Primary Health Care 1978-2008:
The Canadian Experience in a Global
Context
LSBFON
© 2010
AN INTRODUCTION TO THE VIDEO
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Prior to watching this video, please review the Q &
A’s below which highlight the historical context within
which Primary Health Care has evolved locally and
globally during the years 1978 -2008. The video can
then be viewed as a whole or one part at a time.
The two parts are:
PHC: The Canadian Experience in a Global Context
(30 min) and
PHC: A Global Context: The Brazilian Case (15
min.)
ABOUT THE VIDEO
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This video highlights community health nurses’ reflections upon
thirty years of Primary Health Care in Canada. The narratives
confirm that community health nurses (CHNs) support the
values and principles of PHC and share an ongoing
commitment to struggle for the full implementation of PHC
within Canada. Community health nurses, academics, and
administrators/physicians interviewed in the video reflect upon
local and global PHC challenges and best practices. The
Canadian PHC experience is compared with several
international experiences including the Brazilian experience.
This is an ideal teaching tool to support
undergraduate/graduate students, practitioners, and faculty
members as they learn about PHC in Canada within a global
context.
Credits
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Executive Producer:
Dr. Geraldine (Jody) Macdonald, RN EdD
LSBFON, g.macdonald@utoronto.ca
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Producer & Editor:
William (Bill) McQueen,
Fireweed Media Productions,
wmcq@netrover.com
Research Assistant
Pam Walker RN MN
LSBFON
Q: What is Primary Health Care?
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A: Primary Health Care (PHC) is an
approach and philosophy of health care that
was initiated in Alma Ata, Kazikstan, in 1978
at a WHO-UNICEF conference. It set as its
initial goal Health for All by the Year
2000. Although many countries have
integrated PHC into their national health care
systems, the goal of Health for All by the Year
2000 was not achieved globally.
Q: What are the guiding principles of
Primary Health Care?
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A: The guiding principles of primary health
care include Accessibility, Public
Participation, Health Promotion, Appropriate
use of Technology and Intersectoral
Collaboration (Smith, Jacobson and Yiu,
2008).
Q: Does the World Health Organization
still value PHC?
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A: Yes, the WHO does value PHC. In 2008, the WHO
reconfirmed their commitment to PHC as the means and
philosophy guiding equitable health care for the future in their
document - Primary Health Care: Now More Than
Ever. Writing in the UN Chronicle (2010), Dr. Margaret Chan,
Director-General of the World Health Organization confirms the
need to support PHC to ensure the goal of health for all,
including the poor, is reached. Dr. Chan confirms that leaders
in all regions of the world support the renewal of PHC and
commitment towards meeting WHO’s Millennial Development
Goals:
Q: Does the World Health Organization
still value PHC? (continued)
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Health systems will not automatically gravitate towards greater
efficiency or greater equity in access to care. Unless deliberate steps
are taken, steady advances in the biomedical sciences will continue to
benefit a privileged minority, the poor will continue to be excluded from
basic essential care, and the gaps in health outcomes will grow wider,
both within and between countries.
Above all, as experience during the previous decade so clearly
shows, all the cash, commitment, and caring in the world will not
improve health in the absence of well-functioning systems for service
delivery. As a platform for strengthening health systems, primary
health care makes fairness in access to quality health care an explicit
policy objective. The Millennium Development Goals promote health
as a route to poverty reduction. To put it bluntly, if we miss the poor, we
miss the point.
(Chan, 2010)
Q: In 1986 the WHO adopted the Ottawa Charter for
Health. How did Canada’s leadership in Health
Promotion, a key principle of PHC, emerge?
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A: Eight years after the WHO-UNICEF conference at Alma Ata, in
1986, the first International Conference on Health Promotion was held
in Ottawa, Canada. At this conference, a seminal document called the
Ottawa Charter was launched. The Ottawa Charter was intended as a
plan for action to “achieve health for all by the year 2000 and beyond”
(Ottawa Charter, 1986), and established Canada as a leader in health
promotion. The Charter outlines five areas that define health
promotion: Build healthy public policy; Create supportive
environments; Strengthen community action; Develop personal skills;
and Reorient health services (Ottawa Charter, 1986). The Ottawa
Charter defines the prerequisites for health as peace, shelter,
education, food, income, a stable eco-system, sustainable resources,
social justice and equity, and urges the health sector to go beyond
clinical and curative services, include health promotion, and advocate
for equity in health through collaboration with communities and
governments (Ottawa Charter, 1986).
