Universal Primary Health Care Research Articles

PRIMARY HEALTH CARE AND THE NEW FAMILY HEALTH MODEL SINCE THE REFORM HISTORICAL CONTEXT AND REGIONAL

This paper provides an overview of developments in Primary Health Care (PHC) in the Americas during the 21st century. It draws on a report created in collaboration with the Pan American Health Organization (PAHO) for the 40th anniversary of the Alma-Ata Declaration(1) and docu­ments from major international health organizations for the post-pandemic period. The report highlights that Primary Health Care is a key proposal for addressing post-pandemic challenges and promoting sustainable development in healthcare systems. These findings support Chile’s efforts to transform its healthcare system towards universal Primary Health Care.

Measuring access to health facilities in Ghana: Implications for implementation of health interventions and the Sustainable Development Goal 3

Spatial access to health is important for Sustainable Development Goal 3, yet most existing studies have largely focused on the primary health care level without considering other hierarchies of health facilities. This study analyzed spatial accessibility to primary, secondary, and tertiary health facilities in Ghana. Accumulated distance and network analysis were used in measuring accessibility by drawing insights from Ghana's Upper West region. The results show that 61% of the population have access to primary health care facilities within recommended standards. Also, 81% have access to secondary health care facilities, but the degree of access varies with mode of transportation (i.e., motorcycle or car) and other barriers such as speed and road conditions. On the contrary, only 48% of the population can reach tertiary medical centres in the recommended 30-min journey time. Considering other demographic and socioeconomic factors, the results of overall access show that the highest spatial concentration of healthcare facilities does not translate into high overall healthcare access among the inhabitants. The results imply a varied degree of spatial accessibility across different hierarchies of health facilities, with transportation, socioeconomic, and demographic factors playing critical roles in determining overall access. The findings suggest that for progress towards Sustainable Development Goal 3, it is imperative to focus on addressing rural transport infrastructure, inadequacy of doctors, and national health insurance subscriptions to scale up access towards universal primary health care for all and also improve secondary and tertiary access.

Towards quality primary health care: the dilemma of Community-Based Health Planning and Services (CHPS) in health service provision in Ghana

PurposeOver the past two decades, Community-Based Health Planning and Services (CHPS) has been a pragmatic strategy towards universal Primary Health Care (PHC) in Ghana. However, the ability and capacity of these facilities to deliver quality primary health care remain an illusion as they are still crumbling in myriad challenges. These challenges are translated to the poor-quality services provision and low community utilization of CHPS facilities. The study presents a comparative analysis of three communities in the Kassena-Nankana East Municipality, Ghana.Design/methodology/approachUsing a mixed-method research design, the study gathered and analysed data from 110 households, three community health officers (CHOs) and three community leaders using semi-structured questionnaires and interview guides.FindingsThe findings indicated that the facilities do not have the requisite inputs such as drugs and supplies, logistics, appropriate health personnel, good infrastructure, funding support necessary to deliver quality and appropriate healthcare services that meet the health needs of the communities. For the CHPS to realize their full potentials as PHC facilities, it is required that the needed inputs such as logistics, drugs and appropriate staff are in place to facilitate the activities of CHOs.Research limitations/implicationsDue to the limited number of participants and selection of the study communities, the results may generalization. Also, the researchers acknowledged the inability to interview the district level health officials and the Kassena-Nankana Municipal Assembly during the field visits. This could have provided in-depth knowledge on the findings of this research as well as the validation of the results from the communities' perspective. Several attempts were made to contact and interview district-level authorities which proven futile due to the unavailability of targeted respondents. This resulted in limiting the studies at the community level. However, this limitation does not disprove the findings of this study.Practical implicationsThe article implications for planning primary health care strategies include a keen assessment of community health needs and institutional management of primary health care facilities, equip PHC facilities with adequate resources such as drugs and appropriate staffing to provide the health needs of the communities.Originality/valueThe paper fulfils the gap in the literature by providing empirical data on how the challenges of primary health care facilities affected the provision of high quality service and how this can affect community’s use of the facilities.

Social and Behavior Change Communication Interventions Delivered Face-to-Face and by a Mobile Phone to Strengthen Vaccination Uptake and Improve Child Health in Rural India: Randomized Pilot Study.

