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Résumé Les soins de santé primaires tels que les présente la Déclaration d'Alma-Ata impliquent une approche multicausale des problémes de santé, et une organisation des services de santé qui permettent des soins globaux, continus, intégrés, distribués équitablement, dans un souci d'efficacité autant que d'efficience, et en recherchant la participation de la population concernée. Cette approche est actuellement remise en cause par les soins de santé primaries dits ‘sélectifs’ qui, au nom du rendement, arguent de la faiblesse des moyens disponibles pour réorienter les efforts médico-sanitaires dans le Tiers Monde en les limitant à quelques actions prioritaires, visant des pathologies données. Un récent colloque à l'Institut de Médicine Tropicale d'Anvers a nettement critiqué cette vision ‘sélectiviste’ de l'action au nom même de l'efficacité: l'abandondes critéres de globalité, d'équité, d'intégration, de continuité et de participation communautaire condamne des interventions sélectives à l'inefficacite et certainement à l'inefficience à long terme.
Abstract The authors examine the evolution of the PHC approach in historical perspective, present definitions and criteria of what PHC actually means, look upon deviations of conceptual content and practice of PHC and end up with a socio-political as well as a technical critique of the so-called ‘selective’ PHC. Modern health systems evolved in developing countries modelled on the ‘western’ biomedical health care systems. Yet even colonial medical services contained also progressiveelements, as e.g. the acceptance on the need to de-centralise hospital care to peripheral health posts, or the stress on more rational distribution and utilisation of drugs. The vertical programmes developed under this approach showed clearly their limitations and the conference of Alma-Ata can be looked at as a turning point, where a new model of health care, i.e. PHC, was designed. Though there exists a widespread resistance in industrialised countries against adopting this new model, it was not at all limited only to developing countries. As with every innovative idea, the PHC strategy provoked contradictory views and large differences in interpretation. But, the authors stress, PHC is neither a doctrine, or a theory but the outcome of decades of field-experience of concerned scientists and practitioners. The essential criteria of PHC include: —Accessibility: need for improved first contact with the health care system, demanding efforts of decentralising the existing health system without neglecting the quality of care on higher-level medical services. —PHC is essentially an action-programme designed around the well-known eight PHC elements, designed to meet effective demand and to rationalise medical offer. The eight elements rather underline the multiplicity of health action required—they are not considered to serve as ‘chapters’ of PHC policy. —PHC is a strategy for re-organising health services. The hospitals should serve the peripheral health centres and not the other way round. At the same time, curative preventive and promotive actions have to be integrated. This necessitates community participation, as the global health problems cannot be solved by the health services alone. —PHC in so far re-defines the role of medicine and looks at health in a holistic way. Medicine is being de-mystified and individuals and communities are encouraged to take over responsibility for their own health. This is not at all the consequence of an idealistic view, but derived from field experiences in various circumstances. PHC as a new philosophy of health services delivery therefore, stresses: holistic action for global health issues, equity, participation, and cost/efficiency. Among the misconceptions and deviations of PHC practice is especially the fact that many officials conceived it as a further vertical programme to be included in a Ministry of Health's activities. Furthermore, the authors stress that the emphasis laid on developing village health workers' (VHW) schemes is misleading and shows a ‘medicalisation’ of the PHC ideal. They stress that VHW are part of the very communities, whereas the key element of the PHC system should be the peripheral health-team at dispensary level. A misconceptions introduced by the promoters of the SPHC approach is their emphasis on ‘priority’ disease to be attacked, thus rejecting the global/holistic element in the PHC approach, which is a long-term health development approach, that cannot be exchanged with a mere problem-centred medical approach for the sake of ‘efficiency’. The selectivists are clearly demonstrating a ‘marketing’ approach: they are concerned only with how to achieve rapidly total coverage for certain services. Certain critiques therefore suggest that SPHC serves especially the commercial and technical interests of the western drugs and medical industries, including the promotion of private care for needs not covered under the SPHC schemes. SPHC therefore cements the existing of two differing medical and health systems in the First and Third World and promotes no impulses to change the existing power-relations between industrial and developing countries. Technically, the promoters of SPHC haven't yet proved the higher efficiency of this approach. On the contrary, they often mix up effects of multiple variables, or else, attribute these effects only to selective interventions. They do not recognise the effects of underdevelopment on health and their cost evaluations only consider short-term effects. The authors conclude that there is actually the risk that the insights gained in the last decades which led to the development of the comprehensive PHC approach and its universal acceptance in Alma-Ata could be lost. One of these insights was, that populations are more likely to accept specific public health programmes if their everyday problems are also taken