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Community-oriented primary care (COPC) originated in South Africa during the 1940s and 1950s, where it served to inform local church-based and nongovernmental organization-based initiatives during the apartheid years. During the 1990s, COPC played an inspirational role in the process of national health policy formulation. Yet COPC's contribution to current health practice remains more symbolic than substantive. Despite a policy framework that favors the widespread introduction of COPC, various political, structural, managerial, and human resource obstacles constrain its effective implementation. Notwithstanding a rapidly changing health care environment and well-established health transition from infections and nutritional disorders to non-communicable diseases and injury, COPC and its variants remain abidingly relevant to South Africa's-and Africa's-health care reality.

Although community development and social change are not explicit goals of community-oriented primary care (COPC), they are implicit in COPC's emphasis on community organization and local participation with health professionals in the assessment of health problems. These goals are also implicit in the shared understanding of health problems' social, physical, and economic causes and in the design of COPC interventions. In the mid-1960s, a community health center in the Mississippi Delta created programs designed to move beyond narrowly focused disease-specific interventions and address some of the root causes of community morbidity and mortality. Drawing on the skills of the community itself, a selfsustaining process of health-related social change was initiated. A key program involved the provision of educational opportunities.

Community-oriented primary care (COPC) developed and was tested over nearly 3 decades in the Hadassah Community Health Center in Jerusalem, Israel. Integration of public health responsibility with individual-based clinical management of patients formed the cornerstone of the COPC approach. A family medicine practice and a mother and child preventive service provided the frameworks for this development. The health needs of the community were assessed, priorities determined, and intervention programs developed and implemented on the basis of detailed analysis of the factors responsible for defined health states. Ongoing health surveillance facilitated evaluation, and the effectiveness of interventions in different population groups was illustrated. The center's international COPC involvement has had effects on primary health care policy worldwide.

This paper, the first in a series commissioned by NIMH for the "Challenges for the 21st Century: Mental Health Services Research Conference," seeks to provide a broad perspective on the primary care/mental health interface in the United States. The manuscript examines both the care of mental disorders in medical settings, and also the medical care of the seriously medically ill. The first section provides a historical overview of the cycling patterns of growth and retrenchment of primary care medicine during the 20th century, and the how those changes have paralleled the care of mental disorders and the mentally ill. The second section examines the four core features of primary care -first contact, longitudinality, comprehensiveness and coordination -and their implications for these issues. An historical and system-level perspective can provide a crucial step towards improving care on the mental health/primary care interface.

Objectives: A Joint Planning Committee Report was issued in 1974 exploring how Stanford University might itself provide primary care to students, faculty, employees and their dependents at low cost. The report called for the creation of a health maintenance organization owned by its subscribers in affiliation with Stanford Medical Center. However, because the report was dismissed by the dean of the School of Medicine as being unworkable, the Midpeninsula Health Service (MHS) began operating as an unaffiliated, nonprofit health plan in downtown Palo Alto in January 1976. The MHS's planning, early operation, move to the Stanford campus, financial viability and ultimate fate are examined as an example of action research in health care., Methods: Source documents were examined by the authors, a founding MHS board member and its two inaugural medical directors, in compiling a 30-year organizational history., Results: The MHS was remarkably prescient in its early use of small primary care groups that included midlevel practitioners, the principles of evidence-based medicine, the participation of patients in self-care activities, and a commitment to the continuous monitoring and improvement of quality. Imputed annualized costs of care were 30% lower than contemporary fee-for-service care and 20% lower than that of Kaiser, with no discernible difference in health outcomes., Conclusion: Action research methods can be useful in identifying and testing potential solutions to vexing problems in health care delivery.