BackgroundIn resource-poor settings, lack of awareness and low demand for services constitute important barriers to expanding the coverage of effective interventions. In India, childhood immunization is a priority health strategy with suboptimal uptake.ObjectiveTo assess study feasibility and key implementation outcomes for the Tika Vaani model, a new approach to educate and empower beneficiaries to improve immunization and child health.MethodsA cluster-randomized pilot trial with a 1:1 allocation ratio was conducted in rural Uttar Pradesh, India, from January to September 2018. Villages were randomly assigned to either the intervention or control group. In each participating village, surveyors conducted a complete enumeration to identify eligible households and requested participation before randomization. Interventions were designed through formative research using a social marketing approach and delivered over 3 months using strategies adapted to disadvantaged populations: (1) mobile health (mHealth): entertaining educational audio capsules (edutainment) and voice immunization reminders via mobile phone and (2) face-to-face: community mobilization activities, including 3 small group meetings offered to each participant. The control group received usual services. The main outcomes were prespecified criteria for feasibility of the main study (recruitment, randomization, retention, contamination, and adoption). Secondary endpoints tested equity of coverage and changes in intermediate outcomes. Statistical methods included descriptive statistics to assess feasibility, penalized logistic regression and ordered logistic regression to assess coverage, and generalized estimating equation models to assess changes in intermediate outcomes.ResultsAll villages consented to participate. Gaps in administrative data hampered recruitment; 14.0% (79/565) of recorded households were nonresident. Only 1.4% (8/565) of households did not consent. A total of 387 households (184 intervention and 203 control) with children aged 0 to 12 months in 26 villages (13 intervention and 13 control) were included and randomized. The end line survey occurred during the flood season; 17.6% (68/387) of the households were absent. Contamination was less than 1%. Participation in one or more interventions was 94.0% (173/184), 78.3% (144/184) for the face-to-face strategy, and 67.4% (124/184) for the mHealth strategy. Determinants including place of residence, mobile phone access, education, and female empowerment shaped intervention use; factors operated differently for face-to-face and mHealth strategies. For 11 of 13 intermediate outcomes, regression results showed significantly higher basic health knowledge among the intervention group, supporting hypothesized causal mechanisms.ConclusionsA future trial of a new intervention model is feasible. The interventions could strengthen the delivery of immunization and universal primary health care. Social and behavior change communication via mobile phones proved viable and contributed to standardization and scalability. Face-to-face interactions remain necessary to achieve equity and reach, suggesting the need for ongoing health system strengthening to accompany the introduction of communication technologies.Trial RegistrationInternational Standard Randomized Controlled Trial Number (ISRCTN) 44840759; https://doi.org/10.1186/ISRCTN44840759

Building capacity in primary health care to respond to the needs of asylum seekers and refugees in Melbourne, Australia: the 'GP Engagement' initiative.

Asylum seekers and refugees experience poorer health than the broader Australian population. Universal primary healthcare services play an integral role in supporting and optimising the health and wellbeing of these communities. However, clinical-level issues frequently compromise the quality of care provided to these groups. The 'GP Engagement' initiative, implemented in the south-eastern region of Melbourne, aimed to build capacity within universal primary health care to respond to the needs of asylum seekers and refugees. This involved engaging general practice clinics, resourcing them with tools and frameworks, and undertaking collaborative problem-solving on refugee issues. Evaluation methods included: rigorous record keeping; pre- and post-practice assessments guided by a self-reported '12-Point Checklist'; and participant feedback. Findings from 57 participating health professionals indicated changes in the way that GPs work with asylum seekers and refugees. 'GP Engagement' suggests that it is possible to build primary healthcare responsiveness to asylum seekers and refugees through a strategic regional approach that is firmly grounded in evidence-based practice and considerate of the requirements and constraints of GPs.

