4.1 The primary health care approach
Most health projects at the micro-level have adopted the primary health care approach (PHC). The concept of PHC evolved in 1978 as part of the Alma-Ata Declaration, put forth by the World Health Organisation and UNICEF. This was a response to widespread dissatisfaction of people with their health services, as being expensive, inaccessible, and inappropriate.
Primary health care has been defined as 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 self-reliance and selfdetermination.
As an approach, PHC is intended to be dramatically different from the earlier approach to health which stresses medical intervention. PHC is concerned not only with the poor health status of specific population groups, but with the indignity of health and health care being readily available to some, but denied to many.
The three main principles underlying the PHC concept are as follows: first, that health is an integral part of development. Second, the need is not so much to make further advances in medical technology as to reorientate the health system to make existing technology available to all. Finally, the PHC approach maintains that the conscious participation of people in the care for their own health is fundamental to the achievement of good health. In line with these principles, the PHC approach therefore calls for a move from hospitalbased care alone, towards prevention of ill health, and making health services available at the community level, and emphasising 'serf-help': what people can do for themselves.
Primary health care was conceived as comprising of eight essential elements:
· education, concerning prevailing health problems and methods of preventing and controlling them;
· promotion of adequate food supply and nutrition;
· adequate supply of safe water and sanitation;
· Maternal and child health care, including family planning;
· immunisation against the major infectious diseases;
· prevention and control of locally endemic diseases;
· appropriate treatment of common diseases and injuries
· provision of essential drugs.
In its translation from theory to practice, the PHC approach has deviated considerably from its original intent. Experience has shown that many PHC projects act on the basis of false assumptions and premises. Typically, NGOs carrying out PHC projects arrive with a concept of a ready-made solution, instead of relying on community participation to determine their activities. In general, such projects have ignored class, gender, racial, ethnic, and other differences in their programme, treating the community as a homogenous entity.
Despite making significant advances by linking health and development and going beyond medical solutions to health problems, this approach to primary health care is largely insensitive to gender issues in health. This is despite the fact that PHC is supposedly concerned with inequities in health. The ways in which the sexual division of labour, and genderbased discrimination influence women's health status is neither addressed nor understood. PHC does not recognise inequities within the household, nor go beyond viewing women as merely mothers and housewives. Consequently, it confines its vision of women's health needs to the realm of maternal and child health, where the focus is mainly on the child, with the mother seen as a vehicle for child health.
PHC also demands a great deal from women as providers of health care in the household, ignoring their multiple roles and time constraints. The approach focuses on educating mothers, and promoting health interventions at the household level which add further to women's work load. It takes for granted women's role as carers and health providers, while at the same time not acknowledging their knowledge about health care and healing, but imposing ideas from above.
When PHC projects employ women community health workers, they expect them to do voluntary work, while this is seldom the case when men are employed. Worse still, many messages regarding disease prevention have tended to 'blame' women's lack of awareness and ignorance concerning their own, and their children's, illnesses.
However, PHC is an important step forward from the earlier, big-medical approach to the solution of health problems. The need is to make the approach to PHC more gender sensitive, rather than to negate the validity of the PHC approach itself. Addressing gender issues in through a PHC approach would mean
· acknowledging and acting on the premise that the community is not a homogenous group but may be divided along lines of gender, class, race, ethnicity and caste;
· being aware of how gender roles affect women's health needs and the variations in these across different social stratums;
· Addressing problems faced by women as providers of health care within the formal health sectors, and as informal carers at home;
· recognising, valuing, and using women's indigenous knowledge and skills in traditional medicine;
· changing the tendency in health education to 'blame the victim';
· planning in consultation with women, and respecting women's knowledge of the community's health needs.