Selective Primary Health Care Research Articles

Commentary: LiST: using epidemiology to guide child survival policymaking and programming

Commentary: LiST: using epidemiology to guide child survival policymaking and programming

The Impact of Primary Healthcare on Population Health in Low- and Middle-Income Countries

This article assesses 36 peer-reviewed studies of the impact of primary healthcare (PHC) on health outcomes in low- and middle-income countries. Studies were abstracted and assessed according to where they took place, the research design used, target population, primary care measures, and overall conclusions. Results indicate that the bulk of evidence for PHC effectiveness is focused on infant and child health, but there is also evidence of the positive role PHC has on population health over time. Although the peer-reviewed literature is lacking in rigorous experimental studies, a small number of relatively well-designed observational studies and the consistency of findings generally support the contention that an integrated approach to primary care can improve health. A few large-scale experiences also help identify elements of good practice. The review concludes with several recommendations for future studies, including a focus on better conceptualizing and measuring PHC, further investigation into the advantages of comprehensive over selective PHC, need for experimental or quasi-experimental research designs that allow testing of the independent effect of primary care on outcomes over time, and a more detailed conceptual framework guiding overall evaluation design that places limits on the parameters under consideration and describes relationships among different levels and types of data likely to be collected in the evaluation process.

Celebrating the World Health Organization

On April 7, 2008, World Health Day, the World Health Organization (WHO) will mark its 60th anniversary. What better occasion to celebrate WHO’s major contributions to international and global health? Several items in this issue relate to this celebratory theme. Fitzgerald, for example, indirectly underscores WHO’s critical role in monitoring international weapons conventions in his gripping essay on the history of chemical warfare. Bu et al.’s Voices From the Past offering focuses on a selection from John B. Grant’s presentation to a 1951 WHO staff meeting, which provides important historical insights into the organization’s longstanding interest in the most effective models for the organization of health services. A more direct celebration of WHO is Fee et al.’s “birthday card” in the form of an extended Images of Health essay. Here we find visual evidence and supporting text for some of WHO’s most notable achievements: the creation of a global network for the facilitated communication of epidemiological information, the impressive campaign to reduce malaria worldwide, the successful promotion of both comprehensive and selective primary health care, the mobilization of extensive immunization programs, the control of onchocerciasis (“river blindness”) and other tropical diseases, and the leadership in recent decades of efforts in global public health. These achievements over the course of its first 60 years have established WHO’s unquestioned importance as the preeminent international health agency and augur well for the future. There is, however, still more about WHO that we should celebrate on this occasion. These are its lofty ideals captured in the language of the preamble to its constitution, now 60 years old, and of the Alma Ata Declaration, now 30 years old. The former declared that “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being,” (http://www.who.int/governance/eb/who_constitution_en.pdf), and the latter stated that “economic and social development . . . is of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of the developing and developed countries” (http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf). These stirring words have captured the attention of people all over the world and have inspired several generations of health workers. They helped forge an image of WHO as an agency aspiring to the highest idealism, well above the budget-constrained pragmatism and realpolitik that often, of necessity, mark its daily operations. Perhaps no one captured the ideals of WHO better than did Frank G. Boudreau in a December 1951 Journal essay (1951:41;1477–1482): Two-thirds of the world’s population is crying for relief from disease, hunger, premature death, and poverty but does not know where to turn for relief. WHO, above all other international agencies, is fitted to show the way, for its jurisdiction is in one of the few areas where men of all races and creeds can work easily together. . . . Joining hands with our colleagues in other countries, we must take our people up to the mountaintop where they can see the promised land of good health, peace, and freedom stretching before them. Now, we too need to remember not only what WHO has done but also what it has inspired. If its ideals are taken as seriously as they should be, WHO will contribute not only to achieving better health for all but also to creating a better world in which all can live.

