Selective Primary Health Care

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Selective Primary Health Care was evolved from the broader concept of Primary Health Care . It is a more cost focused approach than the traditional Primary Health Care and tries to improve the health of a wide range of people.

The Bellagio Conference and its outcome

In 1979, a new concept of Primary Health Care was established at the Bellagio conference by the Rockefeller Foundation, due to the constant criticism against the Primary Health Care approach: Selective Primary Health Care (SPHC) (Warren 1988). Though the conference was small, heads of important agencies were present, noteworthy two: 1. James Grant, director of UNICEF, and 2. Robert McNamara, president of the World Bank, who were greatly influenced by the new proposal (Cueto 2004: 1868). This new concept is based on multiple regression analysis, where life expectancy and infant mortality rates are crossed with health, economic and social indicators. Therefore after the Belaggio Conference, people started to examine single diseases to see how they were impact-ing on the overall life expectancy (Warren 1988: 891).

The core concept SPHC of the Bellagio Conference was published in “Social Science and Medicine” and in the “New England Journal of Medicine”. In it the “major infectious diseases of the South” were ranked, according to prevalence, mortality, morbidity and the effectiveness and cost of available cures. They were sorted into three priority groups: high, medium, low (Warren 1988: 891 f.).

Ranking of the major infectious diseases:

  • Prevalence
  • Morbidity, or severity of disability
  • Risk of mortality
  • Feasibility of control (including relative efficacy and cost of intervention) (Walsh & Warren 1980: 146).

These are the original diseases on which SPHC should focus:

  • Diarrhoea
  • Measles
  • Malaria
  • Whooping cough
  • Neonatal tetanus.

By 1988, acute respiratory infections gained weight (Warren 1988: 900).

For these diseases the following interventions were derived, offering the possibility to save as many lives as possible at a low cost until comprehensive primary health care could be made available to all:

  • Immunization
  • Oral rehydration
  • Breastfeeding
  • Antimalarial drugs (Warren 1988: 900).

This also means or claims that SPHC was never intended to replace PHC. Nonetheless, the priority has been given to those interventions that will rapidly reduce mortality and morbidity at the least possible cost (Warren 1988: 892).

GOBI

As declared before, UNICEF backed away from a holistic approach to PHC in the years fol-lowing the Bellagio conference. In 1982, the four inexpensive interventions targeting chil-dren’s health were stated: GOBI, which means Growth monitoring of infants, Oral rehydra-tion, Breastfeeding and Immunization. Instead of considering the element antimalarial drugs, UNICEF replaced it with growth monitoring. In the end, these interventions appeared easy to monitor and evaluate because of the measurability and the clear targets. Also, because of the visible rapid success these programs achieved, the funding seemed to be more easily (Warren 1988: 893; Banerji 1984; Cueto 2004: 1869).

GOBI-FFF

UNICEF added another feature to GOBI which became now GOBI-FFF. The three F’s stand for Food Supplementation, Family Planning, and Female literacy, so that the focus was placed now besides on children also on women in the childbearing years. The programme was de-signed to address the most pressing problems of high infant mortality and morbidity rates in developing countries (Banerji 1984: 314).

Advantages and disadvantages of Selective primary health care:

SPHC, as it is presented above, has advantages and disadvantages. These should be consid-ered when trying to take an opinion. First of all, the development of SPHC made a rational debate possible because everything focuses on the economical site. Also, it deals with the most serious Public Health problems rather than conventional Comprehensive Primary Health Care. Five components could be provided either by fixed units or by mobile teams visiting the area on every four to six months. These teams should restrict their activities to a minimum number of health problems affecting a large number of people for which low-cost methods of intervention of proven effi-cacy are already available. Therefore, the resources should be concentrated on the research and the development of less costly and more effective methods of prevention and therapy. As mentioned before, SPHC can be considered as an interim strategy until Comprehensive Primary Health Care can be made available (Banerji 1984: 315). A positive example for SPHC according to its advocates is the Haiti-Project. The target dis-eases included among others diarrhea, tetanus, measles, diphtheria, tuberculosis and malnutri-tion. For a four-year period, the project was built around a 140-bed hospital to study the com-bined impact of hospital services, health surveillance and health services. It was observed that the mortality rate declined by more than 40% so that the advocates of SPHC consider it as clear evidence for a right and effective approach (Banerji 1984: 313).

