Welcome everyone, to Health for All Through Primary Healthcare.

I'm going to call this the Coursera

express. I think we're getting on a bus, and we're going to travel around together. And we're going to
have fun together. We're going to learn new things together, see new things together. We're going to go
backward in time and we're going to go forward in time. We're going to go back to the origins of primary
healthcare, almost 100 years ago. And we're going to think forward about when applying the principles
of primary healthcare might mean for the lives of millions of people around the world. We're going to be
visiting programs as they've been developed in Asia and Africa. And Latin America. And we're going to be
talking about how working with communities and partnership can make a real difference in the health
status and the empowerment of local people. My name is Henry Perry. I'm a faculty member here at the
Johns Hopkins-Bloomberg School of Public Health. And I've spent most of my career working with
primary health care programs in various countries around the world. I've lived for several years in Bolivia,
and Bangladesh, and then Haiti, and I worked in many other countries with many other organizations.
And over this time I have had the great privilege of getting to know some of the great leaders of primary
healthcare. Some of the great innovators, innovators. And I realise the importance of their contribution
now more and more. And I want to share that with you. And so as we move through this course. I'll be
sharing some of my own personal perspectives but also drawing you in to some of the excited things that
have been happening and are happening at the present time. We are all priveleged to be a part of this
global human family but we also realize the great unmet needs that exist, particularly in health. And
these are so tragic because so many people are dying from readily preventable or treatable conditions
some, so many people are suffering because of our lack of interest and compassion, and concern. And so
the purpose of this course is to help you think about how you and your own situation with whatever
need or resources that you may have. Might be able to think creatively. About addressing some of these
issues in partnership with local people whose health needs are not being met at the present time. I
believe that the concepts of primary health care, as we outline them here, and as were first expressed at
the international conference on primary health care in 1978, and the declaration of alma ata. I believe
that these principals deserve an increasingly strong push from all of us who are concerned about these
issues. Not only from us as individuals, or, perhaps, as public health proffesionals. But those of us as
people working in programs, in ministry of health, and MGO's. And maybe government officials of other
kinds, donors, academics, international officials. We all need to be reminded about what these basic
principals are. And how we can more effectively apply them in our work. We live with a terribly unjust
world. We're all aware of this. But still the fact that seven million children are dying around the world
every year from readily preventable or treatable conditions is just tragic. It's morally unacceptable. It's
inexcusable, and we know that through working with partnerships through working with mothers that
many of these deaths could be prevented through very low-cost simple approaches. Handwashing.
1,000,000 deaths each year are caused by a lack of hand-washing. Exclusive breast feeding. We know
that mothers, after they give birth to the, to their child, for the first six months of life, they can provide
all of the baby's nutrient needs through breast feeding. And when they're not exclusively breast feeding,
the children are getting exposed to pathogens that cause diarrhea. And so, we have failed to get the
message across that exclusive breastfeeding is a vitally important healthy behavior that mothers can
undertake to. Give good nutrition to their babies and to reduce the risk of mortality. These are but two
examples of the kinds of things we'll be talking about in this course that are practical, simple, readily
applicable by communities. But, they need help, they need tentacle support, they need some guidance.
They need some encouragement. And so that is what we'll be discussing in this course. This course is for
anybody who is interested in the well-being of our global human family. You don't need any special
technical skills. No formal training in health. We're here to work with you on a very simple, very, very
feasible sort of a way in which you can develop some principals yourself, derived from what we're talking
about that you can use in your own life and work. Primary healthcare and health for all are two of the
most difficult to understand concepts in global health. They seem so simple on the surface, but when we
get into 'em there's a real depth of meaning that is enriching as we think about it. And so I look forward
to working with you and thinking with you about how we can utilize the principles of primary healthcare
as they have been developed and applied by giants in the field. And how we can apply them in our own
lives. In our own work. And so that we can each make a small contribution towards this great goal that
faces our world. That of achieving health for all sooner rather than later. Thank you.

Syllabus
Course Description
Two of the most inspiring, least understood, and most often derided terms in global health discourse are
“Health for All” and “Primary Health Care.” In this five-week course, we will explore these terms in the
context of global health, their origins and meanings, the principles upon which they rest, and examples of
how these principles have been implemented at both small and large scale. We will also explore some
ultra-low-cost approaches to Health for All through primary health care, and the promise that primary
health care holds for eventually achieving Health for All.

The course consists of several short lectures each week (approximately one-hour per week of lectures in
total) with approximately one hour of readings or internet-based presentation, and two additional hours
devoted to studying for each of the four weekly quizzes, writing two short papers, and participating in on-
line discussions with fellow students and the course instructor.