At the beginning of the 20th century, Barbados was described as the most unhealthy place in the British Empire; at the end of the century, it is considered amongst the healthiest of developing countries. At the start of the century the statistics were harsh; for example, there was an infant mortality rate of 400 per 1000 live births. It is now between 10 and 15 per 1000 live births. In the last two-thirds of the century, there was a series of ongoing revolutions in Education, Public Health and Hospital Services that affected the health status favourably. The revolution in education was enhanced by the provision of University education starting with Medicine at Mona, Jamaica. Training of doctors expanded to Barbados in 1967 and has been an essential ingredient in the medical care revolution of the last third of the century. In 1953, the first Public Health Centre was opened and Barbados can now boast the most modern public health and primary care facilities. However, modern lifestyles are associated with an epidemic of obesity, diabetes mellitus and hypertension. HIV/AIDS has emerged as a major problem. Health in the 21st century will need to look at lifestyles--the effects of the internal combustion engine, the availability of tools of violence, the lure of 'illegal drugs', personal relationships and gender as well as the driving forces behind the associated lifestyles.

The development of primary health care in Jamaica is explored, tracing its early roots to the abolition of the slave trade, the collapse of estate-based services after emancipation and the subsequent establishment of the Island Medical Services in 1875. Most development in the health sector occurred after World War I in response to the high infectious disease mortality rates. The Rockefeller Foundation was asked to assist with the control of hookworm, tuberculosis, malaria and yaws. Its recommendations led to the growth of public health programmes (e.g. environmental health, public health nursing, community midwifery) alongside community-based curative services run by hospitals. The most significant period of development occurred in the 1970s when the various vertical programmes were integrated into the current primary care system. Jamaica was integral in the development of the World Health Organization's Alma Ata Declaration on Primary Health Care, tabling the "Jamaican Perspective on Primary Health Care" which set out its goal that all citizens should be within 10 miles walking distance of a primary health care facility. At the close of the twentieth century, the health reform process led to the development of regional health authorities aimed at integrating the management of primary and secondary care under four Regional Boards of Health. This has led to a change in the role of the central Ministry of Health to one of policy-making, health promotion, setting standards, monitoring and evaluation of the quality of health care.

Background: Community-oriented primary care (COPC) is a systematic approach to health care based upon principles derived from epidemiology, primary care, preventive medicine, and health promotion. We describe the development of COPC from an historical perspective. A critical assessment of current trends and implication for physician education and practice of COPC will be discussed in a companion article in the next issue of The Journal., Methods: MEDLINE was searched using the key phrase "community-oriented primary care" Other sources of information included books and other documents., Results and Conclusions: In the 1950s, Sydney Kark showed dramatic positive changes in the health status of the population of Pholela, South Africa, using this approach. Similar approaches showed positive change in the health status of poor and underserved populations in the United States. The results were so impressive that the Institute of Medicine recommended widespread application of COPC in the United States. Successful COPC practices, however, have historically required considerable external funding from private and government sources. Thus, controversy about the feasibility of implementation of COPC in mainstream primary care practices developed. Schools of medicine and the discipline of family medicine have struggled to implement effective training in COPC within traditional medical school and residency structures. Yet, the societal need for recognition of and intervention in community health problems and coordination of community health resources continues.

Nurses have been functioning in expanded roles as nurse practitioners (NPs) since 1965. The role has been characterized by controversy regarding economics, scope of practice, level of independence, accountability, and training since its inception. This article examines the response of the medical community to NPs during the first 15 years of their development. The medical literature from 1967 through 1982 was examined through a Medline search to ascertain the issues, attitudes, and barriers to practice that evolved as a foundation for understanding the present response of medicine to NPs.

This article represents the history of primary care and behavioral health integration at Group Health Cooperative (GHC) over the last decade, and foreshadows probable futures for this work into the next decade. To build from a logical progression, the article responds to a series of questions: 1. Why integrate primary care and behavioral health? 2. What has been done so far and how well has it worked? 3. Keeping the end in mind, what's the idealized picture of integration for the future? 4. How to get from here to there? What will help or hinder the effort? and 5. Again, why make these efforts to integrate?

