($310). The self-administered group came
out as most cost-effective ($164 per case cured). However, the CHW sub
group achieved the highest cure rates (67%), with a cost per case only
slightly higher than the self-administered group ($172 per case cured).
The authors concluded that this approach should be investigated further,
along with other approaches to improving patient compliance.
The limited number of studies available suggest that CHWs
increase the coverage and equity of service delivery at low cost compared
with alternative modes of service organization. However, such services
rarely yield a substantial health impact and the quality of services they
4
J
Damian G. Walker and Stephen Jan 227
provide is sometimes poor.3 CHWs should be seen as complementary to
the formal services and not as cheap substitutes. The particular strengths
of CHWs (e.g., accessibility, acceptability, and cultural sensitivity) as well
as their limitations (e.g., ability to diagnose and treat serious illnesses)
should be considered9 although, as mentioned earlier, the extent to which
they have formally been included in economic evaluations is very low.
DISCUSSION
5
a
©
■
)
i
2
The economic evaluations that have been undertaken to date
tend largely to be conventional cost-effectiveness studies and thus based
on narrowly defined endpoints, e.g., vaccinations administered and
patients treated. The value of such measures is that they provide deci
sion-makers with explicit bases for comparing program alternatives in
terms of inputs and outputs. However, key elements of the program can
be missed through this reductionist perspective. The difficulty in employ
ing conventional economic approaches may be illustrated for instance in
how they deal with the issue of volunteer labor — a major factor in many
CHW programs. As indicated above, conventional forms of economic
evaluation tend to treat volunteer and paid labor interchangeably. The
assumption is that in using a shadow price for volunteer work based on
market wage ratesf one can generalize the findings to settings where vol
unteers are not available and consequently workers need to be paid. The
problem, however, is that the presence and willingness of volunteers is
often specific to the type of community in question and “volunteerism”
may be tied in with other institutional characteristics such as social capi
tal and trust. A community that produces a supply of individuals willing
to volunteer tends to be significantly different to one that does not. The
features of CHW which define it as a qualitatively different input into
health care from other forms of labor are the specific institutional char
acteristics such as volunteerism that it harnesses. The implication here is
that conventional forms of economic evaluation may miss important vari
ables such as these that, in turn, contribute to the perceived value or
benefit derived from such programs.
Other examples of wider benefits that may result from CHWs that
are unlikely to be captured in CEA are employment and training oppor
tunities, the value attached by clients to the process of receiving such ser
vices (e.g., in Aboriginal communities, CHWs are often seen as important
in delivering culturally appropriate services18) and, as alluded to earlier,
institutional change.
Institutions, in this sense,
are defined as the
228
JOURNAL OF COMMUNITY HEALTH
patterns of behavior that determine how individuals, groups and organi
zations interact with one another19 and may be either informal (e.g., vari
ous norms of behavior) or formal (legislation, government policy,
regulations). They are relevant to CHW since such programs are defined
by specific institutions — in particular, the relationships they establish
between provider and client (and the wider community). The develop
ment of such relationships, to some extent, alter the nature of the com
munity itself, e.g., they may increase the level of trust in health services
and individuals’ willingness to use such services which, in turn, may influ
ence the effectiveness of future programs. There has been recent litera
ture examining more holistic approaches to carrying out economic
evaluation using institutionalist methods to account for some of these
broader issues18,20 although these issues have generally not been well-rec
ognized in economic evaluation.
CBA potentially addresses some of these issues because it enables
the inclusion of multiple outcomes and allows for the measurement of
downstream cost implications. One potential weakness, however, is that its
measurement of benefits is based on the elicitation of individual prefer
ences through willingness-to-pay estimates. An implication of this is that it
is weak in terms of measuring benefits that occur in public good form, e.g.
increased vaccination coverage where there is a significant free-rider prob
lem at play and thus its value to society is not fully reflected in the aggre
gate benefits accruing to individuals. Thus, when an objective of a CHW
program is to increase vaccination rates or contribute to any other public
good such as community education or the organization of group activities,
then it is unlikely that CBA would be sensitive to this social benefit.
CONCLUSIONS
This paper has examined community health work and the impor
tance of the institutional context in defining its value or benefit. Conven
tional approaches to economic evaluation, particularly cost-effectiveness,
as reflected in some of the findings reviewed in this paper, tend not to
capture these institutional features of CHW. The development of a more
holistic, institutionalist approach offers a potentially useful framework for
evaluating CHW.
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Wang’ombe JK Economic evaluation in primary health care: The case of Western Kenya com
munity based health care project Soc Sci Med 1984; 18(5): 375-385.
San Sebastian M, Goicolea I, Aviles J, Narvaez M. Improving immunization coverage in rural
areas of Ecuador: A cost-effectiveness analysis. Prop Doct 2001; 31(1): 21-24.
Makan B, Bachman M. An economic analysis of community health worker programmes in the
Western Cape Province. ISBN No 8 1-919743-07-3.
Pegurri E, Fox-Rushby JA, Walker D. The effects and costs of expanding the coverage of immu
nisation services in developing countries: A systematic literature review. Vaccine (in press).
Calderon Ortiz R, Mejia-Mejia J. Estrategia de Contratacion Permanente dentro del Programa
de Vacunacion Universal. Salud Publica Mex 1996; 38(4): 243—248.
Floyd K, Skeva J, Nyirenda T, Gausi F, Salaniponi F. Cost and cost-effectiveness of increased
community and primary care facility involvement in tuberculosis care in Lilongwe District,
Malawi. Int J Tuberc Lung Dis 2003; 7(9 Suppl 1): S29-S37.
Nganda B, Wang’ombe J, Floyd K, Kangangi J. Cost and cost-effectiveness of increased commu
nity and primary care facility involvement in tuberculosis care in Machakos District, Kenya. Int J
Tuberc Lung Dis 2003; 7(9 Suppl 1): S14—S20.
Okello D, Floyd K, Adatu F, Odeke R, Gargioni G. Cost and cost-effectiveness of community
based care for mberculosis patients in rural Uganda. Int J Tuberc Lung Dis 2003; 7(9 Suppl 1):
S72-S79.
Sinanovic E, Floyd K, Dudley L, Azevedo V, Grant R, Maher D. Cost and cost-effectiveness of
community-based care for tuberculosis in Cape Town, South Africa. Int J Tuberc Lung Dis 2003;
7(9 Suppl 1): S56-S62.
Islam MA, Wakai S, Ishikawa N, Chowdhury AM, Vaughan JP. Cost-effectiveness of community
health workers in tuberculosis control in Bangladesh. Bull World Health Organ 2002; 80(6): 445-
450.
Khan MA, Walley JD, Witter SN, Imran A, Safdar N. Costs and cost-effectiveness of different
DOT strategies for the treatment of tuberculosis in Pakistan. Directly Observed Treatment
Health Policy Plan 2002; 17(2): 178-186.
18. Jan S, Conaty S, Hecker R, Bartlett M, Delaney S, Capon A. A holistic economic evaluation of an
Aboriginal community controlled midwifery program in Western Sydney. J Health Serv Res Pol
2004; 9(1): 14-21.
19. North DC. Institutions and economic theory. American Economist 1992; 36(1): 3-6.
20. Jan S. A holistic approach to the economic evaluation of health programs using institutionalist
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17.
3
Berman PA. Village health workers in Java, Indonesia: Coverage and equity. Soc Sci Med 1984;
0277-9536 88 S3.00 + 0.00
Copyright £ 1988 Ptrgamon Press pic
Soc. Sei. Med. Vol. 26. No. 9. pp. 899-902. 1988
Printed in Great Britain. All rights reserved
SELECTIVITY WITHIN PRIMARY HEALTH CARE
Julia A. Walsh
Assistant Professor of Medicine, Harvard Medical School. Boston MA 02115, U.S.A.
1.
J
3
Abstract—While great strides have been made in improving socioeconomic conditions in the developing
world, prospects for health for all remain remote. Resources are few, and difficult decisions must be made
concerning the priorities for their use. This paper addresses several topics involved in making these choices
including the methods for determining priorities and ensuring effectiveness of resource use.
First, prioritizing. Information is needed concerning the prevalence, mortality, morbidity, feasibility and
cost of control for each disease of importance in the area under consideration. Second, use of technology.
In discussion of health care some have denigrated the concentration many programs have placed on
specific methods and technologies. Nevertheless, technological advances, while some have had detrimental
results, have often led to improved living conditions; for example, improved seed and fertilizer use.
improved water pumps, family planning efforts. These technologies required a larger investment in
management, financial and communication systems. Health interventions are frequently more various and
complex than these and need a similar support system for impact. However there are many shortcomings
in health services; the paper looks at some of these learnt through experience, and concludes that the lack
of impact on health of large scale health programs that have provided selective interventions is probably
related to an inadequate recognition of the importance of community and political involvement and of
the necessary social, cultural, financial, management and administrative underpinnings.
Primary health care as described by the Alma-Ata
conference sponsored by the World Health Organ
ization and UNICEF in 1978 specified a full list of
health and multisectorial improvements for reaching
the goal of ‘Health for AU*. This list included specific
medical and public health interventions such as en
demic disease control, maternal and child health, and
treatment of common diseases and injuries, plus
other related interventions such as water supplies and
sanitation, promotion of food supply and proper
nutrition. In the Alma-Ata Declaration, health is
considered comprehensively. It is not just a matter of
lack of disease but rather the social outcome of
national development and progress expressed in
terms of improved quality of life. Attainment of this
goal calls for far-reaching social and economic
changes as well as reorientation of health care deliv
ery systems. In the last several decades great strides
have been made in improving socioeconomic condi
tions in the developing world, but prospects for
‘Health for All’ by 2000 remain remote. The World
Bank’s World Development Report graphically illus
trates this phenomenon [1]. Average annual growth
rates for low and middle income countries have
remained around 5% for the last 20 years and
distribution of income continues to be severely
skewed. At this rate of change, hundreds of millions
will persist in absolute, dire poverty after the end of
this century bereft of the minimal social and eco
nomic conditions associated with health.
Within this context, the efforts to specifically im
prove health, that is, decrease the burden of illness,
particularly of those most in need must be appre
ciated. The resources available for these efforts are
small relative to the sums spent in other sectors of the
economy. Governments apportion on average only
3-5% of their budgets on health; individuals and
households probably spend one to four times as much
[2-4]. Bilateral and multilateral aid amounts to a
small additional percentage compared with these
amounts, but these expenditures are sizable, for
example, American expenditures for health-related
programs for developing nations through public and
private agencies total at least five hundred million
dollars annually.
Government and individual expenditures have ten
ded to concentrate on curative services rather than
preventive ones that may have a greater impact on
overall health or influence life expectancy. These
services usually reach only those who live in close
proximity, thereby missing a substantial proportion
of the population. Even in areas in which health
service are accessible, utilization has frequently been
low [5]. Large scale health programs have frequently
had less impact than expected probably because they
are inaccessible, underutilized, understaffed and un
stocked or the services are incorrectly provided.
