Primary Health Care

Medicine in Its Place

John J Macdonald

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134159697
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

Primary health care (PHC) began as a solution to problems in the developing world and is coming to be seen as a profound challenge to medical attitudes the world over. The book points to three issues at the root of PHC - universal availability of essential health care to individuals, families and population groups according to need, the involvement of communities in planning, delivering and evaluating such care and an organized active role for other sectors in health activities. It is pointed out although these principles may seem uncontroversial their introduction in developing countries has been far from smooth. When it comes to the north the principles of equity, participation and intersectoral collaboration have been resisted even more strongly by both planners and the medical establishment. By examining the lessons learnt from the developing countries, the author demonstrates the necessity to de-professionalize health. He writes at a time when resistance to PHC in the Third World is increasingly being based on dubious northern models for health care. This book demonstrates the way in which a strategy for survival in poor regions becomes a model for adequate and sustainable living everywhere.

Chapter One

The Why of Primary Health Care

Primary Health Care (PHC) is an approach to the planning of health services. In the last twenty years there has been a lively debate in Third World countries about the need for new approaches to health care, the validity of the PHC alternative, as well as about the scope of PHC activities and the consequences of the application of the PHC approach. PHC terminology appears in most national health policy documents. In Western countries, on the other hand, there is almost total ignorance about Primary Health Care on the part of health planners and health workers. This ignorance extends to both the meaning of the concept and examples of its practice. Many people have chosen to believe that Primary Health Care is to be equated with primary medical care. This is not the case and this book will argue that such ignorance cannot be allowed.

Western health services have well-established, not to say entrenched ways of understanding and practising health care. It has to be said, however, that even in these societies the policies and practice of health services are under question. The medical paradigm, our way of conceptualising health and health services, is changing, however slowly. It is commonplace to say that the world is shrinking, that what happens in one corner of the world can have an influence in another, distant part. In the world of health care, the Western mode of practising health care has exerted an enormous influence on health services in the rest of the world; this continues to be the situation. But the Third World is not only the receiver of ideas, it generates them as well. PHC is an example of this: the questions put to medical practice by the PHC approach in Third World countries and the issues it raises are relevant questions and important issues also for Western health services. Attempts to implement the PHC approach in the countries of Asia, Latin America and Africa have given rise to an important questioning of existing health services; the debate could be most useful in Western societies as well.

The words ‘Primary Health Care’ (PHC) are sometimes taken to mean health care at the periphery, or some programmes of extension or adjustment at the margins of the health services where these come into contact with communities. Primary Health Care then becomes equated with primary medical care or simple curative services with the addition, perhaps, of a prevention programme represented by an immunisation service or a water and sanitation programme. If it is only this, or becomes reduced to this, PHC is not particularly problematic or challenging. However, as presented by the international Conference of Alma Ata in 1978 and developed in a variety of contexts since, PHC is much more than an addition to existing health services, much more than primary medical care. It is a reorientation of all health services towards the health needs of communities, both local and national. This reorientation can have dramatic consequences on health care resources allocation, on priorities in planning and on the attitudes of health personnel. The vision of PHC presented by Alma Ata challenges many existing ways of thinking and practice in health services throughout the world.

The PHC approach rose out of the perceived inadequacies of conventional health care to meet the needs of people in Third World countries. It is an attempt to chart the way towards a more appropriate health care system. However, no one should claim that the PHC approach presents us with a magic formula to solve the numerous problems with the health services and of ill-health in these countries; what it does do is to point the way out of existing difficulties without pretending to have all the answers. What we do have, under the banner of PHC, is an opportunity to confront – and to begin to remedy – the imbalance of the past and to lay the foundations of a better health-care system for the future. What is more, it can now be said that the emergence on to the international scene of the arguments provided by PHC for a more appropriate needs-oriented health care system in developing countries can contribute to the movement towards a more appropriate health care system worldwide. The debate concerning PHC as promoted at Alma Ata in 1978 and the efforts to put its principles into practice since that time have put an alternative approach on the international health service agenda. The ideas and principles of PHC will not easily disappear; the issues that it raises demand to be addressed in all societies. The broad outlines of the PHC approach will be presented in Chapter Three. Before that, in order to grasp the full impact of the approach to health care set out by Alma Ata, it is necessary to have some idea of the soil out of which PHC ideas have grown.

In this chapter the question addressed will be: why has Primary Health Care come about? If PHC can be seen as an answer, what are the questions? What were the problems to which the PHC approach has been presented as a ‘solution’? What was so wrong with the way things were in the health services in many countries that many people were led to put the case for and begin to implement, in however piecemeal a fashion, a radically alternative approach?