into account and if they can participate in planning, implementing and evaluating health programmes. The positivist, biomedical selectivist approach on the contrary re-establishes the paternalistic professional view of health and in attracting funds of international and bilateral donors clearly counteracts the idea of PHC. The authors examine the evolution of the PHC approach in historical perspective, present definitions and criteria of what PHC actually means, look upon deviations of conceptual content and practice of PHC and end up with a socio-political as well as a technical critique of the so-called ‘selective’ PHC. Modern health systems evolved in developing countries modelled on the ‘western’ biomedical health care systems. Yet even colonial medical services contained also progressiveelements, as e.g. the acceptance on the need to de-centralise hospital care to peripheral health posts, or the stress on more rational distribution and utilisation of drugs. The vertical programmes developed under this approach showed clearly their limitations and the conference of Alma-Ata can be looked at as a turning point, where a new model of health care, i.e. PHC, was designed. Though there exists a widespread resistance in industrialised countries against adopting this new model, it was not at all limited only to developing countries. As with every innovative idea, the PHC strategy provoked contradictory views and large differences in interpretation. But, the authors stress, PHC is neither a doctrine, or a theory but the outcome of decades of field-experience of concerned scientists and practitioners. The essential criteria of PHC include: —Accessibility: need for improved first contact with the health care system, demanding efforts of decentralising the existing health system without neglecting the quality of care on higher-level medical services. —PHC is essentially an action-programme designed around the well-known eight PHC elements, designed to meet effective demand and to rationalise medical offer. The eight elements rather underline the multiplicity of health action required—they are not considered to serve as ‘chapters’ of PHC policy. —PHC is a strategy for re-organising health services. The hospitals should serve the peripheral health centres and not the other way round. At the same time, curative preventive and promotive actions have to be integrated. This necessitates community participation, as the global health problems cannot be solved by the health services alone. —PHC in so far re-defines the role of medicine and looks at health in a holistic way. Medicine is being de-mystified and individuals and communities are encouraged to take over responsibility for their own health. This is not at all the consequence of an idealistic view, but derived from field experiences in various circumstances. PHC as a new philosophy of health services delivery therefore, stresses: holistic action for global health issues, equity, participation, and cost/efficiency. Among the misconceptions and deviations of PHC practice is especially the fact that many officials conceived it as a further vertical programme to be included in a Ministry of Health's activities. Furthermore, the authors stress that the emphasis laid on developing village health workers' (VHW) schemes is misleading and shows a ‘medicalisation’ of the PHC ideal. They stress that VHW are part of the very communities, whereas the key element of the PHC system should be the peripheral health-team at dispensary level. A misconceptions introduced by the promoters of the SPHC approach is their emphasis on ‘priority’ disease to be attacked, thus rejecting the global/holistic element in the PHC approach, which is a long-term health development approach, that cannot be exchanged with a mere problem-centred medical approach for the sake of ‘efficiency’. The selectivists are clearly demonstrating a ‘marketing’ approach: they are concerned only with how to achieve rapidly total coverage for certain services. Certain critiques therefore suggest that SPHC serves especially the commercial and technical interests of the western drugs and medical industries, including the promotion of private care for needs not covered under the SPHC schemes. SPHC therefore cements the existing of two differing medical and health systems in the First and Third World and promotes no impulses to change the existing power-relations between industrial and developing countries. Technically, the promoters of SPHC haven't yet proved the higher efficiency of this approach. On the contrary, they often mix up effects of multiple variables, or else, attribute these effects only to selective interventions. They do not recognise the effects of underdevelopment on health and their cost evaluations only consider short-term effects. The authors conclude that there is actually the risk that the insights gained in the last decades which led to the development of the comprehensive PHC approach and its universal acceptance in Alma-Ata could be lost. One of these insights was, that populations are more likely to accept specific public health programmes if their everyday problems are also taken into account and if they can participate in planning, implementing and evaluating health programmes. The positivist, biomedical selectivist approach on the contrary re-establishes the paternalistic professional view of health and in attracting funds of international and bilateral donors clearly counteracts the idea of PHC.
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The debate on selective or comprehensive primary health care
Comprehensive can be effective: The influence of coverage with a health centre network on the hospitalisation patterns in the rural area of Kasongo, Zaire
There is an Open Access version for this licensed article that can be read free of charge and without license restrictions. The content of the Open Access version may differ from that of the licensed version.