Primary health care, health policies and planning: lessons for the future.

Choices about forms of health care, including primary health care (PHC), are fundamentally political decisions, reflecting global and national power structures and alliances, changing economic conditions, emerging new health problems and health care challenges, and the development of new health technologies. However, these choices also reflect, and are often expressed in terms of, a philosophy or rationale based on ethical theory or political “ideology”, a set of principles that guides decisions. The philosophical perspectives on ethics underlying health issues have variously been identified as utilitarianism, liberalism, neoliberalism, social egalitarianism and communitarianism (Box 1) [1,2]. As regimes in many developing countries have changed over time, so has the political ideology, resulting in the reinforcement of, indifference to, and sometimes rejection of, the major tenets of PHC. The major tenets of PHC, as they emerge globally and in the Eastern Mediterranean Region (EMR), prior to and following the Alma Ata Declaration of 1978, support universal access to care, health equity and gender equity, community-based activities to link formal health care systems with the communities, and intersectoral action, which are all needed to tackle what we now call the “social determinants of health”. As such, they represent to varying degrees principles of egalitarianism and/or communitarianism. This paper traces the evolution of global and regional policies on PHC and its chequered history, which has been marked by a number of phases when conditions were more, or less, favourable for its development. The paper identifies 3 policy phases: before Alma Ata; Alma Ata – the first 15 years (1978–1993); and the era of health sector reform and the resurgence of PHC (1993–2008). The paper goes on to discuss the regional perspective on PHC and finally closes by recommending a sustainable health system based on PHC.