Primary Health Care

by

Niels Brimnes

• LAST MODIFIED: 17 April 2025
• DOI: 10.1093/obo/9780197768723-0035

Introduction

Primary health care may refer to the first contact between a patient and the health system, but within the history of medicine it is commonly associated with a specific strategy that aimed to achieve “Health for All by the Year 2000” through promotion of basic health services. In this more precise understanding, Primary Health Care was an approach that distanced itself from both sophisticated hospital-based health care for the privileged few and technocentric, single-disease programs. Primary health care saw health in a broader intersectional and community-based perspective, favored simple technologies and affordable interventions, and welcomed the use of semi-skilled personnel as well as practitioners of Indigenous traditions of medicine. The vision of primary health care had historical precedents, but, as a specific approach, it was mainly developed in the 1970s. It was endorsed as a strategy in 1978 when the World Health Organization (WHO), UNICEF, 134 governments, and 67 international organizations at a major international conference adopted the “Alma-Ata Declaration on Primary Health Care.” In the 1980s attempts to implement the new doctrine were carried out throughout the world. This took place in an ideological environment increasingly influenced by neoliberalism, which was ideologically against increasing state involvement in health and in favor of market-driven approaches that emphasized cost-efficiency. It was, therefore, hostile to many of the assumptions underpinning primary health care. A rival approach known as Selective Primary Health Care emerged soon after Alma-Ata, and, in 1982, UNICEF adopted four specific health interventions—known under the acronym GOBI—as the core of its health-related activities. The World Health Organization found itself increasingly isolated as conservative governments in the Global North and major donors, such as the World Bank, distanced themselves from primary health care. By the early 1990s, most scholars agree that primary health care was no longer an important part of the global health agenda, even if it is important to keep sight of diverging regional developments. This article understands primary health care as a vision that was influential from the late 1960s to the early 1990s, and it considers the WHO under Director-General Halfdan Mahler as its main stakeholder. As many of the contemporary texts that went into the making and unmaking of primary health care are easily available as part of primary health care’s historiography, this article contains sections with references to the most important contemporary accounts. The history of primary health care is presented here as consisting of two phases: the 1970s, when the vision was developed and codified, and the 1980s, when attempts were made to implement the vision. Separate sections consider contemporary accounts. The article ends with sections considering developments during both the 1970s and the 1980s in each of the WHO regions, including some examples of contemporary accounts. The article is restricted to material in English.

General Accounts

General accounts of primary health care largely agree on the main features of its history. They identify a diverse set of roots in the 1970s; notably the failure of “vertical” malaria eradication, the call for a New International Economic Order (NIEO), and a broad quest to identify alternative approaches to development. A good place to start is Cueto 2004, which is one of the first genuinely historical interpretations of primary health care and is referred to in virtually all subsequent accounts. Taking a longer perspective, Packard 2016 and Lee 2009 understand primary health care as a second manifestation of ideas, which had flourished under the label “social medicine” in the 1930s and 1940s. Cueto, et al. 2019 shares many analytical points with Packard 2016, but, as an institutional history, it digs deeper into the pathways of primary health care within the WHO. Virtually all accounts are sympathetic toward primary health care and critical toward the competing “selective” approaches emerging in the 1980s. Birn, et al. 2017 offers a critical assessment of developments after the Alma-Ata conference, while Farmer, et al. 2013 considers some positive aspects of these approaches. Somewhat different perspectives are offered by political scientists, who have used the case of primary health care to investigate and illuminate theoretical points from the social sciences. Chorev 2012 analyzes the possibilities and limits for international organizations to act independently through “strategic adaptation”; while Hanreider 2015 employs primary health care to illuminate the “fragmentation trap” in international organizations.

• Birn, Anne-Emmanuelle, Yogan Pillay, and Timothy H. Holtz. Textbook of Global Health. 4th ed. Oxford: Oxford University Press, 2017.

  DOI: 10.1093/acprof:oso/9780199392285.001.0001

  Chapter 2, “Between International and Global Health: Contextualizing the Present” (pp. 43–88), in this general and cross-disciplinary book narrates the history of international and global health from World War II to the twenty-first century. The emergence of primary health care is broadly contextualized in contemporary politics. Notes that while the vision generated “enormous discursive currency,” it quickly faded due to the combined forces of the Rockefeller Foundation, UNICEF, the World Bank, and the conservative administration of President Ronald Reagan, which all favored market-driven interventions and technological solutions.

