Central to the original Alma Ata declaration was the notion of a system, which included the fostering of health through multisectoral collaboration. This aspect often gets referred to as comprehensive health care, in counter distinction to a selective primary health care model, which emerged immediately following the conference, as the former, though laudable in intent, was argued to be unworkable. Indeed from a global perspective, comprehensive primary health care, if noticed at all in the culture of western medicine, was relegated to being of relevance in ‘other’ places: so-called developing countries. Nevertheless, at the beginning of a new century, in a vastly different world to that of the 1970s, it is the central contention of this paper that it is still possible to assert that the primary health care model is still relevant – in all countries of the world. The work on the ‘social determinants of health’ increasingly adds weight to the arguments against the irrationality of an overemphasis on medical technical interventions to the neglect of the health-enhancing or health-threatening contexts in which people live out their lives. Consequently it is now becoming possible to think and plan the management of health, not just the management of disease.

The policy thrust in the health system in many developing countries over the last decade has been on reforming structures. This paper examines such reforms in the light of the principles of primary health care that were adopted at the Alma Ata conference in 1978 and which are re-emerging as underpinning the current WHO global policies. It concludes that many of the reforms at best did not strengthen PHC and at worst ran counter to it.

Health for all was identified by the World Health Assembly in 1977 as the desirable main social target for governments, international agencies and the global community. Primary health care was defined at Alma Ata in 1978 and was then seen as the vehicle to achieving health for all. Governments in sub-Saharan Africa embarked on processes to align their health policies and indeed implement them within the PHC framework. PHC in Africa was seen as an overall strategy for achieving health for all, rather than just as the first level of care. Thus countries restructured their entire health systems in the framework of PHC rather than focus on the first level of care only. The mid to late 1980s saw worsening economic performance which was followed by the enforcement of structural adjustment programmes, sociopolitical instability, man-made and natural disasters and the beginning of the HIV/AIDS pandemic. All these wrecked havoc on plans countries had for implementation of PHC. Within this context, the elaborate policies and plans were not fully implemented. Furthermore, there appears to have been a general underestimation of the resources required. Though there was some initial progress in improving health status as shown by some health parameters, health for all was not achieved by any of the countries.

The need for research that is applicable to the most common health problems is well recognized. Some of this research will be in the area of primary care, and family doctors must contribute to the research for it to be effective in improving care. Using a sample of key informants from 10 different countries, this paper explores the extent to which family doctors are involved in research in the various regions of the globe. We find great variability in the level of research being conducted by family doctors at academic institutions and in the development of the community research structures, such as practice based research networks. Despite the problems, family doctors are involved in research in every region assessed, and there is room for optimism that this role will be substantially expanded.

Ethics have long been recognized as underpinning primary health care. While discrete understandings of ethics have developed to support many areas of health care and research, there has been little attempt to formulate an ethics framework which is focused on primary health care. Developments both within and external to primary health care practice make it timely to address primary health care ethics; in particular, government initiatives contained in Shifting the Balance of Power, the increasing emphasis on evidence based practice, and the greater recognition of patient rights within English law resulting from the Human Rights Act 1998. A starting point to formulating an ethics framework would be to define the domain of primary health care. We can then identify those areas particular to primary health care which raise issues of conflict and change and which would benefit from ethics guidance.

This paper will explore the similarities and contrasts between the United Kingdom, Netherlands and Australian systems of maternity service delivery, focusing on the status of midwives as primary care providers. Increasingly, women in western industrialized nations are subject to medical models of maternity care. These medical models stem from the field of obstetrics, which has an increasing influence in determining service provision in all three countries. The World Health Organization has stated that midwives are the most appropriate primary carers for women during pregnancy and childbirth. Yet the rise of obstetrics as a dominant model of care has displaced midwives as primary carers, giving greater privilege to an obstetric construction of pregnancy and childbirth. While midwives are educated to understand and support normal physiological birth and assess and respond to deviations (wellness model), by contrast, obstetricians are educated to assess risk and address concerns through active clinical management (illness model). It will be argued that the fundamental difference between midwifery and obstetric views of pregnancy and childbirth rest on the differing perceptions of wellness and illness; that the obstetric view has gained broad dominance as a result of unequal power relationships; and, that this in turn has altered service delivery to privilege medical models of care. While service delivery in the UK and Australia has tended to follow a similar pattern of dislodging midwives as primary carers, the Netherlands system of maternity care, while broadly resisting the displacement of midwives as primary carers, is nonetheless provided within a medicalized framework. By contrast, in the UK and Australia there is an increasing awareness of the need to reconfigure maternity services to give greater autonomy to midwifery practitioners, a situation that is not as relevant in the Netherlands. The conclusion highlights the need to develop core principles to strengthen maternity care systems in order to ensure that midwives are not further alienated from service provision, and that strong midwifery workforces can be sustained. The discussion is based on research undertaken during a study tour of the United Kingdom and Netherlands by the author.