With the limited resources available, difficult deci
sions must be made concerning the priorities for their
use. This paper addresses several topics involved in
making these choices including the methods for deter
mining priorities and ensuring effectiveness of re
source use.
PRIORITIZING
When planning health services with the primary
goal of reducing the burden of sickness and death as
efficiently as possible using the available resources,
information is needed concerning the prevalence,
mortality, morbidity, and feasibility and cost of
control for each disease of importance in the area
under consideration. This method for prioritizing
may be applied either to whole populations or to
specific target groups such as wage earners, pregnant
women, children, etc,
Initially, collection of reliable data on burden of
illness includes checking the routine reporting sys899
900
Julia A. Walsh
terns, hospital and clinic records, prior disease con Improved water pumps have increased irrigation and
trol programs, medical schools and other health access to better water supplies. Family planning
related agencies [6,7]. Routine reporting systems efforts are essentially efforts to increase utilization of
frequently have marked deficiencies and data must be specific technologies: condoms, pills, sterilization,
verified and supplemented from other sources (8). injections, etc.
Special population surveys can provide more accu
Agriculture and family planning provide examples
rate determination of disease and incidence and of the requirements for the successful introduction of
prevalence, but can be costly and time consuming; new technology. None of these technologies were
therefore, careful consideration must be made about immediately used by the entire population nor had
the importance and the need for the information in much effect until they were correctedly used and
decision making [9]. Developing a reliable ongoing support systems for them were developed. Commu
surveillance system is imperative to define priorities, nity suppon and evidence of the results from the use
monitor progress and refine future health planning of these technics were closely intertwined. In agricul
and directions.
ture, the household may not have appreciated an
After identifying the major causes of disease, their improved standard of living from use of the new seed
prevalence, incidence, morbidity and mortality, until supplies of seed were stable and established,
within the population under consideration, the fertilizer was available in the required quantities,
efficacious, feasible and cheapest control measures agricultural extension workers were available to an
for each of these should be identified. Several recent swer questions and instruct in proper technics, irri
books have reviewed these [10,11]. Finally some gation systems provided water in the quantities at the
estimates of cost-effectiveness in terms of cost per times needed. Field preparation, sowing, fertilizing,
death averted or years of life saved must be made to watering, weeding or field maintenance had to occur
compare these possible interventions. The estimate according to a fairly detailed plan, harvesting, and
may vary depending on the target group and the then transport systems were needed to distribute and
ecology of the area under analysis. In 1979, Walsh market the product. All together a complex system,
and Warren identified the following high priority but one that has been increasingly utilized with
diseases for control globally: diarrhea, measles, ma outstanding results in many parts of the world.
laria, whooping cough, neonatal tetanus [12]. Since Technological advances continue among seed and
then the major change in ranking is probably acute other agricultural products to lessen the complexity
respiratory infection. Recently, the effectiveness of of the support system needed for increased food
inexpensive antibiotics for respiratory infections used production and make these new products more
according to simple algorithms has been corrobo readily available. For example, some of the newer
rated [13]. Other advances that may be valuable in seeds require less water or have less stringent fertilizer
specific circumstances are vitamin A supplements, requirements or are resistant to more of the pests and
hepatitis B vaccine and ivermectin for onchocerciasis. plant diseases.
Increasing the utilization of the proven efficacious
Family planning programs present another exam
control measures that can improve health with the ple of how technologies shape the distribution system
least cost becomes an evident priority.
and, in turn, the success of the program is essentially
Economic, political, and community interests may determined by population-based utilization of these
influence these decisions on the use of health re technologies. Family planning technologies are rela
sources. Control of an illness may be important for tively few in number and simple compared to health
tourism, livestock production, agriculture, or indus services: condoms, pills, sterilization, IUDs, and oth
trial development. Donor agencies may only offer ers. To ensure utilization among the target groups
specific programs.
within the population has required multi-faceted
programs involving field workers, community com
mitment, social marketing, individual and multi
USE OF TECHNOLOGY
media health education; TV, radio, movie, and other
Health services programs have frequently had less communication media campaigns, linkages with indi
impact than expected for a variety of reasons vidual and community incentives. In addition, suc
[5, 14, 15]. In discussions of health care planning, cessful planning, management, transport, logistics,
some individuals have denigrated the concentration distribution, supervisory and financial systems,
many programs have placed on the introduction and among others have been worked out to provide the
utilization of specific methods and technologies [16]. contraceptives and support the trained personnel.
‘Technological fixes’ seem to substitute for attention Nevertheless, it has become evident that the effect of
to the overwhelming problems of poverty and to the these efforts for education and individual and com
lack of many of the underlying requirements for good munity commitment are frequently short-lived, and
health and may seem to fail as a consequence. In therefore, must persist if family planning acceptance
addition, some technological innovations have had rates are to rise or continue at a high level. Unques
unexpected detrimental results. Irrigation systems tionably, family planning acceptance increases with
have sometimes markedly increased schistosomiasis education, socioeconomic development, health ser
prevalence and intensity. Drilling wells and trypano vices and improvement in other sectors of family and
somiasis control have resulted in desertification from societal life [17, 18], but acceptance rates can increase
overgrazing by livestock. Nevertheless, technological even in areas where these do not improve.’
advances have led to improved living conditions; for
In conclusion, the utilization of new agricultural
example, improved seed and fertilizer use has and family planning. technologies required a large
markedly increased food production and availability. investment in management, financial and commu-
Selectivity within primary health care
nication systems. Health intervention are frequently
more various and complex than these and need a
similar support system for impact.
impediments for effective health services
3
3
-t.
The impact that health services can have in im
proving life-expectancy depends on several factors:
(1) efficacy of the interventions provided, (2) diagnos
tic accuracy of the health worker to correctly identify
the disease for which the interventions are available,
(3) health provider compliance to correctly provide
the intervention or health practice, (4) patient compli
ance to correctly use it (in the case of oral rehydration
solution, to correctly mix and administer in the
home), and (5) coverage, that is the extent to which
the efficacious manoeuver, technology or services are
appropriately utilized by all those who would benefit
from them [19].
Underlying these factors are management, admin
istrative, financial, political and community support
requirements to ensure accessibility to well-trained
health workers who are fully supplied with accurate
diagnostics and active drugs.
A number of small scale primary health care
projects have resulted in substantial reductions in
infant and child mortality [20,21]. Other projects,
particularly those funded in part by donor agencies,
have resulted in little or unknown health im
provement [15]. A number of obstacles have been
identified which frequently interfere with the
effectiveness of primary health services.
The elements of projects which have aided in
success include: easily accessible and well-covered
population, prior well-established relationship be
tween the providers of care and the community,
concentration on a small number of key inter
ventions, easily accessible referral hospital, sustained
funding, comprehensive surveillance system, good
leadership, and established supply systems [20,21].
In contrast, several recent evaluations of donor
funded programs and community health worker pro
grams have identified a number of common short
comings [14, 15, 22]:
1. Uneven distribution of health services. Physicians
and nurses tend to concentrate in the cities. To
achieve effective coverage of the population, large
numbers of less skilled personnel need to be carefully
trained, and these health workers require continuing
supervision, drugs, and supplies and accessible sup
port and referral service. Otherwise utilization of
their services is low and turnover of these workers is
high.
2. Lack of appropriate technology. Several diseases
that arc major causes of morbidity and mortality in
parts of the developing world have only toxic,
lengthy, relatively ineffective, or expensive drugs and
control methods available. Research in these diseases
has increased with the last several years and within
the next decade new vaccines and drugs may be
available for many of these diseases that can be
integrated into the expanding programs for immu
nization.
3. Drug supplies. Supplies of drugs are frequently
erratic and expensive mating the effectiveness and the
credibility of community health workers. Better
901
mechanisms for assessing drug requirements, for or
dering, for procurement, for storage, and for distribu
tion can result in substantial savings plus improved
effectiveness of the health systems.
4. Mana^emeni of health resources. Particularly
rural health programs involve the manning, super
vision, supplies, and maintenance of widely dispersed
facilities. Frequently the administrative chain is
weakest at the district and local levels. The manage
ment of the system requires not only supporting
facilities and personnel but also decisions about
priority and resource allocation that arc based on the
health needs of the population. Skill in using infor
mation systems and epidemiologic perspective are
needed for planning, implementation, evaluation and
supervision, but these skills are rarely pan of the
curricula.
5. Financing of health services. Health must com
pete with other pressing developmental needs for the
extremely limited public resources. Governments and
donor agencies are increasingly wondering how even
the present level of services can be sustained not
including new or future programs (2-4].
6. Surveillance. An up-to-date population census
and careful recording of vital events particularly by
the community health workers’ aides in identifying
high risk groups and insuring their participation in
the health system and diagnoses the community’s
changing health needs. Such a system is valuable to
assure coverage and as a tool for monitoring and
evaluation.
Several donor agencies and international or
ganizations have recognized these deficiencies and
have begun appropriate research and training pro
grams. The World Bank, with several other agencies,
is examining methods for improving management
and logistics. The United States Agency for Inter
national Development has funded several programs
for applied and operational research in health care
financing, diarrheal disease, and immunization. The
World Health Organization has begun a program to
strengthen district level health services management.
The Independent International Commission exam
ining priorities for health research and funded by
several donors has identified management and sys
tems analysis as one of the areas of importance [5].
With these and other efforts underway, the imped
iments to effective health services hopefully will be
decreased shortly.
In summary, the lack of impact on health of large
scale health programs that have provided selective
interventions is probably related to an inadequate
recognition of the importance of community and
political involvement and of the necessary social,
cultural, financial, rpanagement and administrative
underpinnings. With political and community com
mitment and involvement, success is possible. Con
sider the success in Turkey and Colombia for societal
mobilization following recognition that many of the
well-known causes of disease as polio, measles and
tetanus are preventable with vaccines. When these
factors are involved as in the recent UNICEF efforts
for GOBI (Growth monitoring. Oral rehydration.
Breast feeding and Immunization) some impact can
be appreciated. In the words of the iVew York Times
editorial 28 December, 1986 entitled ‘The firepower
902
Julia A. Walsh
of kindness’, UNICEF’s efforts combined with those
of governments and other international agencies have
resulted in “Tangible evidence that a practical pro
gram can make a difference” [23].
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21. Berggren W. L., Ewbank D. and Berggren G. C.
Reduction of mortality in rural Haiti through a primary
health care program. New Engl. J. Med. 304, 1324, 1981.
22. Heiby J. R. Low-cost health delivery systems: lessons
from Nicaragua. Am. J. publ. Hlth 71. 514, 1981.