Q: How did PHC and the Ottawa
Charter change health care locally and
globally?
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A: PHC and The Ottawa Charter began an
era of theorizing and talking about health
care in terms of health promotion and
wellness for all, as opposed to treatment and
curing based on an illness model. Both PHC
and the Ottawa Charter reflect the values of
social justice and equity, and the importance
of building healthy public policy for a healthy
citizenry.
Q: How have PHC and the Ottawa
Charter influenced nursing?
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A: Since 1986 new expectations for nurses were identified which identify
the obligation of nurses to promote accessibility and equity in health
care. Canadian nursing associations now reflect an expectation that nurses
become more involved in social justice and policy advocacy in their standards
of practice and codes of ethics. For example, the Canadian Nurses Association
(CNA) Code of Ethics includes “Promoting Justice” as a nursing value and
ethical responsibility. All of the provincial regulating boards for nursing in
Canada include the CNA Code of Ethics as part of their standards of practice
for nurses. The CNA also has a “Position Statement on Global Health and
Equity,” that states that “nurses have the right and responsibility to raise
awareness of the root causes of inequity…and to participate in finding
solutions” (CNA, retrieved April 2009). The Community Health Nurses
Association of Canada (CHNAC) also includes “Facilitating access and equity”
as one of the standards of practice for Canadian community health nurses
(CHNAC, retrieved January, 2009).
Q: How are the terms ‘PHC’ & ‘primary
care’ related and yet distinct?
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A: Labonte et al. (2008) note that efforts to enhance PHC in wealthy nations such as
Europe and North America have focused largely on accessibility to general practice
physicians, contributing to the confusion between PHC and primary care, or first line
medical care. This has certainly been an issue in Canada, and Smith, Jacobson and Yiu
(2008) make the distinction between PHC and primary care for nursing students, defining
“primary care” as care that is the first point of contact with the health care system, care that
is generally narrow in scope and often biomedical in its focus. The confusion is not only an
issue for students, however, but also for the public and practitioners alike. Wong et al
(2008) interviewed residents of British Columbia to determine what domains of Primary
Health Care were perceived as important by the public. The authors however, confuse the
definition of PHC with primary care, and define PHC “as the first point of contact with the
healthcare system and as the setting where short-term, acute health issues are resolved
and the majority of chronic health conditions are managed” (Wong et al., pp. 91). As a
result, participants in this study prioritize what they think is important when they go to see
their Family Doctor, and for most of them, accessibility is the most important: being able to
see their usual provider in a timely fashion, (waiting no more than one week), (Wong, et al,
2008). PHC does include primary care, but as Nelson (2009) points out, “primary health
care in its broadest sense is not simply a case of having more individual providers…it is
about working with communities…to promote health where it is produced: in people’s
everyday lives” (pp. 8).
Q: What are the ‘social determinants of
health’ (SDOH)?
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A: The ‘Social Determinants of Health-SDOH’ are
key social factors that impact on the health of
citizens in Canada and globally. The Public Health
Agency of Canada identifies the SDOH as: Income
and Social Status; Social Support Networks;
Education & Literacy; Employment/Working
Conditions; Social Environments; Physical
Environments; Personal Health Practices and
Coping Skills; Healthy Child Development; Biology
and Genetic Endowment; Health Services; Gender;
and Culture.
Q: Why has it been so difficult to
address the SDOH in Canada and
globally?
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A: Raphael et al., (2008) identify neoliberal ideology as the barrier to the implementation of
a SDOH agenda in Canada. This article describes how the dominance positivism, the
ideology of individualism and twenty years of neoliberalism have influenced Canadian
health policy (Raphael et al., 2008). The discussion reflects a concern that the Canadian
citizenry is ignorant of the social effects of neoliberalism, that include deep cuts to
government funding of health care and widening inequity in health (Raphael et al., 2008).
