The COVID-19 pandemic exposed deep-seated flaws in global health governance and national health systems, highlighting the urgent need for systemic reform. The pandemic's disproportionate impact underscores the ongoing healthcare crisis and reinforces calls for a fundamental shift in how global health engages with its ontological and epistemological foundations. While various experts advocate for restructuring global health and reviewing its approaches to health systems design, the perennial contestation over these approaches remains a significant challenge. The Alma-Ata Declaration of 1978, which championed the Primary Health Care (PHC) approach, is frequently invoked during health system crises, yet its implementation has been severely limited over the past four decades. This paper argues that attempts to rethink PHC without analyzing the politics of knowledge (PoK) that underpin global health policy and planning will be insufficient. Existing analyses tend to focus on political economy, sectional interests, and financing, overlooking the intellectual processes that legitimize collaborations and shape policy agendas. Therefore, the paper posits that knowledge, as the intellectual foundation of global health policy, is a crucial point of departure for understanding the global health complex.

The paper reviews existing literature on the limited implementation of the PHC approach, noting an academic preoccupation with actors, sectional interests, and financing in global health. It points to a lack of reflection on the intellectual processes that shape policy, including knowledge generation, legitimation, and adoption. The authors critique the conventional view of knowledge translation as a purely technocratic process, arguing that it ignores social, political, and cultural factors. They emphasize the diversity of epistemological traditions in global health, including biomedical versus social science approaches, laypeople versus expert perspectives, and knowledge from historically colonized versus colonizing countries. This diversity, they argue, is often hierarchized, with dominant paradigms shaping policy and practice. The paper draws upon Foucauldian concepts of 'knowledge as power' to understand how power relations shape knowledge production, translation, and circulation, potentially leading to epistemic injustice. The authors intend to use a PoK approach to analyze the Alma-Ata Declaration and its implementation to identify the complexities and power dynamics influencing knowledge translation in public health and health policy.

This paper employs a qualitative methodology grounded in a perspective-building exercise undertaken by a collective of public health academics with extensive experience in community participation and health systems initiatives in India. The authors, combining their roles as healthcare providers, public health practitioners, and researchers, engaged in collective enquiry, desk research, and intensive discussions on PHC, UHC, and PoK over three years (2017-2019). Transdisciplinary dialogues with other academics and health activists further refined their perspective. A narrative review of literature and a document review were conducted, analyzing scholarly works, grey literature, and other information sources on health systems design within the context of the PHC approach. The Alma-Ata Declaration documents (WHO-UNICEF, 1978) were subjected to content analysis and gap analysis to understand the path dependency that has constrained UHC initiatives and contributed to the healthcare challenges during the COVID-19 pandemic. This gap analysis, informed by the PoK lens, served as the foundation for designing an alternative framework, 'PHC 2.0'. The synthesis of peer-reviewed and grey literature, along with the tacit knowledge of the community of public health practitioners and analysts, formed the basis for the gap analysis of the Alma-Ata documents and the subsequent operational design of PHC 2.0.

The paper identifies several key shortcomings in the Alma-Ata Declaration and its subsequent implementation. The Alma-Ata Declaration, while advocating for community participation, appropriate technology, and inter-sectoral coordination, lacked explicit acknowledgement of the Politics of Knowledge (PoK) and its implications for operationalizing PHC. This omission allowed for misinterpretations of PHC as a purely techno-managerial approach. The authors critique the dominance of biomedicine as the sole legitimate knowledge system, leading to PHC strategies that focused on 'health for the people' and 'health with the people' but rarely 'health by the people'. The paper highlights inconsistencies within the Alma-Ata Declaration itself, such as the paradoxical positioning of primary-level care as 'peripheral' despite emphasizing community centrality. The authors also criticize the reduction of PHC to selective approaches, such as GOBI-FFF, which prioritized narrow biomedical interventions over broader social and environmental determinants of health. The rise of UHC, the paper argues, has further reinforced a medicalized view of health, prioritizing medical insurance coverage over addressing the unaffordability of healthcare and neglecting the wider social and cultural impacts of medical interventions. The COVID-19 pandemic response, dominated by top-down command-and-control measures and a narrow focus on vaccines and lockdowns, is presented as a prime example of the failure to adopt a comprehensive PHC approach. The authors highlight the lack of integration of traditional knowledge systems and community-based initiatives, despite their potential for improving health outcomes. This analysis underscores the need for a reorientation of knowledge governance, emphasizing epistemic pluralism and community empowerment.

The paper's findings highlight the limitations of a technocratic and biomedical-centric approach to health systems development. By applying the lens of the politics of knowledge, the authors demonstrate how power dynamics and knowledge hierarchies have contributed to the underimplementation of the primary health care approach. The neglect of diverse knowledge systems, particularly traditional medicine and community-based practices, is identified as a major obstacle to achieving health equity and universal health coverage. The COVID-19 pandemic response serves as a powerful case study illustrating the consequences of a narrow focus on biomedical interventions and a top-down approach to public health. The authors emphasize the need to move beyond a simplistic epidemiological perspective towards a more nuanced understanding of the complex interplay of social, economic, environmental, and cultural factors that shape health outcomes. The proposed 'PHC Version 2.0' seeks to address these limitations by placing community-level care at the center of the healthcare system and explicitly acknowledging the diversity of knowledge systems.

This paper argues for a fundamental rethinking of global health policy and planning, advocating for a more democratic and inclusive approach that prioritizes community participation and recognizes the value of diverse knowledge systems. The proposed 'PHC Version 2.0' framework offers a practical approach for operationalizing the spirit of the Alma-Ata Declaration, emphasizing a shift from a biomedical-centric to a more holistic and community-driven model of healthcare. Future research should focus on developing and testing the proposed framework in diverse settings, further exploring the interplay of power dynamics, knowledge systems, and health outcomes.

The paper's focus on India and its drawing upon experiences primarily from that context limits the generalizability of certain findings to other geographical regions. While the authors synthesize insights from a range of literature and diverse perspectives, the inherent subjectivity in qualitative research methods should be acknowledged. The proposal for 'PHC Version 2.0' is a conceptual framework, and its practical implementation may face various challenges depending on specific contextual factors.