In 1978 the Alma-Ata conference on Primary Health Care inspired a revolution in international health policy by endorsing primary health care (PHC) as the official policy of the World Health Organization (WHO). Noting deplorable health conditions among the world's poor, especially the rural poor, the Alma-Ata declaration stressed the urgent need for a reallocation of health-related expenditures in order to provide adequate, low-cost health services for all. The PHC concept emphasizes the need for health promotion and the universal provision of basic health services rather than costly, high-tech, specialist facilities in urban centers, as has been the typical pattern in most countries. The conference called upon all governments to "formulate national policies, strategies and plans of action to launch and sustain primary health care" within their countries and to adapt PHC to their own local social, cultural and economic conditions.
The response to Alma-Ata has been both encouraging and swift. Within a few years most national ministries of health and virtually all international health agencies had adopted PHC as a "scientifically sound" policy as well as a politically and morally acceptable solution to health problems among the world's poor, particularly in rural areas.
Despite widespread enthusiasm for what Gish described as "the 'new' priority in health care," the PHC approach continues to face many challenges before it can ever become a reality in any developing country. Many of these problems concern (1) shortages of trained staff, (2) organizational arrangements that can distribute basic health supplies and information and (3) a lack of commitment to PHC at various levels within particular health services.
Within the social sciences the PHC approach has had its supporters, its thoughtful critics and its detractors, each identifying in their own ways some of its problems and possibilities. What supporters and critics alike agree on, however, is that the Alma-Ata declaration is an extremely difficult (if not impossible) policy to put into practice. These problems have often been seen as a conflict between ideology and reality.
Anthropologists concerned with health issues have largely seen this tension in much narrower terms, focusing on specific community health programs and how these programs have fallen short of PHC ideals. In part because of their community-based frame of reference, anthropologists have generally accepted the PHC approach in principle to concentrate on problems of implementation. They rarely have examined the concepts and underlying principles upon which the entire PHC movement is based. The most penetrating criticism of PHC raised by anthropologists have been the objection that social science (but anthropology in particular) is consulted far too rarely when new health programs are implemented and that this omission has in turn led to the observed "problems of implementation" in particular cases. Indeed, a major concern voiced by Foster and reiterated by Bloom and Reid is that biomedical perspectives have so dominated PHC research and planning that there is little opportunity for input from the social sciences.
Although it is almost certainly the case that PHC has drawn upon social research far too little, for the reasons cited, my concern here lies with the PHC model itself. The point I want to make is that the tension between ideology and action so often observed in community programs emerges not simply because of problems of implementation, but because of a contradiction or inconsistency in the PHC concept itself. Community involvement, community participation, self-reliance and self-determination are key elements of the Alma-Ata declaration and they are essential ingredients if PHC is to become a reality, but the structure of WHO efforts toward PHC has almost completely excluded any possibility of meaningful local participation and self-determination.
The idea of providing low-cost health care in rural areas, where the majority of the world's people live, is an especially appealing one. It offers an approach to health care that is difficult to criticize because of this appeal. Moreover, the repeated references in the Alma-Ata declaration and subsequent WHO reports to self-determination, community participation and the need for flexibility to accommodate cultural differences are especially attractive to social scientists and other individuals who take cultural difference seriously. Precisely because it respects cultural pluralism, many are hesitant to criticize the PHC approach. For the first time we find in the PHC model a health policy that stresses precisely the kinds of health care reforms proposed by social researchers in the 1950s.
But does the PHC approach genuinely encourage self-determination, self-reliance and community participation? Or alternatively, does WHO interest in centralized planning, technical advice and health education at the local level allow any room for significant community involvement? The PHC approach is not facing difficulties transforming the ideal into the real. Rather, it faces an inherent tension between what the WHO defines as "scientifically sound" on the one hand and the community involvement it hopes to evoke on the other. This contradiction emerges from the superior status granted to "scientific" knowledge about health problems, which all but eliminates the possibility of meaningful local self-determination.