The influence of neoliberalism on health is a concern that is not confined to Canada.
Labonte et al. (2008) note how the market ideology of neoliberalism with
World Bank’s endorsement of privatization has influenced the global development of health
systems and strategies that are cost-effective and ignore the SDOH.
Raphael et al. (2008) suggest that the large numbers of health researchers, promoters and
employees in the health field could use their knowledge to educate the public about the
SDOH (Raphael et al., 2008). To this end they note that there is evidence that the media
and policy makers are receptive to qualitative community-based research that tells the
personal stories of how the SDOH affect peoples’ lives (Raphael et al., 2008). These
strategies together could motivate the public to political action to challenge the Canadian
government’s neoliberal health policies (Raphael et al., 2008).
Q: What challenges do researchers
face trying to promote health for all,
the goal of PHC?
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A: Kalucy et al (2009), in their study of the impact of seventeen PHC
research projects in Australia, note that PHC research that is most
able to impact health policy and practice requires immense effort on
the part of the researchers to disseminate the results. Researchers in
these studies used a wide variety of methods to share their results with
different audiences, including presentations, publications, use of media
and websites.
Nurses, including nurse researchers, often perceive health as neutral
and not political, but health is political, and as a result nursing care is
also political, not neutral (Holmes & Gastaldo, 2002). Labonte et al.,
(2008) found that the political climate in Latin America has influenced
long-lasting and comprehensive PHC programs, especially in countries
that have implemented universal health care and integrated programs.
Q: Why has Brazil been a success
story in terms of PHC?
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A: Labonte et al., (2008) cite Brazil as an
international example of comprehensive
PHC, where political reform in the 1980’s,
coupled with democratization and social
action have lead to the success of large
scale programs. Sampaio and Buss (2008)
note that political support and positive
electoral feedback have helped to sustain
PHC in Brazil.
Q: How has PHC been supported in
Venezuela?
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A: Muntaner et al. (2006) provide an example of how the political
climate in Venezuela similarly influenced the creation of its PHC
program called, “Mision Barrio Adentro” that it implemented in
collaboration with Cuba. Widespread, deep poverty and two decades
of activism led to the 1999 election of Hugo Chavez , and with
extensive consultation throughout the country and public participation,
Venezuela has been able to achieve immense success with PHC
health reform, despite organized medical opposition to health care
reform and strong opposition by affluent Venezuelans (Muntaner, et
al., 2006). A unique feature of Mision Barrio Adentrro is the Health
Committees, a mechanism that was established as part of the program
to support public participation and action of barrio residents (Muntaner,
et al., 2006). Public participation is a key principle of PHC.
Q: In the past thirty years, what
success have countries have
implementing PHC?
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A: Over the last thirty years, countries around the world have gained
experience in trying to implement PHC that is comprehensive, and have stories
of success with strategies that specifically address one or more of the principles
of PHC (Accessibility, Public Participation, Health Promotion, Appropriate use of
Technology and Intersectoral Collaboration). Research and literature on PHC
in recent years also looks at how well different countries have embraced a
broad view of health.
Labonte et al. (2008) found that Aboriginal communities in Australia have been
increasingly able to implement comprehensive PHC programs when the
communities themselves have control of their health services. Key ingredients
for effective health care in Aboriginal communities include public participation
and consultation (Labonte et a., 2008). Similarly, health care provided in
Aboriginal communities in Canada is most effective when it is provided in
consultation with the community (Kingblood and Roberts, 2008; Royal
Commission on Aboriginal Peoples, 1993).
Q: In the past thirty years, what
success have countries have
implementing PHC? (cont’d)
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Since 1977, the people of Thailand have experienced success with
their PHC strategy with dramatic improvements in child nutrition,
immunization rates, clean water, sanitization and the provision of
essential drugs (Labonte et al., 2008. Intersectoral Collaboration
(between education, agriculture and community development) and
community participation (supported by community volunteers and paid
health workers) have contributed largely to the success of PHC in
Thailand (Labonte et al., 2008).
