Examination Of Factors In Improvement Of Primary Health Care

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Main Category: Public Health
Also Included In: Pediatrics / Children's Health
Article Date: 15 Sep 2008 - 0:00 PST

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Countries such as Thailand, Vietnam, Peru and Brazil have made enormous strides towards improving primary health care (PHC) in the face of problems such as political instability, low per capita income, and high HIV/AIDS prevalence. This was discussed in a paper released on September 12, 2008 as part of a special Alma-Ata issue of The Lancet.

The authors focus on the average annual reduction in child mortality between 1990 and 2006, investigating the reasons behind the progress in the 30 best performing countries and the issues behind the worst-performing countries. For example, Thailand's average reduction has been the highest, at 8.5% per year. This is not a coincidence, as the country has achieved universal vaccine coverage and skilled birth attendance. And, the interventions have had low inequity, allowing them to reach people who need it most.

In these countries, which are progressing, several similar characteristics emerge. For instance, nationally agreed packages of PHC, attention has been paid to district management systems, and special investment has been made in primary care extension-workers. This was not limited to countries with great resources, as shown by the great progress shown by Nepal, Laos, Bangladesh  and Guatemala, some of the poorest countries in the world. their successful interventions have involved selective strategies like community health-workers treating children with pneumonia in the home, and implementing high-coverage immunization. The 30 best performing countries included 14 with comprehensive PHC, defined as skilled birth attendance levels above 80%.

Cuba was also used as an example of successful implementation of policy to reduce child mortality. Its child mortality rate is less than that of the United States, even though its per capita income is only 2% of that of the US. Within a year of birth, Cuban mothers and children receive 15 visits from their local family doctors, who focus on preventive care.

In another example, the very location of the influential Alma-Ata declaration has been improved. In 1978, a girl born in Alma-Ata, then in the U.S.S.R., had a 7.3% risk of dying before her fifth birthday. In 2008, a girl in the same place has a risk of only 2.9%.

Worldwide, mortality for children under the age of five has cut in half between 1978 and 2008. This has been less pronounced in poorer countries (42%,) and more in richer countries (77%.) Specific reasons for mortality have included war (Chad and Iraq,) HIV (South Africa and Zambia,) and mortality in adults (such as alcoholism in men in Russia.)

Many of these items prevent these countries from reaching the Millennium Development Goals because the PHC systems are overburdened. "More detailed analysis and evaluation within and across countries  would be invaluable in guiding investments for primary health care, and expediting progress  towards the MDGs and health for all."

Alma-Ata: Rebirth and Revision 4
30 years after Alma-Ata: has primary health care worked in  countries?
Jon Rohde, Simon Cousens, Mickey Chopra, Viroj Tangcharoensathien, Robert Black, Zulfiqar A Bhutta, Joy E Lawn
Lancet 2008; 372: 950-61
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Written by Anna Sophia McKenney
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