Leadership in primary health care: An international perspective

A primary health care approach is essential to contemporary nursing roles such as practice nursing. This paper examines the evolution of primary health care as a global strategy for responding to the social determinants of health. Primary health care roles require knowledge of, and a focus on social determinants of health, particularly the societal factors that allow and perpetuate inequities and disadvantage. They also require a depth and breadth of leadership skills that are responsive to health needs, appropriate in the social and regulatory context, and visionary in balancing both workforce and client needs. The key to succeeding in working with communities and groups under a primary health care umbrella is to balance the big picture of comprehensive primary health care with operational strategies for selective primary health care. The other essential element involves using leadership skills to promote inclusiveness, empowerment and health literacy, and ultimately, better health.

Effectiveness of global health partnerships: will the past repeat itself?

Introduction It is to be hoped that past mistakes are not going to overshadow the effectiveness of global health partnerships (GHPs), as they provide valuable lessons that should be taken into account. The Bulletin publishes a fascinating series of public health classics, consisting of a commentary doing a reality check on what has happened since publication of major public health landmarks. In 2005, Anne Mills commented on a landmark paper on mass campaigns and general health services of 1965. (1) One could get a bit depressed reading her article, because the bottom line is that not much has changed in the past 40 years, which have confronted believers in vertical and horizontal approaches. The terminology has changed, though. Some 20 years ago the topic shifted from vertical versus horizontal programmes to the dispute over the advantages of comprehensive versus selective primary health care. In the 1990s, this discussion cooled down and a combination of the two approaches was translated into health sector reform efforts, with widespread consensus to integrate health actions at district level. This development has been supported by changes in aid modalities such as the sector-wide approach (SWAp) funding mechanism, This evolution has come under threat, however, with the appearance of global health initiatives at the beginning of this millennium, (2) which have brought back this old controversy opposing today's approaches: those that have a more systemic focus or those with a more selective, often disease, orientation. With more than 70 GHPs in existence today, the former selective/ vertical party is seemingly gaining the upper hand again. The difference from before, however, is that aid effectiveness is now receiving more attention. It is noteworthy that in 2005, for the first time, a large group of donor and recipient countries, international organizations and also civil society organizations agreed in the Paris Declaration on Aid Effectiveness to set targets for aid effectiveness and to define a set of indicators to measure progress towards these targets (3) The main argument of this paper is that we should avoid the conflicts of the past. We must strive to achieve a balance between the selective approach of many GHPs and the strengthening of health systems, as they are interdependent. Effectiveness of global health partnerships Although the evidence is still scarce, there are some indications that individual GHPs have had a positive impact in some settings. (4) In many countries, they have helped--albeit in specific areas--to strengthen planning expertise. The focus of major GHPs on performancebased funding has forced countries to improve administrative transparency and strengthen their monitoring capacities. It is also worthy of mention that, through their efforts, awareness of specific health problems has been raised at national and international levels. Last but not least, GHPs have clearly brought to light important health problems, and some headway has been made in fighting AIDS, poliomyelitis and other communicable, otherwise neglected, diseases. Major challenges and questions remain, however. Even though there are good arguments for almost all GHPs, their large number raises the question whether the priorities thus determined for a given country really do respond to the national problem areas. The magnitude of the resources can put a considerable strain on the capacities of countries to absorb the influx of financial resources, particularly with the major bottleneck in many countries caused by the lack of local professional expertise in both quantity and quality. There is also the potential risk of an impact on the economic stability of a country. Another important concern about GHPs is sustainability. In poor countries, health systems are seriously under-funded; even if improvements can be achieved with targeted external support, they cannot easily be sustained after the period for which donor agencies are usually ready to commit funding. …

International aid policy: public disease control and private curative care?