It has been assumed that local health administrations in rural areas in the second half of the nineteenth century functioned in a rather passive and ineffective way. The present study focuses on the activity of the health commissions in the municipalities of Vinje, Seljord, Hitterdal, Gjerpen and Bamble. In the 1860s og 1870s, few meetings were held. Lack of interest and communication problems between doctors (who chaired the commissions) and the municipal councils were pointed out as causes. In commission meetings, the doctors used most of the time to give information on the present health situation in the area and on general medical issues. After 1885 the activity in the commissions gradually increased. New legislation and health regulations gave the health commissions a more important role in public health administration. In Hitterdal and Seljord the health commissions contributed actively to fighting the diphteria epidemics in the late 1880s. With urbanization and industrialisation in lower Telemark, environmental health issues took on added importance for the health commissions of Gjerpen and Bamble. The problems were much more effectively dealt with in Bamble than in Gjerpen, possible because of differences in the organisation of the commissions and in the workload for the doctors who chaired them.

The 20th century is the century of modernity. Medical science and technology have basically and positively changed the health of the population. The serious infectious diseases are under control and the health services and their institutions have expanded extensively, in Norway as throughout the western world. Nevertheless, there is an impression of general frustration and discontentment. The authors reflect over this paradox by reminding the reader of some of the main developments in primary care in this century. They call attention to former Director General of the Norwegian Board of Health, Karl Evang, and his role as initiator and leader, and see him in contrast to former Minister of Health, Werner Christie and his criticism of the system. The authors suggest that the crisis within the health care system emerging over the last decades, should be understood as a crisis of modernity. There is a need to adjust some of the ideals which have dominated our century. In order to face the challenges of post-modern society, they recommend restoring the art of medicine. Above all, there is a need to incorporate pluralism as an essential value in the planning of our future health care system.

Since 1994, health policy in the UK has focused explicitly on making the NHS 'primary care-led'. However, the meaning of primary is contested by different health professions and by policy-makers. This paper charts the major points of debate since the 1960s and suggests that there are limitations as to what general practice can be expected to deliver in respect of primary care.

The development of public health and primary care in Jamaica is examined with particular reference to the historical events which paved the way for their development: notably, the collaborative work undertaken by the Rockefeller Foundation (Commissions on hookworm, tuberculosis, malaria, yaws); recommendations of the Moyne Commission (leading to the establishment of the West Indies School of Public Health); and the Irvine Commission which recommended the establishment of the University College of the West Indies. A confluence of political, social and international activity in the 1970s proved catalytic in the development of the current ethos of primary health care, and the Department of Social and Preventive Medicine was instrumental in the training of the most innovative addition to the primary care health team, the community health aide. Undergraduate and postgraduate training programmes of the Department are highlighted as it celebrates its fortieth anniversary.

Several ideas have currency through long periods of malaria control history and important issues in controlling many communicable diseases have often been fought out over malaria. Health administrators view complex problems of malaria control through these apparently simple ideas. The most important concepts concern the need for specific methods to combat particular features of the spread of malaria and how far this is reflected by the development of specific health services. This paper follows these ideas through the last century and argues that the dead hand of history has played too large a role in determining malaria control generally, and especially over the last two decades, while the whole period provides an illuminating commentary on conceptualization in tropical health and its evolution. The two decades following discovery of the mosquito transmission of malaria saw increasingly specific knowledge about the vectors and approaches to preventing breeding. This required "odd" health workers who poured oil on water and did fresh-water biology and later special engineers who could design reservoirs and irrigation systems hostile to anopheline breeding and apply "species sanitation". The expertise required lay outside the health sector. Later, the DDT phase focused on a single highly specialized control technique, total coverage house spraying, and led on to attempted eradication, whose activities were vertically grouped. Malaria eradication became autonomous within the health department. It became the archetypal vertical programme whose funding levels and early successes made it a model to be emulated. But the need for active case surveillance to be integrated with general health services was a major reason for failure in some countries. The subsequent reaction to failed eradication emphasized horizontal or general health services, and these are very relevant to current pre-occupations with morbidity and mortality reduction by early diagnosis and prompt treatment. The future needs a complex mixture of interventions that cut across traditional views of either specificity or of the horizontal/vertical split in programmes, and development of effective control with imperfect tools requires a more sophisticated analysis of control methods and organizations than is provided by a simple vertical/horizontal debate.

