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Health for All through Primary Health Care (HFA_PHC) from Johns Hopkins University

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  • surendernikhil gupta
    Respected and Dear Friends, I just completed one of the extremely useful courses_Health for All through Primary Health Care (HFA_PHC) from Johns Hopkins
    Message 1 of 1 , Mar 3, 2013
      Respected and Dear Friends,

      I just completed one of the extremely useful courses_Health for All through Primary Health Care (HFA_PHC) from Johns Hopkins University, Baltimore_USA. The grade I got was 91% with certificate.

      Certainly, I have the preliminary knowledge about this HFA_PHC  while pursuing my courses in PGs.  HFA_PHC  was  finally through in international conference at Alma Ata_Khazakhastan (USSR) in 1978. The course was excellently built up MOOC (Coursera) with slides/youtubes/videoes/quizzes/ presentations by Prof Dr. Henry Perry, MD; PhD; MPH. The detailed concept paper of HFA_PHC was scientifically built up from Christian Medical Mission in 1940s to Ding Xian to Hydrick from Indonesia; Stamper from Croatia; major historical contribution by Rockefeller foundation, developing centers from Sri lanka, Kerala in India. In 1950s, Kark et al; Pholela-South Africa to a long journey till 1978 watershed conference where the various medical and non medical personalities from 180 countries participated this making it an historical conference. An overarching theme to be observed in several of the primary health approaches that we have studied is the emphasis on comprehensive care. That is to say that in caring for people in all communities, social, economic, and historical factors should be considered together with health studies. It also means that the whole person is treated, not just the disease. I essayed one of the nearly 800 worded presentations based upon one of the lectures of Carl Taylor, the great contributor to this groundbreaking document of HFA_PHC. I am reproducing a part of it for your kind information please:


      Marching ahead on the formidable steps of Primary Health Care


      In one of the lectures delivered in Johns Hopkins University in 1987, Carl Taylor explained the roots of the Primary Health Care (PHC) and discussed the drafts by WHO and UNICEF leading to international conference on Health for all through PHC at Alma Ata in 1978. At this conference, medical, public health and global policy experts proclaimed: “The Conference strongly reaffirms that health is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity.”1In its boldness, the Declaration, asserts the Director-General of the WHO Dr. Margaret Chan, “articulated primary health care as a set of guiding values for health development, a set of principles for the organization of health services, and a range of approaches for a addressing priority needs and the fundamental determinants of health.”2 It also means that the whole person is treated, not just the disease- a holistic approach. Among the contributors to this groundbreaking document was Dr. Carl Taylor.


      Elaborating historical overview of the PHC, he told that US clinicians first called PHC as the individual focus while community oriented primary care started with Kark in South Africa, then it went to US and Israel. Alma Ata label for PHC meant comprehensive (Horizontal) care but it became selective (Vertical) in 1984 due to the changing perception of donors, for example, the Bill Gates Foundation opted to focus on one global health issue-diseases specific and target to make maximum impact the eradication of Polio. In other words, health has moved from under-investment, to single disease focus, and now to increased funding and multiple new initiatives. Second well-known example of the selective primary health-care approach is the child survival revolution, championed by Jim Grant. This debate—between comprehensive and selective, horizontal and vertical, top-down and bottom-up—was the major topic of discussion in global health for the 1980s and 1990s, with few programs or agencies bridging the gap. Debates of community versus facility-based health care are starting to shift towards building integrated health systems. But now it is shifting towards combining the strengths of both approaches in health systems.


      Carl also mentioned about Community based PHC (CBPHC) and integrating CBPHC with Seed Scales. Highlighting the broad sweep of history of PHC, he underlined the amazing similarities of ancient system of India, China and Greece practicing as natural medicines, role of religions, shamans and Babylon public square concept and further added about hot and cold forms, spirits possession for ill health, humors, miasmas and heating practices3. He enlightened that earlier PHC was preventive and integrated but Hippocrates differentiated medicine and public health streams. Indian systems like Charak, Susuruta, Vagbhata were based upon Ayurveda and Chopra commission legalized it but western doctors defeated it. Successful research on Indian herbs like Rauwolfia for hypertension gave the idea of earning of money to the commercial companies and similarly, yellow emperor’s classic system in China.

                  It was Virchow, the german pathologist who originated modern PHC as social medicine. Later on, post world war-1, Dawson report, Peckham health centers social work centres in US strengthened it. Ding Xian from Beijing introduced the Mao’s concept of Bare food doctors for a quarter of world population but later on, it was collapsed by Deng Xiao Ping’s economic reforms in 1980. Second and third generation projects emerged in late 1930s to 1950s, e.g., Hydrick from Indonesia; Stamper from Croatia; major historical contribution by Rockefeller foundation, developing centers from Sri lanka, Kerala in India. In 1950s, Kark et al; Pholela-South Africa4 developed the health system. In contrast an example of a partly successful run public health program was in South Africa.  The Community Oriented Primary Care (COPC) founded by Sidney and Emily Kark in the rural area of South Africa.  The organization’s philosophy was comprehensive healthcare for all, which focused primarily on the health needs and using preventative care. The Kark's used a team of doctors, nurses and trained healthcare workers for community programs for mothers, children and to strictly promote infant and childhood development and growth. Another of their goal was to train community members to track diseases which were data oriented and it's goal was to keep records of births, deaths, and illnesses in the area.  This model has been proven to be partly successful in South Africa due to the lack of help from the government. This lack of help was political in nature and was strongly tied to Apathied,  hence resulting in the Kark's leaving South Africa. Though partly successful, this was the model that the USA emulated for their Primary Health Care guidelines. From 1960 to 1970, other health systems also came into the existence like Narangwal Punjab, Fendall from Kenya, Geiger from US and Aroles-Jamkhed and finally, in 1978 at Alma Ata. The Jamkhed model has achieved results far in excess of the Millennium Development Goals (MDG) in about 40 years. It transformed the community so much that it is not just healthier; it is also self-sufficient and economically respectable.

