Describe primary health care with its principles and components.

The Alma-ata Declaration and its Principles

• Every phrase of that definition carries weight and should be unpacked, since the definition is itself the argument:
• "essential" — care addressing the main health problems of the community, not everything possible
• "scientifically sound and socially acceptable" — both conditions are required; an intervention that is effective but culturally unacceptable will not be used
• "universally accessible" — to all, not to those who can pay or who live near a facility
• "full participation" — the community as an active partner rather than a passive recipient
• "AT A cost the country can afford" — a deliberate rejection of standards borrowed from rich countries and unsustainable in poor ones
• "self-reliance" — not permanently dependent on external aid
• The historical context explains why the declaration was radical — it rejected the prevailing model of health care as hospital-based, urban, curative, technology-intensive and physician-centred, which consumed most of the budget while reaching a small urban minority
• Its slogan was "health for all by the year 2000"
• The five principles of primary health care must be listed and explained:
• 1. Equitable distribution — services distributed according to need rather than to demand, purchasing power or political influence
• The inverse care law states the problem it addresses — the availability of good medical care tends to vary inversely with the need for it in the population served
• 2. Community participation — involvement of individuals and communities in planning, implementing and maintaining their own health services
• Its justification is practical as well as ethical — services designed without the community are used less, maintained less and trusted less; and the ASHA and the village health committee are its Indian expressions
• 3. Intersectoral coordination — recognising that health is determined by agriculture, food, education, water, sanitation, housing, industry and communication as much as by the health sector
• The health sector alone cannot produce health, and most of the historical decline in mortality was produced outside it
• 4. Appropriate technology — technology that is scientifically sound, adapted to local need, acceptable, and affordable and maintainable by the community
• The classical illustrations are oral rehydration solution and the twin-pit latrine — cheap, effective, locally producible and requiring no electricity or specialist
• The opposite is a donated machine that nobody can repair and for which no reagents can be obtained
• 5. Focus on prevention rather than cure, without abandoning curative care, which is what brings people to the service in the first place
• The eight essential components of primary health care, remembered by the mnemonic elements:
• E — education concerning prevailing health problems and their prevention
• L — locally endemic disease control
• E — expanded programme of immunisation
• M — maternal and child health including family planning
• E — essential drugs provision
• N — nutrition and food supply
• T — treatment of common disease and injury
• S — safe water and basic sanitation
• Later additions — mental health, and dental and elderly care

Selective Primary Health Care, Criticism and Revival

• Selective primary health care emerged shortly after Alma-Ata as a critique, arguing that comprehensive primary health care was too ambitious, too expensive and too vague to implement
• It proposed concentrating instead on a few high-impact, low-cost interventions — the GOBI package (Growth monitoring, Oral rehydration, Breastfeeding, Immunisation), later GOBI-FFF (Family planning, Female education, Food supplementation)
• The debate between the two is worth presenting fairly, since both positions have force:
• For selective care — it is measurable, achievable within a budget, produces demonstrable mortality reduction quickly, and can be managed; and a vague commitment to everything achieves nothing
• Against it — it is top-down and technocratic; it abandons the equity and participation principles that were the political heart of Alma-Ata; it creates vertical programmes that compete for the same staff and fragment the service; it treats symptoms of poverty while leaving its causes; and it fails to build a health system, so each new problem needs a new programme
• The vertical versus horizontal distinction should be explained, since it runs through the whole of Indian health services:
• A vertical programme has its own staff, budget, supplies and reporting line for a single disease — fast, focused and accountable, and capable of achieving elimination, as smallpox and polio demonstrate
• But it duplicates infrastructure, competes for the same workers, and leaves nothing behind when the disease is controlled and the programme ends
• A horizontal approach strengthens the general service to deliver everything — slower and harder to attribute results to, but sustainable and capable of responding to the next problem
• The practical resolution is a diagonal approach — using the energy and funding of a disease-specific programme to build capacity that the general system retains, as the polio programme built a surveillance and cold chain network that outlived polio
• Why "health for all BY 2000" was not achieved — inadequate political commitment and financing; the debt crisis and structural adjustment programmes of the 1980s, which cut public health spending in exactly the countries that needed it; the rise of user fees; the HIV epidemic; population growth; and the target being aspirational rather than operational
• The revival — the ASTANA declaration of 2018, on the fortieth anniversary of Alma-Ata, reaffirmed primary health care as the foundation of universal health coverage
• Its emphases — primary health care as the means to universal health coverage rather than a competing idea; attention to non-communicable disease and to the whole life course; the role of technology and data; and empowered individuals and communities
• The INDIAN application — the three-tier rural infrastructure; the ASHA and multipurpose workers; the National Health Mission; and health and wellness centres under Ayushman Bharat, which represent the most serious attempt yet to deliver comprehensive rather than selective primary care in India
• The enduring value of Alma-Ata — it established that health is a human right, that inequality in health is unacceptable rather than inevitable, and that health is produced by society rather than delivered by hospitals
• Health is produced by society, not delivered by hospitals, which is the enduring claim of Alma-Ata
• The diagonal approach resolves the argument, using disease-programme money to build capacity the system keeps
• Polio left behind surveillance and a cold chain, which is what a vertical programme done well can bequeath
• The inverse care law states the equity problem; good care varies inversely with the need for it
• Both scientifically sound and socially acceptable are required, since an unacceptable intervention will not be used
• Appropriate technology must be maintainable locally, which is why ORS is the classic example and a donated machine the counter-example
• Community participation is practical as well as ethical, since services designed without people are used and maintained less
• Learn elements for the eight components — education, local disease, immunisation, MCH, drugs, nutrition, treatment, sanitation
• Selective care is measurable and achievable, which is the strongest argument its defenders make
• Selective care leaves no system behind, so every new problem requires an entirely new programme
• Vertical programmes compete for the same worker, which fragments the service they are all built on
• Structural adjustment cut health spending in the 1980s, in exactly the countries that needed it most
• Health for all by 2000 was aspirational rather than operational, which is part of why it was not achieved
• Astana reaffirmed primary care in 2018, as the means to universal health coverage rather than a rival to it
• Alma-Ata rejected the hospital-centred model, which consumed most of the budget while reaching an urban minority
• Cost the country can afford was deliberate, rejecting standards borrowed from rich countries and unsustainable here
• Health and Wellness Centres are the comprehensive attempt, and are the most serious Indian move away from selective care
• Curative care brings people through the door, which is why prevention-focused does not mean prevention-only
• Equity means distribution by need rather than by demand, purchasing power or political influence
• Mental health was added to the components later, along with dental and elderly care, reflecting changing burden
• Most historical mortality decline happened outside health services, which is the argument for intersectoral action
• Inequality in health is unacceptable, not inevitable, which was the political claim underneath the technical one