In its recent conference at Jakarta, The WHO South-East Asia Region, released its publication: “Positive practices in developing primary health care-oriented health systems- a collection of case stories from the WHO SEAR Region.”  This publication addresses the challenges countries face in transitioning from selective to comprehensive primary health care (CPHC) by documenting various interventions aimed at overcoming the “problematiques” that every country is facing on its path for achieving this goal. While countries face similar problems, their approaches vary, offering valuable lessons and opportunities for cross learning. More importantly, this demonstrates that these challenges are not inherent or unique, are not insurmountable and transitioning is possible despite the difficulties.

Selective Primary Health Care refers to a policy introduced in the late eighties and early nineties which essentially stated that governments in Low-and-Middle-Income-Countries (LMICs) cannot and should not attempt to provide all health services, but should limit themselves to only some very selective minimal package of services. The package included services that were essential for a reduction of maternal and under-5 mortality as well as to address tuberculosis, HIV and the vector borne diseases. The understanding was that all the remaining services should be left to the market, with or without making arrangements like insurance. Initially promoted by UNICEF, it became the major feature of health sector reforms under structural adjustment policies introduced by the World Bank in the nineties.(WDR, 1993 pgs)  Part of its success in influencing policies was because it was World Bank and IMF loans and developed aid from the US and UK would come with structural reform conditionalities. But an even more powerful driver was the academic discourse that paved the way for legitimation of the selective primary health care approach and its introduction. This discourse also introduced the concept of defining the contents of this package as narrowly as possible based on an index of “dollar spent per DALY saved”. Since under the Millenium Development Goals, the indicators also measured only the outcomes of this minimalist package of services, a country could believe it was doing very well if its under 5 mortality rate or maternal mortality rate came down.

It is worth noting that Thailand’s primary healthcare has always been comprehensive, based on public providers and relatively the most cost-effective system in the world.  Thailand itself attributes their success to having been able to resist the pressures to selective healthcare. Thailand in contrast took a health rights approach- as enshrined in their National Health Security Act of 2002 and the National Health Rights Act of 2007. This publication is silent on why other countries did not make this transition earlier.

One of the immediate drivers for the return of comprehensive primary health care (CPHC) was the recognition that because over 85 percent of health care needs were not covered in the selective package, there was a huge increase in out-of-pocket expenditures that led to increasing impoverishment and inequity and undermined any effort to reduce poverty. The other was an increasing public recognition that all the major causes of premature mortality, and the huge costs of hospital care especially on non-communicable diseases, could be addressed by CPHC. There was also the realization that in the absence of a comprehensive health systems strengthening, even the targets of the selective healthcare could not be achieved. Change was also due to considerable rprotest from people’s organizations and civil society that were giving “voice” to the problems of declining access and increasing costs of healthcare as a consequence of  “leaving majority of healthcare to the markets” Governments tried to address this by introduction of publicly funded insurance programmes- but these could not be designed to address primary care needs-, especially those related to preventive and promotive care. If UHC came to be associated with the move to insurance, it became necessary to spell out that this had to go along with strengthening comprehensive primary care.

Urban Primary Healthcare: There are four case studies related to urban primary health care. Two of these are examples of the Health City Approach that is a WHO intervention that is meant to address the social determinants of health in the urban context. The design of the health city programme in Jaffna is most interesting, but it does not seem to have gone far. The Wajo Regency case study, which is case study of an urban area in a remote Sulawesi island of Indonesia, seems to have done much better and there is a really innovative addition in its approach to engaging the elderly in care for the elderly. Most countries in the region have health city programmes, but there is little heard of it, and probably they have not quite taken off. So, its good that this case study draws some attention to that, since there are few models of integration public health concerns with primary healthcare.

 The other two case studies are from Bangkok city- one on public private partnerships in Bangkok city and the other on digital literacy volunteers. But for the most part urban operational examples tend to be ad hoc dispensaries and there are very limited efforts at serious population based, prevention prioritised primary healthcare that can be promoted as positive practices.

Community Engagement: Six of the case studies are on this theme, and of these the first three highlight the problems and possibilities of decentralization. Nepal has seen one of the most extensive decentralization efforts in recent times, but it is still work in progress. This case study captures the tension between what must be decentralized, the terms of such decentralization, and what needs to remain central. The case study from Kerala captures how decentralization has helped in effective delivery of quality palliative care services even in rural and remote areas. And from Chhattisgarh in India, there is a case study of how local government institutions can be geared to acknowledge and address intra-village inequities in access to all essential public services.

The collection of case studies closes with “two well-known examples of civil society action: one of advocacy and another of service delivery to reach the poor.” The authors note that though the Bangladesh Health Watch is an example of advocacy most of the organizations who participate in it are also involved in service delivery. And the final example is of Gonoshasthaya Kendra, is an example of the major role civil society organizations have played as pioneers, innovators and advocates in advancing the understanding of CPHC and health for all. In both of these domains there are many important examples from India and other countries as well. But it was fitting to take Bangladesh for civil society examples, since the engagement of civil society in the shaping of health systems is much larger and more prominent in Bangladesh as compared to almost any other country. The discussion also pays homage to Dr Zafarullah Choudhury, founder of GK and also of the PHM, as representing the rich history of PHC and Health for All in the WHO Southeast Asia region.

This collection of case studies is worth noting for a number of reasons. First and foremost, we begin to get a glimpse of the “elephant size” challenge of moving towards comprehensive primary healthcare. Quite often the emphasis goes to one or other aspect, and the need for synergistic intervention on so many fronts are lost. Secondly, we also begin to appreciate that many of the problems that appeared intractable have proven amenable to change. We note that the problematics of financing and digitization have not been addressed in this collection and quality of care is only touched upon.  We hope the next reports will tackle with these themes. We also note that all case studies conceptualize health care as common goods and not as market commodities and reform is not a matter of getting the prices right, but rather a problem of institutional design and organizational capacity. We finally conclude with a reflection. It goes without saying that without political will and financial allocations and better terms of employment, none of the efforts will fructify or sustain. However, these are not a given.  While critique of the failures and the gaps is necessary, positive case stories generate optimism and confidence and help mobilize the political will and financial allocations that are required.

We hope you do not stop with this introduction and go onto read the case stories in this publication. All of us who were part of writing this collection had over own favourite learning experience from amongst the twenty. It would be interesting to share what you found must interesting.

To Dr. Shalini Singh for her peer review and Ms. Roubitha David and Mr. Hasan for the technical assistance. And of course to Regional WHO and the team who developed this publication.
The views expressed in this introductory piece are attributable to the author and are not necessarily the views of the other contributors or the World Health Organization.