Contradictions Within the Model
The premise upon which the PHC movement is based is disarmingly simple: health can improve only if health-related facilities are made affordable and accessible to the rural people who need them most. The program outlines by Alma-Ata went considerably further than urging an expansion of existing health services into rural areas previously poorly served. The declaration called for a major reorganization of health services, economic changes and increased concern for health promotion, disease prevention and rehabilitation, in addition to the more customary strategy of curative care. In short, the Alma-Ata declaration was an extremely broad and sweeping statement of the world's health problems and what should be done to alleviate them. Alma-Ata's extraordinary generality and its lack of a specific plan of action was clearly a consequence of the diversity of its delegates. In calling for substantial reforms in social, economic and health care infrastructures, participants were obliged to adopt provisions that emphasized flexibility in order to accommodate varied social, cultural and political contexts. Thus the first point in the Alma-Ata definition of PHC reads as follows:
Primary Health Care:
1. reflects and evolves from the economic conditions and socio-cultural and political characteristics of the country and its communities and is based on the application of the relevant results of social, biomedical and health services research and public health experience.
This simple, if vague, statement illustrates Alma-Ata's concern to integrate local (but variable) contexts with the scientific research that would presumably direct the organization and structure of PHC.
Earlier in the declaration the conference described the PHC approach:
Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford at every stage of the development in the spirit of self-reliance and self-determination.
The "scientific" bias is a very subtle one in the Alma-Ata declaration, but it grants privileged status to WHO advisors and national health planners. This tenet stands oddly in contrast to the "spirit of self-reliance and self-determination" that should play an equally important role in PHC.
This privileged status becomes more obvious in the text of the Alma-Ata reports:
Central planning should aim at enabling communities to plan their own health care activities. It therefore has to provide them with a clear idea of the part they play in the national primary health care strategy and in the overall development process at community level. It has to guide them on how to work out, evaluate and control their primary health care programmes: and it has to provide any essential information that is not available in the community.
Even in this earliest formulation of the PHC approach, tension exists between the decision-making responsibilities of the planners and those of the community, since the community's role in PHC and their information and methods of establishing, evaluation and controlling PHC ultimately derive from central planners.
This tension between self-determination and central planning has not disappeared in subsequent WHO studies. For example, in a report the following year entitled Formulating Strategies for Health for All by the Year 2000, the WHO stated:
Governments, institutions, members of the health professions as well as all agencies involved in health and development, will therefore have to enlighten the public in health matters so as to ensure that people can participate individually and collectively, as part of their right and duty, in the planning, implementation and control of activities for their health and related social development.
WHO documentation does not clarify just what limits should reasonably be placed on this enlightenment; and it seems fair to ask: at what point does local self-determination which differs from central planner's ideas become "unenlightened"?
By 1981 the third volume in the Health for All series, Global Strategies, made quite specific recommendations for the role of central planning in the ministries of health or analogous bodies and, not insignificantly, for the role of WHO itself in coordinating and guiding the development of PHC in various countries. But despite the many pages devoted to the specific responsibilities of WHO and national ministries, only one paragraph deals with how community participation is to be encouraged, and this offers little more specification than previous documents.
WHO repeatedly sees itself as the knowledgeable partner in its relationship to member countries in the developing world - a pattern that is replicated, in turn, between central planners and village communities. On the surface, the organization grants considerable flexibility and national self-determination to individual countries in developing their own PHC systems. WHO literature repeatedly states that the organization offers assistance only when invited by member states; one must, however, remember that little international health aid would be available to a country that refused to open a WHO office. Contrary to encouraging self-determination at the national level, a WHO study of how six countries had implemented PHC in their varied national contexts criticized rather firmly "the fact that, despite an internationally agreed definition, the term 'primary health care' is being applied around the world to a variety of realities and even concepts. Each of the eight recommendations of the Joint Committee on Health Policy contained in this study recommended that UNICEF and WHO take more steps to guide the development of primary health care worldwide. In short, despite words that respect social, cultural and political differences as well as a need for flexibility and locally meaningful PHC systems, the World Health Organization - because it views itself as having a body of "scientifically sound" knowledge - has rather definite ideas about the limits of this flexibility. These limits are, it would seem, in direct opposition to the core notions of national and community-level self-determination.
Impediments to Local Community Participation in Popua New Guinea Health Care System
Papua New Guinea has had a system of village-based health workers since the end of World War II. Although the system has been upgraded and expanded since then, most health planners in the country see this system of village aid posts and supervisory health centers as the PHC approach. There have been many problems in implementing Papua New Guinea's aid post system, but rather than describe in detail why rural health services in Papua New Guinea are not as effective as they might be, I want to consider why these rural health services do not fit the PHC model more closely than they do, particularly in terms of community participation and self-determination.
