At the end of 60’s and during 70’s of the last century it was increasingly clear that the health services in the so called developing countries could not be perceived or oriented according to the western industrial states and societies. Western medicine was one-sided as it emphasized only curative aspects, being limited to the health services in the hospitals, medical Practice and pharmacies based on medicine technology. Prevention (prevention of diseases) had a relatively little place value. Such a one-sided understanding and a one-sided system of health services affected even the young independent states of Africa in which financing health facilities of this system is difficult and has had little success. Researches have shown that about 80% of all diseases in the developing countries were diseases that could be protected (e.g Diarrhoea, lung inflammations, tuberculosis, malaria, to mention just a few).

The transference of western medicine views to the developing countries proved itself to have attained little success regarding its goals.

Transfer problems
Some reasons why the western system of health cannot be absolutely applied in all situations of the developing countries are as follows:

Western systems are one-sided oriented, oriented to curative dimensions while neglecting prevention and aspects of social medicine.
They are too expensive, for instance, the medicine apparatus from the industrial states are unfavourable and unaffordable in the developing countries with regard to price and utility.
They do not fit well in the developing countries, as there is lack of specialists who can handle the high-technical medicine.
The natural and scientific understanding of medicine in the west does not consider the traditional views concerning experiences about diseases and health that has spiritual background of the inhabitants.

Response of the WHO
The World Health Organization (WHO) developed the policy of health as a response to the problems of health in the developing countries, especially about the above mentioned problem of transference as the WHO established the concept of the so called PHC-Concept (PHC= Primary Health Care), which was given a central meaning.

The strategy was introduced in 1978 in the first conference of WHO for health in Alma Ata/Kazakhstan (in the former Soviet Union). Most of the countries that participated in this conference supported the “Alma Ata Declaration” of 1978 that was supposed to be implemented. “Health for all” was the vision of the conference.

This concept is heavily concerned with people, especially with the principles of social justice, accessibility, appropriateness and acceptance of medical services with consideration of the needs of people in the communities, their participation and orientation to the concept of health services.

In the Declaration of Alma Ata it means that:
Primary Health Care is based upon practical, scientific, solid and social acceptance of methods
and technology
. It is fundamentally health care that is generally accessible to the individual and Families in the community through their participation and with a cost that the being of the community life and the country can determine with sustainability in the spirit of self-confidence and self-determination. Primary Health Care systems whose main areas of concern are formed by the community, is dependent upon the general social and economic development of the country.
(Diesfeld, Gesundheitversogung in Entwicklungsländer, 1996)


6 Pillars of Primary Health Care
The results of this conference of Alma Ata are summarized in the so called 7 principles and the
8 elements of Primary Health Care.

The concept is carried out through the following pillars. If some elements are rejected or
overemphasized, the concept cannot function well any more.

-Social justice: Equal distribution of the available resources.
-Preventive Health care: Prevention of diseases in the sense of primary prevention.
-Participation of the inhabitants: Participation of the intended groups in planning and carrying out issues related to people’s health,
-Inter-sector cooperation: Health support outside the medical services,
-Technology that marches with the context: favourable or affordable price and local technology,
-Sustainability of the measures: Guaranteeing curative services including services of medicines.

The PHC-strategies led to the reorganization of the health systems in the developing countries. The efforts of Tanzania led to the further education of the so called paramedicals, Medical Assistants, Rural Medical Aid, Village Health helpers, Village Health Workers, recognition of the traditional healers in the health services as midwives, strengthening of the rural hospitals and health centres (Reference system: District Hospital, Health centre, Supervision of the community oriented structures).

The Meaning of Tübinger Consultation

The development of the so called PHC-concept (PHC-Primary Health Care) is closely related with the emergence of the World Health Organization (WHO) and its former director Halfdan Mahler, but it is also related with the ideas of Christian Medical Mission (CMC) in the World Council of Churches in Genf-Zürich.

The ideas as they are found and summarized in the so-called Tübinger consultation I and II, impressed the co-workers of the WHO, who were seeking the solutions for the health problems of the developing countries. CONTACT, the journal of the Christian Medical Commission (CMC) became a compulsory reading of WHO as Fleßa observes. The journal appeared first in 1970 and was as a forum for exchanging experiences about different forms of health work in the church, ecumenism and mission. For Fleßa, the concept of Primary Health Care as it was introduced in Alma Ata, was a development of the secular declaration of Tübingen. This shows the meaning and impact of the ideas of Tübingen regarding Primary Health Care.

The Role of medical doctors
In our society, doctors, especially the surgeons are glorified. There is an impression that in medicine everything can be done as medicine is viewed as decisive point for health and healing. The doctor is seen as the main actor on whom everything depends. We receive this view and presentations that are transmitted in the media and in the uncountable TV series. The economist for health, Stefan Fleßa, rightly shows the difficulties that accompany the concept of Primary Health Care. Medical work and activities in the hospitals seem to belong together in the eyes of many people, the idea that creates a problem when one wants to implement this concept among the poor in the third world. On the basis of this motivation many hospitals and health stations were built in Africa.
The western doctor is educated with one-sidedness on the aspects of curative medicine, as if curative medicine was the only way of medical practice. People’s traditional medicine, health support, prevention or general social dimensions and the medical healing art are not found in the teaching plans of medicine faculties.
We can differentiate two pillars of medical praxis.

1.Treatment- Restoration of the sick- curative (z.B Hospitals, medicine, operations, laboratories, treatment of outpatients.

2. Prevention of diseases

a.) Primary prevention
Reduction or prevention of immediate causes of diseases.
Poor education
Bad hygiene
Lack of social security
Social Injustices
High productivity
Poor planning for development

Health education, nutrition, water supply and waste disposal.

b.) Secondary prevention: prevention medicine
Pregnant-mother-child service and child care
Protection against Malaria
Health education

Prof. Diesfeld observes the relationship between the two pillars under the conditions of a developing country:

Primary prevention as much as possible,
secondary prevention as much as necessary and
curative medicine where prevention is not possible.

This is, as Diesfeld further says, an economically affordable principle and room for curative medicine that fits the context with optimal costs- utility relationship. He criticizes the predominance of curative medicine that implies wastage of the scarce means on the false place of operation. From an economic point of view regarding health this perspective is meanwhile heavily confirmed.

The community oriented health service with focus on the basic needs and primary causes of diseases can solve various problems of health services in the developing countries. These efforts are portrayed in the declaration of Alma Ata as Primary Health Care (PHC) since 1978.

Health is more than medical factors and medical service. Namely it is dependent upon improvement of life conditions and satisfaction of basic needs. One of these basic needs is the medical basic service, especially the places of first priority.

Prof. Diesfeld writes about the meaning and goals of PHC-concepts:
“Primary Health Care portrays the general approach of improving health situation at the community level. Around the health sector there are other health related and community related areas of nutrition, agriculture, water supply, sewage- and waste disposal, education, and communication, which should be addressed. Description of the views concerning the goals of the Primary Health concept should be considered: no medical concept should be mentioned except social context.

PHC is a concept that perceives health as a result of medical and non medical influence and presents health as a basic need among other needs such as shelter, nutrition, clothes, education).
In order to realize this goal all sectors- medical and non-medical, must work together. An isolated curative health work as it is still found in the health work of the churches and mission today, cannot be justified by this concept of Primary Health Care (PHC).

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