Primary Health Care (PHC): Back to the Future?

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.

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Comment by Renault Yves on March 31, 2009 at 12:24pm
It's an endless fight. As former WHO representative I was very disappointed to see the way WHO let down the Health For All programme, and I can remember several WR-meetings were I and many colleagues demonstrated strongly. The cause of the multiple adaptations in WHO is the way we are dealing with the objectives of the programmes. Putting some irrealistic targets (HFH,AIDS,....) we are turning back when we are not achieving it. For many "donors" and in first line "countries" it is easier to have more vertical,specific programs that are with "one" problem to solve and then with clearer indicators and target that the "well being" of populations-communities. Anyway I am sure that we should put the "competence" of the community first and we can start with something the community feel important and so so or later tha community will realise that the process can be use for many other thing. Constellation start dealing with AIDS, extend to malaria (on request) and can see the process apply for finding a peace prces in conflict situation, where are we going?
For WHO it easear if the Head Quarter go back to a more horizontal design, but the crucial level is to have the country team putting the communities first for ant kind of prormme, and also improving that policy with all the partners at country level. We could see partners and donors as a community and they could adquire some competence also....know with who (WHO & others) you have to work with
Comment by Rituu B. Nanda on March 30, 2009 at 10:33pm
Dear Jean-Louis,

Delighted to see you back in full form.

Engagement of communities is central to sustainable health care solutions. We have a range of studies which capture the qualitative impact of community response to HIV. However, I have not come across many quantitative studies on this subject. Rebeka and I have had a long discussion on the issue. We would like know to about the quantitative studies done to measure the impact of ACP.

Thanks and regards,



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