23. Editorial. The firepower of kindness. New York Times
28 December, 1986.
)
0277.9536/88 53.00 + 0.00
Pcrgamoa Press pic
Soc. Set. Med. Vol. 26. No. 9. pp. 891-898. 1988
Printed in Great Britain
THE EVOLUTION OF SELECTIVE
PRIMARY HEALTH CARE
Kenneth S. Warren
The Rockefeller Foundation, 1133 Avenue of the Americas, New York City, NY 10036, U.S.A.
J
Abstract—This paper traces the evolution of the selective primary health care (SPHC) concept, from its
presentation at a meeting in Bellagio, Italy, and its subsequent publication in the New England Journal
of Medicine in 1979. It reviews the early debate between those in favor of selectivity and those in favor
of comprehensive primary health care (CPHC). While this debate was going on, a breakthrough in terms
of implementation came with UNICEF's launching of its Children’s Revolution in 1982/83, promoting
four specific ‘social and scientific advances’ for improving the health and nutrition of the world’s children.
They were growth monitoring, oral rehydration therapy, breastfeeding and immunization. Meanwhile the
interest of a number of people for achieving ‘Health For All’ by targeting for action an essential short
List of diseases was the impetus for another conference in 1985, Good Health at Low Cost. Through
analysis of the achievements of four societies (Cost Rica, China, Kerala and Sri Lanka) efforts were made
to define further a prioritized health development strategy, and a number of measures were identified as
helping countries achieve good health. While some have argued that SPHC and CPHC are irreconcilable
and diametrically opposed, this paper suggests that both SPCH and CPHC are both acceptable.
Technology has its place. The field of view of SPHC has enlarged drastically, from individual diseases
to the role of other sectors such as education and agriculture. The concept of SPHC has broadened to
accept Rifkin’s and Walt’s assertion that “developmental processes need further exploration and research
strengthening capabilities within countries”. But research effort should not be an either/or. the
development of technology is as important as research into developmental processes.
PRIMARY HEALTH CARE
In September 1978, the World Health Organization
(WHO) and the United Nations Children’s Fund
(UNICEF) convened a conference at Alma-Ata,
U.S.S.R. at which the seminal concept of health for
all by the year 2000 was proclaimed. The means of
achieving this laudable goal was through primary
health care (PHC) which was defined as at least:
“education concerning prevailing health problems and the
methods of preventing and controlling them; promotion of
food supply and proper nutrition, an adequate supply of
safe water and basic sanitation; maternal and child health
care, including family planning; immunization against the
major infectious diseases; prevention and control of locally
endemic diseases; appropriate treatment of common dis
eases and injuries; and provision of essential drugs" [I].
3
In April 1979 John Knowles, President of the
Rockefeller Foundation held a meeting in Bellagio on
Health and Population in Development. Knowles
was concerned with the policy options within the
health sector, specifically, “those that will succeed”
[2]. The principal working paper for the meeting
relied largely on multiple regression analyses com
paring life expectancy and infant mortality rates with
a variety of health, economic and social indicators.
The main conclusion of the paper was that “health
inputs and sanitation facilities were less able to
explain variations in levels of life expectancy than
were social factors’’ [3].
SELECTIVE PRIMARY HEALTH CARE
The combination of the very broad approach to
health of Alma-Ata, and the conclusion of the
Bellagio paper that health inputs were relatively
unimportant, led to an attempt to disaggregate the
components of the mortality and morbidity rates in
the developing world in order to determine the role
of specific medical interventions, which could be
applied at a reasonable cost to rapidly decrease infant
and child morbidity and mortality. As was stated:
“Traditional indicators, such as infant mortality or life
expectancy, do not permit a grasp of the issues involved,
since they are actually composites of many different health
problems and disorders. Each of the many diseases endemic
to the less developed countries has its own unique cause and
its own complex societal and scientific facets.”
This was the core concept of a paper entitled ‘Selec
tive primary health care: an interim strategy for
disease control in developing countries’, presented at
Knowles* Bellagio meeting and subsequently pub
lished in the New England Journal of Medicine in 1979
[4]. The major infectious diseases of the South were
listed in the order of their importance based on
prevalence, mortality and morbidity. The crucial
ingredient of feasibility of control in terms of the
effectiveness and cost of available interventions was
then considered and the diseases were placed into
three priority groups—high, medium and low. Four
interventions were then established as the core of a
program to improve health in many parts of the
developing world. This core could be modified on the
basis of local needs and concerns and on the state of
the health care delivery systems. The measures sug
gested were immunization, oral rehydration, breast
feeding and the use of antimalarial drugs. The paper
concluded that until comprehensive primary health
care (CPHC) can be made available to all, effective
services aimed at the few most important diseases
(selective primary health care—SPHC) may be the
best means of improving the health of the greatest
number of people. It was clearly stated that this
891
r-
892
Kenneth S. W.krxen
approach would be an interim measure and that it
would in no way preclude the use of any other health
or intersectoral measures for fostering the well-being
of the people of the South.
The idea of SPHC seemed to have relatively little
impact at the meeting in Bellagio either when it was
originally presented or at publication in a special
issue of Social Science and Medicine. The Intro
duction to that issue made no reference to SPHC
emphasizing only CPHC [5]. In contrast, publication
of the concept of SPHC in the Nev.- England Journal
of Medicine elicited a spate of critical letters, several
of which were published under the rubric of‘Selective
health care for developing countries' (6). Further
more, in 1982 Social Science and Medicine published
two papers entitled ‘Selective primary health care: old
wine in new bottles’ by Oscar Gish [7] and ‘Selective
primary health care: is efficient sufficient?’ by Peter
Berman (8j. Gish was concerned that the original
SPHC did not directly address the nature of the wide
development process and lacked a social science
perspective. Berman concluded that SPHC is not a
relevant or desirable alternative for most countries.
He felt that the efficacy of medical technology should
be balanced with individual needs and social context,
all at a cost countries can afford. Replies from the
authors of the original paper were included as well as
a commentary by Mack Lipkin. The latter concluded
that, “Planners interested in the health of popu
lations, I would think, would welcome this debate. It
can do nothing but make choices more rational and
thereby serve the interests of the people” [9].
In the meanwhile, concern was voiced at the WHO
concerning three apparently negative aspects of
SPHC: that it involved technology, that it was essen
tially a vertical program, and that it did not respond
directly to the concerns of the people. In order to
provide a forum to discuss these issues the Rock
efeller Foundation (RF) in collaboration with WHO
convened a small discussion group in February, 1983
in Bellagio entitled ‘Control of communicable dis
eases within primary health care' to try to reconcile
any differences, real or perceived. A consensus report
was prepared, the conclusion of which was:
‘‘Primary health care should respond to all of the health
needs of the community, but priority should be given to
those interventions that will rapidly reduce mortality and
morbidity at the least possible cost. The strengthening of an
infrastructure capable of responding to the priority prob
lems offers a particular challenge for bringing us closer to
the goal of health for all” (unpublished document).
During this period a book on SPHC was being
edited by Julia Walsh and the author in which subject
experts prepared in-depth presentations of the opti
mal strategies for dealing with each of 23 major
infectious diseases, and malnutrition. Each paper was
published in Reviews of Infectious Diseases', they were
subsequently gathered together in a book published
by the University of Chicago Press. Discussions with
WHO during this period led to a change in title of the
completed work to ‘Strategies for Primary Health
Care: Technologies Appropriate for the Control of
Diseases in the Developing World' [10]. In his fore
word to the book Halfdan Mahler, Director General
of WHO noted that the authors had “brought to
gether, under one cover, up-to-date information on
the most prevalent communicable diseases in the
developing countries and on modem technology for
controlling them.” He noted that:
“These diseases result and persist because of a combination
of adverse socioeconomic and environmental conditions,
undernutrition, lack of understanding of the determinants
of health and ill health, social apathy, and highly inadequate
health services. The control of these diseases, which is one
of the essential elements of primary health care, requires
attention to all of these factors" [11].
The concluding chapter of ‘Strategies for primary
health care’ by W. Foege and D. A. Henderson was
entitled ‘Management priorities in primary health
care’; it also broadened the concept of SPHC [12],
They stated that “our problem is not a paucity of
ideas, techniques, or effective prevention and treat
ment for improving health. Rather, given the embar
rassment of riches in terms of things that can be done,
the question is one of appropriate stewardship of
scarce national and international resources. What are
the next steps that, in the short run, can provide the
best health returns and, at the same time, provide the
optimal foundation for mid-range and long-term
health activities?” They noted that:
“No simple formula exists for selecting priority programs,
but governing considerations are based on (1) the major
disease problems and the possibilities for prevention, con
trol. or treatment: (2) the existing medical activities and
resources; (3) the skills and abilities ultimately needed in a
fully developed primary health care system and how these
might be fostered; and (4) experience of programs successful
in improving health indexes.”
This echoed a previous publication in the New
England Journal of Medicine by John Evans ei al.
entitled ‘Health care in the developing world: prob
lems of scarcity and choice’ [11]. The authors began
by stating that ‘Tn any circumstances, but particu
larly in these, the strategy to improve health must be
selective. Success will depend heavily on correctly
identifying the most important problems in each
population group, selecting the most cost-effective
interventions, and managing the services efficiently.”
In addition to technical feasibility of the interventions
suggested, Evans added political and administrative
feasibility. He concluded that:
“few developing countries have the institutional capability
to select health interventions on the basis of expected health
impact, least cost, and feasibility of implementation, and to
integrate independent facilities, practitioner, and disease
specific programs into a more coherent, economical, multi
purpose system. A high priority should be given to strength
ening the capability of administrators, physicians, and other
personnel in positions of leadership in the health system at
central and local levels in order to develop a population
perspective in the analysis of health problems, a costeflectiveness attitude toward the use of resources, and
management skills appropriate for a human-services organ
ization. More efficient management of health services is only
one aspect of the problem. It is equally important to
mobilize communities and individuals to take a more active
role in promoting health and in financing health services,
rather than to rely passively on a government system."
A REVOLUTION FOR CHILDREN
While all of the above were ‘merely words’, a major
breakthrough in terms of implementation came with
893
The evolution of SPHC
UNICEF's declaration of A Children's Revolution in
1982/1983 (12]. This was based on “social and
scientific advances" which now offer four vital new
opportunities for improving the nutrition and health
of the world’s children—oral rehydration therapy,
universal childhood immunization, the promotion of
breastfeeding and growth charts.
"For all four actions the cost of the supplies and technology
would be no more than a few dollars per child. Yet that
could mean that literally hundreds of millions of young lives
would be healthier. And within a decade, they could be
saving the lives of 20,000 children each day. It is not the
possibility of this kind of progress that is now in question,
it is its priority."
