The Origins of Primary Health Care The Origins of Primary Health Care and and

Selective Primary Health CareSelective Primary Health Care

Marcos CuetoMarcos CuetoUniversidad PeruanaUniversidad Peruana CayetanoCayetano HerediaHeredia

McuetoMcueto@@upchupch..eduedu..pepe

RelevanceRelevance

--Not studied from an historical perspectiveNot studied from an historical perspective

--Vertical versus horizontal health interventionsVertical versus horizontal health interventions

--Implementation of health policies. Human resourcesImplementation of health policies. Human resources

OutlineOutline

Background & ContextBackground & Context

Actors, Institutions and Health InterventionsActors, Institutions and Health Interventions

Impact & LegaciesImpact & Legacies

SourcesSources: Research at WHO & UNICEF archives. : Research at WHO & UNICEF archives. Examples from Latin AmericaExamples from Latin America

Background and ContextBackground and Context

By the late 1960sBy the late 1960s……

1. Crisis of vertical programs Failure of malaria eradicationFailure of malaria eradication

2. New studies on community healthJ.Bryant, J.Bryant, Health and the Developing WorldHealth and the Developing World, 1969. , 1969. Questioned the hospitalQuestioned the hospital--based health care systembased health care system

K.Newell (ed) K.Newell (ed) Health by the peopleHealth by the people ,1975. ,1975. Excellence in community health.Excellence in community health.

IllichIllich Medical nemesis: the expropriation of healthMedical nemesis: the expropriation of health, 1976. , 1976.

McKeownMcKeown The Role of Medicine: Dream, mirage or nemesisThe Role of Medicine: Dream, mirage or nemesis, 1976.The overall health of , 1976.The overall health of the population bore less relationship to medical advances than tthe population bore less relationship to medical advances than to standards of o standards of living and nutrition.living and nutrition.

Lalonde Lalonde Report. AReport. A new Perspective on the Health of Canadiansnew Perspective on the Health of Canadians, 1974. 4 factors of , 1974. 4 factors of disease: biology, health services, environment, life styles.disease: biology, health services, environment, life styles.

IvanIvan IllichIllich (1926 (1926 -- 2002)2002)

Background and contextBackground and context

3. New Political Context Crisis of the Cold War.Cold War.

Deterioration of U.S. hegemonyDeterioration of U.S. hegemony. Vietnam & African independence

L.B. Pearson—Canada, and W. Brandt—Germany, chaired commissions on development.

1974 UN Resolution on the need of a UN Resolution on the need of a ““New International Economic New International Economic OrderOrder” to improve social conditions in underdeveloped countries

4. Christian movements, NGOs, and alternative experiences

The Luteran Christian Medical Commission (CMC)(CMC) emphasized training of village workers. Published ContactContact..

Red Cross Societies tradition of voluntary work in the community.Chinese barefoot doctors

A medical team in the Wuchih Mountain area; one of them carries a board with a Maoquotation — "set the focus of medical care on the countryside.“ China Pictorial, November

1969 www.morningsun.org/ living/medicine/medicine.htmlwww.morningsun.org/ living/medicine/medicine.html

Actors and institutional changesActors and institutional changes

WHO WHO HalfdanHalfdan MahlerMahlerWHO Director General. 15 years (1973WHO Director General. 15 years (1973--1988).1988).Background in TB, Ecuador & IndiaBackground in TB, Ecuador & IndiaCharisma & Continuity.Charisma & Continuity.According to a CMC member According to a CMC member ““I felt like a church I felt like a church mouse in front of an archbishopmouse in front of an archbishop..””

UNICEF UNICEF Henry Henry LabrouisseLabrouisse UNICEFUNICEF’’s Exec. Director 1965s Exec. Director 1965--1979 emphasized community1979 emphasized community--work work

in health and nutrition projects in rural areas and urban slums.in health and nutrition projects in rural areas and urban slums.

1975 1975 Alternative Approaches to Meeting Basic Health Needs in DevelopiAlternative Approaches to Meeting Basic Health Needs in Developing ng CountriesCountries. Successful PHC experiences in 9 countries. Successful PHC experiences in 9 countries

1975 281975 28thth World Health Assembly. World Health Assembly. ““National Programs in PHC, aNational Programs in PHC, a……priority.priority.””

International Conference on Primary Health International Conference on Primary Health Care, WHO & UNICEFCare, WHO & UNICEF AlmaAlma--Ata, USSR Ata, USSR

66--12 September 197812 September 1978A watershed event. A watershed event. ““worldwide sounding boxworldwide sounding box””

USSR embraced PHC. Competition with China. USSR embraced PHC. Competition with China.

Representatives of 134 governments & 67 international Representatives of 134 governments & 67 international organizations. China Absent. 3organizations. China Absent. 3--4 delegates for country.4 delegates for country.

DelegatesDelegates::

Public Sector:Public Sector:mainly health ministries; few political authorities & education experts

AcademicsAcademics

NGONGO’’s and religious movementss and religious movementsCMC, Red Cross, CARE; Medicus Mundi; Baptist World Alliance &others.

International & UN agenciesInternational & UN agencies:International Labour Organization, FAO, USAID, Peace Corps

Political MovementsPolitical Movements: : PLO and the South West Africa People’s Organization.

International Conference on PHCInternational Conference on PHC

From the 1From the 1stst paragraph of the Declaration of Alma Ata (22 paragraph of the Declaration of Alma Ata (22 recommendations)recommendations)

“Primary health care Primary health care …… forms an integral part both of the forms an integral part both of the country's health system, of which it is the central country's health system, of which it is the central

function and main focus, and of the overall social and function and main focus, and of the overall social and economic development of the community.economic development of the community.””