Current government policy aims to create a wider ‘community of public health practice’ within local systems, working in a coherent and coordinated way in partnership with local people to reduce health inequalities. However, for this to happen policymakers and practitioners across the public sector have to reconsider boundaries, role definitions, professional identities and responsibilities. On the basis of documentary analysis and fieldwork involving interviews with individuals from various sectors and nonparticipant observation of public health nursing and primary care organizations within two local health economies in England, the paper explores the ways in which these processes of reconfiguration have been developing in local health systems. It illuminates new exclusions and tensions emerging from inherent contradictions in national policy and from difficulties individuals have thinking beyond existing spatial, conceptual and organizational boundaries and divisions. Paradoxically, therefore, rather than opening up new spaces for public health practice these tensions may ‘force’ some people back into narrower more traditional roles or ultimately out of public health altogether. The paper also uses the notion of communities of practice to explore issues of ‘agency’ in professional practice – that is the way in which individuals reflexively construct their practice and in so doing engage with or resist the relevant policy imperatives. The research illuminates some of the boundaries that are operating to discourage people from engaging with public health. This analysis suggests people may need more time and support to respond constructively to the new public health agenda. Without this, potential members of the wider public health workforce may respond defensively and resist alignment to public health goals in order to protect their embattled workspaces.

It is no coincidence that in setting the agenda for primary health care (PHC), it was acknowledged that nurses would have to play a major role in helping to shift the health system away from a predominant focus on illness and cure, toward increased attention to health promotion and disease prevention. The goal in primary health care is to ‘protect and promote the health of all people of the world’ where health is defined in a positive sense as well-being, not merely as absence of illness. Health so defined has always been the concern of nurses.

In this paper, the relationship between modern professional nursing and PHC will be discussed. The notion that advancing the primary health care agenda is inherently within the domain of nursing practice will be developed, citing examples from a PHC project that involved nurses working with family physicians in a primary care practice. The position will be taken that primary health care provides an opportunity to revitalize the nursing workforce, by recapturing the vision of early nursing leaders, such as Florence Nightingale, who recognized the need for social reform in improving population health and understood nurses’ role in achieving that.

The 4H Project is a two year study (February 2001 – January 2003) designed to evaluate the impact of a nurse-led community cardiac rehabilitation service in an inner city area. The population has a high prevalence of coronary heart disease and low uptake of existing services for secondary prevention. Based on initial research exploring the needs of potential service users, the community heart nurse (CHN) delivers a holistic service to postmyocardial infarction patients in their own homes. The CHN has also initiated community-based interventions such as the setting up of support groups and a ‘Walk your Way to Health’ group. The CHN offers specialist advice to primary health care teams and works in close liaison with general practitioners (GPs) and practice nurses. This paper reports on service users’ qualitative evaluation of the CHN role. Semi-structured interviews were carried out with 34 service users, from three weeks to 18 months postmyocardial infarction. The following aspects of the service were seen as important: the sharing of information and the accessible way it was presented; offering coping strategies; confidence building and reassurance; home-based care; easy access to CHN; regular checkups; and the opportunity to meet other patients. Additional services provided by the CHN such as advice on benefits or housing were not widely used, but were appreciated by those who did need this type of assistance. The emerging model of service delivery has both strengths and limitations but is entirely consistent with the increased emphasis on reducing health inequalities and promoting evidence-based care. However, with a relatively small caseload of patients, it is not surprising that a high level of patient satisfaction has been achieved. This paper will therefore include reflection on the difficulties besetting research attempting to evaluate complex, community-based interventions.