Introduction
Primary health care (PHC) concept was embraced at the Alma Ata conference in 1978.1 Yet, despite its fundamental importance and incredible promise, it remains a ‘receding dream’2 in need of ‘revitalisation’.3 Several factors have favoured the need to revitalise PHC in low-income and middle-income countries (LMICs). In South East Asia, PHC revitalisation efforts have been driven by the need to strengthen health systems through intersectoral approach in light of rising burden of non-communicable diseases and rural–urban inequities in accessing health.4 Efforts to revitalise PHC in the WHO African region date back to the late 1980s with the Bamako Initiative which focused on the need for PHC self-financing mechanisms, community participation and provision of essential drugs and child health.5 Although there have been several attempts to revitalise PHC, a new wave of interest has been spurred in the wake of COVID-19 based on PHC’s potential to support the twin goals of Universal Health Coverage (UHC) and Global Health Security (GHS).6 UHC has been defined as the ability of all people who need health services to receive them without incurring financial hardship7 while GHS is about the containment of potentially serious and rapidly spreading infectious disease threats.8 The nexus between PHC and UHC rests on the notion that by orienting health systems towards first contact, continuous and comprehensive care (core PHC focus), households and communities are more likely to access the healthcare they need without facing barriers; which is the essence of UHC.
The COVID-19 is certainly not the first event to favour PHC’s re-ascendancy to the health agenda, but it has largely been portrayed as a ‘focusing event’9 for PHC. In other words, the pandemic has been viewed as a catalytic occurrence that exposed gross inadequacies in PHC and the related adverse consequences, thus opening a new window of opportunity for renewed interest in PHC revitalisation in LMICs.10 While we acknowledge the potential of COVID-19 as a defining moment in which to re-affirm PHC, we posit that if lessons from past revitalisation efforts are not taken into consideration, the renewed interest will be to no avail. Indeed, some scholars have argued that revitalisation of PHC is insufficient unless the concept is ‘reframed’.11 In this paper, we seek to understand why, given that PHC had so much promise, it apparently lost momentum. While technical reasons, particularly lack of material resources, are normally put forward to explain revitalisation failure, two aspects are largely ignored: (1) how the portrayal of PHC itself favour or hamper intended reforms and (2) how historical policy choices influence ongoing revitalisation efforts. We argue that well-intended PHC revitalisation efforts applied in ignorance of historical facts miss an opportunity for learning and are doomed to fail or generate unintended consequences. The aim of this paper is to draw historical lessons while welcoming the current ‘comeback’ of PHC.
Conceptual framework: policy image and critical junctures
Policy image encompasses a mixture of empirical information and emotive appeals that explain the issue,12 which forms the foundation of policy-making process.13 Actors use positive policy images to legitimise issues that are in their favour and use negative policy images to discredit issues that are not in their favour. Policy images are critical because they influence the nature of policy responses and what is considered as appropriate or inappropriate. Once a certain policy image has gained traction over rival images, it has the power to shape the future policy direction or define a critical juncture. The lasting impact of choices made during those critical junctures is that such choices are extremely difficult to dismantle.14 Critical junctures are shaped by antecedent conditions (factors preceding a critical juncture) and cleavage (crisis). Although critical juncture theory emphasises the role of history, permissive conditions represent the easing of the constraints for change while productive conditions produce the outcome after the permissive conditions disappear and the juncture comes to a close.15 In the context of this study, productive conditions would facilitate sustained (favourable) attention towards PHC beyond the COVID-19 crisis. In other words, the attention generated towards PHC as a result of COVID-19 (permissive conditions) would be maintained under ‘calm conditions’.