Integrating disease control with health care delivery increases the prospects for successful disease control. This paper examines whether current international aid policy tends to allocate disease control and curative care to different sectors, preventing such integration. Typically, disease control has been conceptualized in vertical programs. This changed with the Alma Ata vision of comprehensive care, but was soon encouraged again by the Selective Primary Health Care concept. Documents are analyzed from the most influential actors in the field, e.g. World Health Organization, World Bank, and European Union. These agencies do indeed have a doctrine on international aid policy: to allocate disease control to the public sector and curative health care to the private sector, wherever possible. We examine whether there is evidence to support such a doctrine. Arguments justifying integration are discussed, as well as those that critically analyze the consequences of non-integration. Answers are sought to the crucial question of why important stakeholders continue to insist on separating disease control from curative care. We finally make a recommendation for all international actors to address health care and disease control together, from a systems perspective.

The community involvement of nursing and medical practitioners in KwaZulu-Natal

AbstractBackgroundThe basis of the health system in South Africa in purported to be primary health care (PHC), as defined by the Alma Ata Declaration of 1978. This approach emphasises community involvement in all health-related activities, but it would appear that a very limited or selective PHC approach in actually being pursued in South Africa, without meaningful community participation or ownership. This study explores the involvement of exemplary medical and nursing clinical practitioners in non-clinical community-wide activities in terms of the primary health care approach, which demands a broader scope of practice than primary medical care.MethodsThe objectives of the study were to identify exemplary medical and nurse practitioners in primary health care, to document their practices and perceptions with regard to their community involvement, to analyse the common themes arising from the findings, and to present recommendations based on the findings. Seventeen primary care clinicians in KwaZulu-Natal...

Social determinants, political contexts and civil society action: a historical perspective on the Commission on Social Determinants of Health

To evaluate opportunities for action on social determinants of health (SDH) requires a historical perspective. Plans for addressing SDH should be developed with an awareness of past similar efforts and factors that contributed to their success or failure. Review of published historical literature on analysis and action on SDH, in particular from the Latin American social medicine movement. In the period since World War II, global public health has oscillated between a social vision of health and a more individualistic, technological and medicalised model. Action on SDH was central to comprehensive primary health care as promulgated at the 1978 Alma-Ata conference and championed by the movement for 'Health for All by the Year 2000'. Subsequently, commitment to addressing SDH declined under the impact of restrictive interpretations of 'selective primary health care' and the pressure of neo-liberal economic and health policies. Through its critique of politically naive medical and public health approaches and of neo-liberal ideology, the Latin American social medicine tradition offers important lessons for today's efforts to advance action on SDH. Key lessons concern: (1) the model of praxis, consciously uniting reflection and action for political change; and (2) the importance of civil society and community participation in action on SDH.

Políticas del Sector Salud mexicano (1980-2004): ajuste estructural y pragmatismo de las propuestas neoliberales

In this paper we describe and analyze health policies impelled in Mexico during 1980-2004 (decentralization, health expenses reduction, selective primary health care, health services privatization) by neoliberal sectors. We describe the trajectory of these policies in a context characterized by poverty increase and socioeconomic inequalities. This analysis shows that these policies are characterized by their strong continuity, their adaptability, and in paticular their social, ideological and political pragmatism. The latter is evident in the use and appropriation by neoliberal functionaries and executives of concepts and proposals developed by medical and social critical approaches.

The origins of primary health care and selective primary health care.

I present a historical study of the role played by the World Health Organization and UNICEF in the emergence and diffusion of the concept of primary health care during the late 1970s and early 1980s. I have analyzed these organizations' political context, their leaders, the methodologies and technologies associated with the primary health care perspective, and the debates on the meaning of primary health care. These debates led to the development of an alternative, more restricted approach, known as selective primary health care. My study examined library and archival sources; I cite examples from Latin America.

