UNIT Introduction to
health, development
3
and Primary Health
Care
Welcome to Unit 3!
So far we have analysed the causes of ill-health and concluded that in order to
effectively and sustainably address health problems we need to not only address the
physical/biological causes but also the underlying socio-economic, cultural and political
root causes so as to make a lasting impact on the health of nations. In this unit we will
assess the impact of colonialism, industrial capitalism, monopoly capitalism and
imperialism on underdeveloped countries. Most people believe that the negative effects
far outweigh the benefits. The results were underdevelopment, increased poverty, a
system of dominant and dominated economies, as well as widening social inequality
between groups of people based on class, race and gender.
Study sessions
There are two Study Sessions in Unit 3:
Study Session 1 The impact of colonialism, capitalism and underdevelopment on
health care
Study Session 2 The Declaration of Alma Ata and the Primary Health Care Approach
Intended learning outcomes
By the end of this session, you should be able to:
Public Health Outcomes
Academic Learning Outcomes






Discuss how colonialism, capitalism
and underdevelopment have
impacted on Africa
Explore how development impacts
on the health status of the population
Describe the origins, evolution and
main features of Primary Health
Care (particularly Comprehensive
Primary Health Care)



Take notes
Compare information in texts
Interpret, compare and draw
diagrams to represent information
Read critically, read for a purpose,
identify key points, classify and
summarise information
Work out the meaning of terms
Draw conclusions from texts
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Unit 3 – Study Session 1
The impact of colonialism,
capitalism and
underdevelopment on health
care
Introduction
In the first study session of Unit 3, we focus on events that took place in Britain during
the 19th century with the growth of capitalism and industrialisation. We examine the
effects on the pattern of disease and death, and how Britain managed to improve the
health of the people through the distribution of some of the resources created by the
new capitalist system – a system based significantly on colonial exploitation. Ironically,
these processes contributed to the unequal development of countries of the North and
South, and a system of dominant and dominated economies. Historically, a more
equitable distribution of power and resources nationally and internationally has been
achieved through various forms of popular struggle.
Session contents
1
2
3
4
5
6
7
8
Learning outcomes of this session
Readings and references
Capitalism and colonialism
A brief history of colonialism and underdevelopment
How colonialism impacted on health systems
The evolution of health policies in underdeveloped nations.
Community-based approaches and national health systems
Session summary
Timing of this session
There are two readings for this session and five tasks. It should take you about 5 hours
to complete.
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1
LEARNING OUTCOMES OF THIS SESSION
By the end of this session, you should be able to:
Public Health Outcomes
Academic outcomes
 Discuss how colonialism and capitalism
impacted on development.
 Discuss how the legacy of colonialism and
capitalism impacts on health care in Africa
 Compare health services and expenditure
in developed and underdeveloped
countries
 Explain the inequitable distribution of
health care resources and measures taken
to address this
 Explain the basic needs approach