Neoliberal regime change and the remaking of global health: from rollback disinvestment to rollout reinvestment and reterritorialization

This article examines the impacts of two interconnected but distinct regimes of neoliberalism on global health. The first is the ‘rollback’ regime associated most commonly with the 1980s and 1990s when efforts to build universal primary health care systems around the world were undermined by Structural Adjustment Programs (SAPs) and associated forms of austerity and market rule. This rollback regime of neoliberal conditionalization led to widespread health service cutbacks, user fees, and other market-driven reforms that effectively replaced plans for ‘health for all’ with more selective and exclusionary approaches. The second neoliberal regime has been rolled-out in part as a response to the resulting gaps in care and associated forms of suffering and ill-health. Where the rollback regime enforced disinvestment, the ‘rollout’ regime insists instead on prioritizing investment. But even as it thereby addresses the health risks produced by financialized neoliberal conditionalization, this reformed rollout regime has doubled-down on selectivity by adapting calculations from global finance to manage global health interventions. This emphasis on rationed and targeted life-saving investment is theorized here as illustrating a shift from the rollback regime’s Laissez-faire ‘macro market fundamentalism’ to an Aidez-faire rollout of ‘micro market foster-care’.

Lekarze podstawowej opieki zdrowotnej w prawie III Rzeczypospolitej Polskiej

In 2019, twenty-five years have passed since the implementation of the first legisla-tive act introducing for the first time family doctors (primary health care physicians) into the Polish model of basic health care. The beginning of changes in this area, falling in the nineties of the last century, was not easy and has not yet been complete but will continue until the end of 2024. Over the years, not only the conditions for the education and professional development of primary health care physicians, in-cluding family doctors, have undergone changes. Also the organisational and legal forms of providing basic health services by this group of doctors were changing, as well as the conditions allowing patients, the recipients of medical services, to choose their doctor from among those with whom health insurance institutions (health insurance funds, or the National Health Fund) concluded agreements on the provision of basic health care services, or those employed by a medical entity with whom the National Health Fund signed relevant agreements.The scope of changes introduced at that time was wide, and when it started at the beginning of the 1990s it was almost impossible to achieve the goals without the support of the World Bank and the PHARE programme, alongside the efforts of the Ministry of Health and Social Welfare and three regional health care consortia (unions). Their work and contribution of each of them and their activities were sig-nificant and together constituted a solid basis for further work on the improvement of the model of a universal primary health care after 1998.The Act on primary health care of 2017 has completed the process of changes in this respect. For the first time, the objectives of the basic, or primary health care have been clearly defined. Although the implementation of each of these objectives is to serve the patient who is the recipient of the services, the value of the services pro-vided by primary care physicians varies. Family doctors (general practitioners) are to provide the patient and the patient’s family with health care services, coordinating at the same time all the stages of the process of their provision. However, the social mission of their profession is to ensure the implementation of broader tasks, such as health promotion adapted to the needs of various groups of society, education of the medical services recipients in the field of responsibility for their own health, as well as shaping pro-health awareness, setting health priorities of the population covered by care and implementation of preventive actions.

Community health extension program of Ethiopia, 2003\u20132018: successes and challenges toward universal coverage for primary healthcare services

BackgroundEthiopia has been implementing a community health extension program (HEP) since 2003. We aimed to assess the successes and challenges of the HEP over time, and develop a framework that may assist the implementation of the program toward universal primary healthcare services.MethodsWe conducted a systematic review and synthesis of the literature on the HEP in Ethiopia between 2003 and 2018. Literature search was accomplished in PubMed, Embase and Google scholar databases. Literature search strategies were developed using medical subject headings (MeSH) and text words related to the aim of the review. We used a three-stage screening process to select the publications. Data extraction was conducted by three reviewers using pre-prepared data extraction form. We conducted an interpretive (not aggregative) synthesis of studies.FindingsThe HEP enabled Ethiopia to achieve significant improvements in maternal and child health, communicable diseases, hygiene and sanitation, knowledge and health care seeking. The HEP has been a learning organization that adapts itself to community demands. The program is also dynamic enough to shift tasks between health centers and community. The community has been a key player in the successful implementation of the HEP. In spite of these successes, the program is currently facing challenges that remain to be addressed. These challenges are related to productivity and efficiency of health extension workers (HEWs); working and living conditions of HEWs; capacity of health posts; and, social determinants of health. These require a systemic approach that involves the wider health system, community, and sectors responsible for social determinants of health. We developed a framework that may assist in the implementation of the HEP.ConclusionThe HEP has enabled Ethiopia to achieve significant improvements. However, several challenges remain to be addressed. The framework can be utilized to improve community health programs toward universal coverage for primary healthcare services.

When Diabetes Confronts HIV: Biological Sub-citizenship at a Public Hospital in Nairobi, Kenya.