Health care systems based on the Western model have been so dominant, so widespread and so powerful, that they have often been treated as being above questioning. The medical culture which has arisen in the twentieth century has brought about a situation of acceptance of the status quo in medical matters. This is manifested, for example, in the way in which patients do not easily question the decisions of doctors, even in matters to do with their own health. Nurses, perhaps, might be questioned, if the patient feels confident or the nurse is approachable; but in general, medicine is enshrouded in a powerful mystique of science and status which inhibits accountability to patients or indeed anyone else in any direct manner. And although ‘public’ health doctors have a brief to work in/for/with communities, it is rare to find a situation where the same public is able to question the policies and practice of public health personnel.

Not only are individual health personnel by and large beyond questioning, the modern health care system is an institution which is almost as beyond critical examination as the Church was in the Middle Ages. It is even very difficult for politicians or political parties seeking to hold on to or acquire power to engage in any critique of the medical services. This is as true in Europe as it is in Asia, Africa or Latin America. In industrialised and non-industrialised countries alike, political parties of all persuasions can be seen treating the medical profession with extreme caution, not on account of an anxiety to hinder the great work of healing which the profession is engaged in, but out of fear of its strong political lobby. In 1990, General Ershad of Bangladesh, the then head of state, proposed a new national health policy which was based on the premise that all was not well with existing health provision and seemed to hold out hope of an improved health service offering a better deal for the majority of the population: ‘The basic main thrusts of the policy are democracy and participation of the people … raising public sector outlay in health and social welfare sectors to 10 per cent in phases, a commendable measure indeed in a region where public health sector allocation is often less than 1 per cent (Link, 1990: 2).

The medical profession objected to these new policy proposals and indeed seemed to have played a role in the downfall of the government proposing such changes. A major factor in the objections of the professionals appeared to have been the proposed restrictions on private practice (idem). In many countries there is still a powerful belief in the altruism of the medical profession which often removes it from the sphere of critical accountability.

It can be very difficult for many people to imagine that there are ways of thinking and doing health work other than those with which we have become familiar. It is also difficult for some to imagine that the present system is seriously flawed. There is a popular image of medicine as not only a notable and high-minded profession but one which is tackling the problems of ill-health in as scientific and concerned a manner as possible. Applied to the Third World, these beliefs contribute to the image of medicine in developing countries as consisting of the efforts of a few dedicated medical specialists to overcome the enormous tides of ‘tropical’ diseases and the ravages of ill-health which attack the defenceless (large) populations of these countries. Some health charities do not always do much to dispel this image when they propagate images of medical ‘rescue’ teams flying in to the aid of particular Third World countries beset with disease or disaster. Of course, rescue is sometimes necessary but both in such extreme cases and in the more habitual situations of ill-health the assumption is that the ‘answer’ to problems of ill-health lies in the medico-technical solution provided by expensively trained health personnel. In many situations this is simply not the case. The UNDP says that in the last decade of the twentieth century, ‘More than a quarter of the world's people do not get enough food, and nearly one billion go hungry. 1.3 billion people still lack access to safe water. 2.3 billion lack access to sanitation’ (UNDP, 1992: 14).

It is difficult to deny that the main answers to the problems of ill-health of millions of people lie outside the health sector and in other areas such as agriculture, education and sanitation. Many of the problems of ill-health facing Third World countries are not susceptible to medical interventions in the first place and what health care is called for can and should be delivered to those who need it by appropriately trained personnel as near and responsive to the community and its health needs as possible.

There is still much misplaced hope that medical systems can solve the world's health problems. The inherent problems of the way we conceptualise and therefore organise health services, what we can call the medical model, will be considered in the next chapter. It is enough to record here that it is the failure of this model of health care to meet the needs of the majority of people in so many countries which has given rise to the PHC movement.

The failure of the conventional system of health care

It is especially in so-called developing countries that the failures of the Western model of health care have become increasingly apparent over the last thirty or forty years. The process of ‘modernisation’ and development in these countries, including development of health services, has involved a long and destructive cultural invasion (Freire, 1970). When one group of people, or indeed a whole culture, experiences a systematic undervaluing of its beliefs, practices and view of the world and begins to see itself through the eyes of another oppressive culture, it can be said to have been culturally invaded. The process of colonisation of the Third World, to justify its very existence, was involved in such a systematic devaluing of all that was ‘native’; in the area of beliefs Christianity was used to label much of what was local as ‘superstitious’, somehow irrational and inferior. In many areas of social organisation this contributed to the uncritical acceptance that ‘West is best’, with the undermining of the colonised people's sense of self-respect and dignity and a loss of a sense of pride in their own value system. In health service development what happened was often the total outward rejection of all traditional therapies and the proliferation of provisions based on a Western medical technical culture with no real attempt to match these to the major health needs of these countries. The colonisers knew what was ‘good’ for the colonised and this included what was good for their health. A considerable part of the message of what was good in health care came from denying the colonised to access of white services. A pattern of expectation was thus created, with distortions which remain to this day. The most obvious manifestation of the mismatch which can result from this medical colonialism is the skewed health budgeting which it inevitably brought. In countries where many of the diseases of the general population in terms of morbidity and mortality are those which are either preventable or easily treatable at the community level – and this is the case for most Third World countries – a large proportion of what little money there is for health often goes to buy Western medical technology for tertiary or secondary care.