Goals
Overall Aim

 To discuss the principles of primary health care established at the 1978 International Conference
on Primary Health Care as described in the Declaration of Alma Ata
 To recognize the potential of primary health care to help achieve Health for All
Learning Objectives

 Critically assess how to contribute to strengthening primary health care and achieving Health for
All
 Identify participatory methods in building community capacity to solve priority problems in varied
health care settings

Grading Policy
There are six graded assessments in this course. They are weighted as follows:

 Quiz 1 = 10%
  Quiz 2 = 10%
 Quiz 3 = 10%
 Quiz 4 = 10%
 Peer Assessment 1 = 20%
 Peer Assessment 2 = 40%
Additional grading notes:

 Percentages are used to calculate a final course grade from a learner’s graded assessment scores.
 Learners must pass every graded assessment to pass the course, regardless of their final grade.

Foundations of Global Health Specialization

A special welcome to those who are here as part of the Foundations of Global Health Specialization. This is
the fourth course in the series, although you are free to take them in which order makes the most sense for
you and your learning goals.

Like the others in the series, this course will contribute to the ultimate goal of preparing you for work in
global health programming and related fields. As always, this course includes an authentic hands-on
project focused on solving a particular global health problem. In this case, you'll be generating your own
ideas about how you can help achieve the Health for All vision working either alone or within an
organization. You'll identify specific actions as well as specific challenges that you expect to encounter. We
hope that you’ll use the project to think about how you will apply these lessons to your work in the real
world.

As always, we encourage you to join the ongoing conversations in the forums. There you’ll find people from
all over the world with a wide variety of experiences and perspectives.

Greetings, everyone. Now that you are on board the Coursera Express, let us begin our journey together.

Play video starting at ::9 and follow transcript0:09

During module one, we will be traveling back in time to the 1930s in China, where the first primary
healthcare project to improve the health of an impoverished population was established.

Play video starting at ::21 and follow transcript0:21

Then we will travel quickly through time to review some of the historical milestones in the development
of primary health care, and the ongoing tensions between what some refer to as selective versus
comprehensive approaches, and others refer to as vertical and horizontal approaches. We will be visiting
Harvard University in the 1950s, and North India in the 1960s and 1970s. Then we will visit Alma-Ata in
the former Soviet Union, which today is a part of Kazakhstan.

Play video starting at ::56 and follow transcript0:56

You will find in the lecture for this week and in subsequent lectures, there may be some repetition of key
concepts. Don't be alarmed by some minor inconsistencies that may crop up in the course of this lecture
or others, and occasional reference to other lectures that are not in this course.

Play video starting at :1:15 and follow transcript1:15

Once you have listened to this week's introduction to primary health care and health for all, I want to
urge you to reflect for five minutes on what you have heard and then post your thoughts on the
discussion forum. If you have questions or comments, if you disagree with something that has been said,
or if you have your own experiences or opinions about the topics discussed, we invite you to post them
on the discussion forum. Your participation in the discussion forum will enrich your own learning, as well
as the learning of your fellow students.

Play video starting at :1:48 and follow transcript1:48

We strongly encourage you to use the voting mechanism to give your opinion about the posts that have
been made.

Play video starting at :1:55 and follow transcript1:55

This will help learners to know which postings are important. Community mentors will be visiting the
discussion forum and will provide assistance. Many of you have had important field experiences and
have been working on the issues that we will be addressing in the course. So, I urge you not to hold back
and to share them and the opinions that you have developed as a result of your own experiences. This
will greatly enrich all of our learning.

Play video starting at :2:25 and follow transcript2:25

The required readings for this module are the Declaration of Alma-Ata itself, only three pages long. And
two reflections on the declaration published in the world's leading medical journal, The Lancet, in 2008.
And a special issue commemorating the 30th anniversary of the declaration. One is written by the
editors of The Lancet and the other is written by Dr. Margaret Chan, Director General of the World
Health Organization. Once you have finished the lecture and required readings, move quickly to take the
multiple choice quiz.

Play video starting at :3: and follow transcript3:00

Please remember that our goal for each module of work for the course is one hour of lectures, one hour
on readings and two hours of reflection, discussion forum participation, preparation for your quiz, and
preparation of the two short papers, one of which will be submitted for module two, and the other with
module four. I think you will find that you can complete the work for module one in a little less than four
hours. However, for modules two and four, when you have to write a short paper, you might have to
spend a bit more than four hours on your coursework. So have a great time completing module one on
the Coursera Express, and enjoy the first leg of your journey.