This article investigates how international donor policies cultivate a form of biological sub-citizenship for those with diabetes in Kenya. We interviewed 100 patients at a public hospital clinic in Nairobi, half with a diabetes diagnosis. We focus on three vignettes that illustrate how our study participants differentially perceived and experienced living with and seeking treatment and care for diabetes compared to other conditions, with a special focus on HIV. We argue that biological sub-citizenship, where those with HIV have consistent and comprehensive free medical care and those with diabetes must pay out-of-pocket for testing and treatment, impedes diabetes testing and treatment. Once diagnosed, many are then systematically excluded from the health care system due to their own inability to pay. We argue that the systematic exclusion from international donor money creates a form of biological sub-citizenship based on neoliberal economic policies that undermine other public health protections, such as universal primary health care.

The effect of the latest health care reforms on the quality of community health services in China.

The Chinese government initiated a new round health care reform in 2009 to provide universal primary health care to the country's population. The aim of this study was to evaluate and compare the quality of community health services before and after the latest health care reforms in China. A series of nationwide surveys were conducted in 2008 and in 2011to assess the development of the community health services. A total of 2274 and 2501 community health centers, 38200 and 42200 prescriptions, and 12163 and 12386 outpatients visited community health centers (CHCs) were investigated in 2008 and in 2011, respectively. Multivariable regressions and Kruskal-Wallis tests were applied to analyze the differences before and after health care reforms. Quality of community health services has been improved significantly at the first stage of health care reforms in China. CHCs were larger and better equipped after health care reforms in terms of average building area and average number of medical equipment. Patient satisfaction increased, and patient payments per visit decreased after health care reforms. But there was no significant improvement in health human resource, and overuse of injections remains prevalent, pointing to the need for further reforms to improve quality of community health services, such as general practitioner cultivation and supervision over prescribing behaviors.

Transition to universal primary health care coverage in Brazil: Analysis of uptake and expansion patterns of Brazil's Family Health Strategy (1998-2012).

Family Health Strategy, the primary health care program in Brazil, has been scaled up throughout the country, but its expansion has been heterogeneous across municipalities. We investigate if there are unique municipal characteristics that can explain the timing of uptake and the pattern of expansion of the Family Health Strategy from years 1998 to 2012. We categorized municipalities in six groups based on the relative speed of the Family Health Strategy uptake and the pattern of Family Health Strategy coverage expansion. We assembled data for 11 indicators for years 2000 and 2010, for 5,507 municipalities, and assessed differences in indicators across the six groups, which we mapped to examine spatial heterogeneities. Important factors differentiating early and late adopters of the Family Health Strategy were supply of doctors and population density. Sustained coverage expansion was related mainly to population size, marginal benefits of the program and doctors’ supply. The uptake was widespread nationwide with no distinct patterns among regions, but highly heterogeneous at the state and municipal level. The Brazilian experience of expanding primary health care offers three lessons in relation to factors influencing diffusion of primary health care. First, the funding mechanism is critical for program implementation, and must be accompanied by ways to support the supply of primary care physicians in low density areas. Second, in more developed and bigger areas the main challenge is lack of incentives to pursue universal coverage, especially due to the availability of private insurance. Third, population size is a crucial element to guarantee coverage sustainability over time.

India’s Frontline Health Workforce: Theoretical Perspectives and Operational Challenges

FHWs are among the most utilized health workforce in majority of LMIC especially in India. Effective use of the FHWs was considered instrumental in the provision of Primary health care (PHC) and the potency of FHW was recognized to be essential to achieve the targets of MDG. FHWs consists of a wide range of health workers such as CHWs, Mid-level care providers, Physician-assistants, Nurses, Doctors etc., who are most of the time the first level contact of the health system to the people, majorly engaged in provision of PHC and the services focusing on disease prevention and health promotion. Unlike the most of FHWs the CHWs are the group of FHWs whose potency is greatly explored and well documented since there conception in 1950’s as barefoot doctors in china. FHWs by itself is a wide area of research and this review does not talk much about already well known areas in frontline health workers. The review is split in to two parts with first part talking about the theoretical perspectives in-terms of FHWs and second part talks about operational challenges. First part focuses much on other theoretical concepts in FHWs such as Task-shifting, Public-health nurses and mid-level care providers etc., which are not very much known, compared to their counter parts and majority of the times ignored. The second part of the review has its emphasis on the prime operational challenges which are faced by the FHWs. By summing-up the majority of literature related to the different theoretical concepts in the area of FHW it reflects on the options available to provide efficient health care to the underserved populations and the challenges being faced while dealing with FHWs. It could be helpful in guiding the planning and implementation of sustainable, holistic and cost effective interventions to provide universal PHC.