2
Preview texts
Take notes
Compare information in texts
Interpret, compare and draw
diagrams to represent information
 Read critically, read for a purpose,
identify key points, classify and
summarise information
 Work out the meaning of terms
 Draw conclusions from texts
READINGS AND REFERENCES
The two readings for this Study Session are listed below. You will be directed to them
in the course of the Study Session.
Author/s
Werner, D. &
Sanders, D.
Sanders, D
& Carver R.
3
Reference details
(1997). Ch 2 - The Historical Failures and Accomplishments of the
Western Medical Model in the Third World. In Questioning the
Solution: The Politics of Primary Health Care and Child Survival. Palo
Alto: HealthWrights: 13 -17.
(1985). Ch 3 - Health, Population and Underdevelopment. In The
Struggle for Health. London: Macmillan: 54-70.
CAPITALISM AND COLONIALISM
In preparation for the main readings in this session, clarify your understanding of the
concept of capitalism.
TASK 1 – Clarify concepts
1. On a mind-map, brainstorm as many key words as you can think of to do with
capitalism.
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FEEDBACK
Capitalism is an economic system in which private owners control the means of
production, including industrial, agricultural and financial resources, with the aim of
making a profit.
In history, capitalism has surfaced in different forms– merchant capitalism, industrial
capitalism and monopoly capitalism.
Merchant capitalism
Merchant capitalism started in the 16th century when European traders travelled to the
Middle East, the Far East and Africa to obtain spices, precious metal and ivory. They
soon also began to trade cloth, guns, beads and other goods for slaves, who were
shipped and sold in the East Coast of South America, the Caribbean Islands and the
southern parts of what is now the United States of America. These slaves worked on
plantations producing cotton, sugar and tobacco. These raw materials were taken back
to Britain and sold at a vast profit. Some of the traders later invested their profit in
industrial production and coal mining in Britain at the time of the ‘Industrial Revolution’.
The growth of industry became known as Industrial capitalism.
Industrial capitalism
Industrial capitalism is based on the private ownership of machines, factories,
industries and the employment of wage earners. The capitalist invests in capital, such
as land, raw materials, machinery and labour, to produce goods that will be distributed
and sold at a profit. In its pure form, industrial capitalism is based on the principle of
‘free competition’, whereby a large number of producers compete with each other to
produce, buy and sell goods or services in the market. The market operates according
to the laws of supply and demand, which regulates the supply and price of goods and
services. Put very simply, when there is more produced or available than can be sold,
the price falls. Conversely, when there is not enough produced to meet the demand,
there is a shortage, and so the price rises.
Monopoly capitalism
When large companies dominate national or international markets this is called
monopoly capitalism. These companies are referred to as ‘conglomerates’,
‘transnationals’ (TNCs) or ‘multinationals’ – the latter two operating in and across many
countries. When giant producers have no more room to expand in their own national
markets, they set up production in other parts of the word, to export their capital and to
conquer new markets for their finished goods. Together, TNCs control most of world
trade. They have no particular commitment to the countries in which they operate, and
their main commitment is to making a profit, using the available resources and labour.
Although they create jobs in these countries, they strive to keep wages as low as
possible. TNCs sometimes have enormous power and leverage over the governments
of these countries.
monopoly
the complete possession or control of something by one group or single producer
conglomerate
a large company that owns companies in different industrial sectors, such as mining,
or manufacturing
multi-nationals/transnationals
huge companies, usually with their headquarters in a First World country, and
factories, mines and offices in developing counties
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The map below shows the extent of the operations worldwide of the transnational Unilever.
The extent of the wealth of TNS and multinationals is enormous, particularly when
compared to the budgets of Third World countries, as illustrated in the table below.
State and Corporate Power, 1994 (US$ billions)
Country or
Total GDP or
corporation
corporate sales
General Motors
168.8
Ford
137.1
Toyota
111.1
IBM
72.0
Unilever
49.7
Nestle
47.8
Sony
47.6
Indonesia
174.6
Turkey
149.8
South Africa
123.3
Norway
109.6
Malaysia
68.5
Venezuela
59.0
Pakistan
57.1
Egypt
43.9
Nigeria
30.4
(Adapted from Fortune Magazine, 1996, World Bank, 1995d and UNRISD 1995)
Colonial domination of large parts of the world was one result of the growth of
monopoly capitalism at the end of the 19th Century. During this period, countries from
the North conquered territories in the South, exploited their wealth, exported capital to
them, and established new industries. We now take a closer look at colonial domination
and how it impacted on the social conditions, health and health care of the colonised
people.
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4
A BRIEF HISTORY OF COLONIALISM AND
UNDERDEVELOPMENT
TASK 2 – Check your knowledge of colonialism
1. What does colonialism mean? What was its purpose?
2. Who were the colonisers? Which continents and countries did they colonise? Jot
down your ideas.
FEEDBACK
Colonialism is the imposition of the power of one state over the territories of another,
(often through military conquest) for political or economic ends. Early colonialism refers to
the period during the 16th century when Latin America was colonised by Spain and
Portugal. However, the main period of colonial expansion was in the late 19th – 20th
centuries and is known as the ‘scramble for Africa’. During this period, European
missionaries, explorers and traders came to Africa. They soon realised the potential
wealth in Africa and saw African countries as a source of cheap, raw materials and an
outlet for the sale of manufactured goods from Europe. Thus, colonialism was geared
towards serving the interests of European industrial capitalism. Although there was
extensive resistance from Africans, by 1900, the whole continent was divided up and new
national and political boundaries were formed, ruled by various European countries.
The process of colonisation usually happened as follows:
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The two maps below show Africa before and after colonisation. Before colonisation, parts
of Africa contained independent African states and kingdoms, where people of similar
ethnic, tribal or religious origins lived. After colonisation, new national boundaries were
formed for most of the continent, ruled by various European countries.
Source: openlearn.open.ac.uk
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Capitalism and colonialism went hand in hand, disrupted traditional social systems, and
created new social classes of capitalist landowners, managers and workers. Although
these changes led to the development of industry and infrastructure and the provision of
services for some, they also served to exacerbate social inequality between groups of
people, based on class and race.
Read this oral history account of colonisation in Tanzania.
Tanzania: Colonialism and capitalism