Welcome everyone to our first lecture on primary health care as a means of reaching health for all. The
title of this lecture is called Primary Health Care in Developing Countries: Origins, Principles and
Evolution. This lecture was originally recorded for a course I teach here at the Johns Hopkins School of
Health called Introduction to International Health. And so, there will be several points in the lecture,
particularly at the beginning where it will be obvious that this was recorded initially for another purpose.
But the first lecture that you'll be hearing today is a portion of a larger lecture that this recording is taken
from. And then next week we will be listening to another portion of this lecture for the first half of next
week's lecture. And then the second half of that will be a recording that Carl Taylor made before his
death about the origins of primary health care. ·I am very pleased to be sharing all this information
with you. It's of deep value to me personally and so the oppertunity to share these important historical
expirences and ideas and principals are a great priviledgefor me, so welcome. As you know I'm relatively
new to Johns Hopkins. I've been on the faculty since 2009 and my own career evolution started out first
as an MPH student here in the early 1970s and then I trained in general surgery and during my residency
training I had the opportunity to visit the Hospital Albert Schweitzer in Haiti. I worked in Bolivia in the
early 1980s starting a community health program and I was doing surgery as well at that time. I spent
ten years living in the mountains of North Carolina practicing surgery and also providing leadership to a
small NGO that I started called Cure America, originally Andino Health Care and I'll be mentioning a little
bit about that. And then in the middle 1990's, I had the great privilege, of moving to Bangledesh and
working with Johns Hopkins on a project there at the International Center for Diarheal Disease Research,
and later with the basics project, concerned with child survival in Bangledesh. And so I'll be referring to,
some of my experiences there in Bangledesh, and then following that I have the great honor of serving
as the director of the hospital Albert Schweitzer in Haiti, which I had first visited quite a few years earlier,
and I'll be speaking a little bit about that. Starting in 2000 I spent a number of years working with Future
Generations which is an NGO that Carl Taylor started along with his son, and I'll be mentioning some of
that as well. As we go through this, I'll be talking off and on about Carl Taylor, who founded our
Department of International Health here in the early 1960's and was a passionate proponent of primary
health care and in fact global leader of primary health care, so we'll get into that in just a minute. But it's
a recurring theme through all of this. Carl always felt that John B. Grant was the father of primary health
care. John Grant was a very distinguished physician who worked with the Rockerfeller Foundation in a
number of countries, but his most important contribution was his work in China back in the 1930s. And
at that time he worked with some of the very well known chinese people concerned with improving the
welfare of rural China, most notably Jinny Ann and CC Chin and through that project gained a lot of
experience that was very influential on the development of primary health care. He wrote this book,
which Carl always referred to as the bible of primary health care, published by the Johns Hopkin press in
1963 called Health Care for the Community. But, in that book he really repeatedly talks about how the
community can and should be linked to health systems and how health is an integral part of
development and how training and research need to be built into all of these activities in order to make
real solid progress. This general philosophical approach is reflected in this statement from John Grant's
book in which he talks about the need to demonstrate feasibility and worth in projects and programs
and to make use of technical methods which are scientifically efficient and economically practical. And
the need to integrate programs horizontally rather than working in narrow single activities this was
written back in 1934 and the themes that he touches on here continue to resonate as being important
once for us to consider. The project that John Grant helped Jimmy Yen and CC Chen develop was called
Ding Shen. It was 100 miles from Beijing. At that time China was among the poorest countries in the
world and in the rural parts of China certainly conditions were among the very worst in the world. And
resources were extremely scarce, and health facilities, health professionals were extremely scarce as
well. And so in the midst of that context, these three people developed some ideas that seemed kind of
simple but still they were very profound and had an enormous influence. The first thing they did was
they conducted surveys to identify what the health problems really were, and then they trained local
people, non-health care professional people with no formal training or formal background in health to
begin to be engaged in important and priority health care activities they got them engaged in recording
vital events, vaccination against small pox, administrating simple treatments, giving basic health
education, and maintaining wells, and these farmers, Farmer Scholars, as they called them, became the
forerunner of the Barefoot Doctor program, which later became so famous, but that experience was also
an important model for what later became China's rural transformation and development. But, this is all,
explained in some detail in this wonderful book that Carl Taylor, and his son Daniel, wrote called Just and
Lasting Change, which I'll, get to in just a minute. Carl Taylor's mentor, when he was a student at
Harvard, was a very, outstanding man, named John Gordon, who actually worked in China with John
Grant, so the personal connections of these people and the ideas that they promoted and built upon,
one leading to another are interesting part of the primary health care story. John Gordon, in his own
work prior to that time had been involved in some work in Romania, with the Rockafeller Foundation.
