Health For All — Reflection On Carl Taylor
Carl Taylor was a global leader of public health care. Became a son of medical missionaries, he lived to see public health care since he was a child. He was a part of the Narangwal project, a community-based health care project in Punjab, which managed to get attentions from high-level ministry of health officials in India. He was also a ‘behind the scene’ person of the declaration of Alma-Ata which became the guidance for world’s primary health care.
In the last lecture titled ‘The Roots of Primary Health Care’, Carl Taylor showed us how the ancient systems of PHC work in China, India, Greece, and Babylon. And then he showed us about ancient herbs researches by the government or companies and syncretism by the traditional practitioners in modern days, and also about the dilemma of competition between modern (western) practitioners versus traditional practitioners.
About the modern history of PHC, Carl told us about the first model of modern PHC, the Ding Xian project. In this project, John B. Grant and his fellows tried to empower people in community level to be trained as health workers. This system was picked up by Mao Zedong and the communist government and in result there were the ‘bare-foot doctors’.
In 1950s Kark had a project in South Africa which later adapted as community oriented primary care which now used in America. In 1960s to 1970s, there were two projects in India, The Jamkhed and Narangwal project. Recently, Dr. Abhay Bang founded an NGO called SEARCH. SEARCH trained community health workers in Gadchiroli, Nagpur which successfully reduce IMR and NMR in that district. While Ding Xian, Jamkhed, and Narangwal projects had a strong horizontal notion, Kark’s project was more vertical in it’s concept, and SEARCH project is an example of the diagonalist.
In 1978, international conference of on PHC was held and the declaration of Alma-Ata was approved. The declaration of Alma-Ata describes PHC with focusing on the very basic conditions that are needed within society to achieve health whether medical care treatments or other so called social determinants of health. It wasn’t received well by the modern medical community.
The declaration of Alma-Ata was considered to be too broad and idealistic. And with the unrealistic time-table, the declaration of Alma-Ata was like Atlantis in the world of primary health care. After that, the challenges are arose. The ‘twin engines of EPI and ORS’ and the GOBI-FFF, these selective and vertical solutions are considered more do-able with the easiness on monitoring and evaluating and getting the indicators of success and reports became their advantages, not to forget the cost-effectiveness. Julia A. Walsh, M.D. and Kenneth S. Warren, M.D. wrote an article about selective PHC as an interim strategy for disease control in developing country but, as mentioned in the title of the article, the selective PHC is of course not suitable as a long term solution because the ideal PHC should have a comprehensive approach not only to certain illnesses.
The health problems in less developed countries are related to social, economy, and political conditions. Many health problems in poor countries can be addressed with simple and inexpensive intervention but these are not usually the priorities of the local people. These dilemma and contradiction over the Alma-Ata PHC (horizontal) and selective PHC (vertical) brought a new paradigm which called diagonalist. The concept is that both vertical and horizontal programs need to co-exist. Unfortunately after Alma-Ata, the vertical programs are more dominant and the horizontals are left behind.
John Wyon told us about three kinds of public health: disease oriented, service oriented, and community oriented. Each complements the other like three legged stool. This might be the best illustration about how the vertical and the horizontal need to co-exist in the primary health care.
In my opinion, in order to attain the ideal PHC, we need to pay more attention on these two statements from Carl Taylor.
“Real social change occurs when officials and people with relevant knowledge and resources come together with communities in joint action around mutual priorities.”
“There is no universal solution, but there is a universal process to find appropriate local solution.”
And one from Dr. Abhay Bang.
“Think locally, act globally.”
Primary health care needs officials (political) and resources (economic and political) which are best provided by the government or by certain people or organization if it’s in poor countries. Primary health care needs people with relevant knowledge. And the main strategy should be to find each local solution and to maintain equity. One village may have different solution from other village. Urban and rural should have different solution too. And of course each country would have different strategy also. The combination strategy of horizontal and vertical should lies upon the condition of the local community.
*This essay is part of the assignments from the course (Health for All Through Primary Health Care) which I’m taking in www.coursera.org .