A Role for Public Health History

A Role for Public Health History

Primary health care: a global overview

Central to the original Alma Ata declaration was the notion of a system, which included the fostering of health through multisectoral collaboration. This aspect often gets referred to as comprehensive health care, in counter distinction to a selective primary health care model, which emerged immediately following the conference, as the former, though laudable in intent, was argued to be unworkable. Indeed from a global perspective, comprehensive primary health care, if noticed at all in the culture of western medicine, was relegated to being of relevance in ‘other’ places: so-called developing countries. Nevertheless, at the beginning of a new century, in a vastly different world to that of the 1970s, it is the central contention of this paper that it is still possible to assert that the primary health care model is still relevant – in all countries of the world. The work on the ‘social determinants of health’ increasingly adds weight to the arguments against the irrationality of an overemphasis on medical technical interventions to the neglect of the health-enhancing or health-threatening contexts in which people live out their lives. Consequently it is now becoming possible to think and plan the management of health, not just the management of disease.

Comprehensive Versus Selective Primary Health Care: Lessons For Global Health Policy

Primary health care was declared the model for global health policy at a 1978 meeting of health ministers and experts from around the world. Primary health care requires a change in socioeconomic status, distribution of resources, a focus on health system development, and emphasis on basic health services. Considered too idealistic and expensive, it was replaced with a disease-focused, selective model. After several years of investment in vertical interventions, preventable diseases remain a major challenge for developing countries. The selective model has not responded adequately to the interrelationship between health and socioeconomic development, and a rethinking of global health policy is urgently needed.

A fundamental shift in the approach to international health by WHO, UNICEF, and the World Bank: instances of the practice of "intellectual fascism" and totalitarianism in some Asian countries.

Navarro has used the term "intellectual fascism" to depict the intellectual situation in the McCarthy era. Intellectual fascism is now more malignant in the poor countries of the world. The Indian Subcontinent, China, and some other Asian countries provide the context. The struggles of the working class culminated in the Alma-Ata Declaration of self-reliance in health by the peoples of the world. To protect their commercial and political interests, retribution from the rich countries was sharp and swift, they "invented" Selective Primary Health Care and used WHO, UNICEF, the World Bank, and other agencies to let loose on poor countries a barrage of "international initiatives" as global programs on immunization, AIDS, and tuberculosis. These programs were astonishingly defective in concept, design, and implementation. The agencies refused to take note of such criticisms when they were published by others. They have been fascistic, ahistorical, grossly unscientific, and Goebbelsian propagandists. The conscience keepers of public health have mostly kept quiet.

Malaria control in selective primary health care an example in the solomon islands

Malaria control in selective primary health care an example in the solomon islands

The impact of primary health care services on under-five mortality in rural Niger.

Despite large investments in basic primary health care in sub-Saharan Africa over the past two decades, quantifying the contribution of national programme efforts to the reduction of infant/child mortality in the region has proven difficult. This study takes advantage of the phased implementation of the national Rural Health Improvement Program in Niger and conveniently timed survey data to reassess programme impact on under-five mortality during the 1980-1985 period. Health service use and under-five mortality rates for children born in the 5 years prior to the 1985 survey are compared for three groups of villages: villages served by a dispensary, villages served by village health teams (VHT), and villages without access to modern primary care services. Multi-level regression analyses using both household- and community-level variables are undertaken in estimating the magnitude of effects. Children residing in villages proximate to health dispensaries were approximately 32% less likely to have died during the study period than children without access to modern health services. Village health teams were not, however, associated with significantly lower mortality probabilities. Formal test for endogeneity indicated that these effects were not the result of non-uniform/non-random allocation of resources. The findings are largely supportive of the key premise underlying selective primary health care interventions - that packages of basic services can be effectively mounted nationally in poor countries and have a significant impact over a short time period. In Niger, less than optimal implementation of VHT appears to have reduced the magnitude of the impact achieved.

Ghana: Selective versus Comprehensive Primary Health Care

The furore which surrounded the debate over selective versus comprehensive primary health care (PHC) world wide appears to have died down. After 10 years of PHC implementation in Ghana, however, it is imperative that we revisit the issue in the Ghanaian context. This is because the choice either way has implications for programme planning, implementation, financing and the achievement of stated health policy goals in Ghana. Here I shall attempt to analyse the issues involved in Selective and Comprehensive PHC, outline the advantages and disadvantages of each strategy and suggest a compromise strategy in the Ghanaian context.

