Soins de santé primaires complets

Return to Health Systems Introduction

PHC was defined at Alma-Ata as a sector of service delivery, a policy model (a set of principles for service development) and a strategy of social change, in particular, social mobilisation to address the political and economic barriers to health development. Alma-Ata was closely linked to the vision of a New International Economic Order promoted by the Non-Aligned Movement in the 1960s and '70s.

PHC, as articulated at Alma-Ata, was a response to urban focused health service development and to narrow vertical programs of prevention and care. Scarce was the ink dry at Alma-Ata than the proponents of vertical programs came back with the idea of 'selective' PHC. However the debate between comprehensive and selective was swamped by the debt crisis from the early 1980s and the damage to health systems imposed by the IMF and WB through structural adjustment. Since 1995 further threats to health and health services have emerged in the rules of the WTO.

Criticisms of selective PHC are well known: they include: failure to focus on health system infrastructure; ineffective prevention (especially where conditions like AIDS, TB and malaria are so embedded in social, political and economic circumstances); lack of sustainability; and failure to recognise local priorities. We will discuss these criticisms.

However, we must also take a critical eye to the comprehensive PHC tradition; are there new directions and new emphases that need to be considered here also?

The WHO World Health Report for 2008 focuses on Primary Health Care. Well worth reading: in English, or Introduction and overview in Spanish.

At the heart of the PHC paradigm is a particular view of the relationships between health and economic development. It is a view of health care and the conditions for health development which challenges the neoliberal orthodoxy of the World Bank and its allies in the health sector.

Readings

• Backman, G., P. Hunt, et al. (2008). "Health systems and the right to health: an assessment of 194 countries." The Lancet 372(9655): 2047-2085. OpenAccess at The Lancet
• Questioning the solution (English)
• Cuestionando la Solución (en español)
• Politics of Health Knowledge Network
• PAHO(2007) Renewal of Primary Health Care (Spanish). English Summary
• The Lancet(2008). Series on PHC "A renaissance in primary health care." Lancet 372(9642). The Lancet Open Access

Presentations

Health System Policies (David Legge, Savar, Nov 2007)
Introduction to the DALY (David Legge, Savar, Nov 2007)

Discussion questions

• Is PHC overburdened as a term; being asked to describe a sector of service delivery, a set of principles and a strategy for health development?
• How should we interpret Alma-Ata in the era of neoliberalism?
• Individual instances of brilliant PHC are easy to find but it is often hard to replicate (or upscale) such leading forms of practice; why might this be?
• How should PHC advocates engage with policy discussions about health care financing?

Assignment topics

Discuss the place of popular mobilisation in PHC and how it can be strengthened in your country or locality or organisation.

Discuss the elements of a health care reform package that would support the practice of comprehensive primary health care.

What are the meanings of 'health systems strengthening'? What are the political and the policy implications of this slogan?