Comprehensive Primary Health Care: a new phase?

Abstract

Clinical Director, Ealing Primary Care Trust, Southall, London, UKIn the first commentary on Alma Ata in this editionof the London Journal of Primary Care, Exworthydescribes how, in 1978, 134 countries and 67 inter-national organisations committed themselves to de-velop a social model of health, to complement thebiomedical model that was dominant at the time. Itaimed to engage all citizens and organisations in asharedeffortforhealth.Theycalledit‘comprehensiveprimary health care’. It emphasises participation,inter-sectoral collaboration and equity. In the secondpaper Macdonald laments the failure to achieve thisambitious model. He concludes ‘it is time to eithertreat seriously the term ‘Primary Health Care’ orabandon it, to avoid the situation where generalpractitionersthinktheyaredoingitmerelybyencour-aging life-style change’.But with hindsight, 1978 was not the right time tomoveforwardthisambitiousvision.AlmaAtadidputits finger on the things a society needs to be healthy.But it forgot to say how difficult these things are toachieve. As Exworthy mildly put it ‘the rhetoric hasbeen comparatively easy compared to the implemen-tation’.Here is the nub of the problem, we lack adequatetheoriesandmodelsofhowtomakeparticipationandinter-sectoral collaboration for health and equity thenorm. A subtle, encouraging approach is likely to beneeded.Butthedominanttheoryusedtogetpeopletodo what we want is instrumental and direct, focusedon discrete projects and short-term objectives. It hasbeenenshrinedinthesoundbite–‘CarrotsandSticks’– a metaphor made to move donkeys short distances.1978 was not the beginning, but the end of an era.Big Politics were about to take an abrupt change.McNultyandFerlieremindusthatthosedayswitnesseda ‘taxpayers revolt’ against the cost of governing theextendedsocialdemocraticState,demandingacurbofState growth and stimulation of markets.