Primary Health Care at a crossroads 

July 28, 2016, 9:19 pm 

The concept of Primary Health Care (PHC) gained acceptance the world over following the famous WHO - UNICEF joint conference in Alma Ata (in former USSR) in 1978. Defined as, "Essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to the individuals and families in the community and the country can afford to maintain at every stage of their development in the spirit of self-determination", its approach was based on the principles of social equity, nationwide coverage, self-reliance, inter-sectoral coordination and people’s participation in planning and implementation of health programmes. Therefore this approach is also commonly known as "health by the people" and "placing people’s health in people’s hands". The concept of PHC was accepted by the member countries of the World Health Organization (in 1981) as the key to achieving the goal for Health for All (by the year 2000).

According to the original Alma Ata Declaration of 1978, the key components of PHC identified were,

* Promotion of food supply and proper nutrition

* An adequate supply of safe water and basic sanitation

* Maternal and Child Health (MCH) Care, including family planning

* Immunization against infectious diseases

* Prevention and control of endemic diseases

* Education about prevailing health problems and methods of preventing and controlling them

* Appropriate treatment of common diseases and injuries

* Provision of essential drugs.

With time, although a few more areas such as mental health, health care of elderly, oral health and school health have been added to this list, the basic objective of the PHC concept has remained the same throughout; "providing the people (especially in the developing countries) with at least the bare minimum of the health services". As a signatory to the Alma Ata declaration, the Government of Sri Lanka is pledged to provide PHC to the people.

Although much social and health developments have taken place over the four decades since "Alma Ata", by and large, realization of PHC has been an illusion. This is quite evident today by the fact that programmes have failed to deliver even in its "bare minimum" health to the large majority of the world’s population - especially the world poor. (On the contrary, health is gradually becoming a "luxury" of a few). Lack of political wisdom, will and patronage, shortages of health manpower (especially at primary care level), entrenchment of a curative culture within the existing health systems and concentration of health services and personnel in urban areas are among some of the universally identified factors that have hindered realization of PHC to its full potential. (In addition Dr. David Werner has identified Selective Primary Healthcare, Structural Adjustment Programmes and "Investing in Health" as another triad that has brought about a negative impact on the PHC - see "Who Killed Primary Health Care?" in the "Health and Society" next week)

Primary Health Care in

Sri Lanka

Historically, Sri Lanka enjoys certain achievements and realization of certain "milestones" with regard to PHC that the country could be proud of. While some of these achievements could be attributed to early establishment (and strengthening) of an organized public health system, others could be seen as the direct and indirect manifestations of some socio-political developments that took place in the country, especially as a result of "free" health and education.

"Health Units" - first of its kind in Asia

After establishing the Civil Medical Department in 1859 (which was to later become the Department of Health Services, and subsequently the Ministry of Health), a "sanitary branch" was created within the department in 1913 to oversee the matters relating to public hygiene and prevention of diseases that are originated from poor sanitary conditions. Establishment of the "health units", with the first in Kalutara in 1926 to be soon followed in many other places like Colombo, Kandy, Galle, Jaffna and Hingurakgoda was yet another important development in the public health arena in this country, and in fact was the first of this kind in Asia. These health units covered large areas and were responsible for the implementation the preventive health programmes.

Malaria "epidemic" of 30s

The country was hit by devastating malaria ‘epidemic" in the early 1930s, which was estimated to have claimed over 80,000 lives. Malaria Control Programme was established in 1936, more health units were established in the malaria stricken areas of the country, DDT spraying started (in 1946) and strategies for "active case detection and treatment" aimed at malaria eradication were adopted later. In fact the results of this intensified anti-malarial action were soon to be seen. The country experienced very low levels of malaria by early 1960s, but to be hit by"resurgence" in 1967, for which some claimed laxities on the part of programme implementation, especially in the stages of "consolidation" and "maintenance".

Improved Maternal

and Child Care

Provision of free ante-natal care for the poor in Colombo was started in the early 1920s. Improved maternal services that followed both in curative and preventive fields, along with the establishment of Family Health Bureau (much later in 1967), which was to provide leadership and guidance to the field health staff involved in delivery of maternal (and child) care was responsible in bringing down the maternal and infant mortality rates in the country appreciably. By the turn of the last century Sri Lanka was able to record maternal and infant mortality rates that were far below than those of the other South Asian countries.

Communicable Disease Control Programmes

With regard to prevention of diseases (that were important public health problems of that time), the TB, VD and Leprosy Control Programmes were established in 1940. BCG immunization against TB, which was the first island wide, regular immunization programme, came into operation in 1949.

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