Editorials

The promise of primary health care

Marcos Cueto1

Twenty-seven years after it was decades it has been difficult to establish four issues and to increase the awareness
embraced at Alma-Ata (now Almaty, an effective financial system with clear of the political contexts in which the
Kazakhstan), primary health care and indicators that ensures sustained sup- strategy might flourish. The persistence
its call for “health for all” still holds port of community participation and of neoliberalism, the transition from
a promise (1). Study of the history of intersectoral collaboration, to mention an “international” to a “global” frame-
medicine suggests its worldwide appeal. just two important but controversial work, and the coexistence of the most
Primary health care is the latest expres- project tasks (W8). terrible expression of human history
sion of a belief that can be traced to Third, implementation encoun- (war) and one of the most idealistic (the
the 19th-century pathologist Rudolf tered resistance from health personnel. Millennium Development Goals) mark
Virchow: the solution to major human Many physicians in less developed a complex political context, in which
disease problems resides not only in the countries were linked to specialized one actor should play a crucial role: the
best science available but also in brave urban hospitals and traditional medical local health worker. As a recent report
political proposals for social justice and schools; they knew much about treat- underscored, dramatic changes have
the improvement of the life of the poor ment but little about prevention. Many occurred recently in the growth, job in-
(2, 3). From this perspective, health is of them hoped that their expertise security and self-assertion of local health
not only a by-product of social changes would facilitate upward social mobil- workers (10). There have never been
but an instrument to promote such ity (W9). Unless health professionals so many health workers in developing
changes — and health workers are in and their systems of training are closely countries with experience in providing
the vanguard. History does not follow committed, a health programme can community-oriented care. Many believe
a linear path of progress, however: be undermined from within. in change from below and have a vested
setbacks, resistance, negotiations and Fourth, restricted primary health interest in the integral improvement of
compromise have existed in the history, care interventions reinforced a culture of health systems. The old fear of losing
design and practice of primary health survival in developing countries, where professional privileges is no longer a
care programmes. many people believe that public health concern because these are evaporating.
Based on reflections by Socrates is an emergency response embodying Mobilizing, empowering and strength-
Litsios (W4) and my own research on vaccines, drugs, ephemeral training of ening these human resources in develop-
the history of primary health care (W5), lay personnel, or the creation of a health ing countries are crucial to pursuing
I suggest four themes for reconsidera- post. Health work is perceived as a low- the promise of primary health care. O
tion: its meaning, funding, and imple- value, short-lived activity from outside
mentation, and the culture created by the community. As a result, a culture References
restricted top-down versions of the phi- of survival among the poor sustains the (References prefixed “W” appear in the
losophy. First, primary health care has privileges of power among politicians. web version only, available from www.who.
int/bulletin)
had several meanings that undermined The poor continue to struggle to obtain
its power as a health paradigm. In its access to fragmented programmes and 1. Primary health care. Report of the International
more radical version, the complete re- foreign aid in order to relieve pain, delay Conference on Primary Health Care, Alma-Ata,
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health care has usually been insufficient In order to renew the promise of health: overcoming the crisis. Washington (DC):
and inconsistent (7). In the past few Alma-Ata, it is crucial to tackle these Communications Development Inc.; 2004.

1
Professor, Facultad de Salud Pública y Administración, Universidad Peruana Cayetano Heredia, Av. Honorio Delgado 430, San Martin de Porres, Lima 31, Peru
(email: marc@dnet.com.pe).
Ref. No. 05-022269

322 Bulletin of the World Health Organization | May 2005, 83 (5)

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Bulletin of the World Health Organization | May 2005, 83 (5) A