And he had onhis own developed the concept of routine systematic home visitation as a way of
providing surveilance data, and he was the first person to record an epidemic from the very first case to
the very last case. This was an epidemic of rheumatic fever that he was always set up to capture and
through that experience as well as others he became aware that home visitation had some real power to
it from public health standpoint and I'll be referring to some of this as we move along, but when Carl
Taylor studied at Harvard Medical School, and then later at the School of Public Health, he took classes in
Epidemiology from John Gordon and John Gordon taught a course on project development and he
served as Carl's mentor in the development of some very important ideas that we'll be referring to. Also,
you see that John Gordon was the mentor of John Wyon, who was a friend of Carl's in India back in the
'50's. And John, as well, fits into this story in a number of different ways. I'll get to that in a minute. Two
of the towering figures in primary health care are Halfdan Mahler and James Grant. Halfdan Mahler is
still living, James Grant died several years ago now. But both were extremely dynamic and charismatic
people. James Grant was John Grant's son interestingly enough and he had grown up in China and had
quite an international experience prior to growing up and spoke fluent Chinese and so forth and so. had
quite a background for this role. He was not a physician, but had worked in development programs, and
had quite a senior career in various development activities before becoming the executive director of
UNICEF. Halfdan Mahler had been a medical missionary in India working in tuberculosis. He is Danish and
he was a friend of Carl Taylor's back in those early days in India, but both of these people had long
tenures at their respective organizations and I think both are considered to be the most outstanding
directors of these organizations that they've ever had and this was an important. Part of the evolution of
primary health care that we'll get into in a minute. Let me just mention a few words about Carl and his
unusual background as well as his enormous contributions. Here you see him as a adolescent I presume,
in India when he was growing up. And on the right you See him about two years before he died when he
had received an honorary doctorate from Johns Hopkins University. His career in international health
spanned from age seven to age 93. So I think that math says that that's about 86 years; extraordinary
career. He has had these accolades from very high powered people John Rohde, who was James Grant's
special assistant for 15 years considers him to be the acknowledged leader of primary care over the
second half of the 20th century. And Hafdan Mahler was quoted in the New York Times after Carl Taylor
died as saying, that he's the greatest public health expert I have come across. So, he's somebody that
Johns Hopkins takes great pride in claiming. Although of course he spent a large part of his life in other
places before coming to Hopkins. But still he started the Department of International Health here and
many people consider that he is the founder of the whole field of international health, not to mention
primary health care. So his contributions are enormous. But here we want to focus on his old work in
primary health care. In this slide you see Karl Taylor's mother and father. They were both medical doctors
and they were missionaries in Northern India in the Punjab and they spend most of their time travelling
from village to village. Treating people and their illnesses. Here on the left you see Carl's father John
treating the men, and his mother Elizabeth treating the women, and they would spend their days
engaged in this kind of work. They had had the opportunity to work in a hospital when they first went
out there, but they later decided that they needed to get out to the village where the people were, and
to really understand and respond to the problems on the ground. And this has importance and
implications in Carl's development as we'll see in a minute. Here you see the kind of paripatetic life that
they would lead. they would go around in these ox carts with their things and go from village to village.
Here you see, in the bottom left, you see Carl as a young child with his brother. And there pet anteater,
and here in the next slide you see Carl with the rest of his family and native Indian garb, so it's a classic
missionary family that's going native, you might say. But they were very much ingrained in the local life
there. Then after Carl finished medical school, he went back to the same areas as a medical missionary
with the Presbyterian Church and soon after his arrival back, their Indian independence came and there
was partition between India and Pakistan and there were massive riots and enormous blood shed and
enormous loss of life and he got engaged in responding to that and got his career started in a very
dramatic fashion. But, several years later, he got involved in, developing, some interesting projects, in
northern India, in the Punjab where he had grown up. He worked with the Ludhiana Medical College,
and they started some projects to train local doctors to work in rural areas, but another important
project they got involved with was something called the Khana study. And here, you see Carl Taylor in
shorts looking towards us and standing. Next to him, to our left is a tall man named John Wyon, who had
also gone out to India as a medical missionary and became friends with Carl and they had a similar
interest in community health and what was going on in the villages. I'll get back to that in just a second.
So here you see the location of Narangwal near Ludhiana, where the Narangwal project was and it's near
where the Khanna project was. The Narangwal Project was Carl's major activity during his early years,
and he had started on that before he came to Hopkins as chair of the department. And for the first 10
years or so that he was at Hopkins, it was the dominant activity in the department of international
health. But it was a pioneering primary health care project that had quite a bit of community based
activities that took place outside the facilities, involving community health workers and home visitations
