Introduction

The two decades before the 21st century brought about major transformations: the Cold War came to an end in 1991 and a new brand of liberalism called neoliberalism emerged. This period is often considered, at best, a quiet time for health systems discussions and, at worst, a period of retrenchment as the key ideas of primary health care (PHC), such as comprehensiveness, the intersectoral approach, and community-centredness, were replaced by selective approaches that embraced the vertical strategy. Demands for equality among countries and dreams of a welfare world gave way to an understanding of basic needs based on individual entitlements. However, while the specific constellation of forces, interests, paradigms, and courses of action around PHC dissipated quickly, its vision has had a long-lasting legacy in health policy. Additionally, a closer look at the interactions between larger structural changes and specific actors and institutions demonstrates continuity of important components of the horizontal approach and universalist agendas, such as Health for All (HFA). This period also witnessed key transformations in the conceptions and expectations of development. The post-1970 debates returned to the economic argument, this time to emphasize its negative costs, such as impacts on savings, limits on work incentives, and dependency (see Hayek’s, 1960, and Friedman’s, 1962, residual welfare discussions).

This chapter begins with an analysis of how the different components of the PHC agenda transformed with the emergence of new actors and shifts in the positions of old actors and their interests, new paradigms, and courses of action. It focuses especially on the structural transformations in the economic, political, and social spheres.