My research on the health services in Western Province of Papua New Guinea shows very clearly that there are problems in staffing, supervision and regularity of supplies. But at the same time there are disparities between health workers' incomes and the incomes of villagers, problems associated with increased professionalization of rural health workers, which lead them away from the villages to urban centers, and the almost total lack of communication about health matters between villagers and health workers. None of these problems is unique to the region in which I worked or to Papua New Guinea; they could be identified in nearly any developing country. This led me to ask: what is preventing Papua New Guinea's rural health care system from being more community based that it is? The system began, after all, as a village-based health care system. Why is there so little overt community participation and self-determination?
Papua New Guinea's health services are by no means a failure. They have unmistakably improved the quality of life, raised life expectancy, lowered mortality and morbidity rates and prevented severe epidemics. But as a PHC system according to the Alma-Ata definition, the system fails in several ways. Villagers and health workers generally do not communicate about how village people define health problems - a state of affairs all but ensured by the structure of a health service that discourages communication from the periphery to the center. Equally important, planners never fully understand how rural health workers perceive their own working conditions and the health services they are expected to provide. How can there be local community participation and self-determination if health care workers and planners are uninterested in the ideas and attitudes of the people they serve?
At the very heart of the problem is a clash between "scientifically sound" health knowledge and community perceptions of their own health problems and needs. What has emerged in Papua New Guinea is a situation that we may think of as the "health educator model" of improving rural health. Rural health workers are expected to educate villagers (Department of Health 1974) who are assumed to be backward and lack knowledge about health matters. Rural health workers are led to believe that they are in a privileged position of superior knowledge vis-à-vis villagers. In general local knowledge, beliefs and ideas about illness and treatment are disregarded, although the research of generations of anthropologists has demonstrated that local ideas do influence local use of health facilities.
At each level, higher-ranking personnel act as if they have privilege health knowledge that lower-ranking staff must passively accept. Health information and policy decisions flow from a "sophisticated" center to an "unknowledgeable" periphery. Thus, WHO advisors offer guidance to the national Ministry of Health; the ministry sets guidelines and policy for the provinces; provincial health officers set policies and issue directives to subprovincial health officers in the outstations; these officers in turn issue directives to aid post orderlies working in the villages, who then tell villagers what they should do.
This chain of command structure is not surprising. Worth noting, however, is the virtual lack of information - except in the form of statistics - that moves from the periphery to the center. Rarely are explanations for new policy and directives communicated effectively from one level to another. This lack of communication is further fostered by the geographical distribution of individuals at each level and the fact that officers at the administrative centers rarely visit officers in more remote postings. Meetings invariably pull remote staff to the centers rather than the reverse, which reinforces the notion of a knowledgeable and privileged center. To explain local failings - noncompliance, poor sanitary conditions, minimal village participation - orderlies would say, "I told the people to do XXX, but they never listen.
This model of resistant villagers and rural health workers is not in the bureaucracies of developing countries. But, empirically speaking, it is inaccurate. Village people are extremely quick to evaluate the advantages and disadvantages of newly introduced health services, but they do so in their own terms. The people with whom I worked had very rapidly incorporated rural health facilities into their own strategies for combating illness. They did not adopt biomedical theories of disease; instead, they interpreted new practices in terms of customary knowledge about illness. Given the fact that rural health workers at all levels look to the administrative center for information, it is not surprising that many are unaware of how little education they actually achieve or how little they know about local health care ideas and priorities. Very few of the community's perceived needs are defined as useful information, although this, of course, is where community participation and self-determination must begin.
Conclusions
While community self-determination is already progressing in a number of small ways in Papua New Guinea villages, the structure of this community participation and self-determination essentially follows networks that would be completely imperceptible to WHO study teams simply because of their informal nature. We must seriously evaluate the role of PHC, but to do so we must broaden our frame of reference to include the lines of communication and the health administration that exist outside the communities we study. We should investigate the ways in which villages and administrative centers communicate - and ways that this can be encouraged. Perhaps more importantly, we should not accept, without reflection, WHO concepts of what constitutes community participation and self-determination. Clearly, planners in national ministries and in Geneva have little knowledge of village-level conditions, yet this is the kind of information the need if they are going to develop more meaningful PHC programs.
Article copyright Cultural Survival, Inc.
