PHC: Now more than ever. That is how WHO labels its 2008 report. Should we rejoice? Are we turning the page of the nineties, the decennium horribile during which only vertical thinking was authorized? Are we allowed to go horizontal again? For all of us who dedicated our professional lives to PHC during the seventies and the eighties, the temptation is great to rejoice and relax.
PHC however was conceptually flawed then, and it is still flawed now for one main reason: it confuses health care with health. Remember “Health for All by the year 2000”? It really meant health care for all, and the world missed the mark on either goal. Unfortunately the 2008 report maintains the confusion, as it uses health system to mean health care system. The distinction is not trivial. When WHO recommends a greater focus on equitable access to quality of care that people can afford, we all applaud! When it recommends new modes of popular participation in the management of health care, all praise to WHO! But please, let us not deceive ourselves any further. Those improvements in the health care system will only produce marginal changes in people’s health.
While health care providers play a central role in health care, people play a central role in health. No amount of “focusing on people” or “people participation” will substitute for people taking charge of their own issues and acting by themselves. Take the AIDS pandemic: does anyone believe that the proposed reforms of the health care system will resolve the issue? In all settings that are making progress on AIDS, people say the same thing: we have made progress because we have acknowledged the issue and responded by ourselves. We are the central actors. We do mobilize support from health services, but we play the central role. What is true for AIDS holds for most health problems: the key for long term health improvements lies in sustained behavior change.
The world needs a common, integrative understanding of health dynamics and systems where individuals, families and communities are the central actors of their own health. Local communities can and do initiate health action. They can transfer their experience and optimism to friends, family and other communities. Transfer from community to community is a key element of large scale change. The function of health care systems is to deliver health care. They can only be seen as one element, or as a subsystem among the many that contribute to health.
WHO should recognize unequivocally that people and not health care providers play the key role in health. Health care providers need to adapt to people’s lives and aspirations, not the reverse.