Questioning global health in the times of COVID-19: Re-imagining primary health care through the lens of politics of knowledge

The paper situates the COVID-19 pandemic within longstanding crises in healthcare systems and argues for interrogating the ontological and epistemological foundations of global/public health. It highlights repeated calls to revive Primary Health Care (PHC) and posits that limited implementation over four decades stems not only from political economy and governance issues but also from the politics of knowledge (PoK) that shapes what counts as valid evidence and solutions. The central research question is how dominant knowledge generation, adoption, and translation processes in global health have influenced PHC implementation, creating path dependencies that constrained Universal Health Coverage (UHC) initiatives and contributed to failures observed during COVID-19.

The paper reviews scholarship on knowledge translation in public health and critiques technocratic models that assume unproblematic evidence uptake. It synthesizes literature on the plurality and hierarchy of knowledge systems—biomedical versus social science approaches, lay versus expert knowledge, feminist and decolonial perspectives, HIC versus LMIC framings—and the role of state, market, and professional power in legitimizing certain knowledges. Drawing on Foucauldian notions of knowledge-power and debates on epistemic injustice, it examines how dominant paradigms problematize issues and privilege techno-managerial solutions (e.g., privatization as ‘efficiency’), shaping policies such as Selective PHC and DALY-based priority-setting that marginalize context-sensitive and community-led approaches.

The study is a collective perspective-building effort by public health academics and practitioners in India, informed by engagement with community participation and health systems initiatives. Methods include desk-based narrative literature and document review, content and gap analysis of the Alma-Ata Declaration (1978) documents, and iterative transdisciplinary dialogues and workshops (2017–2019) with health systems scholars and activists. Tacit and experiential knowledge from practitioners complemented peer-reviewed and grey literature. Insights from the PoK lens were used to design an operational framework termed PHC 2.0, aimed at addressing identified gaps in knowledge generation, translation, and governance.

- The Alma-Ata articulation of PHC, while espousing equity, community participation, appropriate technology, and intersectoral action, implicitly preserved the epistemic supremacy of conventional biomedicine and positioned primary care as ‘peripheral’ to hospital-centered systems, limiting comprehensive implementation. - Key omissions and contradictions included lack of explicit recognition of people’s knowledge and empowerment, insufficient attention to community heterogeneity and power hierarchies, absence of critiques of iatrogenesis and professional ethics, and environmental considerations. - These PoK gaps enabled the rise of Selective PHC (e.g., GOBI-FFF) and DALY-driven, decontextualized priority-setting that favored technological interventions over upstream, community-led, and context-specific solutions, contributing to path dependency. - COVID-19 management exemplified anti-PHC tendencies: top-down, techno-managerial responses driven by modeling and biomedical narratives (lockdowns, ICU/ventilator expansion, vaccine-centrism) overshadowed contextual preventive strategies and primary-level supportive care. Epidemiological realities—approximately 80% mild cases, 15% requiring oxygen, and 5% needing intensive care—were not leveraged through PHC-led systems. - Despite dominant narratives, communities mobilized significant self- and mutual-care responses, illustrating the resilience and relevance of non-dominant knowledge systems, including traditional medicine and experiential practices. - The paper proposes PHC 2.0: a reoriented system design that recenters the individual, family, and community as the core, supported by institutional services, and integrates plural knowledge systems through structured mechanisms for mutual learning and knowledge translation.

Applying a PoK lens clarifies how implicit epistemic hierarchies within the Alma-Ata framing and subsequent global health governance limited PHC’s transformative potential. Recognizing and addressing these hierarchies is essential to reconfiguring health systems toward comprehensive, equitable, and context-responsive care. The proposed PHC 2.0 reframes the core-periphery relation by placing community-level knowledge and practice at the center, with institutional tiers in a supportive role. It argues for democratic knowledge governance that validates plural ontologies and integrates experiential, traditional, social science, and biomedical knowledges to guide priority-setting, technology assessment, and service design. This approach directly addresses the research question by specifying how knowledge generation and translation should be reorganized to enable effective PHC implementation and avoid path-dependent techno-managerialism revealed during COVID-19.

The paper contributes a politics-of-knowledge analysis explaining PHC’s limited implementation and offers an operational redesign—PHC 2.0—that centers community knowledge and practice while re-legitimizing knowledge plurality. It outlines a multi-tiered system with mechanisms for mutual learning and context-sensitive knowledge translation across tiers, aiming to democratize health policy and strengthen resilience. Future research should develop frameworks for transdisciplinary validation and regulation of diverse health knowledges, evaluate community self-care enabling institutions, study knowledge governance models that mitigate epistemic injustice, and generate empirical assessments of PHC 2.0 implementation across varied sociocultural contexts, especially in Asia, Africa, and Latin America.