This year marks the 30th anniversary of the Declaration of Alma-Ata, the first international declaration of the importance of primary health care in achieving greater equity in the distribution of good health, amongst other things.

The World Health Organization’s recent World Health Report 2008, which is even called Primary Health Care, Now More Than Ever,  describes primary health care as a “movement” to tackle the “politically, socially and economically unacceptable” health inequalities in all countries.

Primary Health Care also featured prominently in the WHO’s recent Report of the Commission on the Social Determinants of Health, which says health care systems have better outcomes when built on primary health care. They also have lower costs and higher user satisfaction.

But, having recently returned from an international conference commemorating that historic event of 1978, I have to report that the prognosis for Primary Health Care is not encouraging.

I am reluctant to say this — as one of only a few primary health care professors in Australia — but I think it may be time to declare the demise of this sacred cow.

Primary Health Care was a noble concept with laudable aims but time has proven that the rhetoric about its merits — that it would provide “health for all” and so on — has not been translated into reality.

My diagnosis is based upon my experiences of implementing Primary Health Care in the community and promoting it in higher education in England, in Palestine where I have been a visiting professor for over a decade, in Australia – and this includes some on-going work with Aboriginal people in western Sydney – in rural Zambia and shorter periods in Pakistan, Nicaragua and a variety of Asian and African countries.

The three pillars of Primary Health Care — equity, participation and intersectoral collaboration – are looking decidedly shaky.

Are there many countries of the world where equity is a guiding force in the management of health services? An Aboriginal man can expect to live till his mid fifties, a white man like me can expect another 20 years. But it would be dangerous to limit inequities in health in Australia to the gap between black and white people. A woman living in the eastern suburbs of Sydney can expect longer life expectancy and better health services from the public health sector even than an unemployed man from the western suburbs where I work.

Alma-Ata was a visionary document. It held out a picture of health systems which incorporate affordable, accessible, culturally appropriate health care integrated with those other factors which prevent disease and build the health of populations, such as the economy and schooling.

Thirty years later, to mouth the same words is hypocritical, especially if we do not look at the obstacles to the vision which still stand in the way of any real implementation.

It’s time to bury Primary Health Care with dignity. It has been killed by the combined forces of economic privilege (structural forces which impede equity in health) and the dominance of medical treatment in the world of health.

Imagine the courage it would take to defy the media and medical profession outrage if a Minister of Health were to redistribute money from hospital care to working with the elderly, the post-natally depressed, or those at risk of suicide IN the community? Yet there are moral and economic arguments to support such moves.

I suggest that continuing to use a vocabulary which has become debased does disservice to the very real values of Alma Ata and Primary Health Care.

Maybe it’s time to start talking of “Comprehensive Health Care Systems”. This would oblige medical practitioners to think beyond their preoccupation with clinical interventions and give us a lever to push for evidence of systemic linkages between prevention, promotion and curative care.

Will we have more chance of achieving “better health for all” with this approach?

Professor John Macdonald is the Foundation Chair in Primary Health Care at the University of NSW

Peter Fray

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