That the basic health problems of many countries have not been addressed by considerable investment in institutions of tertiary care, and the concomitant neglect of community-level initiatives of cure and prevention, have been two of the major factors which have contributed to the emergence of the alternative approach to health care which we call Primary Health Care (PHC). Quite simply, despite considerable efforts to implement the Western health care system in Africa, Asia and Latin America, indicators of health status in these countries have continued to paint a very poor picture: UNICEF's annual statistics of global indices such as infant and maternal mortality continue to show high levels in many countries (UNICEF, 1991). It cannot be suggested that the form of health services adopted by Third World countries has been the major cause of ill-health in countries of the Third World, but the mismatch between service and need has been in evidence for several decades and contributes to the problem. In the 1960s and 1970s there was a growing frustration among many health workers with the seeming inability of conventional health care systems to impact significantly on the health status of large populations in these countries. PHC emerged as a strategy when these failures were becoming increasingly obvious. Frustrations with existing approaches led to criticism and, in some contexts, to changes. Innovative practices were tried with apparent success. The dimensions of some of these innovative practices were quite small (Newell, 1975) but the public health improvements in China which inspired some of the early PHC thinking were on a massive scale and involved, for example, the eradication of health-threatening pests, not in the first instance by medicine, but through social organisation and the use of local-level health workers, the famous barefoot doctors (Horn, 1971, Sidel and Sidel, 1982). For example, the mortality rate of infectious diseases in China declined from 116.30 per 100,000 in 1973–4 to 45.13 per 100,000 in 1982 (Huang, 1988:886). There is perhaps less enthusiasm now, even within the country itself, for the approach taken by China to promote health and eradicate disease and we can see there a definite move towards closer alignment with certain aspects of Western medicine. Ironically, the collective local commune organisations which were in some ways central to the grassroots organisation of primary health care in China were dismantled in 1978, the very year of the Conference of Alma Ata at which the Chinese approach to PHC was applauded (Huang, 1988). Recent commentators suggest, however, that the Chinese example of health care still offers a powerful alternative to the Western model.

Seen in this light, the PHC approach is an important part of the search for more appropriate health care for millions of people. The Indian Journal, Health For The Millions (VIHAI) which promotes PHC in that continent proclaims in its title, by implication, one of the major failings of the pre-PHC approach: health care in the old system was NOT for the millions but for the few. But the PHC approach starts from the position that not only are conventional forms of health care insufficient to meet people's health needs, they are also often inappropriate. Many Third World countries have tried with ever-diminishing success to expand the type of health care system they inherited at the time of independence to meet the needs of their populations. The problem is that their blueprint, the inherited model, was fundamentally flawed.

The inherited model: fatal inappropriateness

After the second world war many countries in Africa and Asia sought to rid themselves of colonial subjugation. With political independence, many countries found themselves committed to policies of social improvement. Both in education and in health (and indeed in other crucial areas like agriculture) considerable efforts were then made to expand services which had previously been largely restricted to the white minority and ‘essential’ workers in the colonial system. Inevitably, the new decision-makers and planners, aided by advisers from the West, expanded their social service systems along the lines of the model they had inherited. In Southern and Central American countries a similar process of modernisation was taking place with the dominant influence and role model being, this time, the United States and its value system.

Unfortunately, this model was exported to so-called developing countries at a time of colonial exploitation of which it was also an instrument (Doyal, 1979). Inevitably, the health systems reflected the values and beliefs of the colonisers. There were, of course, beneficial medical technologies in this inheritance. One can think, for example, of the knowledge of sterile operating techniques and, latterly, of antibiotics, to name only two major contributions. But there was much that was negative and destructive. We have already called attention to the attitude of misplaced, arrogant superiority towards most of what was local, however valuable. Indigenous healing systems were considered to be of no worth. In the spirit of cultural invasion, whereby the colonial power h...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgements
• Introduction
• 1. The Why of Primary Health Care
• 2. The Medical Model as Obstacle
• 3. The What of Primary Health Care: Alma Ata
• 4. The Selective Option: The Medicalisation of Primary Health Care
• 5. The First Pillar: Participation
• 6. The Second Pillar: Intersectoral Collaboration
• 7. The Third Pillar: Equity
• 8. Education for Health: Lifestyle Education or Life-context Education?
• 9. The Health Professional and the Macroscope
• References
• Index