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Medcalf A, Bhattacharya S, Momen H, et al., editors. Health For All: The Journey of Universal Health Coverage. Hyderabad (IN): Orient Blackswan; 2015.

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Health For All: The Journey of Universal Health Coverage.

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Chapter 1On the Origin of Primary Health Care

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Primary Health Care (PHC) is usually associated with the declaration of the 1978 International Conference in Alma Ata, Kazakhstan (known as the “Alma Ata Declaration”). Alma-Ata put health equity on the international political agenda for the first time, and PHC became a core concept of the World Health Organization’s (WHO) goal of Health for all. This PHC concept was proposed in a paper submitted to the Executive Board of WHO in January 1975 in the form of seven principles to be followed by governments wishing to improve their health services. These principles stressed the need for shaping PHC around the life patterns of the population; for their involvement; for maximum reliance on available community resources while remaining within cost limitations; for an integrated approach of preventive, curative and promotive services for both the community and the individual; for interventions to be undertaken at the most peripheral practicable level of the health services by the workers most simply trained for this activity; for other echelons of services to be designed in support of the needs of the peripheral level; and for PHC services to be fully integrated with the services of the other sectors involved in community development.

The PHC concept paper was prepared under the guidance of Kenneth Newell, Director of WHO’s Strengthening of Health Services Division. The team responsible for writing it was influenced by many individuals and publications, some of which I am going to trace here. As a member of that team, personally, the most important influences, aside from the case studies that appeared in the publications Health by the People and Alternatives Approaches, were the contact with staff of the Christian Medical Commission (CMC) and its Board—James McGilvray, Nita Barrow, Haken Hellberg, Jack Bryant, and Carl Taylor; they provided inspiration, encouragement and knowledge which extended ours.1 But there were also influences which stretch further back into history: PHC-like ideas dated back to at least the early decades of the twentieth century. Rural health programs in China developed with the assistance of the Rockefeller Foundation and the League of Nations Health Organization in the 1930s and, along with conferences organized by the latter, brought ideas together and outlined a direction for the future. The chapter will explore the actions of some of the personalities involved, their interconnections, ideas and experiences and the role they played in the formation and passing of this declaration.

Interconnections and personalities

UNICEF’s program in basic services; ILO’s in basic needs; and UNRISD’s in civil society served as models for broader developmental frameworks well-suited for PHC’s community focus. Similarly, the writings of Paulo Freire, Ivan Illich, and Ernst Schumacher, each in their own way, contributed to the importance given to appropriate technology and community participation.2 In my belief the PHC of the 1970s was rooted in the work of earlier individuals, the most important of which I believe are Jack Bryant, Rex Fendall, John Grant, Selskar Gunn, Sydney Kark, Maurice King, Milton Roemer, Henry Sigerist, and Andrija Štampar.3

Bryant’s book Health and the Developing World (1969) outlined the important role that universities could play in developing learning settings most suitable for supporting community-level work. Roemer, who wrote the conclusions in the Alternative Approaches study, underlined the importance of a firm national policy of providing health care for the underprivileged, in order to overcome the inertia or opposition of the health professional and other well-entrenched vested interests.

King’s collection of essays reinforced these messages as well as others. He stressed the importance of organizing medical services from the bottom up and not from the top down. Fendall’s numerous papers were drawn upon for the writing of the chapters on health centers and auxiliaries. Fendall also played a central role in the Rockefeller Foundation’s study that led to Bryant’s publication. Another contributor, Kark, outlined an approach to public health which featured the use of community diagnosis for gathering epidemiological data; among the actions needed he considered that of health education as the most essential one. Influence was, however, taken from many areas: evidence suggests that the key South African health leaders, for whom Kark would later work, who were in China in the early 1930s, learned of various innovative rural health programs and brought those ideas back to South Africa on their return.

