PRIMARY HEALTH CARE: AN OVERVIEW
DEBABAR BANERJI
Guest Lecture for National Seminar on Health For All in the New Millenium, NIHFW, February 24-26, 2003. (Professor Emeritus, Centre of Social Medicine and Community Health, Jawaharlal Nehru University)

A WATERSHED IN PUBLIC HEALTH
The concept of Primary Health Care (PHC), which was approved by the World Health Assembly in 1977 and endorsed at the International Conference on Primary Health Care at Alma Ata in 1978, marks a watershed in the discipline of public health.

It had virtually turned the discipline up side down, as it were; technology, administrative practices were subordinated to the needs of the people. Halfdan Mahler, the then Director-General of WHO, had rightly labelled it as a revolution. He had also acknowledged that the work done in India had substantially contributed to the development of the concept of PHC.

The concept of Primary Health Care has to be distinguished from the concept of a Primary Health Centre in India. Failure to do so has very often led to trivialisation of the concept of Primary Health Care. The ideas behind setting up Primary Health Centres can be considered as a component of the concept of Primary Health Care.

Reference to the term, primary health care, is made in the Director-General' s report to the 53rd meeting of the WHO Executive Board as early as in January 1975, proclaiming that `primary health care services at the community level is seen as the only way in which the health services can develop rapidly and effectively'. He had enunciated seven guiding principles for this purpose:

1. to shape PHC `around the life pattern of the population';
2. for involvement of the local population;
3. for `maximum reliance on the available community resources', while remaining within cost limitations;
4. for an `integrated approach to preventive, curative and promotive services for both community and for the individual';
5. for all interventions to be undertaken `at the most peripheral practicable level of the health services by the worker most simply trained for this activity';
6. for other echelons of services to be designed in support of the needs of the peripheral level; and,
7. for PHC services to be `fully integrated with the services of the other sectors involved in community development'.

By the time of the Alma Ata Conference on PHC had taken its now well known form, it was seen as the `key to attaining' the target of health for all by the year 2000 (HFA-2000/PHC). Only the outstanding elements of the Declaration are being presented below:

I The Conference strongly reaffirms that health is a fundamental human right and that the attainment of the highest level of human health is the most important social goal and whose realization requires action in many other social and economic sectors in addition to the health sector.

II The existing gross inequality in health status of the people particularly, between developed and developing countries and as well as within countries is politically, socially and economically unacceptable and is, therefore, of common concern to all countries.

III. Economic and social development is of basic importance to the fullest attainment of health for all and to the reduction of the gap between developing and developed countries. The promotion and protection of the health of the people is essential for sustained social and economic development and contributes to better quality of life and to world peace.

IV. The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.

V. Governments have a responsibility for the health of their people which can only be fulfilled by the provision of adequate health and social measures. A main social target of governments, international organizations and the whole world community in the coming decades should be attainment by all the people of the world by the year 2000 of a level of health that will permit them to live a socially and economically productive life. Primary health care is the key to attaining this target as a part of development in the spirit of social justice.

VI. Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology universally made accessible to individuals and families in the community through their full participation and at a cost the community and the 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 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 country. The first level of individuals, family and the community with the national health system bringing health care as close as possible to where people live and work and constitute the first of the continuing health care process.

Primary health care

1. reflects and evolves from the economic conditions and socio-cultural and political characteristics of the country and its communities and is based on application of the relevant results of social, biomedical and health services research and public health experience,
2. addressses the main health problems in the community, providing promotive, preventive, curative and rehabilitative services accordingly,
3. includes at least: education concerning prevailing health problems and methods of preventing and controlling them; promotion of food supply and nutrition; adequate supply of safe water and sanitation; maternal and child health care, including family planning; immunization against major infectious diseases; prevention and control of local endemic diseases and injuries; and provision of essential drugs,
4. Involves, in addition to the health sector, all related aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communication and other sectors, and demands the coordinated efforts of all those sectors,
5. requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources, and to this end develops through appropriate education the ability of the community to participate,
6. should be sustained by integrated, functional and mutually supportive referral systems, leading to progressive improvement of comprehensive health care to all, giving priority to those most in need,
7. relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries, as needed, suitably trained socially and technically, to work as a health team and to respond to the expressed health needs of the community.

The foregoing quotations from official WHO documents (unavoidably
repetitive) show how revolutionary have indeed been the ideas which culminated from the Alma Ata Declaration on Primary Health Care. These ideas are being put together below in a summary form:

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 considering people as almost passive recipients for them, the Declaration sought to reverse the relationship by considering people as the prime movers for shaping their health services. It sought to strengthen the capacity of the people to cope with their health problems which they have developed through ages.
3. It also visualised a wider approach to health by strengthening such intersectoral areas as ensuring adequate supply of potable water, environmental sanitation, nutritive food and housing.
4. It called for social control of the health services that are meant to strengthen people's coping capacity.
5. It considered health as an intergral whole, including promotive, preventive, curative and rehabilitative components. Any concept of `selective care' was considered antithetical to the concept of PHC.
6. Health services ought to cover the entire population, including the underserved and the unserved.
7. Those aspects of traditional systems of medicine, which are proven to be efficacious or which are the only one accessible to the people, ought to be used in providing PHC.
8. Choice of Western medical technology should conform to the cultural, social, economic and epidemiological conditions prevailing in countries.
9. Particular care is to be taken to use only essential drugs.

It may be emphasised that PHC is a PROCESS; it provides a road map for developing heath service in different countries of the world. Health service development in India is taken up here as a case study.