Primary Health Care

No prescription for Medicine for the Poor

40 years ago, the World Health Organization tried to materialize the Right to Health.

By Andreas Wulf, medico international

40 years ago in Alma Ata in Kazakhstan, then part of the Soviet Union, the governments of the world took a historic decision. Under the call to “Health for All”, they adopted guidelines for the health policy of the WHO that would benchmark their own national policies as well: The Right to healthy conditions of life and access to good health care for all people, enshrined both in the UN Human Rights Charta and in the constitution of the WHO 1948 should now be realized in practice.

“Health for All” this was the title of the Declaration of Alma Ata, and the Primary Health Care (PHC) strategy was the way to reach this goal. It was not a “new prescription” for a simple primary care for poor people, as it was immediately understood by many so-called “developed” countries but should change health and health systems in a much more profound way: a new way of thinking and a new concept of health that would reach much beyond medicine.

The goal was the “right to all for highest attainable standard of (individual and collective) health” and a strategy to materialize this right.

“A functioning Primary Health Care strategy can only exist, if she is rooted in a frame work of a value system of “Health for All”, explained the former WHO Director General Halfdan Mahler, who made the declaration of Alma Ata possible.

This core value is inspiring the work of medico international and its partners until today. Moreover, the PHC Strategy seems to gain traction again in the last couple of years. Because it is increasingly clear, that the single issue campaigns of Global Health to eradicate Polio, to contain Malaria, and even the impressively successful programs to treat now almost 20 Mio people with HIV globally could fail in the end if it is not possible to rethink health care in a broader sense. PHC in its broad meaning is back at least on the level of debates.

So what Primary Health Care stands for? 

Three core principles are the foundation of PHC:

1.       Political and socioeconomic conditions have a crucial influence on health and disease and must be recognized, i.e. the promotion /pursue of social and economic justice is a necessary condition for health

2.       The improvement of health is a multisectoral issue and cannot be handled alone by the health sector: drinking water, sanitation, housing, food security, prevention of violence , are central areas of health promotion, demanding cooperation between very different actors

3.       The concerned people must become actors in the improvement of health conditions and health systems. The participation of the inhabitants of the village, the neighborhood is key and includes acknowledgement of local traditions, resources and experiences, the decentralization of decisions and resources to realize them.


PHC in this comprehensive sense is demystifying the expert knowledge, strengthening the local Community Health Worker. They play a key role in expanding PHC to rural communities. They need to be involved in decision-making. In addition, they have an important advocacy and social mobilizing role. These characteristics are threatening the traditional hierarchical model of medical care as well as local power structures. This is one important cause that the PHC approach was often minimized beyond recognition and only pieces of it were implemented in Global Health Policy.

One of the few positive examples for a successful realization of PHC was Nicaragua. 10 months after the Alma Ata conference, the Sandinistas had ousted the dictator Somoza and his clan. Health was one of the important tasks of the new government. Just three weeks into the takeover, they started with the building of a “unified national health system” that based on the principles of PHC – Equity, Equality – Participation.

The resources of the health budget were distributed more equally among all the provinces, 500 health posts were set up in rural areas. The number of health professionals who worked in the primary level of care tripled. An indicator for the efficacy of this decentralization was the number of medical consultations, which also tripled per person and year from 0,8 to 2,3.

Local Health Councils included representatives of communities, trade unions and local groups of the Sandinista organizations. These councils coordinated big campaigns during national health days, involving thousands of volunteers going out to vaccinate children against the most important illnesses (Polio, measles, diphtheria, tetanus and pertussis) or administered mass treatment against malaria or hookworm. From 1982, Polio had disappeared; measles, pertussis and malaria had dramatically reduced. Only with the increased military conflicts end of the 80ths these numbers rose again.

The successes of these early years were so impressive that the WHO highlighted Nicaragua as an example of the effectiveness of Primary Health Care.

Medico international also participated in this dawn of a better health in Nicaragua: From 1983, medico agreed with the health ministry to build up the health infrastructure in the region Rio San Juan, in the south east along the border with Costa Rica, one of the poorest regions of the country. The goal of this ten years of work was not only the construction of health posts, health centers and a regional hospital, but also the training of hundreds of young people in content and methods of PHC, who then realized a better health care and improvement of livelihood in the remote villages and communities. 28 years after the historic voting out of the Sandinistas 1990 essential parts of this social infrastructure having remained, even if the current government, led by the former commandante Daniel Ortega (and his wife) is ruling autocratically and allows little critique and participation.