Baseline Research for Action: Adolescent Alcohol Consumption in Los Palacios Municipality, Cuba

In Cuba, alcohol is an important contributor to morbidity, mortality and social problems. The foundation of Cuba's universal primary health care coverage, family doctor-and-nurse offices play a critical role in prevention, early detection and treatment of alcohol abuse. Los Palacios Municipality of the westernmost province of Pinar del Río, Cuba, is a socially complex, periurban area where alcohol abuse and alcoholism have been identified as important health problems. Adolescents constitute a population at high risk for alcohol abuse because of their receptivity to social influences, but the precise extent of the problem is unknown. This paper reports baseline findings from a survey and direct observation of alcohol consumption in the catchment area of a primary care center, conducted to inform planning for an educational intervention. KEYWORDS Alcohol, alcoholism, alcohol abuse, alcohol dependence, adolescence, primary health care, Cuba.

Remind me again: why are we here?

On pondering the challenges of communi-ty-based health insurance, we are reminded of a scene in a movie. The leader of a war, after losing many battles and wasting the lives of thousands of men, asks his lieuten -ant: “Remind me again: why are we here?” In the midst of all the battles, war itself had become the goal and the ultimate goal of reaching stability and peace had been forgotten. In other words, the means had become the end.Similarly, in many community-based health insurance schemes, the multitude of logistical demands of initiating, managing and maintaining the schemes seem to over -shadow their original purpose – the health and well-being of a specific community and its members. In addition, the implementa -tion of community-based health insurance in low-income countries, especially in sub-Saharan Africa, is too rigid: the designs are often standardized and lack the necessary flexibility to adapt to the local context.The story of community-based health insurance dates back to the Alma-Ata Conference in 1978, when health ministers made a commitment to reform health sys-tems and extend universal primary health care to poor people. They failed to achieve this due to insufficient resources and lack of political will. Subsequently, the Bamako Initiative of 1987 promoted the introduc-tion of user fees and community involve-ment (and management) of primary care in Africa to achieve universal coverage.

Unique health care utilization patterns in a homeless population in Ghent.

BackgroundExisting studies concerning the health care use of homeless people describe higher utilisation rates for hospital-based care and emergency care, and lower rates for primary care by homeless people compared to the general population. Homeless people are importantly hindered and/or steered in their health care use by barriers directly related to the organisation of care. Our goal is to describe the accessibility of primary health care services, secondary care and emergency care for homeless people living in an area with a universal primary health care system and active guidance towards this unique system.MethodsObservational, cross-sectional study design. Data from the Belgian National health survey were merged with comparable data collected by means of a face-to-face interview from homeless people in Ghent. 122 homeless people who made use of homeless centres and shelters in Ghent were interviewed using a reduced version of the Belgian National Health survey over a period of 5 months. 2-dimensional crosstabs were built in order to study the bivariate relationship between health care use (primary health care, secondary and emergency care) and being homeless. To determine the independent association, a logistic model was constructed adjusting for age and sex.Results and DiscussionHomeless people have a higher likelihood to consult a GP than the non-homeless people in Ghent, even after adjusting for age and sex. The same trend is demonstrated for secondary and emergency care.ConclusionsHomeless people in Ghent do find the way to primary health care and make use of it. It seems that the universal primary health care system in Ghent with an active guidance by social workers contributes to easier GP access.