and so forth as you can see in these slides. But another interesting part of this is that it was a very high
powered research project with various experimental cells. in which villages were assigned to different
kinds of groups for different kinds of activities. And they had a very high level engagement of the
Ministry of Health in these activities. And once a year the project would bring in the Minister of Health
and other high level officials from Delhi to review the findings of the nearing wall project and discuss
their implications for health care services more broadly in India. And here in this next slide you see Carl,
the very dashing man there with the tie on having a reception for these officials at his home in the
village in Narangwal. There are lots of interesting things about the Narangwal project, that I don't have
time to tell you about. A summary of the project is in two volumes published by the World Bank here
back in the early 80's, but one of the interesting aspects of it is that the staff lived in the village, mixed
and mingled among all the other households there. It wasn't like a separate compound, and so this
whole project was integrated into the life of the village and it had a very important impact on the way
the project moved forward. There was a very strong participation of the community in the research
project and discussion of the findings with the community as well as higher level officials too. But this
project was an important foundation for the 1978 Alma-Ata Conference. In addition to the Narowal
project, however, there was a growing recognition that the international health work, up until that time,
was becoming misguided. And the reason I say that is because Christian medical missions were very
hospital-focused and people were realizing that these hospitals themselves weren't really responding to
the major health needs of the people. There was an organization called the Christian Medical
Commission that was formed that had its office in Geneva. And they did a study in which they went
around the world and they looked at the health of the people who lived close to a mission hospital, and
they compared it to health of people who lived further away from the hospital, and they concluded that
there was no difference in the health of people who lived closer to a hospital than people who lived
further away. And so that caused some serious thinking about what was being accomplished by these ,,
very prestigious hospitals that focused on curative care mostly for adults. That whole experience of the
Christian Medical Commission had an important influence, as I'll mention in a minute, on the ,, evolution
of thinking at WHO. In addition to the work of the Christian Medical Commission, the World Health
Organization sponsored the publication of a book called Health by the People, and it was a very clear.
from that book and the examples of community health care from various places around the world that a
whole new approach was needed. And, that book certainly pointed out the fact that the medical model
of curative curve was not going to really be the answer to the health needs of the population and much
of this was hospital focused. So, with that kind of background and Carl Taylor's ,, close relationship to
Halfdan Mahler, that went way back to their time in India. Halfdan Mahler asked Carl Taylor to be his
special envoy and he played a key role in the development of what became the international conference
on primary health care in 1978 held at Alma-Ata at that time it was USSR now in Kazakhstan. And Carl
told me that he was going back and forth to Geneva like a yo-yo, but he spent a enormous amount of
time on that. So, one of the interesting things that happened is that the people working with the
Christian Medical Commission in Geneva started talking to the high level people at WHO, and Halfdan
Mahler having come from a Christian Medical Mission's background he knew these people and he saw
the value of what they were doing and so that relationship lead to quite a strong influence that WHO is
described in this article in the American Journal of Public Health in 2004. Here you see the contents of
this book, called Health by the People, which was published in 1975, which was an important foundation
for the international conference on primary healthcare, and you see the discussion of the barefoot
doctor concept in China is the first chapter in this book. But perhaps the most important chapter in this
book was the one written by Maybelle and Roger Rollies you see on page 7, describing the John Kit
project. The Rollies were students of Curl Taylor's and went to this very deprived area of central India
and started a project that within four or five years had become world famous. And we'll get into that a
little bit more. But, so much of what happened at Alma-Ata, I think was strongly influenced by what the
Rollies did. Here you see a photograph of the meeting itself, very much a Soviet-style type of [LAUGH],
type of setting obviously. The International Conference on Primary Health Care that was held at Alma-Ata
in September of 1978 was. The most important global health conference that had been held in the world
up until that time. It was attended by leading health figures from all over the world. And they focused on
this very important idea of what primary health care is and what it should be, what it might be. And the
outcome of this conference which is so important for our course, and so important historically is the
declaration that was unanimously approved by everyone. We refer to this as the Declaration of Alma-
Ata. The Declaration is only two pages long, and it's available on the internet, and you have it in your
readings. But what makes it special in many different ways is, first of all how well written it is and how
incredibly concise, but still profound the ideas of primary healthcare are that can be seen in this
document and we're going to be talking in the next lecture, next week on what exactly is in this and
you'll be reading it yourself as part of the readings for the course. But, just to give you a few ideas about
why this is so important is that, first of all, the concepts of primary health care that are described in the
declaration are very different from the idea of primary medical care in the developed worlds, so for
