Myths of community-based health care.

Editor – I am responding to Adnan Hyder (1), who says that ‘‘community-based health care has been plagued by principles which have become myths’’. It should be pointed out that his principles/myths were not part of Alma-Ata’s message (2, 3) and mostly emerged five years later in the debate which advocated a shift to selective primary health care. An unfortunate polarization between top-down and bottom-up approaches in scaling up programmes to national coverage since then has often stalled health care reform. The dichotomy is false, since we need both. Community-based primary health care brings together multiple approaches to rationalize the balance. I agreewithHyder in debunking the first myth: there is no ‘‘universal model’’, an idea arising from the common public health preference for a blueprint approach. The second myth of focusing ‘‘only on villages’’ was a claimmade in arguing against Alma-Ata but it was never a principle of the Health for All movement. The same applies to the claim that ‘‘governments are the problem’’, since everyone agrees that governments must be a full partner with communities. When he refutes the claim that communitybased programmes are ‘‘less expensive’’, with no indication of less expensive than what, I agree with him that rigorous analysis of real but invisible costs may help. However, to resolve the old polarization, studies of both governmental and community-based activities are needed which look for points of synergy and mutual facilitation. Most of all, I agree with Hyder when he turns from evaluation by costs alone to introduce transparency, equity and need. In the final paragraph he stresses recognition of ‘‘the value base upon which the notion of community-based health care stands’’. He focuses correctly on the values of equity, empowerment and respect, and emphasizes the overriding need for recognition of the plurality of pathways by which these values are put into practice — hopefully in government and village partnerships. A major problem remains: to change the attitudes of international experts who seem to want to prolong the appearance of an argument as part of academic competition. I hope Hyder’s letter will help each of us to clarify our own myths. n Carl E. Taylor, Professor Emeritus Department of International Health School of Hygiene and Public Health Johns Hopkins University 615 N. Wolfe Street, Suite E8132 Baltimore, MD 21205, USA email: [email protected]