In May 1983 Jonas Salk and Robert McNamara
met with James Grant, Executive Director of
UNICEF to suggest that immunization should be the
spearhead of the UNICEF initiative. The heads of
other major international agencies, beginning with
WHO were approached and in March 1984 another
meeting was held at Bellagio sponsored by WHO,
UNICEF, The United Nations Development Pro
gramme (UNDP), the World Bank and the Rock
efeller Foundation entitled ‘Protecting the World’s
children: vaccines and immunization within primary
health care’ [13]. At the conference a ‘Task Force for
Child Survival’ was organized to coordinate the
massive effort to immunize the world’s children. It
was sponsored by the five agencies and William H.
Foege, formerly director of the Centers for Disease
Control, was appointed as its head. At a subsequent
meeting in Cartagena a year and a half later progress
was reported [14]. The goal of achieving a high degree
of childhood immunization by 1990 appeared to be
within reach, especially with commitments by India
and China. The Pan American Health Organization
has established the goal of eradication of polio from
the western hemisphere and the idea is spreading to
the rest of the world like a pandemic. The degree of
cooperation and collaboration between WHO, with
its ‘Expanded programme on immunization’, and
UNICEF with its ‘Universal Childhood Immu
nization’, reinforced by UNDP with its emphasis on
cooperation among UN agencies, and the World
Bank with its interest in cost-effectiveness is both
remarkable and heartening.
Foege and Henderson described the importance of
this initiative on many levels:
3
1
“Immunization programs respond to problems that are
almost universal in the developing world, and can, in a short
time, reduce childhood mortality and morbidity. In addi
tion, successful immunization programs may improve nutri
tional status, providing benefits beyond the target diseases.
Immunization programs are easy to institute and provide a
positive benefit-to-cost ratio, thereby saving money beyond
the investment in the program. Because the number of
vaccines will continue to grow (malaria, leprosy, rotavirus,
etc.) opportunities exist to control many of the major
infectious diseases over the next two decades. The devel
opment of an immunization infrastructure is one of the most
important primary health care priorities existing today"
ll°]“Not only do immunization programs meet the criterion
of dealing with major health problems (building on existing
resources and responding to the experience of successful
health programs), they also contribute to the general skills
and abilities desired in primary health care programs.
Surveillance, evaluation, management, logistics, outreach,
development of community support, interaction of local and
national abilities, integration of vertical and horizontal
structures, and use of fixed-site and mobile resources are
inherent in successful immunization programs" (10).
As soon as the greatly expanded immunization
program is well on its way to incorporation within the
primary health care infrastructure, it is important to
add other high priority interventions. At the
Cartagena meeting Fred Sai and Michael Merson
discussed the addition of family planning and
diarrheal disease control [14],
GOOD HEALTH AT LOW COST
The concept of selectivity and the development of
priorities on an intersectoral level was presaged by
John Evans in his Shattuck lecture.
"Sri Lanka and the state of Kerala in India and the People’s
Republic of China are examples of countries that have
attained a life expectancy close to the level in the industri
alized world with income levels in the range of the least
developed countries. The achievements may be explained in
part by the public priority given to literacy, food and health
and by special features of social and political organization"
[H].
In April 1985, a meeting was held at Bellagio
entitled ‘Good Health at Low Cost’ in which health
administrators, economists and demographers from
China, Sri Lanka, and Kerala state reported on their
success in achieving life expectancies of 65 with GNPs
per capita of about S300; Costa Rica reported a life
expectancy of 75 with a GNP somewhat over SI000.
The Editor’s Preface to the proceedings of the meet
ing stated that: “The impetus for this conference
emerged from the interest of some of us in developing
a global strategy for achieving ‘Health for AH’ by
targeting for action an essential short list of diseases.’’
This led to efforts to go further by defining a prior
itized health development strategy through analysis
of the achievements of four remarkable societies on
the intersectoral level [15].
Remarks at the end of the conference noted that a
basic theme had been stated by John Caldwell:
"One just can't wait for affluence. ... When this meeting
was being planned the approach fostering affluence was
widely supported. Thus, for the last decade at least there has
been a model for health in the developing world which can
be called the Northern paradigm. The evolution of good
health in the developed world of the North, had been
related, particularly by McKeown, to the process of devel
opment, i.e. the growth of a literate population living in
spacious housing provided with piped water and sanitary
facilities and supplied with the fruits of industry and
agriculture via good roads and communication facilities.
The allopathic medical system which gained ascendency in
the North had little to offer prior to the late 1930s or early
40s. Therefore, the governments of the developing world,
aided and abetted by multilateral, bilateral and non
governmental aid agencies have been attempting to institute
the Northern model of health. The cost of this approach is
staggering” [16].
In contrast, after examining the results presented at
the conference, the participants unanimously adopted
the following recommendations:
"The four states which have achieved ‘good health at low
cost’ have all clearly made a political and social commitment
894
KjENntth S. Warms
IMR Per 1.000
80 --------- r—
70
60
Socioeconomic Progress
22%
F.R
5%
50
32%
40
Oftwvwd R.srftw
30
41%
20
10
0 ----------- -------------------1968
1970
1972
1974
1976
1978
1980
•F.R. — Fertility Reduction
Fig. I. Costa Rica: factors in the decline of the infant mortaiity rate (IMR) according to the model of
multiple regression, 1972-80 [18].
to equitable distribution throughout their societies. Given
that commitment, three additional factors appear to have
played a major role in their success as measured principally
by a marked decline in infant and child mortality rates,
resulting in a commensurate increase in life expectancy
approaching that of the developed world. These factors
constitute recommendations for program-development in
other countries:
A. Equitable distribution and access to public health and
health care beginning at the primary level and reinforced by
secondary and tertiary systems.
B. A uniformly accessible educational system emphasizing
the primary level and then moving to secondary and above.
C. Assurance of adequate nutrition at all levels of society”
(17J.
The specific and remarkable role of health inter
ventions per se is illustrated in the chart provided by
Costa Rica delineating the factors responsible for the
steep decline in infant mortality rates from 1970 to
1980 (Fig. 1).
In contrast to the Northern paradigm described
above, the measures adopted by Sri Lanka, Kerala,
China and Costa Rica themselves were characterized
at the conference as ‘the Southern paradigm’. It was
noted that while the Northern approach must and
will continue to operate gradually, bringing rhe fruits
of development, the Southern approach can provide
vastly improved health at a more rapid rate, which in
its turn will contribute to development [16].
Fortuitously, the results of the GHLC conference
coincided with a rapidly developing WHO program
called ‘Intersectoral action for health' which was to
be the subject of the ‘Technical Discussions’ at the
World Health Assembly in May 1986. In preparation
for that event WHO and the Rockefeller Foundation
held a meeting in Bellagio in March 1986. In the
report of that meeting [19] and also at the Assembly
itself the necessity to develop priorities in the inter
sectoral area itself was emphasized.
“In most countries today the climate is conducive to a
re-appraisal of development strategies, not the least because
diminishing resources are forcing the countries of the South,
in particular, to move away from the historical pathways of
the North. The need to find less expensive and more
cost-effective ways of achieving multiple goals is leading
development planners and decision makers in the key
economic and social sectors toward intersectoral, 'home
grown' strategies targeted particularly toward the vulner
able groups, above all because equity pays off. The trend is
likely to continue, since when an idea's time has come, not
even those who are the most passionately opposed can stem
the tide forever” [19].
CPHC AND SPHC ARE IRRECONCILABLE
A recent paper by Susan Rifkin and Gill Walt
entitled, ‘Why health improves', stated that CPHC
and SPHC are both ‘irreconcilable’ and ‘diametri
cally opposed’ (20). Another publication, entitled,
‘Technocentric approach to health’, has claimed:
“that there is an ominous similarity between the spread of
a highly malignant cancerous tumor and the promotion of
the technocentric approach by western countries, particu-
The evolution of SPHC
895
0 3 MILLION
(3*)
3301 MILLION
(74 5M)
■■■■I
WORLD POPULATION
4432 MILLION
>0.« MILLION
(97*)
18 MILLION
(15*)
103 MILLION
(65*1
0.1 MILLION
tf'*)
—I
ANNUAL BIRTHS
121 MILLION
Key'
I, 1 Developing worlds share
Developed countries snare
Sovrca v-vtwi HUont frona
IB I
ANNUAL INFANT DEATHS
(0-11 MONTHS)
10.7 MILLION
fr.'nMfw Ju^
4.4 MILLION
(06*1
SJITW IP
ANNUAL CHILD DEATHS
(1-4 YEARS)
4.5 MILLION
Fig. 2. The developing world’s share of population, births and deaths [22].
larly the U.S.A. It started almost innocuously in the form
of a very poorly formulated report. . .. There were so many
flaws in the paper written by J. A. Walsh and K. S. Warren
that one felt confident that nobody would take a second
look at the conclusions these authors drew” [21].
The same author in another context quoted in Ref.
20 described several reasons for his concern about the
promotion of the SPHC approach for Third World
people. It:
‘T) negated the concept of community panicipation with
programmes planned from the bottom up; 2) gave allo
cations only to people with priority diseases leaving the rest
to suffer; 3) reinforced authoritarian attitudes; 4) had a
fragile scientific basis; and 5) had a questionable moral and
ethical value in which foreign and elite interests overruled
those of the majority of the people."
&
3
C:
inevitable the consequences which James Grant de
tailed so well in his series of reports on ‘The state of
the world’s children’. Figure 2 shows the developing
world’s share of population, births and deaths. This
graphic depiction is illustrative of the high death rates
in the developing world accompanied by high birth
rates [22]. Africa is the present paradigm for this
dichotomy. Figure 3 shows why the children die in
many parts of the developing world (22). These
figures were confirmed by a recent intensive study of
global and regional mortality patterns by cause of
death.
"Roughly four in every ten deaths in developing countries
are attributable to infectious and parasitic diseases. The
highest percentages of deaths due to these diseases occurs in
Africa (49%) and the lowest in North America (3.6%)’’ [23],
As Lipkin said in his commentary in a previous Many of these deaths can be relatively easily and
discussion of SPHC, ‘‘the debate between Walsh and cheaply averted by modem and not so modem
Warren and the critics fit Pilowski’s dictum: The technology. Future technology, given the quantum
better the ideas around the more acrimonious the leap in the ability to produce new vaccines and drugs
debate" [9].
due to the development of molecular biology, shows
At face value it appears that SPHC and CPHC must particular promise. All of this not only concerns
be reconcilable as the former was never claimed to be children but the health of mothers and the working
more than a small and in many cases interim part of man as well.
the broad concept of PHC. Two of the strongest
If the ‘process’ advocated by Rifkin and Walt,
critics of SPHC, Rifkin and Walt, however, base their “which, is still difficult to define, [but which] reflects
arguments essentially on the fact that advocates of the existing social, political and economic conditions
SPHC "see health improvements as a result of pro of individuals in communities at a given time and
grammes based on medical and technological inter place," is allowed to proceed at its measured pace we
ventions" but advocates of CPHC or PHC “see must consider the consequences.
health as a process dependent on individual knowl
edge and choice, of which medical intervention is
NATURE AS DEMON
only one, and often not the most important, input".
