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The goal of any health care system is to provide universal access to appropriate, efficient, effective and quality health services, in order to improve and promote people’s health. In most developing countries, the 1970s saw grave inequalities in the provision of health services and a worsening burden of disease with rising costs. As a result, in the mid-70s, international health organisations began exploring different approaches to improve health. During this period, China had made significant achievements in its health programmes which, compared to developing country disease-focussed programmes, were community based. This bottom-up approach, which focussed on prevention and management of health problems in their social setting, turned out to be a better option to the typical top-down, technological approach and rekindled hope about the possibility of addressing inequality to improve universal health.(2) Thus, in 1978, ‘health for all’ was introduced and endorsed at an international conference on Primary Health Care (PHC) in Alma Ata, Kazakhstan. To achieve the goal of health for all, global health organisations and national Governments promised to work together toward providing people with basic health needs through a comprehensive approach called primary health care (PHC).(3)
Since the Alma Ata declaration, some countries (such as Brazil and Cuba) have successfully implemented the PHC approach to deliver health services, whilst others (such as Zambia and South Africa) continue to battle with challenges that impede progress in this regard. This paper highlights key aspects of comprehensive PHC implementation and discusses factors that have contributed to its successful implementation or that continue to hinder its progress in various countries.
Definition of primary health care
As defined by the Conference in the Declaration of Alma Ata:
“PHC is essential care based on practical, scientifically sound and socially acceptable methods and technology, made universally accessible to individuals and families in the community through their full participation, and at a cost that 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 the community 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 service.”(4)
PHC, as visualised at Alma Ata, clearly encompasses a comprehensive approach the focus of which is on responding more equitably, appropriately and effectively to basic health needs, as well as emphasising finding ways to solve the underlying economic, political and social determinants of poor health.(5) To achieve this, emphasis was placed on universal access and coverage based on health need, promotion of health, prevention of diseases, enhanced inter-sectoral collaboration and community participation.(6)
Key aspects of comprehensive PHC implementation
The Declaration of Alma Ata highlighted eight elements that form the basis of comprehensive PHC programme interventions in order to achieve the goal of health improvement. These elements include: “education on prevailing health problems and 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, immunisation against major infectious diseases; appropriate treatment of common diseases and injuries; and the provision of essential drugs.”(7)
According to Denhill, King and Swanepoel, overall, in any health care programme or strategy, the successful implementation of PHC must be guided by the following principles:
These guiding principles determine the success or failure of any PHC programme worldwide.
Factors that have contributed to the successful implementation of comprehensive PHC
Most successful comprehensive PHC programmes are as a result of good government policies and legislature for equitable implementation of efficient and cost-effective health care interventions, and have emphasised the need for community and individual participation.(9) Before the implementation of any PHC programme or strategy, there must be political commitment by the ruling Government.(10) For example, Brazil’s health care system is based on decentralised universal access, with local Governments providing comprehensive and free health care to each person in need, financed by states and Federal Government. All three levels of Government in Brazil – federal, state and municipal - aim to encourage the underprivileged to use and benefit from the primary health care system through the Family Health Programme, Brazil’s main primary health care strategy. PHC is now one of the main pillars of the public health system in this country of 190 million people, about 70% of whom receives care from this system.
Government commitment has proved to be crucial in the decentralisation of health services to improve access to PHC - especially in rural areas. In Brazil, health care units were set up in areas that previously had no health services and this contributed to the prevention and control of minor communicable diseases as well as a fall in infant and maternal mortality rates.(11) Similarly, following the endorsement of comprehensive PHC in 1978, the Tanzania Government embarked on a health strategy that led to the doubling of health facilities and an increase in the number of trained community health staff. The Government prioritised expansion of health facilities to rural areas with emphasis on preventive health services. As a result of such key community policies from the Government, infant mortality rates reduced significantly.(12)
Active community participation is also a critical support activity for the PHC system to achieve the goal of health for all. There are three basic characteristics to the concept of community participation: “Participation must be active, people have the right and responsibility to exercise power over decisions that affect their lives, and there must be mechanisms to allow for the implementation of the decisions by the community.”(13) This is not merely a theoretical idea but rather, it is a key principle and if put into action in an organised manner, significantly contributes to the attainment of optimal health of a community or population.(14) The involvement of the community encourages participatory approaches in health care planning and subsequent implementation, leading to improved health outcomes. For example, in the 1980s, Mozambique and Cuba expanded their PHC coverage and significantly improved their health indicators. These accomplishments were largely driven by active community involvement, political will to meet basic health needs of citizens, and increased economic and social equity.
While the implementation of PHC in Mozambique was fleeting due to political instability that deterred its advancement, Cuba has sustained steady progress attributed to its commitment in adopting the comprehensive PHC approach. Cuba’s population indicators are similar to those of developed nations that have comparatively larger budgets. For example, life expectancy is 77 years and infant mortality is 7.7 per 1,000 live births, which puts Cuba among the 25 countries worldwide with the lowest infant mortality rates.