Three main ideas, PHC:Three main ideas, PHC:

Medical TechnologyMedical TechnologyNegative role of “Disease technology”

In contrast: Appropriate technology,scientifically sound, culturally acceptable

ElitismElitismCriticism to medical overspecialization & top-down health campaigns

In contrast: Community participation. Work with traditional medicine

DevelopmentDevelopmentPHC a new center of the public health systemAn inter-sectorial approach to healthPart of a social and political movement for development

FromFrom WorldWorld HealthHealth (1979) WHO(1979) WHO

PostPost--Alma AtaAlma Ata: : Selective Primary Health Care Selective Primary Health Care and and new health interventionsnew health interventions

Shortly after its appearance PHC was criticized for being Shortly after its appearance PHC was criticized for being too broad, idealist and having an unrealistic timetable.too broad, idealist and having an unrealistic timetable.

Conference Conference ““Health and Population in DevelopmentHealth and Population in Development””In 1979 at In 1979 at BellagioBellagio, Italy. , Italy. Rockefeller Rockefeller Foundation , Foundation , The World Bank and USAIDThe World Bank and USAID

Changes in Changes in UnicefUnicef. In 1979 new director J. Grant. . In 1979 new director J. Grant. Charisma.Charisma. “…“…the art of the possiblethe art of the possible””

Conference Based on J. Walsh and K. Warren. Conference Based on J. Walsh and K. Warren. ““Selective Primary Health Care, an Selective Primary Health Care, an Interim Strategy for Disease Control in Developing Countries.Interim Strategy for Disease Control in Developing Countries.”” NEJM NEJM 301:18 301:18 (1979): 967(1979): 967--974 & part of the proceedings of the meeting 974 & part of the proceedings of the meeting Social Science and Social Science and MedicineMedicine 14C (1980).14C (1980).

The article went beyond the traditional composite indicators sucThe article went beyond the traditional composite indicators such as infant h as infant mortality or life expectancy at birth to look at specific causesmortality or life expectancy at birth to look at specific causes of death.of death.

Robert McNamaraRobert McNamara

Selective Primary Health Care, SPHCSelective Primary Health Care, SPHC

UNICEF Declaration of A Children’s Revolution 1982.

Emphasized new technological breakthroughs

SPHC: a package of low cost interventions: G.O.B.I.G.O.B.I.

1.. Growth monitoring. Growth monitoring. For identifying at an early stage children who were not growing as they should, because of poor nutrition.

2. Oral Oral rehydratationrehydratation.. To control diarrheal diseases with ORS, a mixture of water, salt and sugar that could be prepared by mothers.

3. BreastBreast feedingfeeding of infants as a means to prevent diseases

4.ImmunizationImmunization. Vaccines, especially against diseases of childhood(measles, diphtheria, tetanus, polio, tuberculosis and whooping cough)

GOBIGOBI------FFFFFFFood supplementation, Female literacy and Family planning.

Appeared as cost-effective & practical Interventions easy to monitor and evaluate.

The Power of ORSThe Power of ORS

From From David David Werner and David Sanders. Werner and David Sanders. Questioning the Questioning the Solution. The Politics of Primary Health Care and Child Solution. The Politics of Primary Health Care and Child Survival with an inSurvival with an in--depth critique of Oral depth critique of Oral RehydratationRehydratation

TherapyTherapy. Palo Alto: Health Rights, 1997.. Palo Alto: Health Rights, 1997.

SPHC: contradictory experiences SPHC: contradictory experiences and criticism during the 1980sand criticism during the 1980s

Growth monitoringGrowth monitoring became an end in itself rather than became an end in itself rather than a means to improve the nutrition of vulnerable children.a means to improve the nutrition of vulnerable children.

ORSORS Partial solution when water and sewage systems are contaminatedPartial solution when water and sewage systems are contaminated..

Breast feedingBreast feeding faced the propaganda of powerful food industries.faced the propaganda of powerful food industries.

ImmunizationImmunization considered a successful program. considered a successful program.

In 1980 only about 5 per cent of children in the soIn 1980 only about 5 per cent of children in the so--called third world were called third world were immunized against six diseases (measles, tetanus, whoopingimmunized against six diseases (measles, tetanus, whooping--cough, cough, diphtheria, tuberculosis and polio) diphtheria, tuberculosis and polio)

By the end of the 1980s well over half were fully immunized by tBy the end of the 1980s well over half were fully immunized by the time he time they were only one year old. they were only one year old.

Most Latin American countries, especially Colombia, achieved higMost Latin American countries, especially Colombia, achieved high h immunization rates. immunization rates.

Criticism to Selective PHC. David Werner and David Sanders. Questioning the Solution. The Politics of Primary Health Care and Child Survival with an in-

depth critique of Oral Rehydratation Therapy. Palo Alto: Health Rights, 1997.

IMPACT & LEGACYIMPACT & LEGACYDifferent Meanings

First medical contact? Second-class health care? Simplified technology? Poor health care for the poor?

Criticism from Latin America: “Primitive” HCSPHC accused to be a reductionistic approach that recreated vertical programs. K. Newell. “SPHC: The Counter Revolution.” Social Science and Medicine 26 (1988): 906.

FinanceAgencies interested in specific interventions of SPHC. USAID ORS & Immunization.A tradition of financing public health in LDC as a response to emergencies

During the 1980s many LDC confronted global recession & adjustment policies and had to cut back on their health services.

ImplementationResistance of governments and traditional politicians: -Difficult to produce results in the short term

Resistance of medical community and hospital-based health professionals. Fear of losing Privileges. Medical education.

PHC Programs included in Ministries of Health. Coexistence and confusion with vertical programs. Accepted as a normal state of affairs. Cooptation of terms such as ‘participation’

A A polpoliicemaceman n immunizesimmunizes a a

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