• Chorev, Nitsan. The World Health Organization between North and South. Ithaca, NY: Cornell University Press, 2012.

  DOI: 10.7591/9780801463921

  While the approach in Chorev’s important monograph is taken from political science, it also contains a rich historical narrative. Chapter 3, “A New International Order in Health” (pp. 42–85), provides an analysis of how the WHO adapted to a changing political context in the 1970s through the Primary Health Care strategy. The analysis of how the organization through “strategic adaptation” successfully navigated the tensions between developed and developing countries inherent in the NIEO agenda is particularly interesting. Chapter 5, “The WHO in Crisis” (pp. 124–159), analyzes the difficulties encountered by the WHO as it failed to navigate the neoliberal agenda emerging in international politics beginning in the early 1980s.

• Cueto, Marcos. “The Origins of Primary Health Care and Selective Primary Health Care.” American Journal of Public Health 94.11 (2004): 1865–1874.

  DOI: 10.2105/AJPH.94.11.1864

  Cueto lucidly accounts for the most important developments that inspired the growth of primary health care, emphasizing a network of medical missionaries and the popularity of the Chinese “barefoot doctor.” He also takes the reader through the institutional process within the WHO that culminated in the Alma-Ata conference. Cueto then demonstrates how the new doctrine was challenged almost immediately and outlines the opposing positions in the debate on primary health care in the 1980s. This important article has influenced most later works.

• Cueto, Marcos, Theodore M. Brown, and Elizabeth Fee. The World Health Organization: A History. Cambridge, UK: Cambridge University Press, 2019.

  DOI: 10.1017/9781108692878

  In this thorough institutional history of the WHO, chapter 7, “The Vicissitudes of Primary Health Care” (pp. 170–202), is devoted to the rise and demise of primary health care. It provides much valuable information on how primary health care was developed within the WHO as well as on some of the important activities in the 1980s associated with both Primary Health Care and the rival Selective Primary Health Care approach. The treatment of primary health care ends with Halfdan Mahler’s tenure as director-general and the appointment of Hiroshi Nakajima, who had little investment in the ideas associated with his predecessor.

• Farmer, Paul, Arthur Kleinman, Jim Kim, and Matthew Basilico, eds. Reimaging Global Health: An Introduction. Berkeley: University of California Press, 2013.

  This book, which is based on a Harvard Course, is not primarily a historical work, but it contains solid historical chapters. Chapter 4, “Health for All? Competing Theories and Geopolitics” (pp. 74–110), deals with the last three decades of the twentieth century. It contextualizes health and health policies broadly in sociological and economic terms, and it is noteworthy because it is less dismissive than most other accounts of the “selective” approaches emerging in the 1980s.

• Hanreider, Tine. International Organization in Time: Fragmentation and Reform. Oxford: Oxford University Press, 2015.

  DOI: 10.1093/acprof:oso/9780198705833.001.0001

  Uses WHO and primary health care to illustrate the historically conditioned fragmentation that often accompanies attempts to reform international organizations. In the case of Primary Health Care, the price for obtaining support for the new strategy throughout the organization was a territorial fragmentation through the strengthening of the already powerful regional offices. The result of the adoption of the Primary Health Care agenda was, in Hanreider’s analysis, a further decentralization of the WHO.

• Lee, Kelley. The World Health Organization (WHO). London: Routledge, 2009.

  A handy introduction to the WHO organized around the historically evolving tension between (vertical) biomedicine and (horizontal) social medicine. The account is critical toward the results obtained through the vertical campaign against single diseases, more positive toward the horizontal approach manifested through primary health care, and it provides a particularly positive assessment of Director-General Halfdan Mahler.

• Packard, Randall M. A History of Global Health: Interventions into the Lives of Other People. Baltimore: Johns Hopkins University Press, 2016.

  DOI: 10.56021/9781421420325

  The main argument running through this lucid account of global health since the beginning of the twentieth century is that approaches have oscillated between vertical, technocentric, and broader horizontal interventions. In chapter 12, “Rethinking Health 2.0: The Rise of Primary Health Care” (pp. 231–248), Primary Health Care is understood as a second manifestation—after social medicine in the 1930s and 1940s—of the horizontal approach. Packard provides admirably clear overviews of the diverse trends that facilitated the emergence of Primary Health Care and of the equally diverse elements that led to its decline.