Roemer studied medical history under Sigerist during his medical school years at Johns Hopkins, and thus would have been well-indoctrinated in Sigerist’s forceful belief in socialized medicine and the necessity for medical students to study history, political economy and sociology. Roemer would have learned about two of Sigerist’s favourite historical figures—Štampar and Grant.

Štampar was a fierce advocate for social medicine, who almost single-handedly helped Yugoslavia develop one of the finest health systems in the world at the time (1920s). Sigerist judged him to be “one of the most powerful contemporary figures in the public health field”—a “man of action, not of words”.4 Furthermore, Sigerist also had laudable things to say about Grant, with whom he collaborated in assisting the 1946 Indian Bhore Committee in its deliberations. Sigerist qualified Grant as a “brilliant public health man of wide experience, an excellent teacher and administrator, who very tactfully succeeded in inspiring and steering the committee”.5

Roemer and Grant worked in parallel in the early 1950s to develop comprehensive demonstration projects under the aegis of WHO that aimed to demonstrate a unit of well-balanced health services; the application of modern methods and techniques for the prevention of diseases and promotion of health of the people; and how by simultaneously organizing multiple approaches, the social and economic development of a community can be achieved more efficiently and effectively.

Roemer knew about Kark having heard Grant speak in 1947 about his visit to Kark’s Pholela Health Centre in South Africa earlier that year. Roemer reported how Grant informed his American audience that Kark’s work could serve as a model of how to use nursing personnel attached to health centers in areas under-supplied with physicians. Sigerist identified Kark’s Institute of Family and Community Health in Durban, South Africa, as a good example of how young physicians may be trained for practice under special conditions.

Grant and Štampar were together in China in the early 1930s; Grant as a staff member of the Peking Union Medical College (PUMC), Štampar as a League of Nations Health Organization (LNHO) consultant. Both worked to help the Chinese government develop their rural health services and to improve their medical schools. Also present in China was Gunn, Vice-President of the Rockefeller Foundation who developed, with the help of Grant, a rural reconstruction project in China that was based on the recognition that the task facing those working in health was “made more difficult, if not impossible, unless activities in the fields of economics, sociology, agriculture and education are carried out at the same time”.6

Before joining the Foundation in 1917, Gunn’s career was primarily confined to urban and state level public health concerns. It was from Štampar, who Gunn first met when he was responsible for the Foundation’s European office in Paris, that he learned about social medicine, in particular about rural health and the linkages between rural health and other sectors especially that of agriculture. Gunn, himself, was largely responsible for Štampar receiving significant financial support from the Foundation.7

Gunn wrote the introduction to the League of Nations Health Organization Conference on Rural Hygiene that was held in Bandoeng, Indonesia, in 1937—a recognized public health “mile-stone”. The conference approached the problem of rural hygiene from an “intersectoral and interagency perspective and focused not only on the need to improve access to modern medicine and public health but also on the fundamental challenges of education uplift, economic development, and social advancement”.8 However, here we must be cautious. As important as this conference was, there is little direct evidence that it had an impact on global health thinking following World War II, thus the question marks in Figure 1.

Fig. 1. A schematic portrayal of the origins of PHC (Author).

Fig. 1

A schematic portrayal of the origins of PHC (Author).

A revolution in organizing and delivering care

This brief overview has sought to trace what are, in my view, some of the chief actions and personalities in the formation of the primary health care concept. It has also sought to demonstrate the interconnections, and that PHC did not emerge fully formed in an easy manner; there were many influences. The Alma Ata declaration was much criticized for being too idealistic and having an unrealistic timescale. However, PHC revolutionized the way health was interpreted and radically altered prevailing models for organizing and delivering care. Specific approaches have since been made for the control and prevention of diseases but in recent years the World Health Organization has again promoted PHC and many of its concepts underline the new approach of WHO to universal health coverage.

Footnotes

1

Newell KW, editor. Health by the People. Geneva: World Health Organization; 1975. [PubMed: 1181735]; Djukanovic V, Mach EP, editors. Alternative Approaches to Meeting Basic Health Needs of Populations in Developing Countries. Geneva: World Health Organization; 1975. ; Litsios S. The Christian Medical Commission and the Development of the World Health Organization’s Primary Health Care Approach. AJPH. 2004;94(no. 11):1884–1893. [PMC free article: PMC1448555] [PubMed: 15514223].