much of the world and particularly for scientific experts and so forth, the notions here were very
different from traditional medical notions. And as I have said and will continue to say, it very much
focuses on what might be considered his first principles. The very basic conditions that are needed
within society to achieve health, whether they're medical care treatment, or other so called social
determents of health. And as a result, it was not received very favorably by the more traditional medical
scientific establishment, and many considered it to be a radical attack on the medical establishment, as
well. But in fact, if you read and think about what's in the declaration, I don't think that's true, but
because it incorporated new ideas that went far beyond simply the practice of, medicine by doctors, it
wasn't warmly received by everyone. Once it became known and discussed, and was widely publicized
following the international conference on primary health care. When the Lancet published its series on
Alma-Ata in 2008 which was celebrating the 30 years following the conference, Margaret Chan who is
the Director General of the World Health Organization she made this statement in an editorial that
preceded the document which I think, does a great job of focusing in on some of the key values that are
embedded in the Decoration of Alma-Ata, she said that it honors' the resilience and ingenuity of the
human spirit, and made space for solutions created by communities, owned by them and sustained by
them.' And so obviously, you can see just from this that this approach to primary healthcare goes far
beyond the traditional medical model. I wanted to share with you, this statement that came from Mabel
and Roger Arole, in their book called Jam Ked, which is one of the great classics of global health and
primary health care. And so, if you've never heard of it And, really want to get into this whole idea of
primary healthcare, in a deeper way, I strongly urge you, to obtain this book by the Arole's called Jam
Ked: A Comprehensive Primary Healthcare Program. This sentence that you see on your screen here,
again gives the sense of What, the declaration of Alma-Ata is trying to get at. Again, it promotes this
idea, of working with local people. Using, the capabilities that local people have, to engage with them,
and enable them to take responsibility for, and to take action to improve their health. Again, very
different approach, from the traditional medical model of curative care provided by. highly trained
physicians. And so even though this statement is not actually in the declaration of Alma-Ata. I think it
gives a good sense of the deeper meaning of the declaration of Alma-Ata. He goes on to say that and
again, this reflects the challenge to the medical model, he talks about the need to demystify medicine,
and to share knowledge freely with people, so that they can attain and maintain good health.
Hierarchical latitudes which unfortunately are a dominant part of the medical model less so now but,
certainly a part of the history of medicine. Arctic latitudes have to be replaced by team spirit and
equality. The realization that knowledge not only gives power but the cheering knowledge also increases
self estimate is important for the development of the team spirit. So, these philosophical elements are
very much embedded in the whole notion of Alma-Ata. Unfortunately after the international conference
on primary healthcare in 1978 and the enormous enthusiasm that was created, the whole movement
underwent a rapid decline. It's a very important part of the history of global health to look at this and to
think about it and exactly why these things took place is also a fascinating question which people like to
think about, and I'm not sure the final answer has been written on that. But for many people the whole
notion of health for all, by the year 2000 which the declaration of Alma-Ata called for was too broad and
idealistic with an unrealistic timetable. And at that same time as well the importance of immunizations
was being recognized and the low coverage of immunization services in developing countries was
becoming a problem in the early 80s the coverage of immunizations in most poor countries was only 5-
10%. And so people, expert authorities like D.A. Henderson, the former dean here, who was the leader
of the small pox eradication program at WHO began to push for an expanded program on immunization,
EPI. And also, at that time as well, world rehydration solution had been developed as a very simple way
to treat dehydration caused by diahrea, and so these twin engines became very much the favored
approach of Global health experts who weren't in the same philosophical tradition of Alma-Ata, and they
began promoting this, and this became the beginning of what we call today the selective primary health
care approach. Vertical programs which have many different characteristics from what was envisioned at
Alma-Ata But, this later emerged into, what was back in the eighties called as GOBI-FFF (growth
monitoring, oral rehydration, breastfeeding, immunizations, food supplementation, female literacy and
family planning) it was a sort of the extention of a very near but still highly selective vertical approach.
There were lots of reasons why the selective approach became so much more powerful than the Alma-
Ata approach. Julia Walsh and Kenneth Warren, wrote this very famous article in the New England
Journal of Medicine in 1979. Arguing for the cost-effectiveness of the selective approach to poverty
health care, and they made it very clear in their article that they saw this, not the long term answer, but
as a short term interim strategy for disease control. And I think we're finally beginning to move out of
this interim strategy and towards a more comprehensive approach, but there's still a lot of debate about
these two approaches. And I'll get into this a little bit further. We come back here to James Grant who
became the global proponent for the selective approach interestingly enough in UNICEF with its
resources and prestige was the dynamic force that that led to the expansion of programs, particularly for
oil rehydration therapy and for immunizations. And James Grant was very famous for traveling all around
