Conversation About Primary Health Care
Marie Truglio-Londrigan
Joanne Singleton
Sandra B. Lewenson
Liliana Lopez
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It is true that in the future as in the past, the course nursing takes will be determined to a great extent by social forces and conditions which no one can entirely for see or control. But the nursing group, by thoughtful planning and well-directed effort, can do much to influence its own destiny and it is not too much to say that it may also influence the destiny of the human race (Dock & Stewart, 1938, p. 354).
LEARNING OBJECTIVES
By the completion of this chapter, the reader will be able to
Discuss the difference between primary health care and primary care
Describe how the Declaration of Alma-Ata influenced primary health care
Debate the challenges to the delivery of primary health care
KEY TERMS
Cultural authority
Declaration of Alma-Ata
Primary care
Primary health care
Social legitimacy
When the authors of this text began to contemplate what type of content would be presented within its pages, it was clear that the focus would be on the public and how healthcare practitioners may work together with the public in the achievement of one primary goal: health for all Americans. The areas to be discussed would be the science of public health as well as the types of interventions that are necessary for the attainment of our goal. The implementation of these interventions in a collaborative way with the public, however, is not enough. What we need, as a nation, is to shift our worldview so that we first acknowledge that there are ways of practicing other than our present day medical care model, which is not synonymous with health care, and then to have the courage to navigate these uncharted waters.
When President Barack Obama signed the Patient Protection and Affordable Care Act (PPACA) in 2010, the possibilities of what may be for our healthcare system shifted. For some, the imbalance is unsettling; for others, there is excitement. There is acknowledgment among all that this PPACA “does not focus solely on physician-provided medical care to individual patients. Instead, the statute is suffused with provisions that promise to elevate the status of, and national commitment to, disease prevention wellness promotion, and population based interventions” (Deville & Novick, 2011, p. 102).
The authors of this text and of this chapter embrace this shift. It is our belief that the path we must walk is a path known as primary health care. This idea of primary health care has already been discussed elsewhere in this text, so the purpose of this chapter is to reconsider primary health care in light of this previous discussion. We invite the reader to consider all aspects of public health and primary health care in relationship with nursing’s role in making this shift.
The Declaration of Alma-Ata
In 1978, the saying “Health for All” was coined by the World Health Organization (WHO) and the idea of primary health care was derived as the means of achieving this goal. So strong was this belief that at the International Conference on Primary Health Care (1978) the Declaration of Alma-Ata expressed a call to action by all governments and world communities to promote and to protect all people. This Declaration contains 10 principal points, the 6th and 7th of which speak specifically to the idea of primary health care. The entire Declaration may be viewed in Box 18-1.
A careful review of this document informs the reader of the worldview of those who had a vision and put that vision into words so that others may place these words into actions. First and foremost, health is seen as a basic human right that requires the action of many, but it also recognizes that there are inequities that are unacceptable and a concern to all. The declaration acknowledges that health for all is essential to economic and social development and enhances quality of life. Furthermore, the declaration is clear that “the people” need to be active participants in the attainment of this health both individually and collectively. Additionally, not only are people key to the attainment of health, but governments are responsible for the health of their own people and that these governments must formulate policies that will facilitate and sustain primary health care. Finally, primary health care is seen as the key to attaining the health of the people.
Primary Health Care
As mentioned in the previous paragraph, the sixth and the seventh principal points speak specifically about primary health care. The Alma-Ata Declaration of 1978 formally defined primary health care as:
Box 18-1 Declaration of Alma-Ata
Declaration of Alma-Ata International Conference on Primary Health Care, Alma-Ata, USSR, September 6-12, 1978
The International Conference on Primary Health Care, meeting in Alma-Ata this twelfth day of September in the year Nineteen hundred and seventy-eight, expressing the need for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all the people of the world, hereby makes the following
Declaration:
I
The Conference strongly reaffirms that health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.
II
The existing gross inequality in the health status of the people particularly between developed and developing countries as well as within countries is politically, socially and economically unacceptable and is, therefore, of common concern to all countries.
III
Economic and social development, based on a New International Economic Order, is of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of the developing and developed countries. The promotion and protection of the health of the people is essential to sustained economic and social development and contributes to a better quality of life and to world peace.
IV
The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.
V
Governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures. A main social target of governments, international organizations and the whole world community in the coming decades should be the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. Primary health care is the key to attaining this target as part of development in the spirit of social justice.
VI
Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.