LiST: using epidemiology to guide child survival policymaking and programming

in the series 2 included a formal attempt to estimate how many deaths could be saved by each intervention then available. This modelling exercise took into account the levels and causes of deaths in 42 low- and middle-income countries, and the effectiveness of interventions against each of these causes, providing estimates of how many lives could be saved if the current coverage levels could be scaled up to reach all mothers and children. These calculations were carried out using a series of spreadsheets where the best existing data were inserted. 2 The results were remarkable—no fewer than two-thirds of all under-five deaths or 46 million a year could be saved if every mother and child received a handful of proven interventions. The Bellagio spreadsheets were sufficiently accurate for the purposes of this initial exercise, and made an important contribution to placing child survival back on the international agenda. However, from a methodological standpoint there was substantial room for improvement. The articles in the recent supplement of the International Journal of Epidemiology report on the methods and assumptions behind the Lives Saved Tool (LiST). This software was inspired by the Bellagio exercise, but went much further in terms of the background mortality data used, the quality of the literature reviews on intervention effectiveness and of the modelling process itself. LiST is relatively userfriendly and is becoming widely used at country level to identify how much impact can be achieved by scaling up different interventions. 3 A potential critique of LiST is that, by estimating the likely impact of each intervention, it would contribute to the implementation of vertical programmes in the spirit of what used to be known as selective primary health care. 4 As such, it would detract from efforts to build up horizontal, primary health-care systems providing multiple preventive and curative interventions against multiple diseases. However, recent experience of countries that have managed to reduce child mortality rapidly, shows that initial focus on a few priority diseases and interventions is not incompatible with the strengthening of health systems for providing universal primary health care—the combination of these strategies has been described as the ‘diagonal approach’. 5–7 Furthermore, use of LiST can counteract current emphasis on one-size-fits-all intervention packages, by suggesting which specific interventions are more likely to have an impact under different conditions.

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

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

Planning for district mental health services in South Africa: a situational analysis of a rural district site

The shift in emphasis to universal primary health care in post-apartheid South Africa has been accompanied by a process of decentralization of mental health services to district level, as set out in the new Mental Health Care Act, no. 17, of 2002 and the 1997 White Paper on the Transformation of the Health System. This study sought to assess progress in South Africa with respect to deinstitutionalization and the integration of mental health into primary health care, with a view to understanding the resource implications of these processes at district level. A situational analysis in one district site, typical of rural areas in South Africa, was conducted, based on qualitative interviews with key stakeholders and the World Health Organization's Assessment Instrument for Mental Health Systems (WHO-AIMS). The findings suggest that the decentralization process remains largely limited to emergency management of psychiatric patients and ongoing psychopharmacological care of patients with stabilized chronic conditions. We suggest that, in a similar vein to other low- to middle-income countries, deinstitutionalization and comprehensive integrated mental health care in South Africa is hampered by a lack of resources for mental health care within the primary health care resource package, as well as the inefficient use of existing mental health resources.

Is universal access to antiretroviral drugs an emerging international norm?

The international community appears to have embraced a new norm — that of universal access to antiretroviral drugs. The process by which this norm has found acceptance raises interesting questions about how norm entrepreneurs frame their arguments, the role of non-state actors in realizing a norm, and the importance of existent complementary norms. To understand the success of the norm of universal antiretroviral access, I examine the failure of an earlier health-related norm — that of universal primary health care. The campaign for universal antiretroviral access points to a need for a more nuanced understanding of norm evolution within the international community and a more holistic vision of which actors can facilitate the realization of a norm.

Integrated HIV prevention and care strengthens primary health care: lessons from rural Haiti.

Three decades ago, the world's ministries of health declared primary health care--the delivery of basic preventive and curative services--a top priority. Since then, however, the world's poorest countries have not met most primary health care goals. Twenty-six years after the Declaration of Alma Ata, we are said to be living in a time of "limited resources," a phrase that construes various health interventions as competing priorities. As HIV has become the leading infectious cause of adult death in much of the world, it is difficult to argue that AIDS prevention and care are not ranking priorities for primary health care, yet precisely such arguments have held sway among international health policy makers. We present new information emerging from the scale-up of an established and integrated AIDS prevention-and-care program, based initially in a squatter settlement in central Haiti, to a second site in rural Haiti. The program includes robust prevention efforts as well as community-based therapy for advanced AIDS; three related components--women's health and active case finding and therapy for tuberculosis and sexually transmitted infections--were central to this effort. We tracked changes in key indices over the 14 months following the introduction of these services to a public clinic in central Haiti. We found that integrated AIDS prevention and care, including the use of antiretroviral agents, to be feasible in resource-poor settings and that such efforts may have favorable and readily measured impact on a number of primary health care goals, including vaccination, family planning, tuberculosis case finding and cure, and health promotion. Other collateral benefits, though less readily measured, include improved staff morale and enhanced confidence in public health and medicine. We conclude that improving AIDS prevention and treatment can help to reinvigorate flagging efforts to promote universal primary health care.