Another fundamental difference is temporal, in that
The lead editorial in the New York Times on 29
“advocates of programmes (SPHC) expect relatively August, 1986 with the above title poses the essential
immediate and visible results". "Those who accept question:
process (CPHC or PHC) expect that radical health
improvements will only come after a long period in “There’s a dual lesson here for those who sentimentalize
Mother Nature and demonize human technology. Those
which changes must occur on both levels of social, who arc farthest from the jungle are most likely to idealize
economic and political structures, and on the level of the impersonal workings of the rain forest. ... To African
individual and community perceptions" [20].
villagers or Asian peasants, nature is not a friend but a
Why not accept both! To reject technology until hostile force to be propitiated. ... If the Green Revolution
society has undergone major development makes has created food for millions, it is because science has tamed
896
Kenneth S. Warren
2
Key
7.
malnutrition
■w
[__ J Measles
Lower
(XV) respiratory
infection
SSSJTetanus
TJV
u*>
^BMaiana
i1
T7T
T5^
INDONESIA
EAST JAVA
nERal
re RAI
BSx
’aKiSTaN,
PUNJAB
GkanA, EA^TE
REGIONS
Fig. 3. Why children die: percentages of infant and child (ages 0-4) deaths due to preventable diseases
in selected countries (22J.
nature. If more Third-World children survive infancy, it is
because man-made medicine has prevailed over nature.
Technology, when misused, poisons air, soil, water and
lives. But a world without technology would be prey to
something worse: the impersonal ruthlessness of the natural
order, in which the health of a species depends on relentless
sacrifice of the weak. Nature remains what it was to
Tennyson, ‘red in tooth and claw’” [24].
less than 0.1 per annum. For almost three quarters of the
period a very similar rate of change probably took place in
Ido. but over the last dozen years the new health facilities
have probably accelerated that rate to almost one extra year
in expectation of life at birth for every year elapsed” [25].
Another key question is the relative effectiveness of
modem versus traditional technologies. Evans noted
that the use of chemotherapy for tuberculosis in
The result of the unavailability of ‘technology’ was
strikingly depicted in a superbly controlled study of blacks in New York City and Maoris in New Zealand
has shown that advances in medical technology can
two Nigerian villages by Orubuloye and Caldwell.
be very effective in reducing mortality promptly
These villages, one with good medical facilities (Ido)
without
any preceding improvements in living stan
and the other with no facilities other than the tradi
tional ones (Isinbode) were well matched. The two dards [11]. In contrast, Nyazema in his paper entitled
survey sites were culturally and geographically as ‘Herbal toxicity in Zimbabwe’, reported high mor
similar as possible and their social and economic tality rates from poisoning due to traditional reme
indices showed no great differences except in the dies in hospitals in Africa. He described a series of
provision of medical services. The results are graphi traditional remedies which have very severe side
cally shown in Table 1. The authors conclude that: effects, and noted that none of the traditional healers
interviewed believed in documenting their practice,
“continued mortality decline is really not a matter of but 90% were aware that some of their remedies were
overcoming ignorance but providing a sufficient density of toxic [26].
health services of reasonable calibre. Without such services
That health services can even have a marked effect
in the neighborhood, Isinbode would have probably aver
aged an improvement in the longevity of its population of on reducing mortality in the developed world has
recently been shown by Poikolainen and Eskola. In
Finland, in the period 1969-1981, deaths -amenable’
to medical intervention, including infectious diseases,
Tabic 1. .Mortality levels and differentials derived from retrospective
fell by about 65% while those due to ‘non-amenable’
data on vital events during the 12 months preceding the survey*
causes fell by about 26% [27]. Such gains would be
Ido
Isinbode
far greater in the developing world, and there is no
Deaths under one year of
(1)
reason, on the basis of effectiveness and cost, why
age reported per thousand
they should not.
births during year
(la)
(2)
(2a)
preceding survey
Expectation of life at
birth associated with
the infant death rate
recorded in (I) according
to the ‘North’ model
tables (years)
Deaths 1-4 years of age
reported per thousand
births during year
preceding survey
Expectation of life at
birth associated with
the child death rate
recorded in (2) according
to the ‘North’ model
life tables (years)
•Modified somewhat from Table 4. Ref. [25],
99
288
THE ART OF THE POSSIBLE
52
24
99
171
46
30
‘The art of the possible' is the title of a recent paper
by a wise and distinguished scientist from India, V.
Ramalingaswami [28]. If one heeds his admonitions
it seems that the PHC, CPHC and SPHC are indeed
reconcilable. SPHC has evolved, but its central con
cepts of establishing priorities on the basis of
effectiveness, of cost in a resource constrained world,
and of equity remains constant. The field of view of
SPHC has enlarged drastically, however, from indi
vidual diseases to the role of other sectors such as
education and agriculture. It is of crucial importance
to the whole endeavor that the populations be edu-
The evolution of SPHC
cated. A World Bank Staff Working Paper on the
effects of education on health has stated that “the
evidence on the significance of the relationship is
unequivocal” [29]. The conferees at ‘Good Health at
Low Cost’ were all deeply impressed at the effects of
primary education on good health as a crucial ele
ment of demand when the supply was available
through primary health care. Education is essential at
every level so that informed choices can be made
from the individual to the government. Halfdan
Mahler put it so well in his preface to ‘Strategics in
Primary Health Care’:
‘’I hope that the book will be used widely and that the
information it contains will be studied carefully. This will
help each country decide, in the spirit of self reliance that
characterizes primary health care, which diseases deserve
priority attention and what measures are most appropriate
to control them under the local circumstances" [10].
J
J
J?
The concepts have broadened to accept fully
Rjfkin’s and Walt’s assertion that ‘‘it is the devel
opmental processes that need further exploration and
research strengthening capabilities within countries”
[20], But why make it either/or by adding ‘‘this is
where the research effort should be placed rather than
in the development of technology” [20]. We can
certainly have both, because the cost of good re
search, whether in the natural or social sciences is
relatively low. As stated in a recent report entitled
The Rockefeller Foundation in the Developing
World:
“it is the equitable distribution of benefits to end-users that
fulfills the promise of science and technology in the devel
opment process. This is the philosophy against which the
Foundation's science-based efforts a re‘to be measured—not
just food production, but fewer hungry and malnourished
people; not just powerful vaccines, but control and elimi
nation of diseases; not just improved contraceptives, but
increased reproductive choice and safer family planning”
[30).
All methods to achieve this goal will be utilized, from
the technical to the social.
As a means of ending this discussion in a way
which reconciles CPHC and SPHC the words of
Ramalingaswami are most appropriate. In his paper
‘Health without wealth’ he stated that:
3
"Health is both a major pathway to development as well as
an end-product of it. We need to harmonize and balance the
two approaches to development—that of economic growth
and that of fulfillment of human needs. It is futile to
conceive of the health system functioning outside devel
opmental processes in general. While overall development,
the fulfillment of basic needs, and improved sundards of
living are essential to a sustained improvement in a popu
lation’s health and well-being, much can be achieved by the
determined application of appropriate technology for the
control of specific diseases and the primary health care
approach, even while the slow process of a rise in living
standards is taking place” [3!].
REFERENCES
1. Primary Health Care. A Joint Report by the DirectorGeneral of the World Health Organization and the
Executive Director of the United Nation’s Children's
Fund. WHO, New York, 1978.
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897
2. Knowles J. H. Health, population and development.
Soc. Sci. Med. I4C, 67, 1980.
3. Grosse R. N. Interrelation between health and popu
lation. Observations derived from field experiences. Soc.
Sci. Med. 14C, 99, 1980.
4. Walsh J. A. and Warren K. S. Selective primapr health
care: an interim strategy for disease control in devel
oping countries. yVew £>tg/, J. Med. 301, 18, 1979.
5. Bell D. E. Introduction. Soc. Sci. Med. I4C, 63. 1980.
6. Selective health care for developing countries. Hew
Engl. J. Med. 302, 758. 1980.
7. Gish O. Selective primary health care: old wine in new
bottles. Soc. Sci. Med. 16, 1049, 1982.
8. Berman P. A. Selective primary health care: is efficient
sufficient? Soc. Sci. Med. 16, 1054, 1982.
9. Lipkin M. Commentary. Soc. Sci. Med. 16, 1062, 1980.
10. Walsh J. A. and Warren K. S. Strategies in Primary
Health Care: Technologies Appropriate for the Control
of Disease in the Developing World. The University of
Chicago Press, Chicago, III., 1986.
11. Evans J. R., Hall K. L. and Warford J. Shattuck
Lecture—Health care in the developing world: problems
of scarcity and choice. New Engl. J. Med. 305, 19, 1981.
12. Grant J. P. (UNICEF) The State of the World's
Children, 1982-83. Oxford University Press, 1982.
13. Protecting the World's Children: Vaccines and Immu
nization within Primary Health Care. N Bellagio Confer
ence. The Rockefeller Foundation, New York, 1984.
14. Protecting the World's Children: Bellagio H at
Cartagena, Colombia. The Task Forcefor Child Survival.
The Rockefeller Foundation, New York, 1985.
15. Halstead S. B., Walsh J. A. and Warren K. S. Editors’
Preface. In Good Health al Low Cost, p. 6. The Rock
efeller Foundation, New York, 1985.
16. Warren K. S. Remarks. In Good Health at Low Cost
(Edited by Halstead S. B., Walsh J. A., and Warren
K. S.). p. 246. The Rockefeller Foundation, New York,
1985.
17. Conferees Summary Statement. In Good Health at Low
Cost (Edited by Halstead S. B., Walsh J. A. and Warren
K. S.), p. 248. The Rockefeller Foundation, New York.
1985.
18. Rosero-Bixby L. Infant mortality decline in Costa Rica.
In Good Health at Low Cost (Edited by Halstead S. B.,
Walsh J. A. and Warren K. S.), p. 136. The Rockefeller
Foundation, New York, 1985.
19. Intersectoral Action for Health: The Way Ahead. Report
of the World Health Organization/Rockefeller Founda
tion Meeting, 3-6 March, 1986. The Rockefeller Foun
dation, New York, 1986.
20. Rifkin S. B. and Walt G. Why health improves: defining
the issues concerning ‘comprehensive primary health
care’ and ‘selective primary health care’. Soc. Sci. Med.
23, 559, 1986.
21. Banerji D. Technocentric approach to health: western
response to Alma-Ata. Econ. Polit. Wkly 21, 1233, 1986.
22. Grant J. P. (UNICEF) The State of the World's
Children 1984. Oxford University Press, 1984.
23. Hakulinen T., Hansluwka H., Lopez A. D. and Nakada
T. Global and regional mortality patterns by cause of
death in 1980. Ini. J. Epidem. 15, 226, 1986.