Regarding these advantages, the disadvantages should not be left out. One of the problems with SPHC is that the coordination of the different vertical interventions is not necessary. So this means if there is the implementation of different programs, they might handicap each other and all the efforts and investments were put in vain. Moreover, there is a lot of technology involved which might not be manageable for the native people. The reason for that is that these people should live on their own once, the program is imple-mented so that there might not be the chance or competence to use the technology then any-more (Walsh 1988: 901). A big problem exists in the lack of participation of the community. The treated health prob-lems are chosen by externals so that there is no response to the concerns of the people as it is planned without them. To top that, help is only given to people with priority diseases. But it should be clear that there is other suffering which might have been solved with a broader ap-proach (Warren 1988: 895).

The described GOBI-program like other selective programs undermine the process of local definition of needs, local organisation to share knowledge and to struggle for health rights. The reason for that is that local organisation cannot protest against the externals - they trans-form to mere conduits for the delivery of the GOBI package. In this context, another danger of SPHC is that it helps to slow or to divert the growth of local organisations which does not help the countries in the long run (Luce 1988: 968). It is often observed that many projects - especially those funded by donor agencies - have resulted in little or no improvement. In contrast “small scale primary health care projects have resulted in substantial reductions in infant and child mortality”. Furthermore, support systems for all interventions must be devised, which is very cost-intensive and even then the program may not be accepted by the affected people (Walsh 1988: 901). To come back to the example of the Haiti-Project, it should be emphasised that the expansion of the covered population evoke a bigger need of staff. In the end, the criterion “cost-effectiveness” does not count (Banerji 1984: 315).

There have been major shortcomings in the implementation of CPHC in most countries of the 3rd world. But those who claim that the selective approach is a more cost-effective alterna-tive have failed to prove their case (Banerji 1984: 315).

Opinions to the presented topic:

“The concept of 'selective primary health care' was built into the original definition of PHC...this point has often been misinterpreted.” (Taylor & Jolly 1988: 971)


“…the mistaken assumption that CPHC services were supposed to try to implement all eight components of PHC equally and at the same time.” (Taylor & Jolly 1988: 971)


Literature:

Banerji, D. (1984): Primary health care: selective or comprehensive, in: World Health Organisation (ed.), World Health Forum, Vol.5, S. 312-315

Cueto, M. (2004): Primary Health Care and Selective Primary Health Care, in: American Journal of Public Health, Vol. 94, Nr. 11, S. 1864-1874 Taylor, C. & Jolly, R. (1988): The straw men of Primary Health Care, in: Social Science & Medicine, Vol.26, Nr.9, S. 971-977

Luce, H. (1988): GOBI versus PHC? Some dangers of selective Primary Health Care, in: So-cial Science and Medicine, Vol. 26, Nr. 9, S. 963-969

Taylor, C. & Jolly, R. (1988): The straw men of Primary Health Care, in: Social Science & Medicine, Vol.26, Nr.9, S. 971-977

Walsh, J (1988): Selectivity within Primary Health Care, in: Social Science and Medicine, Vol. 26, Nr.9, S.899-902

Walsh, J. A. & Warren, K. (1980): Selective Primary Health Care: an interim strategy for dis-ease control in developing countries, in: Social Science and Medicine, Vol. 14c, S. 145-163

Warren, K. (1988): The evolution of SPHC, in: Social Science and Medicine, Vol. 26, Nr. 9, S.891-898.