My name is Shantsi and I live in Tanzania. This story was passed on to me by my
grandfather. It was told to him by his father who was a young man during the 1880s
when the colonists arrived.
When the whites first came to our country, they came on huge boats made of iron. We
Africans had never seen this before. At first we were curious to meet these strange
white people, but soon we started to hate them. The whites changed all our traditional
ways of living. They forced us to grow crops which we could not eat, like cotton. They
needed these crops in their own country. They turned our chiefs into overseers or
supervisors and made them whip us if we didn’t plant the white man’s crops. Many
families died of hunger because they weren’t allowed to use their own land to grow
food.
The white missionaries told our women to cover their bodies instead of wearing
traditional clothing. They changed our beliefs and forced us to become Christians. We
lost our land, our cattle and our youth, who went to work on the mines and in the new
towns. Many never came back.
(Adapted from ASECA, Development in Africa, Sached Trust, 1995: 3)
Colonisation in Tanzania did very little to develop the country. Traditional social, political
and economic life was totally disrupted. People died resisting colonialism, some died from
hunger, and others provided cheap labour for European-owned industries. With little
infrastructure and an economy built upon cash crops such as cotton, Tanzania was poor
and underdeveloped when independence came.
Most African countries achieved political independence during the 1950s and 1960s. The
last countries to gain independence were Zimbabwe, Namibia and South Africa. Although
politically independent, most African countries did not achieve economic independence.
Some countries, such as Nigeria, inherited huge political problems that have crippled
progress and development. Other countries, such as Tanzania, inherited weak economies
and have been unable to develop themselves.
The poverty and underdevelopment experienced by post-independent countries, can be
partly be explained by historical processes around their economic and political exploitation
through colonialism and capitalism. However, politically independent countries remain
poor and underdeveloped today and are particularly vulnerable to other forms of
economic domination. Can you think of some ways in which these countries continue to
be dominated economically today? Read this extract about Tanzania after independence.
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Tanzania – Post-independence
After independence, Tanzania chose to follow a socialist path of development and selfreliance. This was difficult. Although Tanzania restricted investment by foreign
countries, the government was forced to enter into agreements with some companies,
in order to develop Tanzania’s infrastructure, which in turn would support the growth
of trade and industry.
Here are two examples of what happened:
Britain offered to build a highway in Tanzania for US$110 million. Of this, only $10
million was spent in Tanzania. The rest of the funding was paid to British firms to plan
and build the road. Only eight Tanzanians were involved in building the road.
Tanzania asked a Canadian international development agency to build a new bread
factory in Tanzania. The construction cost Tanzania much more than they had
estimated. Only 60 Tanzanians were employed on this project. Canadian machinery was
used to build the factory, which meant that when it broke down, the Tanzanians had to
pay the Canadian company to fix it.
(Adapted from ASCA, Development in Africa, Sached Trust, 1995: 46.)
You can see from this extract that Tanzania had to depend on aid from the developed
world in order to build the infrastructure it needed. However, the aid really benefited the
developed countries more than Tanzania. So, as during colonialism, the developed world
continued to profit from the underdeveloped world, while the underdeveloped world lacked
power to develop itself. Many African countries found themselves in the same position as
Tanzania. For example, they depended on loans from organisation like the World Bank, in
order to develop their countries. However, these loans came with conditions that had
negative consequences. (For more information on the negative consequences of these
loans refer to IPH, Unit 3, Study Session 3.)
Political independence had not solved the economic problems of the Third World
countries. In fact, Third World countries have remained underdeveloped, and in some
cases have grown even poorer as a result of ongoing exploitation and domination by
more powerful First World countries. Sometimes this is termed ‘neo-colonialism’. New
forms of exploitation and dominance operate in the global world context today.
5
HOW COLONIALISM IMPACTED ON HEALTH CARE
The readings that follow provide an overview of how broader social and economic
developments in different periods impacted on the health of people, and the health
policies and health care approaches that were adopted in the countries of the South. The
first reading brings together and summarises many of the ideas discussed in this
session so far. It also provides useful examples and illustrations of these ideas. The
second readings provides an insight into the underdevelopment of the South, the
influence of the Western medical model, and the eventual rethinking of health care
strategies with a focus on meeting the basic needs of people and addressing the social
determinants of poor health.
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TASK 3 – Preview the text
READINGS
Sanders, D. & Carver R. (1985). (1985). Ch 3 - Health, Population and
Underdevelopment. In The Struggle for Health. London: Macmillan: 54-70.
Werner, D. & Sanders, D. (1997). Ch 2 - The Historical Failures and
Accomplishments of the Western Medical Model in the Third World. In
Questioning the Solution: The Politics of Primary Health Care and Child
Survival. Palo Alto: HealthWrights: 13-17.
1.
Quickly preview the whole of chapter 3 of the first reading (Sanders & Carver,
1985). Then read it carefully and make your own notes.
2.
Preview the second reading (Werner & Sanders, 1997) Now read the first
paragraph of the chapter. It tells us what the aim or purpose of the chapter is. Use
your own words to write down the main aim of the chapter. (Why are we looking at
the history of social and economic development in the Third World?)
3.
Continue reading Werner & Sanders (1997). Read the first sentence of each
paragraph and then answer these questions:
4.
a.
Who has directed the development of the undeveloped, less developed or
developing colonies in the South since colonial times?
b.
What did development planners emphasise in the late 1960s and early
1970s? Why was this trend reversed and what was the consequence?
c.
By the end of the colonial period, what was the Third World’s health care
approach modelled on? What was the main problem of this model?
d.
In the 1970s what new health care strategy emerged? What programme
emerged from this and what kind of methods were used?
e.
What plan was formulated by health ministers from around the world in
1978?
The notes you have made should provide you with a good summary of the main
ideas in this second reading. Compare these with the notes you made for the first
reading? Are they more or less useful, do you think? Why is this? How can you
improve your skills of making notes while reading?
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FEEDBACK
Below is an example of our brief summary of the main ideas in the reading:







The main aim of the chapter is to discuss the changing approaches to health care in
the Third World within the larger context of social and economic development at
various times.
From colonial times the North has directed the ‘development’ of the undeveloped,
less developed or developing colonies in the South.
In the late 1960s and early 1970s development planners emphasised the importance
of eliminating poverty through increasing employment opportunities and more
equitable income distribution. In other words, the focus was on an economic growth
model.
This trend was reversed in the late 1970s due to the economic crisis. The
consequence was growing unemployment and the continued inequitable distribution
of income.
By the end of the colonial period, the Third World’s health care approach was
modelled on that of the industrialised countries, i.e. a Western medical model. The
main problem of this model was that it ignored the underlying socio-economic and
political causes of health problems.
In the 1970s there was a growing move to a basic needs approach strategy. From
this the concept of community-based health care emerged. The Community-Based
Health Programmes that emerged used different methods to help people analyse
their own health needs and take action to organise around these needs.
In 1978 health ministers from around the world met in Alma Ata to formulate a plan
to make health services accessible to all people.
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TASK 4 – Read the text in detail
READING
Werner, D. & Sanders, D. (1997). Ch 2 - The Historical Failures and
Accomplishments of the Western Medical Model in the Third World. In
Questioning the Solution: The Politics of Primary Health Care and Child
Survival. Palo Alto: HealthWrights: 13-17.
1. The first section in the reading, The Development Debate, provides a critique of the development
that took place in Third World countries. Read through the section in detail.
2. Draw a timeline like the one below. Write brief notes on the shifting perspectives of development
since colonial times and some of the consequences this had for the Third World.
Perspective:
Late 19th/20th
century
Consequences:
1950s
1960s
1970s
1980s
1990s
3. Why is this section of the reading called, The Development Debate?
FEEDBACK
2.
Your timeline may look something like this:
Perspective:
Transfer of wealth
from South to North
Late 19th/20th
century
Consequences:
Underdevelopment
Economicgrowth
orientation
Basic services
for basic needs
Economic crisis
and political
shift to
conservative
right
Bail out loans
and cut back
on social
services to poor
1950s
1960s
1970s
1980s
Concentrated
wealth in hands
of a few –
expanding
poverty
No real change
Wages fell,
Unemployment
rose, basic
needs of
majority unmet
Structural
Adjustment
Programmes –
lowered wages,
reduced food
subsidies,
slashed
education and
public health
budgets
Big-business
promoting
policies to
eliminate
poverty
1990s
Gulf between
rich and poor
widening
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3.
The Third World has been subjected to ongoing, systematic underdevelopment by
the First World, in the name of ‘development’. The ongoing agenda has been the
transfer of wealth from the Third World to the First World; and this has harmed rather
than benefited a great number, possibly the majority, of people of the Third World.
6
THE EVOLUTION OF HEALTH POLICIES IN THE THIRD
WORLD
In the first paragraph of the Werner and Sanders (1997) reading we are told that,
“Changing perspectives of development strongly influence prevailing models of medical
and health services and affect who benefits most and who benefits least or is harmed
in some way” (1997:13). You now have some insight into these changing perspectives
and against this background you can now analyse how they affected health policies in
the Third World.
TASK 5 – Plot the development of health policies in Third World countries
READING
Werner, D. & Sanders, D. (1997). Ch 2 - The Historical Failures and
Accomplishments of the Western Medical Model in the Third World. In
Questioning the Solution: The Politics of Primary Health Care and Child
Survival. Palo Alto: HealthWrights: 13-17.
1.
Read the rest of the chapter. While you read, find and note down your answers to
these questions:
a.
Compare Western medicine in the post and traditional medicine in the past in
terms of the categories on the table below.
Western medicine
Traditional medicine
Target group
Aim
Emphasis
Staff and training
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b.
Think about the authors’ use of the term ‘disease palace’. What position do
you think they adopt around the role of the medical profession in health care
in underdeveloped countries in the past? Is it a positive or critical picture?
c.
What is a ‘vertical’ public health campaign, and how effective have they
been?
d.
What is the basic needs approach? How did it attempt to provide basic
services to more people?
e.
What is Community-based health care? How did it attempt to provide basic
services to more people?
FEEDBACK
a.
Here is an example of how you could have filled in the table:
Target group
Aim
Emphasis
Staff and training
Western medicine
Mainly Europeans, urban
areas, minimal care for others.
Combat diseases and
preserve health of Europeans;
maintain healthy workforce to
ensure profits.
Expensive, high-technology
and urban-based curative care
in large hospitals. Some
preventive measure directed
at biological causes.
Western-trained care
providers.
Traditional medicine
Main providers of health care
to local people, all areas –
rural and urban.
Heal, explain spiritual causes
of illness.
Traditional, as well as some
Western illnesses and their
spiritual causes.
Varied kinds of healers,
informal training.
b.
The term ‘disease palaces’ suggests a modern, well-staffed, well-equipped
hospital based in an urban area, which mainly treats diseases of the rich, using
the most expensive, imported equipment and medicines. The diseases of the poor