24. Editorial. Nature as demon. The New York Times A26,
29 August, 1986.
25. Orubuloye I. O. and Caldwell J. C. The impact of public
health services on mortality: a study of mortality
differentials in a rural area of Nigeria. Populn Stud. 29,
259,. 1975.
26. Nyazema N. Z. Herbal toxicity in Zimbabwe. Trans. R.
Soc. trap. Med. Hyg. 80, 448, 1986.
27. Poikolainen K. and Eskola J. The effect of health
services on mortality: decline in death rates from
amenable and non-amenable causes in Finland,
1969-81. Lancet i, 199, 1986.
898
Kenneth S. Wajuuen
28. Ramalingaswami V. Opening address. The art of the
possible. Soc. Sei. Med. 22, 1097. 1986.
29. Cochrane S. H.. O’Hara D. J. and Leslie J. The effects
of education on health. World Bank Staff Working
Paper. No. 405. The World Bank. Washington. 1980.
30. The Rockefeller Foundation in the Developing World.
The Rockefeller Foundation. New York, 1986.
31. Ramalingaswami V. Health without wealth Wld Hhh
Forum 5. 252. 1984.
-
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0277-9536.88 S3.00 + 0.00
Copyright C 1988 Ptrgamon Press pic
Soc. Sci. Med. Vol. 26. No. 9. pp. 963-969. 1988
Printed in Great Britain. All rights reserved
GOBI VERSUS PHC? SOME DANGERS OF
SELECTIVE PRIMARY HEALTH CARE
Ben Wisner
Henry Luce Professor of Food, Resources and International Policy, School of Social Science.
Hampshire College, Amherst, MA 01002. U.S.A.
Abstract—This article enters the debate concerning comprehensive versus selective primary health care
by focussing on UNICEF’s ’child survival revolution’. It is argued that UNICEF is dangerously mistaken
in believing that its present emphasis on selective primary health care is a precursor or ‘leading edge’ of
comprehensive primary health care. The approach of UNICEF—diffusion of a package of technologies
by campaigns organized from the top down—is more likely to undermine the social basis for
comprehensive care.
1
•
;
The kinds of implementation UNICEF has chosen in order to minimize costs and maximize impact
on child mortality, namely ‘social marketing’ via mass media and massive, ad hoc delivery systems
seriously undermine the development of grassroots organization among parents and primary health care
workers. Indigenuous, local organizations are distorted and limited to conduits of a delivery system. Needs
are defined outside the communities affected. In addition, UNICEF*s so-called revolution has in common
with other selective approaches an ideology accepting as inevitable the health effects of economic crisis
in the 1980s, further undermining the confidence of local groups and health workers who might otherwise
conceive of their desire to control health conditions as a right.
The UNICEF interventions popularly known as GOBI-FFF are ’targetted’ at individuals, in particular
‘ignorant’ mothers. As such they are especially destructive to the process of group formation and
self-organization of the poor around their just demands for water and sanitation, land, shelter, and
employment. This article concludes that UNICEF’s GOBI should either be abandoned or integrated into
comprehensive primary health care programs that put parents and local workers in control and that
emphasize continuing political struggle for health rights.
TWO VIEWS OF UNICEF’S ‘GOBI’
J
J
UNICEF presented in its 1982-83 report on ‘The
state of the world’s children’ the outlines of a ‘Child
survival revolution’. This ‘revolution’ was to be based
on widespread adoption of a small number of cheap,
assessible and simple techologies. These technologies
were aimed at conditions that are responsible for a
large proportion of present infant and child mortality
in the third world, while leaving other conditions and
the wider conditions determining access to food,
shelter and sanitation untouched. UNICEF’s ‘revolution’ thus had much in common with other forms in
which selective primary health care (SPHC) has recently been distinguished from more comprehensive
primary health care (PHC) (1—4]. In the case of
UNICEF’s selective approach, the technologies are
referred to as a ‘GOBI’. The acronym ‘GOBI’ is made
up of the first letters of the phrase describing each of
four elements in a package of interventions on behalf
of children: Growth monitoring, Oral rehydration
therapy in case of diarrhea, Breast feeding (as op
posed to early weaning and/or bottle feeding), and
Immunization.
In its simplest form, UNICEF’s argument for
GOBI is compelling and has a lot in common with
arguments heard in favor of SPHC. The argument
runs as follows: (1) Financial and human resources
for primary health care in poor countries are scarce
and growing scarcer due to the recent decade of
international financial crisis. (2) Simple, low cost,
widely accessible technologies for saving children’s
lives exist. (3) Means for popularizing these tech
nologies at low cost also exist. (4) Therefore GOBI
should be implemented as a priority now. The hidden
963
premise, sometimes discussed explicitly, is that PHC
as envisioned only as recently as 1978 at the Alma
jAta Conference [5] is too costly and taking too long
to
l implement. In particular, the emphasis on people’s
<access to means of acquiring basic needs such as food
and
shelter and the emphasis on local control of
:
health
programs are criticized as being unrealistic
1
goals.
j
This line of reasoning can be questioned on a
number
of grounds, but even without an elaborate
i
critique
it is apparent that two possible relations
<
between
GOBI and PHC can be inferred. In more
I
general
terms, it is possible to think of any form of
|
SPHC
relating to PHC in either of these two ways.
I
First, GOBI could be interpreted as an attempt to
speed
up the process of establishing PHC. Thus
:
GOBI
would be seen to be complementary to PHC,
'
providing some of its more important technical ‘con
tent’. GOBI’S success in saving lives would provide
satisfaction in communities and commitment to
wider change that would make it easier for them to
support the grassroots structures of PHC financially
and otherwise. GOBI would be seen, in this view, as
the 'leading edge’ of PHC [6, p. 6).
A second interpretation is that GOBI constitutes
the negation of the participatory and community
based ideals of PHC, not their complement or precur
sor. This view recognizes two opposing forms of
‘basic needs approach’ (BNA) [7]. The ‘strong’ BNA
encourages people to define their own needs, to
organize themselves to demand access to the means
to satisfy these needs, and to struggle to overcome
political and other obstacles to satisfying these
locally-defined needs. The ‘weak’ BNA imposes an
external, expert definition of need on the community.
964
Ben Wisner
Local organization is encouraged only insofar as it is
necessary to make 'delivery' of the good or service
possible. Conflict and struggle are neither encouraged
nor understandable within the universe of the ‘weak’
BNA. According to this second interpretation, SPHC
in general and GOBI in particular belong to the
’weak’ BNA. They are delivery approaches that
negate more participatory and conflictual approaches
to people getting what they think they and their
children need.
For instance, in theory groups of parents can
monitor the growth of their children, produce oral
rehydration mixtures (salt, sugar, water) in their own
homes, speak to one another about the importance of
breast feeding. In fact, the national-scale campaigns
launched so far in support of GOBI actually preempt
these local potentials. Television and other coordi
nated media blitzes extoll prepackaged oral re
hydration salts. In most cases these are prepackaged
in distant capital cities. Breast feeding is ‘sold’ via
radio and television with slogans coined outside the
affected communities, possibly by the same foreign
advertising agencies that had previously sold infant
formula and bottle feeding. Immunization, depen
dent still on a ‘cold chain’ and considerable logistical
preparation, continues to come from ‘the top down’
but now in massive and possibly unrepeatable cam
paigns. Little is done to build confidence in people's
ability to do positive things about health together,
where they live, rather attention is systematically
turned toward the ‘center’ from which wisdom about
the breast, magic salts and vaccine issue.
UMCEF BEFORE GOBI
order coupled with a new international development
strategy.
In its report on the world’s children for 1980-81,
UNICEF highlighted three lessons it claimed are to
be learned by _______
reassessing several decades of development work [12, p. $]:
1. Economic growth is- a necessary but not
sufficient condition for the elimination of poverty.
2. Policies aimed at directly meeting the needs of
the poor are a more promising way forward than
reliance on the trickle-down of growth.
3. The redistribution of resources and incomes
implied by such policies need not detract from, and
may even enhance, the prospects for economic
growth itself.
Suddenly, however, these lessons seem to have
been discarded.
CHILDREN LN DARK TIMES
UNICEF’s report for 1981-82 is entitled 'Children
in dark times’ and catalogs a ’‘slowing down of
progress" in child welfare despite agreements on
PHC [13]. Whereas infant mortality had been falling
steadily:
“for the past five years, it has barely flickered. Average live
expectancy, which increased by seven or eight months a year
’n
1960s and early 1970s, is now increasing by only two
or *three months a year. School enrollment rates, which
again rose by a regular four or five per cent a year up to the
mid-1970s, now seems to have reached a plateau" (13. p. 2],
"In short”, UNICEF summarizes, “the optimism
of the 1960s which gave ground to the realism of the
1970s has now receded even further to make room for
the doubt and pessimism which seems to be settling
into the 1980s.”
Africa is singled out as a prime example [13,
p. 12]: The tenth successive year of declining food
production per capita, food shortages, massive
refugee movements.
This was the year before GOBI emerged, the year
after UNICEF had reported hopefully that ‘lessons’
had been learned from the critique of growth
oriented development strategies, and that as a result
infant mortality could be brought down to below 50
per thousand in all countries by the year 2000. Thus
‘Dark times’ is a transitional statement and can be
read for early signs of three major lines of thought.
These include, first and most destructively, the reas
sertion of a belief dating from earlier decades that
poverty is ‘natural’. Second, the new line of thought
develops an ahistorical and idealistic notion of a
‘safety net* as the answer to the ‘natural' growth of
poverty, ordinary parents' helplessness in its face, and
the framework with in which GOBI will be seen to
function. Finally, technology emerges as the linch pin
of or substitute for a minimal safety net. Analysis of
these characteristics explains why GOBI and other
__
SPHC strategies
are not compatible with broader
social goals embodied in PCH and why, in practice,
implementation of the one blocks development of the
other.
In order to judge these opposing interpretations
of GOBI, it is helpful to review UNICEF writings
on PHC before GOBI came on the scene. UNICEF
was one of the first international agencies to shift
from sectoral health concerns to a comprehensive
approach which was called “planning for the needs
of children” [8,9]. Throughout the 1970s UNICEF
emphasized the importance of ‘participation’ [10]. In
fact, just before GOBI was unveiled, UNICEF was
still distinguishing between a ‘narrow definition’ of
PHC and a broader interpretation in very much the
same terms used
t
to distinguish the‘weak’ and ‘strong’
BNAs above. Thus PHC would recognize “certain
values and principles as requisites of good health
care” including the following [11, p. 37]:
1. Equity and justice. The basic right of every
individual to health implies the reduction of gaps
between those who have access and those who do not
to health and other resources necessary for maintain
ing health—such as income, food, employment, edu
cation ...
2. An overall development strategy that gives high
priority to social goals in addition to economic ones.
