Selective Primary Health Care
Shortly after its publication the Alma-Ata Declaration was criticised for being too broad and idealistic and having an unrealistic time table, especially in the slogan “Health for All by 2000”. In 1979 the Rockefeller Foundation sponsored a conference “Health and Population in Development” in Bellagio (Italy). Important stakeholders attended the meeting, e.g. Robert S. McNamara, President of the World Bank. He promoted business management methods and clear sets of goals, advocating poverty reduction approaches. The conference discussed the paper “Selective Primary Health Care, an Interim Strategy for Disease Control in Developing Countries”. In that paper a strategy based on “basic health services” was presented. Selective primary health care was introduced as the name of the new perspective. The term meant a package of low-cost technical interventions to tackle the main disease problems of poor countries. These interventions were summarised in the acronym GOBIFFF (Growth monitoring, Oral rehydration techniques, Breast-feeding, Immunisation, Food supplementation, Female literacy, Family planning). Selective primary health care quickly attracted the support of donors, scholars, and agencies.
A debate between the two versions of primary health care was inevitable: on the one hand comprehensive primary health care, on the other hand selective primary health care.18 The supporters of comprehensive primary health care accused selective primary health care of being a narrow techno-centric approach that diverted attention away from basic health and socio-economic development, did not address the social causes of disease and supported vertical programs. Newell formulated his critic as follows: “[Selective primary health care] is a threat and can be thought of as a counterrevolution. Rather than an alternative, it can be destructive. Its attractions to the professionals and to funding agencies and governments looking for short-term calls are very apparent. It has to be rejected”. Moreover, the new political context characterised by the emergence of conservative neo-liberal regimes in the main industrialised countries drastically reduced the funding for health care in developing countries. There was also an issue in acceptance of primary health care by health professionals: very often they perceived primary health care as anti-intellectual, promoting pragmatic non-scientific solutions and demanding too many self-sacrifices. The resistance of medical professionals increased, as they feared to lose privileges, prestige and power.
In 1988 the election of Nakajima as WHO director-general, succeeding the charismatic Halfdan Mahler, the “father” of the Alma-Ata Declaration, marked the end of the first period of primary health care. It was only in 2008, with the World Health Report “Primary Health Care: Now More Than Ever!”, that a new era for primary health care started. But the debate between selective primary health care and comprehensive primary health was still ongoing, and transferring funds from vertical disease-oriented programs to strengthen primary health care, remained a challenge.
2008: The 15by2015 campaign
In 2008 different organisations – WONCA (World Organisation of Family Doctors), GHETS (Global Health through Education, Training and Service), The Network: Towards Unity for Health and the European Forum for Primary Care (EFPC) – published an editorial in the British Medical Journal, asking donors of vertical disease-oriented projects to invest 15% of the budgets for vertical programs in strengthening co-ordinated and integrated primary health care. The organisations set up the 15by2015-campaign, calling for major international donors to assign 15% of their vertical budgets by 2015 to strengthening horizontal primary health care systems so that all diseases can be prevented and treated in a systematic way. The example of Mozambique illustrates the approach: in 2005 the total health expenditure in the country was $356m. Foreign assistance accounted for $243m, from which $130m was channelled through disease-specific vertical funds managed directly by donors.
With 15% of that money 65 health centres could be supported for a year, with appropriately trained staff. This could give more than one million people access to improved primary health care.
The vertical disease-oriented programs for communicable diseases have shown to foster duplication and inefficient use of resources. They producegaps in the care of patients with multiple comorbidities, and reduce capacity by pulling health care workers out of the general care in the public healthsectors to focus on single diseases. Therefore, in 2009 the World Health Assembly’s Resolution WHA62.12 urged member states “to encourage that vertical programs, including disease-specific programs, are developed, integrated and implemented in the context of integrated primary health care”.
In the domain of chronic conditions and multi-morbidity the focused selective solution pursued for infectious diseases must give way to a comprehensive and sustainable primary health care strategy.
In view of the achievement of the Sustainable Development Goals and in order to accelerate progress in strengthening primary health care and make Universal Health Coverage a reality, a group of authors from different continents, launched the 30by2030 campaign, with the publication of a perspective in WHO Bulletin in 2020: “Universal health coverage and primary health care: the 30by2030 campaign”