Since the Alma Ata declaration (1978), stating that “The promotion and protection of the health of the people is essential to sustained economic and social development and contributes to a better quality of life and to world peace”, it is commonly acknowledged that development of primary health is rather a failure, at least not a success, in contrast with the true success of millennium development goals (MDG) in the health field.
During the last thirty years, progresses in health have been made largely due to vertical approaches (wide programs, decided by international instances, such as UN, and applied in target countries with the help of thousands of millions of dollars). At the same time, these approaches have sometime disorganised health systems, by draining trained resources from primary health centres, to well-funded WHO and others’ vertical programs, such as vaccination.
Is it possible to “decree” primary health? In many countries, health systems are organised with primary health centres, serving few thousand people, with trained staff usually nurse level, with secondary health centres, serving some tens thousand people, with MD, and with hospitals, serving a hundred thousand people, with all expected services, including maternity. However, in many countries, the attendance of staff in the centres, or the training of staff are often not at the expected level, despite years of effort. Does this mean that there is nothing feasible, and that only privatisation of health is the solution? Not at all. But this traditional analysis relies on the common idea that health is the business of professionals. This leaves mostly aside the key importance of health promotion – although it was at the heart of Alma-Ata – (such as promotion of usage of condom to prevent transmission of sexually transmissible diseases). Indeed, the usage of health mediators, whose role is to inform their communities on health, is transforming health approaches.
The best example is given by Ebola. This name raised so many fears in western countries that agencies pour hundreds of millions, even billion, in cure centres (ETC, Ebola Treatment Centres – those with staff looking like astronauts). In Sierra Leone (and other affected countries), primary health centres, unequipped and with untrained staff, had been deserted as soon as the epidemic struck. However, it was not the ETC which stopped the epidemic; they cured about ten thousands of affected people. In the same time, some NGOs (such as Care, Save the Children and Doctors of the World) gathered to set up a network of more than thousand health mediators around Monrovia. These mediators, coming from local communities, with the help of community leaders, visited every house of their neighborhood to explain how to protect from Ebola. And in the end, they saved millions of life! When new cases reappeared, some months after the first burst of epidemic, they were able to identify immediately the possibility of Ebola, and reacted consequently, avoiding a new epidemic. They are now trained and recognized by their neighbors. This is true community health. And this has to do with collaborative approaches. Indeed, there are plenty of examples of the success of health mediators, coming from communities to help their own community. Examples may be found in detention centres, in Siberian tribes, in farmers communities in some mountain valleys in France… truly, improvements in health will go with development of community health, and not only in “tribes”, but also in villages, townships, slums, …
 Angus Deaton, (2013) THE GREAT ESCAPE, Princeton University Press, 360 p.
 ibido, p.309
 Banerjee, A. V., Duflo, E. and Glennerster, R. (2008), PUTTING A BAND-AID ON A CORPSE: INCENTIVES FOR NURSES IN THE INDIAN PUBLIC HEALTH CARE SYSTEM. Journal of the European Economic Association, 6: 487–500. doi:10.1162/JEEA.2008.6.2-3.487