VII
Primary health care:
reflects and evolves from the economic conditions and sociocultural and political characteristics of the country and its communities and is based on the application of the relevant results of social, biomedical and health services research and public health experience;
addresses the main health problems in the community, providing promotive, preventive, curative and rehabilitative services accordingly;
includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs;
involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sectors; and demands the coordinated efforts of all those sectors;
requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources; and to this end develops through appropriate education the ability of communities to participate;
should be sustained by integrated, functional and mutually supportive referral systems, leading to the progressive improvement of comprehensive health care for all, and giving priority to those most in need;
relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community.
VIII
All governments should formulate national policies, strategies and plans of action to launch and sustain primary health care as part of a comprehensive national health system and in coordination with other sectors. To this end, it will be necessary to exercise political will, to mobilize the country’s resources and to use available external resources rationally.
IX
All countries should cooperate in a spirit of partnership and service to ensure primary health care for all people since the attainment of health by people in any one country directly concerns and benefits every other country. In this context the joint WHO/UNICEF report on primary health care constitutes a solid basis for the further development and operation of primary health care throughout the world.
X
An acceptable level of health for all the people of the world by the year 2000 can be attained through a fuller and better use of the world’s resources, a considerable part of which is now spent on armaments and military conflicts. A genuine policy of independence, peace, détente and disarmament could and should release additional resources that could well be devoted to peaceful aims and in particular to the acceleration of social and economic development of which primary health care, as an essential part, should be allotted its proper share.
The International Conference on Primary Health Care calls for urgent and effective national and international action to develop and implement primary health care throughout the world and particularly in developing countries in a spirit of technical cooperation and in keeping with a New International Economic Order. It urges governments, WHO and UNICEF, and other international organizations, as well as multilateral and bilateral agencies, nongovernmental organizations,
funding agencies, all health workers and the whole world community to support national and international commitment to primary health care and to channel increased technical and financial support to it, particularly in developing countries.
funding agencies, all health workers and the whole world community to support national and international commitment to primary health care and to channel increased technical and financial support to it, particularly in developing countries.
The Conference calls on all the aforementioned to collaborate in introducing, developing and maintaining primary health care in accordance with the spirit and content of this Declaration.
Source: World Health Organization [WHO]. (1978). Declaration of Alma-Ata. Retrieved from www.euro.who.int/__data/assets/pdf_file/0009/113877/E93944.pdf
essential health care based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family, and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process. (WHO, 1978, para. 6)
The Declaration is very specific when it comes to primary health care and highlights several additional areas of interest. These include the notion that primary health care:
Reflects the culture of the nation and its people; therefore, the development of health initiatives takes place with the people and where the people are. In this way, these health initiatives will be culturally sensitive and appropriate, thus making them congruent with the people and their ideas, values, and beliefs.
Addresses all areas of health including health promotion, disease prevention, and curative care, including the availability and accessibility of needed medications and immunizations as well as rehabilitation. In this way, primary health care is seen as a philosophy and a way to practice that is inclusive of all contexts, not just the community.
Includes education toward the attainment of health as well as essentials for public health, such as clean water, sanitation, and nutrition. Education must reflect cultural ideas, values, and beliefs as well as focus on educational strategies that are congruent with the population and their needs.
Involves more than healthcare practitioners and is inclusive of multiple sectors of the community and thus multiple partners.
Requires maximum participation and partnering with individuals, families, communities, and populations. This partnering may be a challenge, but it reflects
a true working relationship where all individuals are considered essential and all voices are heard—where all people assume responsibility in shared decision making in the development of health initiatives and the movement toward stated goals.
Take a few minutes and, as a group, critically examine the Declaration provided for you in Box 18-1, specifically points six and seven. Think about the type of care you have seen rendered in your past clinical experiences. Identify one specific care initiative and answer the following questions:
In what ways is that care initiative reflective of the Declaration and primary health care?
In what ways is that care initiative ineffective?
Can you take one of your clinical experiences and shape and shift it so that it is reflective of the worldview and practices of primary health care?
What Has Been Our Progress?
It has been over 30 years since the introduction of the Declaration of Alma-Ata, and many have questioned how far we have come as a nation and globally. While it is true there have been changes and improvements with water access, sanitation, and antenatal care, there have been other areas where progress has not been as aggressive. For example, health and the attainment of health have been unequal across countries, and the identification of inequalities within countries is noted (WHO, 2008). If one considers the United States as an example, would you say that health and access to health is equitable across all populations? Several trends represent barriers to the attainment of health for all; these are noted in Box 18-2.
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