Changes in use of health services in a rural health zone in Zaire.

As part of the Combatting Childhood Communicable Diseases (CCCD) project funded by the US Agency for International Development (USAID), the Zairian CCCD programme conducted surveys in the rural health zones of Kingandu and Pai-Kongila, Zaire, in 1984-1985 and 1988-1989 to determine whether a strategy of selective primary health care would affect childhood mortality. This paper describes the changes in the medical care infrastructure and the increasing coverage of selected services. The strategies evaluated were vaccination, oral rehydration therapy, and treatment of febrile episodes with antimalarial drugs for children; and tetanus vaccination and malaria prophylaxis for pregnant women. The health infrastructure in the Kingandu and Pai-Kongila Health Zones expanded considerably from 1984 to 1989, with health centres increasing from 7 to 18. During this period, economic conditions deteriorated moderately, with the nation experiencing nearly 700% inflation. Medical care costs remained stable because of external subsidies. Use of health services was assessed in 1984, 1988, and 1989. Between 1984 and 1989, the proportion of children aged 12-23 months vaccinated against measles increased from 22% to 71%. Coverage with other vaccine antigens increased similarly. Women's knowledge of the correct recipe for the preparation of sugar-salt solution increased from 0% to 61%. Reported treatment at home with sugar-salt or oral rehydration solution increased from 6% to 53%. The proportion of children with febrile episodes who were treated presumptively for malaria with chloroquine remained unchanged (47% in 1984; 44% in 1988). We conclude that, despite a moderate deterioration in economic conditions, Kingandu and Pai-Kongila Health Zones achieved remarkable increases in use of selected health services between 1984 and 1989, especially in vaccination coverage.

A Health Risk Index for assessing PHC coverage in urban India

3 women interviewed a female member from each of 606 families living in 2 squatter settlements in Madras India to collect data that would allow health managers to develop a simple measure to identify families most in need of maternal and child health and family planning services. This measure may help in a more equitable distribution for each of 7 selected variables and assigned high risk scores to each to develop the Health Risk Index (HRI). These variables included caste child <5 years old illiteracy employment housing water and tobacco and alcohol use. Only 25.8% of eligible families with 1-2 year old children and those with 15.1% of 2-4 year old children received all child care services (immunization and micronutrient supplementation). Further only 22.5% of eligible families with pregnant women benefited from all 4 components of maternal care (tetanus toxoid iron folate supplementation trained birth attendants and food supplementation). These results demonstrated that the services delivery approach to selective primary health care (PHC) is deficient. Yet the Integrated Child Development Services (ICDS) was able to affect higher levels of enrollment of high risk families. In fact their levels were higher than low risk families. Nevertheless this approach to PHC did not achieve universal coverage. Indeed the fact the those families with the higher rates of morbidity used ICDS services more often than the healthier population reflected the fact that selective PHC did not reduce health status differentials. An HRI can guide a community to develop an intersectoral PHC program which is needed to achieve health for all.

What Happened to Guinea Worm Control? An Issue of Water Quality and Health Improvements

ABSTRACT The prevailing emphasis in child survival programs excludes any integrated efforts in water and sanitation. The reason has been the widespread belief that selective primary health care is more cost-effective in lowering child mortality. Yet this is not the case. Studies have clearly shown that rural water projects are not only affordable, but that the community's active involvement in them stimulates greater participation in other child health activities. This article &scribes the debilitating effectsof guinea worm, a waterborne disease that is easily prevented through simple interventions to improve water quality, but nevertheless is allowed to disrupt all aspects of rural social and economic life through much of Africa and Asia. Studies in two Nigerian communities illustrate that the mothers afflicted were so thoroughly disabled and immobilized, over such long periods of time, that they were unable to care for themselves, their businesses, their homes, or even their children. Such incapacity is...