are neglected. From this term we can detect the authors’ critical stance towards
the role of the medical profession. The illustrations on page 14 of the reading
suggest that the people who benefited most from these disease palaces were the
doctors themselves.
c.
Vertical campaigns were preventive campaigns, narrowly aimed at a single
disease, such as smallpox or malaria. They were expensive to run and were
generally not comprehensive. They were preventive campaigns and often
organised under a separate authority, such as the provincial authorities, rather
than by the Ministries of Health, which were mainly responsible for hospitals.
The basic needs approach was based on the growing understanding that health
care was a basic human right and that more effective ways of providing basic
services to all people needed to be found. Auxiliaries were introduced as a more
appropriate category than medical doctors and nurses, particularly in areas where
d.
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nutritional and communicable diseases were predominant. They were able to
deliver relatively simple interventions required to improve the health of the
majority of people. However auxiliaries had little attachment or accountability to
the communities they served, and many dropped out or migrated up the medical
hierarchy.
e.
Community-based health care focused on preventive measures, health education
and involvement and leadership of members of the community. Community health
workers or health promoters were selected from and by their own communities
and received training in how to help their community diagnose the underlying
causes of poor health and meet their most important health needs. The approach
was focused on taking action to reduce poverty and to improve the circumstances
in which people lived, and in this way address the major diseases affecting
communities.
7 COMMUNITY-BASED APPROACHES AND NATIONAL HEALTH
SYSTEMS
One of the reasons why the barefoot doctor programme in China was so effective was
that it took health care right into the communities that needed it the most. In addition
the programme had the full backing of the central government. In other words, there
was a strong political will and commitment on the part of the government to ensuring
comprehensive health care for all. (The development of political will on the part of
government is extremely important for ensuring that the necessary financial,
institutional and human resources are allocated for health development and for a
reduction of inequalities.) The results grabbed the attention of other health planners
from around the world.
In 1978 health ministers met at Alma-Ata in Kazakhstan, at that time a socialist republic
of the USSR, to adopt what was called, the Declaration of Alma Ata, which expressed
the need for urgent action by all governments to protect and promote the health of all
the people of the world. Health was seen as a socio-economic issue and health care as
a basic human right, and the State was seen as being responsible for providing
adequate health and social measures. Primary health care was seen as the route to
ensure ‘health for all’. The Alma Ata Declaration put health equity on the international
political agenda. You will read more about the Alma Ata Declaration and Primary
Health Care in the next sessions.
8
SESSION SUMMARY
This session has provided a broad history into the ‘underdevelopment’ and the ongoing
high prevalence of ill-health in underdeveloped countries of the South. Through the
readings we discussed how the concept of development for most of the 20th century
was synonymous with economic growth, rather than human development. We
discussed the evolution of health policies in the Third World, from the adoption of the
Western Medical Model to community-based approaches.
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Unit 3 – Study Session 2
The Declaration of Alma Ata
and the Primary Health Care
Approach
“Too often, in planning strategies to improve health, the people whose lives are
most vulnerable have not been consulted. However, the Alma Ata Conference
of 1978 was something of an exception. Among its participants were pioneers
of community-based health care initiatives from several countries. They
emphasized the need, in the pursuit of Health for All, to confront the underlying
social, economic and political causes of poverty and poor health. The result was
the potentially revolutionary Alma Ata Declaration, which promoted a
comprehensive, multi sectoral approach named Primary Health Care. This
called for a New Economic Order based on equity and "social justice", to be
achieved through strong community participation.”
(David Werner, Health and Equity: Need for a People’s
Perspective in the Quest for World Health, 1998)
Introduction
In this study session we focus on health care and the changes that have taken place in
recent times. We start with a brief overview of the Declaration of Alma Ata which was
drawn up and adopted in 1978, and discuss the principle of the Primary Health Care
Approach that it embodies. We then track the implementation of these principles and
the four-pronged strategy that it advocated as a holistic response to health care and
the factors that determine ill-health.
Session contents
1
2
3
4
5
6
Learning outcomes of this session
Readings and references
The evolution of the Primary Health Care Approach
The main features of the Primary Health Care Approach
Rehabilitative, Curative, Preventive, Promotive
Session summary
Timing of this session
This session has two readings and three tasks. It should take about three hours to
complete.
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1
LEARNING OUTCOMES OF THIS SESSION
By the end of this session you should be able to:
Public Health Outcomes
Academic outcomes
 Describe the origins, evolution and main
features of the Primary Health Care
approach
 Explain the terms rehabilitative, curative,
preventive and promotive
 Describe the implementation of the
Primary Health Care Approach since
1978