2

Freire P. The Pedagogy of the Oppressed. New York: Seabury Pres; 1970. ; Illich Ivan. Tools for Conviviality. London: Calder and Boyars; 1973. ; Schumacher EF. Small is Beautiful: A Study of Economics as if People Mattered. New York: Harper & Row; 1973.

3

Bryant J, editor. Health in the Developing World. Ithaca: Cornell University Press; 1969. ; King M, editor. Medical Care in Developing Countries. Nairobi: Oxford University Press; 1966. ; Fendall NRE. Kenya’s Experience: Planning Health Services in Developing Countries. Public Health Reports. 1963;78(no. 22):977–988. [PMC free article: PMC1915383] [PubMed: 14084874]; Litsios S. John Black Grant: A Twentieth Century Public Health Giant. Perspectives in Biology and Medicine. 2011;54(no. 4):532–549. [PubMed: 22019538]; Bullock MB. An American Transplant: The Rockefeller Foundation & Peking Union Medical College. Berkeley: University of California Press; 1980. ; Health Care for the Community: Selected Papers of Dr John B. Grant Seipp Conrad, editor. The American Journal of Hygiene. no. 21. 1963. ; Fendall NRE. Organization of Health Services in Emerging Countries. The Lancet. 1964;284(no. 11):53–56.; Kark SL. Epidemiology and Community Medicine. New York: Appleton-Century-Croft; 1974. ; Roemer M. Rural Health Programs in Different Nations. Milbank Memorial Fund Quarterly. 1948;26(no. 1):58–87. [PubMed: 18898210]; Fee E, Brown T, editors. Making Medical History: The Life and Times of Henry E. Sigerist. Baltimore: The Johns Hopkins University Press; 1997. ; Grmek MD, editor. Serving the Cause of Public Health: Selected Papers of Andrija Štampar. Zagreb: University of Zagreb; 1966.

4

Sigerist HE. Yugoslavia and the Eleventh International Congress of the History of Medicine. In: Roemer M, editor. Henry E. Sigerist on the Sociology of Medicine. New York: MD Publications, Inc.; 1960.

5

Sigerist HE. Report on India. In: Roemer M, editor. Henry E. Sigerist on the Sociology of Medicine. New York: MD Publications, Inc.; 1960. p. 290.

6

Report of the Intergovernmental Conference of Far-Eastern Countries on Rural Hygiene. Geneva: League of Nations Health Organization; 1937. p. 23. [PMC free article: PMC2156046] [PubMed: 18160676]

7

See Litsios S. Selskar ‘Mike’ Gunn and Public Health Reform in Europe. In: Borowy Iris, Hardy Anne, editors. Of Medicine and Men: Biographies and Ideas in European Social Medicine between World Wars. Germany: Peter Lang Internationaler Verlag der Wissenschaften; 2008. pp. 23–43.

8

Brown TM, Fee E. The Bandoeng Conference of 1937: A Milestone in Health and Development. AJPH. 2008;98(no. 1):42. [PMC free article: PMC2156053] [PubMed: 18048776]

© Centre for Global Health Histories, The University of York 2015, United Kingdom.

This book is published by the Centre for Global Health Histories, which is a WHO Collaborating Centre; it is not a publication of the World Health Organization. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.

In relation to the foreword and chapters 12 and 16, the author is a staff member of the World Health Organization. The author alone is responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of the World Health Organization.

Requests for permission to reproduce from this publication should be addressed to The Centre for Global Health Histories C/O The Department of History, University of York, Heslington, York, YO10 5DD.

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Monographs, or book chapters, which are outputs of Wellcome Trust funding have been made freely available as part of the Wellcome Trust's open access policy

Bookshelf ID: NBK316278

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