3. People imbued with a strong sense of self-reliance
and control over their own lives exercising re
sponsibility over their own health. The role of govern
ments and agencies is not to act in the people's behalf
to ‘deliver’ health, but rather to support their efforts The ‘naturalization' of poverty [14J
and take joint responsibility for health.
UNICEF invokes world economic crisis as a fact
4. The emergence of a new international economic of life, something that has 'happened' to poor nations
r;
GOBI versus PHO1
and to poor people. An ‘adverse external environ
ment’ is likely to raise the number of the absolutely
poor to one billion by 1990, we are told [13, p. 2], with
no suggestion that what is ‘external’ to some is the
comfortable ‘internal’ (domestic) economic environ
ment to others experiencing financial boom. Eco
nomic crisis is assumed to ‘strike’ from somewhere
‘out there’ such as ‘natural disasters' (e.g. drought,
flood, earthquake) are thought to 'occur'. The only
concession to the existence of a complex interaction
between society and nature seems to be the com
monly projected image of ‘too many poor people’
pressing nature too hard. The only hint that nations
or classes like landlords or workers might be con
scious agents in conflict are the common platitudes
that poor nations have ‘mismanaged’ industri
alization, debt, marketing, etc. and that workers and
peasants in Africa and elsewhere have ceased to
produce the way they used to.
Subsequently UNICEF added some ‘Fs* to GOBI,
including ‘family spacing’ and ‘female education’ in
a way that considerably strengthened the natural
ization of poverty [15, 16]. Population growth is seen
as a cause, not a symptom of poverty. This is a
‘natural’ cause. Addressing this ‘cause’ with female
education (the woman’s ‘ignorance’ being yet another
‘natural’ cause of poverty from within this point
of view), the more difficult social causes can be
bypassed.
PHC was crystallized as an approach at a time
when there was wide agreement that the causes of
poverty were nonnatural and that social justice was
a requisite for health. By naturalizing poverty once
again by its emphasis on external, uncontrollable
economic forces, population growth, and female
ignorance, UNICEF locates health action wholly
outside the realm of socio-economic rights and re
sponsibilities.
A safety net or *a foor under poverty'
In the ‘dark times’ described by UNICEF, parents
have been deprived of power to protect their children.
Rather than question why this is so and whether it is
a tolerable state of affairs, UNICEF observes that
in such situations ‘the community’ has to take up
the responsibility for children (13, p. 2—3]. And if
the local community is unable to meet the needs
of children, “then the responsibility extends to the
national and international community”. While this
reasoning sounds sensible and humane, taken to
gether with the ‘external’ and ‘natural’ interpretation
of poverty just discussed, what is implied is a danger
ous acceptance of increasing powerlessness of the
poor parent in the national scheme of things and of
the poor nation state in the global order.
In the 1970s, the emphasis had shifted to at least
the rhetorical acceptance of ‘empowerment’ of the
poor as the way forward. Parents, peasant fanners,
workers, women were encouraged to organize them
selves and to demand the power they needed to
achieve a decent standard of living. Various inter
national meetings such as ILO’s World Employment
Conference in 1976 and FAO’s World Conference on
Agrarian Reform and Rural Development in" 1979
had clearly asserted the right of poor people to
organize. At that point, the historical initiative was
965
on the side of the 'strong' BNA. Ten years later,
discussion of a minimal ‘safety net’ leaves little doubt
that the initiative has been lost to resurgent tech
nocracy and the ‘weakest’ possible interpretation of
‘basic needs’. It is simply accepted that the “local
community is unable to meet the needs of its chil
dren’’. UNICEF no longer seeks to aid the process of
empowerment of that local community but merely to
put "a floor under poverty” (17. pp. 39-51].
Technological substitutesfor even a minimal safety net
‘Dark times’ foreshadows GOBI and the other
technological packages that have been added by
discussing control of mortality from diarrhea. We
learn that earlier talk of ‘safety nets’ was not serious.
First UNICEF distances itself from the universality
of the historical form in which European, North
American and some Latin American workers won
social welfare concessions in the 1940s, “a safety net
woven from the strands of minimum wages, un
employment pay, sickness benefit, and family allow
ances” [18, p. 21]. We are told that under present
conditions it is unrealistic to hope for even "a more
elementary safety net of minimum food entitlements,
primary health care, elementary education, safe sani
tation, and clean water”. Instead, GOBI is the “even
more basic, more modest, and more immediate goal”
[18, p. 21].
Technology has become the ‘basic, modest, imme
diate goal’ for a long list of agencies in the 1980s.
Fuel-efficient charcoal and wood-burning stoves, im
proved mud construction techniques, agroforestry
and a hundred more ‘appropriate technologies’ have
become a substitute for social transformation. Means
have taken the place of ends. Are we really supposed
to believe that oral rehydration therapy is an accept
able substitute for the clean water which would
prevent diarrhea, to which parent and child have a
right?
BUILDING ON SOCIAL BREAKTHROUGHS’
OR BLOCKING THEM?
UNICEF’s 1982-83 report, ‘New hope in dark
times’, beings by asserting the necessity of ‘stream
lining’ UNICEF practice ‘against the headwind’ of
world recession [6, p. 2]. This refers not only to the
necessity of reorganizing UNICEF and rationalizing
its ‘basic services strategy1 in order to bring ‘‘more
benefits to children for every available dollar” (6,
p. 12]. The application of the lessons learned from
inefficient and failed projects was discussed in the
prior report and was presumably underway.
The year GOBI was announced seems to have been
one of ideological streamlining as well as UNICEF.
The ‘Children’s revolution’ is a minimal package in
the face of the failure of parents to achieve a revolu
tion in the power relations determining health and a
failure of poor nations to win a New International
Economic Order.
It is not at all that UNICEF ignores grassroots
organization. Quite the contrary, it terms “social
breakthroughs” the growth of “community organiz
ations, paraprofessional development workers, pri
mary schools and the primary health networks, the
peoples’ movements ...” (6, pp. 6—7]. Despite the
966
Bex Wlsx-er
rapid growth of such grassroots institution, parents introduce even a useful life-saving technology like
have lost the power to protect their children against oral rehydration therapy in a way that reinforces
the “headwinds of world recession”. So UNICEF market dependency, urban bias, and an urban-elite
proposes to use this newly achieved level of mass image of development through centralized packaging
organization differently: “These social breakthroughs of the salt/sugar mix.
are the missing link between the know-how of science
By 1985, only six UNICEF-sponsored national
and the needs of people" [6].
and rehydration therapy programs used the ‘cottage
A key question is how grassroots organizations are industry’ approach to decentralized packaging and
understood by an agency backing GOBI or any other distribution. Another 33 were urban-based [18, p. 3].
form of SPHC that formulates its limited package
of interventions outside of the local situation and
mobilizes resources to diffuse that package campaign Social-marketing
style at national scale. One clue is UNICEF’s fre
It is media-technology and the manipulative social
quent reference to the ‘success’ of Asian campaigns psychology developed while ‘selling’ the Green Revo
to introduce high yielding varieties of rice and lution in the 1960s that receive most attention from
wheat and family planning campaigns [19]. The UNICEF as social breakthroughs rather than the
model implied is of local organizations as conduits or self-organization of the poor. “. .. [I]n a world where
delivery points. The kind of ‘participation’ involved information technology has become the new wonder
has been called “instrumental” rather than “trans of our age,” writes UNICEF’s Executive Director
formative’’ [20], People’s participation is invoked [19, p. 3], “shamefully little is known about how to
as acceptance of the package, as recipients of the communicate information whose principal value is
‘message’ but not as transformers of their own situ to the poor.” Such a statement makes a series of
ation.
assumptions that would require justification but do
How can the grassroots be encouraged to trans not receive it in UNICEF texts.
form the conditions of poverty when these national
First, it is assumed that the most useful thing about
campaigns depend entirely on the goodwill and infra which to communicate is technical information,
structure controlled by a national elite whose inter ‘messages’ distilling the useful, simple technologies of
ests are al stake in preserving the status quo? In both which people have been ignorant. Others, however,
symbolic and practical ways the power of national still seem to believe that it is most useful to commu
structures of dominance are reinforced in these nicate about relationships such as those governing
campaigns. Thus when airforce helicopter gunships access to land and income for promoting health
that have been known to terrorize peasants appear (26-28).
ferrying vaccines, a message is communicated about
Second, there is the assumption that commu
power. In practical ways, the GOBI approach rein nication to ignorant people from people with ‘know
forces centralized urban hierarchies that have been how’ is what is required. This overlooks the cardinal
shown to block rural development.
importance of groups of people sharing knowledge
In Honduras, for instance, UNICEF decided to and discovering the usefulness of knowledge that
‘package’ its oral rehydration campaign in sophisti had been denigrated by the colonial encounter
cated ways and to advertise them with television [29-31].
because “mothers were very strongly predisposed
Third, it is assumed that ‘information technology’
towards treatments with sophisticated urban image” is the missing key to communication. However, it
[18, p. 54]. Thus foil-wrapped sachets of oral rehy- has become a commonplace of pedagogy that the
dration salts rather than the use of home-made salt best communication takes place between two people
and sugar solution was adopted for the campaign. of similar backgrounds, status, etc. in face-to-face
But is this consistent with long-term alternatives to encounters [32]. One of the lessons of the Green
an urban-elite image of development? Such urban Revolution, but apparently not one recognized by
cultural bias has been argued to be part of the the xproponents of GOBI, is that useful information
problem, not part of the solution [21]. It is partly spreads with extraordinary speed by word of mouth.
responsible for disastrous shifts in diet and child-care
UNICEF's chosen information technology is re
style such as the shift from locally-produced staple ferred to as “social marketing” [19, 33). Social margrains to imported wheat for bread (22),
. . greatly. keting focusses on products, not on processes. The
increased cigarette consumption [23], and the popu- product can be immunization, use of oral rehydration
larity of bottle feeding [24]—all recognized health salts, family planning. The ‘product* to be sold in
problems.
the social market place via mass media may be a
In much of the third world dependency on internal complex package of products. Nonetheless, the prodmarkets has grown dramatically in the last
20 years.
--------J----- uct exists quite independently of the day to day
Now, at a time when the World Bank and the IMF process ofproblem solving in households and commu
are insisting that governments remove subsidies on nities. What are the limitations of such an approach?
consumption and cut back on public expenditure,
First, communication is ‘one way’. The chance
the poor are highly vulnerable because of their de that the product or package of products is modified
pendency on the market. UNICEF itself has docu though ‘feedback’ through the communication pro
mented the fact that these ‘economic adjustments' fall cess is very small. Where there is such feedback, it
heaviest on women and children [25], and food riots must come through precisely the decentralized, par
in Mexico, Brazil, Sudan, Zambia and Ghana suggest ticipatory programs that are in danger of being cut
that the poor have done supporting research. In back by ministries infatuated with the ‘quick fix’
this light, it is clearly damaging in the long run to social marketing seems to offer.