The unique feature of Cuba’s PHC system is that in Cuba, PHC is law (policy) and the foundation upon which the health system is built. It is not just one of the many integrated approaches in the delivery of health services, as is the case in other countries but rather, it is the vehicle through which all health systems are run. The Cuban PHC system is also driven by community initiatives, where the communities are involved in the diagnosis of their health problems and identify their health priorities. Together with Government representatives, they develop strategies and action plans to address the community health diagnosis priorities.(15)
Cost-effectiveness and equity also form an integral part of primary health care provision. It has been shown that countries with a well-functioning PHC system (such as Cuba, Thailand, Brazil and Oman) have better health outcomes at low costs.(16) Developing countries recognise that better cost-effective measures are desirable if better health outcomes are to be attained. For instance Ghana, South Africa, Uganda and Zambia abolished user fees at the primary care level in the public sector, thereby promoting equity and increasing access to basic health care services for the poor.(17) As a result of the increase in the number of people accessing basic health services (particularly women) in the named countries, there was reduced infant and child mortality through immunisation (though not to desirable levels). In addition, through the health facilities, women also received basic health education which saw to improved clean water and sanitation efforts – as evidenced by the falling number of cases of water borne diseases reported – breastfeeding, household involvement in treatment of diarrhoea, and monitoring child growth and nutrition.(18)
Therefore, it is clear that political commitment, community participation as well as cost effectiveness and equity in the delivery of health services are key factors crucial to the success of PHC, without which, the goal of health for all remains unattainable.
Factors that continue to impede progress in achieving comprehensive PHC
Despite the evidence of the benefits of PHC, most developing countries have not been able to commit to fully incorporating all the essential elements and principles of PHC in their implementation thereof. In many developing countries, health care systems are seriously under-funded and overwhelmed by multiple, disease-orientated programmes. Currently, 70% of health costs in poor countries are spent on 30% of the population, mainly on hospital and specialist care.(19) Furthermore, the health systems in many developing countries, particularly in Africa, developed from colonial health services that put an emphasis on overpriced, high- tech, urban concentrated and curative health care. Thus, when most of these developing countries gained independence in the 1950s and 1960s, they inherited health care systems of developed nations.(20)
In an effort to improve health outcomes following the Alma Ata Declaration, most developing countries developed PHC implementation strategies. However, the implementation of these strategies has been met with serious challenges which include falling gross domestic product (GDP) and shrinking health budgets, inadequate political will, and increased burden on health care services as a result of HIV & AIDS.(21)
Comprehensive PHC is expensive to implement as it requires a multi-sectoral, multi-disciplinary and holistic approach. It calls for an increased number of health staff in all disciplines, proper supply chain system for drugs and laboratory services, improved transport services and infrastructure, as well as sufficient water and sanitation. With falling GDP and shrinking health budgets, comprehensive PHC remains elusive.
Falling GDP and shrinking health budgets have impacted negatively on many countries in Africa. In Zambia, for instance, PHC implementation began in August 1981, with steady progress and interventions that included the training of community health workers, construction and upgrading of rural health centres, improved distribution of medicine, a strengthened transport system, as well as improved health planning and management. These interventions were largely driven by the economic boost that Zambia experienced due to the increase in the global demand for copper - Zambia’s main export product and the country’s major source of income at the time. This progress was, however, short lived. When global demand for copper fell significantly, it had a severely negative effect on the country’s GDP. The health sector was not spared from this economic depression – it experienced a shortage of health staff and deteriorating health services and infrastructure. In addition, there was little or no action by the Government to redistribute the available resources more equitably to districts with the greatest health need - especially in rural areas. Even basic health promotion and prevention activities that had proved to be effective, such as health education, could not be sustained. As a result of these challenges, there was an increase in both vaccine preventable and communicable diseases. Zambia has one of the highest rates of under-five mortality in Africa, at 119 deaths per 1,000 live births. Thus obstacles of falling GDP and budget cuts have seen to the decline of PHC services and health outcomes.(22)
Inadequate political will has also contributed to the failure of PHC in developing countries. For example, South Africa was a worldwide leader in the conceptualisation and development of the PHC concept. However, despite going through years of structural reform and sincere commitment to achieving health for all, the slow response by Government to provide equitable and quality health services to all individuals has hampered progress in achieving the desired health outcomes. This was aggravated by the intimidating state interventions during the apartheid era and weak leadership in the health sector post-independence, particularly related to the decentralisation of health services, poor infrastructure and services - especially in the public sector - inequities in resource allocation and distribution and poor leadership in the management of HIV & AIDS. As a result, the country is faced with a quadruple burden of disease, that is, increased cases of HIV & AIDS and Tuberculosis (TB), non-communicable diseases, violence and injuries as well as high maternal and child death.
