The district health system in the framework of primary health care: Missed opportunities and missing links

Thirty four years have elapsed since the Alma-Ata Declaration on primary health care (PHC) was promulgated in September 1978 through a consensus reached by the world community, as the cardinal strategy for achieving the goal of “health for all”. In 2008 a conference was convened by WHO and UNICEF to examine the intervening three decades of PHC contribution to the health of the world population. The conference scrutinized the achievements made and current health challenges in the light of the experience gained and firmly renewed its commitment to PHC as the way forward in the global health agenda. In the same year, the WHO world health report was dedicated to PHC with the famous quote “PHC: Now more than ever”, reaffirming the strength of the values that lie at the core of PHC, and recognizing it as the most appropriate strategy for the contemporary health challenges and most valid recipe against health inequalities.  In the same report, the WHO Director General expressed great concern about the progress achieved so far

emphasizing that “despite enormous progress in health globally, our collective failures to deliver in line with these values are painfully obvious and deserve our greatest attention”. The report also outlined the inability of health services to deliver effectively and progress towards universal health coverage, meeting the health needs of increasingly impatient populations.

However, this should not undermine the gains achieved by many developing countries that have made significant improvements in their national health systems since the launch of the PHC movement. Globally, over one third of child deaths were averted, the disease burden of major killer diseases lowered, and significant improvements made in antenatal care, sanitation and access to safe drinking water. Yet the health systems of a large number of low and middle income countries were unable to produce the desired health gains. These achievement gaps have often been attributed to financing gaps leading to the inability of health services to mobilize the US$34 per person per year determined by the 2001 report of the WHO Commission on Macroeconomics and Health, as the average cost set for delivering a package of essential health interventions. Other outlined challenges included the shortage of health workforce, poor leadership and management, and the burden of the HIV/AIDS epidemic in addition to natural and manmade disasters that have

These limitations could not solely explain the ensuing colossal performance gaps of the health system, why it was necessary to identify the missing links that are indispensible for PHC mainstreaming. Looking back at the
Alma Ata declaration, we can appreciate that two of the fundamental PHC pillars namely community participation (CP) and intersectoral collaboration (ISC) were not properly executed by a large number of developing countries. The Alma-Ata declaration firmly asserts that “the people have the right and duty to participate individually and collectively in the planning and implementation of their health care”. With regard to ISC, the declaration outlines that PHC “involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sectors; and demands the coordinated efforts of all those sectors”. The inability to assign the necessary attention to these important PHC pillars has posed a real challenge to many health systems and contributed to conditions that have rendered the Millennium Development Goals (MDGs) and the PHC element of equity to remain elusive and unattainable by the targeted date of 2015.  affected many countries rendering their set PHC targets more difficult to attain.

From this analysis we can logically infer that one paramount missing link in the PHC implementation has been the lack of effective CP in the planning, implementation, management, monitoring and evaluation and in gaining and retaining the benefits of the health system. The PHC implementation has to engender an effective mechanism for community empowerment and action through social mobilization and organization and capacity building for needs assessment, planning and management of local interventions. This process should generate authority, voice, self esteem, self help, transparency and representation in all actions addressing the local developmental challenges from health, environment, water, education, livelihoods and other basic human needs.

The public sector will need to meaningfully delegate responsibility and authority to inculcate local ownership and accountability for setting priorities, making decisions and producing the desired outcomes and results. Through this partnership, the community will be able to rally their human and material resources and finally move away from the rhetoric of joint coordination often aimed for formally endorsing decisions made at the different hierarchical levels of the health sector. To sustain the CP process, the management structures of the national, provincial and district teams operating the health sector, need to be reoriented to manifest the correct attitudes and behaviours that will boost the value of CP. An exceptionally constructive PHC strategy was the training of frontline community health workers (CHWs) who serve as a bridge between the community and the health care system. These workers are most effective when they are formally joined to the district health team in terms of remuneration, supervision and support. It will be implausible to consider the establishment of CHWs as a proxy action for CP. Indeed from their operational perspective, CHWs are an integral and vital cadre of the district health team with the advantage of being imbedded in their communities, while CP is a whole of society approach to PHC.

Another major missing link in PHC implementation is the weak ISC. Despite the fact that many health determinants are outside the traditional medical model, most contributions to ISC are short term initiatives not firmly embedded in government policies, structures and operational mandates of the participating sectors. Moreover, the health sector with its internal fragmentation is not prepared to cross its service delivery boundaries and negotiate partnerships for mutually rewarding collaboration. Other sectors have similar inbuilt propensities for inadequate engagement in ISC. Yet it is obvious that without ISC, the access to social determinants of health that breed the causes behind the major causes of ill health will be restricted, leading to one of the great missed opportunities in public health. It is indeed inconceivable to impact on priority public health issues such as malnutrition, the control of diarrhoea, acute respiratory infections, malaria and many other communicable and non-communible diseases without having an effective and solidly institutionalized ISC.   The WHO supported Community based initiatives, where health and social determinants of health are addressed through grassroot based CP and district level ISC, and the Urban Health Equity Assessment and Response Tool (Urban HEART) aimed to identify health inequities and plan intersectoral based interventions to improve people’s socioeconomic conditions are practical models deserving consideration.

To substantiate the benefits of CP and ISC within the context of the recent devolution process in Pakistan and many other developing countries, the state/provincial and district governments should create a balance between the health investments channelled predominantly to the urban curative care often associated with the procurement of costly technologies and the people cantered comprehensive PHC, founded on the pillars of CP, ISC, and equity. To integrate health effectively into the national development process, the government will need to exert the highest political commitment in fostering CP and ISC. The health sector leadership and professional workforce should acknowledge this priority and reform the overarching health system to rectify its current strategic and operational gaps recognizing CP and ISC as critical assets for accelerating the attainment of health for all; universal health coverage, the MDGs and safety nets such as an equity based social health insurance.

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Dr. Khalif Bile Mohamud, MD, PhD, SI

Former WHO Country Representative in Pakistan




  1. Khalif Bile says

    Dear Mariam
    Thank you very much indeed for sharing this article from the News. Our honorable Minister who is also my younger sister and I say this with pride could not have become a Minister and leave health in its dismal fragmentation. God bless her for doing this for Pakistan. The health sector was metaphorically in coma for some years but fully resuscitated now by HE Dr Sania Nishtar. I am sure that the new government will keep this logic and evidence based wisdom unchanged. I am proud of our minister and I pray for her sustained success and for heartfile team as well.
    With best regards
    Dr Bile

  2. says

    The law and provision of these first aid services and health and safety also extends to schools and has done for some time. With our kids spending about a third of the day in school it is not unusual for this to be a location where they experience minor injury and thus having first aid supplies on hand is essential. Children are more mobile and energetic that adults and spend more time running around on a daily basis than we do.

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