BMC Public Health 2004, 4 http://www.biomedcentral.com/1471-2458/4/11 heid South Africa and influenced health programmes in several countries like Israel, UK and the US [51]. In the census based impact oriented (CBIO) approach to PHC, implemented in selected areas of Bolivia, local health pri- orities were determined based on epidemiological infor- mation by the people themselves [52]. In Mexico, a module programme of the Ministry of Health was imple- mented to promote CP in PHC [53]. At the international level, CP became an essential element of health development programmes sponsored by inter- national donors. Multilateral agencies like the World Bank and the Organization of Economic Cooperation and Development have accepted the principle and initiated activities for promoting CP in the development pro- grammes they supported [54,55]. CP was one of the main principles of PHC in the global strategy of Health for All by WHO [56]. Discussion A window of opportunity: Elements of a proposed programme for HP in developing countries In the foregoing discussion it is observed that the ideas of HP, SC and CP emerged almost all at the same time, out of the concerns about the limitations of the professional health systems. Self-reliance and empowerment are the underlying themes of SC and CP. These two concepts are rooted in the broad democratic principles of rights and duties of individuals to participate in the activities that affect their lives. In the literature too, there is considerable overlap between these areas and terms like CP, consumer participation, citizen participation, SC and self-help. For instance, concepts of citizen participation in health encompass activities related to SC and CP. Based on the experience of Western Europe and North America, two main approaches to citizen participation have been sum- marized. The first is the participation of the people in the decision making process, where people participate in pol- icy formulation, planning and implementation. The sec- ond concerns participation in community level activities, which includes a broad spectrum of groups such as self- help groups, voluntary organizations and social move- ments, such as the women's movement [57]. In the HP framework aimed at achieving health for all Canadians, SC was proposed as one of the three key mechanisms [58]. During the last three decades, growth of SC activities has been witnessed mostly in developed countries where health services are accessible to vast majority of the popu- lation. It is in its infancy in developing countries, even though uneven distribution of professional resources leaves a vast proportion of rural and poor masses without access to professional health care. For instance, in India it is estimated that about 75% of the professional health infrastructure, medical manpower and health resources are located in the urban areas, where only 23% of the pop- ulation live [59]. Lower socio-economic status increases the vulnerability of the poor to illness and reduces their ability to cope with it. Similarly large scale programmes to improve CP for HP are yet to be initiated in the develop- ing countries. There is a great window of opportunity for HP among the disadvantaged and poor people of devel- oping countries through SC and CP. A broad outline is suggested for the implementation of such a programme primarily in developing countries, fol- lowing five key strategies of the Ottawa charter for HP and following principles of SC and CP. Figure 2 shows the health care pyramid and proposed model for HP pro- gramme. Health and HP lie at the base of the pyramid. At this level, health SC of the individual is the determinant of one's lifestyle and behaviour. Here lay person plays the most predominant role for his/her HP. The second level is PHC, which is defined as the essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a low cost that the community and the country can afford to maintain at every stage of their development in the spirit of their self determination [56]. It is the first level of contact for individuals, the fam- ily and the community with the national health system. At this level too, lay persons play a major role in their health care, supplemented by professionals. The next levels are secondary and tertiary care respectively, having highly skilled health workers and sophisticated diagnostic and therapeutic technology, where progressively complex health problems are dealt with [60]. Here professionals play the predominant role. The strategies of the proposed HP programme may be pri- marily directed to the first two levels, that is, health and PHC, where SC is the most dominant form of health care. These strategies are not mutually exclusive but synergistic. Similarly, the same strategy may be relevant for both the levels of health care. Structural and policy level actions may be directed for promoting SC and CP. A national body, with members from the community, professionals and officials, may be created for policy formulation and for providing overall supervision for designing and imple- menting the programme in co-ordination with the pro- vincial level organisations. Budgetary allocation for promoting these activities should be made. SC clearinghouses may be established to spearhead the programme at the provincial level, in consultation with lay persons, professionals and national and district level Officials. SC clearinghouse may co-ordinate the design and dissemination of SC information, provide training to the health workers and lay persons, provide consultative Page 6 of 12 (page number not for citation purposes)