2
Preview texts
Read in detail for meaning
Take notes as you read
Summarise texts
Make comparisons
Work out the meaning of concepts
from their root words
READINGS AND REFERENCES
You will be referred to the following readings in this session.
Author/s
Walt, G. &
Vaughan, P.
Publication details
Walt, G. & Vaughan P. (1981). Introduction. In An introduction to
the primary health care approach in developing countries,
London: Ross Institute of Tropical Hygiene: 1–12.
Werner, D. &
Sanders, D.
(1997). Ch 3 - Alma Ata and the institutionalization of Primary
Health Care In Questioning the Solution: The Politics of Primary
Health Care and Child Survival. Palo Alto: HealthWrights: 18-22.
2
THE EVOLUTION OF PRIMARY HEALTH CARE
In 1978 health ministers and their advisers from 134 countries from around the world
met in the city of Alma Ata in Kazakhstan (then in the USSR) at an International
Conference organised by the World Health Organisation (WHO) and UNICEF on
Primary Health Care. Their purpose was to develop a plan to achieve: ‘Health for All by
the Year 2000’.
The final document adopted by the Conference was the Alma Ata Declaration, which
called for, “urgent and effective national and international action to develop and
implement primary health care throughout the world and particularly in developing
countries.”
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Alma Ata, the capital of Kazakhstan, now called Almaty, was the site of the 1978
WHO/UNICEF conference ‘Health for All by the Year 2000’.
The two readings in this session provide you with a good overview of how primary
health care developed historically and what the original approach involved, as set out in
the Alma Ata Declaration. Each reading focuses on slightly different principles from the
Declaration.
TASK 1 – Read about the history of the Primary Health Care Approach
READING
Walt, G. & Vaughan P. (1981). Introduction. In An introduction to the
primary health care approach in developing countries, London: Ross
Institute of Tropical Hygiene: 1–12.
1.
Preview the above reading: What is the title of the reading? What do you expect it
is going to cover? Look at the headings. Skim the first three lines of each
numbered section. Notice that each begins with some dates. What does this tell
you about the likely content of each of these sections?
2.
Read through the text in detail. As you read, underline what you think is really
important.
3.
Summarise in a few sentences the main purpose of the reading and the main
ideas.
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FEEDBACK
This reading gives you an introduction to the Primary Health Care (PHC) Approach. It
attempts to define the concept of primary health care and outline the main principles of
the approach. The Alma Ata Declaration was a declaration of principles and a broad
strategy for implementation of PHC.
To sum up this reading, the evolution of Primary Health Care included:

Changing theories of development which demonstrated the impact that
socioeconomic and environmental factors have on health. (Remember you
studied this in Unit 2 and saw the results than can be achieved when
underdevelopment and social determinants of health are addressed, e.g. the
case example of 19th Century England and Wales).

Concern about population growth which later led to support for material and
child health services.

A realisation that the Western medical model did not address the social
determinants of health.

The reported success of the health achievements that community-based health
projects had achieved in China as well as in several other countries. These
demonstrated the impact of a comprehensive approach to health and health
care.
4
THE RATIONALE AND PRINCIPLES OF THE PRIMARY HEATH
CARE APPROACH
The Primary Health Care Approach that was embodied in the Declaration of Alma Ata
signalled a shift in attitude about health and health care. No longer was health simply
seen as the absence of disease as a result of biomedical interventions; it was now also
seen as a result of social determinants which impacted on health. The spirit of the
Declaration also broadened the focus of development from economic growth to the
development of people and communities. It recognised the basic right to health for
each individual and called for an approach that rested on the principle of equitable use
of health resources.
The basic principles and requirements of Primary Health Care are:

Universal accessibility: The total coverage of the population with basic, but
essential health care, with particular attention being given to the needy,
vulnerable groups (equity).

Comprehensive care: An emphasis on disease prevention and health
promotion.

Community and individual involvement and self-reliance: Communities should
participate actively in the planning, implementation and evaluation of health
services.
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
Intersectoral action for health: Health services should co-ordinate with other
sectors involved in development, since progress in health leads to and depends
on socio-economic progress.

Appropriate technology and cost-effectiveness in relation to available
resources: Health care services should focus on the major health problems,
should be affordable, and employ technologies that are locally appropriate as
well as acceptable.
The elements or programmes of Primary Health Care as stated in the Alma Ata
Declaration are:

The promotion of proper nutrition and adequate supply of safe water and basic
sanitation