Chiarelli and Edwards (2006) describe literacy as a significant health
issue that persists in Canada, and look at policies that can improve
basic literacy, health literacy and reduce disparity in vulnerable
populations (Chiarelli and Edwards, 2006). The authors illustrate how
Intersectoral Collaboration (in this case between health and
education), community-based participatory approaches and university
partnerships with community organizations can positively impact policy
development (Chiarelli and Edwards, 2006).
Q: In the past thirty years, what
success have countries have
implementing PHC? (cont’d)
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Two articles that describe the broad health benefits of
community gardening in South-East Toronto (Wakefield et al.,
2007) and how the greening of school grounds in the Toronto
district school board promoted social inclusion (Dyment and
Bell, 2008). Two additional students present a broad view of
health. Wakefield et al. (2007) provide a rich description of a
positive qualitative community based research project with
methods and results that strongly challenge positivist and
neoliberal themes. The Dyment and Bell (2008) study
demonstrates a relationship between natural environments and
harmonious social relationships.
Q: Why are nurses key to the
successful implementation of PHC in
countries and communities?
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A: In many countries, nursing is the largest group in health, and
plays a major role in the health education of entire populations
(Holmes & Gastaldo, 2002), and nursing has been involved in
implementing PHC, since Alma Ata in 1978. With increased
numbers of nurses earning graduate degrees, more have jobs
that influence health policy and contribute to nursing knowledge
(Holmes & Gastaldo, 2002). We can hope that increased
political influence combined with knowledge of PHC and its
principles, nurses will continue to be able to make a significant
contribution in the future success of PHC, globally and here in
Canada.
Q: How is PHC introduced to
undergraduate nursing students at the
Bloomberg Faculty of Nursing,
University of Toronto?
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A: At the Lawrence S. Bloomberg Faculty of
Nursing, Primary Health Care is introduced as the
foundation for health care reform, locally and
globally, and the content of the community health
course in the senior year of the undergraduate
program considers the contribution of community
health nursing to health care reform (Undergraduate
Courses, Bachelor of Science in Nursing, Lawrence
S. Bloomberg Faculty of Nursing, 10/31/2008).
Q: What text is used to support
nursing student learning about PHC?
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A: The community health nursing text used at the Lawrence S. Bloomberg
Faculty of Nursing, is titled Community Health Nursing: A Canadian
Perspective, includes a chapter dedicated to Primary Health Care that
discusses its philosophy, principles, and values of social justice and health
equity (Smith, Jacobson and Yiu, 2008). The authors note that the political,
social and environmental elements of PHC have been ignored in Western
nations due to the dominance of biomedical and behavioral approaches in
health, and political and ideological reinforcement of the belief that the
biomedical approach equals health: Canada is not spared in their critique, with
its failure to implement PHC and the growing inequity in the country (Smith,
Jacobson and Yiu, 2008). The chapter concludes with an endorsement that
community nurses become involved in PHC reform through political action and
increased participation in community organizations, advocacy and coalition
building (Smith, Jacobson and Yiu, 2008). This text also presents the Canadian
Community Health Nursing Standards of Practice (CHNAC), which are based
on the principles of PHC (CHNAC, 2008). [note a new edition will be published
in 2011 and in the future we will use the new edition]
Q: How does the video portray
Primary Health Care in Canada?
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A: The video highlights the achievements of Canada in promoting
PHC over the past thirty years -- 1978 to 2008. It challenges viewers
to reflect upon the value of equity in health, the important of the social
determinants of health (SDOH), and to assess the contributions of
health care in Canada to meeting the values and principles of
PHC. The video suggests that the Canadian health care system has
achieved much in its progress towards Health for All -- but has not
named PHC explicitly and has not adopted a PHC national health care
system as we have a provincially/territorially funded and controlled
health care system. Part one ends by considering the potential of
Canada to make a stronger commitment to PHC, and leads to part
two, which explores key strengths in the Brazilian global community in
achieving PHC goals, values, and health outcomes.
Q: What references were used to
support this introduction?