The Alma-Ata Conference on Primary Health Care in 1978 marked a turning point in WHO's history and in international cooperation in health. Attempts to put the decisions of that conference into practice have not always been successful, but the principles that were formulated then remain as valid as ever. The author, who was one of the main moving spirits behind this unique event, puts things into perspective.

This paper traces the development of dispensaries in the counties of Armagh and Down in the decades prior to the Great Famine. It examines the number and distribution of dispensaries and discusses their management, finance and daily administration. The role of dispensary doctors, their conditions of employment and the diseases which they treated are also considered.

Family medicine has grown as a specialty from its early days of general practice. It was established as a Board Certified specialty in 1969. This growth and maturation can be traced in the philosophy of family medicine as articulated by Edmund D. Pellegrino, M.D. Long before it was popular to do so, Pellegrino supported the development of family medicine. In this essay I examine the development of Pellegrino's philosophical thought about family practice, and contrast it to other thinkers like Ian McWhinney, Kerr White, Walter Spitzer, Donald Ransom, and Hebert Vandervoort. The arguments focus on whether the goals of family medicine and family practice (possibly two distinct entities) can be articulated, especially considering the definitional problems of "family" and "community." I conclude by echoing Pellegrino's hope that family medicine can contribute a fresh alternative to isolated, individualistic and technological thinking in medicine.

The authors by means of this work report on the history of the Primary Health Care Program for School Children That was initiated in the 1980s in the city of Ribeirão Preto, Brazil.

Despite the political and economic reforms that have swept Eastern Europe in the past 5 years, there has been little change in Poland's health care system. The Ministry of Health and Social Welfare has targeted preventive care as a priority, yet the enactment of legislation to meet this goal has been slow. The process of reform has been hindered by political stagnation, economic crisis, and a lack of delineation of responsibility for implementing the reforms. Despite the delays in reform, recent developments indicate that a realistic, sustainable restructuring of the health care system is possible, with a focus on preventive services. Recent proposals for change have centered on applying national goals to limited geographic areas, with both local and international support. Regional pilot projects to restructure health care delivery at a community level, local health education and disease prevention initiatives, and a national training program for primary care and family physicians and nurses are being planned. Through regionalization, an increase in responsibility for both the physician and the patient, and redefinition of primary health care and the role of family physicians, isolated local movements and pilot projects have shown promise in achieving these goals, even under the current budgetary constraints.

This article provides insights into the history of community health centers (CHCs) and the role that they play in providing care to the poor. The mission of the CHC has always been to provide comprehensive primary care services to community residents regardless of their ability to pay. Health centers served an estimated 7 million people in 1993. In the near future, centers will be faced with new challenges. For example, the nationwide momentum toward managed care is defining new areas of growth for health centers, including new forms of practice management and contractual arrangements with other providers.

Inspiration drawn from South African public health initiatives in the 1940s played an important role in the development of the network of community and migrant health centers in the United States. The first such center at Pholela in Natal emphasized the need for a comprehensive (preventive and curative) service that based its practices on empirical data derived from epidemiological and anthropological research. In addition, community consultation preceded the introduction of new service or research initiatives. The Institute of Family and Community Health in Durban pioneered community-based multidisciplinary training and developed Pholela and other sites as centers for service, teaching, and research. Several important lessons for South African health professionals emerge from the Pholela experience. First, public health models of the past need to be reintroduced locally; second, the training of public health professionals needs to be upgraded and reoriented; third, appropriate research programs need to respond to community needs and address service demands; fourth, community involvement strategies need to be implemented early on; and fifth, funding sources for innovation in health service provision should be sought.