South Africa is currently experiencing an increased burden on health care services largely as a result of HIV & AIDS. It has one of the highest rates of HIV & AIDS in the world at 17% of the population infected, and 73% of all those infected by the HIV are co-infected with TB. Due to the increase in disease burden, efforts to improve PHC have proved to be challenging, as there are shortages of health workers and health infrastructure, all of which have contributed to the current poor health indices.(23)
Despite these challenges, most developing countries continue to strive to abide by the guiding principles of the Alma Ata declaration in their aim to provide comprehensive health care as close to all individuals as possible. For example, South Africa is currently in the process of re-engineering its PHC in order to achieve health for all. The current public health system is two-tiered as well as inequitable and unsustainable in terms of poor financial resource allocation, inadequate human resource and unequal access to health care. The two-tiered system is characterised by poor management and poor quality of care health care services and deteriorating infrastructure in the public sector, whilst the private sector is characterised by over pricing of services. The South African Government has introduced a National Health Insurance scheme, referred to as the NHI, which is currently in pilot phase. The rationale for introducing an NHI scheme is to eliminate the current two-tiered system, where those with the greatest need have the least access and have poor health outcomes. The aim of NHI is to promote universal access to appropriate, efficient and quality health services. One of the key features of the NHI implementation is comprehensive PHC, a key approach in ensuring that health care is available to everyone as geographically close to them as possible.(24)
Comprehensive PHC is costly to implement, however, it provides a more holistic approach to addressing the health needs of individuals, promotes the development of health infrastructure and is critical for sustained improvements in the health of communities. Since the Declaration of Alma Ata, lessons learned from developing countries, that are also applicable to developed countries regarding PHC implementation, include the recognition that better cost-effectiveness measures are necessary; equity is an integral part of a health strategy; and that disease prevention involves community participation and consequently, this needs to be encouraged. PHC services are indispensable to the success of national health systems. With political commitment, an enabling economic environment and equitable distribution of resources, comprehensive PHC has proved to be a better strategy in achieving the goal of health for all.
Written by Rita Magawa (1)
(1) Contact Rita Magawa through Consultancy Africa Intelligence’s Public Health Unit (email@example.com).
(2) Magnussen, L., Ehiri, J. and Jolly, P., 2004. Comprehensive versus selective primary health care: Lessons for global Health policy. Health Affairs, 23(3), pp. 167-176.
(4) ‘Declaration of Alma Ata’, Report on the international conference on primary health care, World Health Organisation, September 1978, http://www.who.int.
(5) Sanders, D., 2003. Twenty five years of primary health care: Lessons learned and proposals for revitalization. School of Public Health, University of the Western Cape, South Africa, pp. 1-15.
(7) ‘Declaration of Alma Ata’, Report on the international conference on primary health care, World Health Organisation, September 1978, http://www.who.int.
(8) Dennill, K., King, L. and Swanepol, T. (eds.), 1998. Aspects of primary health care; community health care in Southern Africa. Oxford University Press Southern Africa: Cape Town.
(9) Black, R.E., 1990. Prevention in developing countries. Journal of General Internal Medicine, 5(5 Suppl), pp.132-135.
(10) Dennill, K., King, L. and Swanepol, T. (eds.), 1998. Aspects of primary health care; community health care in Southern Africa. Oxford University Press, Southern Africa: Cape Town.
(11) ‘Flawed but fair: Brazil’s health system reached out to the poor’, World Health Organisation, April 2008, http://www.who.int.
(12) Oboimbo, E. M., 2003. Primary health care, selective or comprehensive, which way to go? East Africa Medical Journal, 80(1), pp. 7-9.
(13) Dennill, K., King, L. and Swanepol, T. (eds.), 1998. Aspects of primary health care; community health care in Southern Africa. Oxford University Press Southern Africa: Cape Town.
(15) Magnussen, L., Ehiri, J. and Jolly, P., 2004. Comprehensive versus selective primary health care: Lessons for global health policy. Health Affairs, 23(3), pp.167-176.
(16) Logie, D.E., et al., 2010. Affordable primary health care in low income countries; can it be achieved? African Journal of Primary Health Care & Family Medicine, 1(2), pp. 1-3.
(18) Black, R.E., 1990. Prevention in developing countries. Journal of General Internal Medicine, 5(5 Suppl), pp.132-135.
(19) Logie, D.E., et al., 2010. Affordable primary health care in low income countries; can it be achieved? African Journal of Primary Health Care & Family Medicine, 1(2), pp. 1-3.
(20) Magnussen, L., Ehiri, J. and Jolly, P., 2004. Comprehensive versus selective primary health care: Lessons for global health policy. Health Affairs, 23(3), pp.167-176.
(21) Oboimbo, E. M., 2003. Primary health care, selective or comprehensive, which way to go? East Africa Medical Journal, 80(1), pp.7-9.
(22) ‘Experiences with primary health care in Zambia’, World Health Organization, 1994, http://whqlibdoc.who.int.
(23) Kautzky, K. and Tollman, S.M., 2009. A perspective on primary health care in South Africa. Health Systems Trust: South Africa.
(24) ‘National Health Insurance in South Africa: Policy paper’, Department of Health, Republic of South Africa, 2011,http://images.businessday.co.za.