the world, meeting with heads of state. And he would always pull out his oil rehydration salts packet and
promote ORT immunizations. Jon Rohde was his right hand man. A compatent Harvard trained
pediatritian, who saw the power of the selective approach and they worked hand in hand on this, but
Carl Taylor liked to remind James Grant that his own father, John Grant, would not approve of what he
was doing because his father had a much more holistic approach, as that initial statement indicated, that
I talked about at the start of the lecture. Other reasons for the rapid loss of momentum of health for all
movement is many people call the Alma-Ata concepts was the weak leadership at WHO globally and also
weak leadership at the country level in WHO and the medical orientation of what many people refer to
as the world disease organization rather than the World Health Organization. But there was also a lack of
strong scientific evidence of the progress that could be achieved with the broader approaches. And there
was strong scientific achievements that could be shown for oral rehydration therapy and immunizations.
So the scientific part of this was an issue and then there were the politics that fed in this as well and
many people considered Health For All to be a part of the leftist, socialist, communist agenda, so that
didn't help obtaining support for it from the West and particularly the United States. And so we have this
ongoing tension that's still with us today after three decades, more than three decades between the
approach of what many people refer to as a more horizontal approach, Integrated approach, grass roots
approach, that works with the felt needs of people and provides a broader scope of services, as opposed
to a highly selective top down Externally funded approach that's, focused on, highly targeted, but still,
epidemiologically important conditions and diseases, but tied in with these two approaches are also
some themes that permeate global health more broadly, but particularly in the primary health care as
well and that is the reality that health problems are, as in particularly in the very poor countries of our
world today, are still very much a product of the social and economic conditions of people and so
creating a longer term sustained improved response to health conditions, requires addressing the social
economic in terms of health, and that requires a political response in order to make a real difference in
the health in the longer term. But at the same time we recognize that very dramatic things can be done
with inexpensive technical or biomedical interventions, such as the administration of vitamin A, is a pill
that you only need to take every 6 months, and that reduces the mortality rates of children by 1/3. So
how can we not be engaged, as public health professionals in promoting these simple low cost
interventions as well? And so this deilemma continues with us as I said the major funding programs
today are very much disease focused. The Global Fund to fight AIDS, tuberculosis, malaria, PEPFAR, the
President's Emergency Program for AIDS Relief, the President's Malaria Initiative are all reflections of this
top down vertical approach that are extensions of Gobi and the earlier highly selective approaches. But
at the same time, the inability of these very narrow approaches to build up health systems and to build
sustainable integrated programs is also becoming recognized as we're entering a new phase in which
there's a broad agreement that we need to be putting more emphasis on horizontal integrated systems
approaches, and also the need to engage communities and build them in as partners in this process as
well. So some people like to say that we have all become diagonalists now. Jaime Sepulveda, a high level
researcher and policy advocate from Mexico. who more recently has been working with the Gates
Foundation, made the statement very powerfully, in one of his lancid articles about, we need to have
both people recognize that of course the vertical approach is valuable, but we also need the horizontal
approach and they shouldn't be seen as competitors, but as complimentary. Unfortunately, over this
history after Alma-Ata, the vertical approach was so dominant that the horizontal approach was sort of
left behind, so we're now in a faze of building up the horizontal approach. The world health report in
2008 was focused on primary health care and they mentioned some important issues that have
detracted away from primary health care one is what the call hospital centrism, so this early idea of a
that I mentioned with the Christian medical commission of needing to get away from hospitals. Or, I
should restate that. It's not the need to get away from hospitals, but it's the need to get away from
having hospitals as the center of health program activities and by the center I mean where most of the
money is going among other things. That's been a major detractor for developing primary healthcare
services because the political pressure and the people making decisions about funds have given priority
to hospital services and the high technology that goes along with them, and in addition to the hospital-
centrism, this report focused on the problems of commercialization and fragmentation as being
detractors towards the full development of primary health care as we know it, and as a result of these
forces that lead away from permanent health care. We have problems today with health equity, lack of
access to care, and very unhealthy communities. John Grant referred to public health, in this quotation
that you see above here, but it's got a strong relationship to primary healthcare. Public' health is the
science and art of social utilization of scientific knowledge for medical protection by maintaining health,
preventing disease, and curing disease through organized community efforts.' So it's those organized
community efforts that are such a fundamental part of primary health care which again focus on the non
medical model of primary health care and in this vein I wanted to mention some concepts that I learned
from John Wyon, who I have the privilege of working with for a long time in my early career. John always
referred to three kinds of public health: disease-oriented public health, service-oriented public health,
and community-oriented public health.

