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Primary health care and community health

  • Page updated onFebruary 25, 2025
Primary health care and community health
Photo: Bruno Abarca

Although since its inception there have been all sorts of intentions to reduce its meaning to that of "gateway" to the health system or "non-specialized health services", the concept of primary care is as ambitious as you can imagine.. Primary health care is a strategy to achieve the highest quality of life. health for allborn at the end of the twentieth century on a strong foundation: the consensus of the health as a right and the need for a global socio-economic transformation for social justice and community empowerment.

Today, primary health care seems to have taken a back seat, hidden behind the ubiquitous universal health coverage. However, its sound principles are more important than ever, in the face of the growing needs of the population and the shortcuts (with a neoliberal stamp) that are often camouflaged in the new global health financing proposals.

Primary health care: Health, with a capital "H"

In 1978, all member countries of the World Health Organization recognized, in one of the most inspiring global health policies in our history, a strategy that made the leap from the biomedical to the right to health, its social determinants, from the community and for the community.

In fact, the Declaration of Alma Ata included such revolutionary phrases as "the people have the right and the duty to participate individually and collectively in the planning and implementation of their health care.", "governments have an obligation to care for the health of their people, an obligation that can only be fulfilled through the adoption of health and social measures suitable" o "all countries must cooperatein a spirit of solidarity and service, in order to guarantee primary health care for the entire population"..

Primary health care is much more than a front door

Primary health care, in its beginnings, was not only considered as the first level of contact (or gateway) of families and the community with the health system. Nor was it only a bridge to other sectors to address health problems. Primary health care was designed as the central function and main core around which any health system should be built. It is what allows this system to understand health as holistic and to act on the social determinants of health and disease.

The new model gave anyone access to integrated services (prevention, promotion, cure and rehabilitation), longitudinal (with a continuous relationship with people throughout their lives), integrated (considering the biomedical and the psychosocial), accessible (through a reception in health centers in each small population and community) and with a strong community orientation and participation.

Community participation is a pillar of primary care and health systems.

When we speak of community participation in primary care, we are referring to a genuine commitment to it. As it was established in 1978, "primary health care requires and encourages to the maximum extent self-responsibility and the participation of the community and the individual in the planning, organization, operation and control of primary health care".. Successive reinterpretations of primary health care also focused on decision-making processes to make them more democratic, transparent and accountable, thus allowing the community to have power and control in the health system.

From idealism to structural reform in primary health care

In 1982, only four years after the publication of the Alma Ata declaration, there was an enormous world economic crisis that led to the collection of the foreign debt of many middle- and low-income countries that were trying to implement the new strategy towards health for all. The International Monetary Fund and the World Bank provided loans conditioned to the application of structural adjustment policies, forcing these countries to cut back on social policies and sectors such as education and health.

Selective primary health care

As a result of the structural adjustment policies of the 1980s, the citizens of many countries saw how, in just a few years, the dream of primary health care was diluted. Health was no longer intended to be approached with a holistic vision and from a perspective of social justice and community participation. Instead, the door was opened to neoliberal approaches that only prioritized economic growth. The objective was not to promote health, but to facilitate the payment of foreign debt to creditors.

Under this new framework, governments and international health actors reinterpreted primary health care in its minimum expression. To do so, they stripped it of all its revolutionary, social and community bases. Thus, they limited it to the provision of a minimum package of basic and inexpensive services. These included growth monitoring for the prevention of malnutrition, oral rehydration as a treatment for simple diarrhea, promotion of breastfeeding, vaccinations, the spacing of pregnancies and the distribution of nutritional supplements.

At that time, international health initiatives with a vertical approach also appeared. These were focused on the prevention and treatment of a few diseases considered a priority, lacking a vision of strengthening health systems.

The results, evidently, were not equivalent to those expected with a complete vision of primary health care. This led authors to speak of the failure of primary health care, when in fact it had not been implemented.

A new goal: universal health coverage

At the beginning of the 21st century, the political discourse in favor of the primary health care of '78, which many people and civil society organizations had never ceased to demand, was taken up again.

New resolutions and reports (such as the 2005 World Health Assembly resolution 58.33, the 2008 World Health Report, or the 2018 Astana Declaration) seemed to accept that there has been a failure to develop the Alma Ata proposal over several decades. However, when it came to reintroducing interest in primary health care, they twisted the language. Primary health care was now presented as a means to achieve universal health coverage and was in the shadow of this new goal.

Many argue that with the change from primary health care to universal health coverage we've lost out. Under the noble objective of universal health coverage, fundamental aspects of the primary health care strategy have been ignored, such as the need for community participation and control, the importance of influencing the social determinants of health and disease or the obligation of governments to establish a public network of accessible and quality health services.

In place of these pillars stands a single column, the pillar of the financing mechanisms that allow services to be "purchased" from public and private health care providers, and even through private insurers. This results in an opening of doors to the privatization of the heart of health care systemsThe health care system has become less efficient, less equitable and more difficult to govern under a right-to-health approach.

Community health agents: seed of the new primary health care

At the base of the health system and primary health care, since 1978, there have always been community health workers, volunteers who work in all kinds of roles for the health of their neighbors. Their tasks range from supporting periodic or occasional visits by health center staff or providing health education to their peers, to monitoring health problems and risks in their community, advocating for the maintenance and restoration of health services, the epidemiological surveillance, psychosocial support, response to epidemics and diagnosis and treatment of health problems such as tuberculosis, monitoring the health status of pregnant women, and management of common childhood infections (respiratory infections, diarrheal-infections and malaria) and acute childhood malnutrition.

These people, most of them women, have often maintained their commitment despite institutional mistreatment or instrumentalization by political powers as well as by the health services themselves or cooperation actors. Deprived of adequate recognition and incentives, they have been used as cheap labor, without being granted mechanisms for participation and control of the system.

Today, despite continued bashing of primary health care or misunderstood community participation and the failure of numerous poorly conceived or inadequately supported community health agent programs, these people continue to demonstrate their enormous transformative potential in their communities. Therefore, from a vision of equity, social protection, public health and gender, the strengthening of a health system cannot be understood without thinking about the empowerment of these volunteers and the rest of their community.

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