      Three vital pillars of PHC are Equity, intersectoral co-ordination and community participation. Empowering Community in Nagpur, Gadchiroli model in Home Based New Born Care (HBNC) Dr. Abhay Bhang resulted in lowering the Infant Mortality Rate and then Neonatal Mortality Rate to 25/1000 Live Births from 125/1000 live births. The driving force was-Think locally but act globally. The model was replicated in Pakistan, Africa and Bangladesh with equal success by the people power-so called Demographic Dividends. Certainly, achievement of high and equitable coverage of integrated primary health-care services requires consistent political and financial commitment, incremental implementation based on local epidemiology, use of data to direct priorities and assesses progress, especially at district level, and effective linkages with communities and non-health sectors. In order to demonstrate the Demographic Dividends, I am quoting another example to highlight as to how post-war Liberia was built up by Community Health Workers was vividly brought out by Dr. Panjabi. This resolved multiple problems such as providing employment, boosting the economy along with the purpose of spreading knowledge to the people.


                  Carl also emphasized the role of traditional practitioners and their competitions with the modern practitioners in PHC. Their roles are still ambiguous in CBPHC especially in the poorest and the remotest areas. In order to make the public health routine work interesting, he briefed out for some natural experiment and importance of people and not their numbers. Pat Rubinstein and Massachusetts, the great old epidemiologists used to understand the shoe leather epidemiology of diseases, their causation, diagnosis, control and shared with people and work intelligently with the community. Lastly and quite importantly, he concluded the discussion with a trawling question about ways and means for qualified doctors to actually visit the villages for PHC in the developing countries.


      Old health challenges remain and new priorities have emerged (eg, HIV/AIDS, chronic diseases, and mental health), ensuring that the tenets of Alma-Ata remain relevant. We examine 30 years of changes in global policy to identify the lessons learned that are of relevance today, particularly for accelerated scale-up of primary health-care services necessary to achieve the Millennium Development Goals, the modern iteration of the “health for all” goals. Revitalizing Alma-Ata and learning from three decades of experience is crucial to reach the ambitious goal of health for all in all countries, both rich and poor; also for today and tomorrow. Carl has rightly said," There is no universal solution, but there is a universal process to find an appropriate local solution"? 3, 5


      In 20 years from now, at the half century of Alma-Ata,we could see a different world, with basic health care  reaching many of the poorest families. However, to achieve this goal we need to revitalize the original revolutionary principles of Alma-Ata, sticking consistently to the core values of universal access for care, equity, community participation, intersectoral collaboration, and appropriate use of resources. We believe that revitalization of the tenets of the Alma-Ata Declaration is necessary to meet the MDGs in 2015 and beyond. Like the first primary health-care revolution, this will take champions—as Mahler said at the 2008 World Health Assembly “unless we all become partisans in renewed local and global battles for...equity...we shall indeed betray the future of our children and grandchildren.”



      [1] WHO and UNICEF. Declaration of Alma-Ata: International Conference on Primary Health Care.   (http://www.who.int/publications/almaata_declaration_en.pdf 02/01/2013)

      [2] Chan M. Return to Alma-Ata. Lancet. 2008;372(9642):865-6. 


      [4] http://www.ncbi.nlm.nih.gov/pubmed/8328604 02/01/2013

      [5] http://www.medscape.com/viewarticle02/04/2013

      Thank you very much.
      With warm personal regards,
      Dr. Surender N. Gupta,
      PGDCHFWM;FAIMS;;MA (Phil);
      FIMS;MAE (Epidemiology); OCCRTI
      HFA_PHC_Johns Hopkins University, Baltimore, USA
      Faculty cum Epidemiologist-in-Charge, District Chamba; 

      Regional Health and Family Welfare Training Centre,
      Chheb, Kangra-Himachal Pradesh, India.

      01892-265472 (Fax); 01892-263472 (Office)
      Mobile: 094181-28634.

      -Editorial Board Member_African Journal of Environmental Science and Technology;

      -Member_National Editorial Advisory Board_Indian  Journal of Emergency Pediatrics;
      -Editorial Board Member_Wudpecker Journal of Medical Sciences;
      -Editorial Board Member_Journal of Environmental Science & Water Resources

      E-mail IDs: drsurendernikhil@...
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