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A: Please see the following:
Canadian Nurses Association, Position Statement on Global
Health and Equity. Retrieved
April 3, 2009, from http://www.cna/aic.ca.
Canadian Nurses Association, Code of Ethics for Registered
Nurses. Retrieved April 3,
2009, from http://www.cna/aic.ca.
Chan, M. (2010). World Health Organization, Primary Health
Care: Now More Than
Ever. UN Chronicle, XLVII (3), Retrieved December 4, 2010
from http://www.un.org/wcm/content/site/chronicle/home
Q: What references were used to
support this introduction? (Cont’d)
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Chiarelli, L. & Edwards, P. (2006). Building healthy public policy. Canadian
Journal of Public Health, 97, S37- S41. Retrieved August 17, 2008 from
Community Health Nurses Association of Canada, Community Health Nursing
Practice:
Standards of Practice. Retrieved January, 2009, from
http://www.chnac.ca
Dyment, J.E. & Bell, A.C. (2008). 'Our garden is colour blind, inclusive and
warm':
Reflections on green school grounds and social inclusion. International
Journal of
Inclusive Education, 12(2), 169 – 183.
Holmes, D., Gastaldo, D., (2002). Nursing as a means of governmentality.
Journal of
Advanced Nursing, 38(6), 557-565.
Q: What references were used to
support this introduction? (Cont’d)
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Kalucy, L., Bowers, E.J., McIntyre, E., H., A, & Reed., R., (2009). Exploring the impact
of primary health care research. Australian Government, Department of Health
and Ageing, Primary Health Care Research and Information Service.
www.phcris.org.au.
Kingblood, R.J. & Roberts, R.A., (2008). Aboriginal Clients in Stamler, L. L. & Yiu, L.
(Eds.) (2008) (Second Edition). Canadian health nursing: A Canadian
perspective. Toronto: Pearson Prentice Hall. Chapter 21(pp. 320 –330)
Muntaner, C., Salazar, R.M.G., Benach., J., & Armada, F., (2006). Venezuela’s Barrio
Adentro: an alternative to neoliberalism in health care. International Journal of
Health Services, 36(4), pp. 803 – 811.
Nelson, S., (2009). Countdown: the world has been talking about community health for
years. It’s time to act—and for governments to listen. Pulse, 2(2), pp 7 – 8.
Q: What references were used to
support this introduction? (Cont’d)
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Ottawa Charter, (1986). International Conference on Health Promotion,
November, 21,
1986: Ottawa Ontario.
Publications: London.
Raphael, D., Curry-Stevens, A., & Bryant, T., (2008). Barriers to addressing the
social
determinants of health: Insights from the Canadian experience. Health
Policy,
88, pp 222-235.
Royal Commission on Aboriginal Peoples. (1993). The Path to Healing.
Ottawa, ON:
Ministry of Supply and Service.
Sampaio, L.F.R., & Buss, P.M., (2008). Brazilian family health from 1994 –
2007:
Primary Health Care for a continental country.
Q: What references were used to
support this introduction? (Cont’d)
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Smith, D., Jacobson, L., & Yiu., L., (2008). Primary healthcare, in L.L. Stamler & L. Yiu
(Eds.) (2008). Community health nursing: A Canadian perspective. Toronto:
Pearson Prentice Hall, (pp. 111 – 124).
The Public Health Agency of Canada, Social Determinants of Health, retrieved
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Dec. 4, 2010 from (http://www.phac-aspc.gc.ca/ph-sp/determinants/index-eng.php)
Undergraduate Courses, Bachelor of Science in Nursing, Lawrence S. Bloomberg Faculty
of Nursing, 10/31/2008.
Wakefield, S., Yeudall, F., Taron, C., Reynolds, J., Skinner, A. 2007. Growing urban
health: Community gardening in South-east Toronto. Health Promotion
International, 22(2), 92-101.
Wong, S.T., Watson, D.E., Young, E., Regan, S., (2008). What do people think is
important about Primary Healthcare ? Longwoods Publishing, obtained from
http://www.longwoods.com/product.php?printable=Y&productid=19577&cat=52
9&page.