Implementing primary health care: some problems of creating national programmes.

Abstract

While there is a great deal of agreement about the principles underlying Primary Health Care (PHC), there exist many problems, political, planning and management, involved in putting the approach into effect. Some of these difficulties are discussed. It is clear that the PHC approach is essentially political; the way it is implemented in each country will reflect the political priorities and systems of that country. Moreover, ministries of health are not known for their strong position in the ministerial pecking order. Finance and planning ministeries would have to be won over to the importance of the concept of PHC to try to eexpand the health budget and to change the emphasis of existing resource allocation patterns. Costs incurred by a PHC approach ( e.g., expensive transport and communication systems), and resources needed to finance it may be available; however, they may not be channelled to the politically less articulate groups in rural areas. Political implications are not limited to national levels; considerable conflict may exist between different status groups and classes at the village level, thus sabotaging PHC plans. Professional politics will also be played at all levels. It is equally essential to recognize the historical context in which PHC is being introduced. Many countries have inherited colonial infrastructures. Changing the values, perceptions, expectations, administration and organization that accompany such systems is extremely hard, and to put PHC into effect demands radical changes. The planning difficulties which beset PHC are related to the still large private provision of social services like health, and to a flourishing traditional private sector in many developing countries. These may limit the implementation of a national health policy and PHC may thus result in a very patchy service throughout the country. The level of centralized planning will also affect resource allocation and therefore the policy, planning and implementation within the health sector itself. Highly centralized planning may mean difficulty in applying community participation in decision making, an underlying principle of the PHC approach. Moreover, ther are still many unknown factors related to community involvement, e.g., it is uncertain to what extent traditional authority structures are important. Management difficulties perceived by the authors are related to an overemphasis on village health workers and its resulting confused role definition. The dilemma of balancing curative and preventive care at the primary level is given as an example. Purely organizational problems exist too, such as the logistics of supplies. The problems identified here stem from the gap between planning and management in putting plans into effect. The example of coordinating with traditional practitioners in the health system is given as an illustration. Another issue besetting the attainment of Heath For All by 2000 is the neglect of peri-urban and urban dwellers, who make up an increasing proportion of many developing countries' populations. In conclusion, it is argued that the hope that PHC would be a vehicle for radical change and improvements in health care provision and health status was over-optimistic. It is clear that the PHC approach is not the new panacea, yet, ways are here offered in which PHC can become a reality, e.g., by disseminating lessons that have been learnt and by finding alternative methods of financing PHC.