A reminder of this work can be found today particularly in El Salvador, where the FMLN led leftist government is trying for the last 10 years not only to invest more resources in the decentralized health infrastructure, but also revived local health councils and assigned them a strong participatory role. Medico is supporting these health councils on a national level, the regional People’s Health Movement plays also a relevant role in this.

New Challenges

The PHC approach is facing today new challenges. In the 40 years since its drafting, the urban-rural relation of world population has shifted dramatically. In the so-called developing countries, more and more people are living in cities: While in 1960 only 22% were living in urban areas, this percentage had increased to 40% around the turn of the millennium and more than 50% by 2018. In 2030, the urban population is expected to exceed 3,9 billion people.

The social and health divisions in cities are more pronounced in cities that in the rural areas. While better off citizens are profiting from the closer availability of (often privatized) health care, the unregulated, poorer sections of the cities are completely different. Missing or inadequate infrastructure, overcrowded, bad housing, unstable income are increasing the risk of traditional diseases of poverty for the inhabitants, Malaria and dengue transmitting mosquitos have adapted to the urban landscape, new pathogens like SARS or avian flu find in crowded cities ideal transmission conditions. The poorer quarters are also often in the neighborhood of dangerous areas, like industrial sites, whose air and water pollution posing health risks, or on steep hillsides that can collapse with heavy rains.

Other, less dramatic but relevant problems of the cities are also more targeting the poor than the rich: High air pollution, traffic accidents, noise pollution and dangerous working conditions all lead to chronic health damages. Around 20% of all heart and circulation diseases in cities are linked to these specific environmental conditions.

In addition, changes in nutrition due to industrialized, processed food with high sugar, salt and fat content and its massively distribution through modern food production and retail chains, profiting from free trade agreements, are a crucial cause for the “modern epidemic” of Obesity and their consequences like diabetes. Instead of being a “disease of the affluent”, this is in today’s reality a disease of the poor, as traditional food, fresh fruit and vegetables are more expensive and particularly in poorer quarters more difficult to find than the ready to eat mass products.

This specific combination of long known infectious diseases and diseases of poverty   together with “new” chronic health problems is called “double burden” and is characteristic for urban centers in the south.

Private vs public health care

The historic PHC concept focused on public health services, which should guarantee health care for all. This picture has changed considerably over the last 40 years with the strong increase of private health care providers. Not only the rich and the upper middle classes are relying on them today, but also for many poor people, these private health services are the only available ones, particularly in poor informal neighborhoods where public services are scarce. With disastrous consequences: Annually, around 100 Mio people fall under the poverty line due to high out-of-pocket payments for health care, estimates WHO. Often, for too many the little successes to work themselves out of poverty are destroyed by such life events.

This dynamic led the discussion on PHC in the last 10 years strongly in the reformulation of “Universal Health Coverage”, prominently in the debates on the Sustainable Development Goals. UHC remains a highly contested concept that wants to answer foremost to these financial disasters of the poor households. Including the poor and the poorest into such local or even national “insurance systems”, which cover the expenses at a wide range of public, private and non profit health clinics and hospitals seems at first sight a pragmatic step forward. However, the experiences with such insurance systems in countries of the south without a strong regulatory role and experience of the state have shown that these concepts become rather financing mechanisms for the private services and inclusion and quality control remains difficult to realize.

Because of this, activists from the People’s Health Movement remain very critical. They defend and lobby for a functioning public health system that can realize its claim to secure good health care for all its citizens.

Health for All. Period.

While the PHC concept was often understood as a strategy for developing countries to service the poorer segments of society, the claim of WHO to understand Health in a broad sense as social, physical and mental wellbeing and as a human right is posing relevant challenges to the “developed countries” too.

A reformulation of the PHC concept that looks particularly at industrialized countries were done with the Ottawa-Charta of 1986, naming the reduction of health inequities and creating conditions for health promotion as the core tasks of health policy. Only after long delays and negotiations, it was possible in Germany to introduce recently a “health promotion clause”, giving these ideas a formal and financial base. Still, the funds available for health promotion are a fraction of the resources for curative medicine.

Initiatives to support “Health for All” are without any doubt much needed and should move beyond pilot projects with time limited funding: the social inequalities in Germany relating to Health and Life expectancy are still high between the social strata in Germany. In addition, and perhaps the most blatant violation of the Human Right to Health, is the limitation and exclusion of health care for asylum seekers and non-registered refugees and migrants.

Here, the voluntary work of over 30 “offices and networks of medical aid for refugees” is groundbreaking, as they not only content themselves with the individual arbitration of refugees into the formal health system, but demand actively a confidential inclusion for all, that would end discrimination and the threat of deportation through reporting to the authorities while using health care facilities.

Published: 14. March 2018

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