Play video starting at :38:38 and follow transcript38:38

And this is where primary health care and public health become linked, at least in my mind. We know
that disease oriented public health is focused on reducing the effective, a disease, and a population.
Services-oriented health works to get basic services out to a population which I guess is a part of primary
health care. Perhaps. As long as those services are not hospital services. But community oriented public
health is focused on a practitioner of public health working with a community or a set of communities to
help that community improve itself. And unfortunately, community oriented public health and the
primary health care notion that's linked into it is very under-developed in academic public health, and
it's very under-developed and global health more broadly. John always used to like to say that these
three types of public health are like the three legs of a three-legged stool, and they each complement
each other; with one of the legs being weak, the platform of the stool is weak as well, no matter how
strong the other legs might be. So, I've been going in some detail and all of its history and some of the
issues involved in the development of primary health care. Lets take a brake and when we come back
we'll continue this discussion, but bring it into a more current context.

Declaration of Alma Ata

Declaration of Alma-Ata

International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September

1978

The International Conference on Primary Health Care, meeting in Alma-Ata this twelfth day

of September in the year Nineteen hundred and seventy-eight, expressing the need for urgent

action by all governments, all health and development workers, and the world community to

protect and promote the health of all the people of the world, hereby makes the following

Declaration:

The Conference strongly reaffirms that health, which is a state of complete physical, mental

and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental
human right and that the attainment of the highest possible level of health is a most important

world-wide social goal whose realization requires the action of many other social and

economic sectors in addition to the health sector.

II

The existing gross inequality in the health status of the people particularly between developed

and developing countries as well as within countries is politically, socially and economically

unacceptable and is, therefore, of common concern to all countries.

III

Economic and social development, based on a New International Economic Order, is of basic

importance to the fullest attainment of health for all and to the reduction of the gap between

the health status of the developing and developed countries. The promotion and protection of

the health of the people is essential to sustained economic and social development and

contributes to a better quality of life and to world peace.

IV
The people have the right and duty to participate individually and collectively in the planning

and implementation of their health care.

Governments have a responsibility for the health of their people which can be fulfilled only

by the provision of adequate health and social measures. A main social target of governments,

international organizations and the whole world community in the coming decades should be

the attainment by all peoples of the world by the year 2000 of a level of health that will permit

them to lead a socially and economically productive life. Primary health care is the key to

attaining this target as part of development in the spirit of social justice.

VI

Primary health care is essential health care based on practical, scientifically sound and

socially acceptable methods and technology made universally accessible to individuals and

families in the community through their full participation and at a cost that the community

and country can afford to maintain at every stage of their development in the spirit of selfreliance

and self-determination. It forms an integral part both of the country's health system,
of which it is the central function and main focus, and of the overall social and economic

development of the community. It is the first level of contact of individuals, the family and

community with the national health system bringing health care as close as possible to where

people live and work, and constitutes the first element of a continuing health care process.

VII

Primary health care:

1. reflects and evolves from the economic conditions and sociocultural and political

characteristics of the country and its communities and is based on the application of the

relevant results of social, biomedical and health services research and public health

experience;

2. addresses the main health problems in the community, providing promotive, preventive,

curative and rehabilitative services accordingly;

3. includes at least: education concerning prevailing health problems and the methods of

preventing and controlling them; promotion of food supply and proper nutrition; an
adequate supply of safe water and basic sanitation; maternal and child health care,

including family planning; immunization against the major infectious diseases; prevention

and control of locally endemic diseases; appropriate treatment of common diseases and

injuries; and provision of essential drugs;

4. 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;

5. requires and promotes maximum community and individual self-reliance and participation

in the planning, organization, operation and control of primary health care, making fullest

use of local, national and other available resources; and to this end develops through

appropriate education the ability of communities to participate;

6. should be sustained by integrated, functional and mutually supportive referral systems,

leading to the progressive improvement of comprehensive health care for all, and giving

priority to those most in need;

7. relies, at local and referral levels, on health workers, including physicians, nurses,

midwives, auxiliaries and community workers as applicable, as well as traditional

practitioners as needed, suitably trained socially and technically to work as a health team

and to respond to the expressed health needs of the community.

VIII

All governments should formulate national policies, strategies and plans of action to launch

and sustain primary health care as part of a comprehensive national health system and in

coordination with other sectors. To this end, it will be necessary to exercise political will, to

mobilize the country's resources and to use available external resources rationally.

IX

All countries should cooperate in a spirit of partnership and service to ensure primary health

care for all people since the attainment of health by people in any one country directly

concerns and benefits every other country. In this context the joint WHO/UNICEF report on

primary health care constitutes a solid basis for the further development and operation of
primary health care throughout the world.

An acceptable level of health for all the people of the world by the year 2000 can be attained

through a fuller and better use of the world's resources, a considerable part of which is now

spent on armaments and military conflicts. A genuine policy of independence, peace, détente

and disarmament could and should release additional resources that could well be devoted to

peaceful aims and in particular to the acceleration of social and economic development of

which primary health care, as an essential part, should be allotted its proper share.

The International Conference on Primary Health Care calls for urgent and effective national

and international action to develop and implement primary health care throughout the world

and particularly in developing countries in a spirit of technical cooperation and in keeping

with a New International Economic Order. It urges governments, WHO and UNICEF, and

other international organizations, as well as multilateral and bilateral agencies, nongovernmental

organizations, funding agencies, all health workers and the whole world

community to support national and international commitment to primary health care and to
channel increased technical and financial support to it, particularly in developing countries.

The Conference calls on all the aforementioned to collaborate in introducing, developing and

maintaining primary health care in accordance with the spirit and content of this Declaration.