Primary health care: when and where did it all begin?

Continuing the primary health care theme of the previous post, health policy expert Professor Philip Davies investigates the history of the terms “primary care” and “primary health care” – a topical matter given the legal action recently dropped by Primary Health Care Ltd.

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Tracking the long history of primary health care

Philip Davies writes:

After months of legal tussling, Primary Health Care Limited has abandoned its attempt to restrict the use of the term “primary health care”.

According to Henry Bateman, the general manager of Primary Health Care’s medical centres, it was “important … to ensure the brand Primary Health Care was not used in a way that would mislead or create confusion”.

On the other hand, Patrice Cafferky, a Director of one of the organisations potentially impacted by Primary’s action, described the attempt to prevent the use of the term as “abominable”.

When health care insiders refer to primary health care they typically make reference to the Alma Ata Declaration that was produced following the International Conference on Primary Health Care convened by the World Health Organization (WHO) in Alma-Ata, USSR from 6‑12 September 1978.  That definition states that:-

Primary health care is 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 self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.

But was that the first use of the term?

To the best of my knowledge, the first reference to “primary care” (as opposed to “primary health care”) in the context of health services is to be found in the Interim Report on the Future Provision of Medical and Allied Services (commonly known as the ‘Dawson report’) produced by the Consultative Council on Medical and Allied Services in London in 1920.

That report states that:-

 “A Health Centre is an institution wherein are brought together various medical services, preventive and curative, so as to form one organisation. Health Centres may be either Primary or Secondary, the former denoting a more simple, and the latter a more specialised service”  [emphasis added]

The report then goes on to explain that:-

 “The domiciliary services of a given district would be based on a Primary Health Centre – an institution equipped for services of curative and preventive medicine to be conducted by the general practitioners of that district, in conjunction with an efficient nursing service and with the aid of visiting consultants and specialists.” 

The report envisages that services offered at a Primary Health Centre would include, inter alia, “curative and preventive medicine … conducted by … general practitioners”, “care and instruction of pregnant women”, “labour and after-care”, laboratory and dental services.

The specific term “primary health services” arises in the Report’s discussion of teaching hospitals where it is suggested that “The academic influence, and the spirit of inquiry and progress associated with a Teaching Hospital, would permeate the system of secondary and primary health services within the allotted sphere of influence of such a medical school.” (para 75).

Another reference to primary care can be found some 40 years later in the USA where a paper published in 1961 by White, Williams and Greenberg[1] discusses patients who receive “primary, continuing medical care”.

Subsequently, in the USA, the Health Professions Educational Assistance Act which was signed into law by President Gerald Ford in 1976 (some two years before Alma Ata) was “designed primarily to produce more primary care practitioners and improve health services in manpower shortage areas”.

Also in 1976 the US Institute of Medicine produced “A Manpower Policy for Primary Health Care”.  In their efforts to define primary health care, the report’s authors indicate that they found as many as 38 definitions of “primary care”.

The term “primary health care” was also in use in Australia some years prior to Alma Ata.  Examples are:-

• an article (by an anonymous author) entitled “Physician assistants–and others–in primary health care” which appeared in the Medical Journal of Australia on 29 January 1972; and
• an editorial entitled “Primary health care and undergraduate teaching” which appeared in the Medical Journal of Australia on 27 September 1975.

A search of the Medline^® database reveals that a total of 170 papers and other academic articles with the term “primary health care” in their title were published prior to 1977.  Material that refers to “primary care” in its title is more common with Medline^® listing 434 such items that were published between 1948 and 1977 (inclusive).

Some other examples of published materials which contain references to the terms “primary care” and/or “primary health care” and pre-date Alma Ata include:-

• a paper by Cueto[2] which notes that the term “primary health care” was used in the early 1970s in the Christian Medical Commission’s journal Contact;
• a 1972 edition of the peer-reviewed International Journal of Health Services (Vol 2, No 2) which contains papers entitled ‘Primary Care in the Industrial Areas of Britain’, ‘Primary Health Care for the Poor in the United States and Canada’, ‘Primary Medical Care in the Soviet Union’ and ‘The Present and Future of Primary Medical Care in Israel’;
• the Milroy Lecture of the Royal College of Physicians of London which was delivered in 1974 by Dr Julian Tudor hart (a Welsh GP) with the title “The marriage of primary care and epidemiology”; and
• an article by Boerma[3] which reports that “in the Netherlands … primary care was officially identified as a separate echelon in 1974 with the publication of a white paper on the structure of health care.”

Clearly the terms “primary care” and “primary health care” have both been in relatively common usage for many years.

They pre-date both the often-cited Alma Ata Declaration and the establishment of Primary Health Care Limited.  Perhaps it was a smart decision to call off that legal case.

• Philip Davies is Professor of Health Systems & Policy at the University of Queensland