Perspectives in Health Magazine
The Magazine of the Pan American Health Organization
Volume 8, Number 2, 2003

Primary Health Care: A Pending Debt

The first International Conference on Primary Health Care, held 25 years ago in Alma-Ata, Kazakhstan, focused worldwide attention on the responsibility of countries to address their peoples' health as an issue of human rights. It is our fortune to publish a retrospective of Alma-Ata by David Tejada, former deputy director-general of the World Health Organization and the conference's principal organizer. His firsthand account will be of great interest to many of our readers, as will his analysis of why we have not fully achieved the conference's goal of "Health for All by the Year 2000."

Those of us who, like Dr. Tejada, are long-time proponents of primary health care share his frustration at the misunderstandings and distortions surrounding the issue, both at Alma-Ata and in the subsequent quarter century. Fundamentally, primary health care refers to the first level of health care, that is, people's first contact with their country's health system. The idea is that this should take place not at the hospital and not when a patient is already ill, but before and in order to prevent illness. Effective primary health care assumes an integrated health system that reaches out to individuals, families and communities and accompanies them in their development.

A partial understanding of this has led some to think of primary health care as the opposite of hospital care. This in turn has led to a perception that primary care is of lower quality than hospital care, which is seen as more sophisticated and better. Since medical specialists are concentrated in hospitals, many thought that primary health care could be left in the hands of health promoters and volunteers rather than more qualified personnel. Furthermore, because hospitals are generally found in urban areas, some have come to think of primary health care as synonymous with rural care. In fact, effective primary health care should apply to inhabitants of rural and urban areas alike.

What primary health care was for its proponents at Alma-Ata—and what it must continue to be—is a strategy for transforming the health care system and bringing it closer to the people, precisely so that they do not need to go to the hospital except in cases of accidents or unpreventable illnesses. It means that when people must go to the hospital, they arrive not as strangers but with medical histories already known to the system. After they receive treatment, they return to their communities, where the system continues to follow up.

This is not to ignore important work that was carried out in many countries and by international agencies that understood the essence and value of primary health care. Important investments, particularly in human resources, enabled health services to reach people in their homes and communities, offsetting the tendency to concentrate resources in hospitals. Some also rightly emphasized that intersectorial action was needed to address the determinants of health in order to progressively improve health and quality of life.

What has been almost entirely lost, however, is the transformational function of primary health care. In these 25 years, we have seen major increases in health spending, but some 50–80 percent of our countries' health budgets remain devoted to hospitals. When earlier, targeted investments in primary health care began to diminish, particularly under the pressures of health sector reform, people were left once again without services. Had primary health care successfully transformed our health systems, we would never have lost so much ground in the 1980s.

Health systems today are in as much need of transformation as they were in 1978. But we are now much better equipped to carry this out. We understand better what primary health care is all about. Moreover, technological developments make it possible to take health care to the people in ways we could not have imagined in 1978.

At its annual Directing Council meeting this September, the Pan American Health Organization (PAHO) will use the occasion of the 25th anniversary of Alma-Ata to reflect on its success and failures and to reopen the debate on primary health care and the need to transform our countries' health systems. In far too many cases, we have the opposite of "Health for All," with large sectors of our populations almost totally excluded. Until Alma-Ata's dream of universal, multisectorial and participatory health for all is fulfilled, we in international public health still have a pending debt.

Mirta Roses Periago
Director

Back to Index