GOBI versus PHO?
4
♦
Second, the ability to tap local knowledge and skill
is virtually zero. At a time when more and more
authors are discussing the reservoirs of ‘ethnoscience’
still untapped in villages and squatter settlements all
over the world, it is ironic that a method of ‘commu
nicating’ with the masses that cuts the state or
development agency off from such knowledge should
be named a ‘new imperative’ by one UNICEF consul
tant [33].
Third, and even more troubling, the social market
ing message is ‘targeted’ at individuals. ‘Mothers' are
sold oral rehydration salts or IUDs. ‘Farmers’ are
sold new varieties of seed. At a time when there are
many other social and economic forces tending to
fragment extended families, neighborhoods, and ‘self
help groups’, it is alarming that the force of electronic
media should also fragment. A ‘process’ orientation
works against fragmentation, situating possible ‘solu
tions’ to ‘problems’ in the growing understanding of
wider social relations by homogeneous groups. For
instance, small ‘homogeneous self help groups’ of
divorcees and widows in Lesotho grow to understand
their socio-economic marginality and find viable in
come generating activities in this context [34]. Health
improvements for children in these woman-headed
households come as secondary effects of increased
income. Broadly speaking, PHC as defined in Alma
Ata can be interpreted in this way. Ministries that cut
back expenditures on such participatory, empowering
work because social marketing appears ‘faster’ or
more ‘cost effective’ cut the tap root of the newly
sprouting ‘community’ at the increasingly fragmented
and class-polarized grassroots.
CONCLUSION
Dangers of selective primary health care
Elsewhere SPHC has been criticized for claiming
too much for a handful of technologies (35, 36], for
evaluating the costs and benefits of health and disease
in too narrow an economic framework (37,38], and
for thinly disguising and justifying reductions in
public finance for health care in countries feeling the
pressure for IMF mandated ‘adjustments* [7, Chap.
4; 39].
This brief paper has called attention to another
criticism. Despite claims that UNICEF’s GOBI can
be seen as the ‘leading edge’ of PCH, it has been
argued that implementation of GOBI and other
SPHC packages acts, in fact, to undermine the pro
cess of local definition of needs, local organization to
share knowledge and to struggle for health rights.
GOBI does this in several ways.
1. Indigenous, local organizations are distorted and
limited in their potential for channeling protest and
health demands by their conversion to mere conduits
for the delivery of the GOBI package.
2. The effectiveness of local organization is further
undermined by the individualizing orientation of
GOBI elements and their implied model of disease
causation focusing not on social causes but on-igno
rance and faults in individuals.
3. Both these effects are compounded by the ten
dency for GOBI implementation to reinforce the
status symbolically and importance practically of the
i
'A
967
central state, the urban hierarchy and the structures
of dominance, often including national police and
military authorities that are drafted in for logistical
help during national immunization campaigns.
4. Reliance on a limited concept of ‘social market
ing’ and on electronic media for campaigns further
compounds the previously mentioned effects.
5. Finally, GOBI gives the state and international
agencies an excuse for accepting the necessity of cut
backs in social expenditure, and accepting the way in
which the lack of justice in the international eco
nomic system is causing parents to lose control over
the conditions that determine the health of their
children. The excuse is that this is all the product of
an ‘adverse external environment’, and that GOBI
amounts to the best available realistic measure under
such circumstances.
6. The ideology of acceptance and resignation in
the face of the ‘adverse external environment’ can
only serve to discourage parents and grassroots
workers who would otherwise demand more and
organize politically to take more.
Is GOBI useful at all?
There is no doubt that UNICEF’s emphasis on
immunization and oral rehydration therapy have
saved many children’s lives over the last few years.
Were those children subsequently killed by another
disease of poverty not targetted by GOBTs selective
approach? If they are still alive, what future do they
face? If GOBI'S implementation actually undermines
the radical grassroots organizing that alone can direct
demands and struggles for the power to control
health, would it be better not to have GOBI?
The alternative to answering ‘yes’ is to concep
tualize a ‘social’ GOBI that would be the technical
content of a locally determined initial process, truly
the ‘leading edge’ of PCH. However, careful note
should be taken of the word ‘initial*. Appropriate
phasing is essential to the long-term construction of
popular support for the more comprehensive, more
empowering form of PHC launched by the Alma Ata
conference. If GOBI-like starting points were chosen
flexibly with groups of parents to whom the results
of regionally-specific epidemiological surveys were
presented for discussion, one would be building long
term foundations for PHC while also moving dra
matically against the five or six conditions that
account for 80% of child death in the third world
[40].
Care would also have to be taken that whatever the
form of the initial GOBI-like interventions, they
reinforce the social character of the struggle for child
survival. Rather than reinforcing individualistic be
havior and dependency on the central state, GOBIlike interventions could be implemented by groups of
parents and in such a way that the status and role
of local community health workers and traditional
birth attendants are reinforced.
There should be no illusion about the acceptability
of such an alternative to agencies as tightly united in
defence of established economic privilege as are most
states and most of the international development
apparatus. In the 1980s the conditions of profitability
leave less room for officially sanctioned propular
agitation for the right to food and to health. As the
968
Ben Wisner
screw of‘economic adjustment’ is turned in dozens of
2. Walsh J. A. and Warren K. S. Selective primary
health care: an interim strategy for disease control in
third world countries, it is better from the point of
developing countries. Soc. Sci. Med. 14C, 145-169,
view of the international agencies to be able to say
1980.
"we tried PCH, complete with its encouragement of
3.
Boland
P. and Young M. The strategy, cost and
grassroots struggle for rights, and it was too slow, too
progress of primary health care. Bull. Pan Am. Org. 16,
costly, and inefficient’’. The truth may be that how
233-241, 1982.
ever efficient that earlier PHC approach may have
4. Evans J., Hall K. and Warford J. Health care in the
been, any major development approach that empha
developing world, problems of scarcitv and choice Hew
sizes local articulation of political demands such as
Engl. J. Med. 305, 1117-1127. 1981.*
the demand for health will be officially rejected in the
5. WHO. Declaration of Alma Ata (Report on the Inter
climate of the 1980s.
national Conference on Primary Health Care, Alma
Ata. U.S.S.R. 6-12 September, 1978). WHO. Geneva.
One should also guard against idealizing compre
1978.
hensive PHC. Much of the criticism directed against
6. Grant J. P. The State of the World's Children 1982-83.
it is valid. What this paper questions is whether the
UNICEF, New York, 1983. One might want to com
’cure’ (e.g. selective PHC) is worse than the ‘prob
pare Grant's use of the term "leading edge” with
lem’. Comprehensive PHC has, in fact, been slow in
Bennett's more elaborate program for making GOBItaking shape after Alma Ata, and there have been
like interventions the "spearhead" of an "accelerated
numerous distortions and misuses of institutions
primary health care”; see Bennett F. J. Health revolu
dedicated in name to popular control of health
tion in Africa? Soc. Sci. Med. 22, 737-740, 1986.
[39,41]. The ideal of community participation has
7. Wisner B. Power and Need. A Reevaluation of the Basic
Need Approach in African Development. Earthscan
seldom been achieved [7, Chap. 2; 42 ,43). In fact.
Publications. London, 1988. Forthcoming.
Barker and Turshen find that “many proponents
8. Stein H. (Ed.) Planning for the Needs of Children in
of comprehensive primary health care . . . routinely
Developing Countries (Report of a Round-Table Con
reduce PHC itself to a depoliticized and techno
ference. 1-7 April. 1964. Bellagio. Italy). UNICEF.
cratic strategy” in any of the following ways [39,
New York. 1965.
p. 84].
9. Singer H. Children in the Strategy of Development.
1. ThinkfingJ PHC is equivalent to provision of
Executive Briefing Paper 6. UN Cen. Econ. Soc. Inf
basic health service, being really the sum of a list of
and UNICEF, New York, 1972.
technical measures which might add up to a second10. Mandi P.-E. Realiser des modes de vie fondes sur les
rate service provision in areas inhabited by the poor,
ressources locales et la participation populaire. Carnets
I'EnfartceiAssignmt Child. 39, 5-7, 1977.
but which leave ignored, and therefore intact, the
11. Hollnsteiner M. R. The participatory imperative in
curative services available to a privileged few;
primary health care. Assignmt Child. 59^60, 35-56,
2. Ignor[ing] the consideration that good health is
1982.
probably more contingent on overall development
12. Grant J. P. The State of the World's Children 1980-81.
than upon the health sector, and choos(ing) to ignore
UNICEF, New York, 1981.
PHC’s emphasis on community participation, with its 13. Grant J. P. The Slate of the World's Children 1981-82.
underlying threat of mass struggle;
UNICEF. New York, 1982.
3. Look[ing] to traditional medicine or inter 14. For treatment of the way in which the World Bank also
‘naturalizes’ poverty: Allain A. A propos du discours
mediate technologies as ways of letting the state off
de McNamara. In fl Faut Manger Four Vivre. Controthe hook, by providing a shabby alternative to the
verses sur les besoins fondamentaux et le developpcequitable redistribution of health care resources;
ment. IUED and Presses Uni versitair es de France.
4. Enthusiastically propound[ing] community par
Geneva and Paris, 1980.
ticipation and self-help alone as the path to PHC,
15. Grant J. P. A child survival and development revolu
thereby necessarily failing to address the question of
tion. Assignmt Child. 6\J62y 21-31, 1983.
the role of the state, and by implication failing to 16. Grant J.-P. The State of the World's Children 1984.
recognize the issue of equity.
UNICEF, New York, 1983.
Nonetheless, the goal of ‘health for all’ is unlikely
17. UNICEF. Within Human Reach. A Future for Africa's
without the kind grassroots organization envisioned
Children. UNICEF, New York, 1985.
in earlier notions of comprehensive PHC, whatever 18. Grant J. P. The State of the World's Children 1985.
UNICEF, New York. 1985.
fate these visions may have had in practice. It is hard
19. Grant J. P. Marketing child survival. Assignmt Child.
to imagine growing nearer the goal of ‘health for all’
65/68t 3-9, 1984.
without such relatively self-reliant local organizations
20. Kruks S. R. Notes on the concept of 'participation'’
whose demands become more militant even as the
in the Kenya Fuelwood Development Project (with
privileged in all countries refuse to accede to changes
special emphasis on rural women). Discussion Paper.
in the distribution of resources and insist on more of
Beijer Institute, Royal Swedish Academy of Sciences,
the same.
Stockholm, 1783.
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in Urban Bias in World Development. Temple Smith,
or to divert the growth of local organizations capable
London. 1977.
of articulating these demands for change at an histor
ical turning point that can only lead to change or to 22. Dinham B. and Hines C. Agribusiness in Africa. Earth
Resources, London, 1982.
disaster.
23. Muller M. A Burning Issue. Tobacco in the Third World.
War on Want, London. 1977.
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