Maternal and child health care, including family planning

Immunisation against the major infectious diseases

Prevention and control of locally endemic diseases

Appropriate treatment of common diseases and injuries

Health education concerning prevailing health problems and methods of
prevention and control.
The table below shows the change in focus, content, organisation and responsibility
from Primary Medical Care to Primary Health Care. It was developed for a European
audience and hence emphasises doctors (specialists, physicians, general practitioners)
who may not be the most numerous or important health personnel in developing
countries.
Table 1: From Primary Medical to Primary Health Care
Focus
Contents
Organisation
Responsibility
From Primary Medical Care
Illness
Cure
Treatment
Episodic curative care
Specific problems
Specialists
Physicians
Single-handed
Health sector alone
Professional dominance
Passive reception
To Primary Health Care
Health needs
Prevention and care
Health promotion
Continuous care
Comprehensive care
Person-centred
General practitioners
Other personnel groups
Team
Intersectoral collaboration
Community participation
Self-responsibility – people are
partners in managing their own
health and that of their
community
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The second reading will help you to consolidate your understanding of Primary Health
Care and describe developments after Alma Ata.
TASK 2 - Read the Declaration of Alma Ata
READING
Werner, D. & Sanders, D. ((1997). Ch 3 - Alma Ata and the
institutionalization of Primary Health Care. In Questioning the Solution: The
Politics of Primary Health Care and Child Survival. Palo Alto: HealthWrights:
18-22.
1.
Preview the above reading and answer these questions:
a. What is the title of the reading? What does institutionalisation mean?
b. Look at the headings in the reading. Skim the first three lines of each
section. What do you expect the reading to cover?
2.
Read through pages 18–19 of Chapter 3 (up until Resistance to Primary Health
Care) and the Declaration of Alma Ata on pages 21–22. As you read, note down
the key points. Try to use your own words. Here are some questions to help direct
your reading and note-taking:
a.
b.
c.
d.
e.
f.
g.
h.
3.
How is health defined in the Declaration?
What does it mean that health is a fundamental human right?
What does the Declaration identify as the causes of poverty and poor health
that need to be addressed?
Who has rights and responsibilities to participate in health care?
How must governments fulfil their responsibility for the health of their
people?
How is Primary Health Care (PHC) described in the Declaration? Give some
examples of what it includes.
Who should be involved in the health team?
How was it envisaged that health for all people by the year 2000 could be
attained throughout the world?
Now read through pages 19-20 of the reading. On a table like the one below, write
the five basic principles of PHC in Column 1. In Column 2 write brief notes about
the resistance to these principles and the implementation of PHC.
Principles of PHC
Resistance
1.
2.
3.
4.
5.
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FEEDBACK
Question 2:
a. Alma Ata’s definition of health was based on the WHO’s definition, that health is
not just the absence of disease, but also includes a state of physical, mental and
social well-being.
b. Human rights are rights and freedoms that everyone has, just because they are
human. For example, everyone has the right to life. No once can take these rights
from us. Health is classified as one of these basic rights, rather than a luxury for a
privileged few. Human rights must be respected, protected, promoted and fulfilled.
c. The Declaration emphasises the need to address the underlying social, economic
and political causes of poverty and poor health.
d. The Declaration calls for the participation of individuals, families and communities
in controlling their own health, being involved in health programmes, and
decisions that affect them.
e. Governments must provide adequate and equally accessible health services to
all, as well as social measures to ensure the health of their people.
f.
PHC was defined as the first (primary) contact people have with the national
health system; bringing health care to where people live and work. It is also seen
as the first step in the ongoing health care process. The approach to health care
addresses the main health problems and health care needs in a community as
well as the underlying social determinants of poor health. It calls for a more
equitable response to basic health care needs.
g. The health team should include local health workers, doctors, nurses, midwives,
auxiliaries, community workers, and traditional healers.
h. All countries needed to cooperate with each other to ensure primary health care
for all. This would provide a more equitable distribution and use of the world’s
resources.
Principles of PHC
Resistance
1. Health services must be equally
accessible to all. They must be
available to rural as well as urban
people.
Social justice agenda and addressing
root causes of poor health threatened
leaders of many countries.
2. There must be maximum community
and individual involvement in health
care decisions and self-reliance.
National programmes launched but PHC
treated as extension of old top-down
approach.
Often resistance to true participation by
communities.
Central control of PHC and weak
community participation. Not seen as
agents of change.
3. The PHC programmes must provide
comprehensive care involving four
main components: promotive,
Western medical system remained with
emphasis on curative services.
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preventive, curative and
rehabilitative services, with an
emphasis on disease prevention and
health promotion.
4. The methods and technology used in
the health system must be
appropriate, easy to use and costeffective in terms of available
resources.
One example was continuing use of
nonessential drugs in contrast to PHC
ethos of responsible and limited use of
medicines.
5. Health must be seen as only part of
total care which includes all the other
essential requirements. There should
be intersectoral collaboration to
address the social and environmental
determinants of health.
Global health institutions stripped PHC
of its comprehensive and transformative
potential and reduced it to a narrow,
technical approach.
Before ending this session, it is important to clarify some important terms in the fourpronged approach of comprehensive primary health care.
5
REHABILITATIVE, CURATIVE, PREVENTIVE, PROMOTIVE
TASK 3 – Clarify terms
1.
Brainstorm what you understand by the terms: rehabilitative, curative, preventive
and promotive. Give an example of each term if you can.
2.
Which of the four approaches is primarily individually focused, and which is
primarily population focused?
FEEDBACK
Your answers may differ but could include the following:
Rehabilitative comes from the word, ‘rehabilitate’ which means to help someone to
live a healthy active life again after some illness. So rehabilitative services are all those
services involved in assisting the person to recover from a disease. For example,
making sure that the person eats a balanced and healthy diet to help the immune
system recover. These services are primarily individually focused.
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Curative comes from the word, ‘cure’, which means to treat an illness or condition in
some way so that it clears up and goes away. For example, by giving the person
medication. These services are primarily individually focused.
Preventive comes from the word, ‘prevent’, which means to stop an illness spreading
or infecting someone, before it starts. For example, by ensuring that the person is well
nourished and lives a healthy lifestyle. These services are primarily population focused.
Promotive comes from the word, ‘promote’; this means to encourage or persuade
people to support or use something. For example, to teach people how to prevent
illness through keeping themselves and their environment safe and healthy, or to lobby
government for better social services to prevent illness and infection. These services
are primarily population focused.
Academic learning skills
Whenever you need to explain a term or concept, look for the root word that the
concept comes from. You can usually work out the meaning of the word from its
root.
In the comprehensive Primary Health Care Approach, the following four strategies are
used together in a holistic way, rather than only one strategy selected and focused on:
1.
The rehabilitative approach: Emphasises restoring people with an acute or
chronic illness to a state of improved health. For example, exercises to improve
chronic backache pain, or nutrition rehabilitation after a severe childhood illness,
or in the case of TB, both medical and social rehabilitation may be required. This
approach is primarily focused on the individual who is ill.
2.
The curative approach: Emphasises the treatment of the biological and
psychological causes and symptoms of disease, through the use of medicine and
other therapies. For example, the use of Oral Rehydration Therapy (ORT) for
children with chronic diarrhoea or the use of antiretrovirals for people living with
HIV/AIDS. This approach is also mainly focused on the individual.
3.
The preventive approach: Emphasises preventing or avoiding sickness in
populations and individuals. For example, through anti-malarial tablets, the use of
bed nets to protect against mosquitoes, health education and immunisation
programmes. The focus is primarily on populations but some are individually
focused, such as vaccination.
4.
The promotive approach: Emphasises addressing basic social, economic and
political causes of ill-health through advocacy and lobbying government and policy
makers, for example, to ban smoking in public places. It also focuses on
intersectoral interventions directed at households or communities to improve
water supply, sanitation, housing and so on. The focus is primarily on populations.
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6
SESSION SUMMARY
This session has focused on the origins, evolution and rationale for the Primary Health
Care approach. We discussed how the comprehensive PHC approach incorporates
four elements or strategies – rehabilitative, curative, preventive and promotive.
In Unit 4 you will learn more about the PHC Approach and how it has been
implemented since 1978.
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