In the first decades of the 21st century, despite major medical advances, women in the least developed parts of the world are dying in childbirth far more often than women in wealthier nations, and their children are far more likely to die before reaching age 5. The major reason for this is that healthcare in these areas lacks its foundation: basic primary maternal and child healthcare (MCH). Two early examples of primary MCH care showed that the high death rates for mothers and children could be reduced substantially at low cost: David Morley’s Under-Fives Clinic in Western Nigeria, which began in the 1960s, and the Aroles’ Jamkhed Project in Maharashtra State in India, which began in the early 1970s. The lessons learned from these two early projects were also highlighted as principles at the Alma Ata International Primary Care Conference in 1978. They included: 1. Integration of basic curative care with the various aspects of promotive/preventive care, the former building the trust required for full acceptance of the less-understood aspects of the latter, such as immunizations, family planning, and exclusive breastfeeding during the first six months of life. 2. Heavy reliance on well-supervised lower-level health workers (including community health workers) to reach entire target populations. 3. Reliable delivery of a limited formulary of common, low-cost medical supplies and medications. 4. Partnerships among government ministries of health, education, and finance with communities and with local, national and international non-governmental organizations, and, 5. Gradual buildup as the health system and the communities enhance their capacity to support the work, so that success builds on success. It is past time for building primary MCH and eventually total population-based care systems everywhere. The first and biggest benefit will be in least developed societies, where the present rate of preventable mother and child deaths is unconscionable.
David Sanders and Louis Reynolds
The global project to achieve Health for All through Primary Health Care (PHC) is a profoundly political one. In seeking to address both universal access to health care and the social determinants of health (SDH) it challenges power blocs which have material vested interests in technical approaches to health and development. The forces that have shaped PHC include Community Oriented Primary Care and the Health Centre Movement, the “basic health services approach,” and nongovernmental and national initiatives that exemplified comprehensive and participatory approaches to health development. The 1978 Alma-Ata Declaration codified these experiences and advocated Health for All by the year 2000 through PHC. It emphasized equitable and appropriate community and primary-level health care as well as intersectoral actions and community participation to address the social and environmental determinants of health. This would need the support of a new international economic order. The concept of “Selective Primary Health Care” emerged soon after Alma-Ata, privileging a limited set of technical interventions directed at selected groups, notably young children. This was soon operationalized as UNICEF’s Child Survival Revolution. The visionary and comprehensive policy of PHC was further eroded by the 1970s debt crisis and subsequent economic policies including structural adjustment and accelerated neoliberal globalization that deregulated markets and financial flows and reduced state expenditure on public services. This translated, in many countries, as “health sector reform” with a dominant focus on cost efficiency to the detriment of broad developmental approaches to health. More recently this selective approach has been aggravated by the financing of global health through public-private partnerships that fund specific interventions for selected diseases. They have also spawned many “service delivery” NGOs whose activities have often reinforced a biomedical emphasis, supported by large philanthropic funding such as that of the Gates Foundation. Educational institutions have largely failed to transform their curricula to incorporate the philosophy and application of PHC to inform the practice of students and graduates, perpetuating weakness in its implementation. Revitalizing PHC requires at least three key steps: improved equity in access to services, a strong focus on intersectoral action (ISA) to address SDH and prioritization of community-based approaches. The third sustainable development goal (SDGs) focuses on health, with universal health coverage (UHC) at its center. While UHC has the potential to enhance equitable access to comprehensive health care with financial protection, realizing this will require public financing based on social solidarity. Groups with vested interests such as private insurance schemes and corporate service providers have already organized against this approach in some countries. The SDGs also provide an opportunity to enhance ISA, since they include social and environmental goals that could also support the scaling up of Community Health Worker programs and enhanced community participation. However, SDG-8, which proposes high economic growth based substantially on an extractivist model, contradicts the goals for environmental sustainability. Human-induced environmental degradation, climate change, and global warming have emerged as a major threat to health. As presciently observed at Alma-Ata, the success of PHC, and Health for All requires the establishment of a new, ecologically sustainable, economic order.